February 21, 2020

A Cure to Physician Burnout is Being Placed in Our Hands

By Alan L Wagner MD, FACS, FICS


Photo courtesy of Wagner Fine Art Photography

Somewhere around the time that Neanderthals and Homo Sapiens began to mingle and create communities, the first efforts of healthcare began to form. All the interactions were based on first hand observation. The “cures” were mystical, or if on occasion successful, based on little more than random chance. As rudimentary communal living developed, oral traditions and symbology helped pass on valuable survival and life-saving information.  As recordation improved, society advanced, and it became possible for a body of knowledge to develop, move from one generation to the next, and help members of those groups in need. Great value was placed on the heads of individuals that could remember and recite ancient lessons.  Seeing seemingly unrelated individual events as fitting into patterns, recognizing them together as similar to past experience, and predicting their combined outcome, raised that person to the highly-praised status of Oracle.

 The scientific method and ancient Egyptian and Ayurvedic medicine cultures developed the same way.  Very exact and clearly defined physician observations, along with experience, were required to make the decision of a diagnosis and apply one of the treatments from the historic wisdom tradition.  They, too, were Oracles.

To transmit this body of knowledge, much like religions, great care was taken to protect and make holy this information.  Only a select chosen few from each generation were ”worthy” of such significant societal responsibility.

Only recently has this begun to change in Medicine, and the speed of the change is about to accelerate.   The challenge we all face is that the norms that have protected our community from suboptimal quality of care are being challenged and rewritten by the concomitant evolution in our society’s mores (a rise in pluralism) fueled by jaw-dropping advances in ever more readily-available technology.    Most remarkable of these technologies is prediction and its rapidly decreasing cost.

You may be more familiar with the overarching concept of artificial intelligence, AI, and heard of ”deep learning”, and IBM’s Watson.  Artificial intelligence is all based on prediction. The better you can predict something, the better you can forecast and more accurately decide an appropriate course to take given the information at hand.  A growing pre-existing knowledge base, real-time evaluation and subsequent prediction can take the place of the fabled and highly valuable Oracle.  

Before you throw yourself into a new career with this news, remember that it was up to the ancient leaders to determine what to do with the Oracle’s information. The Kings, Queens, and generals were highly valued for their judgement to make good decisions, and to evaluate whether or not, and how, the Oracle’s predictions were to be employed for the public good.  

As physicians, and more recently non-physicians, we have had the combined role of Oracle and leader, determining the best course to take for our patients and communities.

But what if the role of Oracle changes? What if our frequently performed prediction actions are replaced by ”prediction machines” that are inexpensive and complete these tasks as well as, if not better, than we have performed as a group of humans traditionally?

I believe better prediction, AI, will open wondrous opportunities for improved healthcare delivery and access, reduce suffering, and eventually lead to lower costs to society.  Better information upfront leads to better decisions. For example, as the data becomes more robust and the neural network deep learning matures, the frequency of biopsies should decrease as surety in the predictions increase.   We will quickly abandon the multitude of unnecessary follow-up visits, and bring others in much sooner.  Similarly, the lowering cost of AI allows us to understand the cost of our errors, and see more clearly where near and long-term improvements can be made.  Application of AI strengthens the role of the physicians and team leaders as judgement becomes more valuable.  AI will not be the answer for the rare conditions in the near term.  A seasoned professional’s judgement will remain central for the foreseeable future.

AI combined with ever improving data gathering will bring about fundamental changes in the location and process of healthcare delivery.   Who says you need to go to a doctor’s office, or hospital, to find out how your heart is doing?   For less than $100 you can do that right now with your cell phone and an app. Your smart watch can do about the same thing, if not better.  Need an accurate screen for colon cancer depending upon your family history? Head to the endoscopy suite? Instead, find out through the mail by sending a test sample from home.   Blood pressure testing used to be the province of hospitals, clinics, and doctors’ offices–now you can take it anywhere, anytime.   A cellphone image of a questionable bump on your skin can be interpreted within the day.  Radiological and imaging studies are being read at all times of the day and night all over the world, regardless of where the studies were gained. In a few places, the initial report is being generated by an automated system and checked by expert humans.   Automated autonomous readings are now available for fundus images for diabetic and hypertensive patients, relaying risks of heart disease and blindness. 

Considering these examples, did we howl when the Coulter Counter appeared and made hand counting the peripheral blood smear all but vanish?  The automation of sample evaluation improved the quality of the service delivered, and opened the door to a multitude of healthcare advancements.  Buried in the mists of time resides the resistance that some pathologists had to allow non-physicians to peer through a microscope and report on a blood sample.  

Given what is coming our way, we must consider the true meaning of tasks.  A task is a collection of decisions. Our day-to-day tasks in medicine are a series of decisions requiring interpretation and valuation of multiple predictions.  As prediction generation becomes much less expensive, and can be applied more broadly, more opportunities for decision making will present themselves, and make those making the decisions even more valuable.  We will be able to create new questions to answer more complex problems. ith better prediction and automation, the tasks we have historically performed are newly made simple and will be relegated to others.  Our workflow as doctors and care providers will have to change to respond to, and lead, this earthquake of an evolutionary shift in our relationship to a patient’s individual data and the world’s rapidly gathering intellectual resources.  Our responsibility is to lead, not stifle, innovation.

The buggy whip manufacturers protested the advent of the automobile. Wisconsin banned the sale of margarine.   Marie Curie’s “invention” was deemed dangerous by many.  Major medical advances have always been met with protectionism.  There are corners of our profession that resist online care delivery services, provider consultation, purchase of medications, refractions/eyeglasses/contact lenses, etc. or automation of any of our present tasks. 

Imagine the excitement we would feel if it were 1816 and Rene´ Laennec had just given us the first stethoscope ever made to help our patients.  With AI increasingly available to allow us to shape the future the way we believe is best for our patients, we should have that same feeling of wonder right now.  To make the burnout causing constraints of the mundane and repetitive disappear, I urge you to take these new prediction tools robustly into your hands.  Imagine, create, and bravely build a new paradigm that adds value to our noble profession!

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


Understanding Non-Compete Agreements

By Wythe Michael


We are often asked to draft non-competition and non-solicitation agreements on behalf of physician practice groups. We also review non-competition and non-solicitation agreements on behalf of physicians and other health care providers. Many physicians have a belief that these types of restrictions are invalid or even illegal. However, in Virginia, unlike many other states, physician non-compete and non-solicitation agreements are enforceable if the restrictions are reasonable in scope, necessary to protect an employer’s legitimate business interests and are not against public policy. Below is a short summary of how Virginia treats non-compete and non-solicitation agreements.

Virginia courts typically focus on the following three factors to determine whether a non-compete will be enforced:

What is the duration of the restriction?
Generally a restriction lasting more than 2 years will be deemed unreasonable.  However, it is also possible that a shorter time period will be deemed unreasonable.  

What is the geographic range of the restriction? 
The geographic range must closely match the geographic area where the practice group draws its patients.  For example, a physician group in Chesapeake likely would not be able to restrict its physicians from working in Newport News unless the group could show that a large number of its patients travel from Newport News to Chesapeake.     

What is the scope and extent of the activity being restricted?  
The practice group must have a legitimate business interest in prohibiting the type of activity restricted. If the type of activity restricted is overly broad, the court will not enforce the non-compete.  For example, a cardiology practice group generally would be able to restrict its cardiologists from practicing cardiology but would not be able to prohibit its cardiologists from practicing family medicine for a family practice group.

Typically courts will analyze all three factors at the same time and give equal weight to each factor. Each non-compete agreement will be judged based on its own merits including the type of practice, the physician’s specialty and other underlying facts.

Finally, physician practice groups need to keep in mind that Virginia courts will not modify or change a defective non-compete.  If a court finds that a non-compete is unenforceable, the court will not attempt to modify the language to create a reasonable restriction. Instead, the entire non-compete will be thrown out. Therefore, when drafting non-compete agreements, most Virginia lawyers are conservative in drafting the restrictions. It is much safer to err on the side of a more limited non-compete than be in a position of defending a borderline non-compete that could be completely disallowed.

Wythe Michael, an attorney with Goodman Allen & Donnelly, focuses his practice on the representation of healthcare providers.  Often acting as an outside general counsel, Wythe provides practical solutions to legal issues by working with practice groups and individual practitioners to understand and implement their business strategy. goodmanallen.com

On Fish Oil and Snake Oil

Nicholas W. White, DO


As physicians, we are constantly being bombarded with new guidelines, protocols, and studies that are often thrown out or contradicted in the next publication.  We spend our free time sifting through pseudoscience and statistical witchcraft, pulling out what we can and discarding the fluff.  With drug and supplement companies marketing directly to the consumer, 1-800-EVIL-MED commercials, and of course Dr. Google, patient access to information and misinformation alike has led to concerns about medication safety.  Many are seeking more “natural” remedies not always discussed with their providers. 

Americans spend $30 billion annually on substances not approved by the FDA to diagnose, treat, cure, or prevent any disease.  Labeling and purity standards are not enforced with the same rigor as conventional medications, leaving providers questioning the role of supplements in modern medicine.  Most likely, they do neither harm nor good, with the exception of cost and interaction potential, exposing an interesting concern: if a supplement has little chance of harm but is of questionable benefit, should it be addressed?  

Enter Fish Oil
For over a decade, fish oil has been a staple supplement for patients favoring more “natural” remedies.  The emergence of fish oil as a therapy was a result of studies noting lower incidence of CHD death among Greenland Eskimos, a population known for consuming large amounts of fish.  Subsequent investigation found that fish oils, specifically DHA+EPA, have antithrombotic and antiarrhythmic effects, reduce blood pressure and heart rate, and lower triglycerides.

The safety profile of fish oil supplements is fantastic.  Below 3g/day, 4% report nausea.  At 4g/day or more, 20% reported nausea.  The main complaint is unpleasant, “fishy” burps.  

Outcome data suggests the benefits of fish oil are realized at an intake of 250mg to 500mg EPA+DHA daily, with a steep initial response that plateaus above these levels.  Triglyceride reduction demonstrates a more linear dose-response relationship.  Standard 1g daily doses may contain anywhere from 200mg to 800mg of DHA+EPA, the same amount provided by consumption of 1-2 servings of oily fish per week.  

You read that correctly.  Standard daily fish oil supplements are no more beneficial than a diet incorporating fish in 1 or 2 meals per week.  

As a family medicine physician, I see fish oil on medication lists and in pill boxes of patients with statin-worthy cholesterol profiles and triglyceride levels far below the ever-increasing pancreatitis risk threshold.  Often these patients are unaware that fish oil may not be the cardiovascular panacea as was once thought.  Many will leave their statin at the pharmacy and head for the supplement aisle.  

Addressing supplements is challenging when time is at a premium, but it must be done.  Ask patients to bring in information they find and review it with them.  It will surprise you.  They will appreciate the validation and are more likely to follow safe and effective plans they better understand.  For patients seeking a more “natural” approach, making diet recommendations (eat fish 2x/week) always seems to be a welcomed suggestion.  Try to slip some exercise in there, too.

Nicholas White, DO is a family medicine physician at TPMG Tidewater Family Medicine. www.mytpmg.com

New Techniques and Technologies in Spine Surgery

By Zachary Tan, BSc., MD, FRCSC


In modern spine surgery, one of the greatest technical considerations is to limit the extent of iatrogenic soft tissue trauma. Thankfully, emerging innovations will allow us to minimize muscle disruption and improve intraoperative visualization without increased radiation exposure, likely lessening early and late complications. 

Historically, spine surgery obligates a significant amount of muscle stripping and dissection, in order to reveal pertinent anatomical landmarks in the operating room. While very effective for visualization, such disruption of spinal musculature comes at a high biological cost to patients, putting them at risk for increased pain, postural issues and even late spinal deformity.  

In the past decade, the movement to minimally-invasive procedures has reduced muscle injury in many cases. This demonstrably translates into decreased blood loss, improved post-operative pain and shorter hospital stays. However, the endoscopic tube and sequential dilation process is not innocuous to soft tissues. Furthermore, operating with such a limited field of vision can be challenging and time consuming, especially in the case of unexpected complications. This compromises the surgeon’s adaptability and ultimately may affect patient safety. Surgeons also must rely heavily on X-rays and intraoperative CTs due to limited visualization, which increases radiation exposure to patients.  

Today, the pendulum seems to be swinging toward a promising middle ground: continuing to work to minimize muscle injury yet improving visualization via innovative technologies and limited-open surgical approaches. 

One critical innovation is a novel computer navigation system pioneered at the University of Toronto and just now emerging on the North American market – a technology I’d like to bring to Hampton Roads. In my opinion, Machine-vision Image Guided Surgery (MvIGS) systems is a game-changer because it offers extremely accurate, efficient, real-time navigation with limited open exposure. MvIGS utilizes visible light and intraoperative photography to align with specially protocoled low-dose pre-operative CT scans. This quick, cost-effective technology registers anatomical landmarks and surgical targets and facilitates precise screw sizing and safe placement. 

Meanwhile, I employ the Spinous Process Splitting technique to access the posterior spinal elements without needing to injure the adjacent musculature. Visualization is excellent and overall technical utility is much greater compared to standard tubular surgery. My fixation technique of choice includes Cortical Based Trajectory (CBT) pedicle screws and interbody cages, which in combination also significantly decreases the need for unwanted muscle trauma, joint capsule injury and hardware prominence. Overall, these strategies can be very beneficial in the setting of elderly patients with limited spinal muscular reserve to begin with. 

Despite all being said, traditional spinal exposures still have a role in the setting of treating severe deformities and spinal trauma. Yet as computer navigation systems continue to improve – and as more surgeons embrace such technology in a tech-savvy world – the future of spine surgery looks much less arduous for many of our patients.

Dr. Tan is a spine surgeon who specializes in the management of trauma, oncology, deformity and degenerative diseases. He will join the staff at Hampton Roads Orthopaedics & Sports Medicine in August after completing a Spine Fellowship at the University of Toronto, where he also did a residency in Orthopaedic Surgery. hrosm.com

Patient Navigation, Moving from Breast Cancer to Your Specialty

By Matt Zydron


Once considered exclusive to breast cancer treatment, patient navigation (also called patient advocacy) is making its way into other areas of medical care as a beneficial, rehabilitative praxis.

Patient navigation is not new. It had its beginnings in the 1970s, when a nurse set out to review patient records to identify issues that were delaying treatment and discharge. This research unveiled the challenge of coordinating all of the moving parts needed to navigate a patient through cancer treatment.

Fast forward to the 1990s. Dr. Harold P. Freeman, a surgical oncologist at Harlem Hospital, developed a protocol to eliminate barriers to timely cancer screening, diagnosis, treatment, and support. Data collected over years of leading his programs verified the value of navigation protocol in improving the hospital’s cancer treatment outcomes. The studies found that five-year survival rates for breast cancer patients who were involved in the program saw a significant improvement, increasing from 39% to 70%.

Today we are seeing the lessons learned from these early pioneer “nurse navigators” extend to other medical specialties. Shorter hospital stays, multiple care providers, and growing insurance complexities have made treatment more complicated. As a result, patients are finding it increasingly difficult to manage their own care. Patient navigation is gaining awareness as an emerging profession because it helps patients (and their families) steer the way through the challenges of our fragmented healthcare system. 

Hospitals typically employ nurses to serve as their in-house navigators, but more recently social workers, case managers, physicians, and even trained lay workers are becoming part of the patient navigator pool. There is no single model or standardization of services that must be offered; medical practices are developing custom programs to meet their patients specific needs and improve their outcomes.

One of the rehabilitative fields beginning to implement patient navigation is assisting patients facing limb amputation. Prosthetic practices can offer services: providing pre-amputation education, working closely with the patient’s surgeon and post-operative care team, helping find financial assistance and navigate insurance issues. They can also co-treat with physical and occupational therapists, join patients with peer supporters and extracurricular groups, support family members, and advise on any day-to-day issues that the patient may need assistance with. As with breast cancer advocacy, this walking alongside a patient who is going through a very difficult situation is not only helpful to them, but also results in improved treatment and outcomes.

There is no standardized certification for patient navigation at the present time. The Harold P. Freeman Patient Navigation Institute continues to offer in-house training and certification at their New York facility. Others are joining in providing certification for lay people and professionals who possess a baseline level of healthcare experience. As the field continues to grow, it is expected that a standardization in training and credentialing for patient navigators will follow.

For more information on patient navigation see:
Alliance of Health Care Advocates

National Association of Healthcare Advocacy Consultants

Harold P. Freeman Patient Navigation Institute

Matt Zydron, CPO is certified by the American Orthotic and Prosthetic Association and has been a practicing O&P clinician since 2002.He holds extensive knowledge in high-tech componentry and techniques, equipping him to deliver extraordinary care for high activity individuals and children. www.reachops.com

A Powerful New Non-Opioid Treatment for Chronic Pain

By Victor Tseng, DO


While spinal cord stimulation has been available for decades, rapid technological advances during the past year have opened this non-drug therapy to significantly more patients who suffer from chronic intractable back and leg pain. 

One of the most promising developments is a new system that simultaneously combines two frequencies of internal stimulation – one perceptible to patients and one completely unnoticeable – to provide what often is remarkable long-term pain relief – the Spectra WaveWriterTM Spinal Cord Stimulator System.
In my practice, patients have upward of 80 to 90 percent benefit of pain relief from this combination therapy, compared to 50 to 70 percent benefit with more traditional SCS systems. Many of these patients have undergone multiple back surgeries and relied on opioid medications for years, if not decades.

All SCS works by sending low electrical pulses to the spinal cord to interrupt pain signals to the brain. Similar to a pacemaker, systems involve implantation of thin lead wires and a rechargeable battery; wires travel to specific nerves in the spine and the battery is placed just beneath skin in the low back. 

With more traditional technology, known as paresthesia-based or tonic stimulation, patients describe a mild vibrating, pulsing, tingling or buzzing sensation. On the other hand, the new system can perform sub-perception stimulation, also known as “no-feel”, which operates at such a high frequency that patients can’t detect them. I compare it to a wheel that spins so quickly the eyes can no longer perceive motion. 

Each system targets a different area of the spinal cord, thereby activating distinct nerve pathways and brain regions to provide better pain coverage. Tonic stimulation delivers pulses to the dorsal column at the middle to posterior side of the spinal cord, while sub-perception stimulation aims for the dorsal horn, one of the gray longitudinal columns within the spinal cord. We can either pinpoint one specific pain area or use each therapy as needed to manage multiple problem regions. 

Patients vary in which sensation they prefer: some enjoy mild vibratory sensations, while others like the “no-feel” setting. With a combination system, patients can use a handheld remote control to alternate their own settings and stop or start stimulations throughout the day or night. 

The broader audience of potential beneficiaries range from young patients who have suffered a traumatic injury, including some of our military veterans, to older populations who could not tolerate an extensive back surgery. Some people, including my very first patient, have reported near 100 percent improvement. 

Implanted devices can last indefinitely, although they also may be removed at any time. Before implantation – generally an outpatient procedure – patients are able to test SCS during a three- to five-day trial period, using external wires securely taped to their backs. As everyone’s anatomy and pain complaints are different, we also use these trials to determine the ideal placement of internal leads. 

I believe SCS will continue to gain acceptance as a valuable alternative to repeated surgeries and medication, particularly given our country’s current epidemic of opiate addiction. I am committed to educating as many patients as possible about this innovative weapon against life-altering pain.

Dr. Tseng, an Interventional Pain Medicine specialist at Sports Medicine & Orthopaedic Center, is Board certified in both Physical Medicine and Rehabilitation and Pain Medicine. He takes a holistic approach to post-surgical care, injury recovery and pain management, utilizing injections, interventional procedures, physical therapy and advanced treatments such as radiofrequency ablation and kyphoplasty. smoc-pt.com

Riverside Introduces the Next Generation of cancer Technology to its Dedicated Radiosurgery Center

Radiosurgery has become an important tool in fighting cancers throughout the body, particularly in places that are hard to reach with traditional, open surgery. Radiosurgery uses targeted beams of radiation to perform knifeless surgery. 

Since 2005, the Radiosurgery Center at Riverside has incorporated the Gamma Knife® for the treatment of tumors and conditions that affect the brain. As well, a second suite served patients with cancers and conditions that impact the body. 

William Morris and Lee Miller, registered radiation therapists

Riverside is now introducing the Edge™ Radiosurgery Suite, which can accurately target tumors and other abnormalities without an incision or the need for recovery in a hospital setting. The new system is an improved technology that will allow our physicians to perform advanced, non-invasive cancer procedures anywhere in the body – including the brain, spine, head and neck, adrenal gland, lung, liver and pancreas – with extreme precision and low toxicity.

The new Edge system is the only one in Virginia and one of about 40 units available in the country. The care team at Riverside is excited to bring this new system and its many benefits to patients in Hampton Roads.

“We’ve been safely and successfully delivering radiosurgery for over 10 years,” explains Kelly Spencer, a physicist at Riverside’s Radiosurgery Center. “But the technology continues to evolve and platforms to deliver more integrated and more precise care have developed. The Varian Edge was designed exclusively for the type of specialized radiosurgery applications we deliver. We are incredibly excited about the unique features of the Edge that will make treatment sessions faster and more comfortable for the patient without compromising safety.  The integrated Edge platform will allow us to work with the technology instead of fighting it and allow us to devote our complete attention to the patient, which is most important”.

The Edge, created by Varian Medical Systems, uses real-time imaging in tandem with a robotic couch integrated directly into the system, which makes scanning and repositioning patients to deliver their  custom treatment plan more seamless. Patients can also be scanned at any time during the procedure to ensure that proper placement is maintained or adjusted as needed. 

“The Edge system also offers sub-millimeter accuracy when targeting tumors, protecting healthy tissue,” adds Dr. Ron Kersh, a radiation oncologist at Riverside Regional Medical Center.

Patients treated with the Varian Edge can expect faster treatment times with minimal side effects, no incisions, and a return to daily activities right away.

“We are increasingly making cancer a chronic disease rather than a terminal diagnosis,” adds Kersh. “Cancer used to be seen as something you cured or something that you died from. But with radiosurgery, our patients are treating (sometimes multiple) cancers and living with a high quality of life for many, many years.”

Building Upon a Tradition of Advanced Cancer Care Options
Whether a first-time diagnosis, a recurrence, or a metastasis, Riverside has remained on the forefront of delivering the latest treatment options. That’s just one of the reasons they partnered with University of Virginia and Chesapeake Regional to open the state’s first and only dedicated radiosurgery center. 

Gamma Knife has long been considered the gold standard to treat many types of brain tumors, vascular lesions, and other abnormalities in the brain that can be hard to reach with traditional surgery. Using both these advanced technologies allows patients to receive treatments that are much shorter than traditional radiation requires. In addition, patients are able to go home immediately after each procedure with very few side effects and continue with daily routines and activities.

“The treatments offered with Gamma Knife at Riverside are the very same treatments that patients can receive at UVA, University of Pittsburgh Medical Center, or even in Sweden where this technology was developed and first introduced decades ago,” says Dr. William McAllister, a neurosurgeon at Riverside. “Our patients in Hampton Roads don’t have to travel to receive the same care they would get at world-class institutions.”

Riverside has developed its Radiosurgery Center with a commitment to widely-studied and proven methodologies. With a research component that has published multiple studies, the Radiosurgery Center at Riverside often joins national and international academic centers in publishing findings that help shape future standards of care.  

With a multi-disciplinary team that includes neurosurgeons, radiation oncologists, physicists, radiation therapists, and a team of nurses and support staff, the Center has become a model for domestic and international cancer centers providing radiation care. The Center currently treats more than 400 radiosurgery cases every year.

“Very few, if any, community-based hospitals can say they have a dedicated radiosurgery center like the one at Riverside,” adds Kersh. “Our team focuses exclusively on radiosurgery and the quality of our program and our outcomes is on par or better than some of the best-known institutions in the world.”