January 17, 2020

Inpatient Medicine

The role of the hospitalist continues to expand – and so do the challenges
By Bobbie Fisher

In the August 15, 1996 issue of The New England Journal of Medicine, Robert M. Wachter, MD and Lee Goldman, MD wrote an article describing the growth of managed care in the American health care system at that time as “explosive,” leading to “an increased role for general internists and other primary care physicians.”  In their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” Drs. Wachter and Goldman defined the role of these specialists, and coined the name by which they are known today.

These authors were almost prescient in understanding how hospitalists – physicians who practice inpatient medicine exclusively – could assume the care of hospitalized patients, relieving overburdened primary care doctors with less and less time to make hospital rounds; and – by devoting themselves solely to hospital work – how they might function to facilitate the transition to the implementation of the Affordable Care Act.

“Hospitalists were created to respond to a need,” says Lisa Huang, DO, a Board certified internal medicine physician who works with Bayview Physicians Group at Chesapeake Regional Medical Center.  “The traditional internal medicine doctor had to round on patients, then go to the office to see patients, respond to any hospital-based emergency, and return to the hospital to see patients in the evenings.  It put a tremendous strain on the doctor.”

Hardik Vora, MD, MPH, Medical Director of Hospital Medicine at Riverside Regional Medical Center, elaborates:  “When they were working that traditional schedule, going back and forth from the hospital to the office, it was challenging, especially when they had a full clinic schedule and had to respond to ER/hospital calls in the middle of the night.  Physicians were burning out.”

DocPatientSummer2015When Dr. Wachter and Dr. Goldman coined the term ‘hospitalist,’ they envisioned a model where doctors would work exclusively in the hospital, taking some of the burden of the primary care physician.  The goal of the model, says Peter Paik, MD, Medical Director of the Hospitalist Group at Bon Secours’ Maryview Medical Center in Portsmouth, was “to provide more continuity of care, so that physicians who are in the outpatient setting could focus on that, rather than having to run back and forth to the hospital.  Hospitalists can focus on the patient from the moment he or she is admitted.”

Such focused care has greatly benefited acutely ill patients, who need access to their doctors 24 hours a day, says Colin Findlay, MD, Chief of Hospital Medicine at Sentara Medical Group: “These patients are generally sicker, and as hospitals are increasingly dealing with only the most acute phase of care, it becomes more and more important to care for patients as quickly as possible.”

Thus, hospitalists have become an important aspect of any hospital’s safety improvement plan.  “It’s an essential mission of every hospital to minimize the risk to its patients,” Dr. Findlay says.  “Hospitalists focus on things that improve patient safety.”

Hospitalists work at a specific hospital, often affiliated with various primary care practices.  Tamara Jones, MD, is a Board certified internal medicine physician, and a hospitalist who works with the EVMS Internal Medicine Group at Sentara Norfolk General Hospital.  She explains the benefit of the hospitalist to the PCP: “Because we work exclusively at the hospital, we’re available at all times during our working day to meet patients and their families, to order and follow-up labs and other tests, and to respond immediately to problems that might arise, in the moment.  And we can see patients as many times a day as is medically necessary.”

The role of the hospitalist is not to do everything, these physicians caution; rather, the hospitalist needs to be an effective team captain, coordinating the patient’s individual needs and calling for specialists when indicated.  Because all of their cases are inpatients, these physicians have particular expertise in dealing with the myriad issues such patients face.

And because hospitalists work solely in the inpatient setting, they have enhanced knowledge of their hospital’s operating procedures, greater familiarity with hospital staff and a sense of stewardship over the facility’s resources, all of which lead to greater efficiency.  Indeed, studies continue to show that when hospitalists assume inpatient care, hospital stays are shorter and health care expenditures are lowered.

There are benefits for hospitalists, as well – more flexible schedules mean more time to spend with patients, without the worries that come with managing an individual medical office practice.  In an office, when patients are scheduled every 20 minutes, there is always the sense of urgency to get from one patient to the next.  “In the hospital, if I need to spend 90 minutes with a patient or family, I can do it,” Dr. Jones says, but concedes that can sometimes result in 14-hour days.

Fourteen hour days and longer are often par for the course for hospitalists, because they know the relationships between them and their patients is absolutely crucial – and they know they must be established and solidified quickly. Building relationships with patients on short notice can be a challenge.  Often when they’re admitted to the hospital, it’s under acute and very stressful situations, Dr. Huang notes, “so we have to create that bond so patients can trust us to take care of them while they’re there.”

It takes a certain skill to build that trust in a short period of time, and that’s something that can’t always be learned in medical school.  “But the fact is, we’re there in the hospital all day, and we can take more time with each patient,” Dr. Paik says.  “We can sit down and chat with them and with their families, and not necessarily always about medicine or their care.  That allows us to really connect with patients.”

Equally important as building a relationship with a patient is establishing a good working relationship with the patient’s primary care physician.  Each hospital has its own protocol for communicating with its patients’ PCPs, but these hospitalists emphasize that this is a vital element of successful treatment and transition.  If a patient’s stay is lengthy and complex, the hospitalist will generally call the primary care physician more often, sometimes even daily, to confer.  If the stay is less complicated and the patient’s course uneventful, the hospitalist will forward dictated notes regarding the hospitalization at the time of discharge.

The role of the hospitalist doesn’t end there, however.  “We take responsibility for ensuring our patients transition home safely and effectively,” Dr. Findlay confirms.  “All patients need intensive coordination of care between their hospital stay and their resources at home.”  If patients don’t have a primary care physician, Dr. Paik says, “we find them one – even if they don’t have insurance.”

There are some hospital programs that have started post-discharge clinics, Dr. Vora notes.  “These are especially appropriate for patients who don’t have a primary care physician or can’t get an appointment with their PCP right away,” he says.  “In the current health environment, they can have to wait as much as two months or more.  So we will often give these patients our contact information so they can call us if they have questions.  We are definitely there to help them through that phase.”

The American Board of Physician Specialists (ABPS) was the first physician certification body to recognize the emerging importance of hospitalist certification.  In 2009, the ABPS developed the nation’s first board certification for hospital medicine, the American Board of Hospital Medicine (ABHM). Not merely a subspecialty of internal medicine, hospitalist certification through ABHM carries all the standing and prestige of a distinct and vital medical specialty.

The American Board of Internal Medicine (ABIM), recognizing the multi-faceted value of these specialists and the growing number of physicians who were concentrating their practice on inpatient medicine, developed a certification program called “A Focused Practice in Hospital Medicine” to accompany Board-certification in internal medicine.  In addition to meeting the criteria to be Board certified in Internal Medicine, a physician is required to earn additional credits in Practice Improvement Modules and then sit for a separate test in hospital medicine.  EVMS’ Dr. Tamara Jones will sit for the exam in October, and will become the first hospitalist in Hampton Roads to earn the certification.

The American Board of Family Medicine (ABFM), in conjunction with the American Board of Internal Medicine, has similarly established a Recognition of Focused Practice in Hospital Medicine program, in response to the growing number of ABFM-certified family physicians who are primarily caring for patients in a hospital setting.

“About 80 percent of practicing hospitalists are internal medicine physicians,” Dr. Vora notes, “while 10 to 15 percent are family physicians and about five percent are pediatricians.”  However, he notes, there are increasing numbers of surgeons, orthopaedists, OB/GYN physicians and others who are going into hospital medicine.  There’s even a word for surgeons, Dr. Jones says.  “They’re called surgicalists.”



Treating patients like family

Atlantic OB-GYN
Delivers advanced care in a warm setting
By Alison Johnson

(L-R) Craig Ruetzel, MD, Melissa Waddell, WHNP, Kaitlin Cafferky, WHNP, Timothy Hardy, MD

(L-R) Craig Ruetzel, MD, Melissa Waddell, WHNP, Kaitlin Cafferky, WHNP, Timothy Hardy, MD

From routine pelvic exams to advanced robotic-assisted hysterectomies and fibroid removals, the team at Atlantic OB-GYN keeps two words in mind: expertise and compassion.

Practice founder Timothy Hardy, MD, F.A.C.O.G., and his partner Craig Ruetzel, MD, F.A.C.O.G., along with Melissa Waddell, Women’s Health Nurse Practitioner, are dedicated to delivering warm, comprehensive, cost-effective and results-oriented care that recognizes women’s busy lives.

“We never want our patients to come in here and feel small,” Dr. Hardy says. “Each one of them deserves to feel well-cared for and well-informed, whether it’s getting them into an appointment on time or allowing them to recover quickly from what used to be invasive and risky surgeries.”

With offices in Chesapeake and Virginia Beach, Atlantic OB-GYN offers complete gynecological and obstetrical care along with inpatient and outpatient surgeries and treatments for infertility, endometriosis, female infections and sexual dysfunction.

Dr. Hardy, who founded the practice in 1990, is a leader in the region for robotic surgery. The medical team also is skilled in the field of urogynecology, which covers common pelvic floor disorders such as urinary or fecal incontinence, abnormal vaginal bleeding and prolapsed organs.

Available in-office procedures include bone density scans, breast biopsy with ultrasound guidance and insertion of intrauterine devices or vaginal contraception rings. Atlantic OB-GYN offers a full range of infertility services including evaluation and treatment including surgery. Tuboplasty, which is a surgery to repair damaged fallopian tubes, and tubal reanastomosis or tubal reversal surgery are a few of the surgical interventions that can help an infertile woman achieve pregnancy. Dr. Hardy has had up to an 80% success rate with tubal reversals. Atlantic OB-GYN also prescribes regular and emergency birth control pills.

Timothy Hardy, M.D., F.A.C.O.G.

Timothy Hardy, M.D., F.A.C.O.G.

The Benefits of Robotic Surgery
The use of computer-guided instruments has helped transform two common operations for women, hysterectomy and myomectomy, or removal of uterine fibroids that cause pain, bleeding and possible infertility. Atlantic OB-GYN began offering robotic surgery options to their patients six years ago when the technology first came to the Hampton Roads area. Dr. Hardy has completed several training courses with the da Vinci surgical system including most recently the advance course. In fact Dr. Hardy was the first gynecologist in Virginia to operate on the da Vinci XI robotic system, which was recently acquired at Chesapeake Regional Medical Center.

Removing the uterus and cervix once required a major abdominal incision – as big or bigger than the one made during a Caesarian section – and six to eight weeks of recovery. With robotic-assisted laparoscopic hysterectomy, surgeons can control a thin, lighted scope and other instruments through four or five tiny incisions, less than an inch apiece. They work from a computer station in the operating room.

The robot’s steady, precise movements and a magnified three-dimensional view allow surgeons to maneuver easily within the abdominal cavity. Women are generally able to resume normal activities within two to three weeks, and there is a lower risk of post-operative pain and infection. For patients who don’t qualify for vaginal hysterectomy, the robot is still an option.

“It is rare for me to do open surgery today,” Dr. Hardy notes. “It has made a tremendous difference for women, especially if they need to get back to their jobs or families as quickly as possible. This once was a surgery that women were thankful just to survive, so things have certainly changed for the better.”

About 75 percent of fibroid surgeries at Atlantic OB-GYN are performed laparoscopically with robotic assistance. Surgeons generally limit open abdominal operations to women with very large fibroids or more than 10 to 15 of the noncancerous growths. The robot allows for multi-layer stitching of the uterus rather than a single-layer closure, lowering the risk of rupture during any subsequent pregnancy. Finally, robotic surgery can help women with extensive endometriosis and pelvic pain.

Compassionate Care
Technology is just one side of the practice, however. Since obstetricians guide women through emotional and physical changes of pregnancy and gynecologists handle what many women consider embarrassing health concerns, building trust with patients is crucial.

One example is urinary incontinence, an issue that affects up to 10% of young women and up to 75% of women in nursing homes and especially those who have suffered – often unknowingly – muscle or nerve damage during pregnancy and childbirth. As with fecal incontinence, age, weight gain and smoking also are risk factors. The problem can range from an occasional leakage of urine to a complete loss of bladder control, leading to emotional distress, embarrassment and skin irritation with pain, itching and potentially sores.

“Often, women are told that this is just part of getting old and there’s nothing they can do,” Dr. Hardy says. “That’s just not true. We can help patients who have urinary and fecal incontinence.”

The range of potential therapies includes dietary changes, exercises to restore muscle strength, an implanted device that stimulates the sacral nerves and surgery to restore proper position of the bladder. “What women need to know is these are treatable conditions,” Dr. Hardy says. “They don’t need to suffer in silence for years and years.”

Atlantic OB-GYN works hard to create a friendly atmosphere throughout a patient’s experience. That starts with having a real person on the line when patients call – not a recorded message – and a kind and respectful office staff.

“We stay on time whenever possible, because we know long waits are stressful for patients,” Dr. Hardy says. The practice also offers evening hours once a week for patients who can’t take time off work, he adds: “We always want to mindful of their time.”

An Experienced Team
Atlantic OB-GYN’s team is highly trained in their specialties. Dr. Hardy completed a residency in the Obstetrics and Gynecology Department of Providence Hospital, an affiliate of Georgetown Medical Center, and holds a bachelor’s degree from the University of Virginia and a medical degree from Eastern Virginia Medical School. He also completed an internship at Jersey Medical Center in Jersey City, NJ.

Dr. Ruetzel has practiced in Hampton Roads since 1992 and partnered with Dr. Hardy about two years ago. He earned a bachelor’s degree at Duke University and a medical degree at the University of Texas Health Science, followed by a residency at Wake Forest University Baptist Medical Center.

Melissa Waddell, WHNP is a women’s health nurse practitioner who has been with Atlantic OB-GYN for more than a decade. Ms. Waddell holds several degrees: a bachelor’s in biology from Virginia Tech, a certificate in Microbiology/Immunology from Virginia Commonwealth University and bachelor and master degrees in nursing from VCU. Before joining Atlantic OB-GYN, she worked as a registered nurse in the mother/infant unit at VCU Health Systems and served as a clinical instructor-adjunct faculty member in VCU’s School of Nursing.

While Dr. Hardy hopes to grow Atlantic OB-GYN’s services, particularly in urogynecology, he also plans to keep the practice small. “The personal touch,” he says, “is extremely important to us.”

3720 Holland Rd., Suite 101,Virginia Beach, VA 23452
Phone: 757-463-1234 • Fax: 757-340-0717

680 C-Kingsborough Sq., Chesapeake, VA 23320
Phone: 757-548-0044 • Fax: 757-547-0179




Riverside Urology Specialists:


….by any name, Riverside Urology Specialists is the premier provider of urologic care on the Virginia peninsula

Nearly nine decades ago, in roughly 1929 – so long ago that no one remembers the exact date for sure – a medical practice known as Hampton Roads Urology was established on the Virginia peninsula.  The physicians who founded the practice were too busy offering long-needed medical and surgical care to their patients to note the day and time for posterity.

Using the lithotriptor, Dr. Shultz prepares to remove a kidney stone.

Using the lithotriptor, Dr. Shultz prepares to remove a kidney stone.

Today, the inheritors of that practice are continuing the tradition of excellence that earned Hampton Roads Urology a reputation for providing the highest and most innovative urologic care available.  They do so under a different banner:  eight years ago, when the practice affiliated with Riverside Medical Group, they proudly changed the name to Riverside Urology Specialists – although they acknowledge that some patients still occasionally use the old name.

By any name, Riverside Urology Specialists is the largest urologic practice on the peninsula, with offices in Newport News, Williamsburg and Gloucester, treating patients who present with nearly every condition or disease that can affect the very complex human urinary tract system and reproductive organs.  Their patients include both men and women, and range in age from the early teens on up to the elderly.

©[2009] Intuitive Surgical, Inc.

©[2009] Intuitive Surgical, Inc.

The ‘specialist’ designation is particularly apt for this group: while each physician is thoroughly trained in every aspect of urology, each has specific interests and areas of expertise within the many urologic presentations. They consider it one of the strengths of their practice, and routinely refer patients to a partner when appropriate.  They frequently collaborate on complex cases in order to ensure their patients receive the best, most comprehensive care.

Kidney Stones.
Kidney stones are one of the most common disorders of the urinary tract, and research indicates that their

Dr. Burgess performs surgical robotic oncology using the da Vinci robot.

Dr. Burgess performs surgical robotic oncology using the da Vinci robot.

incidence is rising, particularly among women.  “Southeastern Virginia is often referred to as ‘the stone belt,’” says Dr. Henry Prillaman.  “There are a variety of factors that contribute to that, one being our climate.  Particularly at this time of year, dehydration can cause the urine to become more concentrated, which creates the environment for stones to develop.”

There are medications that can alleviate the discomfort of stones, but for patients who require surgery, Riverside Urology Specialists has a comprehensive program that includes all of the current minimally invasive procedures.   One is the lithotriptor, which pulverizes the stones by passing shock waves through a water-filled tube, with the patient lying on a table.  This causes the stones to fragment into pieces small enough to expel in the urine.  For larger, more complex stones, the urologists can go directly into the kidney through the skin and remove stones percutaneously.   Each patient is assessed and the treatment plan individualized based on the size and location of the stone(s).


Dr. Marks discusses the treatment of urinary incontinence with a patient.

“The best thing about stone care today is that over time, it’s become much less invasive,” Dr. Prillaman says.  “Stone disease is miserable for the patient, but with these techniques, people are bouncing back quicker than ever.”

Care for stone disease doesn’t end when the stones are gone: the next step is teaching patients how to keep them from returning.  “There are four tenets of stone prevention for calcium stones,” Dr. Roger Schultz explains: “Drink more water, eliminate salt, avoid foods rich in oxalate and add lemons to the diet.”

For some patients, even adhering to those tenets isn’t enough to keep stones away.  In those cases, Dr. Schultz says, “We’ll do a 24-hour urine collection to see what’s being produced in the urine, to proceed from there.”  They also send the stones to the lab for analysis, says Dr. Karl Pete, “and then we modify treatment based on their composition.  There are several types of stones:  the majority are calcium or oxalate, and the others are uric acid, struvite or cystine stones, those formed as a result of certain medication.”  And, he adds, while stones tend to run in families, they are to a great degree random.”

BPH – benign prostate hypertrophy.
Also known as an enlarged prostate, this condition affects men as they age, and often causes urinary symptoms.  Medications can be effective, but in certain situations, surgery is indicated.  In the past, that meant a hospital stay of one to three days, and the patient required a catheter for several days thereafter.  Recovery time was significant.  “Today, we’re using vaporization techniques on an out-patient basis, which give the same result,” Dr. Steven Marks says, “and at most, patients need a catheter only overnight.  They’re back to work in a day or two.  The procedure is a big hit with men!”

Prostate cancer.
For patients with low-volume, low-stage cancer, the first option is active surveillance, but “We’re not just watching,” Dr. Richard Rento emphasizes.  “We’re doing regular PSA and rectal exams, and when indicated, further biopsies.”


Dr. Rento describes the removal of a kidney stone.

Prior to the 1990s, the only surgical option was an open procedure that required a long hospitalization and painful recovery, including a lengthy period of urinary incontinence and erectile dysfunction.  Laparoscopic radical prostatectomy resulted in less blood loss and pain, shorter hospital stays, lower risk of complications.  But the turning point was the introduction of robotic surgery.  “Robotics allows us even greater precision during the surgery; and from the patient’s standpoint, there’s far less blood loss, less pain, fewer days in the hospital and fewer days with the catheter,” Dr. Rento says.   In fact, the first daVinci robot was brought to the peninsula to treat prostate cancer patients, and two years ago, says Dr. Scott Burgess, Riverside acquired the newest version of the daVinci.

Dr. Rento also performs brachytherapy, the only physician on the peninsula to offer this form of targeted radiation for prostate cancer.  Brachytherapy involves placing seeds of radioactive material inside the prostate, where they remain, emitting radiation for a short time or several months.  These seeds don’t travel beyond their destination, resulting in less damage to surrounding structures.

Kidney cancer.
Dr. Rento and Dr. Burgess perform the practice’s surgical robotic oncology.  In cases of kidney cancer, they are doing a large number of partial nephrectomies, or nephron-sparing procedures, removing the tumor while leaving the kidney intact.  “It’s been shown for the better part of 10 years that you want to save the kidney whenever possible,” Dr. Burgess says.  “Now we know that there are detrimental effects unrelated to kidney function when you remove an entire kidney.”  The criteria includes the size of the tumor, its location in the kidney, and whether it’s on the upper or lower pole.  Because the renal artery is clamped during the procedure, time is of the essence.  The surgeons must complete the entire task within 15 or 20 minutes.

The vast majority of the time when a radical nephrectomy is indicated, it is performed laparoscopically.  “The kidney is about nine to 10 cm. in size, and it’s not uncommon to find tumors that are between 10 and 20 cm. on top of it,” Dr. Rento says.  “In those cases, we take not just the kidney, but several centimeters around that.”

Bladder cancer.
About 85 percent of these cancers are superficial, and can be scraped away.  For the 15 percent whose cancer is already growing within the wall, cystectomies are performed.  Very few patients are candidates for partial cystectomy.  In a radical cystectomy, the bladder and prostate are removed in male patients, and the bladder, uterus and top of the vagina in women.

The majority of bladder cancer in men can be treated through an endoscope, a telescope that goes through the penis into the bladder to resect or remove the cancer.

Urinary reconstruction includes an ileal conduit, or urostomy, through which urine flows into an external bag.  The ureters are sewn to the wall of the conduit, after which a stoma is created through which urine is eliminated.  A different option is continent urinary diversion, which involves creating a new bladder from a piece of bowel, stomach or right colon.  The new bladder is attached inside the body.

Treatment for bladder cancer has few side effects.

For some men, the decision to limit the number of children they father is a welcome and responsible one.  Vasectomy, a quick and simple procedure that can be performed in the urologist’s office in about 15 minutes, Dr. Marks says.  “Recovery is short and easy, and relatively free of long-term side effects.”  In addition, Dr. Pete explains, “Vasectomy is a much safer option for men than tubal ligation is for women.  Vasectomy requires only local anesthesia, whereas women must undergo general anesthesia for sterilization.”

But for many men, being unable to father children creates tremendous angst.  Dr. Schultz spent four years at Naval Medical Center Portsmouth, treating sailors at every stage of their reproductive lives, and acquiring special knowledge in the area of male fertility.  “When couples come in complaining of not being able to conceive – typically after six months of trying – I tell the woman to consult with her gynecologist or fertility expert,” he explains, “and I look at various aspects of the man’s history that might impact fertility, followed by a physical exam and semen analysis.  The most common thing urologists look for is a varicocele, which we can treat surgically or radiologically.  It often resolves the problem, so that sperm quality improves and pregnancy ensures.”

When urologic approaches to infertility have been exhausted, Dr. Schultz and his colleagues will consult with specialists in assisted reproductive techniques.

Reverse vasectomy is rarely requested these days, Dr. Marks says, although the procedure has a fairly good success rate.

Karanvir Virk, MD, is a urogynecologist who collaborates with Riverside Urology Specialists on conditions that affect only the female anatomy, including prolapse, urinary and fecal incontinence, urinary tract infections, hemorrhagia and similar problems.

The most prevalent of these conditions are prolapse and urinary incontinence.  “These are not necessary conditions of older women,” Dr. Virk says.  “These are pathological, and they can be fixed.”

Prolapse is not always symptomatic, and doesn’t require treatment unless and until it interferes with a patient’s quality of life.  When symptoms do appear, the first option is a pessary, a device inserted into the vagina to support the pelvic organs.  Kegel exercises are often prescribed as well.

Reconstructive surgery, which is performed laparoscopically or through an incision, is done to restore the organs to their original positions.  Sexual function is not affected.   In severe cases, obliterative surgery is done to narrow or close the vagina to provide support, after which sexual intercourse is no longer possible.

Urinary incontinence.
Urinary incontinence, or leaking when engaged in even the briefest strenuous activity, is one of the most vexing conditions a woman can suffer, but it can be successfully treated by any of the urologists.  The most common treatment is the installation of a transobturator midurethral sling, a device that acts as scaffolding, or a shock absorber, that essentially closes the urethra so urine cannot leak.

Expanding urologic care to the people of the Virginia peninsula and beyond.
From its earliest days as the first urologic practice on the peninsula, the group once known as Hampton Roads Urology has grown with both the times and the population it serves – and it continues to grow.   Riverside Urology Specialists will add two additional urologists in August 2015 – Dr. John McGill and Dr. Ostap Dovirak.

With a full complement of urologists, the practice will soon offer evening and Saturday hours to accommodate their working patients, to ensure all patients are seen in a more timely fashion, and that all receive the unparalleled treatment that is the hallmark of Riverside Medical Group physicians.


Please call (757) 873-1374 or visit our website: riversideonline.com/services/urology


Discussing Difficult Truths*

weightsPart Two of a Two-Part Article on Adverse Event Disclosure
By Douglas E. Penner, Esquire

In the article that appeared in the Spring 2015 issue of Hampton Roads Physician, we discussed the importance of disclosure.  Here we address handling the disclosure meeting.

Handling Disclosure – A Step By Step Outline 
Patient safety organizations and risk management are constantly attempting to identify areas of healthcare delivery that present avoidable risk of patient harm.  When safety protocols work as intended, they result in “near misses.”  This is when the error or condition is prevented by an error detection barrier (i.e., “the system worked”).

However, the system does not work every time.   When relatively minor harm occurs, a discussion between patient and physician may be all that is necessary.  However, for more severe errors that result in significant harm or even death, a more formal disclosure process is recommended.

1.Manage the Patient’s Condition
The initial focus should be on the patient’s condition and ensuring that the necessary steps are taken to address the patient’s immediate clinical needs.

2.Contact Your Risk Manager, Practice Manager or Legal Counsel As Soon As Possible
These individuals will provide crucial assistance with careful and objective documentation of any medical facts in the medical record, along with preservation of any evidence, if applicable.  In this immediate window after discovery of the harm, an explanation of how or why the event occurred should be deferred until an investigation is completed.

3.Prepare for the Disclosure Meeting
Convene a disclosure team to assist your preparation for the disclosure meeting.  As a team, decide when and where the meeting will take place, and who will attend.   Identify who will lead the discussion and review what will be discussed, avoiding any speculation.  Assess whether the event was a procedural risk or medical error.  Identify a liaison for continued communication with the patient or family.

4.The Disclosure Meeting
The designated individuals, usually two people, will initiate the disclosure discussion with the patient and/or patient representative.   The physician providing care to the patient usually should lead the discussion, but this may not be the case in every situation.  Aim for the meeting to occur within 24 hours of discovering the adverse event.

Express empathy and acknowledge the patient’s/family’s expressed feelings. Consistently communicate what is known or requires follow-up. Ensure patient/family will be kept informed, which means providing appropriate contact names and numbers.  Clarify if the adverse event is an inherent risk of the procedure, rather than an error.  Discuss future known consequences of the injury without speculating about all possible long-term consequences.

After the Disclosure Meeting
A request for a copy of the medical records frequently occurs.  The patient/legal representative is entitled to a copy through the routine request process.

A record should be created of clinical facts relevant to the event discussed with the patient/patient representative.  At a minimum, the documentation in the patient record should include the time, date and place of the discussion, purpose of the conversation and what was discussed (including questions posed and answers), assistance offered, and response to the conversation.  Remember that in Virginia, oral statements made during a disclosure meeting and written documents related to disclosure are not protected from discovery in any legal proceeding.

Organizations should develop clear policies supporting disclosure and enable clinicians to meet their ethical obligations to relate adverse events to patients and families.

*This article is intended as risk management advice.  It does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about topics covered in this article should be directed to an attorney.

PennerDouglas Penner is an attorney with the law firm of Goodman Allen & Filetti, PLLC.  Mr. Penner specializes in hospital risk management, medical malpractice defense, health care law, and State Board licensing and credentialing matters.  For more information, goodmanallen.com.


Non-surgical interventions for pain relief

BlueBackSummer2015By Richard D. Guinand, DO

When many people hear the words ‘disc’ or ‘disc herniation’, they immediately think they’re destined for surgery and a painful recovery.  That might have once been the case, but today, it no longer is.

It’s true that when a patient presents with neck or back pain, disc herniation is a potential diagnosis.  And it’s also true that surgery is one of the options.  But it’s not the only option, and it’s not the first, second or even the third modality available to these patients.  Before any treatment, including surgery, is considered, it’s important to determine the etiology of the patient’s pain.

Once a diagnosis of disc herniation (which some patients refer to as a pinched nerve or a bulging disc) is confirmed, there are four potential treatment modalities.  For these patients, the goal is always to get the pressure off the nerve root.  The first option is physical therapy.  Many times, the physical therapist can get the nerve root free and then the pain goes away.  The therapist will then work on strengthening the small muscle that attaches to the spine to give it stability, so the pain is less likely to come back.  A second option is manipulation by a chiropractor or an osteopathic physician.  These two options will usually be successful in 85 percent of patients.

If the nerve root cannot be freed by PT or manipulation, the patient is a candidate for injection, generally an epidural steroid injection to decrease the swelling and inflammation around the nerve root.  An MRI is ordered to confirm whether any other underlying spinal pathology is causing the patient’s pain.  Whether due to disc or arthritic pathology (or as is often the case in older patients, a combination of both), when injections are added to treatment, the success rate rises to 95 percent.

In some cases, a second or third injection may be indicated to attain relief.  Only about five percent of patients will fail all three modalities – physical therapy, manipulation and injections.  It’s at this point that it’s appropriate to talk to the patient about surgery.  Some will decline, opting instead to seek help from a pain management physician, who can prescribe and monitor pain medications.

But for those patients who do choose surgery, it’s important that they are confident that they and their medical team have exhausted every other potential modality.  When patients are comfortable that they have tried every nonsurgical method to eliminate or reduce their pain, they are less apprehensive and more confident facing surgical intervention – and they have a much greater chance for a better outcome.

RichardSummer2015Richard Guinand, DO is a Board certified family practice physician specializing in nonsurgical spine care at Sports Medicine and Orthopaedic Center, offering initial diagnosis and treatment of general orthopaedic injuries, acute and chronic back pain, worker’s compensation injuries, and nonsurgical management of spine pathology.

Women’s Health:

Incontinence and Physical Therapy
By Brittany Deuso, PT, DPT

Even if patients are hesitant to talk about it, the statistics tell the story.

Incont01Summer2015Incontinence – leakages related to either the bladder or the bowel – afflicts more than 13 million people in the United States annually. For those over the age of 65, incontinence occurs in 51 percent of the population – more often in women, according to the Centers for Disease Control and Prevention.

Incontinence is not inevitable with age, however, and is a treatable and often curable condition – especially when physical therapy is used as a treatment tool.

Physical therapy services aim at increasing a patient’s quality of life through self-management and the use of specific strategies to reduce symptoms and improve function.

Incontinence Risk Factors
For the aging, incontinence is associated with a number of factors, including chronic conditions, such as diabetes and stroke, cognitive impairment and mobility impairment. Bladder incontinence can also be influenced by age-related changes in the lower urinary tract, urinary tract infection and other health-related conditions to include mobility impairment.

Incont2Summer2015Risk factors for bowel incontinence include chronic diarrhea, inadequate fiber and water intake and chronic constipation. Health factors include diabetes, stroke, neurologic and psychiatric conditions, cognitive impairment and mobility impairment.

In addition to the financial burden, people suffering from incontinence may carry an emotional burden of shame and embarrassment that adds to the physical discomfort and disruption of their lives.

Treating Incontinence
People with incontinence suffer most commonly from stress incontinence or urge incontinence.

Stress incontinence stems from the increased abdominal pressure and weak muscles, resulting in the accidental release of urine.  This happens, for example, when people laugh, cough, sneeze or jog.

Urge incontinence occurs when people must get to the bathroom right away from an immediate urge that there is no stopping.

But because people feel discomfort in talking about incontinence issues, this can lead to feelings of shame, isolation and depression. As a result, many people fail to seek treatment, either by a family doctor or physical therapist who specializes in women’s health.

The Role of Physical Therapy
Physical therapy helps incontinence patients gain control of their symptoms, reducing the need for pads, special undergarments and medications.

In a private treatment room of the clinic, patients have their pelvic floor muscles evaluated. Treatment includes heat to relax the muscles, exercise to strengthen the muscles, biofeedback, and manual therapy if indicated.

On the first day of therapy, the therapist spends 20 to 25 minutes simply educating patients on what exactly the condition entails, how to “find” and strengthen the right muscles to improve their quality of life and get back in control of their urges.

BritannySummer2015Brittany Deuso, PT, DPT is accepting new patients at the Tidewater Physical Therapy Great Bridge Clinic in Chesapeake, VA. She provides comprehensive physical therapy treatment services and specializes in treating patients suffering from incontinence and pelvic floor pain.  Deuso holds a Direct Access Certification. Find a clinic near you for your patients and learn more at www.tpti.com.

Hospital Medicine and Retina Vascular Disease

EyballBy Alan L. Wagner, MD

You may wonder, what do Hampton Roads Physician’s article on hospital medicine and my specialty of retina vascular disease research and ocular oncology have to do with one another? As it turns out – a lot!

Twenty four percent of adult patients with known diabetes say that they had been hospitalized in the preceding year. The risk of hospitalization increases with age, how long the patient has had diabetes, and the nature and extent of any other sequelae of the disease. A patient with diabetes is three times more likely to be hospitalized than those who don’t have diabetes. If we look at all the people admitted to the hospital, 12 percent didn’t realize that they had diabetes, or unusually high blood sugars. These are the very patients who are at risk for blindness without warning from diabetes – and one of the reasons the job of the hospitalist is so vital.

EyeSummer2015Hospitalists see their patients more than once during the day, and may have more opportunity to observe the warning signs of diabetic eye disease – which remains the leading cause of blindness and disability in adults in the first world. However, in the outpatient setting, the silent and progressive damage to the retinal vasculature that is preventable can go unnoticed.

The root cause of much of this physiologic mayhem comes from above normal blood sugars. Not “high” blood sugars, just above normal blood sugars! However, it’s really not the elevated blood sugar itself that does the damage. Higher than normal blood sugars cause the immune system to become abnormally and broadly activated, leading to inflammatory changes in the vascular endothelium. As inflammation increases, the endothelium of the eyes, brain, heart, nerves, and kidneys become targets, leading to thrombosis. For similar reasons, platelets become far more active and sticky, compounding the problem. In addition, the elevated blood sugars cause increases in multiple inflammatory pathway associated proteins/markers (interleukins, tumor necrosis factors, growth hormones, advanced glycated End products, etc.). We see the same sort of proteins and damage in patients with arthritis. However, this time it’s the blood vessels that are targeted for destruction.

Hospitalists and their teams can serve as a tremendous educational resource for patients and their families by explaining to them that it doesn’t take very high blood sugars to cause these changes that can lead to blindness. The landmark Diabetes Control and Complications Trial revealed that patients with normal blood sugars were able to reduce their risk of complications from diabetes by almost 50 percent. This is in line with what we already know about reducing the risk of diabetes associated coronary disease, renal disease, neuropathy, and strokes.  In other words, we can show the patients and their families that there really is a big pay-off if they control their diabetes.

Hospitalists do so much good for patients while they’re in the hospital. I encourage our ambulatory care colleagues to also be proactive, by reminding their patients of the critical need to normalize blood sugars, get regular eye examinations, and seek consultation with an eye specialist – particularly if they have or show signs of developing diabetes.  As a memory tool, feel free to use our practice’s take-home message for all of our at-risk patients: “Save your sight by feeding your eyes normal blood at a normal pressure!”

WagnerAlan L. Wagner, MD, FACS founded the Wagner Macula & Retina Center in 1987. He completed medical school at Vanderbilt University School of Medicine, residency at EVMS and a fellowship at Weill Cornell University Medical Center. wagnerretina.com

What is Regenerative Medicine?

By Raj N. Sureja, MD and Mark W. McFarland, DO

RegenSummer2015Far too often, we see patients with conditions for which we have limited treatment options, in both scope and efficacy. Once in a lifetime, real scientific advances are made that change everything for the patient and the physician.   Regenerative Medicine is a real game-changer, in that it potentially allows physicians to heal patients in ways only once imagined.

Due to advancements in immunology, cellular biology, molecular engineering and refinements in existing technologies, science is discovering the previously inaccessible reformative power of the patient’s own cells to rebuild damaged or diseased organs, tissue, or bone.  Diseases like heart disease, diabetes, and arthritis may one day be completely cured, instead of controlled.

You are familiar with the donation of organs for transplantation into ill patients for the purpose of saving their lives.  Perhaps you have used autologously donated bone marrow for the treatment of leukemia and other types of cancers. These types of procedures were the genesis of today’s Regenerative Medicine.

In the early days of stem cell research, the cells were collected from aborted human embryos, with all the attending ethical and moral issues.  Today, stem cells are donated by patients from their own bone marrow.  Alternatively, amniotic stem cells are collected from placentas of babies born by C-section in accredited hospital collection centers.  Parents consent to this before fetal delivery, and are paid for the amniotic fluid, which is then sterilized and frozen for later use.

Regenerative Medicine is divided into several subspecialties: Rejuvenation, Regeneration and Replacement.

Rejuvenation involves using the body’s cells to heal itself.  Just as the skin can repair itself, so can more complex tissues, like the heart and lungs.

Regeneration requires the delivery of cells or cell products, by injection, to certain areas of the body, to stimulate healing of diseased or damaged tissues or organs.   Stem cell or platelet-rich plasma (PRP) are used to heal musculoskeletal conditions, such as arthritic joints, damaged cartilage, partially torn ligaments and tendons, bursitis, and degenerative discs in the lower back.

Replacement involves replacing damaged or diseased organs with healthy cells, tissues or organs from living or deceased donors.  This includes being able to grow healthy organs in a laboratory for implantation into the patient’s own cells, effectively ending organ shortages, the issue of organ rejection and the challenge of patient immunosuppression.

Regenerative Medicine uses autologous or amniotic stem cells, which can develop into many types of cells through a process called differentiation. Autologous stem cells cannot be rejected, and some studies show that one out of every three people could benefit from treatment with Regenerative Medicine.  As so many people in the United States are afflicted with arthritis and other musculoskeletal problems, such as back pain, rotator cuff tears, meniscal tears, etc., stem cell therapy is an excellent non-surgical therapy for patients who cannot have surgery or who choose not to.

RegenAuthorJuly2015Raj N. Sureja, MD (L) is a fellowship-trained, Board certified Interventional Pain Management Specialist.  Mark W. Mcfarland, DO (R) is a fellowship-trained, Board certified Orthopaedic Spine Specialist. Both were named a “Hampton Roads Top Doc for 2015” by Coastal Virginia Magazine and practice at Orthopaedic & Spine Center in Newport News, VA.

CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10

CMSBannerSummer2015With less than three months remaining until the nation switches from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are announcing efforts to continue to help physicians get ready ahead of the October 1 deadline. In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.

Recognizing that health care providers need help with the transition, CMS and AMA are working to make sure physicians and other providers are ready ahead of the transition to ICD-10 that will happen on October 1. Reaching out to health care providers all across the country, CMS and AMA will in parallel be educating providers through webinars, on-site training, educational articles and national provider calls to help physicians and other health care providers learn about the updated codes and prepare for the transition.

“As we work to modernize our nation’s health care infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” said Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services. “With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.”

“ICD 10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD. “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating today can help to mitigate potential problems. We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”

The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions and procedures. The medical codes America uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms.

The use of ICD-10 should advance public health research and emergency response through detection of disease outbreaks and adverse drug events, as well as support innovative payment models that drive quality of care.

CMS’ free help includes the “Road to 10” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation. CMS has also released provider training videos that offer helpful ICD-10 implementation tips.

The AMA also has a broad range of materials available to help physicians prepare for the October 1 deadline. To learn more and stay apprised on developments, visit AMA Wire.

CMS also detailed its operating plans for the ICD-10 implementation. Upcoming milestones include:

• Setting up an ICD-10 communications and coordination center, learning from best practices of other large technology implementations that will be in place to identify and resolve issues arising from the ICD-10 transition.

• Sending a letter in July to all Medicare fee-for-service providers encouraging ICD-10 readiness and notifying them of these flexibilities.

• Completing the final window of Medicare end-to-end testing for providers this July.

• Offering ongoing Medicare acknowledgement testing for providers through September 30th.

• Providing additional in-person training through the “Road to 10” for small physician practices.

• Hosting an MLN Connects National Provider Call on August 27th.

CMSCalloutSummer2015In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.

Also, at the request of the AMA, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.

Emily Lieb, MD

Medical Director, Bon Secours Care-A-Van

Good Deeds 
Honoring physicians who are doing community service locally or outside the state or nation.

EmilySummer2015The statistics are unsettling:  according to a June 2015 report posted on Virginia.gov, nearly a million Virginians still lack health insurance.  In Hampton Roads, almost 15 percent of all residents under the age of 65 are among the uninsured – a population of 240,000.  Many of these are children, and many are overweight or obese adults.  Without insurance, vaperforms.virginia.gov states, citizens often are unable to pay for the medical care they need and frequently forego preventive measures that would make that care unnecessary.

In four cities throughout Hampton Roads, one Bon Secours physician is leading a program that reaches out to these citizens, providing medical care and treatment to those unable to pay for it.  Emily Lieb, MD, a Board certified family medicine physician, is Medical Director of the Bon Secours Care-A-Van, overseeing a staff of physicians, a nurse practitioner, a registered nurse and patient navigator, a licensed practical nurse and Spanish speaking interpreter, and others.  The Care-A-Van is a mobile health care clinic that collaborates with community partners, including free clinics, local health agencies, and numerous faith-based community organizations, to provide free medical services to those in need.

Dr. Lieb, a graduate of the University of Virginia School of Medicine, practiced family medicine in Charlottesville, and later worked in urgent care until she and her husband, Dr. David Lieb, an endocrinologist with EVMS, settled in Hampton Roads.  It was after their three children were born that her neighbor, the previous medical director of the Care-A-Van, asked if she’d be interested in taking over.  “We’d known each other at UVA,” Dr. Lieb says, “and we had worked together at a migrant farmers’ camp.  I took a few days to think about it, but I knew it was the right fit for me.”

The Care-A-Van visits locations throughout Newport News, Norfolk, Portsmouth and Suffolk – all cities that house a Bon Secours hospital.  No one is asked to pay, and with few exceptions, no one is turned away (the exceptions: those who have primary care physicians, have Medicaid, or arrive late when the clinic is full).  There is no geographical limitation: patients come from as far away as North Carolina and Western Tidewater to receive care.

These patients have any number of challenges: they are uninsured, they have transportation barriers, they come from unstable living conditions, they have received fragmented care, and they often have very limited health literacy.  Some are students, some are jobless, some are immigrants and some are indigent.  All are in need of medical care, and all lack the resources to pay for it.

“We serve 12 different locations throughout our service area,” Dr. Lieb says, “in an attempt to reach as many as possible. Often we partner with churches, which post our monthly calendar and offer us the use of their meeting rooms to see patients.”   Many patients come to the Van through word of mouth, referral from social services, or upon discharge from jail.

The Care-A-Van provides lab services, EKGs, PAP smears, minor procedures, flu shots, and, as Dr. Lieb says, “Just about anything you’d see your family doctor for, we can do on the Van.”  If a patient’s presentation is beyond the Van’s capabilities, she will arrange for hospital care, even calling an ambulance for transport, if indicated.

While the majority of the patients are seen for management of chronic diseases, Dr. Lieb has diagnosed stroke, patients with cardiac chest pain, even cancer.  There are often twenty or more patients a day, and if there are two providers on the Van, they can see even more.

Last year, Dr. Lieb says, the Care-A-Van treated 4,125 people.  She expects that many or more this year.