October 14, 2019

Beyond Burnout, What’s Coming?  

By Raouf (Ron) Gharbo, DO


Paradoxically, healthcare burnout has become rampant in healthcare experts.   Currently, the burnout literature is full of terms like compassion fatigue, moral injury and subjective surveys. The root causes are unremitting risk, conflict and pressure, leading to exhaustion, and we need an objective physiology-based model. I am a clinical investigator on several studies led by the University of South Carolina School of Public Health, and I present orientation CME to new providers with Riverside Health System on performance and decision making.  

The logarithmic growth of heart rate variability (HRV) literature reveals these parameters are the established, most sensitive, all-cause mortality biomarker, marker of fatigue, cardiovascular health, predictive of sepsis outcomes, cancer outcomes at any stage and even predictive of long-term diabetic complications prior to the diagnosis of diabetes. HRV software can display anxiety and frustration graphically in real time to increase personal insights into hyperarousal emotional (limbic) decision making and decision fatigue factors. The military already assesses pre-deployment HRV data to predict future PTSD.  

In addition to the HRV biomarkers, HRV biofeedback breathing skills are the only objective method to induce cardiorespiratory synchronization to physiologically reduce the emotional hyperarousal state; these could be the objective backbone to meditative and spiritual practices that have proven, healthy outcomes.  Recently, studies have demonstrated that HRV breathing skills improve decision making under duress by shifting to a more energy-efficient state. One of our randomized control trials is showing that with a handful of training sessions, this skill attainment has persistence for several months.

Faced with daily conflict, many physicians and nurses choose a second major factor in performance: depersonalization. A lack of empathy has been widely shown to have poor performance outcomes, even poor surgical outcomes. I’ve learned from clinical experience during the opioid crisis that there are two basic physician-patient relationships during the rehabilitation process burdened by chronic pain. Patients typically present as transactional customers or engaged partners. The necessary paradigm shift is understanding that the patients and circumstances determine the type of relationship, not the provider. If uncertain, or if I need to assess future risk behavior, I can objectively, even remotely, measure engagement with an HRV breathing prescription of 10 minutes BID & PRN. I am committed to listen, understand and genuinely articulate empathy (cognitively) with all patients, but in difficult situations these HRV skills can allow a provider to physiologically de-fuel needless hyperarousal that can be draining.  This skill empowers providers to be more judicious with triggering of their own cardiovascular system and HPA axis. Some examples include after a code blue or computer lockup, during or before hand washing, and during or after an intense interaction. Currently, consumer-wearable devices are unreliable, but medical-grade tools with intuitive platforms, coupled with value-based payment models, are inevitable. I developed a Stop, Shift & Decide method: stop the racing brain and shift emotion objectively on demand to improve decision making in line with your purpose and values. Both HRV wearables and HRV biofeedback will become ubiquitous, so start getting familiar – the Medical-Wearable Age is coming.  

Dr. Gharbo is a clinical investigator on several HRV studies, led by the University of South Carolina School of Public Health and funded by the VA. He provides monthly CME to orient new providers with Riverside Health System, and he is an adviser for Peerbridge Health.  


Medicine Then & Now Summer 2019

From Infections to Anxiety:
How Pediatricians Face the Challenges of Caring for Today’s Kids

By Kasey Fuqua


Over the last 40 years, pediatrics has been shaped by rapid changes in the world. From the development of vaccines to the advent of the Internet, pediatricians have been changing their practices to fit the needs of new generations of children.

The Vaccine Effect
A major shift in pediatric care began in the 1970s and 80s as more vaccines were developed to prevent life-threatening infections in children. 

Douglas Gregory, MD

Douglas Gregory, MD, FAAP, pediatrician with Bayview Physician Group, has provided pediatric care for 43 years. He recalls seeing many children with severe infections such as meningitis as a young pediatrician. 

“We had any number of children coming in with severe sepsis and bacterial meningitis,” says Dr. Gregory. “Particularly with meningitis, there was a high mortality rate and considerable morbidity with hearing loss and vision loss. Seeing children and families so devastated by these illnesses and then seeing those infections wiped out by vaccines really stands out in my mind.” 

Vaccines continue to affect pediatric care, changing treatment guidelines and the day-to-day work of pediatricians. Instead of focusing on preventing or treating acute infections, pediatricians can spend more time on well-child care.

“While we did routine well-child visits, the major emphasis of care was keeping the kids healthy from infectious diseases,” says Douglas Mitchell, MD, pediatrician at CHKD and medical director of CHKD Medical Group. “We thought about it on a daily basis. With the advent of vaccines, it’s just not the majority of the practice anymore.”

“With the development of vaccines, better antibiotics and better public health knowledge, the emphasis has been switched to preventive health care,” agrees Dr. Gregory.  

A Stronger Focus on Preventive Health
While pediatricians have always provided preventive health care, there is a much greater emphasis on well-child care in today’s world. The Affordable Care Act ensured that all well-child appointments must be covered by insurance, helping families seek out preventive care.

LaTonya Russell, MD, MPH, FAAP

 “Now insurance companies are recommending that you come in for your well-visit,” says LaTonya Russell, MD, MPH, FAAP, pediatrician at Sentara Family Medicine & Pediatrics in Chesapeake. “We have done this paradigm shift from illness care to caring about the whole kiddo, which includes caring for the parents. Our ultimate goal is to do whatever we can to make sure the patient is healthy, which can mean caring for the whole family.”

The scope of a pediatrician’s practice has also changed. In the 1970s, pediatricians typically saw children until the age of 12 or into the early teens. Now many general pediatricians see young people from birth to age 21, allowing greater continuity of care as children and teens finish their growth and development. Pediatricians are also less likely to spend time in the hospital, leaving that to the purview of pediatric hospitalists and spending more time in the outpatient office.

“We are looking more at the development of the whole individual,” says Dr. Gregory. “Society has changed so that we can move into this area of preventive health care and deal with these issues, like obesity, tobacco use or vaping.”

Joseph Baust, MD

The Growing Need for Children’s Mental Health Care 
As the focus on preventive health grows, so does the focus on development and mental health care. From early screenings for developmental disorders or autism to screening for anxiety and depression, pediatricians are spending more time caring for a child’s growing mind.

One major driver of the focus on mental health care is suicide rates, which have been on the rise since 2007, particularly among girls. Suicide is the second leading cause of death for people ages 15-24.

“That’s alarming,” says Dr. Russell. “In general, our pediatrics population is reflecting larger society with the amount of anxiety and depression that we are seeing. We are spending more time on preventive mental health care because we have to.”

Dr. Russell says about 75 percent of children in the United States lack access to critical mental health care. General pediatricians need to step in to fill in the gaps in care. 

“We are starting to see more pediatricians stepping outside of their comfort zone so we can provide mental health care,” says Dr. Russell. “As long as I can remember, pediatricians have kicked parents out of the room to have the sex, drugs, and rock-n-roll talk with teens. Now we have to be more specific and thorough in what we ask during that time.” 

Many pediatricians are seeking out additional training and education in psychiatric care to better meet their patients’ needs.

“When I finished residency 32 years ago, we didn’t have a lot of training in dealing with behavioral and psychiatric issues,” says Dr. Mitchell. “The increase in mental health conditions has required a change in us older pediatricians to better prepare ourselves for what’s changed. Many of us have taken additional training and coursework to step up our game and increase our level of comfort with managing those conditions.”

Children’s Hospital of The King’s Daughters is also striving to meet the demand for pediatric mental health care with the development of its 60-bed inpatient facility and additional intensive outpatient programs. The health system has hired dozens of licensed clinical social workers as well as pediatric psychiatrists over the last few years.

Pediatricians agree that children today are facing more issues than in the past as society grows more complex. 

“People are living paycheck to paycheck,” says Joseph Baust, MD, pediatrician with Tidewater Physician Multispecialty Group. “There are a lot of family stressors. It’s harder for people to get good insurance. It’s hard earning a living. I think parents as a whole are more nervous and anxious than in the past. Kids growing up in those households feel those anxieties.”

Dr. Baust says other factors may be contributing to increasing depression and anxiety in children, including lack of exercise and time spent outdoors. Technology, like social media and video games, may also be affecting children’s mental health. 

The Changing Role of Technology in Kids’ Health
Technology is affecting almost every aspect of health care — for the good and the bad. The American Academy of Pediatrics warns that too much screen time can slow development in young children and affect social interaction in children of all ages. Technology can also harm quality of sleep and learning.

Dr. Baust feels social media has contributed to both higher obesity rates and anxiety, particularly among teenagers.

Social media has negatively affected parents, too, helping give rise to the anti-vaccination movement and other fears about their children’s health.

“We’re living in a strange time where you can go to social media and somebody from five states away says something and you believe it,” says Dr. Baust. “And then you don’t vaccinate your children. In our practice, we don’t accept anyone who doesn’t vaccinate. It’s a shame it’s come to that, but I have to protect the newborns.”

Dr. Mitchell agrees that misinformation online has led to additional challenges in primary care and pediatrics.

“When they are getting bad information online, you have to reeducate parents,” says Dr. Mitchell. “Vaccines have been a victim of their own success because we’ve done a great job with vaccines, so many parents have never seen these infections before.”

Still, Dr. Mitchell says technology has helped parents become more informed about their children’s health and care needs.

“Certainly information and digital access has changed things,” says Dr. Mitchell. “Our parents are more informed and can ask very good questions, which is a positive for patients.”

Over the next 40 years, technology is likely to be a leading driver of change and challenges for pediatricians. But pediatricians will adapt, always focused on their main purpose.

“In pediatrics, we are all about prevention and always have been,” says Dr. Mitchell. “We want to do everything we can to give kids the best life they can have, by preventing complications with physical or mental health. That’s never going to change.”

Medical Update

New Treatments and Challenges of Acute Stroke Care

Pankajavalli Ramakrishnan, MD, PhD

Advancements in stroke care are moving fast, leading to better outcomes for patients and new challenges for healthcare providers.

“Just 5 to 10 years ago is like a different era in stroke treatment,” says Pankajavalli Ramakrishnan, MD, PhD, a neurointerventionalist at Riverside Health System. “There are stark differences in the way that things were treated then and how we care for them now.”

tPA for Small Artery Occlusions
The changes in stroke care began in 1995, when the first trials for intravenous tissue plasminogen activator (tPA) began. These trials showed the treatment could reduce some disability for patients who experienced a stroke.

“Over the next 20-some years, tPA was slowly adopted as the standard for dissolving clots,” says John Baker, MD, PhD, a neurointerventionalist at Chesapeake Regional Healthcare. “Unfortunately, that medication only opens the artery about 30 percent of the time, and only about 50 percent of patients treated with tPA improve.”

John Baker, MD, PhD

While tPA could assist with smaller clots by restoring blood flow and minimizing damage, it has become clear that it is no match for large artery occlusions.

“We needed to have a physical way to remove the larger blood clot and restore blood flow in a timely manner, so you can save the bulk of the brain that would have otherwise died,” says Dr. Ramakrishnan. 

Mechanical Thrombectomy for Large Artery Occlusions
Almost as long as tPA has been around, interventionists have been striving to create devices that would allow the removal of large blood clots from the brain. They began working with engineers to perfect devices that allowed for fast, minimally invasive stroke treatment. Early first-generation devices didn’t always achieve clinically observable results.

“In 2015, overwhelming evidence from studies around the world showed that the second-generation devices were highly successful in opening blood vessels by removing the larger blood clots,” says Dr. Ramakrishnan. “They also clinically made an impact for minimizing permanent disability.”

Neurointerventional surgeons can now use multiple techniques to remove blood clots from the brain. Aspiration thrombectomy uses a catheter and suction to pull out the clot, leading to immediate recanalization. 

Stent retriever thrombectomy deploys a stent through the blood clot, entrapping it. Once the stent surrounds the clot, neurointerventionalists remove both the clot and stent together. 

Surgeons may also use a combination of the two techniques to achieve the best outcomes. So far, studies suggest that both techniques are equally effective in reducing disability.

Initial guidelines for mechanical thrombectomy recommended its use for patients who were seen within 6 hours of their last known well. This window of opportunity was viewed as the time when thrombectomy would have the largest benefit.

“That’s like saying that two people who are the same height and weight can run the same distance in the same timeframe,” says Dr. Ramakrishnan. “However, no two brains have the same ability to withstand the same extent of absence of blood flow. In the past, time was used as a measure of likely viable brain that could still be salvaged by opening up blocked arteries. Now, we can use better techniques in determining the extent of viable brain, rather than using time lapsed without blood flow as a surrogate for salvageable brain.”

Expanding Mechanical Thrombectomy Care with Imaging Technology
Two randomized-controlled trials, called DEFUSE 3 and DAWN, began to look at using thrombectomy for patients who fell outside the six-hour window with a large artery occlusion in the anterior portion of the brain. These studies showed that some patients had a significant mismatch between already infarcted brain and brain that could still be salvaged, suggesting that much larger portions of the brain could be saved even outside of the six-hour window.

Both studies were halted early, as analyses revealed an overwhelmingly large benefit to patients experiencing such a stroke.

“We’ve found that going up into that artery to take out the clot, even all the way out to 24 hours from last known well, can lead to good patient outcomes,” says Dr. Baker. “Because of advances in mechanical thrombectomy, we can get the artery open about 90 percent of the time, with 50 percent of patients doing better.”

New Challenges to Improve Treatment Times
While mechanical thrombectomy is beneficial to many stroke patients, it requires expertise and equipment that may not be widely available. In Hampton Roads, mechanical thrombectomy is available at Chesapeake Regional Medical Center, Riverside Regional Medical Center, and Sentara Norfolk General Hospital. 

“That leaves large portions of our community without a hospital that offers this particular service,” says Dr. Baker. “Those patients would go to the nearest hospital to be evaluated, potentially receive IV meds, then get transported to another hospital to have the procedure. That results in time delays, so we need to determine how to offer treatment to more people, more quickly.” 

Strokes present unique challenges because they require fast care and fast imaging services. It can be difficult to identify a stroke in the field, let alone to know if the stroke is occurring in a small or large artery.

The Virginia Stroke System Task Force is working to map out the state and develop strategies to deliver care more quickly, such as diverting patients to more advanced stroke centers. In some densely populated areas of the country, teams like Dr. Baker’s can go to the patient instead of the other way around. 

“If the person is at a local hospital, the anesthesia and hospital team can get those patients ready for thrombectomy,” says Dr. Baker. “It may save time by bringing the neurointerventional team to the patient instead of sending the patient on a long ride in an ambulance.” 

This paradigm does pose some challenges. It requires hospitals to have the necessary infrastructure, including equipment and personnel, in place. It also can leave gaps in coverage as the treatment team travels to other hospitals. 

In many parts of the country, stroke care is evolving around centralization of expertise, such as for trauma. Two years ago, the Peninsulas EMS Region developed its own protocols similar to those for triaging trauma patients. EMS uses severity measures, such as number of stroke symptoms, to determine if a patient may be more likely to have a large artery occlusion. If the patient’s travel time doesn’t increase by more than 15 minutes, the patient is taken to Riverside Regional Medical Center for care first instead of traveling to the nearest hospital. 

“The results that we have so far show that people who are eligible for IV tPA still get it, but patients who benefit from thrombectomy are getting it faster and having less disability,” says Dr. Ramakrishnan. “The efforts started by our partnership with Peninsulas EMS have been recognized by the Virginia Stroke System Task Force and the Department of Health.”

Other EMS regions are beginning to emulate the Peninsulas’ efforts, working to train their EMS in the new stroke assessments.

Despite challenges in delivering care, both Dr. Baker and Dr. Ramakrishnan agree that stroke care has vastly improved and believe it will continue to improve.

“It’s an exciting time in comparison to when I first started,” says Dr. Baker. “Back then, we could only watch what happened as the brain died. It’s been wonderful to follow the progression of treatment in the last 25 years.”

“It’s the best time to do what we do in caring for stroke patients,” says Dr. Ramakrishnan. “They’ve never had more options than they have now; it’s just a matter of getting them to the right place as quickly as possible.”

My Favorite Charity

The Cornerstone Foundation
John T. Sinacori, MD, EVMS Otolaryngology


For the past 12 years, Dr. John Sinacori has spent a week each fall caring for ENT patients in what was once an isolated, neglected region on the northern coast of Honduras. 

Not long ago, residents in the impoverished municipality of Balfate had to travel for a full day to access medical care, navigating hilly, dirt-and-gravel roads. Children who couldn’t get simple ear tubes for chronic infections lost their hearing and never developed speech. Cancers and thyroid disorders went untreated for years. 

Then came the Cornerstone Foundation, a nonprofit, hospital-based Christian outreach founded in 1992 by an American general surgeon, Dr. Jeff McKenney, and his wife, Rosanne, a surgical and obstetric nurse. The two had traveled extensively in the Central American nation. 

The 30,000-square-foot Hospital Loma de Luz (“Hill of Light”) opened first, in 2003, with staff housing on site. During the next two years, the foundation started El Camino (“The Way”) Bilingual School to educate local kids and the Sanctuary House Children’s Center to provide foster care services. Cornerstone also offers trade and agricultural training. 

In 2008, Dr. Sinacori, an ear, nose and throat specialist for Eastern Virginia Medical School, Children’s Hospital of the King’s Daughters and Sentara Healthcare, led his first mission to Loma de Luz. He was invited by Dr. Kaalan E. Johnson, then a fourth-year EVMS resident who had journeyed there during medical school. 

“That trip refreshed my thoughts on what medicine is all about,” Dr. Sinacori recalls. “It’s not just about fixing diseases but building connections with people and entire communities. It restored my faith in humankind and what we can do for each other.” 

Dr. Sinacori now travels to Balfate each September or October, usually with two other attending physicians, Dr. Stephanie Moody and Dr. Jonathan Mark, three EVMS residents, two scrub technicians, an audiologist and an anesthesiologist. On a typical mission, they treat about 70 patients in clinic and perform roughly 20 surgeries, some of them complex procedures that take up to six or seven hours. 

Cases range from inserting ear tubes and correcting cleft palates to managing advanced thyroid and head and neck cancers. One recent patient had a basal cell tumor on his eyelid that had begun to erode his eyeball after several years without treatment. By removing the damaged eye, Drs. Sinacori and Mark prevented a curable cancer from fatally penetrating the man’s skull and brain.  

The Cornerstone Foundation shies away from so-called “Santa Claus” care, or one-way, one-time giveaways of either medical treatment or donated goods. When Dr. Sinacori brought soccer balls for the foster kids, for example, they had to complete chores to earn them.

Throughout the year, Dr. Sinacori’s team stays in touch with Honduran-based physicians and patients, often via email. They also coordinate with a second American team led by Dr. Johnson, now with Seattle Children’s Hospital, that travels to Honduras each spring.    

“I’ve learned that the most important part of mission work isn’t how many cases you can do in a single trip,” Dr. Sinacori notes. “The goal is to establish friendships and relationships in order to provide a real continuity of care.”  

As the Cornerstone Foundation continues to grow, it has transformed the area’s standard of living. The hospital now provides outpatient, inpatient and surgical services to about 20,000 patients a year and will soon expand its two operating rooms to four. 

The school, currently serving pre-kindergarten through sixth-grade students, hopes to add a grade each year until it runs through high school. The orphanage, which works in conjunction with child welfare officials, is a safe haven for more than 40 kids. In total, the foundation employs about 80 local residents.  

Dr. Sinacori may establish a Norfolk-based nonprofit to help fundraise for future mission trips, with the next one scheduled for late September. “It’s always a unique experience for our medical residents,” he says, “and a deeply meaningful one for me.”

To learn more, visit crstone.org.  

Advance Practice Providers

Congratulations, it is an Honor to Feature
Kathy J. Green, MSN, FNP-BC
TPMG – Neurology at Williamsburg


Whenever she meets new patients, Kathy Green likens each one to an onion. Her job is to ask the questions that peel back their layers so she can understand them on a deeper level, which is when she can truly help them. 

Green, a nurse practitioner with TPMG Neurology, prioritizes educating her patients on how they can protect their brain health, often by minimizing risk factors or making simple lifestyle changes that may ward off or lessen debilitating symptoms. 

“Many patients tell me, ‘Wow, no one’s ever asked me that question before,’” Green says. “It’s so important to take that one-on-one time with them, so I can take them under my wing and show that I care and have confidence in them. I really love each one of them.” 

Many of Green’s patients are recovering from strokes, coping with migraines, headaches, or exhibiting signs of cognitive decline. Increasingly, research has shown that controlling blood pressure, exercising, losing weight as needed and quitting smoking can be equally – if not more – effective than medication for proper brain function, she notes.  

In addition to scheduling annual checkups with a primary care physician, Green urges patients to socialize, tackle new activities and play memory games on a daily basis, from learning a foreign language to taking group fitness classes to enjoying a fast-paced card game. She herself picked up kayaking this past year, often with her poodle-Pit Bull mix, Lexi, along for the ride.  

“People can become complacent as they get older,” she notes. “They stay at home and don’t engage or challenge their brains. You need to consistently push barriers and use all of your senses to build and maintain neural pathways.”

For headache and migraine patients, quick fixes such as improving posture, hydrating well, sleeping with a flatter pillow, or switching to a different work desk can guard against neck or lower back issues that frequently contribute to chronic pain, she adds.  

Green has wanted to be a nurse since early childhood. Yet she had temporary second thoughts when she worked part-time in an emergency room while an undergraduate at Longwood College in Farmville. 

Witnessing the hectic pace and sometimes-gory jobs that nurses had to handle, Green pivoted to a chemistry major and spent five years as a chemist for a pharmaceutical company in Richmond. There, she helped develop methods for the Food and Drug Administration to analyze new medications. 

“It was very interesting, but I truly missed taking care of people,” she recalls. “I went back to school to become a registered nurse and have been in love with my job ever since.” 

Green earned her RN credentials at J. Sargeant Reynolds Community College in Richmond, followed by a master’s degree in Nursing Education from George Mason University and a post-master’s certificate as a Family Nurse Practitioner through St. Joseph’s College of Maine. Her first nurse practitioner positions were in family medicine and urgent care. 

In 2018, Green switched to neurology after she and her husband, a leadership consultant with a law enforcement background, moved from Northern Virginia to Williamsburg, which is a favorite vacation spot. Looking for a more focused specialty, she also valued the patient-centered approach of the neurologist in her practice, Patricia Mayes, MD.  

“We both worry about our patients, even after we’ve gone home,” Green says. “It’s important to motivate patients, celebrate small accomplishments such as losing five pounds, and even let them vent their frustrations when needed.  All of that can be part of the healing process.” 

Meanwhile, Green has passed along her passion for caregiving to her children: her son is a firefighter/medic; her daughter is a neuroscience major at Christopher Newport University and will attend Edward Via College of Osteopathic Medicine in Blacksburg next year. 

“This career is so rewarding,” Green says. “The brain is fascinating, and there’s never a one-size-fits-all approach to care.”

Just like no two onions are quite the same.  

We are grateful for local Nurse Practitioners and Physician Assistants who serve our health care community! 

Please let us know if there is an NP or PA you would like to see honored in a future edition. holly@hrphysician.com

Gilbert M. Snider, MD

Neurological Associates of Hampton Roads, P.C.; Chesapeake Regional Medical Group Neuroscience Institute


At the beginning of his long career, people often asked Dr. Gilbert Snider why he would want to be a neurologist. Back in the 1970s and 80s, neurologists could diagnose patients with complex diseases but frequently couldn’t do much to help them.   

No one asks Dr. Snider that question today. 

“We now have treatment options for a very large number of conditions,” he says. “In some cases, we’re not just addressing symptoms anymore, but getting at the basic cause of an illness. We’re giving hope to patients who, not so long ago, wouldn’t have had much hope at all. We no longer have to watch them just gradually get worse.” 

Dr. Snider, a Board certified neurologist who has practiced in Hampton Roads for 37 years, has taken a particular interest in patients with Parkinson’s disease and Multiple Sclerosis (MS). His connections with those long-term patients with chronic diseases are deeply rewarding. 

“It’s my job to lead them through some very difficult times in their lives,” he says. “We have a lot of one-on-one discussions about what therapies are best for them based on their specific symptoms, challenges and side effects.” 

Happily, those conversations have grown longer in recent years. When Dr. Snider was a resident, steroids were the lone treatment option for MS patients, and those were prescribed only after flare-ups. Today, he can draw from about 15 different medications, taken subcutaneously, orally or intravenously. 

Similarly, Parkinson’s patients have access to many more therapies, including taking the mainstay treatment, Levodopa or L-dopa, in an inhaled form or through a pump directly to the stomach. In addition, deep brain stimulation (DBS) has had success in lessening tremors and stiffness via targeted electrical pulses that improve cell communication. 

DBS also has shown great promise for dystonia, a once-untreatable condition marked by involuntary and often painful muscle contractions. Some patients now can try a surgically implanted medical device similar to a cardiac pacemaker. 

“This is a treatment we wouldn’t have ever dreamed of years ago,” Dr. Snider notes. “Deep brain stimulation isn’t for everyone, but it is exciting to finally be able to fight some of these debilitating illnesses.” 

The list of advances goes on: Epilepsy patients who don’t respond to medication no longer have to wait a decade or longer before turning to surgery, once considered an absolute last resort but now safer and more effective. Stroke patients are making remarkable recoveries after cutting-edge procedures such as surgery to pluck out blood clots. Treatments for neuromuscular disorders such as Myasthenia gravis have multiplied rapidly in the past decade. 

And in just the past five years, researchers have discovered the glymphatic system of the brain, a macroscopic waste clearance system. Repairing a system that clears out toxins could be a powerful new approach to slowing the progression of Alzheimer’s disease, Dr. Snider hopes. 

Understanding of the glymphatic system also has helped explain why lifestyle changes that benefit the vascular system – such as healthy eating and exercise – seem crucial for warding off dementias. 

“If the vascular system is damaged, that will impair circulation in the glymphatic system,” he explains. “I believe exercise, even just brisk walks, can benefit so many of my patients.” As can proper sleep, he adds: “We now know that certain brain cells shrink during sleep, which allows for more interstitial fluid and more opportunity to flush out toxins. It’s fascinating.”  

Dr. Snider, a native of Brooklyn, N.Y., followed his older brother, a retired internist in Boston, into medicine. He quickly gravitated to neurology during medical school at the University of Michigan, enjoying the cognitive nature of a specialty full of complex chronic illnesses. After completing an internship in medicine at St. Vincent’s Hospital and Medical Center in New York, he returned to Michigan for a neurology residency and an electromyography fellowship.  

In 1982, Dr. Snider and his wife, Judy, moved to Virginia Beach in search of a warmer climate. A member of the Chesapeake Regional Medical Group Neuroscience Institute, he has served as an Assistant Clinical Professor at Eastern Virginia Medical School and taught students in Chesapeake Regional Medical Center’s nurse residency program. He is also Board certified in Electrodiagnostic Medicine and does free electromyograms for Chesapeake Care Clinic patients.    

Dr. Snider is a member of the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Medical Association and the American Academy of Neurology, as well as a regular honoree on Coastal Virginia Magazine’s “Top Docs” lists. 

Outside work, Dr. Snider is a creative writer who has published the book “Brain Warp: A Medical Thriller”, about a neurologist’s investigation into a plot to poison the President of Ukraine. He is currently shopping a second book, “The Last”, which features an infectious disease physician with MS, to agents. He and Judy also co-write song lyrics with a country-western and pop flair and run a Web site with their works, gilsnider.com.   

Meanwhile, Dr. Snider has passed along his passion for medicine and the brain to the oldest of his two sons, Jonathan, a neurologist specializing in movement disorders and a faculty member at Medical College of Virginia in Richmond. Younger son Nick is a senior project manager with an Internet firm that works to improve government efficiency and transparency. 

After nearly four decades of practice, Dr. Snider remains as dedicated to his patients as ever – and more optimistic than ever. 

“I have loved watching my specialty change through the years, and changing my practice along with it,” he says. “I have seen what it was, what it is today, and what it may be in the future. I have so much hope for neurology.”

Crystal M. Proud, MD

Physician Partner, Children’s Specialty Group; Attending Physician, Children’s Hospital of The King’s Daughters; Assistant Professor, Eastern Virginia Medical School


As a subspecialist in pediatric neuromuscular neurology, Dr. Crystal Proud’s focus was once on optimizing quality of life for babies and children with severely shortened life expectancies – some less than two years – while supporting their devastated families. 

In the past five years, however, medications have begun to emerge for some of the most ruthless degenerative conditions, including spinal muscular atrophy (SMA) and Duchenne muscular dystrophy. Dr. Proud, a principal investigator in multiple clinical trials on promising drugs and gene therapies, suddenly could talk about hope. 

“My conversations with patients’ families are so very different now,” she says. “We are going to get to see what more and more of these amazing kids can contribute to the world, because they will have a chance to live.”

During her two fellowships at Stanford University and now as physician and researcher at Children’s Hospital of The King’s Daughters, Dr. Proud has helped test and develop therapies that have gone beyond easing symptoms as children gradually grew weaker. 

The medication Spinraza, for example, stimulates the production of a protein that supports motor neurons in patients with SMA, which is similar to Amyotrophic Lateral Sclerosis in adults and is the leading genetic cause of infant death. The drug gained FDA approval in 2016, and Dr. Proud has prescribed it to 30 patients and counting at CHKD. 

“In the past, most of these babies didn’t live past age 2,” she notes. “Yet suddenly, we found they were getting stronger. That was revolutionary. It was impossible in the natural history of this disease.” 

The first baby to receive Spinraza in trials is now 6½ years old. Dr. Proud recently treated a now-thriving little boy who, after starting the medication at just 2 weeks old, pulled himself up to a standing position at 8 months old. Typically, that child never would have sat independently, but now Dr. Proud expects he will one day gain the ability to walk. 

Dr. Proud also is involved in research on the first form of gene therapy for SMA, the drug Zolgensma. Just this May, the medicine gained FDA approval in an intravenous form for babies; it is in trials for possible use in older children and adults with neuromuscular disorders via delivery to spinal fluid.   

Gene therapy also has the potential to transform treatment of Duchenne, Proud says. The disease typically robs children of their ability to walk by age 12 and causes heart and/or lung failure and death by their 20s or early 30s. Until now, physicians have mainly relied on steroids to help kids delay wheelchair use for a few more years. 

Dr. Proud was part of a clinical trial on exon-skipping technology, one of several studies she has joined on drugs designed to extend patients’ lifespans. The therapy creates a molecular fix of a small mutation in a large gene, aiming to boost production of a protein critical for muscle development. One of her patients was among 12 boys in the first trial, which led to accelerated FDA approval in 2016. 

Other rare diseases that could respond to gene therapy include limb-girdle muscular dystrophy, Charcot-Marie-Tooth neuropathy and Friedreich’s ataxia. 

 “With gene therapy, the landscape in my specialty is about to become dramatically different,” Dr. Proud says. “This is where novel therapies are going, and we’ve been able to establish CHKD as a premiere site for some of these groundbreaking trials.”

A Newport News native, Dr. Proud was the first person in her family to go to college. She was fascinated by brain anatomy in a high school psychology class and majored in neuroscience at the University of Virginia. 

“Sometime during my first year, I started thinking about becoming a doctor because I loved the idea of taking care of people,” she recalls. “My mom asked me, ‘How do we do that?’ and I said, ‘I don’t know.’ My mom just said, ‘Well, we will figure it out.’”

Dr. Proud went on to Eastern Virginia Medical School, followed by a residency in pediatrics at Emory University and fellowships in child neurology and pediatric neuromuscular medicine at Stanford University. She is Board certified in all three specialties. 

While Dr. Proud was at Stanford, researchers were part of a clinical trial on Spinraza, which gained federal approval about a year after she arrived at CHKD in 2015. She remembers the exact date, in fact: Dec. 23, 2016, two days before Christmas.  

Now married to the son of a longtime and beloved CHKD geneticist, Dr. Virginia Proud, Dr. Proud is raising her own 5-year-old twins – the beach is a favorite family spot – while giving other children an opportunity to grow up. 

To increase early diagnoses of neuromuscular disorders, Dr. Proud serves on a statewide newborn screening committee that should soon lead to all babies being tested for SMA immediately after delivery. She expects such testing will expand to other diseases as treatment options increase. In addition, she is part of a clinical trial on the administration of gene therapy to infants who don’t show signs of SMA but have parents who are carriers.  

Meanwhile, Dr. Proud is asking completely new types of questions: What type of physical therapy could help SMA patients sit up, stand or walk? How might the right nutrition increase strength? When should physicians add medications to combination treatment regimens? 

“There was never a reason to think about any of this before,” she marvels. “This is such a time of hope, and we have so much more to explore in the future.”  

John N. Livingstone II, MD

Staff Neurologist, Riverside Neurology Specialists


Thirty years ago, Dr. John Livingstone picked a specialty based on a hopeful bet. Major advances in neurology during his lifetime, he felt, would transform care for patients who had little to no hope of recovery.  

Today, even Dr. Livingstone has been amazed at how right he was. 

The longtime neurologist and researcher with Riverside Health System has watched treatment options for devastating progressive diseases rapidly multiply. As medical director of Riverside’s Stroke Program for more than a decade, he also has seen the crucial time window for helping stroke patients continue to expand. 

“There’s been a total paradigm shift in care in so many areas,” Dr. Livingstone says. “We’re seeing turnarounds in patients that we never would have dreamed of before. As a doctor, it’s just immensely satisfying to be able to offer so many more options.” 

Perhaps nothing has undergone such dramatic changes as stroke care, which along with movement disorders is a particular area of interest for Dr. Livingstone. He is the physician leader of the dynamic stroke team at Riverside Regional Medical Center, a comprehensive stroke center that has quickly incorporated standard-of-care updates for administration of the two most effective therapies, tissue plasminogen activator (tPA) and thrombectomy.  

The timeframe in which tPA can dissolve blood clots after a stroke, already up from the originally-approved three hours to 4½ hours, is soon expected to increase to up to nine hours after an expedited expert review of new research data.  

A thrombectomy for a large vessel occlusion, meanwhile, now can be done up to 24 hours after a stroke, as compared just six to eight hours not long ago. Dr. Livingstone helped the stroke team that led the way in enacting this critical change at Riverside during the past two years. 

Currently, Riverside is an integral part of a regional team of emergency providers that has created an EMS algorithm on which patients would benefit from early transfer to a comprehensive stroke center, thus potentially bypassing a primary stroke center to expedite care. Ultimately, Dr. Livingstone hopes those guidelines would be adopted statewide. 

“I’m proud to be part of an amazing team that is at the forefront of acute stroke treatment, which truly is changing every year,” he says. “We have some patients coming in paralyzed on one side, unable to speak, seemingly destined for a nursing home environment, yet they walk out of the hospital. It’s unbelievable.” 

For patients with multiple sclerosis, epilepsy, Parkinson’s disease and Alzheimer’s disease, Dr. Livingstone also has choices he never did before, thanks in part to clinical research done by him and fellow Riverside physicians. 

This year, Dr. Livingstone is enrolling patients in two trials on long-term treatments for Secondary Progressive and Relapsing Remitting MS, the latest in a series of MS trials at Riverside. Both are double-blinded, randomized studies on potential oral medications. 

For his patients with epilepsy, Dr. Livingstone has access to dozens of medications, more effective surgeries and implanted devices such as the vagus nerve stimulator, designed to prevent seizures. While Alzheimer’s and Parkinson’s remain incurable, symptom control has vastly improved in the last two decades. 

“When I was in medical school, there were no treatments for Alzheimer’s or MS,” Dr. Livingstone recalls. “Nothing new had come out for Parkinson’s in 16 years, and there had been one new anti-epileptic drug in 20 years. Now we’ve got 28 approved medications for epilepsy, 16 for MS, four for Alzheimer’s, and seven to 10 new Parkinson’s drugs – and counting.” 

A Georgia native, Dr. Livingstone graduated with a biology degree from King College in Bristol, Tenn. At Medical College of Georgia, he considered going into pediatrics until summer research work with a pediatric neurologist put him on a new path.  

Dr. Livingstone completed a residency in Neurology at the Mayo Clinic. Board certified by the American Board of Psychiatry and Neurology, he has worked at Riverside Neurology Specialists – formerly known as Hampton Roads Neurology – since 1994. 

A member of the American Academy of Neurology and Past President of the Virginia Neurologic Society, he has served on multiple leadership teams at Riverside, including the Medical Ethics, Pharmacy & Therapeutics and QPC committees.   

Inevitably, Dr. Livingstone still must care for patients with incurable illnesses, including the always-fatal amyotrophic lateral sclerosis. His philosophy, however, is that an important part of his job is to keep people from losing hope. 

“Though certain diseases may be untreatable, every patient is treatable,” he explains. “I don’t ever want anyone to feel a sense of abandonment. I am there to help refocus them on positives and to give them the best quality of life for as long as I can, even if all I really can do is sit and talk to them.” Not surprisingly, patients rate Dr. Livingstone an average of 4.9 on a 5-point scale on independent patient satisfaction research surveys. 

Outside work, Dr. Livingstone is a married father of four with his first grandchild due in December. In addition to spending time with his family, he enjoys outdoor cooking on his combination smoker-grill. 

Along with continued improvements in stroke care, Dr. Livingstone believes the next frontier in neurology will be true treatments for neurodegenerative disorders. 

“There’s so much research into these diseases that are huge long-term burdens for families and our entire country,” he notes. “It’s still a time of exciting discoveries, just like when I started out, which is why I chose neurology. We still have a long way to go – but we’ll get there.” 

Keep in mind, he was very right before.

The “Personal Guarantee” in Business:

5 Tips to Avoid Putting Your Personal Assets at Risk 

By Erica Pero


Have you ever been asked to sign a personal guarantee for something business-related? Lenders and Landlords (a.k.a. “creditors”) frequently require business owners (“debtors”) to sign a personal guarantee before lending money or leasing commercial property. I totally understand why creditors require such a commitment, as new businesses are inherent risks. As doctors and business owners, however, my clients are usually pretty attractive risks; they make lots of money, and they’re usually really smart people. BUT – and it’s a big one – just because you’re smart doesn’t mean you don’t need to review the paperwork VERY CAREFULLY. Here are five tips that will help you protect your personal assets from a personal guarantee:

1 “But I’m NOT a ‘new’ business!!” If your practice/business is already fairly well-established, you might be able to avoid a personal guarantee. If you can prove you’re a trustworthy ongoing operation, you might be able to shed the personal guarantee altogether. Flashing last year’s balance sheet might be enough if there’s substantive profit.

How ‘bout THIS collateral?? If you can’t convince the Landlord that you’re already a successful business, request that your business assets serve as collateral rather than your personal assets. If your business goes to sh!t, you will lose your X-ray machine, but that’s better than your house, right? A word of caution here: make sure that you’re not breaking a promise to another creditor by pledging your business assets as collateral.

You mean for the whole time? If you have a five-year lease, the Landlord will often require a five-year guarantee. Consider asking for a shorter time period for your personal guarantee. For example, if you have a 10-year lease, consider negotiating a five-year personal guarantee. After five years, you should be able to prove that you’re a worthy credit risk, and if all goes well, your business will have enough collateral to get your personal assets off the hook.

Default, schmee-fault. Many times, a contract defines “default” as a myriad of events, such as non-payment, vacancy, bankruptcy, etc. – which makes a lot of sense. However, the definition of default regularly includes a phrase that often sounds something like, “If creditor feels that debtor is in breach or threatens breach of this agreement, debtor is in default.” Um, could you be any more vague?!? This wording is problematic even when there isn’t a personal guarantee, but this kind of leeway COUPLED with a personal guarantee is like a super-highway to your personal assets. Make sure to tighten up the language so “default” is clearly defined and can be objectively measured.

JSL baby, JSL. Most contracts and personal guarantees use the phrase “Joint and Several Liability” (JSL), which is a fancy way of saying that the creditor doesn’t have to pick who to sue. If you signed a personal guarantee the creditor can sue you AND your business at the same time. Make sure there is language in your contract that requires the creditor to sue the business first before proceeding against you personally to enforce the personal guarantee.

If you’re ever asked to sign a personal guarantee, make sure to read everything thoroughly. (And if you find the paperwork incredibly confusing, find a great healthcare attorney who LIKES to read through this kind of stuff who can explain the terms, negotiate on your behalf, and minimize the reach of the personal guarantee!!)

Erica Pero, an attorney with Pero Law, focuses her practice on health law. She helps healthcare professionals navigate the complexities of running a business in today’s healthcare  industry.  Pero Law is a lean law firm committed to excellent customer service and exceptional legal representation. perolaw.com

Just Set It, And Forget It?

By Alan L Wagner, MD, FACS, FICS


Our existence, and survival, is an amazing balancing act of homeostasis. Most of the time, our hormonal, neurological and structural systems work “automatically” without a thought on our part. Yet when the wheels come off, all heck breaks loose.

These days, we’re understanding the antecedent events to an organ system’s decompensation better than ever. Yet most of our colleagues have a blind spot. I want to bring your attention to a major problem that was brought to light more than 20 years ago yet is rarely discussed: the diabetic patient possessing autoimmune autonomic dysfunction and associated autonomic neuropathy – Diabetic Autonomic Neuropathy (DAN). With DAN, our “automatic systems” are broken, and multiple life-threatening problems develop. 

Groundbreaking research regarding both the autoimmune nature of autonomic neuropathy and the significant disease burden associated with this condition was accomplished by EVMS’s own Aaron I. Vinik, MD, PhD, FCP, MACP.  

My earliest exposure to autonomic neuropathy was over 25 years ago. After attending several of the Diabetes Institutes’ grand rounds, where leading-edge autonomic neuropathy research was presented, I had a hunch that a challenging diabetic patient had the multiple system hallmarks of the recently-described DAN. Together, Dr. Vinik and I collaborated on the patient’s behalf regarding his intractable, progressively blinding, diabetic macular edema owing to autonomic neuropathy. Aggressive, minimally responsive, multi-system compromise was also present.

Why was his macula swollen and degenerating? The first clue was finding that one random evening, his blood pressure was very high. At that time, his problem was called “paradoxical nocturnal hypertension.” We found that it was secondary to underlying autonomic neuropathy. Every night, he went from a relatively hypotensive state while spending the day sitting to having significant hypertension once he was recumbent in bed! This was confirmed with a positive tilt table test. To address this issue, we used a trial of the patient sleeping with his head moderately elevated and short-acting blood pressure control agents immediately prior to bedtime, along with selectively suppressing his autoimmune rheologic profile. His macular edema quickly resolved, and his lower limb edema also improved.

Dr. Vinik and his team penned a landmark “must read” article regarding DAN (Diabetes Care 2003 May; 26(5): 1553-1579), describing it as a “serious and common complication of diabetes”.  However, DAN is still grossly underappreciated and often undiagnosed. Preventable complications, or misidentification of root causes, abound.

For the benefit of both your Type 1 and 2 diabetic patients, please review what DAN is all about and become familiar once again with the importance of irregular heart rate variability (HRV) as a negative prognostic sign for survival. Genitourinary tract pathology (infections, dysfunctions, etc.) are not always structural in origin. Dry, cracking skin that ultimately leads to infections and limb loss has inappropriate pseudomotor tone as its origin, and it won’t be improved by just a bit more lotion or fish oil. Rapidly advancing diabetic retinopathy from nocturnal hypertension can frequently be seen as orthostatic hypotension as an early clinical complaint. 

In our practice, we see friends and neighbors ravaged by end-stage diabetic disease accelerated by autonomic neuropathy, much of it preventable. Early awareness of, and the need to interdict with, autoimmune DAN is crucial. Together, we can prevent a multitude of disabling and life-threatening complications of limb loss, cardiac death, renal failure and blindness, to name but a few.

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