Carilion Medicine fall 2017

Carilion Medicine FALL 2017

In partnership with the Virginia Tech Carilion School of Medicine and Research Institute

CARING FOR ONE’S OWN

Carilion Clinic is using targeted programs to meet the health needs of rural residents

Eugene Yopp is a patient at Carilion’s family medicine practice in pastoral Shawsville, Virginia

contents FALL 2017

CARILION MEDICINE

Departments 2 FROM THE CMO 3 IN BRIEF

ajor biomedical research expansion; national M recognition; leadership past and present

7 GRAND ROUNDS

Education initiatives both classic and with a twist

42 THE ART OF MEDICINE: HEALING ART IN THE BLUE RIDGE

16

ROUGH AND READY: As he was growing up in small-town Virginia, Adam Tate watched his physician father care for patients with a range of ailments. “In rural family medicine,” the younger Tate, now a medical student, says, “you have to be ready for whatever comes in the door.”

Carilion celebrates the power of art to create moments of respite for patients and caregivers.

45 CHEERS FOR PEERS

Recognition for Carilion clinicians

48 BACKSTORY: WOMEN IN HEALTH CARE Getting a seat at the executive table often means sticking your neck out.

BY NANCY HOWELL AGEE

SPECIAL REPORT

Rural Outreach 10 CLOSING THE GAP

16 THE ROAD LESS TRAVELED

For Carilion Clinic, meeting the health needs of rural residents is more than just a medical challenge. It’s about caring for one’s own.

Carilion training programs are preparing medical students, physicians, and advanced clinical practitioners to meet the needs of rural populations.

22 THE RURAL ROUTE

BY CHARLES SLACK

BY DAVID BUMKE

BY PAULA BYRON

The terrain and wildlife of southwestern Virginia and the lifestyles of its residents create challenges beyond those of mere remoteness.

PHOTOS: JARED LADIA, COVER AND ABOVE; ILLUSTRATION: MIKE LEMANSKI

Features 24 STRONG MEDICINE

28 THE AFTERMATH

32 THE COSMOS OF OUR CELLS

38 ROOM WITH A VIEW

BY VERONICA MEADE-KELLY

BY JESSICA CERRETANI

BY ASHLEY WENNERSHERRON

BY JARED LADIA

Once just a hospital-owned athletic club, Carilion Wellness has transformed itself into an active partner in the Carilion care team.

Law-enforcement officers aren’t the only witnesses to violence; health care providers often find themselves on the front lines as well.

Scientists are using cryoelectron microscopy at unprecedented resolutions to witness the self-destruction of mutated breast cancer proteins.

A day in the life of the neuroangiography suite at Carilion Roanoke Memorial Hospital provides glimpses into high-tech miracles.

my hometown of brodheadsville, Pennsylvania, was once rural farmland. Our town in the Poconos was small. The closest hospital was 20 miles away, a distance I recall well when, as a four-year-old, I was rushed there with a compound-fractured arm. I still vividly remember another day there, years later, when I had an appendectomy. It was, after all, the day Elvis died.

I guess you could say my experience in rural medicine began at an early age.

As the youngest of four, I was my father’s last hope for continuing the family plumbing, heating, and remodeling business. Then, one day in college, I finally admitted: I wanted to become a doctor.

I went on to medical school in Philadelphia and trained to become an OB/GYN in the Lehigh Valley at a large tertiary care center. It was only 45 minutes from Brodheadsville, but it seemed a world away.

Later, as an OB/GYN resident, I was asked to go by helicopter to pick up a woman in labor with pre-term twins. As I climbed aboard, the pilot asked whether I’d ever been to the Poconos. I couldn’t help but chuckle and reply, “Never by helicopter!”

We landed near Pocono Community Hospital, the same place I was born and the same place I’d had surgery the day Elvis died. The twins received the care they needed in our NICU. The event was big news, and we made the front page of the local paper: “Local hero returns home to save twins.”

Now, as chief medical officer of Carilion Clinic, I once again find myself dealing with the challenges of caring for patients in some of our country’s remotest areas. Our 20-county, mostly rural service area stretches from central and southwestern Virginia to southern West Virginia, with 230 miles separating our furthermost practices. Times have changed, but we still face challenges of geography and health disparity. People who live far from our cities often lack access to health care.

For some people, the nearest family physician may be hours away and they must travel even longer distances at significant cost for specialty care.

People living in rural areas are more likely than those in cities to die from heart disease, cancer, unintentional injuries, stroke, and chronic lower respiratory disease.

Carilion is confronting the challenges in the same way it has since its founding more than a hundred years ago as a scrappy little hospital for immigrant railroad workers: with a spirit of self-reliance. We continue to push ourselves to find creative, new ways to bridge the gaps between patients and providers.

The solutions aren’t easy, but they’re vital. All our patients deserve the chance to go home again—or to stay in the home they love.

Patrice M. Weiss, M.D. Chief Medical Officer and Executive Vice President Carilion Clinic

2 CARILION MEDICINE | FALL 2017

Carilion Medicine President and Chief Executive Officer Nancy Howell Agee Chief Medical Officer and Executive Vice President Patrice M. Weiss, M.D. Editorial Advisory Panel Nathaniel L. Bishop, D.Min.; Cesar Bravo, M.D.; John Burton, M.D.; Kimberly Carter, Ph.D., R.N.; Kimberly Dunsmore, M.D.; Evelyn Garcia, M.D.; Mark Greenawald, M.D.; Daniel Harrington, M.D.; Cynda Johnson, M.D., M.B.A; Donald Kees, M.D.; Wilton Kennedy, D.H.Sc., P.A.-C.; Michael Nussbaum, M.D.; John Pastor; Paul Skolnik, M.D.; Robert Trestman, M.D., Ph.D.; Fidel Valea, M.D. Chief Administrative Officer Jeanne Armentrout Vice President Mike Dame Executive Editor Linda Staley Editor Paula Byron Art Director Laura McFadden Special Thanks Catherine Doss, Mark Lambert, Steven Mackay, Alison Matthiessen, Laura Mitchell, Anne Shaver CARILION CLINIC 1906 Belleview Avenue P.O. Box 13727 Roanoke, VA 24036 CarilionClinic.org 800-422-4842

Carilion Medicine is published twice a year at: 213 McClanahan Street, Suite 200 Roanoke, VA 24014 Phone: 540-266-6586 Fax: 540-266-6608 Email: CarilionMedicine@carilionclinic.org Web: CarilionClinic.org/carilionmedicine

On the pulse of the Carilion Clinic community

GROUNDBREAKING FOR RESEARCH EXPANSION Carilion Clinic and Virginia Tech officials symbolically broke ground in October to begin construction on a new facility to expand biomedical research and provide enhanced experiential learning opportunities to students at all levels.

Known as the Virginia Tech Carilion Biomedical Research Expansion, the 139,000-square-foot building will rise on the Virginia Tech Carilion Health Sciences and Technology Campus in Roanoke. An elevated walkway will connect the structure to the Virginia Tech Carilion School of Medicine and Research Institute.

The $90-million building, expected to open in the spring of 2020, will be a physical manifestation of the success of the Virginia Tech Carilion Research Institute.

The expansion will enable additional stateof-the-art laboratories organized around interactive research themes, from neuroscience to cardiovascular science, metabolism and obesity research, and biomaterials and body–device interfaces.

During the groundbreaking event, the project leaders—including Timothy Sands,

THE FUTURE IS NOW: The new biomedical research expansion will be built at the heart of the Virginia Tech Carilion Health Sciences and Technology Campus in Roanoke. The building will be organized around highly interactive research themes.

Ph.D., Virginia Tech president; Nancy Howell Agee, Carilion president and chief executive officer; Michael Friedlander, Ph.D., Virginia Tech Carilion Research Institute executive director; and Patrice M. Weiss, M.D., Carilion chief medical officer and executive vice president—all talked about rising expectations for the partnership.

Rising in the Ranks of Hospitals In 2017, Carilion Clinic’s flagship hospital rose to its highest ranking ever in U.S. News & World Report’s annual assessments of hospitals. Out of nearly 130 hospitals in Virginia, Carilion Roanoke Memorial Hospital was named the third best hospital in the state.

The hospital was also one of 48 hospitals nationally—and the only one in Virginia—to be rated “high performing” in all nine chronic conditions and surgical procedures the magazine reviewed, an achievement that placed it in the top 1 percent of the more than 4,500 hospitals evaluated.

Carilion Clinic is a nationally ranked integrated health care system headquartered in Roanoke, Virginia. Its flagship, Carilion Roanoke Memorial Hospital, is the clinical affiliate of the Virginia Tech Carilion School of Medicine and Jefferson College of Health Sciences. © Copyright 2017 by Carilion Clinic. No part of this publication may be reproduced or transmitted in any form or by any means without written permission from Carilion Clinic. All editorial rights reserved. Opinions expressed herein may or may not reflect the views of Carilion Clinic.

PHOTO: JARED LADIA

in brief

RENDERING: AECOM

“In the first 10 years of the Virginia Tech–Carilion Clinic partnership, we created a research institute that makes a huge impact for its size, and we created what is regarded as one of the best research-oriented medical schools in the country,” Dr. Sands said. “More faculty members and students from Virginia Tech’s colleges will be involved in this next phase.”

Officials said the new building will be the next—yet not the last—product to spring from the partnership.

“Looking back more than 10 years ago, two aspirational conversations were happening in parallel—one at Carilion Clinic, one at Virginia Tech,” Agee said. “We began to think, ‘Wow, what if we do something together? And what might that look like?’

And I think that was the launch of something phenomenal. What we’ve gained from it is truly exponential, and the biggest gains in terms of growth and service to the community are still ahead of us.”

CARILION MEDICINE | FALL 2017 3

honors

VTC Innovation Fund The Virginia Tech Foundation and Carilion Clinic have formed a $15-million VTC Innovation Fund focused on investing in life sciences and disruptive technology opportunities.

The private fund will support late-seed and growth-stage companies in efforts to commercialize groundbreaking research as well as innovative products and solutions.

“The fund will invest in promising new companies and bring innovations to the marketplace,” said John Dooley, Ph.D., chief executive officer of the Virginia Tech Foundation. “It aims to help commercialize viable life sciences or accelerate general technology assets and attract corporate or venture capital. The investments may lead to real-world applications for the high-quality research coming out of Virginia Tech, Carilion Clinic, and other sources with strong connections to the Commonwealth of Virginia.”

Many of the companies will be within 150 miles of Roanoke or have a strong connection to Carilion or Virginia Tech.

“We have extremely gifted faculty and students,” said Timothy Sands, Ph.D., president of Virginia Tech. “By providing opportunities for our own startup companies to take their ideas into the marketplace, we are helping fulfill our land-grant mission to transfer technology and economic opportunity to the people of Virginia and the world. Some of the most innovative ideas in science and technology are being developed

at Virginia Tech, many in collaboration with Carilion Clinic.”

The VTC Innovation Fund is just one of the latest collaborative efforts in the partnership between Carilion and Virginia Tech.

“We know how important our efforts are to our region’s future and we take that responsibility very seriously,” said Nancy Howell Agee, president and chief executive officer of Carilion. “As we move forward, we want to make sure infrastructure is in place to make game-changing new achievements in health, medicine, and technology.”

Growth-stage companies in a university and research environment often depend on sources of capital such as the VTC Innovation Fund to drive proven ideas from the research bench to the marketplace, said Michael Friedlander, Ph.D., executive director of the Virginia Tech Carilion Research Institute.

“Intellectual property is developed across Virginia Tech and in collaborative research partnerships with Carilion Clinic,” said Dr. Friedlander, who also serves as Virginia Tech’s vice president for health sciences and technology. “Investors are needed to take the work being done in the lab to the market because you can’t use research grant money or university money for those purposes. It takes private investment capital to take an idea to the next stage and build a virtuous cycle of discovery, innovation, translation, application, and commercialization.”

DISCOVERY CHANNELS: The VTC Innovation Fund is the latest collaborative effort in the expanding partnership between Carilion Clinic and Virginia Tech.

4 CARILION MEDICINE | FALL 2017

FORMER CARILION PRESIDENT REMEMBERED

Agee

MAKING THE LISTS For the second year in row, NANCY HOWELL AGEE, president and chief executive officer of Carilion Clinic, has been named to Modern Healthcare’s list of the 100 Most Influential People in Healthcare. Her ranking for 2017 rose to number 23 on the list.

“This honor recognizes Nancy’s tireless efforts in our own community, in addition to the substantial contributions she makes to local, regional, and national conversations on health care,” said James Hartley, Carilion’s chairman of the board. “We in southwestern Virginia have long known that Nancy is a strong, competent leader. It seems the rest of world may now be catching on.”

Hartley noted that as proud of this honor as Agee should be, he was certain her greatest pride lay in Carilion’s team of professionals.

“Nancy’s—and Carilion’s—star is rising on the national stage,” Hartley said. “The work that Carilion’s compassionate and talented professionals do each day continues to be recognized in the industry. That reputation has enabled the organization to continue to build strong partnerships.”

Earlier in the year, Agee was also named to Modern Healthcare’s list of Top 25 Women in Healthcare.

PHOTOS: DAVID HUNGATE (LEFT); JARED LADIA (TOP)

EDWARD MURPHY, M.D., former president and chief executive officer of Carilion Clinic, died of cancer on October 15 at the age of 61.

A native of upstate New York, Dr. Murphy received his bachelor’s degree from the University of Albany and his medical degree from Harvard Medical School.

Rather than entering full-time medical practice, he chose health care research and administration. Early in his career, he served as a clinical professor at the University of Albany School of Public Health and adjunct assistant professor at Rensselaer Polytechnic Institute’s School of Management, based in Troy, New York.

He assumed the presidency of Leonard Hospital, also in Troy, in 1989. He later negotiated the creation of Seton Health System, an integrated health care system, for which he served as president and chief executive officer.

In 1998, Dr. Murphy joined Carilion Health System as executive vice president and chief operating officer. Three years later, he assumed Carilion’s top position, which he held for 11 years. During that time, he presided over some of the most dynamic moments in the organization’s history, including the transition from a system of hospitals to a physician-led clinic model. At the time, he likened his vision for Carilion with that of Mayo Clinic, noting, “It’s not a hospital business that owns doctors. It’s a physician business that has hospitals.”

One accomplishment he was most lauded for was, in collaboration with

“

Charles Steger, then president of Virginia Tech, the vision for—and creation of— the Virginia Tech Carilion School of Medicine and Research Institute.

At the groundbreaking event for a $90-million expansion of the Virginia Tech Carilion biomedical research campus in Roanoke less than two weeks after Dr. Murphy’s death, Timothy Sands, Ph.D., the current president of Virginia Tech, paid tribute to him.

“Because of Dr. Murphy’s original vision and his close working relationship with President Steger,” Dr. Sands said, “we have made many great accomplishments and are positioned very well for the future.”

Upon leaving Carilion in 2011, Dr. Murphy went into health care consulting in Connecticut, including, most recently, as executive chairman of Management Murphy Health Solutions. Throughout that time, he continued to serve his community by accepting leadership roles in numerous nonprofit organizations dedicated to education, health care improvement, and quality of life. He also served on the board of the Virginia Tech Carilion School of Medicine.

Dr. Murphy is survived by his wife, Arlene Murphy, and daughters, Sarah Elizabeth Murphy and Emily Anne Murphy.

“Ed will be missed by the many who worked with him,” said Nancy Howell Agee, Dr. Murphy’s successor as president and chief executive officer of Carilion. “His imprint on our community will be felt for generations to come.”

It’s not a hospital business that owns doctors. It’s a physician business that has hospitals.

PHOTOS: DARRYLE ARNOLD

”

briefings

Chairman Honored JAMES HARTLEY, chairman of Carilion Clinic’s Board of Directors, has received the 2017 Excellence in Governance Award from the Virginia Hospital & Healthcare Association.

The award honors those in governance roles who have a history of making significant contributions to the health care field through commitment to service and leadership.

Hartley joined the Board of Directors of Carilion Giles Memorial Hospital in 1980 and, nine years later, the Board of Directors of what was then Carilion Health System.

“James’ dynamic leadership, sound judgment, and humility made him an ideal candidate for this prestigious honor,” said Nancy Howell Agee, president and chief executive officer of Carilion. “It is truly a privilege to work alongside such a dedicated and passionate leader.”

Leader in Patient Care Carilion Roanoke Memorial Hospital has once again been recognized on Becker’s Hospital Review’s 2017 List of 100 Great Hospitals in America.

The hospitals included on the list are all acknowledged industry leaders in innovation, quality patient care, and clinical research, and they have received recognition across a range of publications and accrediting organizations.

CARILION MEDICINE | FALL 2017 5

award

RICHARD VARI WINS PRESTIGIOUS NATIONAL AWARD FOR MEDICAL STUDENT EDUCATION

Vari

The Association of American Medical Colleges has honored RICHARD C. VARI, Ph.D., senior dean for academic affairs at the Virginia Tech Carilion School of Medicine, with the Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award.

The prestigious award provides national recognition to faculty members who have distinguished themselves in medical student education. Each Liaison Committee on Medical Education–accredited medical school in the United States and Canada may nominate only one faculty member each year for the honor.

“Getting this award is the pinnacle of my career and such an honor,” said Dr. Vari.

“Rick is one of the most energetic, engaging, and effective teachers I have ever seen,” said Cynda Johnson, M.D., M.B.A., founding dean of the Virginia Tech Carilion School of Medicine. “He is one of a kind. He teaches his students from his heart, his passion for his work is infectious, he leads his faculty by example, and he is revered by the students.”

“I always thought that Dr. Vari was influential in my ending up at VTC, because I remember feeling a connection with him when I interviewed,” said Christopher Vieau, M.D., a graduate of the school’s charter class and now a family medicine physician at Union Family Practice in Carolinas HealthCare System. “He inspired confidence in me that this school would be successful, even though on that day, there were no books and no physical school. That 6 CARILION MEDICINE | FALL 2017

so many students from VTC have enjoyed success is truly a testament to the type of man he is. Dr. Vari is deserving of the highest honor in teaching, and I couldn’t be happier for a mentor and a friend.”

Dr. Vari has been involved in medical education for more than 30 years. As a college student, he was planning to become a physician until work in a physiology laboratory convinced him to pursue research rather than medicine.

At the same time, Dr. Vari found himself more involved in the development of medical education curricula. While at the University of North Dakota School of Medicine and Health Sciences, he was asked to serve on a council tasked with recommending a new curriculum. He and his fellow council members ended up recommending adoption of a problem-based learning curriculum.

“I had been teaching medical students for 10 years or so and had never seen them so engaged and excited about learning,” he said. “There was something about it; I didn’t know what it was, but if we could capture it, that’s what we wanted to do.”

The curriculum was later recognized by the Carnegie Foundation in the Flexner II Report as an exemplary medical education program.

When Dr. Johnson was named dean of the Virginia Tech Carilion School of Medicine, leadership had envisioned a problem-based learning curriculum. She knew she needed Dr. Vari to make it a reality.

“There was no individual in this country with credentials better suited to be our founding associate dean of medical education,” she said.

Dr. Johnson hired Dr. Vari to lead efforts and build the curriculum from scratch. “Starting a new school meant we didn’t have anything to tear apart so we could essentially do what we wanted to do,” Dr. Vari said.

In addition to problem-based learning, Dr. Vari helped establish two important curricular elements—research and interprofessionalism—and embed them into each year of the four-year curriculum. The curriculum now helps attract competitive students from across the country.

“We managed to pull something off that’s pretty phenomenal here,” Dr. Vari said. “We have a lot of wonderful faculty, a lot of people who really care about the school. Our students have been incredible. The work has been very gratifying.”

most wired

Making Numbers Work for Patients For the 14th time—and the ninth year in a row—Carilion Clinic has received Health Care’s Most Wired designation from the American Hospital Association’s Health Forum.

According to the stated criteria for the designation, Most Wired hospitals transform care delivery through knowledge gained from data and analytics. They invest in analytics to support new delivery models and effective decision-making, and they train clinicians to use analytics to improve quality, provide access, and control costs.

“We are constantly evaluating ways to improve the experience of our patients,” said Keith Perry, senior vice president and chief information officer for Carilion. “The Most Wired designation is a nice affirmation of the work we are doing every day.”

grand rounds SURGERY FELLOWSHIPS Carilion Clinic’s Department of Surgery is now offering a postgraduate Advanced Clinical Practitioner Fellowship in Surgery aimed at preparing physician assistants and nurse practitioners for careers in general and acute care surgery. The fellowship is intended to be a complement to Carilion’s established general surgery residency.

EXPANDED RESIDENCIES

BEYOND TEXTBOOKS: Students taking the Clinical Neuroscience in Practice course are able to watch neurosurgical procedures live.

From Classroom to Operating Room The Clinical Neuroscience in Practice course in Virginia Tech’s School of Neuroscience is no ordinary class. It offers undergraduates the opportunity to experience the world of neurosurgeons in both the classroom and the operating room.

After receiving lectures from surgical residents and attending physicians, the students enter operating rooms of Carilion Roanoke Memorial Hospital—scrubs on, notebooks in hand—to watch brain and spine surgeries.

The experiences are one of a kind.

“I keep telling the students every single time we come here, this is not normal, you are seeing a neurosurgery team opening their world to undergraduates,” said Harald Sontheimer, Ph.D., executive director of the School of Neuroscience.

The course is a collaboration between Virginia Tech and Carilion Clinic. Gary Simonds, M.D., chief of neurosurgery at Carilion, joined Dr. Sontheimer in designing the course to be all encompassing. It was Dr. Simonds, in fact, who made it pos-

sible for students to learn by the side of neurosurgeons in a hospital setting.

“It is such a fantastic opportunity to be around the people at Tech and, we hope, they feel the same way about us and this creates that bridge,” Dr. Simonds said. “For us, and particularly for our residents, we feel that the better physicians are as educators, the better they are as physicians.”

Among the students who took the class in the spring of 2017 was Amy Wells, a senior double majoring in psychology and neuroscience in the Virginia Tech College of Science. Wells watched a neurosurgery team led by Carilion neurosurgeon Lisa Apfel, M.D., who is also an assistant professor of surgery at the Virginia Tech Carilion School of Medicine. Before the surgery, Dr. Apfel briefed the students on the patient’s history and what would happen during and after the surgery.

“I am a very visual learner,” Wells said, “and to see the cases and see what is happening, that is a very big learning tool for me.”

PHOTOS: JIM STROUP (FAR LEFT); STEVEN MACKAY (ABOVE); DAVID HUNGATE (RIGHT)

The Virginia Department of Medical Assistance Services has awarded Carilion Clinic a $2-million grant to add six internal medicine residency slots a year for three years. The principal goal will be to provide both Medicaid and self-paying patients in southwestern Virginia with better access to primary care.

RESEARCH AWARD Oscar Alcoreza, a third-year Virginia Tech Carilion School of Medicine student, has been awarded a highly competitive Howard Hughes Medical Institute fellowship, which will allow him to spend a year at the Virginia Tech Carilion Research Institute conducting mentored biomedical research on epilepsy.

Oscar Alcoreza (center) with Dr. Susan Campbell and Dr. Harald Sontheimer.

CARILION MEDICINE | FALL 2017 7

landmark

JEFFERSON COLLEGE OF HEALTH SCIENCES TURNS 35 In October, Jefferson College of Health Sciences celebrated its 35th anniversary as a degree-granting institution.

During a gala with more than 250 guests, Nancy Howell Agee, president and chief executive officer of Carilion Clinic, spoke about the history of its college. She noted that the college traces its earliest roots to 1914, when the Jefferson Hospital School of Nursing opened with six students.

Between 1914 and 1965—when it joined with the Lewis-Gale School of Nursing to form the Community Hospital of Roanoke Valley School of Nursing—the school trained 658 new nurses.

In 1981, the Community Hospital Board of Trustees agreed to turn the school into a hospital-based college that could grant two-year degrees in nursing and allied health. A year later, the Community Hospital of

Roanoke Valley College of Health Sciences was established, becoming the first hospital-based college in Virginia.

Since then, Agee said, Roanoke’s only downtown college has helped revitalize the area. Today, the college educates a range of health care professionals at the associate, bachelor’s, master’s and doctoral levels, and its record number of students represent 35 states and territories.

“The accomplishments of the various iterations of our college over the past few decades have laid the foundation of a proud tradition upon which to build the health care of the future,” said Nathaniel L. Bishop, D.Min., the college’s president since 2010.

“Today, Jefferson College of Health Sciences sits at the intersection of education and health care, where it prepares ethical, knowledgeable, competent, and caring health care professionals.”

c. 1916

The Early Days The earliest iteration of Jefferson College of Health Sciences opened as a nursing school in 1914, with a grand total of six students.

1982

Capping It Off In 1980, the school’s then administrator, William Reid, commissioned a task force to investigate the feasibility of establishing a hospital-based college that could grant two-year degrees in nursing and allied health.

A year later, the Community Hospital Board of Trustees made a commitment to such a school, and in 1982 the Community Hospital of Roanoke Valley College of Health Sciences was established.

1988

Tradition of Caring As the decades passed, the college expanded not only its student class, but also the numbers and levels of educational programs available. By 1988, the college had 200 students and three programs; in 2017, it has 1,200 students and 23 programs.

2012

Founder’s Circle The true founder of the modern version of Jefferson College of Health Sciences is considered to be William Reid (right), pictured with the current president of the college, Dr. Nathaniel L. Bishop. Reid still sits on the college’s Board of Directors.

2017

35th Anniversary Celebration Nancy Howell Agee, Carilion’s president and chief executive officer, and Dr. Nathaniel L. Bishop celebrate at the college’s 35th anniversary gala, held in October.

8 CARILION MEDICINE | FALL 2017

PHOTOS: COURTESY OF JEFFERSON COLLEGE OF HEALTH SCIENCES

CARILION MEDICINE | FALL 2017 9

CLOSING THE GAP For Carilion Clinic, meeting the health needs of rural residents is more than just a medical challenge. It’s about caring for one’s own.

BY CHARLES SLACK IN A RURAL COUNTY MILES FROM ROANOKE, A WOMAN IN HER LATE 50S

calls 911 to say she’s not feeling well. Just minutes after the EMS team arrives at her home, she goes into cardiac arrest, setting in motion a series of intricately coordinated and—ultimately—lifesaving actions.

First, the EMS team restores a steady pulse. Instead of the familiar hands-on-chest method, they use an advanced portable device capable of continuing CPR even while the patient is being moved.

But that calls up a crucial question: where to? Recognizing the

10 CARILION MEDICINE | FALL 2017

SPECIAL DELIVERY: Retired roofer Eugene Yopp, shown in front of an outbuilding on his 25-acre property in rural Shawsville, Virginia, receives his medical care at the local Carilion family medicine practice.

CARILION MEDICINE | FALL 2017 11

severity of the woman’s condition, the EMS team— specially trained and authorized to make such decisions—bypasses the local hospital in favor of Carilion Roanoke Memorial Hospital. Though farther away, it has an advanced cardiac catheterization lab and a coronary care unit capable of handling the most life-threatening emergencies.

As the crew races toward Roanoke, workers at Carilion’s Transfer and Communications Center are ready. Within minutes they have alerted the emergency room, the cath lab, and the coronary care unit about the woman’s condition and imminent arrival and arranged for admission.

After arriving at Carilion, the woman suffers a second and third cardiac arrest. With no time to spare, coronary specialists insert a stent that opens a severely blocked artery. Her brain is kept artificially cool to protect it from damage. Hours later, though still in serious condition, she’s stabilized and expected to recover.

At any stage of this odyssey, a misstep, delay, or breakdown in communication might have spelled disaster, says Paul Frantz, M.D., Carilion’s medical director of cardiac services. “If it hadn’t been for the EMS training, access to the compression device, and

the rapid response team first in Carilion’s emergency department and then in the cath lab and coronary care unit, I’m not sure she would have survived.”

It was for just such emergencies that Dr. Frantz and several other Carilion cardiologists and cardiothoracic surgeons started HeartNet of the Virginias back in 1989. Since then, the program has saved untold lives that might have been lost to the tricky navigation of the region’s beautiful yet rugged and sparsely populated terrain.

A Widespread Challenge However dramatic, such emergencies represent just one of the many challenges of providing health care to rural residents. Nationally, rural areas have fewer than 40 primary care physicians per 100,000 people, compared with more than 53 in urban areas, according to the National Rural Health Association.

Noting that some 70 rural hospitals have closed in just the past seven years, the association projects a shortage of 45,000 doctors by 2020.

And access to physicians and quality health care, though vital, accounts for just 20 percent of an area’s overall health, according to the County Health Rankings, a national research project by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. Other factors presenting outsized risks for rural residents include social and economic issues such as education, employment, and income (40 percent); behaviors such as smoking, poor diets, and lack of exercise (30 percent); and environmental factors such as water and air quality and housing (10 percent).

While some national health observers have framed rural health care as a newly emerging crisis, it’s a challenge that Carilion—by nature, history, and disposition—has been addressing for generations. Far from closing down rural facilities, Carilion in the past decade has doubled down on its longstanding commitment to family and community medicine throughout its 20-county, mostly rural service area stretching from central and southwestern Virginia to southern West Virginia. A key to that commitment has been the transformation over the past decade of a health system into a clinic model that emphasizes primary care.

“I CAME TO REALIZE THAT

once you get to know these people, they don’t want anyone to take care of them other than the person they know cares about them and they can trust.” —Dr. Christopher Mertes (pictured above with a patient)

12 CARILION MEDICINE | FALL 2017

PHOTOS, THIS STORY: JARED LADIA

Still, the challenges are stark. According to the County Health Rankings, while a number of counties in the region are showing improvement in health status, others—most notably in far southwestern Virginia—actually declined from 2016 to 2017. Contributing factors range from economic and wage stagnation to persistent tobacco use, poor diets, diabetes, and a rise in addictive drugs that reaches deep into rural communities.

As a nonprofit, community-owned institution, Carilion has a special sense of mission when it comes to finding solutions.

“We’re charged with providing leadership in care for patients throughout our area,” says Dr. Frantz.

“That means care that is healthy not just to the clinic’s bottom line, but the entire spectrum. That takes a hospital that’s not only willing to provide that care, but is large enough to do it.”

And because rural health care is a multipronged challenge, Carilion clinicians and administrators are working simultaneously on a variety of fronts—from educating local populations about healthy lifestyles to encouraging clinicians to follow the less-traveled but hugely rewarding path of rural medicine.

The Human Factor For Christopher Mertes, M.D., who serves patients out of Carilion’s family medicine clinic in Blacksburg, Virginia, the decision to focus on primary care and rural populations was not so much a process of elimination as one of inclusion.

“I went into medical school thinking I would become a surgeon,” he says. “But I began to realize I really liked the separate subareas, whether it was pediatrics, internal medicine, general surgery, orthopaedics, or oncology. It dawned on me that family medicine was a perfect opportunity to take care of the whole person. That entire spectrum of care is what appealed to me; it integrates right into family medicine and it’s what Carilion stands for.”

A native of Chicago, Dr. Mertes says one of the things he finds most appealing about treating rural patients is the human connection sometimes lacking in more densely populated areas.

“In Chicago,” he says, “I recall people thinking, ‘I would never want to go to a doctor who knows who I am. I would be embarrassed. I want to see a stranger.’” But after experiences training in rural medicine in Illinois and North Carolina, “I came to realize that once you get to know these people, they don’t want anyone to take care of them other than the person they know cares about them and they can trust.”

To encourage more young physicians to follow in the path of Dr. Mertes and others, the Virginia Tech Carilion School of Medicine has launched ru-

ral health education programs encouraging medical students to experience the rewards of rural medicine (see “The Road Less Traveled,” page 16).

Community Health and Outreach As vice president of planning and community development, Shirley Holland oversees Carilion’s efforts to assess community needs and plan responses.

“Our role is to understand the health status of our region, the communities in which we are involved, and how we as an organization can convene community partners and resources to help,” Holland says. “Strong collaborations in the community can get us so much further than anything we can do by ourselves.”

To that end, Carilion partners with some 50 national, state, and local organizations, including the United Way, Virginia’s Department of Health, community associations, food banks, libraries, law enforcement, and volunteer organizations. Every three years Carilion coordinates exhaustive, county-by-county Community Health Assessments, drawing on insights from these and other groups, as well as surveys of local residents, aimed at determining where the needs are greatest. In most recent reports, residents cited alcohol and drugs, obesity, mental health issues, limited access to healthy foods, and diabetes as the top challenges to health in the community.

Part of the response goes beyond screenings and flu shots to provide creative community education programming, such as Be a Quitter, a smoking cessation program; a peer-to-peer recovery support initiative; Healthy Walks and Talks; Wellness Workshops; and A Matter of Balance, a falls prevention program.

An urban farm and a network of community gardens have also been established.

“We’re putting more value on preventive care and health literacy,” Holland says. “Helping people understand how their behavior affects their overall health is critical. Many still don’t know, for example, the role that diet and exercise play in the onset of type 2 diabetes.”

Sometimes, it’s not so much about scarcity of resources as educating people that the resources are there. Holland adds, “Oftentimes the community isn’t aware of the services available to them or how to access them. So coordination of care is a big opportunity.”

Health care is one of the few industries dedicated to its own demise, in the sense that perfect health would obviate the need for hospitals, clinics, physicians, and nurses. While no one envisions that future, much of Carilion’s outreach with local partners involves education and shaping behavior to lessen CARILION MEDICINE | FALL 2017 13

ALTHOUGH TELEMEDICINE

is not a replacement for more intensive therapy, after a brief consultation with a patient a psychiatrist can often make key recommendations about medications and further treatments.

JUST A CLICK AWAY: Using his computer in Roanoke, Dr. Robert Trestman, Carilion’s chair of psychiatry, consults with a family physician, Dr. Robert Devereaux, 70 miles away in Pearisburg, a small town in rural Giles County, Virginia.

the need for emergency department visits and help people avoid the hospital.

“It’s not just the hospital where health care is delivered anymore,” Holland says. “We’re starting much earlier by connecting with people in their communities.”

Possibilities in Telemedicine Carilion is also using technology to try to ameliorate the geographic challenges of rural health.

“We’re seeing issues related to social isolation and depression,” Holland says. “When you can’t get around, when you can’t take care of your home, when you have limited transportation and the nearest grocery store is 15 miles away, these are very real issues in rural areas.” Indeed, the need for psychiatric care in rural settings has never been higher, thanks in part to rising use of opioids and other drugs of abuse, and the addiction problems that go hand in hand.

In Virginia, as around the country, traditional resources for treating psychiatric patients have been overwhelmed in recent years, according to Thomas 14 CARILION MEDICINE | FALL 2017

Milam, M.D., a member of Carilion’s psychiatry and behavioral medicine team. “Many people with severe mental illness or substance abuse issues have not been properly diagnosed, and many don’t have access to insurance,” Dr. Milam says. Although the commonwealth took a step forward in April 2017 by approving Medicaid payments for substance abuse treatments, many rural residents lack both access to psychiatrists in their communities and the means to travel to cities where services are more plentiful.

Three years ago, Dr. Milam launched a pilot program in rural Giles County to help fill that gap remotely by offering telepsychiatry—secure, confidential video conferencing—between Carilion psychiatrists in Roanoke and patients in Giles. Working with the eight-member staff from Carilion’s family medicine practice in Giles, Dr. Milam developed a system that was inexpensive, mobile, and flexible, requiring only a pair of iPads for teleconferencing.

When a Giles patient needs psychiatric consultation, the staff sends Dr. Milam a message requesting a meeting.

Although telemedicine is not a replacement for more intensive therapy, after a brief consultation with a patient a psychiatrist can often make key recommendations about medications and further treatments. Just as important, the calls allow patients unaccustomed to seeking medical help to develop a sense of treatment continuity. Indeed, while 35 percent of Giles County residents said they would consult friends and family to discuss a mental health or substance abuse problem, and 15 percent their church, just 10 percent would consult a psychiatrist.

Telemedicine also shows promise in educating the staff at the local clinic on handling such cases.

“It’s really a collaborative effort between the psychiatric specialist and the primary care clinicians,” Dr. Milam says. “They feel empowered, they deepen their knowledge base, and they’re reassured that we’re there to back them up.”

Building on the promise of Giles, Carilion recently received a $435,000 grant from the U.S. Department of Agriculture to help expand the idea to 15 rural clinics throughout Carilion’s service area.

Although telemedicine remains in its infancy, Dr. Milam sees the approach as helping usher in “a new era of how we envision rural health care.

INSIDE THE NERVE CENTER When a medical emergency arises in Roanoke or surrounding counties, there may be no busier room in all of southwestern Virginia than the Transfer and Communications Center at Carilion Clinic.

With rows of workers wearing headphones and staring intently at large, ever-changing screens, the center has the look and feel of an air traffic control room. Yet while air and ground traffic is part of the job—Carilion counts three stateof-the-art rescue helicopters and 40 ambulances in its fleet— the true mission is about more than transportation. It’s about saving lives.

When the center receives a call from an emergency medical services unit, a rural hospital, or an accident scene, “As soon as they call and tell us what kind of patient it is, we’re connecting them to the appropriate doctor, we’re scanning our bed board to determine whether that type of bed is available,” says Melanie Morris, R.N., the center’s senior director.

“And while the doctors are talking about the patient, we’re simultaneously sitting right next to the people who dispatch the helicopters and ambulances,” Morris adds. “So before the physicians even hang up the phone, we’re telling them whether we can take their patient, and, by the way, we’ve got a helicopter that can be to you in 15 minutes, or an ambulance that can be to you in 20 minutes.”

A native of the area, Morris gained her first experience at Carilion in the 1980s as a teenaged candy striper. She returned in the 1990s as an inpatient nurse before getting her “dream job” as a flight nurse on one of Carilion’s rescue helicopters. Beyond the excitement of the job was the satisfaction of the immediate difference she was making in people’s lives.

“We’re intersecting with people who may be awaiting a lifesaving intervention or treatment,” Morris says. “I’ve heard

We’ll include mental health and substance abuse treatment from the beginning. It won’t be an afterthought; it won’t be an embarrassing thing to bring up to your family doctor. It will be something that every patient who presents is screened for, because now they have the access.”

A Call to Serve Even as these long-term efforts evolve, life’s emergencies will continue to unfold in real time. To

them refer to the helicopter crew as angels swooping down from above and bringing them life.”

One man, badly injured in a motorcycle accident on a rural road more than a decade ago, regularly reaches out to Morris after all these years to thank her for her role in saving his life.

In other cases, it’s about saving lives at the very outset, such as providing emergency neonatal intensive care. “We’ve got a specialty neonatal transport team that we can send to transport those babies,” Morris says.

Beyond directing patients to the appropriate care, the center’s electronic patient care records system ensures that clinicians receive vital patient information in real time.

“This interconnectedness is really important,” says Paul Frantz, M.D., Carilion’s medical director of cardiac services.

“It keeps us from having to repeat tasks and trying to locate somebody by telephone. Everything is at our fingertips.”

LIFESAVER: Melanie Morris works with a team of dispatchers who connect patients with appropriate doctors, arrange transport, and secure bed placements.

fulfill its mission to rural residents, then, Carilion must keep one eye on the future and the other on the here and now, responding to sudden illnesses and accidents and changing lives for the better.

For Carilion staff, the call to serve rural and urban residents alike is as personal as it is professional, Holland says.

“Carilion started in the late 1800s,” she says.

“Our roots are here. Our 13,000 employees don’t just work here; we live here. The community’s issues are ours as well.” CM CARILION MEDICINE | FALL 2017 15

THE ROAD LESS TRAVELED

COUNTRY ROADS: The site of his four-week rural family medicine rotation—the small town of Shawsville, Virginia— reminded medical student Adam Tate of his rural hometown of Laurel Fork, Virginia.

BY DAVID BUMKE

Carilion training programs are preparing medical students, physicians, and advanced clinical practitioners to meet the unique health needs of rural populations.

IT WAS A WELL-MEANING EFFORT THAT FELL VICTIM TO

unintended consequences. Local communities in Kansas, trying to encourage physicians to put down roots in small towns and rural outposts, created a program that paid medical residents to commit to practicing there as family doctors.

Once the physicians agreed to stick around, they faced a steep financial penalty for pulling out.

Although the program succeeded at first, within a few years a widening gulf between primary care salaries and much higher compensation for specialists led more and more young physicians to buy themselves out and leave. That swelled the

16 CARILION MEDICINE | FALL 2017

CARILION MEDICINE | FALL 2017 17

program’s coffers—“it had gobs of money,” says Cynda Johnson, M.D., M.B.A., founding dean and president of the Virginia Tech Carilion School of Medicine—but it folded because it couldn’t find enough residents willing to take the cash.

Dr. Johnson, after training in California, had returned to her Kansas roots, and she saw firsthand a problem that persists to this day. Stark disparities exist between the care most rural residents receive and what people in more populated areas can expect. Farmers and others who can scarcely spare the time may need to drive hours to see a doctor, and getting to specialists or the nearest hospital takes longer still. Death rates are higher in rural areas than in the cities and suburbs, and so is the percentage of people without health insurance. By just about any statistical yardstick, the situation is in serious need of improvement.

“It’s not a sudden crisis, because the problem has persisted for as long as I can remember,” says Dr. Johnson. “But there is an urgency in the need to keep physicians in rural areas.”

Despite financial incentives, so few doctors coming out of medical school intend to practice in remote places that their numbers barely register in surveys such as the annual Medical School Graduation Questionnaire from the Association of American Medical Colleges. In 2017, just 1.8 percent of new physicians said they planned to work in a rural area or a town with fewer than 2,500 people. In a

SPECIAL DELIVERY: As a family medicine physician, Dr. Cynda Johnson appreciates the value of rural medicine.

18 CARILION MEDICINE | FALL 2017

national graduating class of more than 19,000, that adds up to about 350 doctors—seven per state.

Among many efforts to improve on those numbers, Carilion Clinic and the Virginia Tech Carilion School of Medicine have launched initiatives to help expose medical students and residents to the life of a rural doctor, and to prepare them for the clinical needs of rural populations. An additional program focuses on physician assistants and nurse practitioners, who can provide the essential care that many patients might otherwise not receive.

“What do students need to help them face the challenges of rural practice?” asks Dr. Johnson.

“They need experience, they need to understand rural communities, and they need to have some way to feel they’re not alone.” Carilion programs approach all of those issues from several crucial angles.

“WHAT DO STUDENTS NEED

to help them face the challenges of rural practice?

They need experience, they need to understand rural communities, and they need to have some way to feel they’re not alone.” —Dr. Cynda Johnson

Lessons in a Rural Environment The Virginia Tech Carilion School of Medicine’s four-week elective in rural family medicine seeks to immerse students in both the challenges of primary care in such settings, as well as the unique relationships clinicians develop with rural patients.

For fourth-year medical student Adam Tate, taking the elective last summer recalled his upbringing in Laurel Fork, Virginia, a town of about 1,200 people near the North Carolina border, where he watched his physician father take care of patients with wide-ranging maladies. He understood that in such places, even today, a physician may resemble a doctor in a Norman Rockwell painting, a revered figure everyone knows and runs into on a daily basis.

“You’re part of the community,” Tate says, and he notes that living among your patients can also confer significant clinical benefits. “You really get to know the people who come to see you on a personal level—you see how to interact with them, and the best ways to get them on board with the care plan you have for them.”

In his previous medical rotations, the physicians Tate observed and worked with in the hospital and in urban practices could take advantage of cutting-edge technology and the easy availability of other physicians for consultations or referrals—luxuries not available to most rural doctors. Yet Tate feels those rotations were excellent preparation for anyone considering hanging a shingle far from urban and suburban resources.

“In rural family medicine, you have to be ready for whatever comes in the door,” Tate says. “In our third year of medical school we get broad exposure PHOTOS: JARED LADIA, PREVIOUS SPREAD; DAVID HUNGATE, LEFT

ACCESS FOR EVERYONE: Under the supervision of Dr. Julia Hemphill, medical student Adam Tate takes a biopsy from patient Eugene Yopp at the Carilion Clinic Family Medicine practice in rural Shawsville, Virginia.

to all kinds of care, and it’s all applicable in terms of taking care of patients yourself or, if it’s something you can’t do, knowing whom and where to refer to.”

Even when a referral may be the best option, however, Tate understands that many rural patients will choose to be treated right then and there.

That happened all the time when Dr. Johnson treated patients in small-town Kansas. “They just wanted me to sew up whatever cuts they had, and it didn’t matter if I told them we had a plastic surgeon available,” she says. “‘Could you just do it for me, Doc?’ they’d say. ‘I’m a farmer. I have to be back in the fields.’”

PHOTO: JARED LADIA

That reality, in turn, may help shape the plan for a particular patient. “If you know your patients can’t afford things or you think they might be less likely to go see someone else for whatever reason—that’s something you need to be prepared for in a rural practice,” Tate says. “Then you can make sure you’re providing care that’s actually helpful to them and that they can follow through on.”

Tate, who holds a master’s degree in public health, often thinks about what it may take to improve medical access and care for rural patients—and technology is high on his list. As the clarity of audio and CARILION MEDICINE | FALL 2017 19

video used in telemedicine improves, it gets easier to link patients with physicians and specialists across long distances.

“It’s especially helpful to have telemedicine available for psychiatric and psychological counseling,” Tate says. “In my community, there’s not much access to those, and mental health is a big issue.”

Doctors for All Seasons With his clear affinity for rural medicine, Tate hopes one day to be able to practice in an area where the skills he has developed during medical school can be put to good use. And although plans for his upcoming residency are still being formulated, he and others who want to continue preparing themselves for a professional life far from population centers could consider the Virginia Tech Carilion Family Medicine Residency, which includes a third-year elective in rural medicine.

“When people go into family medicine, they often want to help underserved populations,” says Nancy E. Misicko, M.D., M.P.H., program director of the residency. “The rural rotation within our program adds another layer to their knowledge and skills. For those who do go out and practice in outlying areas, it’s exciting, because you feel like you’re helping patients who may not have had anybody before.”

The rural elective is part and parcel of the broader family medicine program, Dr. Misicko says. Resi-

dents who opt for the elective in the second or third year of their three-year residency normally don’t relocate to Martinsville, Virginia, where the rural rotation is based, but rather split their time between there and Roanoke or Salem. “They still follow their continuity patients here at our practices,” she says, “but they spend much of the week in Martinsville.”

Yet even the parts of family medicine training that take place in Carilion clinics and hospitals prepare physicians for rural practice.

“Everything you do in the residency, while not specifically targeted to whether you’re going to practice rural medicine, still trains you for that,” says Dr. Misicko. “When you do your regular rotation in adult or pediatric emergency medicine or in critical care or on the family medicine inpatient service, all of those help you learn how to care for patients in any setting. They help you learn how to be a critical thinker for patients with acute care problems.”

Of course, not everyone who chooses the rural elective will go on to practice far from the madding crowd.

Understanding the particular challenges of treating rural populations, however, can be invaluable wherever someone chooses to be a doctor. “In rural settings, you see things you won’t necessarily encounter in your typical training,” says Dr. Misicko. You may be called on to treat victims of a tractor accident, for example. Or you may realize that something that’s routine in the hospital is much more complicated when you’re working in a small office on your own. “You have to learn to think on your feet,” she says.

“To me,” she adds, “our goal has always been to educate people to be well-trained physicians, so they can go wherever their interests take them, to serve whatever community they choose to be a part of.”

Into the Real World, Rural or Not

BACK ROADS: Dr. Joshua Nichols, shown on a hike near the Blue Ridge Parkway, has learned that wilderness medicine encompasses more than rescuing errant adventurers; it also requires educating the public.

20 CARILION MEDICINE | FALL 2017

Christopher Vieau, M.D., and Joshua Nichols, M.D., illustrate Dr. Misicko’s point. Both young physicians attended the Virginia Tech Carilion School of Medicine, and both have had experience in treating rural populations. Their career paths now underscore the flexibility of their education and training.

Dr. Vieau is from Syracuse, New York, and went to college in New York City, so rural medicine was not in his DNA. Yet as a family physician, he knew he wanted to be where he could help patients get access to the care they needed, and he says the rural rotation he did in medical school was “deeply influential” in his decision last summer to enter a private practice in rural Union County, North Carolina.

PHOTO: JARED LADIA

“IF YOU CAN GET A TEAM

together—a family doctor, a pharmacist, and a nurse practitioner, say—you can cover many patients while giving each other relief and support.” —Dr. Cynda Johnson

In all of the small towns in which he has practiced—in his medical school elective, in rural rotations during his residency, and now in his new permanent position—Dr. Vieau has been warmly embraced by patients and doctors. And already, in the early days in his new practice, he has been reminded of what he considers one of the most important attributes for anyone going into medical practice, regardless of the setting.

“Patience is a virtue,” he says. “In a rural situation, as in any other kind of practice, you have to build a relationship with your patients, and that takes time. But if your patients learn they can trust you, you’re going to have better outcomes.”

Dr. Nichols, meanwhile, is only the second physician to undertake Carilion’s recently established one-year Wilderness Medicine Fellowship. Traveling to remote mountain trails and deep into the woods to provide whatever care may be needed, often without the benefit of modern medical technology close at hand, is one more way to hone skills that are needed every day in rural medicine.

“You see the possibilities for practicing in austere environments with minimum resources,” says Dr. Nichols. “In rural practice, you can be confronted with situations where you just don’t have the right materials. This fellowship prepares you to keep your mind flexible in coming up with different solutions.

Stabilizing fractures, evaluating airways, checking breathing and circulation, treating environmental injuries, such as hypothermia and heat stroke—you treat the patient as well as you can immediately, and then get them to definitive care.”

Dr. Nichols notes, too, the critical importance of community education. “We try to prevent accidents from even happening,” he says, “by teaching people how to be safe when they go into the wilderness.”

Sharing the Load Dr. Nichols plans to work in rural medicine, and he looks forward to meeting just those kinds of challenges—and to settling into a community after a dozen years of higher education and training.

Chances are good that he’ll practice alongside a nurse practitioner or a physician assistant, a pro-

fessional trained to deliver essential medical care as part of a multidisciplinary team.

“Interprofessionalism is very important to what we do,” says Dr. Johnson, in describing the educational approach of the Virginia Tech Carilion School of Medicine. “Our medical students do projects with nursing students and physician assistants in training, they learn about each other’s professions, and they work in teams—all great preparation for a rural practice, where it really helps to have colleagues. If you can get a team together—a family doctor, a pharmacist, and a nurse practitioner, say—you can cover many patients while giving each other relief and support.”

Toward that end, Carilion’s Department of Family and Community Medicine offers an advanced practice fellowship for physician assistants and nurse practitioners in urgent care and rural health.

In a one-year fellowship, designed to mirror family medicine residency training for physicians, physician assistants and nurse practitioners acquire the specialized skills and knowledge they would need in a rural practice. That focus is a logical extension of Carilion’s long-time commitment to training nurses and other professionals through its affiliated Jefferson College of Health Sciences.

Dr. Johnson notes that the mission of the Virginia Tech Carilion School of Medicine isn’t rural health care—“it’s to educate physician thought leaders through inquiry, research, and discovery,” she says.

“Often, in rural areas, doctors ask themselves, ‘Am I doing a good job? Am I practicing up-to-date medicine?’” Students who come out of the medical school do clinical research with their own patient populations—a focus that is sorely needed, Dr. Johnson says, because so much research looks at hospitalized patients mostly in cities and suburbs.

Dr. Johnson notes that being able to contribute to new research that more accurately reflects the broader population is one more way in which committing to a life as a rural practitioner can be professionally and intellectually fulfilling while bringing enormous benefits to an underserved community.

“To me, as a family doctor,” says Dr. Johnson, “that’s the way to give students more confidence to practice in rural areas.” CM CARILION MEDICINE | FALL 2017 21

81

THE RURAL ROUTE

64

Carilion Stonewall Jackson Hospital

Lexington

Carilion Clinic encounters scenic beauty and special challenges THE TERRAIN AND WILDLIFE OF SOUTHWESTERN VIRGINIA—AND THE LIFESTYLES OF ITS

residents—can create challenges for clinical care beyond those of mere remoteness.

For years now Carilion Clinic has been forging solutions to ensure the nearly one million residents in its service area have access to quality care as well as emergency services ranging from air ambulances to a regionwide cardiac response network.

These services—together with Carilion’s network of other resources, including community hospitals, primary care and urgent care sites, and telemedicine initiatives—prove that rural isolation does not need to mean clinical abandonment.

460

Pearisburg

460

Blacksburg

Virginia Tech Carilion School of Medicine and Research Institute Jefferson College of Health Sciences

Virginia Tech

Carilion Tazewell Community Hospital

81

Tazewell

501

581

Carilion Giles Community Hospital

460

81

Lynchburg

Carilion Roanoke Community Hospital

Roanoke

Blue Ridge Parkway 460

Bedford

Carilion Roanoke Memorial Hospital Carilion Children’s Hospital

Primary Care

Radford University

Urgent Care

Carilion New River Valley Medical Center Carilion Clinic Saint Albans Hospital

Home Care and/ or Hospice

Smith Mountain Lake

Rocky Mount 81

Hospital

220

Educational Institution (Carilion Affiliate or Partner)

122 Carilion Franklin Memorial Hospital

77

Life-Guard Air Ambulance Base

Terrain

Outdoor Sports

Wildlife

Hunting

Limited Access to Care

Diet and Exercise

Opioid Abuse

Tobacco Use

The beautiful yet rugged terrain of southwestern Virginia often exacerbates the challenges of rescuing injured and ill people, from Appalachian Trail hikers to those living in remote areas.

The region’s growing popularity as a destination for outdoor adventurers has led to a spike in mountain biking, hiking, swimming, rock climbing, and boating accidents.

Celebrated for its abundant wildlife, the area also faces dangers from critters, including snakebites, collisions with deer and, more recently, Lyme disease and other tick-borne illnesses.

Hunting can prove dangerous for hunters as well as the hunted, with tree-stand falls and shooting accidents accounting for a significant portion of emergency department visits.

Nationally, rural areas have far fewer primary care physicians than urban areas. In southwestern Virginia, relatively low incomes and employment rates further hinder access to care.

Lifestyle choices have led to high rates of obesity, which in turn have fueled a diabetes epidemic.

Poor diet and exercise have also contributed to some of the nation’s highest rates of stroke.

Substance abuse has reached epidemic proportions in the region, with southwestern Virginia confronting the state’s highest mortality rate from opioid overdoses.

People in rural areas have up to 20 percent higher lung cancer rates than those in cities. People in Appalachia also have a greater risk of hospitalization for chronic obstructive pulmonary disease.

22 CARILION MEDICINE | FALL 2017

ILLUSTRATION: MIKE LEMANSKI

Note: Map is for illustration purposes only; icons of perils are intended to be representative of the region rather than specific localities.

CARILION MEDICINE | FALL 2017 23

S

T

R O

N G

Medicine

Once just a hospital-owned athletic facility, the Roanoke Athletic Club—now Carilion Wellness—has transformed itself into an active partner in the Carilion care team.

B Y V E R O N I C A M E A D E - K E L LY

IT’S BEEN TWO YEARS SINCE THE ROANOKE ATHLETIC CLUB

CALL TO ACTION: Les Perdue never worried about his health—until the day he had a stroke.

His prognosis was grim, with the specter that he may never walk again. Then he received a prescription for a supervised fitness program at Carilion Wellness. Since then, he and his wife, Pat, pictured at right, both focus on staying physically fit in retirement.

24 CARILION MEDICINE | FALL 2017

and its fellow Carilion-owned fitness centers, Botetourt Athletic Club and RAC Express, were rebranded as “Carilion Wellness” centers. And while the new moniker might not roll off the tongue as easily as “the RAC and the BAC,” as the clubs were once affectionately known, there’s a consensus that “Carilion Wellness” descriptively captures the shift in culture and mission that has taken root in these facilities.

Bud Grey, vice president of wellness for Carilion Clinic, traces the transformation back five years. At the time, the clubs served Carilion’s then roughly 12,000 employees, along with members of the local communities, using a fitness-club membership model that is common nationwide.

“But then we had an epiphany,” Grey explains. “We realized so many physicians in the Carilion system were recommending exercise for their patients. But it was clear they didn’t necessarily know where to send those patients after making that recommendation.”

The realization inspired staff at the fitness club to create “Fit Rx,” a 60-day prescription exercise program that gives patients referred by physicians access to one-on-one personal training sessions with a nationally certified trainer. The trainers, in turn, exchanged feedback with the prescribing clinicians.

The program took off. Nearly 7,000 participants have completed the program since its inception—and its appeal hasn’t been limited to fitness fanatics.

“What was interesting was that, for the first time, we were reaching sedentary people who had either never exercised or hadn’t done so in years—and we were reaching them with

CARILION MEDICINE | FALL 2017 25

remarkable success,” Grey says, noting that this once-sedentary group has accounted for about 75 percent of Fit Rx participants. “It was an exciting breakthrough for us.”

Just What the Doctor Ordered In the age of desk jobs and screen-time, so-called “exercise prescriptions” are fairly common. Many people live sedentary lifestyles, and the lack of exercise increases the risk of muscle atrophy and other physical impairments.

It also invites obesity, which now affects over a third of American adults and is a leading risk factor for conditions such as diabetes, hypertension, and heart disease.

Clinicians routinely recommend exercise to minimize these long-term health risks. They also prescribe exercise to stave off recurring injuries and even to mitigate debilitating symptoms that accompany chronic disease. It’s all part of a growing clinical focus on preventive care. And it’s here, Grey says, that the missions of the fitness clubs and the broader Carilion system align: both believe in the power of exercise to improve the wellness of the communities they serve.

The recognition of this shared mission—and the success of Fit Rx—inspired the fitness center leadership to broaden its clinical approach, and the focus of the centers turned to “wellness” rather than memberships.

With that shift came new programs. One, Recovery Rx, is a physician-referred program designed for people recovering from injury, pre- and post-surgery. It’s meant to fill the care gap left at a particularly vulnerable time—after insurance-covered physical therapy ends, but before patients are back to their pre-injury selves.

Other programs are aimed at people with chronic disease. So far, Carilion Wellness offers classes for people with Parkinson’s disease and multiple sclerosis, with programs being developed for people with cancer. All programs are priced to make them as accessible as possible, with fees comparable to copayments that the participants would have paid for physical therapy. Limited-income patients are eligible for financial assistance; the Carilion Clinic Foundation offers assistance for people with multiple sclerosis and, in alliance with the foundation, a community donor provides support for people with Parkinson’s disease.

Much-Needed and Welcome Support The development of the chronic disease programs, now known as Take Control Rx, reflects a growing appreciation in the medical community for the pivotal role exercise can play in maintaining the health of the chronically ill. These programs also reflect the reality that certain health factors, such as symptoms that affect balance and coordination, require the type of monitoring and assistance during exercise that only physical therapy or programs like those at Carilion Wellness can provide.

Joseph Ferrara, M.D., a Carilion neurologist, recommends regular exercise for the vast majority of his Parkin26 CARILION MEDICINE | FALL 2017

son’s patients, as studies suggest exercise improves many symptoms that would otherwise be difficult to treat.

“Motor symptoms often respond well to exercise, and so can a variety of nonmotor features, including sleep, mood, energy levels, and cognition,” Dr. Ferrara says, adding that there is also some evidence that aerobic exercise may slow disease progression. “The goals of every patient embarking on therapy are a little different, as are the outcomes, but I have seen meaningful improvements in gait, and many of my patients report improvements in their function, safety, and quality of life.”

Pat Grisetti has experienced the benefits firsthand.

The retired law enforcement coordinator from Boones Mill, Virginia, was diagnosed with Parkinson’s last year.

She said that, even more than the motor challenges posed by the disease, she was moved to join the Carilion Wellness program because of the illness’s associated risk of dementia.

“The thought of one day not recognizing my husband, children, and two precious grandsons frightens me to death,” she says. “I asked my doctor, ‘What medications can I take? What foods do I need to eat? Are there any experimental treatments?’ His response was, ‘Exercise, exercise, exercise. You can’t do enough.’”

Grisetti says she’s more than willing to put in the physical work if it can help keep her mind sharp. When her current 12-week program ends, she says she’ll join a bicycle spinning class that Carilion Wellness offers to those who have completed the program.

“Parkinson’s disease is making it difficult for me to do many things I used to take for granted, but I know this program is helping me both physically and mentally,” she says, noting that the camaraderie and support of other program participants with Parkinson’s have also helped boost her spirits.

Karen Anderson, director of Take Control Rx, says that along with the program’s cardiovascular and social benefits come improvements to mobility, stability, and body mechanics that enhance quality of life.

While traditional group exercise classes such as cycling and boxing are available to people diagnosed with Parkinson’s disease or multiple sclerosis, the primary focus of Take Control Rx is functional training. Twenty-four hundred square feet formerly reserved for racquetball courts have been converted to a functional training studio where classes focus on developing the core muscles, balance, and flexibility needed to carry out the routine activities of daily life, from carrying groceries and caring for children, to climbing steps, driving, or swinging a golf club.

“These exercises aren’t about maximizing one’s bench press,” Anderson says. “There’s a reason behind the exercise we do with the participants. Our ultimate goals are keeping these people independent and out of the hospital, reducing their medications, and giving their caregivers support by trying to limit the physical ailments that participants and their families have to contend with.”

PHOTO, PREVIOUS SPREAD: DARRYLE ARNOLD

Karen Anderson (left), director of Take Control Rx, helps patient Valerie Church fill her exercise prescription.

M O

T

O R

symptoms

often respond well to exercise, and so can a variety of nonmotor features, including sleep, mood, energy levels, and cognition.”

—Dr. Joseph Ferrara

Paving a Better Road to Wellness In her native Australia and elsewhere, Anderson says, programs that use fitness and functional training to help manage and prevent illness—like those now offered at Carilion Wellness—are relatively common. Not only are they thought to improve quality of life for participants, but they have also been shown to lower systemic medical costs from medication, hospital visits, and long-term care. Yet the programs remain difficult to find in the United States. In fact, when Grey was looking for models to emulate while devising the Carilion programs, he came up empty-handed.

“I didn’t want to reinvent the wheel,” he says, “but when I reached out to colleagues, many said they’d been looking into it but hadn’t yet developed any programs.”

Grey says that Carilion was fortunate to hire Anderson, a chronic disease specialist and accredited exercise physiologist with experience in the field. With the help of her expertise, Carilion Wellness has become one of only a few centers on the East Coast to define itself by this preventive care model.

PHOTO: JARED LADIA

And Grey is quick to note that this clinical approach isn’t limited to prescription-exercise programs: all Carilion employees and Carilion Wellness members benefit. The centers—which now include two other Virginia branches, in Blacksburg and at Smith Mountain Lake—offer education classes that cover everything from yoga to painting. These centers also host “Healthy Happy Hours” both at their facilities and out in the community, where people can eat, socialize, and talk to experts about a range of health topics. The Carilion Wellness team even offers such services as mammogram signups and biometric screenings at these events.

It’s all part of the Carilion Wellness focus on preventive care, which is not only about physical fitness, but also on building a healthy mind and body to increase enjoyment of life.

“Wellness is about so much more than caloric expenditure,” Grey says of the centers’ new mission. “There’s a role for wellness in everyone’s life regardless of age or physical condition, and centers like ours should be there to help you do whatever it is that makes your life more fulfilling.” CM CARILION MEDICINE | FALL 2017 27

THE AFTERMATH

by Jessica Cerretani

LAW-ENFORCEMENT OFFICERS AREN’T THE ONLY ONES WHO ROUTINELY WITNESS THE EFFECTS OF VIOLENCE; HEALTH CARE PROVIDERS ARE OFTEN ON THE FRONT LINES AS WELL. CARILION IS HELPING IN EFFORTS TO PROTECT THE VULNERABLE.

ILLUSTRATIONS: BRIAN STAUFFER

CARILION MEDICINE | FALL 2017 29

T’S BEEN A LONG DAY IN THE EMERGENCY DEPARTMENT, and it’s about to get even longer. Amid the typical flurry of patients with chest pain or sprained ankles, a nurse spots something unusual. At first blush, little Aidan* isn’t much different from other kids in the emergency department: His parents have brought him here, worried that he’s hurt his leg. But as pediatrician Donald Kees, M.D., begins to examine him, some red flags appear.

“I don’t know what happened,” his mother says. “He just seemed fussy and then his leg started to swell.” But Dr. Kees

knows that’s unlikely. Aidan’s femur is broken—and he’s only two months old.

As the doctor asks more questions, the story starts to change. “I think he fell off the couch,” his father offers haltingly.

Yet that account doesn’t make sense either.

“The basis of the medical relationship is trust, and we should never jump to conclusions,” Dr. Kees, who has been brought in to consult on the case, explains later. “But in some cases, the history given by the parents just doesn’t match the baby’s injuries.”

FORENSIC NURSES: Uncovering the Crime, Aiding the Victims In the examination room, the nurse carefully inserts a speculum into the patient and swabs her genital area. But this isn’t a typical gynecologic exam, nor is she a typical nurse.

Instead, the act is one component of a sexual assault forensic evidence kit, colloquially known as a rape kit. And the clinician is a forensic nurse examiner who provides specialized care for patients who have experienced violence.

Since 1995, Carilion Clinic’s team of forensic nurse examiners has offered a full spectrum of care to trauma patients—a service that’s been described as the intersection of health care and the legal arena. Although sexual assaults comprise most of these cases, forensic nurses see a range of patients, including those who are victims or perpetrators of child abuse, intimate partner violence, elder abuse, trafficking, and attempted murder.

“Whatever hits the emergency department, our forensic nurses are there to provide support,” explains Janet Young, M.D., medical director of the program. “Even beyond the emergency department, they give medical treatment, social support, and legal support, acting almost as physician extenders. These nurses have a unique niche in health care that no other profession provides.”

In addition to treating patients’ injuries, forensic nurse examiners test and provide prophylaxes for possible sexually transmitted infections, provide emergency contraception, and collect evidence that may later be used by law enforcement officials. They also offer emotional support, provide domestic violence victims with safety planning and safe shelter referrals, report to social services and law enforcement as appropriate, and refer patients to child advocacy groups, counseling, and follow-up medical care. Later on, they may provide medical testimony in court. Along with pediatricians, forensic nurses also serve on case-review teams to understand why violence happens and how to prevent it.

30 CARILION MEDICINE | FALL 2017

“We see patients from the moment they enter the hospital until they’re discharged—and sometimes afterward, for follow-up examinations in the emergency department,” says Melissa Harper, M.S.N., a founding member of Carilion’s Forensic Nurse Examiner Program. “It’s a very intense form of nursing.”

In such situations, when emotions are understandably running high, forensic nurses say they must focus on the importance of stepping away from snap judgments and staying calm—especially in cases of child abuse and domestic violence, where the perpetrator may be right at the victim’s bedside.

“We have to be as methodical and meticulous as possible, without condemning or showing any bias,” explains Harper.

“If they think we’re judging them, they may clam up and not share important information. People’s lives depend on what we say and how we act, not just on what evidence we find.”

Yet such vital programs are not the norm: According to the International Association of Forensic Nurses, just one of 10 hospitals in the United States has a forensic nurse examiner program, and even fewer have comprehensive programs that address crimes beyond sexual assault. For this reason, Carilion provides forensic nurse services for agencies across its service area.

Now in its 22nd year, Carilion’s Forensic Nurse Examiner Program has six full-time forensic nurses. Sensitive to the issue of provider burnout, Dr. Young conducts regular debriefing meetings that allow the nurses to discuss recent cases, gain new insights, and, sometimes, vent. The program is also in the early stages of developing a more routine system of mental health counseling for the nurses. In the meantime, some of the greatest support comes from the team itself, and from recognizing they aren’t alone.

“It takes many talented people to make this program work,” says Harper. “We work closely with our physicians, as well as with police and social services. Forensic nursing is just one small piece of the puzzle.”

IN THE IMMEDIATE AFTERMATH OF VIOLENCE, THE PRINCIPAL FOCUS OF CLINICIANS IS ALWAYS ON TREATING INJURIES AND SAVING LIVES. BUT THEY’RE ALSO COGNIZANT OF THE INVISIBLE SCARS THAT CAN LINGER LONG AFTER A CAST COMES OFF OR STITCHES ARE REMOVED.

Dr. Kees gently informs Aidan’s parents that his suspicions require him to call Child Protective Services. As a pediatric hospitalist at Carilion Children’s Hospital, Dr. Kees is well versed in detecting possible cases of child abuse. Yet he’s just one of a cadre of clinicians at Carilion dedicated to helping care for Virginia patients in the wake of sexual assault, child abuse, and other forms of violence. The clinic’s designation as a Level I trauma center makes its position on the front lines of post-trauma medical and psychological care a natural one.

“So many patients suffering from violent injuries land on our doorstep,” says Dr. Kees. “It’s our responsibility to help them.”

Strength in Community In the immediate aftermath of violence, the principal focus of clinicians is always on treating injuries and saving lives. But they’re also cognizant of the invisible scars that can linger long after a cast comes off or stitches are removed.

There’s little doubt that violence can have lasting effects.

Survivors can experience serious mental health problems, including depression, anxiety, and post-traumatic stress disorder.

They are also at higher risk for developing chronic conditions such as cardiovascular disease, asthma, and cancer—perhaps because, as research suggests, they are more likely to smoke, make unhealthy food choices, and abuse alcohol or drugs after experiencing a violent crime.

“This is a major health care issue, but not everyone realizes that,” says Melissa Harper, M.S.N., a founding member of Carilion’s Forensic Nurse Examiner Program. “It’s been gratifying to see our leadership acknowledge that violence is a true public health problem that extends beyond hospital walls.”

Indeed, Carilion has long partnered with community programs to ensure that patients who have suffered abuse, sexual assault, and other types of violence have access to the resources they need after they leave the hospital. By maintaining working relationships with a range of community programs—such as the Children’s Advocacy Center, which is part of Children’s Trust; the Domestic Violence Council; and Turning Point, the Salvation Army’s domestic violence shelter—emergency clinicians can feel more confident that their patients have options rather than being forced to return to a potentially dangerous home environment.

“The hospital’s involvement with these groups has been somewhat of a natural evolution,” says Dr. Kees, who is also *Name and details have been changed to protect patient confidentiality.

vice chair of Carilion’s Department of Pediatrics. “We all work together as a team to help vulnerable patients.”

Recently, Carilion expanded its support when a Community Health Assessment identified mental health services as a top priority for patients. Since issues like sexual assault and child abuse can negatively affect mental health—and people with mental illness are significantly more likely to experience trauma—clinic leadership has begun funding valuable programs aimed at stemming the tide of violence in the community.

This year, Carilion committed to provide financial support to the Southern Virginia Child Advocacy Center, which offers a comprehensive and coordinated response to criminal and civil cases of child abuse and neglect in the region. Similarly, the clinic stepped in to help keep doors open at Sabrina’s Place, the area’s only secure supervised visitation and safe exchange program for families affected by domestic and dating violence, sexual violence, stalking, and child abuse.

“Carilion has been really supportive of helping clinicians address the causes and effects of violence, not just within the hospital, but where our patients live and work,” says Harper.

The Long View Back in the emergency department, Dr. Kees tries to keep everyone’s emotions in check—including his own.

Although he suspects the baby’s injuries were intentional, he’s still Aidan’s doctor, and that means he’ll need to continue to work with the family and care for the little boy, regardless of the legal outcome. Even with the call to protective services, Aidan won’t necessarily be taken from his family.

Depending on the investigation, he may eventually go to live with a relative, enter foster care, or even return to his parents once they have received appropriate preventive resources and interventions.

Everyone’s goal is to ensure that abuse doesn’t happen again—which is why Dr. Kees and his colleagues provide a range of services beyond standard care, whether that’s helping connect parents with educational programs and social workers, testifying at trials, or reviewing previous cases to glean useful insights. Above all, the focus is on the patient.

“It’s not my place to say who committed the abuse,” says Dr. Kees. “It’s my job to help keep children safe and to give the vulnerable a voice.” CM CARILION MEDICINE | FALL 2017 31

The Cosmos of Our Cells A Virginia Tech Carilion Research Institute scientist sees cancer with new vision. BY ASHLEY WENNERSHERRON Breast cancer vexes Deborah Kelly.

“Cancer is merciless,” she says. “It doesn’t discriminate.”

Dr. Kelly, an associate professor at the Virginia Tech Carilion Research Institute, wants to eradicate breast cancer for the same noble reason others study the disease—to rid the world of a threat that’s expected to kill more than 40,000 women in the United States and 500,000 worldwide this year alone.

“That’s always the ultimate goal, to improve human health,” she says. “But there’s something else here. Breast cancer cells move around in ways they shouldn’t. They outsmart other cells.”

The strangeness challenges her to think about cancer differently.

PHOTOS: DSCIENCE SOURCE

CARILION MEDICINE | FALL 2017 33

“Our goal is to see the BRCA1 protein in its most pristine condition at the atomic scale,” Dr. Kelly says. “The electron microscope affords us that opportunity.”

“Cancer cells don’t fit a natural patThe image could be a topographic map can make a person’s body build mutated tern,” Dr. Kelly says. of the moon; it’s reminiscent of the first BRCA1 proteins.

And she likes a good pattern. She first photos taken by a lunar rover in 1966, Dr. Kelly learned about the inner noticed natural patterns when she was in with dark peaks and valleys, populated workings of proteins while an underelementary school. by small dots. graduate; by then, she had traded her “I’d seek out pictures of space, this The molecules on the screen are breast telescope for a microscope to study the strange place that looked so different cancer–susceptibility proteins, known as cosmos of our cells. At first, she was fofrom anything I knew,” says Dr. Kelly. BRCA1. They’re the health enforcers of cused on gene regulation, trying to un“But I noticed a familiarity in the images: our cells. Found in every cell throughout derstand how proteins are made and how colors and shapes repeated throughout the body, not just breast tissue, BRCA1 that process can go awry, a subject she the galaxy, including on Earth.” proteins work to repair DNA damage and continued to study in graduate school.

H I in - R Eprevent S O L the U Tout-of-control ION FIGU RE P R O O F“When she decided to join my lab, I ofShe recognized the same patterns cellular probiology: The symmetries and fractal im- cesses that lead to cancer. fered her a project that was pretty much a ages she saw in space were mirrored in The proteins can break, however. Risk sure bet to work, and an alternative project our very being. factors, such as smoking or genetics, that would have higher impact, but might “Natural patterns consistently repeat,” she says, “from planets down to atoms.”

But breast cancer doesn’t fit any THE BUMPY ROAD TO UNDERSTANDING BREAST CANCER known pattern. The broken symmetry bothered Dr. Kelly—so much so that she Dr. Deborah Kelly led a research team to see the breast cancer–susceptibility protein for the first time. By visualizing the protein in health, as shown below, built her research program on underthey were able to see how mutated proteins had a specific bump in what standing the secrets of these dangerous researchers call the modification hotspot zone. cells. The first step?

“To solve a problem,” she says, “you need to see the culprit.”

The Observable Truth There’s a click, barely audible above the hum of machines unknown. The room is dark, with only the glow of a computer monitor lighting half of Dr. Kelly’s face.

She peers down an eyepiece. Without shifting her gaze, her hand dances across a control panel. She taps a button and tweaks a knob. When she lifts her head, she’s smiling. She presses another button, eliciting a small whine from the machine towering over her.

Dr. Kelly turns her attention to the computer screen to the right. She palms the mouse and clicks a few times. A grainy black-and-white image appears.

“That’s it,” she says, admiring the features on the screen. “My version of space exploration.”

34 CARILION MEDICINE | FALL 2017

SUPER COOL: Researchers in the Kelly Lab use liquid nitrogen to freeze breast cancer proteins for high-resolution imaging. Members of the team include, from left, Dr. William Dearnaley, Brian Gilmore, Yanping Liang, Dr. Deborah Kelly, Cameron Varano, and Nicholas Alden.

not work,” says Kenneth Taylor, Ph.D., a professor of biological science at Florida State University who advised Dr. Kelly as she earned her doctorate in molecular biophysics. “She chose the project with the greater impact. I have met few students as ready to take up a new technique and put in the effort to master it once they determined that it could facilitate their desire to solve a particular problem. I admire her for venturing into the unknown.”

As Dr. Kelly worked in Dr. Taylor’s lab and attended conferences, she made a startling discovery about the state of research on the breast cancer–susceptibility protein.

“BRCA1 is a prime suspect implicated in breast cancer, and no one knew what it looked like,” Dr. Kelly says. “How could that be? It’s so important!”

Researchers were limited by the existing technology, so Dr. Kelly and her team changed the technology.

Seeing the Unseen “Our goal is to see the BRCA1 protein in its most pristine condition at the atomic scale,” Dr. Kelly says. “The electron microIMAGE: COURTESY OF THE KELLY LAB

PHOTO: DAVID HUNGATE

scope affords us that opportunity. It’s unbiased and tells you the observable truth.”

Dr. Kelly was specifically interested in seeing BRCA1 and learning more about its collaborations with other molecules in the cell. It proved a difficult task. If the sample preparation didn’t inactivate the protein, the electron beam certainly did.

“Imaging optics were improving,” Dr. Kelly says, “but we still couldn’t see the things we wanted to see, in the way we needed to see them.”

Her team began developing better biochemical techniques to isolate the proteins from human cells without damaging the proteins. She then turned her attention to improving upon the substrates traditionally used in electron microscopy.

By this time, Dr. Kelly had completed a postdoctoral fellowship at Harvard Medical School and moved to Roanoke to set up her lab at the Virginia Tech Carilion Research Institute.

“There are unlimited possibilities for growing a research program at the institute,” says Dr. Kelly. She credits Michael Friedlander, Ph.D., the institute’s founding executive director, for providing the

support and freedom to pursue her research questions.

“We were extremely fortunate to recruit Dr. Kelly as one of the original institute research team leaders,” said Dr. Friedlander, who is also Virginia Tech’s vice president for health sciences and technology. “Debbie has exceeded our expectations, developing a premier structural biology research enterprise and applying powerful molecular imaging and computational approaches to develop new insights into cancer.”

According to Dr. Kelly, there’s a spirit of innovative collaboration at the institute, especially when it comes to developing and improving the tools needed for avant-garde scientific pursuits.

“I’ve been lucky with my research team as well,” says Dr. Kelly, who is also an associate professor of biological sciences in Virginia Tech’s College of Science. “We have a talented team of both early-career and more seasoned scientists.”

Dr. Kelly began to collaborate with Protochips, Inc., a North Carolina company specializing in electron microscopy. Working with engineers at the company, she deCARILION MEDICINE | FALL 2017 35

“We can rotate their 3-D structures on a computer screen and examine them from different angles. This information reveals how BRCA1 interacts with other factors in cells.”

SPOTTING THE HOTSPOT veloped improved preparation approaches, as well as better substrates to attract biological samples to the microchip surfaces to enable examination.

The techniques involve carefully preparing cellular samples to separate out the desired biological specimen. Dr. Kelly and Protochips engineers developed specialized microchips coated with antibodies to attract and trap the prepared samples. The antibodies can be changed to create broadly “tunable” devices on which the desired research subjects have an affinity for the chip’s coating.

The antibody layer attracts BRCA1 protein assemblies—the cancer-related culprits—directly viewable with the electron microscope. The result is that Dr. Kelly can tap a button to the left of her electron mi-

croscope to take a grainy black-and-white photo of thousands of BRCA1 proteins.

“The use of this approach was a major step forward in seeing cancer proteins for the first time,” Dr. Kelly says. “But the images alone aren’t enough. We have to analyze the images statistically to gather meaningful information.”

With modern computing algorithms developed by other colleagues in the field, Dr. Kelly and her team used their collected data to calculate the first three-dimensional view of BRCA1 proteins, in both healthy and genetically damaged states.

“Finally, we can really see these naturally occurring cancer proteins,” Dr. Kelly says. “We can rotate their 3-D structures on a computer screen and examine them from different angles. This information

reveals how BRCA1 interacts with other factors in cells.”

Second Sight Dr. Kelly struggles to capture the magnitude of that moment, years in the making, when she first saw the protein’s full structure. She borrows from Marcel Proust’s In Search of Lost Time to better explain. “‘The real voyage of discovery consists not in seeking new lands, but seeing with new eyes,’” Dr. Kelly says, her own eyes lighting up. “It was worth it. I love the complexity of research—seeing things for the first time and working toward discoveries.”

Dr. Kelly began to see differences between the healthy and mutated BRCA1 proteins formed in breast cancer cells.

FROM TELESCOPE TO MICROSCOPE: Dr. Deborah Kelly redirected her attention from the stars to structural oncology, a field of research made possible by the electron microscope. She uses cryo-electron microscopy to study frozen biological samples and determine their structures.

36 CARILION MEDICINE | FALL 2017

Cameron Varano, a doctoral student in Virginia Tech’s Translational Biology, Medicine, and Health Program, is a member of the Kelly Lab. She prepares the samples of the mutated BRCA1 protein for imaging, from which Dr. Deborah Kelly’s team found a structural bump in the mid-section of the protein that leads to self-destruction in the cell.

PHOTO: JIM STROUP

The mutated BRCA1 protein is implicated specifically in triple-negative breast cancer. This type of cancer lacks the three receptors—estrogen, progesterone, and human growth factor receptor 2 (HER2)— that clinicians may be able to use for targeted treatments. Triple-negative breast cancer has the highest rate of recurrence for all breast cancer types, meaning that while treatments like chemotherapy may be able to push the cancer into remission, the likelihood that the cancer will return is greater.

Even mutated BRCA1 proteins retain some ability to repair DNA damage, yet cancer still occurs. Dr. Kelly set out to understand the compromised protein’s deficiencies in the cell.

“We found that the cancer cells signal the mutated BRCA1 proteins to self-destruct, on the path to forming tumors,” Dr. Kelly says. “We wanted to see why this process occurred and then try to intervene in this self-destruction.”

In the repair process, BRCA1 interacts with a molecular partner to form a clamp-like structure. The molecules work together to relay the message of damage to other proteins in the nucleus. It’s a barn raising for genetic damage—all the required proteins jump in and help rebuild the broken molecules.

When BRCA1 is mutated, the cell silences this protein warning system. The cell initiates the degradation of BRCA1 and loses a critical component of its rePHOTO: DAVID HUNGATE; IMAGE: COURTESY OF THE KELLY LAB

pair system. Eventually, the unrepaired DNA damage leads to cancer.

An Extra Bump In Dr. Kelly’s field of work, which she’s dubbed “structural oncology,” she saw that the mutated BRCA1 proteins looked physically different from healthy proteins.

“The mutated protein has an extra little bump,” Dr. Kelly says. “We refer to the site on BRCA1 that receives the bump as the ‘hotspot.’”

The presence of the bump in the hotspot zone alerts the cell to the fact that BRCA1 isn’t healthy, so the cell triggers a cascade of events to destroy BRCA1. The researchers theorized that they could restore the structural properties of mutated BRCA1 by simply removing the self-destruction signal from the hotspot region.

“These experiments worked beautifully—upon treatment, the mutated BRCA1 protein looked perfectly normal, no bump,” Dr. Kelly says. “We’re now testing whether the normal duties of BRCA1 can also be restored in cells using the same treatment idea.”

Scientists are still years away from a restorative or preventative treatment for breast cancer, according to Dr. Kelly, but the ability to see BRCA1 come to life in its entirety is providing new insights for rational drug design. The BRCA1 protein looks normal, so now it might function normally.

Should Dr. Kelly’s hypotheses prove correct, people with a known mutation might one day be able to avoid a cancer recurrence by undergoing a treatment that restores their mutated proteins to a healthy structure.

“There’s a lot of potential here,” Dr. Kelly says. “BRCA1 is associated with breast cancer because that’s where the genetic inheritance component was first understood. Yet we have BRCA1 in every cell in our bodies.

What if these proteins play an equally critical role in other cancer types? Could BRCA1 be restored in other tissues in the same manner? Is this the pattern we’ve been searching for with cancer cells?”

Dr. Kelly, still driven by the uniqueness of cancer cells, hopes to find more answers.

“We’re just beginning to understand how breast cancer–related proteins look and work and how things can go wrong,” she says. “We still have much more to do.” CM CARILION MEDICINE | FALL 2017 37

photo essay

with a

A day in the life of the neuroangiography suite at Carilion Roanoke Memorial Hospital PHOTO ESSAY BY JARED LADIA

INSIDE THE WALLS OF CARILION ROANOKE MEMORIAL HOSPITAL’S

biplane neuroangiography suite, neurointerventional radiologists

SEEING THE BIG PICTURE: Dr. Andrew Nicholson, a neurointerventional radiologist at Carilion Clinic, uses three-dimensional images to guide a tiny catheter through arteries to a patient’s brain aneurysm.

38 CARILION MEDICINE | FALL 2017

perform nearly 1,000 procedures each year. Technological advances are enabling the doctors to deliver stents, coils, flow diverters, and clot retrievers to affected vessels with precision and a high degree of success for treatment of brain aneurysms and ischemic strokes.

Guided by high-resolution, three-dimensional images displayed on a 60-inch flat screen, doctors deftly thread tiny catheters through blood vessels in the groin or arm directly into the problem area. The neurointerventional radiologists and endovascular neurosurgeons can then deliver interventions through holes as tiny as pinpricks, resulting in good outcomes and shortened recovery times for patients.

The results can be dramatic, such as during a “Stroke Alert,” when clinicians race the clock to remove a blood clot from a patient’s brain mid-stroke, often restoring normal function almost immediately.

“Patients who used to spend months in rehabilitation, often with significant residual disability, can now go home feeling totally normal,” says Andrew Nicholson, M.D., a neurointerventional radiologist at Carilion. “Sometimes they can go home the very next day.”

CARILION MEDICINE | FALL 2017 39

POINTS OF VIEW Clockwise from top right: Radiologic technologists Randy Shrewsbury and Patricia Smith help fifth-year neurosurgery resident Cara Rogers, D.O., get prepped for a procedure; Andrew Nicholson, M.D., and Dr. Rogers look at a patient’s brain to evaluate it for aneurysm coiling; Dr. Nicholson examines a patient’s diagnostic imaging to plan for the procedure; a radiologic technologist prepares a catheter to be inserted through arteries to a patient’s brain aneurysm for treatment; Dr. Nicholson stands at the monitor to teach Dr. Rogers during a procedure. Dr. Rogers, like all neurosurgery residents, is undertaking a rotation on the neuroendovascular service as part of her training.

AMPLE SAMPLE Biraj M. Patel, M.D., chief of neuroendovascular radiology, verifies that a spine biopsy has yielded an adequate sample for testing. The sample was obtained using biplane fluoroscopy guidance to insert a needle with precision through a tiny nick in the skin and into the spinal bone.

40 CARILION MEDICINE | FALL 2017

CARILION MEDICINE | FALL 2017 41

the art of medicine

ART THERAPY This artwork is just a small sample of area artists’ pieces that line the hallways of Carilion Clinic and provide visitors with views of life in the Blue Ridge.

A. Tina McConchie, “Untitled” B. Patricia Placona, “Sunday in the Park” C. Nancy Stellhorn, “Late August Palette” D. Mary Boxley Bullington, “Untitled” E. Sharon Strite, “Evening Splendor” F. Helen Hublar, “Mother”

HEALING ART IN THE BLUE RIDGE Carilion celebrates the power of art to create moments of respite for patients and caregivers alike. B Y PAU L A B Y R ON

P

C

AIN IS OFTEN AN INVISIBLE SPECTER LURKING

in the corridors of places of healing. Sometimes the pain is physical or psychiatric; other times it may take the shape of grieving, or the anxiety of an unfolding medical drama.

Over the years, Carilion Clinic’s recognition of the role of art in soothing pain has resulted in the collection of more than 1,000 original works of art. Many of these pieces—which span a range of mediums, from sculpture to oil painting, photography, and watercolor— brighten spaces in Carilion’s hospitals, physician’s offices, and other places of healing.

“More than decoration, the works adorning our interiors create pockets of respite for patients, families, visitors, and staff,” says Nancy Howell Agee, president and chief executive officer of Carilion. “We’ve long known the power of art to enhance the healing process.”

Carilion has now assembled representative works of its collection in a curated book, Healing Art in the Blue Ridge. With so many of the artists capturing the landscapes they live in, the art has been organized into several regions: the history-steeped Shenandoah Valley; the Roanoke Valley, home to Carilion’s flagship “little hospital on the hill”; and the rugged terrain and natural resources—including one of the world’s oldest rivers— of the New River Valley and beyond.

“Our devotion to landscape and community has led us to focus on works that reflect the natural beauty and cultural diversity of our area,” says Agee. “Through the work of so many talented artists, we’ve woven our surroundings throughout our places of healing, just as Carilion has been woven through the decades into the fabric of the communities we serve.”

The Carilion art collection represents generous contributions, special acquisitions, and the work of the Carilion Clinic Foundation for the Dr. Robert L.A. Keeley Healing Arts Program.

42 CARILION MEDICINE | FALL 2017

B

A

F

D

E

PHOTOS OF ARTWORK: KEVIN HURLEY

CARILION MEDICINE | FALL 2017 43

cheers for peers Family Medicine

H

G. Walter Biggs, “Reverie” H. Eric Fitzpatrick, “Autumn” I. Dorothy Blackwell, “Plank Road” J. P. Buckley Moss, “Fire and Ice” K. Robert E. Tuckwiller, “The Seasons of Life “ (detail) G

MARK GREENAWALD, M.D., vice chair of academic affairs and professional development, was a co-presenter for several Chief Resident Leadership Development Program workshops of the American Academy of Family Physicians. Topics included the fourth aim, team building, negotiation, leadership, and emotional intelligence. Dr. Greenawald also coauthored an article titled “Coaching in Healthcare” for the magazine TD at Work.

ROGER HOFFORD, M.D., published information on cryptosporidiosis in Essential Evidence Plus, an evidencebased, point-of-care clinical decision support system published by Wiley.

PRISCILLA TU, D.O., program director of osteopathic medicine, gave several oral presentations

spotlight on I

at the American Osteopathic Association of Sports Medicine Preconference on Musculoskeletal Ultrasound. Topics included

ERIC CHEN, M.D., and medical resident KEVIN COOKE, M.D., were co-presenters for a session on wellness at the Society of Teachers

Michael Nussbaum, M.D.

A nationally recognized expert in the areas of gastrointestinal, endocrine, and minimally invasive surgery has joined Carilion Clinic as chair of its Department of Surgery.

MICHAEL NUSSBAUM, M.D., arrived in Roanoke by way of the University of Florida College of Medicine–Jacksonville, where he was an endowed professor and chief of the Division of General Surgery. There he had earlier served as chair of the Department of Surgery, surgeon-in-chief of the University of Florida Health Jacksonville, and program director for the surgery residency.

Dr. Nussbaum was instrumental in starting a surgical robotics program at the University of Florida Health Jacksonville and

J

anterior hip ultrasound, performance-enhancing drugs, knee procedures, and anterior hip surgeries.

was program director for the Advanced Gastrointestinal/Minimally Invasive Surgery Fellowship.

Prior to that, he played many roles at the University of Cincinnati, including interim chair of the Department of Surgery and program director of the surgery residency.

Dr. Nussbaum, who now also serves as chair of surgery for the Virginia Tech Carilion School of Medicine, brings an extensive background in surgical education and leadership. He has held leadership positions with numerous national professional organizations and is currently a senior director for the American Board of Surgery.

Dr. Nussbaum received his bachelor’s degree from Northwestern University and his medical degree from the Perelman School of Medicine at the University of Pennsylvania. He completed his residency at the University of Cincinnati Hospital, where he was a faculty member for 22 years.

K

44 CARILION MEDICINE | FALL 2017

PHOTOS OF ARTWORK: KEVIN HURLEY

PHOTOS: JARED LADIA (ABOVE); DARRYLE ARNOLD (TOP RIGHT)

CARILION MEDICINE | FALL 2017 45

cheers for peers

spotlight on

Kimberly Dunsmore, M.D.

KIMBERLY DUNSMORE, M.D., a nationally recognized expert in pediatric hematology and oncology, has joined Carilion Clinic as chair of its Department of Pediatrics.

Most recently, Dr. Dunsmore served as the associate chair for clinical program development and the Karen Jargowsky Endowed Chair for Pediatric Hematology/Oncology at the University of Virginia Children’s Hospital.

While with the University of Virginia Health System, Dr. Dunsmore was the primary investigator for the Children’s Oncology Group. She sat on the Acute Leukemia Committee and was the international primary investigator for the T-Cell ALL Treatment Protocol Committee.

She also served as director and primary investigator for the University of Virginia Health System’s Comprehensive Pediatric Sickle Cell Program and Hemophilia Treatment Center. She also founded the first pediatric hospice program at the University of Virginia.

Her research interests are in the areas of T-cell immune dysregulation, T-cell leukemia, clinical trials in pediatric oncology, innovative therapeutics for pediatric cancers, and pediatric hemophilia.

Dr. Dunsmore, who now also serves as chair of pediatrics for the Virginia Tech Carilion School of Medicine, has authored or co-authored numerous articles in peer-reviewed journals and book chapters and has been an invited presenter at a number of national and international conferences. She has received awards for both teaching and clinical excellence.

Dr. Dunsmore received her bachelor’s degree from the University of Tennessee and her medical degree from Emory University School of Medicine. She completed her pediatrics residency and a fellowship in pediatric hematology/oncology at Duke University Medical Center.

Dr. Dunsmore focuses much of her research on innovative therapies for children with cancer.

46 CARILION MEDICINE | FALL 2017

of Family Medicine Annual Spring Conference. MARY BETH SWEET, M.D., co-presented a poster titled “Do You See What I See? Comparing Faculty Evaluations of Residents” at the same conference.

Internal Medicine PAUL DALLAS, M.D., and MICHAEL WIID, M.D., associate program director for Internal Medicine, served as co-leaders for the precourse “Point-of-Care Ultrasound for Internists and Hospitalists” at the American College of Physicians meeting.

JON SWEET, M.D., co-presented the concluding talk at the American College of Physicians annual meeting. The talk was titled “Internal Medicine Meeting 2017 Highlights and Doctors’ Dilemma: The Finals.”

Obstetrics and Gynecology PATRICE M. WEISS, M.D., chief medical officer and executive vice president, and JONATHAN GLEASON, M.D., chief of urogynecology and vice president for clinical advancement and patient safety, presented at the Becker’s 8th Annual Meeting. The presentation was titled “Carilion Clinic: Formation and Transactions—Physician Leadership and Its Impact on Liability, Engagement, Competition and Production.”

JANET OSBORNE, M.D., chief of Gynecologic Oncology, submitted Carilion’s multidisciplinary Enhanced Recovery After Surgery (ERAS)—Hyster-

ectomy project to the National Improvement Challenge on Prevention of Surgical Site Infections in Major Gynecologic Surgery. The project was reviewed by the Council on Patient Safety in Women’s Health Care and tied for first place.

Psychiatry WILLIAM REA, M.D., vice chair of Psychiatry, was the keynote speaker at the Opioid Epidemic in Rural Virginia conference in February. The conference was sponsored by the Virginia Rural Health Association.

Radiology EVELYN GARCIA, M.D., chair of Radiology, was the keynote speaker at the 11th World Congress on Neurology and Therapeutics in Madrid, Spain.

Her keynote speech was titled “Comprehensive Stroke Care in the Rural Setting.” She also gave a topic speech on structural heart disease, minimally invasive procedures, and the relationship to thromboembolic cerebral disease.

Surgery SANDY FOGEL, M.D., associate program director for the General Surgery Residency, and JING CHEN, Ph.D., a student at the Virginia Tech Carilion School of Medicine, participated in the scientific session at the annual meeting of the Central Surgical Association. Dr. Chen presented their research, “Can Enhanced

Recovery in Emergency Cases Protect Against Post-Operative Pneumonia and Lower the Rate of Re-Intubation?” The paper will also be published in Surgery, the official journal of the Society of University Surgeons, the Central Surgical Association, and the American Association of Endocrine Surgeons.

Residency and Fellowship Programs CARA ROGERS, D.O., a PGY-5 neurosurgery resident, was selected as a Council of State Neurosurgical Societies Socioeconomic Fellow. The fellowship was created as an educational opportunity for neurosurgical residents interested in socioeconomic education.

It provides fellows with broad exposure to pertinent neurosurgical socioeconomic issues and an introduction to the world of organized neurosurgery. Just 12 fellows are chosen from across the United States each year.

Dr. Rogers’ faculty mentor for the fellowship is GARY SIMONDS, M.D., chief and program director for Neurosurgery.

spotlight on

Robert Trestman, M.D., Ph.D.

A nationally recognized expert in psychiatry and population health has joined Carilion Clinic as chair of its Department of Psychiatry.

ROBERT TRESTMAN, M.D., Ph.D., joined Carilion from the University of Connecticut School of Medicine, where he was a professor of medicine and psychiatry with a joint appointment as a professor of nursing.

While at the University of Connecticut, Dr. Trestman served as executive director of Correctional Managed Health Care, a division of the University of Connecticut Health Center, where he led a program that provided health care to all inmates within the state’s Department of Corrections. Under Dr. Trestman’s leadership, the program went from having budget and regulatory concerns to being a national leader in correctional health care.

Dr. Trestman now also serves as chair of psychiatry for the Virginia Tech Carilion School of Medicine. His research interests include mental health services and the neurobiology and treatment of people with severe mood and personality disorders.

He serves on the American Psychiatric Association Council of Psychiatry and the Law, on the Data Safety Monitoring Board of the National Institute of Mental Health, as board secretary for the Academic Consortium for Criminal Justice Health, and as chair of the Research Committee for the American Academy of Psychiatry and the Law Institute for Education and Research. He also serves on the editorial boards of two academic journals and is a referee for many others.

Dr. Trestman received his bachelor’s degree from Carnegie-Mellon University and his doctoral and medical degrees from

Dr. Trestman is interested in the treatment of people with severe mood and personality disorders. the University of Tennessee. He completed his internship and residency at Mount Sinai Medical Center in New York City, followed by training as a research psychiatrist at the Bronx Veterans Affairs Medical Center and Mount Sinai Medical Center.

noteworthy

Orthopaedic Surgeon Returns to His Athletic Past THOMAS K. MILLER, M.D., vice chair for Orthopaedic Surgery at Carilion, was named assistant medical director for the Ironman World Championships. He was also elected chair of the Ironman Global Medical Advisory Board.

Dr. Miller, who serves as chief of Sports Medicine at Carilion, participated in the Ironman World Championship in 1996.

PHOTOS: JARED LADIA (TOP LEFT AND ABOVE); DAVID HUNGATE (RIGHT)

CARILION MEDICINE | FALL 2017 47

backstory

Top 1% in the Nation.

WOMEN IN HEALTH CARE Getting a seat at the executive table often means sticking your neck out.

N A N C Y HO W E L L AG E E

M

AO’S APHORISM IS WELL KNOWN: “WOMEN

hold up half the sky.” In health care, you’d better add the sun and the moon!

Women drive the engine of health care, holding 75 percent of all health care jobs.

Yet women occupy only 26 percent of chief executive officer positions. In this, health care organizations mirror Fortune 500 companies, where women hold a similar percentage of executive and board positions.

Clearly, opportunities exist for women in leadership positions.

When I grew up, women were not expected to become executives, board members, or even physicians. My career began as a nurse at one of Carilion Clinic’s hospitals—the very same hospital in which I was born. As I moved through management, I thought hard about what kind of leader I wanted to be. And I decided that leadership works best when it flows not from the top down, but from the bottom up. It wasn’t until some years later that I learned my conviction was actually a well-established philosophy.

Robert K. Greenleaf founded the modern-day servant-leadership movement with his 1970 essay, “The Servant as Leader.”

The proof of a servant leader, Greenleaf wrote, manifests in those led: “Do those served grow as persons? Do they…become healthier, wiser, freer, more autonomous?

And, what is the effect on the least privileged in society?

Will they benefit—or at least not be further deprived?”

Servant leaders listen, assess, and identify and remove barriers so those they lead—in our case, physicians, nurses, technologists, therapists, and many others—can focus on the magical moments between caregiver and patient.

48 CARILION MEDICINE | FALL 2017

Of 4,500 hospitals evaluated by U.S. News & World Report, Carilion Clinic’s flagship facility was one of only 48 in the nation to earn top ratings in all nine surgeries and conditions. A leader in innovative, collaborative care, Carilion Roanoke Memorial Hospital works every day

It takes courage to lead. It also takes courage to innovate—to take risks without recklessness. A leader must be intentional, thoughtful, and purposeful.

Leadership is learning. It’s engaging. It’s growing yourself and growing others. It’s about putting people first. And, though it sounds corny, a servant leader leads with heart. People know when you are undisciplined, insincere, or motivated by money or advancement. Leading with heart draws on the most basic and important human values: trust, empathy, forgiveness, understanding, love.

And servant leadership is not just about the present. It’s also about the future—bringing along the next generation of leaders. Including more women in senior leadership is critical for the same reason any diversity initiative is important—hospitals and health systems are more effective when they are representative of the communities they serve. Diversity in the boardroom leads to richer conversations and better decisions.

For women to have a seat at the executive table, we need to venture out and speak up. On my desk, I keep a small brass turtle figurine. It’s my daily reminder that a turtle gets nowhere until she sticks her neck out. With commitment to diversity, development of others, and the fostering of workplace cultures that allow all to thrive, I’m confident in the future of health care in this country. CM

to advance our mission: Improve the health of the communities we serve.

Nancy Howell Agee is president and chief executive officer of Carilion Clinic and chair-elect of the American Hospital Association. Modern Healthcare has recognized her as one of the nation’s 100 Most Influential People in Healthcare for the past two years—most recently ranked at 23—as well as among the Top 25 Women in Healthcare.

ILLUSTRATION: JING JING TSONG/THEISPOT

CarilionClinic.org/toprated

CARILION CLINIC P.O. BOX 13727 ROANOKE, VA 24036-3727

NON-PROFIT ORG. U.S. POSTAGE

PAID ROANOKE, VA PERMIT NO. 247

28 | THE AFTERMATH Law-enforcement officers aren’t the only ones who witness violence; health care providers are often on the front lines as well. Carilion is helping in efforts to protect the vulnerable.

online exclusives

Class Operation Virginia Tech students have the rare opportunity to witness live surgeries.

Strong Medicine A 12-week exercise course is making all the difference for Parkinson’s patients.

Room with a View Carilion’s neuroangiography suite allows instant clinical successes.

Please visit us at CarilionClinic.org/carilionmedicine. If you would like a complimentary subscription to Carilion Medicine, please email us at CarilionMedicine@carilionclinic.org.