April 2, 2020

Practice Management Winter 2014

Footing the Bill for Healthcare
By Bassam A. Kawwass, FACHE

As the administrator of a large, independent cardiology practice, I regularly scour the media and healthcare journals for news that might directly affect our patients, as well as our practice. Especially since the passage and implementation of the Affordable Care Act, culling through this material can be a full-time job, but it’s absolutely critical.

Of particular interest to patients and independent physician groups is the spate of hospital systems acquiring physician practices, and the corresponding unintended consequence of patients being charged higher fees for tests and procedures at hospital-owned practices for the identical services and tests previously provided in their independent physician’s office.

One of the relevant articles written on this topic appeared in the June 14, 2013 issue of The New York Times, entitled “Medicare Panel Urges Cuts to Hospital Payments for Services Doctors Offer for Less.” In the article, veteran reporter Robert Pear wrote that the 17-member Medicare Payment Advisory Commission’s report found that, “In many cases, a physician’s practice that is purchased by a hospital stays in the same location and treats the same patients,” but “Medicare and beneficiaries pay more for the same services.”

Pear wrote that the federal advisory panel concluded “that Congress should move immediately to cut payments to hospitals for many services that can be provided at much lower cost in doctors’ offices,” and urged Congress to equalize payment rates or at least reduce the disparities for doctor’s office visits and hospital clinic visits in which similar patients receive the same or similar services.

This topic has been much debated since Pear’s article appeared last June, with emotions running high on both sides of the issue.

In the January 20, 2014 edition of Modern Healthcare, Joe Carlson writes in his article, “Revealing times:”

“Growing pressure by policymakers, employers, consumers and the media to publicly reveal the prices charged by healthcare providers and reimbursed by payers is forcing providers and payers to reconsider their long-standing opposition to price transparency. Last week, the CMS announced it would start providing information under Freedom of Information Act requests on how much Medicare pays individual physicians. Employers, news organizations and watchdog groups have been seeking that information for many years. The American Medical Association immediately protested that the policy could violate the privacy rights of doctors and patients. In addition, experts are pointing to a little-noticed, 56-word provision buried in the Patient Protection and Affordable Care Act requiring all hospitals to publish a list of their standard charges for items and services…  While HHS hasn’t yet issued a rule implementing that provision, Section 2718(e), some experts say that when it is implemented, it could create powerful pressure for even greater price transparency.”

The provision in question reads as follows: “Each hospital operating within the United States shall, for each year, establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups, established under Section 1886(d)(4) of the Social Security Act.”

Patients believe they have a right to know what they’re paying for, whether they’re at the car dealership or the doctor’s office – or in the hospital. The focus must be on VALUE.


KAWWASSBassam A. Kawwass, FACHE is the administrator for Cardiovascular Associates, Ltd. (www.cval.org), the premier largest independent, full-service cardiology practice. E-mail: bkawwass@cval.org. Mr. Kawwass served as past Regent at Large for the American College of Healthcare Executives. He earned a Master’s in Health and Hospital Administration from Virginia Commonwealth University, a Medical Records Administration degree from St. Louis University, and a Bachelor’s in Business Administration from the American University of Beirut, Lebanon.

The Future of Physical Therapy

ByJeff Verhoef, PT, MBA

exerciseIt’s no secret that medical practice owners live busy lives. And so do patients.

When physical therapy is the best course of treatment for patients – whether prescribed after a surgery, as a conservative approach to help prevent the need for surgery or to help manage the pains associated with a chronic illness – that can often mean a suggested two to three appointments per week for anywhere from several weeks to several months.

For patients, even when they fully understand the value of the physical therapy to their future quality of life, all those appointments mean time away from work, family and other activities.

It can also seem costly when evaluating the co-pays many insurance carriers require at every visit.

But physical therapy is an extremely cost effective treatment for musculoskeletal disorders and can often take patients beyond rehabilitation to prevention of further injury, and the need for more costly medical procedures.

In today’s ever-changing healthcare and economic climate, patients are forced to make more conservative decisions about their health based on what they can afford to do.

That’s why, when looking to refer patients to a physical therapist, it’s important to evaluate the value the practice puts on access. Access is crucial not only for patients, but also for the future of physical therapy.

Research shows that patients can heal better and faster when they can get into a physical therapy clinic quickly and in a place that’s convenient and at a time that works around their schedule.

What is access?

It’s the location of clinics where patients live and work, in urban regions and rural outskirts, along medical corridors and in shopping districts, near key neighborhoods and close to major highways.

It’s the times the lights get turned on and off – the hours of operation and clinicians who start treating patients early, throughout the lunch hour and into the evenings.

Access includes coverage and the acceptance of every major insurance company.

And it covers specialties and education. Clinics should have a broad base of general therapy practice as well as specialties that include, among others, vestibular, women’s health, work hardening, hand therapy, pediatric services and temporomandibular joint disorder therapies. An investment in the continuing education of therapists often helps support the need for specialties and ensuring clinicians are constantly learning new treatment methods.

Those treatment methods and the unique understanding of how the body moves that physical therapists have make up their unique skill set that from a preventative medicine standpoint can cut down health care costs and keep patients better longer.

Not to mention, it’s the future of physical therapy.


J-VerhoefJeff Verhoef, PT, MBA  is the Chief Executive Officer for Tidewater Physical Therapy, an independent, physical therapist-owned outpatient practice headquartered in Newport News, Va. Verhoef joined the practice in 1995 and soon after became one of its four partners. Learn more about Tidewater Physical Therapy at www.tpti.com.

Uni Knee Offers Alternative to Total Knee Replacement, Shorter Rehabilitation for Knee Surgery Patients


By Dr. Anthony Bevilacqua, Sports Medicine and Orthopaedic Center

Knee pain is one of the most common ailments for athletes, weekend warriors, runners and even equestrians. All too often, patients push through the pain or ignore the warning signs, hoping things will get better.

That approach often starts from a place of fear – fear of knee replacement surgery, long recovery times and the concerns about never returning to an active lifestyle. Thankfully, advancements in knee surgery have put many of these fears to rest.

For many patients, an unicompartmental knee arthroplasty (Uni Knee) is an alternative to full knee replacement surgery. Uni Knee is a partial knee replacement that conserves two-thirds of the knee, compared to a total knee replacement.

As a result, patients experience a more natural-feeling knee and shorter recovery times, because the surgery is less invasive. One of the goals of the Uni Knee procedure is to conserve bone and soft tissue, giving patients a solution to knee pain, before the disease progresses to the whole knee.

Osteoarthritis that affects the cartilage of the knee can require a total knee replacement, involving all three compartments of the knee and the ACL. When the disease is caught early enough, the Uni Knee allows patients to keep the healthy portions of their knee and ACL.

Given the Uni Knee option, it’s even more important for those experiencing knee pain to get an assessment sooner, rather than later. Although every patient is different, Uni Knee accommodates a range of motion from standing (0 degrees) to kneeling (155 degrees), which is an improvement over previous partial knee replacement options.

The Uni Knee is now possible on an outpatient basis in healthy patients, particularly among athletes, runners and equestrians who typically suffer from knee pain. Regardless of the treatment solution, knee pain should not prevent you from remaining active and keeping your heart healthy.


Dr.-BevilacquaDr. Anthony Bevilacqua is a Board certified orthopaedic surgeon with Sports Medicine and Orthopaedic Center (SMOC). Visit smoc-pt.com to learn more about Dr. Bevilacqua and the rest of the team at SMOC. He performs Uni Knee surgery at Sentara Obici Hospital and at Obici’s Ambulatory Surgery Center in Suffolk, next to SMOC’s Suffolk office.


Patient-Specific Knee Implants for the Treatment of Osteoarthritis and Joint Damage

By Robert J. Snyder, MD

ladykneeW14It’s a fact of life that as we age, our knees deteriorate and develop arthritis. Some patients are genetically blessed and don’t seem to develop significant arthritis. Others aren’t as lucky, and older age, previous injuries and damage to the knee produce severe, life-style altering changes.

Knee replacement surgery has evolved significantly over the past 40 years in terms of materials and designs available. The holy grail of replacement has been to develop a system that most naturally replicates the normal knee.

Historically, most knee replacement systems utilize pre-made metal alloy pieces to fit on the femur and tibia bones. Between the metal is a plastic spacer to act as a bearing. Each manufacturer has proprietary minor changes that separate its knee system from those competitors. These include geometric changes to the metal pieces or altering the manufacturing and processing of the plastic.

However, one fact remains. With the exception of one company, ALL knee replacement companies manufacture their implants in bulk. This means they produce an array of different sizes of implants and a variety of different thicknesses for the plastic to cover the spectrum of expected patients.

Recently, imaging, 3-D modeling and manufacturing processes have improved, making it possible for a company called ConforMis (www.ConforMis.com) to produce truly custom, patient-specific implants to treat arthritis of the knee. ConforMis also made it possible to selectively replace only the worn areas of a knee, allowing replacement of the medial or lateral side only, replacement of a medial or lateral side with the knee cap or a replacement of all three areas of the knee.

The steps involved require a pre-op CT scan of the knee from which a digital 3-D model is made. ConforMis then makes the actual metal and plastic pieces and sends them to the hospital to be available for a patient’s surgery. The new knee has the same curves and size of the patient’s old knee. It will feel like their old knee did before it had arthritis.

A word of caution. Some companies advertise their knee is custom-made and they may order a pre-op CT scan or MRI, BUT their implants are still mass-produced. They use the pre-op study to manufacture a plastic cutting block that guides the surgeon in making the first bone cut. After that, the surgeon utilizes the older style guides until the practice pieces fit and then the actual pieces are opened and assembled. Another company uses a robotic approach that lets the surgeon remove a precise amount of bone. If the surgeon deviates from the programmed cuts, the robotic arm freezes, preventing the surgeon from cutting outside the line.

ConforMis has made it possible to produce a knee replacement, that when compared with other companies’ products, most naturally replicates a normal knee.


Dr.-SnyderRobert J. Snyder, MD is an Orthopaedic Surgeon who practices at Orthopaedic & Spine Center in Newport News, Va. For more information on Dr. Snyder or OSC, call 757-596-1900 or go to www.osc-ortho.com.

Medical Professional Spotlight Winter 2014

Recognizing Outstanding Nurse Practitioners and Physician Assistants in Hampton Roads

Christine K. Daley, NP
By Alison Johnson

Christine-DaleyDuring her 11 years as an adult nurse practitioner in Virginia, Christine K. Daley has thrown her energy into advancing her profession locally and across the state.

Daley, a member of the Cardiothoracic and Vascular Surgery team at Riverside Regional Medical Center, is certain that nurse practitioners will play an increasingly important role as more people obtain health insurance but face a growing shortage of physicians.

As President-Elect of the Virginia Council of Nurse Practitioners, she is an important leader in an ongoing push to boost the legal autonomy of advanced practice nurses, making them better collaborators with time-pressed physicians. Her message: NPs are well-trained to diagnose and treat many medical conditions without direct oversight, and they often have more time for patient education.

“There’s so much we can do independently to help both physicians and patients,” Daley says. “Nurse practitioners have become essential players in providing good care, along with greater access to care for patients. I want us to be able to practice to the full extent of our abilities.”

Daley, a mother of two, has been a registered nurse since 1986. She completed her nurse practitioner training in 1997 at Harbor-UCLA Medical Center in California and worked in Arizona before moving to Virginia in 2003. She has worked with cardiothoracic patients at Riverside ever since.

Each day, Daley devotes hours to patients before and after surgery. Working in partnership with surgeons, she does everything from calming nerves in pre-operative rooms to completing hospital rounds to carefully reviewing follow-up care plans. “I absolutely love what I do,” she says. “Everyone deserves the best possible health care.”

While Daley has worked with state legislators on bills to remove some supervisory requirements for nurse practitioners, she’s quick to add that her colleagues aren’t out to replace physicians. “We’re not wannabe doctors,” she says. “We just want to be the best nurse practitioners we can be.”

Daley’s two-year term as President-Elect for the VCNP will begin in March, followed by two years as President and another two as Past President. She’s active in leadership at Riverside, too: she’s Vice-Chair of the Advanced Practice Provider Committee, which the hospital started about three years ago to augment the role of NPs and Physician Assistants, and served on the faculty of Riverside’s nursing school for about five years.

Additionally, as a quality data manager for Riverside, Daley participates in the Virginia Cardiac Surgery Quality Program, which draws together representatives from hospitals throughout the state – including major programs such as the University of Virginia Health System and VCU Medical Center – to discuss best practices and compare patient outcomes. “We don’t just consider survival rates,” she says. “We want to be sure we’ve done all the right things for our patients.”

As federal health care reforms go into place, Daley expects the role of nurse practitioners to keep expanding in both family practices and specialty offices. More men also are joining its traditionally female ranks, she notes. “I’m excited to continue our journey,” she says. “It’s all about keeping more people healthy.” <


If you work with or know a physician’s assistant or nurse practitioner you’d like to nominate for a profile in Hampton Roads Physician, please visit our website – www.hrphysician.com – or call our editor, Bobbie Fisher, at 757-773-7550.


Good Deeds Winter 2014

Honoring the Volunteer Service of
Harry Lee Kraus, MD

When Dr. Harry Kraus decided to take a mission trip, he had no idea he was about to change his family’s life forever.

He called Samaritan’s Purse, an organization run by Franklin Graham, son of evangelist Billy Graham. “I told them I had three weeks off, and wanted to take my son on a medical trip to provide services,” he recalls. “They sent us to Kenya.”

harryW14Something happened during that short trip: Dr. Kraus’ eyes were opened to the tremendous and growing need in Africa. And after just two weeks, his son looked at him and said, ‘Dad, tell Mom to pack her bags.’ Dr. Kraus remembers thinking at the time, “That’ll go over big: I come home after three weeks and tell my wife we ought to move to Africa?”

They had a comfortable life; he was in private practice as a general surgeon in Harrisonburg; they had three healthy boys. But the entire family supported the idea, and when his practice offered him a year’s sabbatical, they moved to Kenya.

“We never intended to stay for the better part of a decade,” Dr. Kraus says, “but after the first year, we loved it. The boys liked their school, they were making friends, and enjoyed riding their motorcycles out to chase zebra and giraffes. They’d sleep under the stars, and shoot their own food with blowguns. It was an adventure.” They signed on for another three years – and after a short break, another three.

And of course, the need everywhere was so great. Dr. Kraus was treating more and more Muslim refugees who came seeking care, and the more he interacted with them, the more they urged him to visit their country. He went to a Muslim country in North Africa to teach in a medical school, and ended up organizing a number of trips both to teach and to operate. Once Al Shabaab withdrew from the capital city, he began going there. “I never dreamed I’d be making rounds accompanied by soldiers with automatic weapons,” he says.

He remembers discussing these visits with his wife Kris, talking about the risks of going into one of the world’s most dangerous cities. “I once asked her what she’d say if I were killed going there at such a dangerous time,” he recalls. “She told me she’d say that I died doing what I was passionate about. Then I knew I could go. I knew she was OK.”

That kind of strength comes from one place in the Kraus family: their Christian beliefs. “We were motivated by faith,” Dr. Kraus says. “Jesus made some strong statements about loving your neighbor. We felt like we were asked to go love these people, so that’s what we did.”

As they were contemplating the decision, the Krauses turned to the Bible. “We found this verse in Galatians,” Dr. Kraus remembers: “‘As you have opportunity to do good, do it.’ For us it was just as simple as that.”

harry2W14In 2013, when their youngest son was getting ready to go to college in the States, the Krauses knew it was time to return home. Dr. Kraus had been in contact with the new Riverside Doctors Hospital in Williamsburg, and was invited to join the medical team. He’s been on staff since September.

Despite settling in, and maintaining a busy surgical schedule, he still finds time to work on another of his passions: he’s the best-selling author of several Christian-inspired novels – he calls them ‘contemporary drama with a realistic medical stripe’ – and several works of non-fiction. “God’s grace is a theme that runs through all of my writing,” he says.

And clearly through his life, as well.

If you know physicians who are performing good deeds – great or small – who you would like to see highlighted in this publication, please submit information on our website  — or call our editor, Bobbie Fisher, at 757-773-7550.

Bon Secours Surgical Specialists, Colorectal Division

Changing – and Saving – the Lives of Patients with Colorectal Disorders

boncover02_14Historically, many patients with colorectal disorders have gotten little help from doctors – even if their symptoms were painful or embarrassing enough to make their lives miserable. That’s what happens as people age, they heard, or that’s an inevitable consequence of pregnancy. Patients who did find treatment often faced only highly invasive options.

Those limited options are not acceptable to the colorectal specialists with Bon Secours Surgical Specialists, a practice dedicated to comprehensive, coordinated care of conditions of the bowel, rectum and anus.

The team of three physicians is exceptionally experienced; they are experts in colorectal surgery and offer a full range of diagnostic and therapeutic services, including advanced non-surgical treatments, endoscopy and minimally invasive procedures.

Each team member is committed to treating the full spectrum of bowel disorders in a comfortable and supportive environment, from common complaints such as hemorrhoids and anal fissures and fistulas to life-threatening cancers and complex or rare conditions.

All patients have access to prominent specialists and cutting-edge technologies such as robotic surgical options, the region’s most advanced physiology laboratory and defecography X-ray equipment – which can fluoroscopically evaluate the anatomic condition of the pelvic floor and anorectal structures.

Prompt evaluation, early diagnosis and customized care, along with fully electronic medical records, can significantly improve patient outcomes.

“We are excited about introducing a new era in unmatched, patient-centered colorectal medicine and surgery right here in Hampton Roads,” says Philip D. Kondylis, MD, FACS, FASCRS. “Sometimes a small procedure can fundamentally change a patient’s quality of life. Every day we see somebody who has tried to get treatment for years; some are despondent. It’s extremely satisfying to be able to help them.”

The center’s physicians are all fellowship trained colorectal surgeons and have extensive clinical experience treating patients in both academic and community-based medical settings. They also work in collaboration with a variety of dedicated nurses specializing in clinical care, endoscopy, enterostomal therapy, biofeedback therapy and physiology lab techniques– as well as a caring nurse navigator available to address questions and concerns 24 hours a day.

In addition to colonoscopy, the precise diagnostic tests offered include: anorectal ultrasound, to study muscle structure and function; transit time studies, to follow how well food moves through the digestive tract; high-resolution anal/rectal manometry, to measure pressure and sensation using a digital monitor; needle-free electromyography (EMG), to assess the health of both muscles and the nerves that control them; pudendal nerve testing, to identify anal sphincter nerve damage and responsiveness; and MRI fistula evaluation, to provide a highly detailed view of perianal anatomy.

Emily B. Rivet, MD, MBA, FACS

Emily B. Rivet, MD, MBA, FACS

With detailed information on a patient’s condition, physicians can move as quickly as possible to address:

• Anal pain and itch

• Hemorrhoids

• Rectal bleeding

• Colorectal polyps and cancer

• Crohn’s disease and other inflammatory bowel disorders

• Ulcerative colitis, damage to the lining of the colon and rectum

• Diverticular disease, bulging tissue pouches in the colon and/or inflammation of those pouches

• Constipation and/or diarrhea

• Bowel leakage

• Rectocele, a prolapse of the wall between the rectum and the vagina

• Rectal prolapse

• Anorectal infection

bongroupW14“We have established and are now growing our center of excellence, where we can radically change how we approach many of these conditions,” says Chong S. Lee, MD, FACS, FASCRS. “We have upgraded all aspects of the delivery of colorectal surgical care to go above and beyond what has traditionally been provided in our community.”

Treatment options include second opinions, medical therapies, biofeedback therapy, office-based hemorrhoid procedures and advanced endoscopic therapies for hemorrhoids, fissures and fistulas such as Botox injections, fibrin glue, collagen plug fistula ablation and several minor surgical procedures. Those include the Ligation of Inter-sphincteric Fistula Tract (LIFT) procedure, Procedure for Prolapse and Hemorrhoids (PPH) and Transanal Hemorrhoidal Dearterialization (THD).

The list of minimally-invasive colorectal surgeries covers fully laparoscopic surgery, single incision laparoscopic surgery and transanal endoscopic microsurgery. Bon Secours physicians also are highly experienced with anal sphincter-preserving rectal cancer surgery, sacral nerve stimulator surgery, artificial bowel sphincter surgery and pelvic floor operations.

Furthermore, the team is eager to educate residents on early symptoms of colorectal cancer and the importance of screening tests, particularly colonoscopies that generally should begin at age 50. The disease has a fairly high incidence in the Hampton Roads region.

“Colonoscopy is one of the few medical screening tests that has been proven to reduce cancer rates,” says Emily B. Rivet, MD, MBA, FACS. “If we can find a tumor at an early stage, it can mean the difference between a one-day outpatient procedure and about a year of multi-modality treatments: chemotherapy, radiation and multiple surgeries.”

The center’s surgeons currently are based at Bon Secours Maryview Medical Center in Portsmouth and Bon Secours DePaul Medical Center in Norfolk, with the physiology lab at Bon Secours Health Center at Harbour View in Suffolk.

The practice is dedicated not only to bringing relief to patients but to helping them feel empowered –never frustrated or embarrassed – throughout their treatment. As Patient Care Coordinator for the colorectal program, Robin Boothe, RN, provides her cell phone number to patients and encourages them to call her anytime with questions about symptoms, treatments and special preparation plans they should follow in the days leading up to certain tests.

Boothe, a registered nurse for 37 years, is also happy to simply listen to their fears and concerns. She has worked with the Bon Secours colorectal program for eight years.

“I try to put myself in their place, and think about how I would want myself or one of my relatives to be treated,” she says. “It’s often an uncertain time for them, and they don’t want to talk about these issues with just anybody. I love being there to educate them and to hold their hands. We’re committed to being a high-tech but also a ‘high-touch’ practice.”

Pelvic floor disorders and disorders of the rectum
Many colorectal practices focus on performing colonoscopies and treating classic conditions such as hemorrhoids, fissures and fistulas, all high-volume and high-profit endeavors. The Bon Secours Colorectal Center is eager to help those patients with basic but life-changing procedures such as hemorrhoid ablation or drainage of a perirectal abscess.

The center can also handle less common and more complex conditions, including defecatory disorders that can be difficult to diagnose. That level of expertise is not typically found in most community-based centers.

Doctors’ understanding of anal-rectal physiology and continence has advanced greatly over the past 10 to 20 years. “It’s an exciting time for the field,” Dr. Kondylis says. “Twenty years ago, for example, patients with incontinence had so few options beyond colostomy. Now, colostomies are almost unheard of because treatments have changed so fundamentally.”

Dr. Kondylis has more than 20 years of experience in his specialty. He came to Bon Secours last year from Erie, Pa., where he served for 12 years as a core faculty member and most recently director of the colorectal surgery program at Saint Vincent Health Center. He earned a medical degree from the University of Massachusetts Medical School, where he also completed a National Heart, Lung and Blood Institute student research fellowship.

After medical school, Dr. Kondylis did a general surgery residency at the Yale University-affiliated Hospital of Saint Raphael in New Haven, Conn., and a colorectal surgery fellowship at Saint Vincent. A registered investigator for the National Cancer Institute, he has given 34 major research presentations and written 14 peer-reviewed publications.

A good number of patients who come to see Dr. Kondylis have been misdiagnosed or suffered in silence, sometimes for months or even years. “If you have something like anal leakage, you’re likely going to wait for a long time before reporting it to a doctor,” he says. “If you’re then brushed off, you may never ask anyone else.”

Just one example of a frequent misdiagnosis: women with a rectocele, a bulging of the front wall of the rectum into the back wall of the vagina that can require surgical repair, often are told they have constipation and instructed to eat more fiber, drink more water and use a stool softener. “None of that works because there’s nothing wrong with the consistency of their stool,” Dr. Kondylis says.

The center also treats many women who begin experiencing progressive bowel habit disturbances – straining, pelvic pressure and never feeling empty – one or two decades after having children. Almost a third of women who give birth vaginally suffer some sort of injury to their anal sphincter, even if they don’t tear externally during delivery. That scar tissue can weaken with time and contribute to significant bowel leakage or incontinence.

Women who have Caesarean sections aren’t immune either, as supporting the weight of a baby strains the pelvic floor. More than half of pregnant women also experience minor damage to a nerve that stretches to the anal sphincter.

“In many cases, treatment can be very simple,” Dr. Kondylis reports. “Dedicated biofeedback therapy to strengthen a damaged sphincter might be all a woman needs.” That therapy uses computerized feedback to retrain muscles to relax during evacuation and contract at appropriate times, as well as teaching patients to build strength and endurance with sphincter contraction.

Men who have undergone treatment for prostate cancer, particularly radiation therapy, are another vulnerable group. Radiation can damage the same nerve to the anal sphincter, as well as nearby blood vessels. Many patients respond well to medication or Argon beam therapy to destroy abnormal vessels.

The key to tailoring the best treatment is to have a detailed diagnosis. At the physiology lab at Bon Secours Harbour View in Suffolk, experts can fully evaluate the anal sphincter muscle and nerves that nourish it, as well as precisely measure pressures generated by the contraction of the sphincter.

The procedures, usually no more involved than a rectal exam, utilize a finger-sized ultrasound probe – that offers a 360-degree image inside the anal canal – or a soft plastic tube about the size of a drinking straw that can digitally calculate contractions. Patients don’t need an intravenous line or sedation. Testing also can uncover a failure in colon function in patients with profound constipation, another population that tends to be overlooked and mistreated with laxatives.

“In regards to colorectal surgery, we are virtually a one-stop shop,” Dr. Kondylis says. “We want people to stay locally rather than have to travel for treatment.”

Chong S. Lee, MD, FACS, FASCRS

Chong S. Lee, MD, FACS, FASCRS

Catching cancer early
Physicians in the colorectal surgery division are passionate about educating local residents on the importance of regular screening for colon cancer. The five-year mortality rate for colon and rectal cancers is consistently higher in Bon Secours’ primary service area than nationwide, according to data from the National Cancer Institute.

From 2006 to 2010, the age-adjusted death rate for the cities of Chesapeake, Newport News, Norfolk and Portsmouth was 18.3 deaths per 100,000 of population, about 11 percent higher than the national rate of 16.4 per 100,000. Within that primary service area, Portsmouth topped the list at 20.4.

Colon cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death in men and women combined in the United States, according to the Colon Cancer Alliance. The American Cancer Society estimates that 143,000 people are diagnosed each year; about 51,000 die. Data shows that 72 percent of cases originate in the colon and 28 percent in the rectum.

Five-year survival rates increase dramatically if colon cancer is caught early. More than 90 percent of patients diagnosed when cancer is found at a local stage – confined to the colon or rectum – live more than five years, alliance statistics show. If the cancer is regional and has spread to surrounding tissue, that rate drops to 69 percent; once it has spread to distant sites, it plummets to just 12 percent.

However, the majority of colon cancers are not discovered early: 39 percent are found while the cancer is at a local stage, 37 percent at a regional stage and 20 percent after the disease has spread to distant organs. By the time colon cancer causes symptoms such as pain, bleeding or obstructed bowel movements, the disease usually has spread beyond the local stage.

A traditional colonoscopy is the gold standard for screening, although physicians also can gain valuable information from sigmoidoscopy, fecal occult blood testing and virtual colonoscopy. Most people should schedule an initial colonoscopy at age 50 because while the disease can strike at any age, about 90 percent of new cases occur in people ages 50 and older. Those at higher risk due to family history should consult their doctor about starting earlier. Schedules for follow-up screens vary based on individual results and medical history.

Colonoscopies can not only find small tumors but polyps that might one day become problematic. “In many cases, we can remove polyps before they ever have a chance to become cancerous,” Dr. Rivet says. “The procedure itself is very quick and has a low rate of complications. I can’t tell you how many people have said to me, ‘Wow, that was so much easier than I thought it would be.’”

To catch rectal cancer early, Dr. Rivet also urges people to seek help if they see bright red blood, experience rectal pain or itching, or feel as if they have abnormal tissue protruding from their anus.

“Often within 15 minutes, I can reassure someone that there is not something significant going on, or make a plan to perform further evaluation,” she says.  “If needed, our team can provide comprehensive guidance through the treatment process.”

Small rectal tumors can sometimes be removed through the anus in a quick outpatient procedure, sparing patients far more grueling cancer treatments. “My feeling is that people in our community are very stoic and might delay approaching a doctor until it’s too late for that level of care,” Dr. Rivet says. “That’s one reason we are dedicated to raising awareness.”

Lifestyle choices also may help prevent colon cancer. While no study to date has found a direct correlation between one behavior and increased risk of disease, healthy habits – eating plenty of fruits, vegetables and fiber, limiting processed foods and smoked meats, exercising regularly and not smoking – are always wise.

Like her two colleagues, Dr. Rivet has experience treating a wide variety of colon and rectal diseases in men and women. In fact, she chose to specialize in colorectal care for the interesting mix of cases, along with a personal reason: her grandmother died of colorectal cancer.

Dr. Rivet came to Hampton Roads in 2008 after her husband, a neurosurgeon, began practicing at Portsmouth Regional Naval Medical Center. She has a medical degree from the Washington University School of Medicine in St. Louis, Missouri, and completed her surgical training, including a general surgery residency and a colon and rectal surgery fellowship, at Barnes-Jewish Hospital in St. Louis. She also holds a master’s in business administration from Washington University, with a focus on professional ethics and health care systems.

Dr. Rivet has won numerous awards for academic achievements and surgical expertise and, following an interest in promoting patient safety in a hospital setting, has published articles on peri-operative patient care and the critical care of surgical patients.

The colorectal surgeons with Bon Secours Surgical Specialists “all have slightly different passions but work together seamlessly,” she says. “Put bluntly, we all understand why there’s the expression ‘pain in the butt.’ There’s almost nothing that’s more miserable for patients, and when we can help people feel better, they are exceedingly grateful. We consider it our privilege.”


Philip D. Kondylis, MD, FACS, FASCRS

Philip D. Kondylis, MD, FACS, FASCRS

Minimally invasive options and patient support
Fortunately for patients who need surgery, Bon Secours Surgical Specialists physicians can perform about 80 percent of colorectal operations with a minimally invasive approach, thanks to specialized surgical techniques, interventional radiology and state-of-the-art equipment.

“The result is better outcomes, higher patient satisfaction, shorter hospital stays and faster recovery time,” says Dr. Lee, who has more than 19 years of experience managing complex colon and rectal surgical diseases. He joined Bon Secours last summer.

Laparoscopic surgery now is standard practice for common conditions such as inflammatory bowel disease, diverticulitis and Crohn’s disease. Most Crohn’s patients – often young, in their 20s or 30s – no longer have to lose much of their small bowel. “It’s much less disfiguring, which can make an enormous difference in terms of patient satisfaction,” Dr. Lee says.

For patients with chronic or complicated ulcerative colitis, there are sphincter-saving surgeries designed to preserve fecal continence, avoid a permanent abdominal ileostomy and improve quality of life. Patients with rectal prolapse, which frequently causes incontinence, can benefit from the Altemeier procedure, a perineal approach done under regional anesthesia that also allows for repair of pelvic floor muscles if necessary. Without making an abdominal incision, surgeons can remove the prolapsed rectum through an incision in the protruding rectum.

Colorectal Center physicians also have experience in treating complex cases that otherwise would require a trip to a major academic medical center. One of Dr. Lee’s specialties is removing presacral tumors or masses – very rare growths in the space between the rectum and lower spine, most common in young women – using a discreet, approximately inch-long incision in the tailbone area. That compares to a major, highly visible incision and removal of the tailbone in traditional surgery.

Among Dr. Lee’s goals is to expand robotic surgical options, the most advanced form of minimally invasive surgery available today, for colorectal patients. He led a similar effort in his previous post as Service Chief of Surgery at Henry Ford West Bloomfield Hospital in West Bloomfield Township, Mich.

Surgeons are now beginning to use the da Vinci Surgical System – previously adapted for urological and gynecological cases – for bowel cases, both colon cancer and non-cancerous colon diseases.

“The task now is to fine-tune the system for more colorectal cases,” Dr. Lee says. “More innovative equipment is likely to come out in the near future, and we are committed to taking advantage of that. I really see robotic surgery as replacing laparoscopy in many cases.”

Robotic surgery offers many benefits to patients compared to open surgery, including shorter hospitalization time, reduced pain, faster recovery and return to normal activities, reduced blood loss and smaller incisions, resulting in minimal scarring and a reduced risk of infection. For surgeons, assistance from a self-powered, computer-controlled robot and 3-D camera allows for enhanced dexterity, flexibility, visualization and precision.

Dr. Lee, like Drs. Kondylis and Rivet, specializes in colorectal surgery but also has a background in general surgery. He holds a medical degree from the University of Illinois College of Medicine in Urbana, Ill., and completed his internship and residency in general surgery, as well as colon and rectal surgery fellowship, at the University of Minnesota Hospitals in Minneapolis, Minnesota. He joined the Henry Ford Health System in 1994 and was heavily involved in General Surgery Residency education and Colon & Rectal Surgery education from the onset, until he left to join the Bon Secours DePaul Medical Center in August, 2013. He contributed in 10 peer reviewed publications and presented in seven national and international surgical meetings. Dr. Lee has been recognized in Best Doctors in America® and as Hour Detroit magazines Top Docs. Dr. Lee also holds a Master’s Degree in Electrical and Computer Engineering from the University of Illinois, Urbana-Champaign.

Regardless of what kind of treatment a patient needs, the entire Bon Secours team is there to offer support to individuals and their families. Boothe, the Patient Care Coordinator, starts by helping patients adhere to pre-operative and pre-testing guidelines. People who need a barium enema, for example, have to follow a special diet two days beforehand.

“I don’t want them to make a three-day commitment before they understand exactly what they need to do to get the results we need to best help them,” she says. “I am there to translate any language that’s confusing into very simple terms.”

As for cancer patients, many still come in for colonoscopies and post-operative care long after their initial treatments and even after five-year checkup appointments. “Those people are mine for life,” Boothe says. “Sometimes I end up taking care of their relatives, too, if a disease has a genetic component. We become a family.”

Sharon Winchell, RN, Clinical Program Coordinator for the oncology department at DePaul, feels the same. Winchell works closely with Dr. Lee to help cancer patients and their families navigate multiple appointments, tests and treatments. The team also is careful to clearly explain all treatments so each patient is more likely to stay in compliance and follow appointment schedules, thereby enjoying the best possible long-term prognosis.

“We give them everything that they need to make the most informed decisions for their care,” says Winchell, who is oncology-certified and has worked with colon cancer patients for more than 16 years. “Our patients deserve, and get, a powerful combination of expertise and compassion. We know the word ‘cancer’ is scary, and we don’t want them to feel rushed or overwhelmed.”

The Bon Secours team plans for a future of growth, by adding more talented colorectal surgeons to the staff and hopefully initiating a fellowship training program. “We want to bring in young surgeons to mentor them,” Dr. Lee says. “By offering state-of-the-art, innovative care, we have an exciting potential for recruitment.”

Physicians encourage any person who suspects a bowel disorder – due to pain, constipation, incontinence or other troubling symptoms – to get to a specialist sooner rather than later. At Bon Secours, nobody will tell them they’re just getting old.

“We’re in a position now where we can help a lot of people,” Dr. Kondylis says. “We can improve their daily lives in a significant way.”

For more information about Bon Secours Surgical Specialists’ Colorectal Division, please contact us at
483-3030 or 889-6830
or visit us online at bshr.com/bsss.

The Legal Perspective Winter 2014

The Benefits of an Employee Handbook

By Stephanie P. Karn

Regardless of the size of your practice, an employee handbook can be a valuable tool. The overwhelming goal of such a handbook is to establish clear and uniform communications with your employees. As the courts in Virginia have recognized, “[t]he primary purpose of these manuals is to educate and insure uniformity of treatment among similarly situated employees.” Bryarly v. Shenandoah Univ., 41 Va. Cir. 238, 243 (Winchester 1996). To avoid claims of disparate treatment (claims that can and do lead to litigation), your employees should be subject to the same policies, job requirements, and expectations as every other similarly-classified employee.  An employee handbook, then, can be used to thwart a claim that an employee was promised special treatment or is somehow “above the rules.”

Even in the smallest of organizations, a handbook can ensure that everyone understands both the goals of the business and what is expected of each employee. If you asked your employees to describe your business, it is likely that each person would answer differently. Moreover, as employees change jobs and careers more frequently, a single source of practice offerings and expectations can make day-to-day office management easier and more efficient.

Employee handbooks do not need to be all-encompassing or updated daily to be effective. A handbook that addresses basic but essential information can be prepared by legal counsel fairly quickly and at low cost. Once in place, provided you reserve the right to amend the handbook (as discussed below), minor and/or periodic updates are even quicker and more efficient. Providing a handbook to each employee – at hiring and again upon updates or on an annual or biennial basis – ensures that no employee can claim ignorance of an established policy or practice.

Key provisions of any employee handbook would include the following:

• Declaration of at-will1 status and written acknowledgment by the employee

• Statement that the employer can change any and all policies in the handbook

• Attendance requirements, including call-in obligations (Failure to abide by a company’s policy, established in its handbook, to confirm posted work schedules and report all absences may be used to deny claims for unemployment compensation)

• Equal Employment Opportunity policy

• Discrimination and Harassment policy

• Overtime policy (Requiring prior written approval, for example)

• Employee conduct and work rules (Providing examples of conduct that may result in disciplinary action, up to and including immediate dismissal)

• Leave policies, vacation pay, paid time off

• Electronics communication policy – confirm no expectation of privacy on any electronic device owned or supplied by your practice

• Drug and alcohol testing

• Prohibitions against outside employment, solicitations

• Social Media use

Finally, if you already have a handbook, an annual review will help ensure that your policies are up-to-date and in accord with current laws.

1In the absence of any contract, employment in Virginia is considered “at-will,” which means both the employee and the employer are free to terminate the employment at any time, for any reason, with or without notice, except as prohibited by applicable law.


Stephanie-KarnStephanie P. Karn is an attorney with Goodman, Allen & Filetti, PLLC. Stephanie oversees the firm’s employment practice; for more than 18 years, she has litigated claims and counseled employers on all aspects of employment law, including the development and implementation of policies, compliance with employment statutes and regulations, investigation of employee misconduct and employee termination. Visit www.goodmanallen.com for more information.




Jerry L. Nadler, MD

Eastern Virginia Medical School
Vice Dean of Research, Harry H. Mansbach Endowed Chair in Internal Medicine

Jerry L. Nadler, MDAlthough there were no physicians in his family, Dr. Jerry Nadler remembers always being interested in science and medicine. “Actually, my Uncle Sam influenced me,” he says. “He had what we today call Adult Onset Type 1 Diabetes. Growing up, I saw all the problems he had: heart attack, circulation problems in his leg, all of it. His mind was always sharp, but his body gradually had all of the complications of diabetes.” It made an impression.

In college, he got excited about a research project in endocrinology, an interest that became solidified when he went to medical school. His family had moved to Florida, so he chose the Miller School of Medicine at the University of Miami. Between his first and second years, he had the opportunity to work with Dr. Daniel Mintz, the founding Scientific Director and Chief Academic Officer of the Diabetes Research Institute. “He was a visionary,” Dr. Nadler remembers. “I was doing islet cell transplants in animal models to reverse diabetes. It was the first time that had been done. That’s when I decided I wanted to go into internal medicine, with a focus on diabetes.” He was hooked on research, he says, a theme that has informed his entire career.

He did his internship and residency in internal medicine at Loma Linda University Medical Center, and specialized endocrinology training in research at the University of Southern California. He did extra work at USC, funded by the National Institutes of Health and the American Heart Association. “That’s where I got my dual interest in heart disease and diabetes, and how to reverse diabetes,” he says.

Dr. Nadler stayed on at USC as tenured faculty, but when word came that the City of Hope Medical Center in nearby Duarte was looking for a director to build up its diabetes program, he enthusiastically took the position. “When I got there, there was one nurse, one full-time and one part-time doctor,” he recalls. “It was a real opportunity to focus on research.” Over the next nine years, and with the support of a local philanthropist, the program grew into a major diabetes center, and is today considered one of the most influential diabetes research programs in the world.

The next call came from the University of Virginia, asking him to head up the diabetes and endocrine division. The Nadlers were enjoying California, and said no to the offer three times. “But the offer got better and better, so we came to Charlottesville,” Dr. Nadler says. “We were there nine years, and during that time, the endocrine division was listed in the Top Ten in the country almost every year. We were No. 5 one year, ahead of Harvard and other programs.”

But the Nadlers were used to a big city, and missed the water. So when Dean Gerald Pepe called saying he needed a Chairman of Medicine and someone to head EVMS’s diabetes center, Dr. Nadler was very excited. “I’m going on my sixth year,” he says, “and I’m still excited about the work we’re doing at EVMS.”

During that time, a number of world-class physicians and endocrinologists have been recruited, including both Dr. Joseph Aloi and Dr. David Lieb. While there is a national shortage of endocrinologists, EVMS has doubled the size of its endocrine fellowship. Because there are so few endocrinologists, Dr. Nadler points out, most diabetes patients are cared for by family doctors and primary care physicians. “Here at EVMS, we see the most difficult patients, some of whom go on insulin pumps,” he says. “We’re very happy to partner with general practitioners in caring for them, because of the severity of their disease.”

Research remains his passion. The Diabetes Institute is involved in several studies he finds very exciting, particularly those dealing with reversing diabetes. “We’re working on research now to reverse Type 1,” he says. “We can do it in mice, but we can’t yet do it in people.” It would require stopping the body from destroying its insulin cells, because even if these cells could be regenerated, the body would simply try to destroy them all over again. “I am very fortunate to be collaborating with a wonderful physician scientist, Dr. Yumi Imai, who just got a grant from the state to use a combination approach, using one compound to regenerate cells and another drug to stop the immune system from destroying them,” Dr. Nadler explains. “The goal is to start doing that in the animal model, and if it works well, we can move it up to the clinic. It’s exhilarating.”

He’s working on another grant studying the causes of the tremendous increase in heart disease and heart diseases related death among diabetics. Another grant seeks to identify a virus that might be one of the triggers of Type 1 diabetes, which might ultimately lead to the development of a vaccine.

Despite the grim statistics (“we’ve already exceeded the number of diabetics estimated for the year 2025,” he notes), Dr. Nadler is hopeful that as the country moves into a new health care era, focusing on prevention and lifestyle change and being rewarded for that – and with continued vigorous research – “We might be able to stem the tide.” In the meantime, he and his colleagues offer a great opportunity for the people of Hampton Roads: “We do outreach, we do prevention, we try to reverse disease,” he says, “and we provide exceptional treatment for the diabetic patient.”

David C. Lieb, MD

Eastern Virginia Medical School
Associate Program Director, Endocrinology and Metabolism Fellowship

David C. Lieb, MDWhen Dr. David Lieb meets diabetic patients at their initial visit, one of the first things he tells them is that he understands what they’re going through. Those aren’t just empty words: Dr. Lieb was diagnosed with Type 1 diabetes when he was 12 years old, and has been dealing with the disease ever since. “I was always a husky kid,” he says, “and I started losing a lot of weight. I was drinking a lot of water, and urinating with increasing frequency.” While he and his mother were delighted with his weight loss, his father – a practicing dentist who had taught anatomy at MCV – suspected something wasn’t quite right. “My dad had done research on diabetes,” he says, “so he made sure I was tested.” There was no significant family history of the disease, just one great uncle with Type 2 diabetes.

But the tests confirmed his father’s fear: David had Type 1 diabetes, the less common, auto-immune form of the disease in which the body recognizes its own insulin-producing beta cells as foreign, and attacks them. The year was 1989.

It wasn’t necessarily the diagnosis that led Dr. Lieb to a career as an endocrinologist. He’d always been interested in science because of his father’s influence. He majored in cell biology at the University of Maryland, where he was exposed to research as a summer student at the National Institutes of Health. He earned his medical degree at the University of Virginia in 2003, where he first met Dr. Jerry Nadler. “I wasn’t just his student there,” he explains, “because of my diabetes, I was also a patient.”  He did both his internship and residency at Oregon Health and Science University before returning to UVA for a fellowship in endocrinology.  “Because endocrinology deals with hormones, which affect every part of the body, I knew I’d get to work with many different health care providers,” he says. “That appealed to me.”

As a graduating fellow, Dr. Lieb recalls the email he received from Dr. Nadler, who had come to EVMS and had an opening in the clinical educator program. Eager to work with his medical school mentor – and to work in an atmosphere that would welcome a clinician who also wanted to teach – Dr. Lieb joined the EVMS staff in 2009, reuniting with his mentor as well as with Dr. Aloi, another recruit from UVA.

Today, Dr. Lieb splits his time between caring for patients in all stages of diabetes, teaching, and researching the effects of bariatric surgery on Type 2 diabetes. “We have good therapies for diabetes,” he says, “but nothing works as well as weight loss and dietary changes. Research shows that bariatric surgery is one of the most effective treatments for Type 2 diabetes. The data are striking, and now, both the American Diabetes Association and the American Association for Clinical Endocrinologists mention bariatric surgery in their guidelines for the management of diabetes.”

Dr. Lieb is optimistic about the vast research being done at EVMS, but responds cautiously when patients ask about the possibility of cure. “I remember when I was diagnosed, somebody came into my hospital room and said, ‘don’t worry, there’ll be a cure in ten years.’ Twenty-five years later,” he says, “the technology for managing the disease is worlds different, with wearable sensors that measure blood sugar and pumps that can distribute insulin” – but he emphasizes that diabetes remains a chronic disease that patients have to learn how to live with.

He has reason to be concerned about a cure: as the father of three sons, Dr. Lieb knows that their risk of developing Type 1 diabetes is five percent greater than if his wife had the disease. “There’s something about the Y chromosome,” he says. “We don’t yet know why.”

But a healthy lifestyle can influence the outcome of every diabetic, he tells his patients. Dr. Lieb introduces them to the concept of mindfulness about their diet, their exercise habits and how they deal with stress. “There’s data that these things can really help with blood sugars,” he tells them.

That’s a message he shares with the students he teaches, in addition to their regular medical curriculum. He gives them another piece of advice, as well: choose your study partners wisely. In medical school, he says, he was paired with a fellow student named Emily White. “Emily and I studied together, and worked on projects together, and I fell in love,” he says. Today, Dr. Emily Lieb is a family practitioner working in the Bon Secours system. She sees patients and is the medical director of the Hampton Roads Care-A-Van Mobile Free Clinic.