Sea of change - Richmond Academy of Medicine

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Sea of change
BY PETER A. ZEDLER, MD
RAMIFICATIONS
S P R I N G 2 0 1 4 n V O LU M E 2 0 n N O. 2
W W W. R A M D O C S . O R G
The price is…?
BY CHIP JONES
Peter A. Zedler, MD, FACOG
is a partner at Virginia Women’s
Center and president of the
Board of Trustees of the
Richmond Academy of Medicine.
S
hortly after my election
as president of the Richmond Academy, one of our
members, a friend, jokingly
wished me “lots of luck.” He reminded me that health care over the next
few years is in for a rocky ride.
I have to admit over the next couple
of weeks I had a few sleepless nights.
I knew that there are many changes
coming in health care, highlighted by
Dr. Mayes
At our March General Membership
Meeting, University of Richmond health
policy economist Rick Mayes sparked a
lively panel discussion by reviewing national trends that showed what he called
“an evaporation of smaller practices.” The
percentage of independent practices has
plummeted from 57 percent in 2000 to
33 percent in 2013.
And by 2020, Mayes predicted, “Less
than 20 percent of physicians will be
independent.”
“If physicians aren’t selling out to
hospitals, they’re more and more going to
larger practices.”
One reason for this trend is that the
overall rate of health care expenditure
growth in the U.S. has slowed from 6.5
percent for most of the past decade
to just around 3.6 percent since 2009,
making it harder to operate, much less
expand, a practice. In other words, while
expenses have continued to increase,
revenue growth has slowed.
Along with this trend comes another
source of “downward pressure on pricing”:
the Affordable Care Act, said Mayes.
With more price transparency either
required by law or simply expected by
consumers, Mayes said, “This could be one
of those awkward moments when people
know what individual doctors are paid…
This started in California, but is gaining
momentum across the country.”
The spread of high-deductible
health insurance plans is also “creating a
tremendous push-back by patients who
don’t want to pay” deductibles of more
than $3,000 per year. It’s no wonder,
then, that some patients delay or reject
medical treatment.
Mayes noted that Wal-Mart is
contracting with health systems known
for innovative practices—such as the
Cleveland Clinic, the Geisinger Health
System in Pennsylvania and Kaiser
Permanente in California.
It’s clear that for the foreseeable
future, physicians must keep adapting
to a shifting landscape, even one where
a discount retailer may be calling—or
ordering—the shots. R
the start of the Affordable Care Act.
I was aware that the Academy, now
2,300 strong, is made up of physicians,
midlevel providers and administrators who come from the full political
spectrum and from all practice styles.
We are made up of independent, employed and academic doctors. All have
opinions and we all know our own
opinions are the right ones!
How does a group this diverse, this
“herd of cats,” maintain a sense of
identity as we enter a sea of change?
In 2014, that sea appears to be the
largest ecosystem on earth. At the
federal level, we navigate the Affordable Care Act. We can agree that
increased coverage for those without
insurance is a positive
change. How we get there
and whether it is a success
is another question altogether. The accompanying
rules and regulations seem
to add credence to the
saying that “sometimes the
treatment is worse than
the disease.”
A number of Academy members started
the year by visiting the
state legislature where we
met with Lt. Gov. Ralph
Northam, a fellow physician, and with our local
legislators. In conjunction
with our friends at MSV, we did have
some success getting our legislative
priorities communicated. It was clear,
however, that the “Big Enchilada”
was, and is, what to do about Medicaid. What is going to happen to those
400,000 Virginia patients who fall
in the gap between current Medicaid
and the benefits of the Affordable
Care Act? This decision affects physicians, hospitals, taxpayers and, most
of all, patients. Again, this is political
football, with our members on each
side of the scrimmage line.
Earlier this month we heard from
Rick Mayes as well as three of our
own about the changing landscape of
“Change,” continued on page 2
The making of doctors:
looking back, looking forward
B Y I S A A C L . W O R N O M I I I , M D , FA C S
T
his issue of Ramifications focuses on changes in
medical education that are occurring all over the
United States and right here at home in Richmond at Virginia Commonwealth University.
The combination of a new building and, more importantly, a new curriculum is transforming how students are
educated to become medical doctors here in our city. I have
read through communications sent out by my medical school
just up the road that the same changes are happening at the
University of Virginia.
In reading Lisa Crutchfield’s article on the new curriculum at VCU’s School of Medicine (page 4), I was struck by
the radical change that has occurred during the first two
years of medical school in particular. Gone are the days
of dark lecture halls where first and second year students
sat for hours while lectures on biochemistry, anatomy and
physiology were delivered, notes taken, and after-class
study focused on the memorization of large numbers of
“Forward,” continued on page 3
4 A fresh framework for VCU
12
Surgeon in
Afghanistan
2 SPRING 2014
R
“Change,” continued from page 1
RAMIFICATIONS
RAMIFICATIONS
SPRING 2014
VOLUME 20
n
NO. 2
PRESIDENT
Peter A. Zedler, MD
VICE PRESIDENT
Harry D. Bear, MD, PhD
TREASURER
Ritsu Kuno, MD
S E C R E TA R Y
Sidney R. Jones III, MD
EXECUTIVE DIRECTOR
Deborah Love
EDITOR
Isaac L. Wornom III, MD
C O M M U N I C AT I O N S A N D
MARKETING DIRECTOR
Chip Jones
[email protected]
(804) 622-8136
ADVERTISING DIRECTOR
Lara Knowles
[email protected]
(804) 643-6631
ART DIRECTOR
Jeanne Minnix Graphic Design, Inc.
[email protected]
(804) 405-6433
RAM MISSION
The Richmond Academy of Medicine
strives to be the patient’s advocate,
the physician’s ally, and the
community’s partner.
Published quarterly by the
Richmond Academy of Medicine
2201 West Broad Street, Suite 205
Richmond, Virginia 23220
(804) 643-6631
Fax (804) 788-9987
Non-member subscriptions are
available for $20/year.
The opinions expressed in this
publications are personal and do not
constitute RAM policy.
Letters to the editor and editorial
contributions are encouraged, subject
to editorial review. Write or email
Communications and Marketing
Director Chip Jones at
[email protected].
To become a member of
The Richmond Academy of Medicine,
Inc., visit www.ramdocs.org and join
today. For membership questions,
please contact Kate Gabriel
at [email protected] or
(804) 643-6631.
ON THE WEB
www.ramdocs.org
© Richmond Academy of Medicine
health reform. The future of health
care will result in changing relationships. Will the rise of mega-groups,
hospital ACOs or physician associations be worth the effort? Will they
provide better care or will they serve
only to further divide the medical
community? Will all the new rules
and regulations make us better, or
force some to leave the profession?
While this may seem like the neverending winter of discontent, I think
there is a reason for encouragement. I
am speaking about two items of good
news! Things that all members of the
Academy, as physicians and others
involved in caring for patients, can
feel good about.
Last year, the Board of Trustees of
the Academy approved dedication of
time and treasure to develop a program of advance life care planning for
the Richmond community. Earlier this
year, all three Richmond health systems—Bon Secours Richmond, HCA
Virginia and the VCU Health System—joined our effort. This program,
long overdue, will help patients and
their families understand the choices
of end of life care planning and reassure patients that both family and
healthcare providers will respect their
wishes. Whether we are the patient or
the doctor, I am confident that this is
a program worthy of our support and
of which we can be proud.
In early March, the VCU Health
System Authority Board voiced its
support for discussions with organizations, including Bon Secours and the
Pediatricians Associated to Care for
Kids (PACKids), for the development of a free-standing, independently operated children’s
hospital. This significant action
shows willingness on the behalf
of the health system to be a
partner, not owner, of a tremendous community resource.
VCU brings to the table
recognized pediatric medical education, acknowledged
research breadth and vigor, a
steady supply of well-trained
pediatricians, and the experience needed to offer tertiary
care for children with serious
or chronic conditions.
The community brings to the
table a broad and deep network of well-respected pediatricians,
specialists and subspecialists who daily
treat thousands of infants and children. These doctors understand parental preferences, and have the pediatric
understanding and passion to envision
what a facility focused exclusively
on children can achieve. The community also brings to the table strong,
determined and willing philanthropic
support that is essential for the success
of this enterprise.
The VCU Medical Center’s support
for an independent governing board
for a new children’s hospital moved
this vision one step closer to reality.
We have the opportunity to help
promote this endeavor by encouraging thoughtful collaboration by so
many talented individuals. Both VCU
and the community pediatricians deserve our support and encouragement
for the actions each has taken for the
sake of children’s health. As Gandhi put it, “You must be part of the
change you wish to see in the world.”
Perhaps the single most important
element of our support begins when
we are open to laying down old perspectives, embracing new ideas, and
holding clear and present the vision
of a better Richmond for all children.
I do not know how our state’s or
our nation’s attempt at healthcare reform will turn out. Nevertheless, I do
know we have two opportunities to
improve how health care is delivered
in our community—the advance care
initiative and the children’s hospital
initiative. We need to come together to
recognize, support and celebrate those
efforts that make care better for all. R
Dr. Bob Bennett:
Electrifying Access Now
BY CHIP JONES
Dr. Robert M. Bennett is widely
known for helping start the Goochland Free Clinic in 1999. But what’s
less well-known is his behind-thescenes role in helping to develop an
electronic medical referral system
for the uninsured population of the
greater Richmond area.
More than a decade later, Dr.
Bennett’s early work with a group of
engineering students is much appreciated by the Academy’s charity care
program, Access Now. Known as
a “free clinic without walls,” more
than 900 specialists from RAM,
along with mid-level providers, provide uninsured patients with access to
care in nearly 40 specialties.
Access Now also is supported by
Bon Secours Virginia, HCA Virginia
and a number of generous grants
from area foundations, including the
Virginia Health Care Foundation,
Jenkins Foundation and Richmond
Robert M. Bennett, MD
Memorial Health Foundation.
Bennett’s invaluable work on electronic medical records for the uninsured began 10 years ago up the road
in Charlottesville, where he was mentoring a group of senior engineering
students at the University of Virginia.
Earlier, in 1998, Bennett had taken
an extended sabbatical as a cardiologist in Richmond. At the time, he recalls, “I wanted to put my two loves
together—engineering and medicine.”
“One of my professors used to
dock me a letter grade because he
knew I was going to medical school,”
Bennett ruefully recalled.
So it was that after retiring from
private practice, he earned a master’s
degree in systems engineering at UVa.
in 2002.
After he began teaching there, he
recognized the untapped potential of
taking systems engineering concepts
and using them to improve health
care delivery.
“I was practicing then the same
way as when I graduated from medical school in 1972…Your processes
were still pen and paper—the same
way it was in 1950.”
Prescriptions were written on
pads, records were kept in folders and referrals were sent by fax.
So when a fellow UVa. professor
challenged Bennett to design a new
“Bennett,” continued on page 3
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3
“Forward,” continued from page 1
facts to eventually be regurgitated on
tests. This has been replaced by team
learning, early exposure to patients
and an emphasis on interdisciplinary
care.
For most of us practicing medicine
here in Central Virginia, I suspect
those dark lecture halls do not hold
fond memories. I for one could not
wait to get out of them and into my
third year of medical school when I
would actually get to see patients.
I don’t remember much about
the Krebs cycle but I remember
with clarity the occasional “clinical
correlation” during my first year
of med school at UVa. when a real
patient would actually appear in the
lecture hall with his/her doctor. I
can tell you all the details about the
urologist, Darracott Vaughan, and
the patient with renal cell carcinoma
he brought in to talk to us about the
illness and its treatment and how it
impacted life and family and what
was done to fight the disease. If the
new changes are bringing more of
this type of experience, I am sure the
students are happier, and I would
guess the anatomy and physiology
facts they learn are applied to clinical
situations earlier.
When I started to see patients
during my third year of med school I
did not really think the dark lecture
halls had prepared me very well for
what was expected of me. I was really
uncomfortable at first on the ward
and remember being very unsure of
myself. I did, however, have lots of
knowledge of anatomy and physiology and various diseases, and over
my third year of medical school the
clinical skills that would serve me well
for the rest of my career slowly began
to develop. These skills developed by
watching good doctors work and emulating them and continuing to study
and think about the patients I saw and
their illnesses using the facts learned
the first two years. My sense is that
one of the goals of the new curriculum
is to develop those skills sooner.
When I started to see patients during my third
year of med school I did not really think the dark
lecture halls had prepared me very well for what
was expected of me.
For me personally, however, it was
in surgical residency that my growth
and development as a physician took
off. Part of that was the immense
amount of time I was required to be
at the hospital then; like many in my
generation I pretty much lived there
during residency. More than that
though, it was the first time I felt true
responsibility for what was happening
to my patients. With responsibility
came emotional involvement and
caring. With caring came the intense
learning that imprints your brain
with things you never forget. These
experiences emphasize what the great
Dr. Francis Peabody said in his famous
lecture at Harvard Medical School in
1925, “For the secret of the care of the
patient is in caring for the patient.”
In addition to the changes in
medical school, one of the biggest
changes in the past 10 years has
been the installation of an 80-hour
workweek for residents — a far cry
from the 100-hour-plus workweeks
many of us survived. This change was
done primarily in the name of patient
safety so exhausted doctors who
could potentially make more mistakes
would not be caring for patients
when they were tired. One of the
potential problems with this change
in graduate medical education, which
is undoubtedly here to stay, is that
residents will not have the same
opportunity as those of us from the
past did to see patients all the way
through the acute stage of their
illness because they have to go home.
This may slow their acceptance of
responsibility which is the key to the
most intense learning.
“Bennett,” continued from page 2
course that would apply information
technology to medical records, the
proverbial light bulb went off.
Several years before the creation of
Access Now by the Richmond Academy of Medicine in 2007, Bennett and
his team approached the RAM board
with a project proposal “to design an
electronic medical referral system for
the indigent population in Richmond,
Virginia, which will facilitate specialist health care for the uninsured and
underinsured,” according to a paper
written by the UVa. team.
The project was enthusiastically
backed by RAM’s board of trustees,
and RAM put his team in touch with
area free clinics, including Cross-
Over Healthcare Ministry. They also
received funding from HCA Virginia and Bon Secours Richmond to
conduct the in-depth analysis of what
were then 14 area safety net clinics.
Today, Access Now works with 22
free clinics with an electronic database
that fulfills Bennett’s vision of a decade
ago. “I found it very gratifying to see
this vision turned into a reality.” R
Chip Jones is RAM’s communications
and marketing director.
Finally, I think the new emphasis
on interdisciplinary team care in
medical school is long overdue and
will yield great dividends in the future.
I am writing this while at the annual
meeting of the American Cleft Palate
— Craniofacial Association. ACPA,
which is 71 years old this year, was
founded on the principle that children
with cleft lip and palate should be
cared for by a team of surgical, speech
and dental specialists who talk to
each other. This organization was
ahead of its time. For many diseases
we treat, such as cancer, heart disease,
debilitating neurologic conditions
and cardiovascular disease, the same
principles apply. Often teams of
various doctors, nurses, social workers
and other health care personnel who
talk to each other are rendering care
together for the good of the patient.
RAM Ad 4.875 x 7.75
1/6/14
11:36 AM
The sooner new medical students
learn to function in a collaborative
way, the better for all of us.
It will be very exciting going
forward to see how these changes in
medical education impact the finished
product. I for one am hopeful the
physicians of tomorrow will be
bright, collaborative, responsible,
caring doctors who spend time
talking to their patients and rendering
excellent care. R
Dr. Wornom practices at
Richmond Plastic Surgeons and
is a past president of RAM. He
can be reached at Wornom@
richmondplasticsurgeons.com.
Page 1
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4 SPRING 2014
The McGlothlin Medical Education Center connects to VCU’s Main Hospital.
A fresh framework:
VCU has a new curriculum that fits its
ultramodern medical education building
BY LISA CRUTCHFIELD
25,000
square feet
Amount of
dedicated space
for human
simulation
training on two
floors of the
new center.
“It is easier to move a cemetery
than to change a curriculum,”
Woodrow Wilson observed while
serving as president of Princeton
University.
It’s definitely not easy, but sometimes it’s necessary, and so Virginia
Commonwealth University’s School
of Medicine introduced its most
significant curriculum change in more
than 30 years this past fall.
The change is aimed at getting
medical students into clinical areas
earlier, to work as part of teams and
to be ready to face the challenges of
Jerome F. Strauss III, MD, Ph.D.
21st-century medicine.
It’s a fairly radical change from the
old curriculum, which relied on largegroup lectures the first two years and
lots of memorization. That model was
more than 100 years old, reflecting
recommendations in a 1910 report
by Abraham Flexner, an American
educator who never attended medical
school but nevertheless was tapped
by the Carnegie Foundation to study
medical education.
Today, educators believe that
developing problem-solving skills,
teamwork and early exposure to clinical situations better prepare future
doctors for residency and ultimately
practice. “It’s about creating an active
curriculum,” notes Jerome F. Strauss
III, MD, PhD., dean of the VCU
School of Medicine. It’s also about
maintaining accreditation, and VCU—
faced with pending accreditation
requirements—decided to act. The
school opted to go above and beyond
minimum requirements, however,
seeking to develop the most compre-
Isaac K. Wood, MD
hensive medical education possible.
Tasked with leading the curriculum change was Isaac K. Wood, MD,
senior associate dean for Medical
Education and Student Affairs. Wood
scoured the country looking at curricula. “We could not find anything
that we felt consistently fit our needs.
So we had to come up with something new.”
VCU’s new curriculum—studentcentered, clinically relevant and
competency-based—was developed
with the input of more than 200
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faculty members and students. And—
an added bonus—its debut coincided
with the opening of a state-of-the-art
medical education building, designed
especially to enhance the curriculum.
The new curriculum came about
from a “backwards design,” said
Susan DiGiovanni, MD, assistant dean
for Medical Education, who supervises
first-and second-year students. “We
started out by thinking about what we
want our graduates to look like when
they walk out the door.
“We listed a lot of knowledge,
skills and attitudes,” she said. “A lot
of this has to do with professionalism
and communication and empathy
and respect and things that are as
important as just knowing which
medication to use.
“And from there, we designed our
curriculum.”
It was a laborious process, said
Wood. “We had to sit down and
dissect every old course and every
lesson and every topic and figure out
where in the new curriculum they fit
together.
“Our goal was to graduate
students who were much more
advanced than their peers from other
medical schools when they started
their internship.”
The traditional 2+2 curriculum
Michael Ryan, MD
Memories of Med School
Susan DiGiovanni, MD
(two years of preclinical followed
by two years of clinical) changed to
something more akin to a 1.5+2.5
model. The first year remains what
most physicians remember: biochemistry, anatomy, histology, etc., and
now the second year is taught by
organ system, first teaching the normal and then the abnormal. As part
of this new integrated curriculum,
students can begin working in the
hospital during the second year.
At the core is the Practice of Clinical Medicine (PCM) course, designed
to integrate basic principles into clinical scenarios. M1 students don’t spend
all their time in lecture halls; instead,
they’re thrust into situations requiring
hands-on practice. “We had a boot
camp the first week,” said DiGiovanni. “Students saw a standardized
patient and were making a diagnosis
in their first week of medical school.”
During the school year, students
alternate between small groups and
standardized patient scenarios.
“Students might learn the
normal anatomy of the back and
shoulders one day and then the
next, orthopedic surgeons might be
showing them how to treat a sprain,”
said DiGiovanni.
“Framework,” continued on page 6
Virginia Commonwealth
University’s School of Medicine
introduced its most significant
curriculum change in more than
30 years this past fall.
The new curriculum stresses the importance of working in teams, which is aided by large,
u-shaped tables.
L. RANDOLPH CHISHOLM, MD
Midlothian Family Practice
I graduated from Eastern Virginia
Medical School in 1977 where a new
school emphasis was placed on the
psychological aspects of medicine.
Students were placed in patient care
situations early in our school year
learning how to talk with patients even
though we did not have any idea what
we were doing. The school wanted us to
learn how to listen and interact. Classes
were small, consisting of 35 students.
1970s
JOHN F. BUTTERWORTH IV, MD
Department of Anesthesiology
VCU School of Medicine
I attended MCV between 1975-1979.
We spent most of the first two years
seated in two classrooms in Sanger Hall.
It’s a wonder that we did not develop
decubitus ulcers.
AARON S. ROSENBERG, DO
Chief Medical Officer Virginia
Medicaid/Medicare Program
Senior Medical Director National
Medicare
When I attended medical school in the late
1990s, the initial two years were primarily
lecture-based learning. The entire class
of over 100 students attended the same
lectures. The lectures were primarily driven
by Microsoft PowerPoint slides.
1990s
JULIE KERR, MD
Commonwealth Ear Nose
and Throat Specialists
I missed one lecture in the first two years.
It was helpful to hear what the professors
focused on, and courses ranged from
biochemistry to anatomy to military
medical history. I then completed clinical
training for medical school in the next
two years at the Uniformed Services
University. I most recall lots of note
taking, putting together power point
presentations that I saved on those old
square hard discs for computers, and
quite a few of my professors/proctors.
This was mixed in with my Army training
as a physician with field training exercises
that included care of simulated battle
injuries in simulated combat zones, and
summer experiences with 18D (Special
Forces Medics) and Apache Pilots.
USU prepped us to handle extreme
circumstances for patient care. I’d go
back and do it again in a heartbeat.
2000s
SARAH G. WINKS, MD
Third-Year Resident,
VCU Medical Center,
Department of Radiology
For the class of 2010, traditional
lectures were supplemented with
small group experiences, including an
early introduction to clinical medicine
through the Foundations of Clinical
Medicine course.
2010s
5
6 SPRING 2014
“Framework,” continued from page 5
The McGlothlin Medical Education Center was designed to complement VCU’s new curriculum.
“Studies have shown that students
can better retain information this
way.”
The lessons of the first two
years of the old model now are
concentrated into 18 months, as
the new curriculum eliminated
many redundancies. “Not much has
changed in what they’re learning,”
said Michael Ryan, MD, assistant
dean for Clinical Medical Education,
who oversees third-and fourth-year
students. “What’s changed is how
they’re learning it.
“Nowadays, doctors are part of
interdisciplinary teams, and a big part
of the new focus is learning how to
communicate across the disciplines,”
he said.
That interdisciplinary approach is
one of the things that sets VCU apart,
said Wood. Another is the focus on
patient safety, such an important
consideration that VCU recently hired
Gene N. Peterson, MD, Ph.D., as
associate dean for patient safety and
quality care in the School of Medicine
and chief safety and quality officer for
the VCU Health System. It’s a dual
role that incorporates the realms of
clinical work, academics and research,
reflecting medicine’s increased
awareness and focus on safety.
Another feature of the curriculum
is the work students undertake in
the 25,000-square-foot Center for
Human Simulation and Patient
Safety, which features high-tech
mannequins to simulate procedures
from childbirth to colonoscopy, as
well as live standardized “patients,”
often drawn from VCU’s Department
of Theatre.
Small groups of students interview
a standardized patient, work through
the case using specialized computer
programs and “order” physical
examinations and laboratory tests.
Those exams and tests are measured in
time and money, which students must
justify. From that, they’re expected to
make a diagnosis. “They’re getting
feedback in practical material from the
moment they get here,” said Wood.
The curriculum change reflects
changes in how today’s physicians
are treating patients, said Ryan.
“Naturally, there have been changes in
medicine in the past 100 years. When
the [old] model was constructed,
most people were dying of acute lifethreatening infectious diseases such as
pneumonia or tuberculosis, and so on.
It’s shifted, and now people are dying
of chronic diseases such as diabetes
and hypertension. So the framework
of training students had to shift.”
In addition, some specialties,
such as radiology, anesthesiology
and emergency medicine, were
underrepresented in the traditional
model. “Every student might not
need to know how to read an X-ray
or CAT scan,” said Ryan. “But they
need to know when to order it, the
pros and cons, and the indications.”
At the same time Wood and other
faculty members were developing the
Today, educators believe that developing problemsolving skills, teamwork and early exposure to
clinical situations better prepare future doctors for
residency and ultimately practice.
An end to
“silos”
The collaborative
nature of 21st
century medicine
marks a shift
away from the
“silos” that have
often separated
medical students
from peers in
related health
professions.
The Center for Human
Simulation and Patient
Safety offers students a
chance to learn from hightech mannequins.
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new curriculum, the $158.6 million
James W. and Frances G. McGlothlin
Medical Education Center was
going up on campus between Main
and West hospitals. The curriculum
planning committee was able to
integrate components of the new
courses into the physical space of the
12-story, 200,000-square-foot facility.
School of Medicine technology
experts created a computer system
to complement the new curriculum
and even some of the desks were
designed to foster the team approach
to learning.
Early reaction to this year’s crop
of M1 students has many faculty
members convinced of the strength of
the new curriculum, said DiGiovanni.
“The faculty has commented on how
mature the students’ notes are.”
Schools that have had similar
curriculums in place for several years,
such as Case Western Reserve, have
published data showing that board
scores have risen and students have
reported being much better prepared
for residencies than their cohorts,
she said.
VCU’s curriculum, Wood believes,
is unique in the nation, going
above and beyond all licensure and
accreditation standards.
“Framework,” continued on page 8
McGlothlin
MEC honored
Designed by I.M. Pei’s
architectural firm, the
James W. and Frances
G. McGlothlin Medical
Education Center was
honored last year by an
educational planning
& design organization,
American School &
University, in the
category of specialized
facilities.
A simulated patient (middle) takes questions from students trying to diagnosis her illness.
Bright and open spaces invite students to take time out to chat between classes.
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“Framework,” continued from page 7
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“In building the new curriculum,
we envisioned medical education as
a continuum from undergraduate
to postgraduate,” said Strauss. “In
building course and curriculum
objectives, we paid a lot of attention
to residency curricular programs.
So we were in fact harmonizing the
graduate medical education experience
to what these students are moving on
to when they start residencies.”
Wood hopes that students won’t
be the only ones benefiting from the
facilities and program; he thinks area
physicians can play a role in their
own continuing education, whether
it’s practicing new techniques in
VCU’s simulation center, talking to
students about real-world experiences
or even being a standardized patient
themselves.
When considering applicants for
the medical school, VCU admissions
staff are looking for learners who can
embrace the new philosophy, said
Strauss.
“We have to select people who
are going to be successful with this
new learning paradigm. Students are
smart. They understand that they
have different learning styles. But we
need to be sure the people who come
here are not the passive learners.
They have to be ready to step up.”
VCU has a wealth of candidates
to choose from, as applications have
nearly doubled since Strauss assumed
his role nine years ago.
In addition to being open to modern learning styles, Strauss is looking
for another quality. “We’re looking
at our applicant pool for leadership
potential. There are huge changes
in [health care] policy and a need to
move medicine in a way so it’s more
cost-effective and accessible. That’s
going to require people stepping up
to the plate and being proactive.
“We’re looking for people who
will improve the health of our
patients and improve the health of
our nation.”
School of Medicine faculty
members are pretty sure students will
have the best education to go out and
do that. “I’ve been saying that if I
didn’t have to pay the tuition, I’d love
to go back to medical school,” said
DiGiovanni. R
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w w w.ramdocs.org
9
A time to be cherished
B Y S H I K H A G U P TA
98
%
of the 186
VCU School
of Medicine
students
participating
in the 2014
Match Day
found residency
positions.
Second-year medical student Shikha Gupta (right) with fellow M2 Mark Hylton. They are student trustees on the RAM board.
B
y nature, human beings are
storytellers. The sharing of
stories and experiences has
long-served as the backbone of knowledge and information
transmission, and despite the advent
of dramatic technological changes,
the oral passage of advice and history
from teacher to student remains a
constant. As one of a very small (but
growing) cohort of medical student
members of the Richmond Academy
of Medicine, I am privileged to be
ters. One motif, however, weaves a
ubiquitous thread through all of these
physician-student interactions: Medical school is a unique, once-in-a-lifetime opportunity for self-discovery,
personal and academic growth, and
exploration of the capacity and limitations of the relationship between
medicine and the human experience.
It is, despite its great challenges and
seemingly endless demands, a time to
be cherished.
The four years spent within the
It is a well-kept secret that medical
school is, at various times, awe-inspiring,
transformative, and (believe it or not) fun.
one of two student trustees on the
Academy’s board. I’m no stranger to
being on the receiving end of advice,
nostalgia, and stories from practicing
and retired physicians.
These exchanges range from cautionary tales of the perceived rising
opportunity cost of practicing medicine in the wake of a rapidly changing healthcare climate to starry-eyed
recollections of first surgical experiences and notable patient encoun-
walls, both real and imaginary, of
medical school offer an incubatory
time period for student doctors to
bridge the gap between our former,
non-medical lives and our future
lives as capital P Physicians. To some
extent, medical students are insulated
from the “real world,” which gives
us the opportunity to devote the time
and energy necessary to excel academically in a competitive medical
school, but renders us mostly useless
in conversations about current events,
pop culture, and general knowledge
outside the field of medicine. (Medical students, on the whole, are not
great candidates for trivia teams.) As
has been the tradition for centuries,
the art and science of undergraduate
medical education revolves largely
around consuming, digesting, and
regurgitating vast amounts of information in small periods of time.
Despite being a great champion of
tradition, however, the VCU School
of Medicine is challenging the adequacy of the status quo of traditional undergraduate medical education
on nearly every front. The current
first year members of the Class of
2017 are in the thick of the inaugural
year of a brand-new medical curriculum that condenses the typical
four preclinical semesters into three,
providing earlier, longer exposure to
clinical clerkships for MCV students.
Dr. Chris Woleben, associate dean for
Student Affairs and MCV alumnus,
acknowledges that the implementation of the new curriculum has had
its share of growing pains, but points
out that “VCU is leading the pack in
ingenuity and innovation in undergraduate medical education. We are
creating an educational system that
lends itself to a longitudinal, integra“Cherished,” continued on page 10
10 S P R I N G 2 0 1 4
58
The number of
VCU medical
students
matched into
primary care
fields, including
Internal
Medicine (31),
Pediatrics (14)
and Family
Medicine (13).
“Cherished,” continued from page 9
tive, technology-driven understanding of medicine that will provide our
students with a distinct advantage as
practicing physicians.”
To complement the new curriculum, the architecturally inventive and
academically advanced McGlothlin
Medical Education Center (MMEC),
the new (and vastly improved) home
of the medical school, opened its
doors in March 2013. The 12-story,
200,000-square-foot building boasts
four floors of “Learning Neighborhoods” designed to facilitate the transition from a primarily lecture-based
curriculum to an active, team-based
learning model structured by clinical
cases. The state-of-the-art LEED-certified building also houses the two-story
Center for Human Simulation and
Patient Safety, which provides students, residents, and faculty alike with
unparalleled access to realistic clinical
simulations, patient mannequins, and
standardized patient encounters.
As a member of the last class of
MCV students being educated in the
style of the “traditional” curriculum,
I have to admit that I approached
these changes with a distinct sense
of trepidation. The administration
wanted us to interact with fellow
students, read textbooks instead of
pre-prepared outlines, and (horror of
horrors) actually show up to class.
The 75 percent of my class comprising the pajama-clad cohort of “home
studiers” shook its fist and voiced its
vehement disapproval of any curriculum that required leaving home study
spaces (read: beds). We were dubious
about listening to faculty members address us face-to-face in real time rather
than listening to lecture recordings at
double speed later. Shake our fists as
we might, it quickly became clear that
the curriculum was changing with or
without us, so our only option was to
go along for the ride.
Though it was a distinctly bumpy
ride at times, it was incredibly refreshing to leave the confines of the lecture
hall to tackle clinical cases in teams
of my peers. The opportunity to
directly apply my hard-earned medical knowledge to clinical scenarios
in a group setting tested my capacity
for creative thinking, peer teaching,
and, of course, rapid-fire Googling. I
walked away from “new curriculum”
courses with not only a deeper, more
thorough understanding of the material, but with a distinct sense of accomplishment at the ownership I was
(politely) forced to take over my own
education. The marriage of the new
medical school building and curriculum is seamless, and the thousands
of hours of strategy sessions poured
into its development are apparent
in every detail, from the inclusion
of social spaces on each floor to the
selection of lecture hall chairs that
lend themselves to hours of comfortable studying to the whiteboard walls
throughout the building.
To me, the most notable feature of
the rapidly evolving climate of change
and development that is almost palpable in its intensity on the MCV campus is the willingness and desire of the
faculty and administration to incorporate the student perspective into the
decision-making process. All students
are encouraged to take advantage
of our deans’ open-door policies to
make suggestions and voice concerns,
and elected student representatives
serve as a streamlined conduit for
information exchange between the
student body and the administration.
Kunal Kapoor, president of the Class
of 2017, says, “What strikes me the
most is that the administrators are
not only very down-to-earth, but also
express a genuine interest in making
sure we succeed.”
On a personal note, I have spent
the past year transforming MCV
into the closest approximation of
w w w.ramdocs.org
Hogwarts (the fictional wizardry
school in the Harry Potter book
series) that I can. The student body
is divided into four societies that
competed to earn points for their
houses all year in a tournament
composed of a series of community
service, academic, athletic, and spirit
events, culminating in the inaugural
Strauss Cup Society Field Day,
named for Dr. Jerome Strauss III,
who began his tenure as dean of the
medical school in 2005. The event
received unprecedented support from
the entire school, and it functioned
as an opportunity for students,
faculty, administrators and their
families to come together for a day
of camaraderie, school spirit, friendly
competition, and the opportunity to
see some of our favorite professors
and student leaders in the dunk tank.
It is a well-kept secret that medical
school is, at various times, awe-inspiring, transformative, and (believe
it or not) fun. My motivation for
devoting the time and energy required
to organize these events is two-fold.
First, MCV is on the cusp of becoming one of the premier medical
education institutions in the nation,
and it is time to forge a series of new
traditions at this school that represent
the diversity of backgrounds, interests, and personalities of our student
body. The development of the societies and the Strauss Cup Tournament
is a tradition that is equalizing and
accessible to all members of the MCV
family. Second, when I look back on
my time as a medical student 10 years
from now, I expect that I will have
forgotten the names of the enzymes in
the Krebs cycle, and the memories of
the stress of studying for exams will
have faded with time, but I hope to
look fondly back on the time I spent
becoming the person I will be as a
practicing physician.
When I eventually transition from
the role of student and recipient of
knowledge to that of teacher and
storyteller, I will tell future aspiring
physicians about the years I spent at
MCV with pride, both in the quality
of the education I received and in the
role my peers and I played in helping
to shape this institution into what it
will one day be. I feel privileged to
have the opportunity to learn the tools
of my future trade here, and I make
a concerted effort each day to cherish
this uninterrupted time for personal
growth and the development of the
collection of skills, experiences, and
advice from which I will draw and
pass along to my own students as
a practicing physician. Even as the
field of medicine faces a challengingly
uncertain path in the years to come,
the future for MCV students is bright
and we will meet the challenges ahead
armed with the knowledge that we
received an excellent, well-rounded
undergraduate medical education. R
11
VCU’s medical
students had
good success
matching into
other specialties,
including
Anesthesiology
(21), Obstetrics
and Gynecology
(15), Emergency
Medicine (14),
General Surgery
(10), Diagnostic
Radiology (8)
and Orthopedic
Surgery (8).
Shikha Gupta is in her second year
at VCU Medical School. She can be
reached at [email protected].
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Neighborhood
The health care services and programs of VCU Medical Center are now closer
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South Hill, Virginia 23970
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VCU MCV Physicians at Temple Avenue
Puddledock Medical Center
2035 Waterside Road, Suite 100
Prince George, Virginia 23875
(804) 957-6287
Internal Medicine and Pediatric Associates
Chesterfield Meadows Shopping Center
6433 Centralia Road
Chesterfield, Virginia 23832
(804) 425-3627
VCU MCV Physicians in Williamsburg
1162 Professional Drive
Williamsburg, Virginia 23185
(757) 220-1246
South Hill Internal Medicine and Critical Care
412 Durant Street
South Hill, Virginia 23970
(434) 447-2898
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140103_Ramifications.indd 1
1/6/14 4:27 PM
12 S P R I N G 2 0 1 4
Ready to serve. Dr. Cliff Deal (first row, 2nd from left) with members of the 945th Forward Surgical Team at FOB Apache’s trauma center in a remote part of eastern Afghanistan.
Under the gun: a combat
surgeon in Afghanistan
BY CHIP JONES
Editor’s note: This is the first of a series
of articles about Academy members’
military service.
Dr. Deal with Kim Accardi, MD, an orthopaedic surgeon from Philadelphia, in the trauma
bay at FOB Apache.
O
n his first tour of duty in 1989, Cliff Deal had no time to think
before leaving for his first combat deployment.
As part of the U.S. Army’s 82nd Airborne Division heading
into Iraq during Operation Desert Storm, Deal said, “We were the
alert battalion for the entire United States. They called on a Sunday night, and I
didn’t come back to the U.S. for eight months.”
With his Washington & Lee roommate also answering the call to battle, they
ran out of the house in Fayetteville, N.C., where they were stationed at the time.
“You could see the trail of our various clothing items. … You put on your uniform and ran out the door.”
He was a freshly-minted Army lieutenant at the time. Today, Dr. Clifford L.
Deal III is a surgeon at Richmond Surgical and a board member of RAM. In a
recent interview, he shared his experiences from 2013 during a four-month-long
deployment as a combat surgeon in Afghanistan. As he operated in a forward
operating base in a remote part of eastern Afghanistan, he survived a firefight with
a rogue Afghan soldier that took place dangerously close to his operating room;
he was later awarded a Combat Action Badge.
Deal was in the thick of a complex, often troubled military action, which led
to severe precautions in his OR. After a number of attacks by Afghan soldiers
on American forces, whenever American doctors operated on non-NATO
personnel they were closely guarded by an American soldier with a drawn M16
automatic rifle.
Deal’s surgical team also had to use metal-detecting wands on every patient to
ensure no bombs or weapons were sneaked into the OR. Soldiers from Taliban
units were blindfolded as they were taken off helicopters and carried on stretchers.
“It’s not your normal medicine,” Deal observed.
w w w.ramdocs.org
He was well-prepared to deal
with the “fog of war” from his early
experiences during Desert Storm. Back
in 1989, after a long flight to Saudi
Arabia, he and fellow soldiers were
amped up as they landed at a military
base, dressed in full combat gear.
When the plane dropped its ramp and
the soldiers disembarked, “We were
pointing our weapons out of the back
of the plane, and there’s an Air Force
guy with a Walkman on who says,
‘Yo! What’s up?’”
His part of the 82nd Airborne
was attached to a French light armor
division and in this joint military
operation to drive Saddam Hussein
out of Kuwait, the joint forces attacked Iraq’s western flank. As they
encountered Iraqi units in this desert
territory, he recalled, “It was either
total destruction or total surrender.
… Resistance was fairly light.”
After four years of active duty service, Deal left the Army to enter the
Medical College of Virginia where he
studied to become a surgeon. But he
remained in the U.S. Army Reserve,
assigned to a combat surgical team.
Based in Minnesota, the 945th
typically is activated for nine months
at a time—this includes medics and
nurses—while doctors usually have
90-day rotations, with another month
to prepare. “If you’re in private practice, you can imagine the overhead
you have,” he explains.
He began preparing for his latest Reserve tour duty last August. It
would last through December. First,
he went to Fort Benning, Ga., where
he had to qualify with his Beretta
9mm pistol—which he did, just missing expert by one point. (“I practiced
Steep toll
of war
…whenever American doctors
operated on non-NATO
personnel they were closely
guarded by a U.S. soldier with
a drawn M16 automatic rifle.
before I went down there,” he noted.)
Then he flew to Kuwait—arriving
in 115-degree heat. He experienced
a bit of déjà vu, thinking about his
arrival 23 years before that in Saudi
Arabia, but this time he flew commercial, and marveled at the amount of
security, with bomb-sniffing dogs and
other precautions. Another big difference was the nature of today’s combat
surgery: During Desert Storm, with
ground transportation available in
Iraq and Kuwait, medical teams could
operate behind the lines and injured
troops could be driven to them.
In Afghanistan, though, roadside
bombs and the remote locations of
American troops battling Taliban
forces made ground travel deadly. So
Deal found minimal movement on
the ground and air transport more
commonplace.
His Afghan duty had two distinct
Since the U.S.
launched military
operations in
Afghanistan in 2001,
followed by those
in Iraq, U.S. service
members have paid a
steep price. This count
was compiled Feb. 1,
2014, by the Wounded
Warrior Project:
6,795
Dead
51,876
Wounded
320,000
Traumatic brain
injuries
400,000
with PTSD
“Surgeon” continued on page 14
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14 S P R I N G 2 0 1 4
“Surgeon,” continued from page 13
phases—one filled with action, the
other not so much. The slow part
came first when he was sent to the
huge American base at Kandahar in
the southeastern region. First built
by the United States in the 1960s, the
air base later was occupied by the
Soviets after their 1979 invasion, and
then was rebuilt by the United States
after it invaded in late 2001 during
Operation Enduring Freedom. Today,
Kandahar is the country’s second
main international airport and can
handle up to 200 military aircraft.
While the base’s size and scope
is impressive, Deal often found
himself twiddling his thumbs over
a seven-week period in Kandahar.
“Our mission was to be the theater
reserve,” which meant his team
would help with any surgical work
that couldn’t be done by the Navy
medical staff on the base.
With 20 people on his forward
surgical team—four surgeons, two
certified registered nurse anesthetists
(CRNAs), plus more than a dozen
medics and other nurses—Deal
said, “We as a team needed to be
performing our mission to jell.”
The second phase began nearly
two months into his deployment
when he took half his team into a
mountainous valley in eastern Afghanistan called Qalat, which means
“fortress” in Arabic. In Army parlance it was FOB (forward operating
base) Apache, and serves as headquarters of the 3rd Brigade, 1st Infantry Division—also known as “The
Big Red One.”
“You could hear outgoing fire,”
Deal recalled, “there was a howitzer
about 100 meters from my tent firing
at Taliban.” The enemy forces usually
were operating 3 to 4 miles away in
the surrounding mountains.
Deal had little time to watch the
artillery fire, though, since his team
started operating right away. As part
of the ongoing downsizing taking
place with the American forces, his
10-person team replaced a Navy
medical team that was three times the
size of Deal’s operating unit.
“In our first 48 hours there we
operated almost nonstop,” typically
on Afghan troops who’d been shot
or severely wounded by improvised
explosive devices. “Honestly, we wondered how we were going to keep up
at that pace.”
Operating on little or no sleep,
they managed to save as many lives
as possible—including those of the
Taliban wounded who also were
brought in. “At Apache, I had a
flimsy building, but it had a modern
anesthesia machine, and a modern
OR table.”
He was asked to compare the surgery he performed in the battlefield to
his work in Richmond, particularly
when he serves as a trauma surgeon
at VCU. (Deal practices breast and
general surgery at Henrico Doctors’
Hospital, where he serves as department chairman.)
“The difference between there and
here is that you are really skinny on
people,” that is, “you’re alone” in
combat. “It’s just me, an orthopedic
surgeon and a CRNA. … At VCU
I’m used to being the attending, while
supervising surgical residents, so I
know how to oversee care of several
injuries at the same time.”
At FOB Apache, “I had to do the
same thing with three medics,” each of
whom served as a trauma team leader.
His time on call at VCU’s trauma
unit has proven to be invaluable to his
work as a combat surgeon. “Continuing to do that while I practice saved
me while I was in Afghanistan and
absolutely led to the saving of some
lives, because I had that experience.”
Whenever trauma occurs, the first
job is to stop the bleeding. In Richmond, “most people are shot with
low velocity weapons,” such as pistols, causing “a lot less damage.” In
Afghanistan, the wounds come from
high-velocity assault rifles, so “if you
get hit in the leg it will almost take
your leg off.”
Typically, after stopping the bleeding, the next job is to control any
contamination in the wound, and if
necessary, evacuate the soldier to the
next highest level of treatment, usually by helicopter back to Kandahar for
U.S. troops, or to Afghan facilities for
their troops. While the U.S. offers its
wounded soldiers and Marines “the
best prosthetics that money can buy,”
it’s not the same for Afghan soldiers.
For those who became paraplegics,
for example, “That’s often a death
sentence, because they don’t have any
support.” The same principle applies
to burn victims in Afghanistan versus
Americans who receive treatment
back in the States.
Asked about the stress level of his
three months of combat duty, his
pulse rate jumped the most one day
when he heard gunfire outside his
OR: An Afghan guard was firing on
U.S. troops. For the first and only
time during his deployment, Deal
grabbed his pistol and prepared to
defend himself and his OR.
He fired no shots, however, and
was soon operating on one of the
American soldiers who’d been shot in
the incident. The soldier was mortally
wounded, however.
Deal grows emotional as he recalls
his return to the U.S., landing in
Portsmouth, N.H.. “Practically the
whole town was there,” he says.
Since he deployed as an individual,
there was not much official fanfare
on the return home, which made the
New Hampshire welcome reception
especially meaningful. The Pease
Greeters [as in Pease International
Airport] have been welcoming home
troops 24/7 since the start of the
desert wars.
Looking back on the conflicted nature of the American military mission
in Afghanistan, and the overall lack of
awareness of the war today in the U.S,
he said, “Going over and coming back,
it’s like it doesn’t exist. There’s such a
disconnect.”
Nonetheless, he feels strongly
that this is a war worth fighting as
a means of clearing out the terrorist
haven that Afghanistan had become
before 9/11 when the U.S. drove alQaida’s leadership, including Osama
bin Laden, into hiding.
Asked whether he suffered extreme
stress, he said, that unlike combat
troops, “I wasn’t kicking down
doors every day.” For those soldiers,
“That’s a whole other order of magnitude of what I experienced. I wasn’t
in immediate fear for my personal
safety most of the time.”
Trying to explain his thought
process in the combat zone, he
concluded, “It’s like you’re worried
about walking in a bad neighborhood
where you shouldn’t be.”
Deal thanks his partners for
covering for him during his
deployment: Drs. George A. Knays,
Eric P. Melzig, William E. Kelley Jr.,
Richard J. Pettit, Debra A. Hutchins
and Richard F. Carter. R
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than an agency that was created by physicians? We understand
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MSVIA_HelpYou_ad_RAM2013.indd 1
4/4/2013 10:20:58 AM
THE MEDICAL SOCIETy OF VIRGINIA’S POLITICAL
ACTION COMMITTEE would like to thank the Richmond
Academy of Medicine staff and members for being the top
contributing district in 2013! A special thank you to:
w w w.ramdocs.org
15
GroUPS
PLATINUM ($10,000+)
OrthoVirginia
David R. Antonio, M.D.
Rachael Ashworth, PA-C
John W. Ayres II, M.D.
Matthew Hadfield Blake, M.D.
Andrew Miller Bogle, M.D.
Kacie Brosious, PA-C
Michael Heath Brown, M.D.
Barry W. Burkhardt, M.D.
Matthew P. Carleton, PA-C
Lindsay Carter, PA-C
Paul C. Celestre, M.D.
Andrew Basler Dahlgren, M.D.
Gordon Vincent Dalton, M.D.
Kennedy Scott Daniels, M.D.
Thorp J. Davis, M.D.
Mark Edwin DeBlois, M.D.
Sanjay S. Desai, M.D.
Jan-Eric Esway, M.D.
Jay Mark Evans, M.D.
Scott R. Frank, PA-C
Lockett Wootton Garnett, M.D.
Mark Halverson Hadfield, M.D.
Barton Harris, M.D.
Clifford Tate Hepper, M.D.
Marilee Horn, PA-C
Kurt Hossler, PA-C
E. Claiborne Irby Jr., M.D.
Steven H. Jones, M.D.
Mark McClellan Jones, M.D.
Glenn J. Kerr, M.D.
Susan D. Kewer, PA-C
Christopher Kisok Kim, M.D.
Joseph Sang Kim, M.D.
Paul George Kiritsis, M.D.
Christopher E. Mahan, PA-C
Michael W. Mariscalco, M.D.
Daniel McCall Martin, M.D.
David Wayne Miller Sr., M.D.
David Daniel Nedeff, M.D.
Jonathan James Newman, PA-C
William E. Nordt III, M.D.
Ricky James Placide, M.D.
William R. Polhamus, PA-C
Jacob Puglisi, PA-C, ATC
John Gordon Rawles Jr., M.D.
Abilio Antunes Reis, M.D.
Julia Saddington, PA-C
Thomas Neil Scioscia, M.D.
Anthony Joseph Shaia, M.D.
Harry Joseph Shaia, M.D.
Baljit S. Sidhu, M.D.
Emily Sigmon, PA-C
Julious Perry Smith III, M.D.
James E. B. Stuart V, M.D.
Brian James Swinteck, M.D.
Michael Thornton, PA-C
Julie Thornton, PA-C
Renarda S. Tolbert, PA
Lindsey Townsend, PA-C
Charles William Vokac, M.D.
John Vollmer, PA-C, M.H.S.
Matthew Holmes Walker, M.D.
Robert Douglas Wills, M.D.
Jeffrey Kent Wilson, M.D.
Michael Allen Wind Jr., M.D.
Dale Christopher Young, M.D.
Steven W. Young, PA-C
Virginia Eye Institute
Evelyn L. Baker, M.D.
William H. Bearden III, M.D.
James William Bowles, M.D.
Donna Dodson Brown, M.D., FACS
J. Paul Bullock Jr., M.D., FACS
Walter E. Bundy III, M.D., FACS
Thomas S. Carothers, M.D.
Jason A. Chiappetta, M.D.
James L. Combs, M.D.
Geoffrey Guy Cooper, M.D., FACS
T. Todd Dabney Jr., M.D., FACS
Eleanore M. Ebert, M.D.
Ethnie Small Jones, M.D.
Robert Mark Knape, M.D.
Seth R. Krawitz, M.D.
Byron Scott Ladd, M.D.
Francis A. LaRosa, M.D., Ph.D.
Evan J. Leslie, M.D.
Inna Marcus, M.D.
Read F. McGehee III, M.D.
Polly A. Purgason, M.D.
Grover C. Robinson IV, M.D.
William Rosenberger II, M.D.
George E. Sanborn, M.D., FACS
Jeffrey H. Slott, M.D.
Brent Elliot Smith, M.D.
E. Winston Trice, M.D.
Theodore T. Wu, M.D., Ph.D.
The Virginia Urology
Center
Cameron Ryan Barnes, M.D.
Gary Brooks Bokinsky, M.D.
Samir B. G. Boutros, M.D.
Timothy James Bradford, M.D.
Robert David Brown, M.D.
Judy Ling Chin, M.D., FACRO
Joseph Anthony Concodora, M.D.
Eric Paul Cote, M.D.
John Paul Delisio, M.D.
Katherine Flouras, M.D.
Michael Edmond Franks, M.D.
David Brendan Glazier, M.D.
Meghana Gowda, M.D.
Jill Marie Hilburger, M.D.
Mary Henderson James, M.D.
Charlie Jung, M.D.
Eugene Vincent Kramolowsky II, M.D.
Lang Robertson Liebman, M.D.
Douglas Henry Ludeman Jr., M.D.
James Madison McMurtry, M.D.
Wilson Caton Merchant III, M.D.
David Aaron Miller, M.D.
Mark Brown Monahan, M.D.
Margaret Thomas Montgomery, M.D.
William Ritchie Morgan, M.D.
David Patrick Murphy, M.D.
Kinloch Nelson, M.D.
Robert Tyrone Nelson Jr., M.D.
David Lee Palombo, M.D.
Dharamdas Motilal Ramnani, M.D.
David Elliot Rapp, M.D.
James Ellis Ratliff, M.D.
Scott Jackson Rhamy, M.D.
Kent Lawton Rollins, M.D.
Bruce Clifford Rowe, M.D.
Charles Alexander Seabury, M.D.
Anthony Michael Sliwinski, M.D.
Jason Scott Szobota, M.D.
Taryn Gayle Marie Torre, M.D., M.B.A.
George Alexander Trivette, M.D.
Charles Wadsworth, PA-C, M.P.A.S.
Jo Anne Walker, M.D.
Timothy Jude Wallace, M.D., Ph.D.
GOLD ($5,000+)
Virginia Physicians for
Women
Ramzi Elias Aboujaoude, M.D.
Alexis Grace Bachrach, D.O.
Rebecca Jayne Bedingfield, M.D.
Stephen H. Bendheim, M.D.
Todd Evan Billett, M.D.
Shannon Elynn Brim, M.D.
Warren Alan Broocker, M.D.
Samuel Jacob Campbell, M.D.
Mary Lynn Coble, M.D.
Leslie Lynt Davis, M.D.
Jennie Elizabeth Draper, M.D.
Cara Teres Golish, D.O.
Mark P. Hyde, M.D.
Kimberly Woods McMorrow, M.D.
Kenley Ward Neuman, D.O.
Christopher Emilio Paoloni, M.D.
John Robert Partridge, M.D.
Stephen Patrick Pound, M.D.
Ingrid Annemarie Prosser, M.D.
Nathan Rabhan, M.D.
David C. Reutinger, M.D.
Erica Madlock Royal, M.D.
Padmini Santosh, M.D.
Emily Joan Stone, M.D.
Corinne N. Tuckey-Larus, M.D.
Amanda Burton Vaughan, D.O.
SILVER ($2,500+)
Advanced Orthopaedic
Centers, P.C.
Chris Arnold, PA
Larry Leone Benson, M.D.
William Darnell Brickhouse, M.D.
Cary E. Cowlbeck, PA-C
Adam Christopher Crowl, M.D.
Michael John Decker, M.D.
Rebecca Ellen, PA
Bradley S. Ellison, M.D.
Steven Mark Fiore, M.D.
Keith A. Glowacki, M.D.
Jeff Grant, PA
Marion M. Herring, M.D.
Geoffrey B. Higgs, M.D.
Douglas E. Jessup, M.D.
Warren Byars Kirby, M.D.
Robert Klase, PA
Cyrus Scott Kump II, M.D.
Sean Little, PA-C
Thomas Paul McDermott Jr., M.D.
Chris Newlin, PA
Douglas Matthew Okay, M.D.
Steven Glenn Reece, M.D.
Jose Salvador Reyes, M.D.
Rozita Reyes, PA-C
Joy Vashisht Sharma, M.D.
Blakely Stank, PA
J. William Van Manen, M.D.
Douglas A. Wayne, M.D.
Vince Williams, PA
Kenneth R. Zaslav, M.D.
Commonwealth
Radiology, PC
Todd Biery Baird, M.D.
Jessica Berliner, M.D.
Robert R. Beskin, M.D.
James Elam Bosworth, M.D.
Douglas Eugene Cook, M.D.
David Glenn Disler, M.D.
Mark Shepherd Dixon, M.D.
Jean M. Dufour, M.D.
David Price Ekey, M.D.
Maurice Frank Finnegan Jr., M.D.
Robert A. Goldschmidt, M.D.
Amos Quintino Habib, M.D.
Karen Leann Killeen, M.D.
Pamela Elaine Kiser, M.D.
Turner Morrison Lewis, M.D.
Namit Mahajan, M.D.
Bobbette Linder Newsome, M.D.
Brian Joseph Pacious, M.D.
Alan Vaden Padgett, M.D.
Austin Ellerbe Peat, M.D.
Susan Prizzia, M.D.
Christian Edward Shield, M.D.
Alex Leonard Sleeker, M.D.
Lori Verdol Smithson, M.D.
Richard Alexander Szucs, M.D.
Mark Edward Vaughn, M.D.
Gregg David Weinberg, M.D.
Janette L. Worthington, M.D.
OTHER
Colon & Rectal
Specialists, Ltd.
Paul Daniel Charron, M.D.
Cary Lofton Gentry, M.D.
Sean C. O’Donovan, M.D.
Crawford Cunningham Smith, M.D.
William Bruce Stewart, M.D.
William Richard Timmerman, M.D.
Andrew James Vorenberg, M.D.
INdIVIdUaLS
SILVER ($600+)
Thomas Lee Moffatt, M.D.
Richard Pete Sowers III, M.D.
Dianne L. Reynolds-Cane, M.D.
Lawrence E. Blanchard III, M.D.
John F. Butterworth IV, M.D.
Chickahominy Family
Practice
Margaret A. Dossie, PA-C
Anup J. Gokli, M.D.
John Peter Kowalski, M.D.
Joseph Moore, PA-C
Hamdy Ibrahim Sayed, M.D.
Charles K. Sparrow Jr., M.D.
Dennis Lee Thomas, M.D.
Jessica Utt, PA-C
Christina C. Wills, D.O.
Bobby A. Archuleta, M.D.
Tracey C. Deal, M.D.
Timothy Earl O’Neil, M.D.
Dominick J. Pastore, M.D.
Carrilynn Greenwood Sykes, M.D.
GOLD ($1,200+)
PAC150 ($150+)
Suzanne M. Everhart, D.O.
Hazle S. Konerding, M.D.
Christopher G. Acker, M.D.
Robert S. Adelaar, M.D.
Michael Armstrong Jr., M.D.
William H. Bearden III, M.D.
Lillie R. Bennett, M.D.
Richard Leroy Bennett Jr., M.D.
Joel Alan Bennett, M.D.
Peter Condro Jr., M.D.
Kieran Gorman Cross, M.D.
Thomas Darice Dayspring, M.D.
Melani Binaka DeSilva, M.D.
Jeffrey Sheridan Engel, D.O.
Daran Graham Glenn, M.D.
Mary Helen Hackney, M.D.
Sidney R. Jones III, M.D.
Donald Perry King, M.D.
Joanne E. Lapetina, M.D.
Kenneth D. Lipstock, M.D.
Linda Gale T. May, M.D.
Georgean G. DeBlois, M.D.
Siobhan Stolle Dunnavant, M.D.
Lisa LaFollette Ellis, M.D., FACP, MS
Ibe O. Mbanu, M.D., M.B.A., M.P.H.
Thomas Ralph Victors, D.O.
PAC365 ($365+)
James Terrell May III, M.D., FACP
William Paul Murphy, M.D.
Richard Alexander Szucs, M.D.
David Stanley Wilkinson, M.D., Ph.D.
Sharon S. Camden, M.D., Ph.D.
Owen W. Brodie, M.D.
Tamera Counts Barnes, M.D., FACEP
David Alan Bettinger, M.D.
Gerard P. Filicko, M.H.A., CMPE
Joseph S. Galeski III, M.D.
David Wolf Galpern, M.D.
Richard M. Hamrick III, M.D., M.B.A.
Cyrus Scott Kump II, M.D.
Ritsu Kuno, M.D.
Pediatric Associates PC
David Francis Martin, M.D.
Peyman Nazmi, M.D.
George Broadie Newton, M.D.
John M. O’Bannon III, M.D.
Timothy Earl O’Neil, M.D.
Katherine L. Smallwood, M.D.
John W. Verheul, M.D., M.P.H.
Johnny C.L. Wong, M.D.
Helen Montague Foster, M.D.
Perry Wesley Mullen, M.D.
Polly Laura Stephens, M.D.
Peter A. Zedler, M.D.
Donald M. Switz, M.D.
James W. Wooldridge Jr., M.D.
Virginia Ear Nose &
Throat Associates, PC
Robert Jay Brager, M.D.
Alan John Burke, M.D.
Clifton Claude Hickman, M.D.
Jin Sung Lim, M.D.
James Terrell May IV, M.D.
Michael Romney Perlman, M.D.
Peter Lawrence Rigby, M.D.
Thomas Carter Robertson, M.D.
David Ross Salley, M.D.
Nicholas G. Tarasidis, M.D.
James Callen Tyson, M.D.
Daniel John VanHimbergen, M.D.
OTHER
Gary Douglas McGowan, M.D.
Mark Harold Merson, M.D.
Russell H. Myers, M.D.
David Daniel Nedeff, M.D.
Satish Ramanbhai Patel, M.D.
H. Brian Peppiatt, M.D.
Prescott W. Prillaman, M.D.
Giles Mebane Robertson Jr., M.D.
Frank M. Sasser Jr., M.D.
Georgia Kannon Seely, M.D.
William Scott Smith, M.D.
Suzanne Granados Spadafora, M.D.
Robert I. Sprague, M.D.
Donald A. Taylor, M.D.
Shreyank D. Tripathi, M.D.
Hans Robert Tuten, M.D.
Terry L. Whipple, M.D.
C. Bert Wilson III, CMPE
Patrick M. Woodward, M.D.
Susan Whitelock Bennett, M.D.
Robert R. Beskin, M.D.
Martin F. Betts, M.D.
B. Boyden Clary III, M.D.
James R. Darden Jr., M.D.
Jerome Imburg, M.D.
John Robert Onufer, M.D., FACC
Patricia Neyland Reams, M.D.
Anthony D. Sakowski Jr., M.D., FACS
Stanley C. Tucker, M.D.
Erica L. Wynn, M.D., M.P.H.
Wendy Simons Klein, M.D.
Russell Lee Brock, M.D., J.D.
Joseph W. Boatwright III, M.D.
Charles Frost Gould II, M.D.
Barbara Thrush Lester, M.D.
Joseph Moore, PA-C
James A. Shield, M.D.
Emily Jean Onufer
Not a doNor yet? Need to reNew?
Contact Patti Seitz at 377-1051, email [email protected] or visit www.msvpac.org.
16 S P R I N G 2 0 1 4
Are physicians protecting
ALL of their income?
B Y M A T T H E W D . B R O T H E R T O N , A I F, C L T C
Matt Brotherton is president
of 1752 Financial. He can
reached at (804) 283-1920 or
[email protected]
Do you have enough disability
insurance?
Most of us understand the need
for long term disability coverage, but
the bigger question is… Is it enough?
Typically, coverage maxes out at
about 60% or 70% of gross (pretax)
rently covered by a Group Disability
Policy, your practice will pay your
disability insurance policy with pretax dollars. This means your benefit
payouts will be taxed as income and
you will likely receive considerably
less than you had planned for. Your
payouts will be reduced by a third or
so (depending on your tax bracket),
cutting the benefit to about 40% of
your pretax salary, rather than the
60%–70% you expected.
To give an example, if you are
making 100K, your disability policy
will likely cover about 65% of your
salary, or 65K (if this isn’t the case for
you, it’s time to update your disability
policy!). If this is paid with pretax dollars, your benefit will drop to about
44K after taxes. So instead of 65%
coverage, you are really looking at
44%, a precipitous $20,000 drop in
income. That could leave the fridge
It is important to complete a thorough
review of ALL of your disability policies
in order to make sure it is protecting all of
your income.
earnings. This is enough to let you
plan for mortgage payments and
keep the refrigerator stocked. But, if
like many people, you get physician’s
disability coverage as part of your
benefits package at work, watch out.
Nine times out of ten, if you are cur-
pretty bare. The same scenario applies
for any disability insurance for which
you pay using pretax dollars.
The other side of the coin is paying
for your disability insurance with
post-tax income. If the coverage is
paid by you personally, you won’t
be taxed on the benefits. The same
holds true if you pay with after-tax
dollars through payroll deduction.
What to do?
Once you realize you don’t have
enough coverage, it’s time to review
your policy. You need to perform a
thorough analysis to determine your
maximum potential benefit depending
on your current disability policy portfolio. Let’s say you are maxed out
at your highest potential benefit. If
that benefit, or even a portion of that
benefit is pretax, we can supplement
your Group Disability Policy with
individual, non-cancelable disability
coverage at an affordable discounted
price. There are also a number of
other reasons you would benefit from
a simple disability insurance policy
review.
Solve the problem
It is important to complete a thorough review of ALL of your disability
policies in order to make sure they are
protecting all of your income. Individual disability insurance is powerfully
associated with the medical and legal
professions. Our partnership with the
Medical Society of Virginia now gives
us access to a wide variety of programs
that can best meet your needs, including policies with monthly benefits up
to $25,000. We can provide a free and
quick policy review or consultation at
your convenience.
For more information, see
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w w w.ramdocs.org
TRANSFORMING
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17
18 S P R I N G 2 0 1 4
An EMR-related claim
B Y D AV I D B . T R O X E L , M D
20
%
of claims in
which the
EHR was a
contributing
factor resulted
from incorrect
information in
the EHR.
Source: www.psqh.com
O
n April 23, a 58-yearold female presented to
the medical group’s Dr.
A with symptoms of a
urinary tract infection (UTI). In the
electronic medical record (EMR)—an
early EMR system considered dated
by today’s standards—he documented
the presence of a 2 cm left upper lobe
thyroid mass and recommended a
thyroid ultrasound (US).
to reflect the presence of the thyroid
mass. On May 8, the patient called
the group, requesting the results of
the thyroid US. Staff advised that the
US results were pending.
A note in the EMR dated May
10 stated, “Patient was seen by Dr.
A, and an US on May 1 revealed a
2.3 cm left thyroid mass; a nuclear
medicine scan to exclude neoplasm
was recommended. EMR will have
Multiple EMR-related problems contributed to
this claim, which fundamentally resulted from
poor physician(s)-patient communication.
On May 1, the patient’s US exam
demonstrated a 2.3 cm mass in the
left thyroid lobe. The differential
diagnosis included a neoplasm, and a
radioactive iodine uptake (RAIU) test
was recommended. The US report
was not available until May 10.
On May 5, the patient saw Dr.
A for follow-up of her UTI. The US
report was not yet available, so the
EMR included no reference to the US
study. His physical exam note stated,
“The neck/thyroid is supple, without
adenopathy or enlarged thyroid.”
It was later assumed that this note
was an EMR default setting for the
history and physical (H&P) that Dr.
A did not notice and then override
US report scanned.” The note also
stated that Dr. B was the “rendering
provider” (even though he was out-ofstate on this date) and confirmed that
someone in the group received the US
report. Despite the instruction, the US
report was not scanned into the EMR.
In addition, there was no EMR documentation that the patient was advised
to have a RAIU—and no indication of
any attempt to schedule one.
On February 22 of the following
year, the patient saw the group’s Dr.
B for diarrhea and recent weight loss.
On examination, he noted the solitary left thyroid nodule. He ordered
a TSH and free T3/T4 and stated he
would consider a thyroid US if these
tests were normal. The patient didn’t
mention that she’d had a thyroid US
10 months earlier. Dr. B subsequently
stated that when the EMR was later
printed, a section titled “Diagnostics
History” appeared and documented,
“US exam of head and neck ordered
April 23.” He said that the patient’s
diagnostics history did not appear on
the computer screen when he made
his note on this visit because “he did
not know that he had to click on a
drop-down menu to view it.” Therefore, during the patient’s February
22 visit, Dr. B was unaware of the
patient’s US the previous year.
On March 16, the patient was seen
by the group’s Dr. C to discuss her
thyroid function test results (which
were normal). The EMR entry noted
“nontoxic uninodular goiter; etiology
uncertain.” The patient mentioned
the prior US study, but the May 1 US
report was not in the EMR. Again,
the Diagnostics History section did
not appear on the screen, because Dr.
C was also unaware that she had to
click on a drop-down menu to see it.
Dr. C ordered a thyroid US, which the
patient had on March 24. The thyroid
mass had increased in size from 2.3 to
4.1 cm, and the RAIU was ordered.
After numerous efforts to obtain
authorization for the RAIU study,
it was performed on June 30 (three
months after being urgently requested)
and showed a “photopenic mass in
the left thyroid.” The possibility of ma-
w w w.ramdocs.org
lignancy was raised. An US-guided thyroid biopsy was performed on August
17. The group’s EMR did not contain
the pathology report, but Dr. C noted
that the biopsy showed medullary
carcinoma of the thyroid. On October
4, the patient underwent a total thyroidectomy, left neck dissection, and
tracheotomy. Left paratracheal nodes
were positive, and tumor infiltrated the
recurrent laryngeal nerve. The patient
had not consented to a laryngectomy,
so she returned to surgery three days
later for a total laryngectomy.
Discussion
Multiple EMR-related problems
contributed to this claim, which
fundamentally resulted from poor
physician(s)-patient communication.
Issues in this case included the
following:
1.The autopopulation of data fields
in the May 5 H&P, which stated,
“The neck/thyroid is supple,
without adenopathy or enlarged
thyroid,” when the physician had
documented the presence of a
thyroid mass two weeks earlier.
Some EMRs auto-populate fields
as a default in the H&P; entering
erroneous information into the
EMR can create liability.
19
probably explains why the May
10 note stated that Dr. B was the
rendering provider when he was
out-of-state.
2.Computer-assisted documentation
produces structured progress notes
which often contain redundant information, making it easy to overlook significant clinical information. Communication with on-call
and consulting physicians may be
compromised. In this case, because
Drs. B and C did not know how
to view the Diagnostics History
section, they were unaware of the
prior US. Whether this resulted
from faulty software design is
unknown. Vendor contracts may
attempt to shift liability for faulty
4.The group’s IT personnel later
established that the May 10 note
was prepared on that date by Dr.
C; for unknown reasons, the note
did not become part of the patient’s EMR until two years later,
on September 21—the same date
the medical group received notice
of a suit. They further discovered
that sometime after September 21,
someone unlocked the May 10
note, presumably modified it, and
relocked it. Thus, there is no way
to determine if the current version
of the note is the same as the original note created on May 10.
software onto the physician. Read
all contracts carefully.
3.It was later discovered that some
of the group’s EMR problems
involved difficulty accessing entry
and progress notes from prior
visits. The notes could be locked
by the physician making the entry,
rendering them inaccessible to
subsequent physicians. However,
if left unlocked, the name of the
physician making the subsequent
entry would be added to the unlocked prior note. This situation
Doctors are responsible for information to which they have reasonable
access. In this case, the May 10 US
report was posted on the radiology
group’s website for downloading.
Had the medical group accessed it, the
delay in diagnosis that resulted in this
claim might have been prevented. R
David B. Troxel, MD, is medical
director of the Board of Governors
of The Doctors Company.
Evers
Friedman
Gandhi
Goble
Gonzalez
Hagan
Khatcheressian
Lewkow
Machado
May
McFarlane
Mitchell
Nalluri
Qureshi
Samdani
Schunn
Schwarz
Trent
Voelzke
Wade
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of Richmond Magazine’s 2014 “Top Docs” for Oncology. Four of our doctors were
just recognized by OurHealth’s Bedside Manner Awards. And every physician here
is committed to bringing the world’s latest advancements to people with cancer
while helping them live as full a life as possible. Great doctors and a treatment
plan that’s centered around the patient. That’s fighting smart.
Call us or visit vacancer.com to learn more about the latest cancer treatments from
the independent practitioners at Virginia Cancer Institute.
WEST END
Reynolds Crossing
Parham Doctors’ Hospital
SOUTHSIDE
Thomas Johns Cancer Hospital
St. Francis Medical Center
Joseph P. Evers, MD
Elke K. Friedman, MD
James L. Khatcheressian, MD
Joshua J. McFarlane, MD
R. Brian Mitchell, MD
Ghulam D. Qureshi, MD
David F. Trent, PhD, MD
Sharon A. Goble, MD
Pablo M. Gonzalez, MD
Lawrence M. Lewkow, MD
James T. May III, MD, FACP
Attique Samdani, MD
Gisa Schunn, MD
Will R. Voelzke, MD
HANOVER
Bell Creek Square
Medical Office Park
TRI-CITIES
Southside Regional Medical Center
John Randolph Medical Center
M. Kelly Hagan, MD, FACP
Maurice C. Schwarz, MD
S. McDonald Wade III, MD
Yogesh K. Gandhi, MD
Mitchell Machado, MD
James T. May III, MD, FACP
Shobha R. Nalluri, MD
Attique Samdani, MD
20 S P R I N G 2 0 1 4
Mingling at Membership Meetings
Enjoy the summer and see you in September at the next membership meeting!
Valerie Brookeman, MD and Wilson Sprenkle, MD
Rebecca Woo, MD; Rodrick Love, MD; Jessica DeMay, MD; and Brenda Burgess
of Virginia Women’s Center
$1200
out of
pocket
$500
out of
pocket
LArGe CHAin
HoSPiTAL
medArVA
STonY PoinT
SurGerY CenTer
Olivia Mansilla, MD and Andrea Gonzalez, MD
“Of all the things I do for
my patients, having Stony
Point Surgery Center as a
value option for surgery
makes sense
because of
their lower
overhead
and efficient
process.”
– Dr. Juan astruc,
retina institute of virginia
Common ProCedure
Same dOCtOr.
Same PrOCedure.
repair of cavities and
Possible extractions of
Decayed teeth
range:
$275–$1,200
ear tubes (unilateral)
$781.00
ear tubes (Bilateral)
$1,171.50
adenoid removal
$1,171.50
tonsil & adenoid removal
BIg dIfferenCe.
our PriCe
ear Drum repair
$1,726.00
$3,037.00
Hernia of groin area repair
through open incision
$1,180.00
repair of crossed-eye
$1,169.00
Kidney stone removal
$3,037.00
See for yourself. Visit www.stonypointsc.com and explore how performing your
next outpatient surgery at medarva can lower out-of-pocket expenses.
the costs provided are only an estimate. Your actual costs will depend upon the surgical procedure(s) performed by your physician. Please contact us for more information.
R
RAMIFICATIONS
Richmond, Virginia 23220
2201 West Broad Street, Suite 205
Richmond Academy of Medicine