January 17, 2020

Anthony J. Caterine, MD

Consultation and Geriatric Psychiatrist, Riverside Health System


AnthonyAnthony Caterine says he always knew he wanted to be a doctor: “My father was a surgeon, so I was interested in medicine early on.”  He recognized early on that people seemed comfortable talking to him (he was elected president of his junior and senior classes in high school), and he chose psychiatry because he excelled in it in medical school (Stritch School of Medicine, Loyola University, ’88.)  He completed his residency in psychiatry at Shand’s Teaching Hospital in Gainesville Florida in 1992.  He also took specialized training in forensic psychiatry under Dr. George Barnard at the University of Florida. Dr. Barnard, he notes, was one of the Forensic Psychiatrists who evaluated Aileen Wuornos, the serial killer from Florida who was portrayed in the movie “Monster.”  Dr. Caterine conducted 194 forensic psychiatric evaluations, and provided expert testimony in 30 court cases.

He began his career in a standard, inpatient/outpatient practice, being interested in both aspects.  But as he got further into his career, he realized he had an affinity for working with patients in the more acute hospital setting.

He had joined a practice in the Midwest, but found himself gravitating more and more toward treating dual diagnosis patients, with acute physical and psychiatric problems.  In 2002, Dr. Caterine took advantage of the opportunity to move to Virginia to work on a medical psychiatric unit, part of the Riverside Health System.  “These patients were too medically ill to be in a regular psychiatric hospital,” he says, “but they still required intensive psychiatric treatment.”

When that unit closed, Dr. Caterine remained within the Riverside system.  “Riverside has a very large, comprehensive lifelong health program,” he says.  “They have a focused geriatric practice, with twelve nursing facilities as part of the system.  They knew I was Board certified in Geriatric Psychiatry, so they asked me to start doing psychiatric consults there initially, while I continued doing consults at the general hospital.”  He moved over to the lifelong health division, and since 2005, has confined his work to consults at several Riverside Hospitals and the various nursing facilities.

“The biggest change for me in the last couple of years has been telemedicine,” Dr. Caterine says.  “I used to literally drive to all of the nursing facilities, which are all over the place.  One year I logged more than 10,000 miles!  Such an inefficient use of my time with so many patients needing treatment, patients I couldn’t physically get to.”

Today, through telemedicine, he’s able to do consultations at Riverside’s Tappahannock, Gloucester and Eastern Shore hospitals as well as the nursing facilities in similar areas.  “With telemedicine, I can schedule my time, but can also do consults the same day they are asked, if indicated,” he notes.

His interest in and compassion for the concerns of severely ill and psychiatric elderly patients is reflected in the research he has done and the many presentations he has given, particularly in the areas of depression, bipolar disorders, geropsychiatry and geriatric psychopharmacology.  He was recognized by J. C. Penney’s Partners in Peace Award for Contributions to Senior Strength Program Center for the Prevention of Abuse in 1997.

As a geriatric psychiatrist, Dr. Caterine believes passionately that society has a responsibility to better prepare for the number of people who will need treatment for dementia.   “People are living longer and longer, and as we know, Alzheimer’s is a disease of aging.  By the time these people are 85, they’ll have a 30-40 percent chance of developing Alzheimer’s.  And the risk keeps going up after that.”  With the Baby Boomers entering ages associated with dementia, there is going to be a significant increase in people with dementia.  He sees these patients every day and many are happy and coping well.  “But some are not,” he cautions, “and they can be very difficult to take care of.  If we don’t think about this and plan, these people are going to fill up our ERs, hospitals, and then – because they will have nowhere else to go – the younger people who need treatment in those settings will have a harder time getting the treatment they need.”

Dr. Caterine enjoys finding novel ways to assess patients’ ability to engage with him,  as a sign of possible depression or apathy.  Lately, he’s been asking, “Who are you voting for president this year?”  He finds it telling that many are replying, “No one.”

Gary L. Munn, MD

Adult Inpatient Psychiatry
Naval Medical Center Portsmouth


MunnGary Munn was commissioned an ensign in the United States Navy in June, 1976, upon graduation from the U.S. Naval Academy.  He found an easy rapport with the sailors he supervised as a division officer: “They’d come to me for counseling,” he says, “and I had insights into some of the tragedies in their lives.  I wanted to be able to help them.”  He earned his medical degree at New York Medical College in Valhalla, New York, in 1988, and completed both his internship and residency in psychiatry at Naval Medical Center Portsmouth.

During a long and storied career in the United States Navy, Dr. Munn had a number of experiences that provided him the opportunity to make significant contributions to the advancement of military medicine.  From 1992-1995, while assigned to U.S. Naval Hospital Sigonella, Dr. Munn served as both Mental Health Department Head and Chairman of the Bioethics Review and Medical Records Review Committees, as well as the psychiatric advisor to the Family Advocacy Case Review Committee.  In 1995, he deployed to the Baltic Sea for BALTOPS 1995, aboard USS OLIVER HAZARD PERRY, to demonstrate shipboard medicine capacity to representatives of the former Soviet Bloc nations.

Returning to Portsmouth in 1995, he served in numerous positions in inpatient and Emergency Psychiatry. In 1997, he deployed to Roosevelt Roads, Puerto Rico aboard USS BATAAN in support of recovery and clean-up efforts following Hurricane Georges.  A year later, he was sent to U.S. Naval Hospital Guam, where he ensured continuance of the mission by providing interim psychiatric coverage during a shortage.  He went on to serve on the 2nd Fleet Service Support Group platform at Camp Lejeune, where he trained staff to identify and manage Combat Stress.  He was named Head of the Psychiatry Department in 2001.  In 2003, he received the call to deploy with BRAVO Surgical Co to Kuwait and Iraq, where he served as the Officer in Charge of the Combat Stress Platoon.  Under his leadership, his team had a 100 percent return-to-duty rate.

Later in 2003, Dr., Munn was transferred to National Naval Medical Center, Bethesda as the Department Head for Adult Inpatient Behavioral Health.  In 2004, he was awarded the H. James Sears Award for Excellence in Navy Psychiatry.  In 2007, he was recognized as the Naval Medical Center Portsmouth Psychiatry Residency Teacher of the Year.

Dr. Munn returned to Kuwait in 2007 as the Officer in Charge of COSTNAV [Combat and Operational Stress Team, Navy], supervising the provision of mental health care at four remote bases.  After completing his tour overseas, Dr. Munn returned to serve on the psychiatric wards at Naval Medical Center Portsmouth, where he also expanded the ECT Services.

Dr. Munn retired from the Navy in 2008, but says, “I was really blessed as I was approaching retirement.  A company with a contract opening at Portsmouth Naval Hospital offered me a position. I was able to start work as a contractor the day after I retired.”  He practices exclusively at Naval Medical Center Portsmouth, while holding associate professorships in clinical psychiatry and behavioral sciences at Eastern Virginia Medical School and the Uniformed Services University.  His years of experience in military inpatient psychiatry are unparalleled.

Dr. Munn and his colleagues at Naval Medical Center Portsmouth also support the airmen at Langley Air Force Base, soldiers at Ft. Eustis and Ft. Story, and Coast Guardsmen locally and in Elizabeth City. He adds, “we get referrals from around the world – the entire eastern half of the United States as well as Europe and Africa.  Whenever service members are in need of inpatient psychiatric treatment, Portsmouth is generally where they come.”

Practicing psychiatry in the military is gratifying, Dr. Munn says, because “we’re not operating under the constraints of insurance companies, or answering to third party payers.  We’re able to provide the care to our service members and veterans in ways we feel most appropriate, and we have the support of the command and the Congress and federal government to do just that.”

However, he acknowledges, the practice of military psychiatry has also gotten more complex over the years.  “We’ve always had to balance having to understand the needs of the military in addition to the emotional and medical needs of the service member,” he explains, “and doing our best to not compromise between the two, but to carve a new path so the needs of both are best met.”

These servicemen and women are fighting a war on two fronts, with an all-volunteer force, and Dr. Munn is treating soldiers and sailors who are making their fourth, fifth or sixth deployments.  “It’s tough on the service members and their families, and mental health services are in high demand within the department of defense,” Dr. Munn says.

Not surprisingly, between 2007 and 2015, Dr. Munn received more and more inpatient psychiatric referrals related to substance abuse disorders.  He helped establish the Substance Abuse and Detoxification Unit at Naval Medical Center Portsmouth.

The demands on service members seem greater than they’ve ever been, he notes, “But whereas psychiatry used to be the ‘stepchildren’ of military medicine – last in line to be considered for budgetary issues – now the value of military mental health is absolutely recognized, and there are plenty of resources being directed toward us.  We can take the best care of our beneficiaries.”

Maria R. Urbano, MD

Eastern Virginia Medical School Department of Psychiatry



Having enjoyed the research aspect of her undergraduate degree, she enrolled in Michigan State University to earn a master’s in microbiology.  She again found herself working with plants, this time looking at nitrogen fixation on clover plants.  It was interesting work, she says, “but I knew I didn’t want to spend my days working in a lab, with only a research assistant for company.  I was really missing people.”

She left Michigan State with more than a master’s degree: it was there that she befriended several medical students (including one very special friend), and began to envision a career in medicine for herself.  “It seemed like the perfect way to combine my love of science and my need to be with people,” she says.  She applied to EVMS, and earned her medical degree in 1983.  Dr. Urbano thought she wanted to practice family medicine, right up until she did a rotation in psychiatry.  “We did it at the Naval Hospital in Portsmouth,” she explains.  “We didn’t have a resident or an intern, so it was the students and the attending.  We had the opportunity to do much more than we would have ordinarily and really got to know the patients.   I knew I had found my specialty.”  She completed a residency in psychiatry in 1987, and was Board certified in 1988.

As for that special friend she met in Michigan – Tom Manser – he remained in Michigan for his internship, but moved to Virginia for his residency at EVMS, and to propose.  Today, Dr. Manser is Chief of the General Medicine Division at EVMS.

Dr. Urbano completed one year of internal medicine residency before starting her psychiatry residency.  “It wasn’t unusual back then to enter psychiatry in the second year,” she says.  “But after that first year, I realized it wasn’t what I wanted to be doing.  I kept remembering something one of my favorite professors told me: ‘your goal is to get the patient’s story.’  And it’s true: by getting patients to tell their stories, you learn about their lives, and then you can find ways to create effective interventions to help them.”

Dr. Urbano acknowledges that there can be many layers of stories before a patient gets to the real story, depending on their problem.  “People have a lot of defenses,” she says.  “From a psychological perspective, the goal of the defenses is to keep emotional conflicts hidden away from consciousness, so they don’t disturb you too much.  But they end up causing anxiety or anger or sadness, so it takes time to go back and find what the root cause of the feelings was.”  In practice, Dr. Urbano says, we learn to ask the questions that help patients develop their stories.

Her tradition is psychodynamic psychotherapy, the oldest of the modern therapies.  “It’s associated with Freud,” Dr. Urbano explains. “It’s helping patients look at relationships from childhood and learning how those relationships affect their current abilities as adults to form (and maintain) their own relationships.”

The goal, she says, is that when patients learn to explore both past events and feelings, they can connect them to their current life situations, which can result  in changes in personality or behavior. Then they can make better choices, or have more options in the present.

When she’s not counseling patients, Dr. Urbano is teaching (she’s a full professor at EVMS), publishing (she’s led or been secondary author of a number of medical publications), participating in funded and unfunded research and training grants, or giving presentations both locally and across the country.

Many of these activities are based on the topic of Autism Spectrum Disorder.  “When Dr. (Stephen)Deutsch MD, PhD came to EVMS in 2009 as our chairman, he was doing research in autism,” Dr. Urbano says.  “I was interested because there are individuals with ASD in my family.  At the time, very little attention was being paid specifically to the older adolescent/young adult ASD population.”

Dr. Deutsch was working with a strain of mice that don’t interact as normal mice do – just as people with autism often avoid social contact with other people.  “He had tested a tuberculosis drug that had been found to change social behavior in these mice,” Dr. Urbano explains.  “We received a grant from the Hampton Roads Community Foundation to fund the study on young adults with autism.  The drug (D-cycloserine) was shown to be effective in improving stereotypic symptoms and increasing social behaviors in older adolescents and young adults with ASD.  It was also safe and well tolerated.  It was very exciting.”

It also represents a professional frustration.  “One of the challenges we face in studying autism is finding the resources to pursue scientific avenues that we have evidentiary reason to believe will be fruitful,” she says.  “In academic research, it always comes down to a question of resources.  It’s particularly vexing because we’re dealing with such young patients, the adolescents and young adults, at a critical time in their lives.”

Physical Therapy for Overactive Bladder…

…a vital tool for urologists and their patients


BallWomanMore and more urologists are referring their patients with bladder symptoms to physical therapists, with excellent results.  In physical therapy, patients learn how to properly use their pelvic floor muscles to help retrain their bladder; they learn about foods and drinks that may be contributing to the problem, as well as some simple behavioral strategies to help control their bladder frequency and urgency.

In a specialized pelvic floor physical therapy practice, the patient’s pelvic floor muscles are assessed, using state-of-the-art equipment, enabling the therapist to determine what is contributing to bladder problems. Some patients may need to strengthen their pelvic floor muscles and learn strategies to inhibit unwanted bladder contractions, while others may need to learn to release their pelvic floor muscles to more completely empty their bladder.

Trained therapists provide neuromodulation, a painless electrical stimulation treatment that can help calm an overactive bladder or help build strength and sensation in the patient’s pelvic floor muscles.  Percutaneous Tibial Nerve Stimulation, or PTNS, has been found to be effective for patients with nocturia, significantly reducing the number of nighttime visits to the bathroom.  Other applications of electrical stimulation are available, based on the patient’s needs and lifestyle.

Pelvic muscle exercise and many of the treatments provided by pelvic floor physical therapists have been recommended by the American Urological Association as a first line of treatment; thus many urologists are referring their patients for physical therapy before attempting more invasive treatments.  Overactive bladder, which affects 30 percent of American men and as much as 40 percent of women, can be a vexing, disruptive condition.   Physical therapists, working in concert with urologists, can provide effective, compassionate care for these sufferers.

GlaceErin Glace, MSPT, PRPC, BCB-PMD is the Director of Physical Therapy and Urodynamics at Urology of Virginia Physical Therapy Department. www.urologyofva.net

Neuromodulation Provides Relief for Patients with Chronic Back Pain

…adapted from the technology behind pacemakers, spinal cord stimulation is reducing and even eliminating pain.

By Michael Ingraham, MD, Sports Medicine & Orthopaedic Center


BackPainIn pain medicine, the most common complaint we hear in an average day – and we hear it every day – is back pain.  It’s not surprising, given that more than 80 percent of the population will experience back pain at least once during their lives.  Most recover within a few months.  Unfortunately, for those who do not, back pain can become a chronic condition that renders even the simplest daily task insurmountable, causing tremendous disruption in their lives and their families’ lives.

In appropriate cases, neuromodulation – or spinal cord stimulation – has been shown to provide significant relief from chronic back and leg pain in as many as 85 percent of patients.

The typical candidate is a patient who presents with a history of long-standing back and leg pain: a classic sciatica presentation.  The patient has failed conservative management, may have undergone surgery(ies), but the pain has not resolved with traditional treatment, including opioid medication.

After assessing the patient’s receptiveness to the concept of neuromodulation, we do a five-day nonsurgical trial to determine if the technique will be effective.  This involves numbing the patient’s skin, and through two small needles, we pass a catheter into the epidural space.  We then stimulate the spinal cord, blocking some of the pain signals coming from the brain.  Thus, rather than pain, the patient feels a slight tingling – or in the best case scenario, nothing at all.

The trial procedure takes less than an hour, and the patient can go home after the leads are placed.  If the trial is successful, and the patient enjoys relief from pain, we can then repeat the process, this time implanting a small battery under the skin, akin to that used in pacemakers, to power the stimulator.

The different models available allow us to customize both the procedure and the kind of device we implant.  Some patients don’t like to charge their devices, and thus prefer a permanent battery, which must be replaced after three to five years.  Some of the more technologically savvy like the ability to change the settings throughout the day, increasing or decreasing stimulation in response to their symptoms.  As the technology has become more sophisticated, we’ve developed new and innovative ways of using these devices, and many patients who had all but given up hope are experiencing as great as a 70 percent reduction in their pain.

In two recent randomized controlled trials of patients with predominant leg pain, spinal cord stimulation was found to be more effective than reoperation and conventional medical management. It’s also been demonstrated to be more effective in treating persistent sciatic pain after spine surgery, often eliminating the need for reoperation.  Additionally, in a conventional medical management study, more subjects randomized to spinal cord stimulation had a significant reduction in leg pain.

Today, rather than waiting until all other treatments have failed, neuromodulation is beginning to be introduced earlier into the algorithm.  We’re starting to offer it earlier and earlier, as new research proves it to be an ever more viable option.

MichaelIngrahamMDMichael Ingraham, MD is a fellowship trained pain medicine physician, who will join Sports Medicine & Orthopaedic Center in August 2016. He completed his internship at Harvard University/Beth Israel Deaconess Medical Center, and his residency in physical medicine and rehabilitation at Georgetown University/National Rehabilitation Hospital.  He did his fellowship in pain medicine at the University of Virginia School of Medicine.  smoc-pt.com

Acute Care Surgery at EVMS

… providing 24/7, 365 emergency surgical and critical care


The surgeons of the EVMS Acute Care Surgery service are (L-R) LD Britt, MD MPH; Jessica R. Burgess, MD; Timothy J. Novosel, MD and Leonard J. Weireter, Jr., MD (seated) Jay N. Collins, MD (inset) Rebecca C. Britt, MD

The surgeons of the EVMS Acute Care Surgery service are (L-R) LD Britt, MD MPH; Jessica R. Burgess, MD; Timothy J. Novosel, MD and Leonard J. Weireter, Jr., MD (seated) Jay N. Collins, MD (inset) Rebecca C. Britt, MD

Acute Care Surgery is an evolving specialty that arose following a 2005 survey conducted by the American College of Surgeons.  The survey demonstrated that trauma and critical care surgeons were increasingly responsible for emergency surgical care; in fact, nearly 75 percent of emergency departments identified inadequate on-call specialty coverage.  A 2006 Institute of Medicine report on the future of emergency care confirmed the national shortage of on-call specialists.

In 2007, recognizing the growing and disturbing trend, Eastern Virginia Medical School established the Acute Care Surgery service at Sentara Norfolk General Hospital.  Today, Acute Care Surgery (ACS) consists of five full-time EVMS surgeons, all Board certified and fellowship trained in trauma, emergency general surgery and critical care medicine.

Trauma accounts for only a portion of the work these surgeons do.  Jay N. Collins, MD, a member of the ACS team, explains: “We are available every day of the year, and every hour of the day, for any kind of surgical emergency people might have.  Whether for common diseases like appendicitis, diverticulitis or gallstone problems, or more complex cases involving perforations and serious infections of the abdomen, bowel obstructions of both the small and large intestines, and cancers that perforate into the abdomen, the team is immediately available.”

These conditions are unrelated to trauma, but each is serious and each can be potentially life threatening in its own right.  Each represents no less dramatic a medical catastrophe, requiring no less a skilled, expert specialist.

In a typical scenario, a patient might experience abdominal pain and sit around the house, resting, hoping it will pass.  But when symptoms don’t resolve, these patients arrive at the emergency room with fever, weakness, dizziness, hyperventilation and, by that time, often in need of urgent medical care.  “When they come to Sentara Norfolk General,” Dr. Collins says, “they undergo an exam and are given blood tests, x-rays, CT scans if needed, and we are immediately contacted by the ER physicians.  Any time of the day or night, one of us is on site, ready to examine and evaluate these patients, and if necessary, take them to the operating room without delay to correct their problems.”

Fortunately, not everyone who is seen by ACS requires surgery immediately.  It’s as important to know when to operate as it is to know when not to, Dr. Collins emphasizes.  In some instances, with very complicated cases, e.g., a patient with a cardiac or lung diseases who presents with appendicitis, the surgeons may choose to administer antibiotics initially and then monitor the patient carefully.  ACS surgeons may consult with the patient’s specialist(s), but if during the course of treatment the patient worsens, it is the ACS surgeons, who have been continuously watching the patient, who make the determination that the time has come for surgery.

When they do need surgery, one of the benefits for patients of Acute Care Surgery is that they remain under the direct care of these five surgeons throughout their entire hospitalization.  Some of these patients may be very ill post-operatively, requiring mechanical ventilation, medications to maintain blood pressure if in septic shock, and careful monitoring.  They are admitted to the ICU by their ACS surgeon, and treated by the ACS team until discharge.

In addition to caring for the patients who go directly to Sentara Norfolk General’s emergency room, the EVMS Acute Care Surgery service has established relationships with several freestanding emergency rooms throughout Hampton Roads and on the Eastern Shore.  The smaller community hospitals in the area often refer their patients with complicated medical problems – such as smokers with COPD, a history of multiple heart attacks, pulmonary emboli or transplants – to ACS as well, recognizing the experience of surgeons who work in a tertiary care hospital.

That experience is vast and comprehensive: with referrals from virtually every physician, hospital system and private practice in the community, the surgeons of Acute Care Surgery at EVMS evaluate as many as 1,200 patients every year.

EVMS Brickhouse Professor and Chair of Surgery LD Britt, MD, MPH, author of the name “Acute Care Surgery”, served as Editor-in-Chief for the first textbook on the subject, Acute Care Surgery Principles and Practice, and later was the senior editor for the second textbook, Acute Care Surgery.  The follow-up edition is currently in progress.

Mental Health Services in Virginia

Where are We Now? 
By Bonnie P. Lane, Attorney at Law Goodman Allen Donnelly PLLC


The sufficiency of Virginia’s behavioral health laws has been thrust into the spotlight due to two tragic events: the shooting at Virginia Tech in 2007, and the November 2013 attack on Senator Creigh Deeds by his mentally ill son. The Senator’s son was sent home after a psychiatric bed was unable to be located; he subsequently attacked his father and then committed suicide.

The Legislature responded to the demands for substantial changes to the existing structure of the mental health system to include some positive changes to the laws regarding emergency custody orders (ECO) and temporary detention orders (TDO).  Currently, the time period in which a person can be held under an ECO extends to eight hours. Each person taken into emergency custody receives a written summary of the emergency custody procedures and the statutory protections associated with those procedures. Additionally, patients brought to hospitals under an ECO who also qualify for a TDO no longer can be released when the ECO expires simply because a facility cannot be located. The state psychiatric facility in the region where the patient is located is the TDO facility of last resort and the patient must be admitted there if no other facility can be located to accept the patient.  The time period for holding PATIENTS under a TDO has also been extended from 48 to 72 hours before THEY MUST BE discharged or ATTEND an involuntary commitment hearing. A statewide web-based psychiatric bed registry has been created to help locate available beds.

These changes come as an effort to reduce the number of individuals at risk of causing harm to either themselves or others, and who are in need of hospitalization or medical treatment from being released without getting the help they need.  In many instances, this can lead to those individuals committing serious offenses and ending up in the criminal justice system. In 2015, 25.29 percent of the female Virginia inmate population, and 13.63 percent of the male population, was diagnosed as mentally ill.  46.82 percent of the mentally ill population and 7.87 percent of the general population were diagnosed with a serious mental illness. There is no state-funded mental health treatment program operating within jails, and private contractors provide the most significant portion of mental health treatment in jails.  Community Service Boards only have a statutory requirement to evaluate inmates for whom a TDO is being sought, with no obligation to provide treatment.  The Department of Behavioral Health Developmental Services has waiting lists for individuals coming from jails.

The Legislature continues to work to improve the system.   The Center for Behavioral Health and Justice has been established to achieve greater behavioral health and justice coordination across public and private sectors. Joint Subcommittees and task forces are also working to institute additional statutory and regulatory changes, hopefully in the near future.

BonnieBonnie P. Lane is an attorney at the Norfolk office of Goodman Allen Donnelly PLLC, and focuses her practice primarily on medical malpractice defense litigation and healthcare issues. www.goodmanallen.com

Mindfulness as a Treatment for Chronic Pain

By F. Cal Robinson, PsyD


The rigors of contemporary life have left scores of people unwell in mind and body.  For many, modern medical and psychological treatments haven’t satisfactorily addressed their need for health, peace and well-being. Thus, we’re witnessing a return to ancient and tested practices, including holistic health care, plant-based diets, naturopathic medications, meditation and mindfulness.

Mindfulness has been featured in the news lately, on TV, radio talk shows and magazines, and social media.  What is it that’s generating so much buzz?  How are business leaders using mindfulness to improve the lives of those with whom they interact, as well as to sharpen their own focus, leadership and relationship in the marketplace? Why are physicians and psychologists recommending it for their patients as an effective adjunct/alternative to medications or surgery?

For starters, it works and the proven results are based on sound science.   It’s an effective treatment methodology for any number of behavioral health issues – anxiety, restlessness, depression, OCD, substance abuse and eating disorders.  It’s shown to relieve stress, lower blood pressure, treat heart disease, lessen chronic pain, improve sleep and help with gastrointestinal issues.  In business, those who practice mindfulness see an improvement in focus, concentration, problem-solving and conflict resolution ability.  Overall, it contributes to improved life quality by decreasing worry and stress over the “what-ifs”.

Mindfulness is the practice of focusing attention on the “now,” or the present, with purpose and non-judgmental acceptance. Thoughts and feelings are allowed to wash over a person’s consciousness freely, but without the nagging reminders or value judgments we tend to assign to each thought. Most wisdom traditions have a prayer or meditative component for a reason, and mindfulness is a reflection of that; it slows the mind and allows peaceful focus and contemplation on the larger issues of life.

I use mindfulness to treat many cognitive issues, but my main focus is patients with chronic, intractable pain, most of whom spend a majority of time trying to either avoid, discount or alleviate their pain.  This leads to a life unfulfilled, as pain becomes the sole focus.  Patients may ignore family, friends, work and their values as they search for relief. They may seek stronger medications and substances or undergo multiple surgeries to make the pain go away. It can be a horrible existence.

Mindfulness training can help by getting the patient to focus on the pain and accept it as a part of life, rather than wasting energy avoiding it.  This doesn’t mean resigning oneself to pain.  Rather, it means being with the pain and ending the struggle with it. By harnessing its natural healing power, we “re-train” the brain through mindfulness meditation.  Meditation practices are shown to smooth the brain patterns of those with chronic pain.  Over time, this reduction becomes hard-wired, resulting in less experienced pain.  Clinical trials have shown a pain reduction of 57 percent by those who practice; very skilled meditators can reduce pain around 90 percent.

I am profoundly amazed at the capacity our brains have for learning and adapting to pain.  The results I see in my own practice are gratifying for me and life-changing for my patients.

RobinsonDr. Robinson is a Board certified medical psychologist.  He joined Orthopaedic & Spine Center in August 2015.  Dr. Robinson received his Doctor of Psychology from the Forest Institute of Professional Psychology.


Strategies to Maintain a Small, Independent Practice

Are they real? And do they work?

By Christopher L. Graff, JD, CPA


StrategySmaller independent practices, consisting of only a few physicians, are increasingly rare.   In today’s healthcare environment, sub-specialist physicians who have no or limited hospital duties tend to be more successful in maintaining their independence, e.g., ophthalmologists and dermatologists, as they are able to see large numbers of patients.  Unfortunately, many other practices, particularly primary care practices like family medicine and internal medicine, often have more difficulty seeing the number of patients necessary to succeed in private practice.  To achieve median compensation for their sub-specialties, primary care providers typically have to see 25 or more patients a day, which was difficult even before the advent of the ACA EHR requirements.  Many small to mid-size practices have accumulated so much debt associated with meeting these requirements that the only way they have been able to survive was to become part of a larger group or to add a concierge component to their practices.

Although the integration of the hospitalist model into many hospital systems has taken some pressure off smaller practices because their doctors no longer have to round in the hospitals, this model can cut both ways.   Many physicians, especially those who have grown up participating in a call rotation, find it difficult to back away from the hospital environment.  They tend to lose a lot of collegiality with other physicians; they feel stuck in the office; and they are often dissatisfied having to deal with the pressure of getting their numbers up.

More often than not, though, private practices tend to find it more profitable not to be in the hospital.  The physicians who make that choice often end up spending more time with their families, developing their hobbies, and getting more sleep (see our cover story for the importance of that!).  They also tend to make as much, or more, money – I have yet to have any clients who left the hospital and did not end up doing better on their own from a financial standpoint.

However, leaving the hospital is still a big adjustment.  Physicians will generally have to see more patients, and if that option is not palatable to them, non-physician providers can contribute to a successful outpatient practice.   If physician owners can comfortably add non-physician providers (“NPPs”) without believing that they need to micromanage them, NPPs can bring in additional revenue and allow the physician owners to either maintain their existing practice at their traditional pace and/or allow the physician owners to become even more efficient with their practice as a whole.

To survive in today’s environment, physicians need to be creative and learn to rely on others to maintain and to grow their practices.  Although selling out to a larger group or to a hospital system seems like an easy way out from a financial perspective, the lack of control over a physician’s practice can prove to be a greater cost to the more entrepreneurial-minded physician than the financial security generally associated with these larger, more corporate-minded healthcare systems.

GraffChristopher L. Graff, JD, CPA  has worked for The Medical Management Consulting Group, Inc. since 1994, received his bachelor’s degree from the College of William and Mary in 1991, received his law degree from Widener University School of Law in 1994, is licensed in VA and PA, and became a CPA in 2000.


Companion Diagnostics and Colorectal Cancer

By Michael Schwartz, MD


The goal of personalizing cancer treatments by targeting molecular alterations in tumors has seen rapid advances in the past 20 years. Knowledge of the mechanisms associated with cancer initiation and progression has recently improved with the increasing use of molecular techniques, enabling identification of alterations in cancer cells and subsequent development of therapeutic agents targeting these alterations. Central to the drive for personalized medicine is the need to develop specific diagnostic tests that facilitate identification of patients who are most likely to respond to a given treatment.  Such tests have been referred to as “companion diagnostics” (CDx), and can play an essential role in outcome prediction as well as therapy monitoring.


Immunohistochemical staining patterns of MSI tumout. (A) H&E of tumor. (B) Strong positive internal control of normal glandular epithelium. (C) Negative staining for MLH1. We emphasise the importance of a positive internal control (stromal cells and lymphocytes). (D) Positive immunohistochemical staining for MSH2 with nuclear staining in both tumput and stromal cells.

The lifetime risk for colorectal carcinoma (CRC) is about five percent in developed countries.  New molecular testing guidelines are currently being developed. Per the draft guideline, all patients with CRC being considered for treatment with the EGFR inhibitors cetuximab and panitumumab should undergo extended RAS mutational testing to predict their response to the drugs. The draft guideline calls for extended mutational analysis that includes KRAS and NRAS codons 12 and 13 of exon 2, codons 59 and 61 of exon 3, and codons 117 and 146 of exon 4. Studies have shown that patients who had mutations in KRAS exons 2, 3 and 4 and in NRAS exon 2 and 3 do not benefit from anti-EGFR therapy and could suffer from those agents. The guidelines are expected to recommend BRAF V600 mutation analysis in conjunction with deficient DNA mismatch repair/microsatellite instability (dMMR/MSI) testing for patients with metastatic colorectal carcinoma, and dMMR/MSI testing in all patients for prognostic stratification and identification of Lynch syndrome.  The final guideline should be published in the near future.

For CRCs, TNM stage remains the best predictor of survival after resection and the key determinant of patient management. Nevertheless, stage-independent variability in clinical outcome is sometimes observed and likely due to molecular heterogeneity. This is particularly important in early stage CRC where patients can be potentially cured by surgery alone, and only a proportion derive benefit from adjuvant chemotherapy. For these patients, identification of prognostic molecular markers to supplement conventional staging can change management and outcomes. For example, CRCs with dMMR and MSI have a better stage-adjusted survival compared to proficient MMR or microsatellite stable tumors. In addition, most studies indicate that patients with stage II dMMR CRCs do not benefit from 5FU based chemotherapy and can be treated by surgery alone.

A recent article (N Engl J Med 2016;374:211-222) identified a subgroup of patients with stage II colon cancer who appeared to benefit from adjuvant chemotherapy. In this study, those whose CRC lacked nuclear expression of CDX2 (a master regulator of intestinal development) by immunohistochemistry were associated with a lower rate of five-year disease-free survival than CDX2 positive tumors. Furthermore, the rate of five-year disease-free survival was higher among patients with stage II CDX2-negative tumors who were treated with adjuvant chemotherapy than among patients who were not treated with adjuvant chemotherapy.

Companion diagnostics are continuing to evolve in CRC, where they are becoming an essential tool for selecting the most appropriate personalized therapeutic treatment.

SchwartzCont_2015Dr. Schwartz attended medical school at SUNY Upstate Medical University in Syracuse, NY and completed his residency in combined Anatomic and Clinical Pathology at the University of Pittsburgh Medical Center where he was Chief Resident and later a staff pathologist.  He is a member of Peninsula Pathology Associates and works at Riverside Regional Medical Center in Newport News. ppapathology.com