Coping with Chronic Illness

Posted by Eunice / Tuesday, February 21st, 2012

Living Well After the Diagnosis

By Sarah Markel with Lynn Norusis / Photos by Jonny Meyer

Managing a chronic health condition is not easy. The diagnosis usually comes as a shock, and when there is no cure, the future can look bleak. But the wealth of medical and social resources in this region means that achieving wellness again is possible for those with the right kind of determination and grit.

This month, we profile area residents who refuse to allow their conditions to define them. They are not just coping; they are thriving even as they struggle with denial and fear, go to bat with health insurers and seek out cutting-edge medical interventions which allow them to live their lives on their own terms.

Stuart Bloch

Still Swinging
A Lawyer Takes On Diabetes

Stuart Bloch was building his legal practice when the diagnosis came. His real estate law work kept him on the road. The long hours already cut into the time he wanted to spend on the golf course. His wife was the Ambassador to Nepal. “I didn’t have time for diabetes,” he admits with a wave of his hand. “I figured that I wasn’t taking sugar in my coffee, so I was OK.”

Like his grandparents before him, Stuart Bloch, 69, has Type 2 diabetes. Bloch took his insulin in a haphazard fashion for three decades. “If I was thirsty or tired, I’d take a shot, but that was it.” He kept his diagnosis from his family. “I didn’t want people to think of me as a sick person,” he explains.

According to the American Diabetes Association, diabetes affects more than 25.8 million Americans. Managing diabetes requires careful routines, attention to diet, sleep, exercise and medication. Studies have shown that controlling blood sugar, cholesterol and blood pressure can pay off by reducing the risk of complications such as renal failure, blindness, heart and vascular disease and stroke.

For Bloch, the wake-up call came in 2005, when he went into renal failure. “After that, I got religion,” he says, opening a folder containing detailed records of glucose levels, medication and other medical data. He and his wife developed a unique diet, which addressed both Bloch’s renal failure and his diabetes. They researched vitamins and supplements, and developed a game plan for managing the side effects of kidney dialysis. They also found a kidney donor.

Bloch in his home in D.C.

By the time Bloch met Dr. Keith Melancon, a transplant specialist who was at Georgetown University Hospital (GUH), his blood sugar levels were near normal. “He ignored himself for years and then realized his mortality,” notes Dr. Melancon. “He totally shifted gears.”

Currently, 95,000 Americans are waiting for a kidney transplant. The majority of these patients also suffer from diabetes. Only 16,000 transplants are performed annually although the odds of getting a new kidney locally have improved in recent years thanks to a series of kidney exchanges led by Georgetown Hospital.

According to Dr. Melancon, “The Washington area has the highest incidence of kidney disease in the country and the highest incidence of kidney disease plus diabetes.” This is due to obesity and “other factors,” which Dr. Melancon says doctors have yet to fully understand.

In 2009, Bloch and 13 other patients participated in, what was at the time, the world’s largest kidney exchange. The transplant team at GUH matched kidneys with living donors and used plasma exchange to assist where blood types were an imperfect fit. All the patients are now doing well. Dr. Melancon describes the living donors as “the best of humanity.”

Bloch celebrated the arrival of his fully functioning kidney by giving it a name. Six weeks after the transplant, Bloch took “Sydney the kidney” golfing.

“The types of people able to concentrate on minute details tend to do better with chronic disease,” Dr. Melancon says. “You have to be the type of person willing to be a proponent for your own health. You have to be committed to a healthy lifestyle and to asking questions.”

Dr. Melancon notes that Bloch’s ability to belatedly embrace his health was a major factor in salvaging his life. He is back to working, traveling and raising money for charity, although he makes time for his wellness regimen. Bloch swallows a handful of pills every day. He takes multiple injections and tests his blood sugar every few hours. A healthy diet, exercise and regular sleep round out the routine.

While his experience has changed his life, he refuses to let his physical condition define him. “Now I am out of the closet,” he jokes, “but sometimes I want to go back in. Figure out what you are dealing with and deal with it.” He pauses, adding, “Anticipatory anxiety pays no dividends.”

Cooper Elliott

A Brave Mom
Fights for Her Boy

Cooper Elliot loves “Star Wars” and “Transformers.” Only one thing makes him different from the other 5-year-old boys in his preschool class: When Cooper was 2-days old, surgeons at California’s Loma Linda University Medical Center, inserted a pacemaker roughly the size of a quarter into his heart.

It had been a difficult pregnancy for his parents, Dustin and Stacy Elliott. Stacy suffers from the autoimmune disease Lupus. When an ultrasound revealed the twins she was carrying both had congenital heart defects, Elliott, now 28, was hospitalized for seven weeks before the babies were born prematurely.

The smaller infant, Mason, lived only a day. Cooper, who weighed three pounds, had Congenital Heart Block (CHB). The top chambers of his heart could not communicate with the bottom chambers.

According to Charles Berul, M.D., chief of cardiology, at Children’s National Medical Center (CNMC) in Washington, congenital heart defects are the most common birth defect, occurring in about 1 in 200 children. There are 18 types of defects, and some even heal on their own.

There is no cure, however, for CHB. In order for Cooper to survive, he will require a new pacemaker every five to 10 years for the rest of his life. After receiving his first pacemaker, Cooper spent four months in the NICU.

By the time the Elliott family moved to Springfield, two years ago, Stacy knew that access to cardiologists experienced in performing the latest interventional techniques was crucial to managing Cooper’s health. When her insurance company rejected a referral for Cooper to see Dr. Berul at CNMC, Elliott fought back.

She argued that Cooper required a continuity of care and level of expertise offered only by Dr. Berul, who is a pioneer in the field of pediatric electrophysiology. Using precisely maintained records, which she keeps in a binder, and citing specific details from Cooper’s case to make her point, she prevailed. “I eventually went to case management,” she explains. “I don’t want a secretary making decisions about my child’s medical care.”

The case manager agreed with Elliott, although she has had to revisit the issue several times. Last summer, Dr. Dilip Nath, a cardiothoracic surgeon at CNMC, performed open heart surgery on Cooper to replace his pacemaker.

The surgery should have taken just over an hour. Instead Cooper was in the operating room for five and a half hours. The old pacemaker proved difficult to remove. Cooper’s heart became irritated. The cardiac team had to shock Cooper’s heart five times that afternoon. Dr. Berul, who had scrubbed in simply to observe, connected the new pacemaker and stayed with Cooper the entire time. “All that fighting was worth it to have him [Berul] in the O.R.,” says Elliott.

Despite the trauma, Cooper recovered from the surgery beautifully and within a month was playing on the beach in Maui.

Next time Cooper needs a pacemaker, the device will be fitted transvenously. Cooper was a candidate for cardiac catheterization this time, but, as Dr. Berul explains, “He is going to need pacing, hopefully for another 80 or 90 years, and we wanted to preserve the vein.”

A generation ago, doctors did not expect children with cardiac disease to live long lives. Families were even advised to keep children out of sports. “Now we are much more permissive,” says Dr. Berul, who sees allaying parental anxiety as part of his mission.

Dr. Berul runs a sleep-away camp for children with cardiac diseases, called Camp Heartbeat. “We allow them to play sports and go swimming and do all the things that their parents and teachers and coaches have been afraid to let them do,” he says. “We show them they can do it.”

Dr. Berul knows parents are always thinking ahead, even when they try not to. “I think people need to realize this can be a major illness and a lifelong process to deal with, but the majority of people who have congenital heart disease, even some of the complex diseases, can do more than they think they can do.”

Still, Elliott cannot help but wonder what the future holds for Cooper. The time will come when he has to come to terms with his illness, and she is not sure that her own journey with Lupus offers many guideposts. Acceptance is a very individual thing.

“Right now, we say, ‘You are special,’ and he’s like, ‘OK, I’m special.’” She watches Cooper push a toy truck over the sofa cushion before adding, “Hopefully girls will like his sternotomy incision.”

A Patient Refuses to Ignore Her Instincts

Holly McManus’ medical odyssey started in Mississippi after the birth of her third child. Two years postpartum, she still felt constantly fatigued. “Just walking up the stairs wore me out,” McManus, now 42, recalls. Her primary care physician ran a battery of tests. Nothing came back to explain McManus’ lassitude, inability to sleep at night (despite falling into bed exhausted) and her heart palpitations. “I felt like my whole body was not working right,” she explains.

She also began to experience digestion problems. A doctor diagnosed her with Irritable Bowel Syndrome and prescribed her anti-depressants. McManus refused them. Then her primary care physician referred McManus to an oncologist. “The oncologist looked me in the eye and told me I was depressed,” remembers McManus. “I felt like she had given up on me and wanted me to give up.”

Meanwhile, McManus began to experience something akin to panic attacks. “I would get overwhelmed with the idea of doing anything more than my daily routine.” She tried yoga and meditation but found it difficult to sit still. She stopped doing things she previously enjoyed, including entertaining. Thinking about the clean-up could reduce her to tears.

When McManus’ husband, who works in hospital administration, moved the family to Great Falls, he learned about the alternative medical approach offered by Dr. Grace Keenan at Nova Med Group in Sterling. McManus decided to make an appointment.

Nova Med Group practices integrative medicine. That is the practice houses medical doctors and naturopathic doctors, plus a range of other holistic practices, under one roof. All consults are recorded in one electronic chart. Insurance does not cover all of Nova Med Group’s services, but the integrative approach offers patients the opportunity to explore alternative modalities such as vitamin supplements, Chinese medicine and massage therapy, while still remaining under the supervision of an allopathic, i.e. Western, doctor.  This appealed to McManus who was wary of trying alternative therapies because of the lack of industry regulation.

Dr. Keenan says integrative medicine allows her to address not just the ailment but the root cause. She estimates that the vast majority of her patients have stress-related ailments, which is not to say they are imaginary. Stress, as Dr. Keenan points out, is a chronic condition which has been implicated in rising rates of cardiovascular disease, diabetes, autoimmune disorders and obesity.

According to a 2010 study by the American Psychological Association, two-fifths of adults admitted overeating because of stress. Four in 10 Americans reported lying awake at night due to stress.

In McManus’ case, Dr. Keenan suspected something called adrenal fatigue. This condition, she says, is not something doctors learn about in medical school. Traditional Western medicine does not even recognize the condition. Dr. Keenan became familiar with it when she started working with naturopaths. The idea is that a person suffering from chronic stress wears out their adrenal glands. As a result, the body produces inappropriate amounts of adrenaline and cortisol. This can damage cells and affect functioning. Naturopaths believe there are vitamins and supplements that can nourish and calm the adrenals.

The Endocrine Society describes adrenal fatigue as “an unproven diagnosis” and urges patients with fatigue, weakness and depression to be tested for “other health problems.”

After Keenan had ruled out the usual fatigue-related suspects, including Addison’s Disease, chronic fatigue syndrome, fibromyalgia and cardiac disease, she referred McManus to Dr. Teerawong Kasiolarn. Kan, as he is known to his patients, is an in-house naturopath and a member of the American Association of Naturopathic Physicians (AANP).

After saliva tests ordered by Dr. Keenan showed fluctuations in McManus’ cortisol levels that matched her health narrative, Dr. Kasiolarn put her on a regimen of vitamins, herbs and a natural thyroid supplement. “I felt like a million bucks,” says McManus, who feels she avoided the side effects of anti-depressants by seeking a natural option.

“Mainstream medicine would balk at this,” Keenan admits. She cannot offer statistics on adrenal fatigue, though she sees it often, especially in female patients. “I think it’s the rare patient we don’t help.”

Drs. Keenan and Kasiolarn also worked with McManus on lifestyle and dietary changes to help her manage stress. “We need to help patients understand their stressors and find more productive and constructive ways of helping them cope with those stressors,” says Keenan. For McManus, that involved making time to jog, joining a book group and entertaining friends. Dr. Kasiolarn offered “tweaks” to improve her intake of nutrient-dense, fresh foods and eliminate processed foods.

Looking back, McManus draws two lessons from her experience: to keep looking for the right doctor, and adapting to the changes that come with chronic illness, not an easy feat. “We just pile a lot on ourselves,” she says. “Our society rewards those who do more, rather than those who do less to take care of themselves.”

The Experts

	Dr. Berul Specialties: Pediatric Cardiology Hospital locations: Children’s National Medical Center		Dr. Meloncon Specialties: Transplant Specialist Hospital locations: formerly at Georgetown University Hospital
	Dr. Keenan Specialties: Internal, Integrative and Holistic Medicine Hospital locations: Nova Med Group, Inova Loudoun Hospital, Reston Hospital Center		T. Kasiolarn Specialties: Naturopathy and Accupuncture Hospital locations: Nova Med Group

Heart Healthy
Get a One Up on Heart Disease

Cardiovascular disease is the leading cause of death for Virginians, and it is “entirely preventable,” says Dr. Eric Thorn, cardiologist with Virginia Cardiovascular Associates, who says he is seeing more cases in middle-aged smokers, and the younger population is seeing risk factors sooner due to the weight issues our society is facing. “They are laying the groundwork,” he explains. “Luckily, treatments have improved.”

Dr. John S. Golden, cardiologist with Mid-Atlantic Permanente Medical Group, concurs saying, “The numbers of deaths from stroke, and at least coronary heart disease, are both actually going down, and have been for quite some time … largely because of better control of high blood pressure and cholesterol abnormalities [in patients].”

The biggest way to combat heart disease and stroke is to know your risk, Dr. Golden advises. Many factors can play into this such as knowing if there is a predisposed genetic link, knowing your blood pressure and cholesterol levels, and getting regular assessments.

“Heart disease and stroke are really equal opportunity—they really hit all racial and ethnic groups, although the complication rates may be different based on race and ethnicity. What we are seeing in cardiology is really a product of our own successes,” Dr. Golden adds. “In treating some of these risk factors so that people dying from a stroke and heart attack happens much, much less frequently.“

However, because these issues are being dealt with early on through better awareness, Dr. Golden says, people who are predisposed to these conditions are living longer, leading to a rise in numbers of patients with congestive heart failure and atrial fibrillation. — LN

Tips for a healthy heart from Dr. John S. Golden
Know your risks, both genetic and personal, by seeing your doctor at a minimum of every other year for a healthy person.

Stop smoking.

Exercise for a minimum of 30 minutes at a moderate level (walking) at least five days a week; or vigorous exercise (jogging or similar intensity) for at least 20 minutes three days a week; “But the more the better,” he adds.

Eat a diet rich in fruits and vegetables, fiber, whole grains.

Restrict intake of saturated fats, fatty meats, high-fat dairy products.

Restrict salt intake.

Moderate alcohol intake.

Take beneficial supplements such as a fish oil supplement, especially for those who do not eat a lot of fish in their diet.

Manage your weight.

(February 2012)

NoVA’s Pediatric Future

Posted by Eunice / Monday, February 21st, 2011

Evolving with the Demand for Specialized Care

By Lexi Gray

Throughout the 1990s, nationwide trends in pediatrics showed residents entering general medicine, instead of more specialized fields—enough so that it caused concern in the academic community at that time.

From 1990-1998, the percentage of pediatric residents entering subspecialties dropped from 33 percent to 20 percent, according to an article published in the journal “Pediatrics & Adolescent Medicine” in 2005. It wasn’t until the early and mid-2000s that pediatrics saw a shift toward residents choosing more specialized areas of medicine.

Ian Leibowitz, M.D., director of the Pediatric Digestive Disease Center at Inova Fairfax Hospital for Children in Fairfax, says there are a number of reasons why pediatric specialties were somewhat slow to develop. Leibowitz, a pediatric gastroenterologist, explains that he chose this specialty because he loves working with children and it offered him the opportunity to deal cognitively with diseases while also working with his hands through endoscopy.

“There are fewer pediatric patients with any given disease, so the need is less. There are also far fewer training programs for pediatric specialties. In the 1990s, it was thought that there would be an excess of specialists, so some programs even shrunk. Yes, the so-called health care experts were wrong in their predictions,” Leibowitz says.

Changing face of medicine calls for a greater focus on children
The trend toward expanding pediatric subspecialties is very much represented in the Northern Virginia region, due in part to the comprehensive pediatric hospitals and their affiliates available here, including Children’s National Medical Center and Inova Fairfax Hospital for Children. (Children’s National Medical Center represents more than 50 pediatric specialties and programs. Inova Fairfax Hospital for Children represents more than 40 medical specialties, including a pediatric intensive care unit and a neonatal intensive care unit.)

Pediatricians in the Northern Virginia region represent a diverse number of specialties and subspecialties, but some fields have such a narrow focus that only a handful of new doctors are added to them nationally each year. The result is that, in certain specialized cases, our region may have only one or two physicians in a particular subspecialty, and a significant waiting period may be required before a doctor is available.

The American Academy of Pediatrics (AAP) lists approximately 30 pediatric medical and surgical subspecialties, and almost every one of those can be broken down into smaller foci. Pediatric orthopedic surgery and cardiology are some of the better-known specialties and it is not uncommon for physicians in these fields to narrow their focus to one specific region or part of the body.

Emily A. Hattwick, M.D., M.P.H., is a pediatric orthopedic hand surgeon who works at Children’s National Specialists of Virginia in Fairfax, which serves the patient populations of Northern Virginia and the greater Metro-D.C. region. Hattwick was originally poised for a career in adult orthopedics, but changed her focus to pediatrics due to a fellowship she completed at Shriners Hospital for Children, in Sacramento, Calif.

“After working with the children at Shriners, it just felt right to go into pediatrics. Dealing with children is great because there is no hidden agenda, and it’s a very rewarding career,” Hattwick says.

Though Hattwick’s medical focus is narrow, she does not think her career is uncommon for today’s workforce of pediatricians. “I do see a trend toward subspecialty in pediatrics, and I agree with that trend,” she says. “Increasingly, I see pediatricians focusing on one small area of medicine so they can master it and provide more specialized care.”

Hattwick says she treats a significant enough number of children to warrant the possibility of needing a second regional physician who shares her realm of expertise. “Truthfully, I could use another physician with the same focus—there is that much of a need—even for such a specialized area of medicine,” she notes.

Charles Ira Berul, M.D., chief of cardiology at Children’s National, was born and raised in the Washington, D.C. area. A graduate of the University of Maryland’s School of Medicine, Berul enjoys a unique perspective of how the region’s health care systems have changed since the 1980s.

“When I became a doctor more than 20 years ago, pediatric cardiology seemed to be quite a niche. Now people are coming out of training who have an even more specialized focus on pediatric cardiology. Some physicians deal with catheterization, some with imaging and echocardiography, and some are focused only on fetal cardiology,” says Berul.

Kanwal K. Kher, M.D., a pediatric nephrologist at Children’s National, concurs, saying that his specialty is one that has major potential for growth. “In the last five years, we have been seeing greater numbers of children with hypertension, especially in association with obesity.”

David Wessel, M.D., senior vice president of hospital specialties at Children’s National, says, “Pediatrics has been forced to subspecialize, because there is such a demand for it.” A decade ago, according to Wessel, it was common for pediatric intensive care units to include all types of surgeries. “Now you have intensive care units specifically for cardiac surgery, neurosurgery and so on. One area of sub-specialization that strikes me as remarkable is fetal medicine. We now take care of babies before they are even born. And even that focus has been narrowed, as some physicians practicing fetal medicine only address the neurological issues of the fetus.”

Preventative care such as fetal medicine is one of the reasons why pediatric subspecialties continue to grow, says Inova’s Goldberg. “Issues like obesity have grown over the past several decades, and as a result, pediatricians have become much more focused on preventative care to minimize this ailment going into adulthood.” Goldberg also notes that Inova recently hired a pediatrician whose focus is solely on obesity.

The landscape of pediatric medicine has changed over the past several decades, according to Beth Pletcher, M.D., F.A.A.P., chair of the American Academy of Pediatrics Committee on Pediatric Workforce, which was the impetus for specialization of preventative care. “Many pediatric subspecialists are seeing patients with more complex problems than in prior decades, and there are increasing numbers of children diagnosed with ADD/ADHD, autism, depression, bipolar disorder, anxiety, obesity, asthma and diabetes that are packing the offices of these specialists,” Pletcher says.

The future of pediatric specialties on a national level may have an uncertain future, she states. “Enticing pediatric residents to pursue subspecialty training—especially in specific areas of undersupply—is problematic. There may be relatively few incentives to add on extra years of training rather than practice in a primary care setting, or to go into a more cognitive subspecialty like developmental pediatrics as opposed to a more procedure oriented subspecialty such as pediatric cardiology.”

Training requirements and the correlating paycheck
Pediatric dermatology is growing slowly, according to Robert A. Silverman, M.D., F.A.A.D., F.A.A.P., a pediatric dermatologist in Arlington. The certifying exam is only given every two years since only 20 training programs exist. It is probable that the same reasons for low enrollment in pediatric dermatology can be attributed to most specialties of pediatrics, he says. Among those reasons, Silverman explains, is the cost of training. Debt incurred from medical training often reaches well into six figures, and cannot be paid off in a relatively short time. Therefore, the extra years of training for a pediatric specialty might be a major financial hardship. He adds that specialties like dermatology are cognitive—meaning they are not primarily surgical or procedurally-based—so reimbursements are low.

Silverman continues, “Pediatric dermatologists not only see patients, but most have to teach pediatricians about skin, and teach dermatologists about children and their diseases. There are only a few of us in ‘private practice,’ and we still do a lot of teaching.” John S. Myseros, M.D., F.A.C.S., F.A.A.P., a pediatric neurosurgeon at Children’s Hospital in the district, is another representative of a specialty that has a very small stream of new physicians entering each year. Myseros agrees that compensation is one aspect of pediatric subspecialties that might deter medical residents.

“Students with a lot of loans might be more attracted to the higher paying areas of medicine,” Myseros says. “People who take care of kids generally do it because it’s in their soul—they have a passion for children and finances don’t play a role in that.”

Myseros notes that he certainly recognizes the niche aspect of the specialty he chose. “With my own specialty you can’t really get more specialized than that.” It wasn’t until he was well into college that Myseros decided he wanted to go to medical school. Originally, he was interested in becoming a general surgeon. Yet after completing a one-year fellowship at The Hospital for Sick Children in Toronto, Canada, he decided his future was in pediatric neurosurgery.

“Pediatric neurosurgery is certainly a small piece of the medical pie, with sometimes less than 10 individuals finishing fellowships each year, nationally,” Myseros says. “There aren’t that many of us, but there are enough in the Metro-D.C. area, in my opinion. Of course on the national level, some areas are underserved while others have more than the population demands.”

Myseros points out that statistics show the need for about one pediatric neurosurgeon per 1 million people. Each hospital system may have its own goals for how many specialists they would like on staff, adds Mysersos, but that number might differ from the needs of the patient population.

Are NoVA specialists ready to treat the onslaught of child patients?
According to the information provided by Pletcher, the local region appears fortunate to have such a comprehensive range of pediatric subspecialists, regardless of any waitlists that might exist.

“Recent surveys of pediatricians in general practice indicate that they are having more and more difficulty getting their pediatric patients in for needed subspecialty care,” Pletcher says. “The problems are worse for doctors practicing in rural areas where their patients need to travel long distances to a tertiary care center for this type of care, but these barriers exist even in highly populated urban areas.”

Pletcher notes that, nationally, the medical subspecialties identified as having the greatest deficit include child and adolescent psychiatry, pediatric dermatology, pediatric rheumatology and pediatric neurology.

Both Inova and Children’s have physicians dedicated to each of these nationally underserved departments. The Children’s staff, alone, includes nine psychiatrists, two rheumatologists, and 27 neurologists.

David Goldberg, vice president of Inova Fairfax Children’s Hospital, says his hospital remains abreast of any trends in the local market through a third-party company that is hired to analyze and identify any shortcomings in the system. He adds that, in a broad sense, Northern Virginia’s supply of pediatric specialists meets the needs of the local population.

Goldberg assuages the critical deficit of pediatricians seen in other parts of the country is not as apparent with regard to Northern Virginia and the Metro-D.C. area. “We do have shortages in some specialties, which is common in today’s medical field. There isn’t one pediatric specialty that I could say is not constantly busy,” he explains.

“Sometimes the waitlist is longer than we would like, but we are constantly assessing how we can partner or employ medical staff to round out service for the community,” Goldberg adds.

Pletcher says that nationally, the pediatric surgical specialist supply may experience a critical deficit, due to drastically shrinking numbers of physicians choosing to train in those areas.

The causes of a pediatric specialist shortage would happen due to any number of reasons, including time and money according to Pletcher, who says the two may play a role in which specialty a resident will choose. Pediatric specialists are sometimes required to complete several years of additional training, yet in many cases receive lower compensation than their adult-specialty medical counterparts.

“For a urologist to specialize in the care of children, he or she needs to first complete residency training in adult urology and then go on for additional years of training in pediatric urology,” Pletcher explains. “Once completing this additional training, these specialists are ‘rewarded’ by significantly lower compensation than their adult surgical counterparts. It is clear that this disincentive to care for children remains an ever more ominous barrier to training these much needed pediatric specialists.”

Silverman says the wait time for his pediatric dermatology practice can be anywhere from three to four months for non-emergencies, and appointments are usually by referral only. Silverman notes that his is among the smallest of pediatric specialties, along with child psychiatry.

“There are 167 Board Certified pediatric dermatologists in the United States,” Silverman states. “That is approximately one pediatric dermatology specialist per 385,000 children under 18 years of age. Fewer than half of the pediatric dermatologists are Board Certified in pediatrics as well.”

Jay Greenberg, M.D., a pediatric oncologist, has seen his profession change dramatically during his time in the field, even though he does admit to some shortages in pediatrics as a whole.

Greenberg says, “Yes, there is a shortage of pediatric specialists and will continue to be as society seems to place greater value on caring for adults—meaning a pediatric specialist may earn only 30-50 percent of what the corresponding medical specialist might earn.”

“On the other hand, after watching the practice of medicine for over 30 years, I am always impressed by the continued influx of very intelligent, dedicated, hard-working young doctors into these fields of practice. In Northern Virginia we are very fortunate for the comparatively large number of pediatric specialists in our area,” he adds.

He continues: “The field of pediatric oncology, perhaps more than other area of medicine, has made major advances during the period of my career. Not only do we save more than twice as many children with cancer, but the experience has actually become tolerable. What greater reward than to help a family go from the devastation of being given a terrible diagnosis, to pronouncing them cured? What can be more rewarding than to attend the graduations and weddings of patients treated when they themselves were infants and toddlers?”

Though the Metro-D.C. region is home to about 5 million residents, Myseros opines that it would be unusual for a parent to say they were unable to find adequate regional medical providers for their child’s health care needs.

Even though in some cases it may take months before child patients get an appointment with a pediatric specialist, this doesn’t always mean that there is a significant shortage of available providers, says Paul Kaplowitz, chief of endocrinology at Children’s National Medical Center.

Regarding his own specialty, Kaplowitz says, “I think the NUMBER of pediatric endocrinologists is adequate in most parts of the country but there is an increased demand for our services for a couple of reasons. One is that with the epidemic of obesity, we have seen a big increase in referrals for weight gain, type 2 diabetes, pre-diabetes and signs of early puberty.”

Pediatric endocrinology is a growing field, states Kaplowitz—due in part to the increase of both Type 1 and Type 2 diabetes. “These conditions—especially Type 1—are very intensive in terms of how much physician and nursing time they require. Many practices need to bring on more staff just to keep up with the growing diabetes population.”

As for the future of pediatric specialties in Northern Virginia, both Children’s Hospital and Inova Fairfax have pledged to continue growing and hiring specialists as needed.

“Our job is to balance the needs of the community while keeping costs down. But there is nothing more important than making sure the community is taken care of. We never want anyone to have to leave our area in a quest to receive quality care,” Goldberg says.

Getting Past the Gatekeepers
Five Tips for Booking the Appointment You Need

By Sarah Markel

Research was the easy part. Now that you’ve found the right doctor, getting a timely appointment can be a genuine challenge.

According to Trisha Torrey, patient empowerment expert and author of “You Bet Your Life! The 10 Mistakes Every Patient Makes,” “The doctors you do want to see are often the doctors you can’t see.” Many highly rated physicians are booked months in advance or are not accepting new patients.

Here are five tips to help you get that difficult appointment:

Check for coverage: Call the physican’s office to ensure they accept your insurance plan. This step is crucial. According to Torrey, “If they don’t accept your payer, it’s next to impossible to get in.”

Remain patient: If the doctor accepts your insurance, but is fully booked, ask to be put on the call list in case they receive a cancellation.

Persevere (Politely!): Try calling the doctor’s office near the end of the work day to see if there have been any last-minute cancellations for the following day.

Enlist professional help: If possible, seek a referral from another physician. Typically, another doctor can get you in to see your preferred provider more quickly that you can on your own.

Create a backup plan: If you can’t get an appointment in the near term, make one for six months out, even if it means seeing someone else right away. Once you are on a physician’s books, it will be that much easier next time around.

When all else fails, keep researching. One thing that does not work, however, is whining or bluster. “The gatekeepers don’t want to hear anyone whining,” Torrey says. “I really don’t recommend that approach.”

(February 2011)

Small Patients, Big Treatments

Posted by The Editorial Desk / Tuesday, December 9th, 2008

Advancements at the Children’s National Medical Center

By Sarah Markel / Photograpy by Jonathan Timmes

Children’s National Medical Center, in Northwest Washington, is the area’s only medical system devoted entirely to caring for children and infants. Because Children’s Hospital has outpatient centers across the region, including two in Fairfax, those in need of care can better access most of its 367 pediatric specialists, many of them leaders in their respective fields. These doctors never forget that they aren’t just saving lives.
They’re saving families.

Dr. Michael Boyajian
Pediatric Plastic Surgery
Approximately one in 700 children is born every year in the United States with cleft palates. In the Mid-Atlantic region, most of those babies will see Dr. Micheal Boyajian, director of plastic and reconstructive surgery at Children’s Hospital.

Boyajian’s specialty is craniofacial surgery. He rebuilds faces, repairing cleft palettes so well that the scars are barely visible and correcting malformed infant skulls, often within hours of delivery.

Recently, medical advances have changed the landscape for children recovering from plastic surgery. It used to be that doctors fixed bones using titanium screws. Boyajian now uses screws made of absorbable material.

“It takes about a year to be fully absorbed,” he warned. But for growing bodies, this means no leftover materials to get in the way of facial growth, particularly unformed teeth.

Boyajian is always looking for ways to improve upon his work. Children’s was the first hospital in the country to modify the absorbable screws into pegs so they could be pushed into place using ultrasonic waves. This technique saves time and offers a better grip.

Pediatric plastic surgeons earn far less than their adult counterparts, but that doesn’t upset Boyajian. “I love my work,” he said. “To be able to close a cleft lip and bring it to a point where the deformity is small enough that it is below the threshold of what people can pick up, that is a big deal, and it’s privilege for me to be able to do it.”

Dr. Richard Jonas, Dana F. Higdon (mom) and Walter Higdon (patient)

Dr. Richard Jonas
Neonatal Cardiac Surgery
Dr. Richard Jonas, chief of cardiovascular surgery and co-director of the Children’s National Heart Institute, has been a pioneer in the field of early intervention for congenital heart abnormalities. About eight in 1000 babies are born each year with such defects. Formerly, doctors preferred to postpone corrective surgery until the child was older.

Jonas disagreed. “You are better off giving a child a normal circulation as early in life as possible. It benefits the brain, and the child will achieve normal developmental milestones,” he said while stuck in traffic after a day in which he completed three neonatal heart surgeries.

For more than two decades, this Australian father of three has been repairing the hearts of tiny patients, some as small as 2 pounds. He and a massive team of doctors and staff work with clocklike precision, using magnifying telescopes. “We have to work fast. The heart can’t withstand having no blood supply for a couple of hours.”

Some of Jonas’ earliest patients are now college students. The trio of babies he operated on recently? They’re fine.

Dr. John Myseros, Deborah Triggs (mom), Jessica Triggs (sister) and Matthew Triggs (patient)

Dr. John Myseros
Pediatric Neurosurgery
When a CT scan revealed a massive tumor on the right side of 9-year-old Matthew Triggs’ brain, his mother, Debbie Triggs, thought the news couldn’t get worse. But finding a neurosurgeon willing to take on the case proved challenging, as the dangers of bleeding and brain damage were so high.

Luckily, their pediatric oncologist, Dr. Marianna Horn at Inova Fairfax, referred them to Dr. John Myseros, a pediatric neurosurgeon at Children’s Hospital.

At 43, Myseros is something of a surgical wunderkind. He is already one of the leading experts in removing tumors from children’s brains, and he has a reputation for pushing the boundaries of what neurosurgeons can and will do to save lives.

Matthew’s tumor was so tangled in his brain that conventional treatments would have removed a significant amount of healthy tissue along with the tumor. His parents were warned he could wind up on a ventilator for life. That was, if he survived.

Myseros spent hundreds of hours studying Matthew’s MRI and conferring with other doctors to develop a novel approach for removing the tumor. He called in neuro interventional radiologist Dr. William Bank from Washington Hospital Center to perform an embolization to block off the blood to the tumor. The procedure reduced the bleeding so Myseros would have time to work.

“I know I can do this,” Myseros had assured Triggs before beginning the 12-hour operation. The surgery, in which he painstakingly unpicked the tumor from the nerves that control Matthew’s breathing and the movement in his face, was an unqualified success. As Myseros put it, “Matthew is now a neurologically normal boy.”

“When you are dealing with a life-or-death situation, you want someone who is confident,” Triggs said. “That man is larger than life.”

(February 2008)

Death Defying

Posted by The Editorial Desk / Tuesday, December 9th, 2008

Patients Who Beat the Odds and the Doctors Who Helped Them

By Jan Linley / Photography by Jonathan Timmes

Eight patients faced with very different life-changing medical challenges discovered that having the best of the best in medical care goes a long way toward survival. While these patients are different in many ways, they have more than a few things in common. Each is inspirational, brave and trusting. And each has a top doctor using cutting-edge medical technology.

Clinton Johnson/Pat Divinnie | Survivor/Donor

The Best Birthday Gifts
Clinton Johnson was diagnosed with sarcoidosis (an inflammatory disease that produces granule-sized lumps of cells in various organs in the body) in 1995. It affected his kidneys. Three years ago doctors told him he needed to prepare for dialysis. The 58-year-old Johnson was opposed to the treatment, but went ahead with dialysis classes. After his last class, he made up his mind to find a kidney.

He understood that putting his name on a wait list for kidney donation would mean just that—waiting. There are 850 on Washington Hospital Center’s list, 2,200 in the area and 70,000 in the country. The wait time can be up to five years. Johnson became proactive and put the word out that he needed a kidney. “I didn’t ask, I told them. I need a kidney.” He had willing donors, but none were a match.

His wife Pat Divinnie knew she was not a match for her husband, but that didn’t mean she wasn’t a match for someone else. She volunteered to go on the list as a healthy donor for another recipient, moving Johnson up on the list as a result.

It was about a month before they met their match. Divinnie, 55, was the match for Young Hwang, a 64-year-old diabetic who had already started dialysis. His organ failure was the result of the diabetes; the kidney problem presented itself while he was on a three-day fishing trip and his face “swelled up like a round ball.” Hwang was on the transplant wait list for more than two years. His 63-year-old wife, Sun Hae, was also on the list as a donor. She never thought she might be the match for Johnson.

Sun Hae/Young Hwang | Donor/Survivor

Johnson chose Washington Hospital Center because he knew about Dr. Jimmy Light, director of transplantation services. Years ago they had both worked at Walter Reed Army Medical Center. Light, 63, has been doing transplants since 1971, almost as long as the field has been in existence. “At the time it was very, very challenging, very new. It was absolutely clear people would really benefit.”

Johnson, who is a former professional football player, insisted on having the operation after the Super Bowl. Four operating rooms were simultaneously prepared Feb. 12, 2007, two days before Valentine’s Day, three days before Sun Hae’s birthday, and four days before Johnson’s birthday.

Reza Ghasemian, 49, director of transplant and urology, was Sun Hae’s surgeon. “Transplant surgeries are very satisfying. You see the results almost immediately. You remove the kidney; it’s transplanted and starts working immediately after the connection. Three to four hours after the surgery, the patient feels the difference.”

The couples stay in touch, but so far have no plans for an anniversary celebration. Maybe because they have all been too busy traveling recently, one of many activities made possible by the transplants.

The Little Girl Who Could
Renay Hannon was 34 and had a perfectly normal pregnancy when she gave birth to her daughter, Caleigh Haverland, in September 2000. So when she went in for Caleigh’s two-week checkup and was told her daughter had a heart murmur, she wasn’t too concerned. “A lot of kids have that. I didn’t think it would be a big deal.”

Caleigh was born with Tetralogy of Fallot, a congenital heart condition in which there exists a hole between the two ventricles of the heart, allowing blood to go from the right to left ventricle and then through the aorta, never passing through the lungs for oxygen as it would normally. Caleigh’s condition was further complicated because her left pulmonary artery was not connected to her lung.

Her first surgery to connect the pulmonary artery took place when she was about 4 months old and her heart was about the size of a plum. At 9 months, Caleigh had surgery to repair the hole in her heart.

In November 2006, Caleigh underwent her third heart surgery. She had outgrown the graft that connected the pulmonary artery to the rest of her heart. After each surgery, Hannon, a flight attendant, told herself everything would be fine and that she would soon be “able to be like the regular moms.”

Caleigh’s first surgeries were performed by the late Dr. Bechara Akl. Hannon was understandably concerned about who would perform the next one. She and her husband met with Dr. Irving Shen, director of pediatric cardiac surgery at Inova Hospital for Children. “He was just amazing right off the bat,” Hannon said. Shen, 45, explained a number of possible scenarios and how they would be handled.

It is common for children like Caleigh to have multiple surgeries as they get older and outgrow their original surgeries. Each time a surgery is performed, scar tissue grows around the heart, which can complicate subsequent surgeries. Shen said, “You have to tease everything up.”

He refers to pediatric cardiac surgery as a team sport. Between him, Dr. Lucas Collazo and a team that includes other cardiologists, anesthesiologists, nurses, interventionists and assistants, approximately 300 pediatric surgeries are performed annually at Inova Fairfax Hospital for Children.

Both Shen and Collazo, 42, spend a great deal of time thinking about the surgeries they perform and the children and families they treat. “We orchestrate the whole operation in our heads. We do it again and again,” Shen said, likening the process to athletes’ mental preparations.

Caleigh, who turned 7 in September, is very social and loves most of the things kids her age do—camp, play dates with friends and especially dance classes. Her mom is thrilled. “It’s the most wonderful thing ever to have Caleigh, and I’m so thankful.”

60-year-old Tom Shaw knew exactly what was happening when he suffered a massive stroke in a nearly empty movie theater in the middle of a December afternoon.

Racing Against the Clock
As the owner of Outcome Communications, Inc., a health care marketing and educational company, 60-year-old Tom Shaw knew exactly what was happening when he suffered a massive stroke in a nearly empty movie theater in the middle of a December afternoon. He also knew he had three hours to get treated before any long-term serious damage set in. “It was the ultimate race of my life.”

A throat cancer survivor, Shaw had a laryngectomy and uses an electrolarynx for speech. He usually uses his right hand to operate the device, but the stroke had incapacitated the right side of his body. He managed to use his left hand and turn enough in his seat to ask one of the two other patrons there that day to get the theater manager.

When paramedics arrived on the scene Shaw was coherent enough to ask to be taken to Alexandria Hospital, where his wife Karen is technical supervisor in the Cardiovascular and Interventional Radiology Department.
Interventional radiologists Dr. Keith Sterling and Dr. James Cooper treated Shaw at Alexandria. Cooper, 46, explained that most people have four main arteries, two carotid that supply blood to the front of the brain and two vertebral that supply blood to the posterior part of the brain. Unbeknownst to Shaw, he had been living with only one functioning vertebral artery, most likely since birth. So when the stroke happened due to an extensive clot in the other vertebral artery, the blood supply to the back of the brain was cut off. “People can live off of three arteries and not skip a beat their whole life,” said 43-year-old Sterling.

Strokes are typically caused by a pea-sized clot in one of the arteries. Shaw’s clot was “extensive,” blocking the entire vertebral passage. When Cooper and Sterling saw Shaw’s CT scans, they weren’t optimistic. Cooper said, “There’s no cookbook for what he had.” Sterling agreed. “We pulled out all the stops.” Interventional radiologists perform minimally invasive procedures to treat a wide range of conditions throughout the body. Using X-rays, MRIs and other imaging, they advance a catheter, usually through an artery to the source of the problem. In Shaw’s case, Sterling and Cooper and their team first performed an angiogram to locate the clot. They gave Shaw tPA, a clot-busting drug, and removed the clot using small catheters to suck it out. They widened a narrowing in the artery by using stents (wire metal mesh tubes) to prop it open. All of this was done through one small incision in the leg and in less than three hours.

Shaw was lucky but also well-informed. Cooper and Sterling stressed the importance of stroke awareness. “The key is to know when you develop symptoms to seek medical attention.”

Choosing Life Over Existence
The first thing you notice about Alice Gaines is her striking beauty. It is incongruent with the Parkinson’s disease she’s had for the past 14 years. Now 49, she was just 35 and pregnant with her second child when first diagnosed. Initially she sought treatment for knee pain, thinking she had arthritis. About six months later her leg began to drag intermittently. Doctors diagnosed Alice with depression and put her on muscle relaxants and antidepressants. When she started experiencing muscle rigidity in the form of a stiff neck, doctors thought it was stress.

It wasn’t until after she gave birth and discovered she couldn’t walk that doctors prescribed Sinemet. A positive response to this drug confirmed Parkinson’s disease.

For five years Gaines functioned on Sinemet, but the Parkinson’s continued to progress. Although driving and handwriting became difficult, she stayed at her job full time. It was about this time Gaines lost her mother, then six months later her 40-year-old husband to a massive coronary.

Eventually she could no longer drive or write. Getting out of bed took two hours, and her vision became so poor it was difficult to watch television. “I was just existing.”

One night she saw a television program that featured Georgetown University Hospital’s Dr. Christopher Kalhorn performing deep brain stimulation (DBS) on a Parkinson’s patient. Gaines phoned for an appointment the next day. To gain eligibility for DBS, patients must undergo detailed motor testing and still be responsive to the Parkinson’s drugs Sinemet or Levodopa.

Kalhorn, the 36-year-old director of epilepsy and functional and pediatric neurosurgery at Georgetown, was first exposed to DBS in the late ‘90s through his medical training at Baylor College of Medicine. “I thought, there’s an operation where you really impact on someone’s quality of life.”

The DBS surgery takes about five hours. Two electrodes are implanted bilaterally in the brain with sub-millimeter accuracy. The patient is heavily sedated and anesthetized, but still awake so they can respond to the implants as the surgery proceeds. Kalhorn singles out neuron-anesthesiologist Dung Q. Tran for keeping patients comfortable during the surgery.

A month after the brain surgery, a pacemaker is implanted underneath the collarbone in the chest. It operates similarly to a cardiac pacemaker, but delivers electrical stimulation to the brain, overriding faulty signals and reducing tremors and some of the other symptoms of Parkinson’s patients. Medication is still required, but usually at lower doses.

Being able to be there for her sons RJ, 14, and Sam, 11, motivated Gaines to have surgery. Now she can enjoy some of the routine mom activities again, like playing board games, going to festivals and even throwing the football around.

DBS is not a cure for Parkinson’s, but it does improve quality of life for those who are able to undergo it. Current data indicates that patients do significantly better with motor movement five years after the surgery than prior to it.

Kalhorn views his “role as a neurosurgeon as a great privilege.”

Gaines sees it a different way. “He gave me my life back.”

One day while doing a handstand in yoga her teacher told her to close her mouth and breathe through her nose. That’s when Shearer discovered, “I couldn’t breathe at all.”

It’s Not Allergies—It’s Cancer
When 44-year-old Maureen Shearer, also known as Mia, started having trouble breathing, she thought she had a stubborn cold or was developing allergies. Then one day while doing a handstand in yoga her teacher told her to close her mouth and breathe through her nose. That’s when Shearer discovered, “I couldn’t breathe at all.”

She went to urgent care, where she was diagnosed with sinusitis and given antibiotics and later Allegra and Flonase. When nothing helped she saw her family physician, Dr. Michael Rodriguez, who took a look in Shearer’s nose and sent her to have a CT scan with Dr. Betsy Vasquez. Vasquez discovered a mass. Surgery was scheduled, but Shearer remained unconcerned that it was anything serious. The mass was removed and biopsied.

Within two days of her surgery Shearer had lumps on her neck. She and her husband assumed her lymphatic system was crashing. They phoned Vasquez, who told Shearer’s husband David that Mia had nasopharyngeal cancer, a cancer that is rare in Caucasians and much more common in Asian men. Vasquez had already made an appointment for Shearer with Dr. Kin-Sing Au, a radiological oncologist at Inova Loudoun Hospital.

Shearer and her husband had no idea what to expect when they first went to see Au. “He made us feel like everything was going to be OK,” Shearer recalled.

After meeting with her, the 52-year-old oncologist thought Shearer would be a good candidate for intensity-modulated radiation therapy (IMRT). Historically, because there are a lot of critical organs in the area, patients treated with radiation for nasopharyngeal cancer have suffered from long-term side effects including hearing loss, jaw problems, vision problems, brain damage and tooth loss from dry mouth caused by the loss of saliva glands. Au explained that IMRT is a very targeted form of radiation that approaches the tumor area from multiple directions, shooting beamlets of radiation at the unhealthy tissues and avoiding healthy surrounding tissues. Shearer was the first patient treated with IMRT in Northern Virginia.

Au scheduled her right away to get a mask made for her face. The mask is marked so the radiation hits precisely the right spots each time it is beamed at the patient. IMRT was then performed in tandem with chemotherapy.

Au’s team consists of several top-notch people, including a dosimetrist and a medical physicist. The dosimetrist is responsible for radiation dose calculations. The physicist assists with those calculations as well as doing quality assurance calibrations on the equipment. Because the team, including Au, had not done this IMRT before, Au himself stayed well into the night on several occasions and figured out the calculations for Shearer’s treatment.

Shearer’s successful treatment lasted about seven weeks, five days a week. Au said, “That’s the rewarding part of my specialty, a patient like Mia.”

(February 2008)

Breakthrough Medicine

Posted by The Editorial Desk / Tuesday, December 9th, 2008

New Procedures Easing the Aches of Pain

By Sarah Markel and Lindsay Holst / Photography by Jonathan Timmes

Never mind the traffic. Forget the cost of living. When illness strikes, having immediate access to top-of-the-line medical care makes up for many of the stresses of Northern Virginia life.

From Head to Toe: Medical technology that is changing and saving patient lives
Just over half a million doctors are currently practicing in the United States. And right in our own backyard, the latest innovations in the treatment of life-threatening illnesses are increasingly being developed and tested. Here are the doctors pushing the envelope every day in search of minimally invasive, more effective procedures that save lives.

Bank combines a state-of-the-art Bi-plane X-ray, which allows him to see inside the brain from every possible angle, with endovascular procedures to treat aneurysms without traditional surgery.

BRAIN
Dr. William O. Bank
Washington Hospital Center; Bi-plane X-Ray
Until recently, the prognosis had been dire for patients with cerebral aneurysms and tumors in the head, neck and spine. Aneurysms in the brain are notoriously hard to detect and difficult to access. Once they rupture, the brain is flooded with blood, often resulting in death.

For those who did survive, the only recourse was open brain surgery. Dr. William O. Bank, director of neuro interventional radiology at Washington Hospital Center, has a better way. Bank combines a state-of-the-art Bi-plane X-ray, which allows him to see inside the brain from every possible angle, with endovascular procedures to treat aneurysms without traditional surgery.

“The Bi-plane X-ray has been around for 20 years,” Bank said. But only recently has the technology gone digital. “Now it is more precise,” he said. “I can look through two different directions at the same time.”

The digital Bi-plane X-ray instantly transfers brain images to the computers at Bank’s worktable, where he then measures the aneurysm to hundredths of a millimeter. After consulting with neurologists and surgeons, Banks quickly returns to the patient. Using the Bi-plane X-ray as his eyes, he threads tiny platinum coils up through the groin into the aneurysm so that blood cannot enter it.

A lover of the impressionists, he takes inspiration from the works of Monet and Van Gogh. “The practice of medicine and surgery is not an exact science. What I do is an art,” Bank said. “And I have to do it well every day.”—SM

Satler is leading an investigational trial to study the safety of inserting an artificial aortic valve through a large needle puncture in the leg rather than through open heart surgery.

HEART
Dr. Lowell Satler
Washington Hospital Center; Heart Valve Replacement without Open Surgery
The telltale sign of heart surgery, that pale vertical chest scar, may one day become a thing of the past, thanks to Dr. Lowell Satler, director of cardiac interventions at Washington Hospital Center. Satler is leading an investigational trial to study the safety of inserting an artificial aortic valve through a large needle puncture in the leg rather than through open heart surgery.

Currently the study is only open to elderly patients too weak to undergo surgery. “For the higher risk subset, surgery is not a good option,” Satler said. “Many patients succumb to chest pain, are hospitalized and eventually die. This is an alternative strategy.”

Pricilla O’Donnell’s 95-year-old father was one of the first patients to undergo this minimally invasive procedure. The valve replacement has given her more time with her father. More importantly, she said, it has given her dad the freedom he thought he had lost. “He is now able to walk unassisted and without oxygen. He feels like this procedure was nothing short of a miracle for him. He is really loving life now.”

Satler hopes one day that more patients will be able to undergo valve replacement via catheterization. “This has the potential to replace open heart surgery if the valves demonstrate durability.”—SM

VEINS
Dr. Richard Neville
Georgetown University Hospital; Propaten Vascular Graft and Silverhawk
Dr. Richard Neville, chief of vascular surgery at Georgetown University Hospital, has devoted his career to saving legs. Patients, particularly the elderly and diabetics, too often ignore the pain that comes from clogged arteries in the legs. Sometimes they leave it so long that the only recourse is amputation.

Neville will try just about anything to avoid taking a leg, including inventing his own procedures to create systems for blood to bypass clogged arteries. He is currently testing the Propaten Vascular Graft, a minimally invasive bypass that “tricks a vein into thinking it’s an artery,” Neville explained. Neville was the first surgeon to use the graft below the knee. He also helped develop the Silverhawk, a tool used to scrape out the clogged veins of patients too sick for bypass surgery.

“Sixty percent of what we do is endovascular,” Neville said. “That allows us to work through a small needle puncture.” Patients come from across the country to see Neville. Very rarely today does he have to tell them there is nothing he can do to save the leg. “And even then,” he said, “I can often think of something.”—SM

Deaton, who is recognized as the foremost authority in his field, is leading a clinical trial to test a new, minimally invasive approach to repairing abdominal aneurysm by stapling a synthetic vein, or Aptus endograph, to the aorta.

ABDOMEN
Dr. David Deaton
Georgetown University Hospital; Aptus Endograft
Ed Mooney’s abdominal aortic aneurysm gave him no trouble. “I didn’t have any symptoms,” said Mooney, 71, whose aorta, the main blood vessel in the abdomen, had swelled to nearly five centimeters, more than twice a normal size. Left untreated, the chances of sudden death from aortic aneurysm hover at about 90 percent.

In 2006, Mooney’s doctor noticed the aneurysm during a routine ultrasound and referred him to Dr. David Deaton, chief of endovascular surgery at Georgetown University Hospital. Deaton, who is recognized as the foremost authority in his field, is leading a clinical trial to test a new, minimally invasive approach to repairing abdominal aneurysm by stapling a synthetic vein, or Aptus endograph, to the aorta. Mooney became the first patient in the United States to receive the Aptus endograph.

“It took about three hours,” Mooney said. “I was in the hospital overnight. They let me out the next day.” Deaton explained that traditionally aortic aneurysms are repaired through open surgery, followed by several days in ICU and a week in the hospital. “With the endovascular surgery, we replace the aorta with a catheter through a groin incision. There’s no pain and less trauma to the body.”

A native of North Carolina, Deaton’s style is as relaxed and unassuming as his accent. “I like to say it’s like being able to go to California on a jet plane instead of a horse,” he joked.

For Mooney, being on the vanguard of experimental medicine gave him no qualms. “Dr. Deaton is so calm and straightforward. When he explained the procedure to me I thought, This makes sense.”—SM

Dr. Tom Fishbein
Georgetown University Hospital; Multiple Organ Transplant Surgery
When the Washington, D.C. State Health Planning and Development Agency (SHPDA) granted Georgetown University Hospital, in collaboration with Children’s National Medical Center, a Certificate of Need to allow physicians to perform life-saving small bowel transplants, doctors were able to bring hope to many cases that hadn’t seen any for a while.

In small bowel transplantation, a surgeon transplants a portion of the small intestine from either a living donor or a cadaver. The surgery can restore intestinal function when the intestine has failed due to illness or trauma and when intravenous feeding is no longer an option. Only about 100 patients receive a new small intestine each year in the United States, and Georgetown’s program is the only one of its type in the Mid-Atlantic region. Dr. Tom Fishbein, Georgetown’s director of small bowel and pediatric liver transplantation, has done as many as six organ transplants at one time and has performed small bowel transplantations in a wide range of patients, from small babies to older adults.

Fishbein is a nationally recognized surgeon and has performed approximately 20 percent of all intestinal transplants in the United States.—LH

Dr. Ali Fazel
Inova Fairfax Hospital; Endoscopic Mucosal Resection
Inova Fairfax Hospital’s Center for Advanced Endoscopy, which made a spring 2007 announcement that it would use endoscopic procedures on patients with benign and malignant diseases of the digestive tract, pancreas and bile ducts, is the first program of its kind in Northern Virginia.

In the center, a multidisciplinary team that includes surgeons, oncologists and gastroenterologists uses endoscopic techniques to treat Gastroesophageal Reflux Disease and the damage that can result from the disease; remove large colon polyps that would have previously required surgery for their removal; manage digestive cancers, primarily of the esophagus, stomach, bile ducts, pancreas and colon; and treat benign blockages, stones and inflammation in the pancreas and bile ducts. It’s a one-stop center that offers a wide range of cutting-edge endoscopic services.

The doctors use endoscopic ultrasound and techniques such as endoscopic mucosal resection (EMR) to earlier detect and remove digestive cancers. “EMR allows the endoscopist to shave off the inner layers of the digestive tract without causing damage to the deeper layers,” said Dr. Ali Fazel, the center’s medical director. “Because cancerous and precancerous legions of the digestive tract arise from the innermost layer, by shaving it off, you’re able to remove cancerous legions.” Fazel, who was in charge of a similar endoscopy program at the University of Florida, is very pleased with the program’s growth. “This is such a strong medical community, and this is just one service that happened to be lacking. We’re very happy to be able to fill that niche,” he said.—LH

Dr. Ivan Ducic, chief of peripheral nerve surgery at Georgetown University Hospital, has built a devoted following among migraine sufferers nationwide ... he refuses to take a routine approach to migraine pain.

NERVES
Dr. Ivan Ducic
Georgetown University Hospital; Peripheral Nerve Surgery
Dr. Ivan Ducic, chief of peripheral nerve surgery at Georgetown University Hospital, has built a devoted following among migraine sufferers nationwide. Patients who have failed one treatment after another come to Ducic because he refuses to take a routine approach to migraine pain.

“In about 25 percent of cases there are strong individual characteristics,” said Ducic, who is renowned for the extensive amount of time he devotes to puzzling out the source of a given patient’s problem.

“When you have patients who have seen a number of good specialists, and they are still continuing to have problems that affect the quality of their lives, you need to start thinking outside the box.”

Accordingly, Ducic, who has a Ph.D. in addition to his medical degree, tries to reconstruct the events leading up to nerve pain so that he can better treat it surgically. “Unless you understand the source of a problem,” he insisted, “you can’t fix it.”—SM

Dr. Keith Sterling, Inova Alexandria’s medical director of cardiovascular and interventional radiology, is combining ultrasound energy with thrombolytic drug-containing catheters that administer medicine into a clot-containing vein.

BLOOD
Dr. Keith Sterling
Inova Alexandria; EKOS Clot-Busting Treatment
Dr. Keith Sterling, Inova Alexandria’s medical director of cardiovascular and interventional radiology, is combining ultrasound energy with thrombolytic drug-containing catheters that administer medicine into a clot-containing vein.

The high-frequency ultrasound enhances the drugs’ ability to quickly dissolve the clot in a procedure that typically takes less than 24 hours. The tool is essentially a catheter lined with tiny transducers whose ultrasound energy pushes the drug into the clot, which the ultrasound also alters.

Sterling said that the ultrasound energy makes the dissolving process quicker and allows the doctor to use a lower lose of the clot-busting agent. The first hospital in the D.C. area to conduct this new therapy, Inova Alexandria has found great patient success with the procedure. “We use the EKOS catheter system for three main areas: blockages in arteries, veins and the brain,” Sterling noted. Sterling said the EKOS ultrasound-enhanced clot-busting procedure provides more safety and efficacy than traditional procedures, and patients are often able to leave within 24 hours “with a Band-Aid.”—LH

When using the Birmingham Hip Resurfacing procedure for hip replacement, the doctor does not cut the ball off, but rather trims the edges and puts a high-carbide cobalt chrome cap on it.

BONES
Dr. Andy Engh
Inova Mt. Vernon; Birmingham Hip
Someone who is 55 years old has a good chance of success with a regular hip replacement—a procedure in which the doctor cuts off the ball and inserts a metal rod into the thigh bone, which holds the new ball, lasting them the rest of their life. However, someone who is younger than 55 or more active than the typical 55-year-old is likely to eventually need a second operation.

“A high-demand, highly active patient is more likely to wear his or her hip out. These are the patients that might want to take a chance on the newer technology, which is why hip resurfacing is so appealing to high-demand patients,” said Dr. Andy Engh of Inova Mt. Vernon Hospital, which features this advanced procedure.

When using the Birmingham Hip Resurfacing procedure for hip replacement, the doctor does not cut the ball off, but rather trims the edges and puts a high-carbide cobalt chrome cap on it. Laboratory research has shown that the metal-on-metal joint may be more wear-resistant than the traditional metal-on-plastic joints, but doctors say only time will tell. “What we believe right now is that the resurfacing saves more bone—nobody will debate that it’s a bone or a skeleton-preserving hip replacement,” Engh said. “So if I do a regular total hip replacement on one 50-year-old and a resurfacing on another 50-year-old on the same day, and they both go bad 15 years down the road, I will have more bone to work with and the operation should be easier with the resurfacing patient than with the total hip.”

Dr. Mark P. Madden
Reston Total Joint Center; Joint Replacement
At Reston Hospital Center’s Total Joint Center (TJC), it isn’t unusual for a joint replacement patient to be walking the afternoon of their procedure, nor is it strange for the patient to be discharged from the hospital in just three days.

The TJC, formed in 2002 and recognized as a Center of Excellence by Mid Atlantic Medical Services, Inc., represents the collaborative efforts of orthopedic surgery, rehabilitation and anesthesia professionals.

Loraine Zolkiwsky, who had her knee replaced at the TJC in January 2007, said that the informational nature of the center made her experience “just fabulous.”

“I think half of the problem with many surgeries is that there’s this mystery aspect; all the patients know is that they have to show up at the hospital that day,” she said. “At the TJC, you had to attend a class ahead of time and everything was broken down almost to-the-minute. Nothing was a mystery when you went in.”
“We’ve got not just one mind or set of eyes looking at a problem, but four or five. It’s an organized plan rather than a hit-or-miss strategy,” said orthopedic surgeon Dr. Mark Madden.

The team Madden refers to consists of physician’s assistants, physicians, physical therapists, nurses and discharge planners. The center has features like “joint camp,” where patients attend a preoperative class with their own coach, learning to mentally and physically prepare for their joint surgery. Camp continues after surgery, as do group exercise and therapy sessions and educational classes on living with a new joint.

“For lots of people, there’s this mental block when it comes to big surgeries. But if you have the information and are mentally prepared, it really works. It can be a really positive experience,” said Zolkiwsky, who has been fully recovered from her surgery for months and feels “15 years younger.”—LH

PROSTATE
Dr. A. Daniel Laurent
Reston Hospital Center; GreenLight PVP
Previous treatment for Benign Prostatic Hyperplasia (BPH), a condition common in males over the age of 50 where the prostate becomes enlarged and puts pressure on the urethra, required patients to stay at the hospital for several days and nearly a month away from work.

“Up until approximately four years ago, the ‘gold standard’ for treatment for symptomatic BPH was the TURP, or transurethral resection of prostate,” said Dr. A. Daniel Laurent, urologist at Reston Hospital Center, which began offering the GreenLight procedure three years ago. Physicians at Reston Hospital Center said the TURP procedure posed a high risk of complications and several unpleasant side effects in patients. GreenLight PVP (photoselective vaporization of the prostate), a laser procedure offered by urologists at the center, is far less invasive than previous procedures, while providing the same favorable outcome.

“The main issue with TURP was the increased risk for bleeding both during the procedure and after,” Laurent said. “Patients were typically hospitalized for two to three days with a catheter, and even after going home were told to avoid strenuous activity and car riding for several weeks to avoid delayed bleeding, which could at times be severe. In rare instances after having a TURP procedure, men developed urinary incontinence and impotence.”

According to Laurent, the GreenLight laser procedure offers an effective treatment without an ugly aftermath. “The end effect of the procedure is identical to that of a TURP, in that a wider urinary channel is created, immediately relieving the blockage. However, the laser energy simultaneously vaporizes the obstructing tissue and seals the blood vessels. This allows an almost bloodless procedure,” Laurent said.

As such, a return to normal life can occur simply after an extended weekend of rest.

“Reston Hospital Center is unique in that it provides the GreenLight technology on a full-time basis, which offers greater flexibility in scheduling. We have had a very positive response to the treatment. The results have been excellent, and the complication rate is very low.”—LH

Carroll and fellow Georgetown University doctor Nadim Haddad are now using endoscopic ultrasound techniques to diagnose the cancer before the disease advances to an inoperable point.

CANCER
Drs. John Carroll and Nadim Haddad
Georgetown University Hospital; Endoscopic Ultrasound
Short of having a family history, it’s hard to say who is considered “high risk” for pancreatic cancer, and it used to be that when doctors had any suspicions of the cancer in patients, they would use a CAT scan to get a better look.

“A CAT scan just didn’t give as good of a resolution. You would just see a density and wouldn’t know exactly what it was,” said Dr. John Carroll, a gastroenterologist at Georgetown University Hospital. “At that point, you could do exploratory surgery in advance … or just watch and wait.”

Carroll and fellow Georgetown University doctor Nadim Haddad are now using endoscopic ultrasound techniques to diagnose the cancer before the disease advances to an inoperable point. In this procedure, the doctors pass an endoscope with an ultrasound component through the patient’s mouth and into the stomach. With the standard endoscope, doctors only see the inner lining of the digestive tract; with the ultrasound imaging, they can see all the layers and surrounding structures, including the adjacent pancreas, getting close enough to look for any masses, cysts or abnormalities. Some patients’ cancers cannot be seen on the CAT scan, but are detectable using the endoscopic ultrasound imaging. “Endoscopic ultrasound has been around for a while now, but the scopes are getting better, and the needles that we use are better as well, so that when we see a small cancer, we can get a biopsy early on,” said Carroll, who began training in endoscopic ultrasound in 1997.

“The accuracy and the reliability—both from the equipment standpoint, our experience and the pathologists’ experience—it’s all a lot better.”—LH

Dr. Gregory Gagnon
Georgetown University Hospital; CyberKnife
Some cancers are inoperable. Ask Joan Schwab. A former smoker, she had already lost part of her right lung to a cancerous growth. Afterward, breathing became difficult.

So when doctors at Georgetown found cancer again, this time in the left lung, 67-year-old Schwab knew surgery was out of the question. Instead, she was referred to Georgetown’s new state-of-the-art robotic radiosurgery system called the CyberKnife. This $6 million machine delivers an intense beam of radiation to tumors from as many as 1400 different angles. For weaker patients like Schwab, or those with inaccessible cancers, the CyberKnife is their last and best resort.

“The first surgery was quite awful,” recalled Schwab, who is now cancer-free and back to walking her dog. “The CyberKnife was different. I lay down, got up and drove home. No pain or anything.”

Dr. Greg Gagnon, chief of radiation medicine at Georgetown University Hospital, leads the CyberKnife team. “This is 10 times more precise than standard radiation, and because the dose fall-off is so abrupt, we can deliver a high dose to a very small area. It’s like a knife, in a way.”

With traditional radiation, patients are exposed to a high degree of excess radiation, which causes damage to surrounding organs. “There are dosage limitations with standard radiation,” said Gagnon. “With CyberKnife, it’s so accurate that you can use a higher dose.”

Perhaps most exciting are the unexpected benefits of CyberKnife. “Some cancers, like prostate, seem to have a radiobiologic response,” Gagnon said. “They are sensitive to this intense radiation.”

For now, CyberKnife is reserved for patients who cannot undergo surgery. But Georgetown University Hospital staff members are ready for the day when they become the first choice for certain cancers; they just bought a second CyberKnife.—SM

(February 2008)

Top Doctors 2007

Posted by The Editorial Desk / Monday, December 8th, 2008

Northern Virginia and environs could be considered an embarrassment of riches in terms of excellent medical care, yet one can be at a loss to identify physicians with superb credentials, experience and reputation when such things really matter. On these pages you’ll find 100 practitioners who excel in 33 fields of specialty. We profile seven of them. Culled by independent, physician-led research firm Castle Connolly, these physicians are not only highly regarded by their peers, but carefully vetted and selected. Come meet our top doctors. They are among the best in the nation.

By Sarah Hamaker, Sarah Markel, Brenda M. Melvin and Jan Maxwell
Photography by Anastasia Chernyavsky and Morgan Howarth

At The Top of His Game
Dr. Gary C. Dennis

Photography by Anastasia Chernyavsky

Surgeon. Teacher. Researcher. Policy Advocate. Dr. Gary Dennis is a veritable renaissance man. “I like to perform surgery that makes a dramatic difference for the patient,” says Dennis, Chief of the Division of Neurosurgery at Howard University Hospital and Associate Professor of Neurological Surgery at Howard University College of Medicine.

One need only peruse Dennis’s case files to see a man at the top of his game. There’s the case of the 17-year-old who, crop dusting with his father, disembarked from their helicopter, whence its propeller lopped off a third of the back of his head. Dennis and his team worked all night on delicate reconstruction of the blood vessels and cranium. The patient walked out of the hospital three weeks later.     There was the bedridden octogenarian who wanted to regain mobility, and though surgery at her advanced age is considered risky, Dennis agreed to perform the spinal procedure. The plucky 96-year-old poker wiz is eternally grateful. Then there was the man with tuberculosis of the spine who was almost completely paraplegic. Dennis operated to de-compress the spinal cord, and today the patient is fully mobile with no neurological impairment.

The list goes on.

Early Influences
Dennis’s exposure to neuroscience began with a motorcycle accident when he was 17 years old and treated by a neurosurgeon for head injury. “The tests were impressive yet rudimentary compared to today’s technology, but it was enough to pique my interest.” As a student at Boston University, Dennis participated in research involving Rhesus monkeys, where electrodes were neurosurgically implanted into monkeys to stimulate their brains. Researchers would record their responses and evaluate their ability to learn and perform tasks. The neurosurgeon made a major impact on the students, Dennis says. “When he came in, it was like Moses parting the Red Sea. I said to myself, ‘that is the person I want to be.’” Dennis chose Howard for medical school, thinking he would pursue a career in psychiatry. He delved into Freud’s Interpretation of Dreams and even learned hypnosis. In the end, though, his affinity for neuroscience won out. “I found clinical work fascinating and I decided that I no longer wanted to be a bookworm. I wanted to be a clinician.”

Dennis completed a general surgery internship at Johns Hopkins and trained in neurosurgery at Baylor University, in one of the nation’s busiest trauma centers. A few years later, he was lured west for a faculty position at the University of California, San Diego.

Coming Home
Born in Washington, D.C. Dennis retained a soft spot for his hometown. When presented with the opportunity to become Chief of Neurosurgery at Howard, he says he couldn’t refuse. He moved back in 1984.

“Neurosurgery is an area that is very intricate. Many medical students shy away from it because they think it’s too hard. I wanted to give back to the community by teaching students and residents how to become successful neurosurgeons.”

Dennis is proud of his involvement in a mentoring project for gifted students at D.C.’s Benjamin Banneker High School. Those considering a career in medicine, students are paired with doctors to learn more about their fields; they sit in on medical school lectures and observe surgical procedures.

The Wonders of Technology
Dennis marvels at recent years’ major advances in neuroscience. “Neuro-imaging has improved astronomically.” We can see very clear pictures of the brain using sophisticated new diagnostic tools, and MRIs and CAT scans generate images of the nervous system that can be viewed remotely, by email, he says. “A doctor can see the problems a patient might have without actually being present.” Techniques such as real-time visualization allow operating surgeons to determine where they are in a patient’s brain compared to where they think a tumor is located.

Dennis hopes neurosurgeons will soon be able to employ three dimensional imaging technology to perform surgery remotely using controlled robotics.

With such advances, surgical procedures will become less invasive, he says, resulting in a safer patient experience, less hospital time and shorter recovery period. “It will be possible to perform major miracles without having to do extensive operations. This will be true for both brain work and spinal work,” he predicts.

Ongoing Research
Though he has taught and practiced neurosurgery for years, Dennis hasn’t lost his passion for research. Partnering with a neurophysiologist colleague, he is studying the respiratory center of the brain stem. Together they have looked at things such as the effect of cocaine use on the brain—in an effort to develop treatment that can prevent patients from dying from overdoses.

The improvement of patients with spinal cord conditions is another project to which Dennis devotes significant time and attention.

Dennis writes and speaks widely about health care disparities—the unequal access to health care experienced by various ethnic groups, minorities and social stratum.

He has secured funding for a comprehensive study on the issue; has chaired various political action committees, and has testified before the D.C. City Council on matters related to the health of city residents.

A Day In The Life
Dennis walks the talk when it comes to diet and exercise issues. The doctor’s day begins with a 5:30 a.m. workout followed by a light breakfast where he tries to fit in the first of nine daily servings of fruits and vegetables. In his office by 7:00, he operates two days a week and sees patients three days a week.

On the days he’s not scheduled for surgery, Dennis tries to spend the first two hours of his work day reading. To hear him speak of it, these hours are sacred. “I like to read when I can see the sun when it rises and hear the birds sing. I get a lot of work done during this period.”

Dennis starts seeing patients at around 9:00; a full day may consist of 25 appointments. Then it’s on to student lectures, “consults,”  committee obligations and the inevitable emergencies that arise. Dennis tries not to operate for more than eight hours and handle no more than three cases in a day. “On a good day, I’m home by six.”

So, what does the good doctor do to unwind and stay sane? “I have a strong belief in God, I love my wife, and I love music. A good jazz concert usually makes my day.” Dennis is an accomplished violin player, part of a group of doctors and other healthcare professionals who perform regular gigs at the University of Maryland in Baltimore. —Brenda M. Melvin

Steady Hand, Warm Heart
Dr. Alan Egge

In the highly unlikely event that ophthalmology doesn’t workout for Dr. Alan Egge of Dominion Eye Care in Manassas, he may well have a future in journalism. It was only when I was well into the not inherently interesting story of how I financed my education that I realized how skillful he is at putting people at ease.

Sure, Egge (pronounced Eggy) has performed over 7000 successful eye surgeries using both laser and microscopic technologies. But his real gift is in getting his patients to relax enough to forget that he is about to operate on their eyeballs.

Despite the ubiquity of modern eye surgery, Egge practices a difficult art. During microsurgery, he operates within a tiny field, using even tinier instruments, while looking through a microscope. He cuts open the cornea. Egge’s work requires tremendous concentration, which he describes as “being mentally in the room with the patient at all times.”

This intense concentration is something he honed as a coping mechanism during an emotionally brutal pediatrics residency at the University of Chicago during the late 70s.

During a subsequent ophthalmology residency at the Doheny Eye Institute at the University of Southern California, Egge found that concentration equally useful in microsurgery.

Today Egge is a board-certified pediatrician and an ophthalmologist with a 20-year-old practice in Manassas and Warrenton.

Although he doesn’t practice pediatric ophthalmology, an advanced sub-specialty, Egge often treats children at Dominion Eye Care because the population of children in Northern Virginia is growing faster than the number of local pediatric ophthalmologists, he says.

Egge also treats uninsured children at the Manassas Free Clinic where he volunteers on Thursdays as a pediatrician. Most of his patients are there for basic primary care such as colds, rashes and flu.

The best part of his work, Egge says, is the ability to provide both ends of the spectrum of medical care. Egge relishes the opportunity to practice advanced surgery, and he clearly enjoys the patient interaction involved in primary care.

“It’s a good mix.”

He smiles easily.

Dominion Eye care has grown with the region. Egge credits his local success to the fact that two decades ago, Manassas was similar in feel to his native town of Sumner, Washington (pop. 3000). “I don’t know that I could have made it in a city,” he muses.

Alan Egge is married to Kathleen Cox, the former head of the Corporation for Public Broadcasting.

They live in Fairfax and have four children. —Sarah Markel

When Knowing is Strong Medicine
Dr. Claudine Isaacs

Photography by Anastasia Chernyavsky

Women at high risk of breast cancer used to live under a black cloud of dread. Today, doctors are using the knowledge gained from genetic testing to fight breast cancer. And the clouds are lifting.

In my experience, cancer centers are not pleasant places. They are whispering, metallic-smelling other
worlds where fear lurks and mothers grow old before your eyes.

But the Lombardi Comprehensive Cancer Center at Georgetown University seems different somehow. Teeming with doctors and students, it seemed brighter; less a place of darkness than of possibility.

“Call me Claudine,” is the first thing the director of the Clinical Breast Cancer Program, Dr. Claudine Isaacs, says as she appears, smiling, through a passing throng of students.

Isaacs is one of those super doctors; besides being a pioneer in clinical research, she teaches medicine and oncology and sees cancer patients in the clinic two days a week.

Her office is what you would expect of an academic. Piles of documents are neatly stacked on desks and tables. An incongruous calendar of European castles hangs on the wall—a gift from her two sons, eight and eleven.

Isaacs’ work at the Lombardi Center involves using clinical trials both to study the genetics of breast cancer and to learn more about ways of treating it. She is changing the way others look at the disease.

In the 14 years since coming to Georgetown Hospital from her native Montreal, she has published over a hundred articles and papers on breast cancer, genetics testing, and counseling.

Isaacs is a tireless speaker on issues of hereditary breast cancer, and an irrepressible advocate for the power of genetic testing to transform lives.

Much has changed since the genetic abnormalities that predispose a person to breast cancer, BRCA1 and BRCA2, were identified in the early nineties. “We used to sit across from high-risk patients and we had so little in the way of data to offer them,” she recalls, speaking of the close team of
genetic counselors and behavioral scientists with whom she works.

Isaacs describes the worry that high risk patients used to live with.

I know that black cloud of dread well.

Today people who are found to be BRCA carriers have a handful of good options for reducing their risk of actually getting cancer. And if they do get cancer, better screening has increased the chance that it will be found early and successfully treated. During those years of assessment and evaluation, relationships form. Friendships grow.

Isaacs tells the story of “Sue,” who came in for a consultation a decade ago because her sister had tested positive for BRCA1. As a young mother of three, Sue was scared, although less for herself than for her daughters’ future.

Isaacs encouraged her to undergo genetic testing. And when the tests showed that she too had the genetic mutation, Isaacs recommended removal of her ovaries, which has been found to be an effective option for reducing the risk of developing breast cancer.

Sue agreed to the surgery. Years passed. She continued to see Isaacs for follow-up and to take part in cancer studies. One such study compared the relative effectiveness of mammogram, ultrasound and MRI as screening tools for cancer.

No one expected to find anything. Sue’s chances of getting breast cancer had been reduced 50 percent by the surgery. Plus she was still young. The mammogram and ultrasound came back clear, but the MRI showed a tiny irregularity.

It was cancer. She had her chemotherapy at the Lombardi Center. Today, Sue has had five cancer-free years. To her daughters, now teenagers, and with the help of Isaacs, Sue is passing on some hard-won knowledge.

According to Isaacs, genetic testing can provide information that makes a huge difference in the types of care available to patients. And it changes families.

Sue still participates in cancer studies. She looks upon her involvement in the MRI study as life saving. “You are my guardian angels,” she tells Isaacs and her colleagues.

“A good day,” says Isaacs, “is when you make a difference in some else’s life. That was a good day.”

Near the end of the interview I tell Isaacs that my mother has breast cancer, her second relapse.

She nods thoughtfully and asks several questions about our family history. She doesn’t say “oh-my-God-I’m-so-sorry” and look at me with pity the way most people do.

Instead, she encourages me to talk with my mother about genetic testing, and to be honest with her about my fear. Basic stuff, really.

As I leave the interview and walk across the campus, my step is lighter. I kick at the fallen leaves, not just because the interview has gone well, but because she made me see that breast cancer is just a disease. It isn’t a death sentence. —Sarah Markel

Breathing Lessons
Dr. Steven T. Kariya

Photography by Anastasia Chernyavsky

Trying desperately to save patients while tuning out the constant ringing of gunfire can be a real challenge for a young doctor, a lesson learned by pulmonologist Steven Kariya during his days as a volunteer assigned to tend to Cambodian refugees. Indeed, the road from Thailand to Silver Spring, Maryland has been a storied one for this lung and respiratory disease specialist, who now runs Pulmonologists, PC, and serves as Medical Director of Respiratory Therapy at Holy Cross Hospital in Silver Spring.

Kariya received his Bachelors degree from Harvard College and his M.D. from Cornell University Medical College. “I think of myself as an applied physiologist, one who thinks about how the body works overall and uses this insight to educate and treat patients,” says Kariya. His decision to specialize in pulmonary care was the result of having asthma as a child and having mentors during his training years who were pulmonologists. “The practice of medicine is an honorable profession that allows me to help people in spite of the bureaucracy that is often involved. Sadly, [respiratory disease] is a growing problem. People are sicker, smoking is on the rise among many groups, and patients often suffer from chronic illnesses as they age.”

Kariya’s cases run the gamut from common sleep disorders to some of the rarest forms of lung cancer. While many of us take a good night’s sleep for granted, people who suffer from a condition known as sleep apnea actually stop breathing, or underbreathe, in their sleep several times in a night.

Kariya has apnea patients go through a lab-based sleep study to observe their sleep patterns and confirm the diagnosis. A typical treatment requires the individual to wear a continuous positive airway pressure (CPAP) mask that blows air into the nose to keep the windpipe open—an effective, fairly simple remedy for a serious problem. Non-treatment of sleep apnea can lead to high blood pressure, heart failure or stroke.

One of Kariya’s more complex cases involved the decade-long journey of a patient to whom he recently had to bid farewell—in a good way. Kariya met the woman ten years ago and diagnosed her with cancer of the windpipe, right where the right and left lungs divide. He consulted with a thoracic surgeon who performed a unique operation to remove the cancer and repair the windpipe. Following surgery, the patient literally had her chin sewed to her neck for a week to restrict movement and ensure proper healing. Thereafter, Kariya saw the patient annually for ten years to perform a broncoscopy, a procedure in which a fiber optic tube the diameter of a pencil is inserted into the windpipe to look for signs of cancer. Happily, the patient reached her ten year mark with no signs of cancer, and she was officially “fired” by Kariya.

Despite the long hours required by his critical care practice, Kariya manages to find time for community involvement. He helped establish the nonprofit Northern Virginia-based Campbell Hoffman Foundation, which seeks to increase access to healthcare for the underserved.

When he’s not on call, look for him on the soccer field where he is likely putting his son’s team through the paces for their next big match: “It’s hard work, and I can’t bill the hours, but I enjoy it!” —Brenda M. Melvin

Guts and Glory
Dr. Fredrick Brody

If Top Gun had been about gastrointestinal surgery, it would be easy to see Dr. Fredrick Brody of George Washington University in the role of Maverick.

Brody’s handsome, self-confident and smart as, well, you know.

At 40, he has already published a mountain of articles on gastrointestinal surgical procedure. He has contributed to books, starred in educational films, and is at the forefront of cutting edge research to unravel the science behind chronic obesity. He doesn’t go in for small talk.

“I have four favorite types of surgery,” he says at a clip, as soon as we begin the interview, “but I really like to do foregut.”

It’s late afternoon and Brody’s been in surgery since dawn. He’s blowing on a cup of tea and talking fast.

Foregut is stomach and esophagus, he explains.
Now he’s describing his other favorite surgical procedures: “Achalasia, esophageal or GERD, and gastric, especially when it’s gastro-peresis and we have to use electrical stimulation.”

I can’t spell half of what he’s talking about and he knows it. He slows down and explains that 75 percent of his work involves laparoscopic surgery: “Big surgery, small incision.” The benefits of laparoscopy are less pain for the patient and faster recovery time. The rest of his surgical time is divided between big incision gastrointestinal surgeries, and bariatric work, which includes any kind of surgery to treat obesity.

The bariatric work, he says, is a very small part of any given day, but it’s hugely important because of a project he’s spearheading. It’s called the Bariatric Surgery Program.

Brody isn’t just interested in solving obesity problems, he and a close team of three surgeons, several nurse practitioners, plus a host of other physicians, including cardiologists and pulmonologists, are working together to try to figure out the genetic mechanisms behind the condition.

This intersection of the academic and the clinical is called Translational Medicine. But call it what you will, it is a tough business—fighting for funding, collecting and analyzing data, and publishing findings.

This is in addition to seeing patients, teaching, surgery, and managing a practice. Members of the medical faculty are not employed by the university and are essentially independent contractors. That’s why Brody has an MBA and no time for hobbies.

There’s a set of tiny pink albums on his desk. I ask if he gets tired during surgery.

Nope.

Lose your concentration?

Nope.

He follows my gaze to the albums. “She’s a good baby.”

He describes how during surgery the adrenaline surges through you with such force that no matter how tired you may be, concentration is not a problem. Then when you go home, you crash.

So surgery is a Zen-like experience?

His eyes roll upward behind the still steaming tea. Nope.

For crying out loud, Maverick, help me out here, I wail inwardly.

And at this point, Brody seems to understand that I am just not getting it. How can he lead such a grueling and intellectually demanding professional life and remain so cool?

Leaning forward, he says, “to excel at anything, you have to love what you do. Sure, it’s a constant juggling process—the phones, the papers, pre-op, post-op, patients, residents, students…. But, it’s a dynamic field. There is always something to learn.” He gives the tiniest of shrugs and grins. “And it’s really fun.” —Sarah Markel

The Art of Neurology
Dr. Ruben Cintron

The mysteries of the human brain have fascinated scientists for centuries.  Although it weighs only a few pounds, the brain contains over 100 billion cells that process and transmit information, controlling everything from breathing to vision to thought. Unlocking its secrets can lead to medical breakthroughs, and one of the people most interested in doing that is Dr. Ruben Cintron of Reston.

Cintron is a neurologist, a doctor who diagnoses and treats nervous system disorders, including diseases of the brain, nerves, muscles, and spinal cord.  As part of his daily practice, Cintron tests muscle strength, balance, speech, and other cognitive abilities in patients who suffer from a wide variety of these disorders. Once a diagnosis is made, he sets about finding the right mix of drugs and therapy for each situation.

A normal day may find Cintron treating patients with a range of illnesses, from migraines to brain tumors to degenerative disorders such as Lou Gehrig’s disease and Parkinson’s.  Although multiple patients may suffer from the same disease, each case is unique.  “You can’t write a computer program to evaluate a neuro case,” says Cintron. “They are all different.”

Cintron received his B.S. degree from Wake Forest University in Winston-Salem, North Carolina in 1986. He went on to Wake Forest’s Bowman Gray School of Medicine, where he graduated in 1990. It was during those four years of medical school that Cintron developed interest in neurology.

“I read the book, The Man Who Mistook His Wife for a Hat, which was written by a neurologist named Oliver Sacks. In the book, Sacks described some very interesting cases, and I became absorbed by the unknown territory of the brain.” Cintron began to pay close attention to the neurosciences and realized he had found his niche. “It’s a great specialty, as we see a large variety of disorders and no two patients are the same.”

When he completed his internship at Washington Hospital Center in D.C., Cintron moved to Georgetown University Hospital, where he began a three-year residency in the Department of Neurology. There he was involved in Parkinson research, testing a new synthetic drug that gave extended relief to patients. The study was a success, the drug received FDA approval, and it has been on the market for several years.

After completing his residency, Cintron felt that he had not had sufficient exposure to neuromuscular disorders, so he stayed at Georgetown for another year as a Fellow in Neuromuscular/EMG medicine. One of the neuromuscular diseases that fascinates him is Myasthenia Gravis, an autoimmune disease that attacks muscles and creates weakness. It can be hard to detect since screening tests are often normal.

“Sometimes you have to treat the patient to make a diagnosis,” says Cintron. A woman suffering from Myasthenia Gravis came to see him after a major university program had told her that her symptoms were psychological, rather than physical. After examining her, Cintron disagreed and treated her with a therapy that slowed down her immune system. She had dramatic improvement.

Cintron sees many patients who have chronic, ongoing diseases. These illnesses take a toll on the whole family, not just the patient and Cintron sees his role as supporting the entire group. “When people develop a chronic neurological problem, I get to know the families as well as the patients. I have the opportunity to help them all as they struggle over many years.”

Carol Welsh is one such patient. She is a six-year survivor of an adult ependymoma, a rare brain tumor, and has been with Cintron throughout most of her disease. “Dr. Cintron is terrific, kind and generous. I wish all doctors could be like him,” she says.

Raised in Northern Virginia, Welsh was looking toward a bright future until the day in 2000 that doctors discovered her brain tumor. Unfortunately, the tumor was attached to several cranial nerves on her brainstem. These nerves are the source of a person’s ability to see, chew, move and hear, among other vital processes. Three brain surgeries left her cranial nerves damaged. She now faces problems with headaches, balance, swallowing, double vision, and debilitating pain.

Cintron helps her make it through each difficult day. At a typical appointment he will do neurological testing and then decide on the optimal blend of drugs that will make Carol the most comfortable and give her the highest level of functionality. He also helps her translate the highly technical reports she gets from her neurosurgeons. Welsh appreciates the fact that Cintron does not sugar-coat the truth. “He is low-key and realistic about things. I really appreciate his empathy and good sense of humor.”

As we begin the 21st century, Ruben Cintron sees breakthroughs ahead in neurology. He is impressed with the work being done in genetic engineering, where infusions could help genes make proteins that might correct a variety of disorders. Cintron is also an advocate of stem cell research, where healthy stem cells could be programmed to replace diseased cells in patients who suffer from diseases such as Parkinson’s. In both areas, critical work is now underway in research centers around the world. “The future is already here,” says Cintron, and he’s excited to be a part of it. —Jan Maxwell

Nurturing the All of Them
Dr. Elizabeth Anderson

Photography by Anastasia Chernyavsky

Dr. Elizabeth “Beth” Anderson is so well-liked in her internal medicine practice that a patient once wrote a poem for her. “I’ve been very fortunate to have lots of patients who have touched my life,” she says.

“I’ve wanted to be a doctor for as long as I can remember,” says Anderson. “I simply never wanted to do anything else. That single-minded desire and true passion for caring for the sick has sustained me through many obstacles—be it histology lab, which I hated, or managed-care restrictions, which drive me nuts!”

Her background includes degrees from Emory University (BA) and East Carolina University School of Medicine (MD), as well as residencies at both Georgetown University Medical Center and George Washington University Medical Center in Washington, D.C, and a research fellowship at the Veterans Administration Medical Center in Washington, D.C. Anderson first had a surgical residency and then transitioned to an internal medicine residency for a total of seven years’ worth of post-medical school training. She met her husband, got married and gave birth to her two children while doing her residencies. “Residency was probably the toughest part of my preparation,” she says.

Anderson’s medical focus these days involves the development of atherosclerotic [a degenerative disease of the arteries] complications affecting two specific patient populations: individuals affected by diabetes mellitus, and women. In particular, she focuses on how cardiovascular risk factors are different in a female population, how that difference puts women at risk and what needs to be done to assess and to reduce risk to women’s health.

“When I first started in medicine, I did two years of bench research looking at why specific complications develop in patients with diabetes,” she says. “That, and seeing women with risk factors for heart disease that remained unrecognized and under-diagnosed, sparked my interest in this area.”

Most studies done in this area were conducted on a male population, and some of the guidelines and risk factors that contribute to the development of heart disease and diabetes that came out of these studies may not apply to women, she says. “Our bodies just work differently than the typical male pattern. For example, the typical risk factors are high blood pressure, diabetes and cholesterol problems, and those are very important problems for women as well, but there’s also something called syndrome X. That means, because of estrogen loss, there’s a change in the character of blood vessels that puts women more at risk. That’s why you see women develop heart disease a few years after men.”

In her current practice at Internal Medicine Associates in Centreville, Va., Anderson strives to catch potential problems in patients before they can develop into established diseases.

Her physician philosophy revolves around her desire to create relationships with her patients. “If you establish a relationship with people, you have a shared partnership working toward a specific goal. That’s much more effective in the doctor/patient relationship because you can work together to accomplish things,” says Anderson. “Some of that has been lost with the way that managed healthcare has developed. I have a very stable patient population—I know them, I know their kids, their jobs, etc…I think patients respond much better to a relationship approach than to the old paternalistic model.”

This has led Anderson to consider many of her patients as friends as well as clients. Two of her patients—a retired husband and wife—ended up with various illnesses that required one or the other to see her once a week for an entire year.

“The thing that so impressed me was they never got depressed about their situation,” she says. “We got to be very good friends throughout that year.” Anderson even ran interference for them to get a test scheduled when the couple encountered roadblocks with their insurance company and the testing facility. The husband, who writes poetry for fun, penned her a poem entitled “Don’t Mess With Beth” in gratitude for her assistance. “It was all about if you ever needed anything, I was the one you could go to,” she says, and smiles.

She says when she addresses residents, she tells them: “Remember, you are the patient’s advocate. You have a huge gift and responsibility in terms of their most basic needs. It doesn’t take that much time to help them out and people are so grateful when you do.” —Sarah Hamaker

(February 2007)