The study, published in BMJ Neurology Open, examined the relationship between the post-seizure episodes and longer-term mental health disorders. Using information from patients’ medical records, researchers compared the outcomes of patients who experienced temporary psychotic symptoms after a seizure with similar patients who did not.

"For years, we've known these episodes can happen after a seizure, but we didn't know what they might mean for a person's long-term mental health," said Varsha Nandwana, MD, a neurologist at Carilion Clinic and lead author of the study. “Our findings suggest they shouldn't simply be viewed as something that comes and goes. They may identify patients who would benefit from closer follow-up."

While the study did not confirm that these episodes cause mental illness, the findings show a strong link between the two conditions and could change the way doctors care for patients with epilepsy. Rather than ending treatment once the symptoms disappear, clinicians may consider monitoring patients' mental health more closely in the months and years that follow. Earlier recognition of psychiatric symptoms could lead to earlier treatment and support.

"This study reminds us that epilepsy can affect more than neurological function, it can also affect mental health. By paying attention to these warning signs, we may be able to identify patients who need additional care sooner and perhaps understand the origin of mental illness better," said Aashit Shah, MD, chief of neurology at Carilion and professor of medicine at the Virginia Tech Carilion School of Medicine, a collaborator on the study.

The study was led by Nandwana in collaboration with Shah and Anita Kablinger, MD, vice chair of research for Carilion Clinic’s Department of Psychiatry and Behavioral Medicine; Geetika Bajpai, assistant professor of neurology at the University of North Carolina at Chapel Hill; and Ching-Fang Sun, child and adolescent psychiatry fellow at the University of Washington School of Medicine and Seattle Children's Hospital.

The study was funded by the Carilion Clinic Department of Medicine.

Original study: DOI:10.1136/bmjno-2025-001473

The Tazewell practice opened to patients In June. The 12,000 square-foot building was constructed in partnership with the Tazewell Community Foundation, Tazewell County, and The Innovate Fund.

“This practice signifies improved primary care access close to home for our community,” said Grant Greenberg, M.D., senior vice president and chair of Family and Community Medicine. “What’s really exciting is the opportunity to build on existing capabilities with our teams to expand primary care offerings in an efficient, convenient way for patients.”

The practice's basic family services including acute visits, same-day access, chronic condition management, preventive and wellness services, treatment for minor injuries, pediatric and well-child visits, immunizations, and an on-site lab. The care team includes 2 doctors, 2 physician assistants, a nurse practitioner, and a registered nurse.

“Expanding access to trusted primary care experts continues to be a priority for our teams,” said Lindsay Collins, interim vice president of Family and Community Medicine. “With this project, we were able to customize a brand-new layout and flow to best meet the needs of our community. We look forward to welcoming patients onsite.”

Using MyChart, Carilion's secure online health management tool, patients can schedule upcoming in-person visits. Practice hours are Monday – Friday, 8 a.m. – 5 p.m. To learn more or to schedule an appointment, you can reach the practice at (276) 988-8850 or CarilionClinic.org.

Carilion ranks #140 on the list, which includes 58 hospitals and healthcare systems.

Fortune evaluated companies from mid-August through late December last year. Thousands of employees, management consultants, patent attorneys, recruiters and human resources experts were surveyed about how companies spark innovation through research and development, product invention, process streamlining, and collaborative and thoughtful leadership.

The ranking is based on a methodology resulting in scores in three categories: 

• Product innovation — based on analyzing the intellectual property (IP) portfolio covering a company's products and services. 
• Process innovation — reviewing a company's sourcing, production, marketing, sales and support.
• Innovation culture — with attention to how a company promotes entrepreneurship and creativity among employees and allows teams to carry out new ideas. 

The America's Most Innovative Companies 2023 list can be found here (subscription required).

A Friend for the Journey

A woman newly diagnosed with breast cancer typically has many questions, medical as well as existential. “The first question always is, ‘Am I going to die?’” says Seyi White, D.N.P., “followed by ‘I don’t know what to think or what to do.’” It’s normal to feel overwhelmed and lost if you’ve never experienced cancer before, White tells her patients. “But you have me at your side, and I’ve worked with many women with cancer that is just like yours.”

White is one of two doctorally prepared nurse practitioners who run Carilion’s Breast Cancer Survivorship Clinic. Every day, patients treated for breast cancer at Carilion come to White for the moral support, strength, and knowledge they need to prepare themselves for what lies ahead. “Wherever my patients are on their journey with breast cancer, from that devastating moment when they get their diagnosis throughout the course of their life, I will meet them there,” White says.

For cancer survivors, information is power, and White gives her patients plenty of it. Women who are diagnosed at younger ages want to know how treatment will affect their fertility and when it’s safe for them to get pregnant after treatment, so White refers them to a specialist in reproductive endocrinology. She talks to her patients about how treatment might affect their sexual health, and the importance of staying fit. “The more active people are, the more comfortable they are in their own bodies and the better they feel,” she says. “Exercise also decreases the risk of breast cancer recurrence.”

White can connect newly diagnosed patients with survivors who have already completed treatment to get first-hand information about breast reconstruction, the challenges of treatment, and what their lives will look like in years to come. Anxiety and depression is a frequent topic—along with medication, mindfulness, and deep-breathing exercises that can help. When patients ask whether their cancer will come back, White never tells them they have nothing to worry about—even if the cancer was caught early. “Because recurrence is always a possibility with breast cancer,” she says. Instead she shows patients how their risk decreases when they adhere to their treatment plan. They have a choice, she tells them: either be crippled by the fear of a recurrence, or lower the risk and continue with their lives. “There are always things you can do—exercise, choosing a healthier diet, and reducing the anxiety that increases the risk of a cancer coming back,” says White.

Close monitoring is key to survivorship. Post-treatment, White will see survivors every six months for five years, and then once a year after that. Often, she treats a host of maladies in one visit.

Recently, a patient complained of heaviness in one arm, as well as depression and menopausal symptoms related to endocrine therapy. “I referred the patient to occupational therapy for treatment of lymphedema, started her on an antidepressant to help manage menopausal symptoms, encouraged her to increase physical activity, and directed her to the Survivorship web page for access to exercise videos and psychosocial resources,” White says.

Sometimes she has to dispel misinformation— like when a survivor wanted to stop endocrine therapy because she read on the internet that it increases the risk of developing endometrial cancer (it wasn’t true for the medication she was taking). When patients miss follow-up appointments— some of them live more than four hours away from Carilion—White keeps in touch with them until they can make it in. She takes meticulous notes and listens to her patients’ concerns, always encouraging them to achieve their short- and long-term goals and aspirations.

One newly widowed survivor recently confessed to White she was afraid to drive alone for six hours to see her son and grandchildren, a visit she had looked forward to for weeks. White helped the patient come up with a plan: her daughter- in-law would fly in and the two would drive together. She even called her patient to help solve last-minute logistical challenges. “That was the most important goal that day for my patient,” White says. “So we tackled it together and made it happen.”

Better Living After Endometrial Cancer

When Shannon Armbruster, M.D., M.P.H., began her residency in obstetrics and gynecology, she was alarmed at the state of her patients’ health. “We were curing women of cancer, yet as survivors, they often struggled emotionally and physically with poor quality of life and poor health,” says Dr. Armbruster, now a board-certified gynecologic oncologist at Carilion Clinic and assistant professor at the Virginia Tech Carilion School of Medicine.

For the last 13 years, Dr. Armbruster has made it her mission to improve the quality of life for survivors of endometrial cancer, the most common gynecologic cancer. In 2019, she joined Carilion Clinic for the opportunity to build a survivorship research program for gynecologic cancers. And in May of 2022, she received a competitive career development award from the integrated Translational Research Institute of Virginia (iTHRIV) Scholar Program; it will provide training and mentoring to help translate her research into clinical care. “Ultimately,” she says, “I hope to apply what I’m learning about enhancing the lives of survivors of endometrial cancer to patients with other types of cancer at Carilion and across the country.”

One of her prime targets is obesity. People who are obese have a higher risk of developing 13 different cancers. For women, endometrial cancer tops the list. Upwards of 70 percent of women with that diagnosis are obese, and about half of U.S. endometrial cancer cases are attributed to obesity. “Fat cells make estrogen, which stimulates the lining of the uterus,” explains Dr. Armbruster. “An excess amount of estrogen causes the cells to keep replicating, which can lead to a hyperplasia, or pre-cancer, and ultimately cancer.” Although rates of other cancers have fallen over the years, the incidence of endometrial cancer has risen in lock step with the rise in obesity in the United States.

Just as it increases the risk of developing endometrial cancer, obesity can also send survivors to an early grave. “Five years after diagnosis and treatment for endometrial cancer,” says Dr. Armbruster, “women are more likely to die from cardiovascular disease related to their obesity than they are from their cancer.”

The Group Effect

Inspiring people to move is challenging— only 20 percent of the general population gets the recommended amount of exercise, and even fewer endometrial cancer survivors do. Dr. Armbruster—together with her co-investigator, Samantha Harden, Ph.D., a registered yoga teacher who is associate professor and exercise extension specialist in the Department of Human Nutrition, Foods, and Exercise at Virginia Tech—is trying out a possible solution.

The pair have devised an eight-week lifestyle intervention they hope will show endometrial cancer survivors the benefits of incorporating physical activity, along with a few fruits and veggies, into their lives. In previous research, Dr. Armbruster demonstrated that survivors of endometrial cancer who exercised had better quality of sleep and sexual health, and lowered their body mass index.

The new intervention is a specially tailored version of FitEx, a group-based online physical activity and nutritional program that is offered by health educators of USDA’s Cooperative Extension System in at least 14 states. After conducting surveys and focus groups with Carilion patients, Dr. Armbruster felt confident that FitEx, customized with content relevant to endometrial cancer survivors, would be an excellent intervention to pilot-test. “We found that our survivors did not want a weight-loss intervention,” she says, “but they did want to focus on their health. And they wanted to connect with other survivors, but not in a face-to-face group.”

Dr. Armbruster and Dr. Harden recently wrapped up a proof-of-concept study on their FitEx version, which they call FitEx-ECS (for “endometrial cancer survivor”). They enrolled six survivors and fourteen family members and friends, who were the survivors’ supporters and participated in FitEx activities with them.

Teams racked up a credit of one mile for each 15 minutes of their chosen activity. Participants also tried to eat five servings of fruits and vegetables per day. The intervention included a weekly 30-minute virtual group session for participants to talk about a topic related to cancer and do yoga or exercise together.

“We know from behavioral science studies that people who do things in a group are more successful at that activity,” says Dr. Armbruster. “This is a personalized intervention that allows survivors to choose their support group and what exercises they will do, and it avoids the negative connotation of exercising solely to lose weight.”

By Anita Slomski

For more information on Carilion clinical trials, click here. 

Anita Haymaker had already been through a lot. Several years ago, although she felt generally healthy, “I was breaking out all over,” she says. So she saw her doctor, who ordered tests that led to her first cancer diagnosis: a neuroendocrine tumor in her pancreas.

Haymaker had surgery to remove the tumor, but two years later the cancer returned, this time in her liver. She had another operation and, when the cancer came back again, she had a hysterectomy. “After that, my doctors said they didn’t think I was a candidate for any more surgery,” says Haymaker, who lives with her husband, Kenny, on Smith Mountain Lake, southeast of Roanoke.

But doctors found more cancer in Haymaker’s pancreas and liver, and she began receiving chemotherapy at Blue Ridge Cancer Care. That’s when her doctor suggested she see David Buck, M.D., president of Blue Ridge Cancer Care and medical director of Radiation Oncology at Carilion Clinic’s Cancer Center.

Dr. Buck also serves as chair of Carilion’s oncology committee and head of radiation research for the U.S. Oncology Network, of which Blue Ridge Cancer Care is a part. He was recruiting patients for a trial of a radioactive compound called lutetium dotatate.

In Haymaker’s meeting with Dr. Buck, he explained that this new treatment was being tested in patients whose tumors were no longer responding to other therapies. If she chose to participate in the trial, she would receive multiple treatments, spaced about six weeks apart. Although the infusion of the radioactive compound itself would take only half an hour or so, she would also receive intravenous amino acids before and after to help protect her kidneys, so she should expect to be at the clinic for most of the day for each treatment.

“He told me they would bring the drug in a little metal box because it was nuclear,” she remembers. She found that a little disconcerting, like something out of a science fiction movie. But with the effectiveness of other treatments fading fast, she felt she had little choice but to give this experimental therapy a try. “Sign me up,” she told Dr. Buck.

A Better Way to Target Cancer

Lutetium dotatate, now marketed under the name Lutathera, is one of several injectable radiation therapies now being tested or already in use. This form of precision medicine goes by a catchy name—theranostics—because it uses radioactive isotopes for both diagnostics and therapy. The special compounds are used to locate tumor cells and then to destroy them.

“Employing radioactive therapies against cancer isn’t new,” says Dr. Buck. “What has changed is the degree to which they can be precisely targeted to attack tumor cells while sparing healthy cells.”

Historically, Dr. Buck adds, the trouble has been that these treatments weren’t specific enough. “The hallmark of all of these therapies is that they emit very high energy radiation that extends over only a very short distance,” he says. “That’s perfect for going after cancer cells, but only if you can
direct them to exactly the right places, where the tumors are.”

What you need to find, says Dr. Buck, is a kind of cellular receptor that exists only on tumor cells. The next challenge is to identify an imaging agent that can zero in on that particular receptor. In the case of carcinoid tumors, a kind of neuroendocrine tumor, that imaging agent is a radioactive compound known as gallium dotatate. After being injected, it seeks out and attaches itself to carcinoid tumor cells. Then, a positron emission tomography (PET) scan can show exactly where in the body the tumor cells are and how extensively the cancer may have spread.

That’s the diagnostic part, says Jackson Kiser, M.D., chief of molecular imaging in Carilion’s Department of Radiology. The big recent advances in nuclear medicine therapy came when researchers realized they could pair the precision of an imaging isotope such as gallium dotatate with other types of radioactive materials that can be used to destroy tumor cells, Dr. Kiser says.

That second kind of material includes alpha and beta emitters that can get into the machinery of cancer cells and disrupt their DNA, according to Dr. Kiser.

“Alpha emitters cause double-strand DNA breaks, destroying the DNA,” he says. “We don’t have many alpha-emitting therapeutics, but we have several kinds of beta emitters, which cause single-strand DNA breaks that destroy a cell’s DNA production. In both cases, they can render a tumor unable to replicate itself.”

To develop Lutathera, scientists removed the gallium in gallium dotatate and replaced it with lutetium, creating lutetium dotatate. “That pairing, of gallium dotatate and lutetium dotatate,” says Dr. Kiser, “was the breakthrough that made theranostics possible.”

Improvements in Quality of Life

Carcinoid tumors are rare, affecting only about 8,000 people a year in the United States, and they grow very slowly. That makes them a poor match for standard chemotherapy and radiation, which home in on cells that are dividing quickly. But carcinoid tumor cells do have a unique receptor, which can be targeted with a drug called octreotide. Even then, however, the effects tend to decrease over time.

In an important clinical trial, Lutathera was tested against an increased dose of octreotide to determine which did a better job of controlling patients’ carcinoid tumors. After two and a half years, octreotide was still working for only one in 10 patients. But the tumors of two-thirds of the patients who received Lutathera continued to be controlled after the same amount of time.

“It was a dramatically positive study,” says Dr. Buck. “And it got people excited about the possibilities for this kind of therapy.”

Now, although anyone with a carcinoid tumor will still be treated with octreotide initially, “the minute they progress, they now go on Lutathera,” says Dr. Buck.

Dr. Kiser notes that for many patients with these tumors, any relief is welcome. “Often, they’re just miserable,” he says. “Many have severe, almost constant diarrhea.” There’s a kind of preclinical trial called an expanded use protocol, also known as “compassionate use,” and when it was announced that Carilion, under that protocol, was going to be able to provide lutetium dotatate to a handful of patients, Dr. Kiser started hearing from people all over the country who were desperate to participate.

“I had to tell them we could only enroll six patients,” he says. “We had to see whether this thing would work.” But once Lutathera was approved, Carilion could treat anyone for whom it was an appropriate therapy. “We were among the first in the country to offer this,” says Dr. Kiser.

For most patients, Lutathera isn’t a cure, but it has extended patients’ lives and made them much more comfortable. “In the trials that were done in Europe, before this treatment came to the United States,” Dr. Kiser says, “patients were having up to five years of progression-free survival. That basically means that although the cancer is still there, you’ve rendered it unable to grow or spread. And for cancer, adding five years of progression-free survival is a home run.”

New Hope for Prostate Cancer

Now the search is on for other receptors that exist only on a particular kind of tumor cell, and not also on cells in healthy tissue. And one of the most exciting of those involves prostate cancer, the second-leading killer (after lung cancer) of men who die from cancer. In 2020, nearly 250,000 men in the United States were diagnosed with prostate cancer, and about 34,000 died from the disease.

The FDA recently approved two PET imaging drugs for men with prostate cancer that bind to something called prostate-specific membrane antigen, or PSMA. Because most prostate cancer cells seem to have elevated levels of the antigen, PSMA has emerged as an important target for prostate cancer imaging. That’s beneficial for diagnostic purposes, helping physicians see where a man’s cancer is and how far it has spread.

“Fortunately, we can approach this in the same way we go after neuroendocrine cancers,” says Dr. Kiser. “Once you’ve identified the extent of disease using a radiolabeled PSMA agent, you can take the diagnostic isotope off and put lutetium on.” That produces a therapeutic agent, lutetium-PSMA, that can seek out and destroy the cancer cells.

In June, results from a clinical trial of that compound in men who had exhausted other treatment options showed a six-month improvement in impeding the proliferation of cancer cells and a four-month improvement in survival.

“Those are significant gains in patients who had already failed hormone therapy and chemotherapy,” says Dr. Buck. But what if the theranostic agent were given earlier, in combination with—or even instead of—other therapies?

“Now they’re beginning to test when the best time is for this treatment,” says Dr. Buck. “Should we do it right after someone has failed hormone therapy? Should we do it when someone walks in the door with a prostate cancer diagnosis?”

Two large U.S. clinical trials are now examining the questions of when and how to use the PSMA theranostics approach.

What’s Next for Theranostics?

Dr. Kiser is extremely optimistic about what the future holds for theranostics. “This is simply one of the most exciting things to happen in cancer therapy,” he says. “The list of what can be treated is almost endless.”

Beyond neuroendocrine and carcinoid tumors and prostate cancer, that list includes lymphoma, meningioma, thyroid cancer, glioblastoma, and other malignancies.

“Breast cancer is one particularly promising frontier,” Dr. Kiser says, “as there can be three types of receptors, and some breast cancers have all three.” Those include receptors for estrogen and progesterone as well as for a growth factor called HER2.

There’s already an imaging agent that can help locate the estrogen receptor, and although it doesn’t yet have an associated therapeutic that could kill targeted tumor cells, Dr. Kiser and his team at Carilion have applied for intellectual property protection for such a compound that they hope to develop with a private company.

“What’s exciting is that you don’t have estrogen receptors just in breast cancer,” he says. “They’re also found in several other types of cancer. And you can target the progesterone receptor, and there’s a therapy, Herceptin, that targets the HER2 receptor. Think of the wallop you could pack with all of those therapies. You could really blow up the cancer.”

If a cancer has a specific receptor or a metabolic pathway associated with it, and if there’s an imaging agent that can target that receptor or pathway, “then you should be able to put something therapeutic, an alpha or beta emitter, on that agent,” Dr. Kiser says. “I call this designer therapy, because it’s specific to the patient. One patient with lung cancer might have one kind of receptor and another patient may have a different one. This way, you can give each of them the right therapy.”

Another fascinating possibility involves a diagnostic agent called fibroblast activation protein inhibitor, or FAPI. “Most kinds of cancer make a type 2 fibroblast; it’s something only cancers can produce,” says Dr. Kiser. “You can image the fibroblast with FAPI and basically see the extent of the disease. That gives you another way to image and potentially treat many kinds of cancer.”

There are potential risks involved with theranostics that need to be acknowledged or overcome, Dr. Kiser says. “Even when it’s targeted, radiation can cause collateral damage,” he says. “There can be bone marrow damage, particularly if you’re treating myeloma, which likes to live in the bone marrow.”

The radiation targeted to that tumor could harm the bone marrow, leading to a low count of white bloods cells or platelets. Radiation could also stay in the bloodstream and damage the kidneys as it makes its way into the urine and out of the body. But bone marrow tends to repair itself, and that’s why patients receive those infusions of amino acids, to protect the kidneys.

There’s also a problem of getting radioactive agents from the reactors or cyclotrons where they’re produced to the hospitals or clinics where they’re administered to patients. These are short-lived compounds, and time is of the essence in theranostics.

Yet there are few significant impediments to the kind of future for theranostics that Dr. Kiser and many others have described. And Carilion Clinic and Blue Ridge Cancer Care, pioneers in this approach to treating cancer, expect to be at the center of those advances. Additional research collaborations offer the opportunity for other radiotracers and radiotherapeutics to be developed in the Roanoke region, and Carilion is building new infusion centers and reaching out to global partners.

“We want to be one of the superior sites in the country for these therapies,” Dr. Kiser says.

Enjoying Life with the Grandkids

Anita Haymaker’s treatment with Lutathera has exceeded almost everyone’s expectations. “I can’t say that I’m cured,” she says. But four years after she first spoke with Dr. Buck, her cancer is almost completely gone, and so far, her periodic scans have shown no progression.

Haymaker, now 76, spent part of this past summer with her grandchildren. “We live at the lake,” she says, “and they go in and out of the water the entire time.”

By David Bumke

BACK IN THE SADDLE:  Randy Ayers' goal was to ride her horse without supplemental oxygen. That goal became a reality when she received her endobronchial valve.

Four years ago, Randy Ayers of rural Goodview, Virginia, did something many lifelong smokers find impossible: She quit. Yet that victory gave her scant comfort. By then she was already suffering from emphysema, a condition that falls under the umbrella of chronic obstructive pulmonary disease (COPD).

Although only in her 60s, Ayers had trouble walking distances, and even taking a shower had become a terrifying ordeal.

“You lose your breath, and it’s very scary,” she says. But the worst part for Ayers, an avid equestrienne, was no longer being able to ride her beloved gelding, Waylon, whom she’s owned for 25 of his 30 years.

Even with oxygen at her side, Ayers says, “I would go to the barn to brush him for a few minutes and then I’d get winded. That’s all I could do. It was too hard to ride.”

She adds, simply: “I quit smoking too late.”

Then, in 2019, Ayers made an appointment with Maria del Mar Cirino-Marcano, M.D., a pulmonary specialist at Carilion Clinic. Dr. Cirino-Marcano told Ayers about an endobronchial valve, a device that can help some people with COPD, and she wondered whether her patient might be a candidate for it.

“When I interview patients to see whether they qualify for the valve, I ask them what their plans are,” says Dr. Cirino-Marcano. “And Randy was clear about what she wanted. ‘I want to ride my horse,’ she told me, ‘and if I can do it without supplemental oxygen, even better.’”

A Better Quality of Life

Endobronchial valves are small, specialized devices that are implanted in the lungs to close off airways leading to diseased areas and to allow greater airflow to healthier areas. With the lungs not working as hard to deliver oxygen, patients often find they can breathe easier and resume routine activities with less shortness of breath, says Edmundo R. Rubio, M.D., chief of Pulmonary and Critical Care Medicine at Carilion.

The valves don’t cure COPD; so far, cures for the chronic condition are elusive. What they do offer, says Dr. Rubio, is the potential for a better quality of life.

“If you can breathe easier, you have more stamina,” Dr. Rubio says. “As activity increases, patients may feel more energetic. They’re better able to eat, and they sometimes feel less depressed. One thing leads to another.”

After months of delay because of the COVID-19 pandemic, Carilion launched an endobronchial valve program in the summer of 2020, with Ayers among the first of a handful of recipients. Nationally, studies are still underway to determine more precisely their long-term effectiveness. Yet the results so far are encouraging—and for people like Ayers, relief can’t come fast enough.

The region Carilion serves has an unfortunate abundance of patients with COPD. This is tobacco country, and southwestern Virginia has the state’s highest rate of smoking—18.1 percent of residents, compared with just 7.7 percent in Northern Virginia.

“It’s a prevalent condition” says Dr. Cirino-Marcano, “and in any pulmonary clinic, people with COPD make up the bulk of the patient population.”

The Perfect Candidate

Endobronchial valves aren’t right for every patient with COPD, according to Dr. Rubio. “Candidates include those with some mobility who have had a significant impact on their daily activities,” he says. “You want someone who can walk in the range of 100 to 500 meters. Those unable to walk 100 meters may not be able to tolerate the procedure, while someone who can walk, say, 1,000 meters or more without severe discomfort may not need it.”

Although Ayers could still walk short distances, decades of smoking had damaged her lungs. Over the years, smoking can destroy the lung’s alveoli, which are responsible for exchanging oxygen and carbon dioxide. Smoking can also cause the narrowing and scarring of airways, known as remodeling, and it can enlarge the lungs, a condition known as hyperinflation.

“With hyperinflation, some parts of the lung get destroyed,” says Dr. Cirino-Marcano. “The lungs become like stretched-out balloons. They get really, really big.”

When inhalations introduce a large volume of air into the lungs, the recoil of that “balloon” is insufficient to expel all of the air. “That’s part of the reason for shortness of breath,” says Dr. Cirino-Marcano. “The lungs are so big they’ve stretched the muscles that help us breathe, and those respiratory muscles don’t work well anymore.”

For more than a century, physicians have been searching for a safe, effective way to reduce the size of the hyperinflated lungs of COPD patients. In some cases, surgery is the answer. “With the perfect candidate, surgery can be very beneficial,” Dr. Cirino-Marcano says. But surgery can have significant complications, she adds, and it’s helpful if only the upper parts of the lungs are affected. For a much greater number of patients, endobronchial valves inserted into the lungs can be an effective alternative.

The Procedure

During an evaluation before the procedure, a CT scan is used to assess damage to the lungs. Then, with the patient under anesthesia, pulmonologists advance a balloon that allows them to block an airway, essentially simulating what would happen if they were to put the valve there. They need to make sure the damaged part of the lung will deflate.

If that test succeeds, the balloon is removed and an endobronchial valve is inserted in its place in a minimally invasive, nonsurgical procedure using a flexible bronchoscope. The valve is designed to let air escape from the damaged area, but not enter. If the airway is too large, doctors may instead place multiple valves on smaller airways feeding that section. The procedure typically takes 20 minutes to an hour.

Recovery time for most patients is minimal; they awaken within two hours and are quickly able to eat, get out of bed, and walk. Most remain in the hospital several days for observation, however, to ensure no new air leaks have developed.

Breathing Freely

After the procedure, improvement comes gradually. Immediately afterward, patients may even see their symptoms worsen.

“By around the third day, most people are back to where they were, and after about a few weeks, they’ll tell me they’re able to take a deeper breath than before,” says Dr. Cirino-Marcano. “Then, every time I talk to them, there will be something else they can do. They may say, ‘Now I’m able to talk longer without getting out of breath.’ And the next time, that shower that used to take an hour may take 20 minutes. One patient was excited because she could get into her neighbor’s pool for the first time in years. Another, who works in a supermarket, was thrilled to be able to walk up and down the aisles without feeling short of breath.”

Ayers experienced steady improvement following her procedure in September 2020. Although she still gets winded with exertion and keeps her oxygen nearby, she has been able to resume activities that once seemed impossible. “Taking a shower is a lot easier,” she says. She can slowly climb stairs, and she even bought a treadmill and a stationary bicycle.

A moment of truth came when she went to lead Waylon around the arena for the first time in ages, wondering whether he would still “follow me around like a puppy,” with no lead line, as he had always done in the past. To her immense gratification, he stayed behind her step for step. And that made everything worthwhile.

Well-Tested in Europe

The first endobronchial valve—the Zephyr Valve, now manufactured by Pulmonx—was approved by the U.S. Food and Drug Administration in 2018. But it has been around for much longer.

Dr. Cirino-Marcano was involved in the first U.S. trial when she was a fellow at the Tulane University School of Medicine in 2005, and the valve has been available in Europe for almost 20 years. In the United States, doctors have used the valve to alleviate other conditions—such as bronchopleural fistulas, a serious condition often associated with lung cancer surgery—for years.

That long experience, involving thousands of patients, has been reassuring. “They have good safety data,” says Dr. Cirino-Marcano.

For the COPD treatment to succeed, patients will typically receive three to five valves. Although the valves can be quickly and easily removed if a problem arises, most patients do well with them. As long as the valves are helping, they can stay in place for the rest of the patient’s life.

A Range of Possible Solutions

Dr. Cirino-Marcano says that most patients with COPD tend to end up with a variation on the same treatment. Typically they’re given an inhaler with either a bronchodilator or a steroid, and they may also be given oxygen.

“One thing the endobronchial valve procedure has taught us is that not all patients with COPD are the same,” she says. “Although the valves can help a large swath of patients, they aren’t for everyone.”

Other patients need other solutions. “In the workup for this procedure, we look at other factors associated with COPD,” Dr. Cirino-Marcano says. Carilion runs a pulmonary hypertension clinic that identifies the causes of the disease and the best therapies for each patient. Some patients may be referred for possible surgery or even a lung transplant.

Triumphant Outcome

At Carilion and across the United States, endobronchial valves are still in their infancy as a treatment for COPD. As Dr. Rubio notes, more time and more procedures will be needed to get firmer numbers on the percentage of patients who experience improved breathing, and whether the valves truly enable better oxygenation in the lungs, thus freeing more people from oxygen machines.

Yet for Ayers, who recently turned 70, the evidence is already in. Although she knows her condition has no cure, she’s enjoying rides with Waylon. She felt confident enough to enter a local horse show recently—and together they took first prize.

Written by Marcia Lerner

Brain Injuries Decoded

Several million new mild traumatic brain injuries occur each year in the United States, mostly because of falls, auto accidents, and sporting mishaps. Many patients with the condition will heal quickly, but others may develop prolonged and disabling physical and emotional symptoms. Patients at risk for more serious effects from their injury must be identified quickly, to ensure the best outcome possible.

In 2018, an interdisciplinary team joined to create BRAINBox, a handheld device that enables a blood-based test to be administered directly at the point of care, providing rapid results. The test also aims to provide short- and long-term prognoses, including identifying early those at risk for prolonged or severe effects from their injury.

Timeline

November 2012

The Richmond, Virginia–based diagnostics firm ImmunArray licenses a panel of brain injury markers developed by Johns Hopkins University researchers Jennifer Van Eyk (now at Cedars-Sinai Medical Center) and Allen Everett.

January 2014

ImmunArray receives a $300,000 grant from the GE NFL Head Health Challenge to further develop the Johns Hopkins panel of brain injury markers.

December 2018

ImmunArray spins off a new company, BRAINBox Solutions, Inc., to commercialize tests for diagnosing and monitoring mild traumatic brain injury.

Virginia Catalyst awards a $500,000 competitive grant to a collaborative bioscience commercialization project including a team from the Virginia Tech Carilion Research Institute (now the Fralin Biomedical Research Institute at VTC), the University of Virginia, Carilion Clinic, and BRAINBox Solutions.

June 2019

The U.S. Food and Drug Administration grants BRAINBox Solutions a breakthrough designation for it first-of-kind device to aid in the diagnosis and prognosis of concussions. Virginia Tech, with the Fralin Biomedical Research Institute and its clinical partner, Carilion Clinic, serves as one of the national anchor research and clinical sites to validate the test. Faculty members with the University of Virginia Health System perform parallel diagnostic blood tests, neuroimaging, and neuropsychological studies.                           

September 2019

The U.S. Patent and Trademark Office expands BRAINBox Solutions’ patent on its multi-modality approach by adding a portfolio of biomarkers that have characteristics for diagnostics, such as robust levels in concussion and mild traumatic brain injury, extended kinetic profiles after injury, and a strong correlation to subtle microvascular injuries that are more difficult to assess. The biomarkers are novel astrocyte-injury–defined biomarkers, including Aldolase C or a trauma-specific breakdown product of Aldolase C.

How Brainbox Works

A core component of the BRAINBox system is a blood-based biomarker test that can be administered in an emergency department, an urgent care center, a clinic, or even eventually a sports field to provide a rapid-result assessment of a mild traumatic brain injury and a prognostic view of a patient’s likelihood of post-concussive symptoms.

The system uses a multianalyte immunoassay to identify specific proteins that have leaked from injury-damaged cells in the brain. The patient’s blood sample is placed on a small cartridge, which is inserted into a handheld device that can rapidly measure molecules and identify the proteins that have been released.

The panel of biomarkers is then paired with a functional assessment on a tablet. The functional component stems from validated neuropsychiatric testing and cognitive assessments delivered through an artificial intelligence–driven algorithm.

The BRAINBox system integrates the biomarker data and the neurocognitive assessment to produce a single simple and easy-to-understand score. The integrated score appears within a half hour.

Clinicians can also conduct balance and coordination assessments to complement that score for a more complete diagnosis and prognosis.

BRAINBox’s Principal Collaborators

Stephen LaConte, Ph.D.

Associate Professor, Fralin Biomedical Research Institute at VTC

“One of BRAINBox’s goals is to go beyond diagnosing mild traumatic brain injuries and provide prognoses. We want to predict short- and long-term outcomes, including identifying those at risk early for prolonged or severe effects from their injury.”

Damon Kuehl, M.D.

Vice Chair of Emergency Medicine, Carilion Clinic

“These injuries are some of the most challenging to diagnose. Other than using a CT scan to look for bleeding and doing a basic assessment of ability to function when the patient presents, we still don’t have really good diagnostic tools to find out which patients will do poorly and which will be fine.”

Donna Edmonds

Chief Executive Officer, BRAINBox Solutions, Inc.

“This is a game changer. The brain is extremely complex, and to understand what is going on during a head injury requires a multi-biomarker, multi-modality approach.”

Michael Friedlander, Ph.D.

Executive Director, Fralin Biomedical Research Institute at VTC

“This research represents a collaboration of creative scientists and physicians who are committed to the power of large-scale, rigorous scientific testing to advance the diagnosis of mild traumatic brain injury.”

John Tuttle, M.D., didn’t intend to transform orthopaedic surgery.

The sports medicine physician was simply trying to solve a niggling problem he often encountered in practice: fixing soft tissue to bone when repairing an injury. While it’s a common procedure for those in orthopaedics and sports medicine, the technique can be challenging, and success depends on a variety of factors. “I knew there had to be a better way to do it,” he says.

Now, thanks to an inspired collaboration with Prachi Joshi, who leads invention development with a background in biomedical engineering, and the rest of the team at Carilion Clinic Innovation, Dr. Tuttle is moving a surgical “what if” closer to a game-changing reality. Known as the soft-tissue fixation button, the invention, says Joshi, “is different from anything else that’s currently out there.”

Identifying a Surgical Challenge

Dr. Tuttle has spent his career helping injured athletes—from weekend warriors to professionals—get back in the game.

A childhood love of basketball, baseball, and football while growing up in Ohio eventually led him to a fellowship in sports medicine at Northwestern University, where he helped provide care to players on teams such as the Chicago Cubs, Bears, and Blackhawks. Since joining Carilion Clinic in 2017, he’s worked with some local teams, including those from the Virginia Military Institute, Southern Virginia University, and Washington and Lee University.

“I’ve always felt really at home on the sidelines and in the locker room,” he says. “I enjoy working with this patient population because they’re so motivated to get back to a high level of functioning.”

In treating athletes, Dr. Tuttle has become intimately familiar with sports injuries and their repair. One such repair involves reattaching tendon to bone following a tear. This can occur with the biceps tendon, particularly the long head of the biceps tendon, which connects the biceps muscle to the shoulder socket. Unexpected force—falling on an outstretched arm or lifting a heavy weight, for instance—can damage the tendon, as can repetitive motions and long-term overuse.

Minor tears don’t always need treatment, but people who especially depend on the strength and function of their biceps tendons, such as athletes and manual laborers, often require surgical intervention.

These days, surgeons usually repair such ruptures and tears arthroscopically; both physicians and patients tend to prefer this minimally invasive approach. The challenge, says Dr. Tuttle, comes in successfully fastening the tendon to the bone. When repairing a long head of the biceps tendon, the tendon can either be cut and released or, preferably, cut and then attached to the humerus bone in the upper arm.

The problem: “Each patient has a natural tension relationship between the tendon and bone,” says Dr. Tuttle. “It can be difficult to determine how much tendon to cut so we can reestablish and maintain that tension once the tendon is reattached.”

Dr. Tuttle knew what he and his colleagues wanted: a way to fix the tendon to the bone before they cut it. But creating that solution would take more than just wishful thinking. There was much to consider.

“It would mean coming up with something that offered secure fixation, minimized the amount of tendon to be removed, maintained the force coupling of tendon to bone, was reliable, and—most important—was achievable technically,” he says. “I kept thinking about it, going through many trial-and-error scenarios in my head.”

Then, just a few years ago, the solution began to crystallize when a new knotless anchor hit the market. This innovative surgical device allows physicians to drill into bone, attach a suture, and lasso soft tissues to the area without tying knots.

“I had a lightbulb moment,” Dr. Tuttle says. “It occurred to me I could use this anchor as a springboard for a new type of soft-tissue fixation. My wheels started turning.”

Back-of-the-Napkin Idea

Around the same time, Joshi was transitioning from the National Institutes of Health’s Pitt Clinical and Translational Science Institute to a new role as innovation manager at Carilion Clinic Innovation. Under the leadership of Troy Keyser, she manages the department’s proof-of-concept program, guiding early- to mid-stage innovation projects from ideation to possible commercialization—all with the ultimate goal of improving patient care.

For Dr. Tuttle, it was perfect timing. He had finally devised what he thought was a viable solution to the challenges of tendon repair: a button that could be secured to the new knotless anchor. As with a button on a shirt, this approach would allow surgeons to affix soft tissue onto bone, where, over time, that tissue would eventually establish itself. “It was one of those back-of-the-napkin ideas,” he says, referencing the classic brainstorm sketched roughly onto a cocktail napkin.

“I’m not sure if we even had a sketch when we started,” Joshi says. “But Dr. Tuttle had an idea, and the way he was able to articulate that idea and its potential clinical impact really drew us in.” Intrigued, she and the team told Dr. Tuttle they were on board.

What happened next was the ultimate collaboration between the fields of medicine, engineering, and design. Working with one of the team’s engineers, Dr. Tuttle refined his idea based on computer-aided design models, which were 3D-printed as prototypes in Carilion Clinic Innovation’s makerspace, tested, and refined yet again—a process that took about eight months. Now, working with a final prototype, 
Dr. Tuttle has begun testing both the button and the procedure itself.

“We believe that it’s an easier, faster, and more reliable approach to soft- tissue fixation,” he says. “But the biggest question remains: How strong is that fixation?”

To learn more, Kendall Carter, a student at the Virginia Tech Carilion School of Medicine, is leading a project that compares Dr. Tuttle’s prototype to a commercially available button and explores alternative techniques that test the approach from a biomechanical standpoint. Together, they are conducting in-vitro testing in tissue-based models to determine the clinical relevancy and biomechanical properties of the latest prototype.

Austin Petty, an undergraduate at the Virginia Tech College of Engineering, and his mentor, Vincent Wang, Ph.D., an associate professor of biomedical engineering and mechanics, will analyze the study samples using a biomedical apparatus they’ve designed. They expect to have preliminary results later this year.

A Dream Almost Realized

Meanwhile, Dr. Tuttle has filed a patent for his innovation. The goal, he says, is to get a working product on the market that expands surgical options and provides physicians with a new way to help patients. “I’ve never tried anything like this before,” he admits. “I have many ideas and ‘wouldn’t it be nice’ notions, but now this is more than just a whimsical thought. It’s starting to become a concrete product and a real option.”

It’s a dream almost realized—and one
he believes wouldn’t be possible without Joshi and Carilion Clinic Innovation.

“I don’t have the time, resources, or expertise to create something like this on my own,” says Dr. Tuttle, who joined Carilion because he wanted the opportunity to teach, conduct research, and explore innovation in addition to providing patient care. “Prachi and her team have been ready to help me every step of the way, and that’s allowed me to focus on my clinical practice while really getting this innovation moving.”

For Joshi, it’s a prime example of why she, too, landed at Carilion. “Our vision is to help develop inventions that have a real clinical impact and that can be realized broadly through commercialization,” she says. “We provide the resources and give inventors everything they need to create and play.
Dr. Tuttle is the clinical expert. My job is to enable him to do what he loves.”

And Dr. Tuttle has no plans of stopping. Although it’s too early to share the details, he’s working with Joshi and Carilion Clinic Innovation on several other projects, too—all stemming from the challenges and questions that occur during clinical care.

“My patients inspire me to keep searching for new answers to issues that arise,” he says. “I’m full of ideas for the future.” 

Written by Jessica Cerretani 

The Information Age has been all about connectivity. The boom in transformational technologies—particularly from the world of computing—has allowed people to access and transmit information and communicate with others around the world with unprecedented ease.

At Carilion Clinic, the obsession with connectivity has become embedded in its philosophy on innovation. Whether it’s developing groundbreaking technologies that take advantage of connectivity to provide better care for patients, or putting researchers and clinicians in touch with the right business partners to bring new ideas and products to market, making connections is central to the process.

Perhaps nowhere is this spirit more evident than in Carilion’s recent partnership-building efforts—particularly its growing maturity in working with startups. Carilion has been keen to take advantage of this open, increasingly connected environment to find new opportunities to collaborate.

As Troy Keyser, director of Carilion Clinic Innovation, explains: “Our mission is to look at our research and operations, to see what we’re doing versus what nirvana might look like, then look across the marketplace to identify where we might be able to fill the gaps. We want to facilitate the development of solutions that can help not only our patients, but potentially patients across the country, if not the globe.”

On-Site Navigation

Carilion has bolstered and formalized its innovation efforts over the past decade to keep pace with and take advantage of technological advances, leading to the creation of Carilion Clinic Innovation.

“The R&D portfolio had grown, so there was a natural offshoot of translatable research that had the potential to have patient impact,” Keyser explains. “We needed to be able to bring those innovations to market more effectively so patients could benefit from our research.”

That effort is far from a solitary one. Carilion has benefited from a rich biomedical ecosystem that, along with enabling technology, has made it easier to connect, collaborate, and identify new opportunities. Significantly, Carilion’s affiliations with academic institutions such as Virginia Tech provide a pipeline of new scientific research and ideas ready to be tested in the clinic, as well as connections to entrepreneurial alumni and not an insignificant amount of funding.

Moreover, the extended network of hospitals within the Carilion system makes it easier to bring medical specialists together to collaborate and bring forward innovations of their own, along with the resources and opportunity to partner with patients to conduct proper testing of new treatments and processes.

In the arena of partnerships specifically, Middleland Capital’s VTC Ventures and the LINK + LICENSE + LAUNCH program at Virginia Tech have proven to be essential, like-minded partners. VTC Ventures, under the management of James Ramey, J.D., helps identify external partnership opportunities for Carilion Clinic Innovation and others, and provides seed investment in potential new technologies. Meanwhile, LINK + LICENSE + LAUNCH—a unique program at Virginia Tech that combines the patent and licensing services of a traditional tech transfer office with the external networking expertise of a strategic partnership office—connects university researchers with appropriate partners for development.

“Sometimes people think of Virginia Tech principally as an engineering school, but life sciences–related discoveries represent a significant and important part of our asset portfolio,” says Brandy Salmon, M.B.A., Ph.D., who leads LINK + LICENSE + LAUNCH as the university’s associate vice president of innovation and partnerships. “The health sector constitutes 20 percent of the nation’s economy and, of course, carries significant human and economic impact. Faculty and researchers across multiple colleges, institutes, and units at Virginia Tech are making discoveries and developing technologies with applications to the health sector. It’s exciting to think about the potential these discoveries could offer if they were translated to the marketplace.”

With the possibilities for investment continuing to grow across biomedicine, there needs to be a way to prioritize projects. For Carilion, that involves keeping patients top-of-mind.

 “First and foremost,” Keyser says, “the question we always ask ourselves is: Will this innovation help our patients or help our providers care for our patients?”

The benefits Carilion Clinic Innovation looks for include improved diagnostics and treatments, as well as a better patient experience from appointment scheduling, through office visits and follow-up. But benefits may also extend into patients’ communities.

“Part of Virginia Tech’s mission—as well as Carilion’s—is to promote economic prosperity and improve the human condition,” says
Dr. Salmon. “One way to do that is to create economic development opportunities, such as startups, that can scale, become regional employers, and create jobs. Carilion has done that in magical ways in the region, and we are looking forward to building on the momentum of both organizations to create ‘the next.’”

Running Diagnostics

To benefit the community, potential Carilion partners need to have a regional tie—an existing footprint in the Roanoke or Blacksburg area, for instance, or a willingness to bring part of their operation to the area. That can include opening a development office in the region, or working with Carilion-affiliated investigators to develop a product or run clinical trials.

Sometimes, the potential partners are connected by school ties.

Ontera was co-founded by a Virginia Tech alumnus, William Dunbar, Ph.D. In their roles connecting people and ideas, members of the LINK team helped Dr. Dunbar and his colleagues engage with a range of potential partners and collaborators. Ramey at VTC Ventures, for example, ultimately connected Ontera with Ralph Whatley, M.D., a pulmonologist who serves on the scientific advisory board for Carilion’s venture funds.

The funds took an interest in Ontera, and Carilion is now set to embark on clinical trials of a fast and easy-to-use diagnostic system Ontera is developing for COVID-19. It’s a novel use of Ontera’s existing system, which uses nanopore technology to detect the presence of a specified pathogen. The system consists of a cassette containing a special molecule designed to latch onto part of a pathogen of interest. A biological sample—the contents of a nasal swab, for instance—is put into the cassette, which is then inserted into a small, easily transportable machine. If the pathogen is present, it triggers a chemical reaction and an electrical signal that sets off the nanopore sensor.

The machine detects minuscule concentrations of a given pathogen, so a surface-level nasal swab should theoretically be enough to accurately detect the virus that causes COVID-19. The challenge lies in creating the right molecule to bind to the virus and trigger the sensor. Ontera developers believe they’ve done that hard work and now, with the help of Carilion, they’re set to test it in the clinic, where they will compare the accuracy of their diagnostic system head-to-head with that of the PCR-based tests that are the current gold standard.

If successful, this faster, simpler test could be a game-changer for patients. Results return in under 20 minutes, and the machines are easy to set up and use virtually anywhere.

“This could be deployed rapidly and used by almost anyone, so long as they’re trained to take a nasal swab and run the device. It’s not sent out to a lab,” Dr. Whatley explains. “From a Carilion perspective, that means it could be quickly and widely distributed to the more than 200 practice sites in our system—even in the most remote, mountainous, and rural parts of Virginia.”

And the utility of the device could extend beyond COVID-19. In fact, Dr. Whatley says, the technology first appealed to him because of its potential to detect other diseases—respiratory illnesses such as tuberculosis, for instance, or sexually transmitted infections.

“Ontera has already done proof-of-concept studies for other infectious diseases. COVID is certainly timely, but I might be more interested in the technology for other reasons,” Dr. Whatley says, noting that COVID-19 might be less of a concern by the time the study concludes.

Bringing this sort of innovation to patients across Virginia is one of the clearest benefits to working with external partners—and clinical trials remain the most common form of partnership. According to Andrea Bidanset, M.H.A., director of clinical trials at Carilion, the health system has more than 120 clinical trials open involving outside pharmaceutical and device companies, testing promising new drugs and biomedical devices.

“One of the biggest advantages to having a robust portfolio of clinical trials is the access it provides our patients,” Bidanset says. “It has the potential to improve quality of life for people living in our region because they don’t necessarily have to travel several hours to a larger, urban academic medical center to get cutting-edge treatments.”

In the case of the Ontera device, the benefit is in early diagnosis. As
Dr. Whatley puts it, “Imagine being able to walk into a primary care clinic, having a precise diagnosis in less than half an hour, and walking out the door with a plan or even a prescription. What more could a patient want?”

Optimizing Searches

Some health care innovations are more or less invisible to patients, affecting care behind the scenes. In recent decades, the Information Age’s data deluge increased demand for innovation in health care, and greater oversight of providers has translated into crushing administrative costs and strains on clinical manpower—both of which affect how patients are served and at what cost.

Carilion innovators who are looking for ways to offset these burdens are more frequently turning to health information technology to streamline administrative processes. Such machine-based solutions are now second only to medical devices in terms of investment in health care technologies.

Through VTC Ventures, one of Carilion’s investments in health information technology has been in MetiStream. According to Keyser, MetiStream’s natural language processing (NLP) technology came onto the radar of Carilion’s chief medical information officer, Stephen Morgan, M.D., several years ago. The company specializes in delivering NLP and analysis of unstructured clinical data for patient and population insights in health and life sciences.

“Dr. Morgan thought the off-the-shelf products available from MetiStream were more than enough to justify becoming a customer,” Keyser recalls. “But it was clear that there were other, unexplored applications for their platform. My office set out to find what needs at Carilion weren’t being addressed by the market already, and where MetiStream could potentially help.”

In addition to contracting for MetiStream’s existing module for annotating and analyzing pathology reports for colonoscopy screening, Carilion is partnering with the company to develop a new product that automates the chart review process for reporting surgical quality data. Such data are requested by a range of external entities, from the American College of Surgeons to U.S. News & World
Report to Medicaid.

 “MetiStream’s NLP technology essentially reads text and extracts meaning from it,” explains Jacob Gillen, M.D., a trauma surgeon and critical care provider who leads Carilion’s efforts with MetiStream. “We’re trying to use that technology to enhance and augment what our human readers do when we submit data to NSQIP, the main surgical quality database.”

Currently, human readers have to go through charts line by line to extract information—such as symptoms, treatment paths, and outcomes—to report into NSQIP (the National Surgical Quality Improvement Program). NSQIP then returns valuable data that benchmark Carilion’s care against that of other providers across the country. The results help Carilion surgeons recognize areas of weakness and make improvements.

While valuable, the collection of such data is labor-intensive and comes at a cost, limiting how much information Carilion can report. MetiStream’s NLP uses machine learning to make quick work of the text. The technology—dubbed the Surgical Clinical Reviewer module—is trained to identify specific variables; Dr. Gillen estimates that NSQIP considers more than 180 variables. The NLP then scans documents quickly for those variables, then quantifies and reports results.

Dr. Gillen likens the process to a highly sophisticated version of the “find” function on a PDF or the way Google rapidly returns results from search queries. Human reviewers can then check that work for accuracy instead of having to read every word of text. 

“The idea,” Dr. Gillen says, “is to increase the volume of patient charts that we can submit, to get more and better data on our outcomes—and then use that to drive better care for our patients.”

Carilion recently executed a collaboration and license agreement with MetiStream to co-develop the Surgical Clinical Reviewer module, which the partners believe has the potential to improve patient care nationally and internationally. Already the module is being used to detect adenoma rates for identification of patients at high risk for colon cancer.

 Minutes Instead of Months

While partners can bring technological elements and expertise to the table, there’s no shortage of innovation within Carilion’s walls.

ArchiveCore is a startup founded by two Carilion physicians, Keel Coleman, D.O., an emergency medicine provider, and Lennox McNeary, M.D., a physical medicine and rehabilitation specialist. The company evolved out of conversations they were having several years ago, when Dr. McNeary was voicing frustration about delays in the medical credentialing process. Dr. Coleman, who was studying business at the time, had become fascinated by the ability of distributed ledger technology (DLT) to verify and secure identity.

“It seemed obvious to both of us that DLT could be used to solve the medical credentialing problem,” says Dr. McNeary. “It was a solution looking for a problem, and we had a use case looking for a solution.”

Medical credentialing is an essential process required before any medical specialist is allowed to start work in a health care facility. It’s needed to ensure that those hired to provide care indeed have the proper training to do so.

When a new doctor is hired, his or her education and other medical credentials need to be verified. The process takes three to four months on average, during which the hiring clinic exchanges countless phone calls and faxes with offices at the various institutions where the doctor worked or studied. Since medical education spans several years and multiple locations—often in different states—the process is arduous.

“The grim side of that process is, if you’re hiring a new specialist, they’re needed in that place at that time, so the delay in credentialing becomes an access issue for patients,” Dr. McNeary says. “And on the health care revenue side, having that clinician sidelined costs the system about $7,000 a day in lost revenue, so the wait hurts health care institutions as well.”

ArchiveCore uses DLT to secure medical credential records and make them readily available for hiring institutions to speed up the credentialing process. A distributed ledger is essentially a secured spreadsheet of sorts that is available on the internet to anyone with access. Perhaps the most commonly known use of DLT is blockchain for securing cryptocurrency.

ArchiveCore’s DLT allows credentialing institutions to log a document, such as a diploma or license, which is then “hashed,” or turned into a single line of encrypted code. That entry is also marked in the ledger, or spreadsheet, which is also secured. Users can then see the record of the transaction and get a copy of the original, hashed document, which has been stored and encrypted, through a secured email service. As long as the verified and secured records are on file, the credentialing process could take minutes instead of months.

 “Part of the beauty of the system is that it’s institution agnostic, so no matter where in the world a clinician trained, the credentialing process would be accelerated,” says Dr. Colemen. “We are hoping this in-house innovation can be adopted more broadly to help health systems across the country.”

Here, too, Carilion’s commitment to fostering innovation has helped, by providing the resources needed to pilot ArchiveCore’s technology.

“That partnership has been critical to us having access to the world of graduate medical education, the credentialing verification office, and the health system so we can test the technology and make improvements,” Dr. Coleman says. “We are grateful for our partnership with Carilion.” 

Written by Veronica Meade-Kelly

Troy Keyser is looking for the next good idea to help clinicians better care for their patients not just at Carilion Clinic, but nationally and even internationally.

Keyser leads Carilion Clinic Innovation, a partner for Carilion’s innovative staff that works to propel their ideas and inventions for improving care to the larger marketplace through commercialization. Innovations can be brought to market by an industry partner or spun out as a startup so patients across the country and globe can benefit from employees’ curiosity and commitment to innovation.

Carilion employees have shared more than 80 ideas, or “invention disclosures,” since the program launched in 2020. More than 40 invention development projects have been funded and managed, a dozen patents have been filed, three startups have received investments, and several commercialization agreements have been executed.

Inventions that are in the active pipeline include an improved orthopaedic procedure with accompanying novel devices, an artificial-intelligence-decision-support module for cardiac PET, and a personalized sensoring device for pulmonary patients.

“I always try to reflect on Carilion’s original vision and goals,” Keyser says. “How can we improve the health of our community through innovation? How do we build a thriving innovation ecosystem within Carilion? And how can we strengthen our region’s role as an economic engine for health care innovation?”

Carilion Clinic Innovation

Keyser was working in Boston, one of the country’s centers of health innovation, putting together clinical trials, licensing, and collaboration deals for Harvard-affiliated hospitals, when he learned of the opportunity in Roanoke. He jumped at the chance to build a new department focused on commercializing Carilion innovations and growing the region’s health and life science startup ecosystem.

“First and foremost, the area has an authentic collaborative spirit,” Keyser says. “That’s what really struck me. This is a very intentional community at a large scale, a community that understands the power of coming together.”

Keyser soon connected with serial entrepreneur Victor Iannello, Sc.D., who was setting up Carilion Clinic Innovation to encourage employees to develop and commercialize inventions to improve health care.

When Keyser first joined Carilion, the majority of inventions were concepts or rough sketches, and it became clear that greater resources would be needed to move the inventions through the development lifecycle. He has since recruited a biomedical engineer, Prachi Joshi, to lead Carilion Clinic Innovation’s invention development arm, and molecular bioscientist Aileen Helsel, Ph.D., to lead the commercialization arm.

Keyser says each idea is scored to determine whether it is novel, rather than just a tweak to existing devices, and whether it has commercial potential. Qualifying inventions can receive up to $50,000 in funding, along with project management resources guided by agile and lean methodologies. Carilion owns the intellectual property generated by employees, and then reinvests any proceeds as part of a virtuous cycle. Carilion handles the patents, develops the ideas, and markets the products. If an invention is successfully commercialized, the inventor receives at least 40 percent of the revenue generated.

“Our focus is on innovations with commercial potential,” Keyser says. “Not only might our patients benefit, but if we were able to license that intellectual property to, say, a medical device company that could bring the innovation to a larger market, patients across the country, if not the globe, could benefit. To get to that endpoint, we needed to make sure we had the right infrastructure to assess employee inventions to understand the commercial potential.”

The Human Factor

Beyond Carilion Clinic Innovation, Carilion’s innovators have a dedicated latticework of resources and funding opportunities. Close to home is Carilion’s Center for Simulation, Research and Patient Safety, which houses the Carilion Clinic Innovation makerspace, complete with high-performance 3D printers for rapid prototyping.

Sarah Henrickson Parker, Ph.D., senior director of the center, works to translate evidence into practice. As chair of health systems and implementation science at the Virginia Tech Carilion School of Medicine, she seeks to support inventions through the end use.

“When someone develops a new technology or drug, there’s a lot of excitement around the potential,” she says. “And when it receives FDA approval, that’s the pinnacle of promise. But then when it comes to actually implementing the innovation, to getting it used, the process gets really, really hard.”

Take the development of COVID-19 vaccines. Those working to make the vaccine were not the same people designing the syringe, figuring out how to transport the vaccine, or mounting a public health campaign.

“An entrepreneur, particularly in the biomedical sciences, frequently thinks about that first phase of the awesome new technology or drug,” Dr. Parker says. “Where I feel we are uniquely positioned—particularly with the human factors team, and with the medical school’s focus on health systems science—is to enter into the latter part of the conversation.

“You’ve got this great evidence-based innovation or best practice,” she says. “Now, how do you design it so it can be implemented quickly, correctly, and efficiently, without messing up everyone’s day-to-day work? This is what the human factors team does. Our discovery process centers on implementing innovations properly, so patients get the best care possible.”

Dr. Parker says she has found at Carilion an appetite to try new things and a nimbleness to gather data to figure out how to improve processes, systems, and devices for better patient care.

“We’d like to think implementation of a best practice is entirely evidence based,” she says. “Yet a lot of implementation comes from relationships and trust. Maybe you can get a subject matter expert to tell you, hey, that’s a good idea, but we need to tweak the implementation hardware, or that new process may not work in our context. Or, I’d be willing to give that a go. Carilion is the right size to build those critical partnerships and that trust.”

Taking the Ramp 

Carilion, Virginia Tech, and Roanoke have designated an innovation corridor between Carilion’s Roanoke campus and downtown to provide a physical space for entrepreneurs, scientists, health providers, and those who support them to interact and build those relationships.

Within the corridor, the city joined with Virginia Western Community College and the Roanoke-Blacksburg Technology Council to create the Regional Accelerator and Mentoring Program, or RAMP.

“We’re trying to help technology-based startups jump hurdles a little faster,” says Mary Miller, director of RAMP. “We help them avoid wasting resources, particularly financial resources, and we try to stop them from going down wrong paths.”

RAMP is a twist on other mentoring accelerators started by venture capitalists looking to increase the success of startups they’ve backed. Roanoke’s leaders viewed RAMP more as a way to encourage young companies in high-paying tech fields to grow in place.

“Many regional accelerators have demonstrated the benefits of supporting startups,” Miller says. “If you show them the support that a region or community can bring to the table early in their journey, then they stay. That’s the magic: the mentoring, the resources, the care and nurturing a company can receive.”

Young tech companies make pitches to RAMP through a competitive process. Miller taps into a deep bench of mentors who then help the entrepreneurs learn how to develop, manage, and market their businesses. By the end of 2020, two dozen tech startups had gone through the program, and RAMP won a $1 million U.S. Economic Development Administration grant to double its capacity. It recently added a second cohort focused only on life and health sciences.

The region is rich in mentors, Miller says, yet it needs a deeper pool of early-stage money. “The most critical money is the first money,” she says. “When you’re just getting started, a $50,000 investment can make a big, big difference, but it’s absolutely the hardest to raise because it’s also the riskiest for investors.”

Miller plans to create an angel investor group to help support early-stage startups. Rounds would raise $500,000 with a rule that no one person can put more than $5,000 in any one fund. Initial investments for any one company would be held to no more than $50,000, so the investor’s risk would be no more than $500 for any one company.

“Many people have expressed an interest in this idea,” Miller says. “Many potential angel investors just don’t know how to get started, and this would be a new pathway. Their support would be critical, as all the research finds that companies thrive in regions where early-stage money is more available.”

On the Verge

All these efforts together are accelerating innovation.

“This is not traditional economic development, where you try to land a company that will bring a hundred jobs into a box plant you built in an industrial park,” says Greg Feldmann, executive director and chief executive officer of Verge, a collaboration of partners focused on supporting the region’s innovation economy. “This is ground-up economic development, where you are taking many acorns and nurturing them, hoping a few turn into some pretty tall oaks.”

Feldmann says Virginia is trying to catch up to its peers. In 2018, the state looked at its lifecycle of innovation and whether ideas and products were making their way out of labs and into the marketplace.

“Roughly $11 billion of sponsored research was taking place statewide,” Feldmann says. “Relative to our population and size, that was a decent number.” But the study also found Virginia needed more venture capital invested before its many innovations could move through research and development and result in new companies and jobs.

“Maintaining the status quo is not a good strategy here,” Feldmann says. “If we want to participate in the innovation economy, we need to take action because market forces alone aren’t going to change things.”

In 2020, the commonwealth created the Virginia Innovation Partnership Authority to foster greater collaborations with governments, businesses, and universities, as well as the development of regional counterparts. In southwestern Virginia, Verge was formed by joining programs from the Roanoke-Blacksburg Technology Council, RAMP, and the Valleys Innovation Council.

“If you want to understand our passion and purpose,” Feldmann says, “we’re trying to organize the resources we have in our own backyard strategically, so we can be a regional technology hub that generates interesting and meaningful new companies and jobs.”

Through its affiliated organizations, Verge is building RAMP’s capacity to help more startups, providing networking, educational programs, and talent development initiatives for the technology sector through the Roanoke-Blacksburg Technology Council. Verge is also helping address capital access issues by supporting Common Wealth Angels and building bridges to investor groups beyond the region.

VTC Ventures

While the region is what many venture capitalists consider “flyover country,” unworthy of even a downward glance from a passing plane window, James Ramey, J.D., managing director of Middleland Capital, is convinced it can become a health and life science destination for innovation.

In 2016, as part of Carilion’s broader investment portfolio, Carilion and Virginia Tech created a venture capital fund to invest in high-growth companies within the greater region and across the VTC ecosystem. Since inception, this initial fund has matured into multiple investment vehicles operating as VTC Ventures.

Managed by Middleland Capital, VTC Ventures has two primary funds: the VTC Seed Fund, which invests up to $500,000 in early-stage, post-proof-of-concept companies, and the VTC Innovation Fund, which invests up to $5 million in mature companies that are still fairly early in their lifecycles. Ramey, who oversees both funds, says Carilion and Virginia Tech have collectively contributed just over $50 million across the funds.

Generally, portfolio companies need to be physically located near Roanoke, or have a meaningful connection to Virginia Tech or Carilion. In addition to investing in high-potential, high-performing companies in the region, VTC Ventures works with investors locally, nationally, and internationally to catalyze investment across the VTC ecosystem.

Ramey notes that most of the nation’s venture capital is concentrated in a handful of places such as Boston and San Francisco. Of the country’s 3,300 counties, about 40 of them receive more than half of the funding.

“We view this as an opportunity to invest in high-quality management teams with strong intellectual property that are under other investors’ radars, as these companies are off the beaten path,” Ramey says. “We find great companies in underserved geographies, including Roanoke and Blacksburg, where we then can leverage our national and international relationships to build strong investment syndicates.”

In addition to finding, funding, and helping to develop top-performing companies in the Virginia Tech Carilion ecosystem, VTC Ventures finds companies outside of the ecosystem and integrates them into Virginia Tech, Carilion, and sometimes physically in Roanoke and Blacksburg.

“We’ve had a lot of early success getting companies from outside the region with no previous connection to Virginia Tech or Carilion to become collaborators,” Ramey says. “We then show these companies what Virginia Tech, Carilion, and this region have to offer. They learn quickly that they don’t have to spend millions building their own labs, recruiting Ph.D.s, or hiring employees in high-cost geographies. These companies work with both Virginia Tech and Carilion to outsource their R&D, co-develop products, run clinical trials, and hire or contract with people in Roanoke and Blacksburg.”

Ramey also keeps in close contact with portfolio companies and entrepreneurs and provides them with substantial feedback and guidance.

“We’re not passive investors,” he says. “We work closely with our portfolio companies to help the management teams in any way we can. This includes providing strategic advice, raising capital, or introducing them to other investors or clients.”

Although VTC Ventures makes equity or convertible debt investments, not grants, and is focused primarily on investment returns, ecosystem growth is a key component of its mission.

“We aim to deliver strong investment returns, and making disciplined investments in great companies enables these returns,” Ramey says. “The success of these companies ultimately drives economic growth across an ecosystem. We view ecosystem growth as an intended consequence of our investment activities. One begets the other.”

Ramey has felt encouraged by the growth of startups in the region during the funds’ first few years.

“As we continue to string wins together, the Virginia Tech Carilion ecosystem ascends in the eyes of the world,” he says. “Our aim, over time, is for entrepreneurs and financiers to stop considering this flyover country. We are working hard to help make that ecosystem a destination for cutting-edge research, entrepreneurship, and innovation both within health care and beyond.” 

Written by Luanne Rife

Consider this one measurement: The Fralin Biomedical Research Institute at VTC had more than $31.5 million in research spending in 2019.

To put that figure in context, it is more than the research spending of all Roanoke’s 15 peer cities combined.

Then consider this: None of the infrastructure existed just a dozen years ago.

“That’s considerable growth in biomedical research and development expenditures within a decade,” says Amy Holloway, director of Ernst & Young’s Economic Development Advisory Services. “If health care remains a target of economic development, and collaborations among Carilion Clinic, Virginia Tech, and others continue, we would expect that investment to increase and economic development—whether it’s entrepreneurial startups or the attraction of new businesses—to expand as well.”

Holloway worked with the Roanoke Regional Partnership, the area’s economic development marketing arm, to develop its current strategic plan. In the broader region that encompasses Virginia Tech’s home base of Blacksburg, nearly $542 million was spent in 2019 on university research and development. Those 15 benchmark regions that include places such as Savannah, Georgia; Asheville, North Carolina; and Erie, Pennsylvania? According to the National Science Foundation Higher Education Research and Development Survey, their cumulative spending totals $29.2 million.

The figures do not yet capture the return on investments that both Carilion and Virginia Tech are making to bring more researchers, innovators, and entrepreneurs into an innovation corridor that is springing to life in a former railroad town that, until a few years ago, lacked a large state university presence within its borders.

“In terms of the lifespan of these industries and other regions, it’s sometimes decades before they reach maturity,” Holloway says. “For the Roanoke region, it’s early still, so the job numbers are not high yet, but the innovation assets—which is the starting point—show this region is off to a good start.”

Amid this success, Nancy Howell Agee, Carilion’s president and chief executive officer, feels the urge to accelerate. “Innovation is academic, it’s clinical, it’s all mixed together, and that creates real excitement for people,” she says. “The more you do, the more people want to be part of it.”

That wasn’t always the case. Carilion met much resistance when it began its transition from a collection of hospitals and primary care practices into an integrated delivery network that would offer highly specialized care.

“I would say now, more than a decade later, we’re being pushed to go faster and harder,” Agee says. “A dozen years ago, though, it was, what the heck are you doing?”

Vision and Leadership

Some of that earlier skepticism centered on Carilion’s attempt to seed a biomedical institute near its flagship Roanoke Memorial Hospital. The institute, it was hoped, would help develop and commercialize medical products.

“While that effort didn’t work out as planned, it started people thinking about the notion that Virginia Tech and Carilion, the largest employers in the western half of the state, have a mutual interest in health care,” says Ray Smoot, who was at the time chief executive officer of the university’s foundation and a Carilion Clinic board member.

“I was in the position—as a senior administrator at Virginia Tech and a Carilion director—of having oars on both sides of the boat,” says Smoot, who is regional chair for Growth and Opportunity for Virginia, better known as GO Virginia, a statewide economic development grant program that encourages regional collaboration. “That strategic vantage point gave me an understanding of how both organizations were looking at this opportunity and a perspective that allowed me to serve in a translator role.”

Virginia Tech needed a medical center to realize its vision of becoming a top-ranked research university, and Carilion needed an academic partner to realize its vision of integrated care delivery.

Charles Steger, Ph.D., then president of Virginia Tech, and Ed Murphy, M.D., then chief executive officer of Carilion, forged a public-private partnership to build both a medical school and a research institute in Roanoke.

“Their leadership was critical,” says John Dooley, who earlier this year retired as chief executive officer of the Virginia Tech Foundation. “Leadership also came from the state, which has been generous with appropriations, and local governments, which helped support the vision.”

Roanoke spent about $30 million to purchase the brownfields on which the Virginia Tech Carilion Health Sciences and Technology Campus was built. The state provided bricks-and-mortar funds.

Dooley also credits Virginia Tech and Carilion leaders with making excellent hires to run both the medical school and the research institute.

“Boy, they outdid themselves by recruiting top talent before there was even much of a product to sell,” Dooley says. “And since then, those talented leaders have been so effective in encouraging others to embrace the vision.”

One of those leaders, Michael Friedlander, Ph.D., founding executive director of the Fralin Biomedical Research Institute, believes successful, sophisticated scientists and entrepreneurs want to be part of a vibrant environment.

“That environment wasn’t here at the time,” he says. “We had to build a base that wasn’t about hype. Now we have a solid, outstanding biomedical research enterprise populated with people who have earned—or are in the process of earning—national and even international reputations in their fields. You don’t need a sales pitch and hype. What we’ve built speaks for itself.”

Dr. Friedlander credits the university and Carilion for standing up both a biomedical research institute focused on excelling in several key areas and a medical school with a major emphasis on student engagement in meaningful research with institute scientists and Carilion clinicians. The institute has grown to more than 400 faculty, staff, and students, with dozens of research teams and an extramural grant portfolio currently valued at over $140 million. Those teams have already spun out five biotechnology startup companies, winning multiple federal small business and technology transfer grants.

The partners also invested heavily in the venture while other funders, including the National Institutes of Health, had pulled back support during the Great Recession. The research institute has since doubled its size, and Virginia Tech has invested in building out its health sciences programs in Roanoke.

Carilion Chief Financial Officer Don Halliwill thinks the ability to start from scratch helped fuel success. “At academic health centers with decades if not centuries of tradition, it’s hard to effect change,” he says. “Our relative youth has allowed us to be nimble, and it’s one reason I say with confidence, and not over confidence, that the best is yet to come.”

Innovation within Carilion

While Virginia Tech was building the research side, Carilion recruited more than 700 physicians, including specialists and subspecialists, who were attracted to the opportunity to create an academic medical center. The health system expanded its footprint, enlarging Carilion’s Roanoke campus by creating institutes devoted to cardiovascular care and to orthopaedics and neurosciences, and by developing a standalone outpatient pediatric center.

Yet something was missing for serial entrepreneur Victor Iannello, Sc.D. As a Carilion Clinic board member, he sat in on interviews to help recruit department chairs.

“We were hiring many high-level people from organizations with robust research and innovation programs,” Dr. Iannello says. “They expressed the desire for those kinds of opportunities here. One reason I was talking to them was because, as an entrepreneur, I was also excited about innovation.”

Dr. Iannello looked at research dollars and the number of patents filed, and saw opportunity. “There was so much more potential here than was being realized,” he says.

After rotating off the Carilion Clinic board, Dr. Iannello submitted a proposal to develop an in-house innovation program.

“I proposed a framework for funding proof-of-concept ideas and moving them through a funnel to license technology, spin out a company, or partner with a company with the expectation that somewhere along the line it would return some financial benefit to Carilion,” he says. “This program would also serve as a way of keeping physicians engaged. These are intelligent, creative people for whom innovation provides another avenue to express themselves.”

Dr. Iannello identified Troy Keyser to lead Carilion Clinic Innovation, which launched in 2020 and has since evaluated more than 80 ideas, with 50 now in various developmental stages. The team invests up to $50,000 of milestone-based funding to ready an invention for the next stage of commercialization.

Carilion Clinic Innovation has invested in three startups, including Chorda Pharma, a company Dr. Iannello is now leading that focuses on developing opioid-free pain relievers. Projects developed by Carilion staff can also be considered for funding through Carilion and Virginia Tech’s early-stage venture capital fund.

“About six years ago, we made a major commitment with the foundation on behalf of the university and then Carilion to launch what is now known as VTC Ventures,” Dooley says. “The compelling argument is that we could nurture the innovation environment, but if we’re going to be serious about starting up companies, and spinning out the ideas from the research institute and Carilion, we’re going to have to provide some level of funding infrastructure.”

The funds offer up to $500,000 for technologies and companies in the riskiest early stages, and up to $5 million for projects further along on the commercialization path.

“It’s not as though there was a moment when we said, ‘We’ll do more innovation,’” Agee says. “It was this yearning, the sense that we needed to get in front of whatever’s new, whatever’s next, and be a part of that. It’s been evolutionary.”

Agee says while health care providers are by nature curious and quick to identify problems and solutions, the medical field as a whole is slow to adopt change. She thinks the collaborative, quick global response around COVID-19 may serve as a catalyst.

Within Carilion, the pandemic led to innovative solutions to unique problems the highly contagious virus posed, including an intubation hood and fogless face shields for Life-Guard flight crew helmets.

Agee says she’s also seen the benefits of the Center for Simulation, Research and Patient Safety, where human factors experts devise solutions, perfect designs, and test prototypes.

“We take on tools our care teams use every day and work with them to find ways to improve those tools,” she says. “The classic example is our work with a defibrillator manufacturer whose device was recalled because of its potential to fail in critical situations. Our team discovered that the problem was something so simple as having the same button for ‘on’ and ‘off.’ Hitting the button twice could present catastrophic consequences.

“It’s incredible to be able to influence changes that benefit the entire field,” Agee adds. “Innovations that make things better for patients and caregivers are very exciting.”

What’s Needed Now

“We’re not done with what we can accomplish here,” Smoot says. “The next big matter to resolve is to what extent Carilion wishes to further evolve as an academic medical center. Carilion’s primary role is providing quality care, but I think we’re going to see much more research going on across the system.”

Smoot says Carilion’s continued evolution is necessary if Virginia Tech is going to reach its full potential. “Now, that’s easier said than done,” he says. “The first thing that comes to mind is, who will pay for these positions, such as clinicians and technicians, who are engaged in research and not generating billable hours?”

Dr. Friedlander, too, is eager for Carilion to move deeper into research, finding better ways to share patient data and hiring physician scientists who both care for patients and spend time on research.

As Carilion progresses to this next level, Agee says, “We’ll look for other ways to bring in revenue, potentially through philanthropy, and we’ll work with our colleagues at the state and federal levels to find additional funding for research and innovation.”

Dr. Friedlander says it’s a long-term investment. “If you’re looking at your bottom line, it’s going to enhance your brand and your reputation, which in health care translates into referrals,” he says. “But that’s going to take at least 10 years, maybe even 20. And what does that do for the community in terms of health? It brings researchers and physicians together, so cutting-edge research is happening here. It gives your patients access to advancements now.”

Halliwill views it similarly.

“The way we spend our patients’ money is visible in the care we provide every day, whether emergency care, surgery, or delivering a baby,” he says. “But we also allocate some money toward care that will benefit patients in the future through our work in innovation. I think of this investment as a long play. We’ve already accomplished so much. Just imagine what it will be like 10 or 15 years from now.”

Beyond the Campus

In 2019, Carilion asked the University of Virginia’s Weldon Cooper Center for Public Service to measure its impact on the local economy. The center found that Carilion had contributed $3.2 billion to the state’s economy the previous year, and accounted for about 10 percent of the Roanoke region’s $17 billion gross domestic product.

The center also projected that, within a few years, the research institute will have a $465 million annual impact on the economy.

“All the nation’s cities that have developed world-class research institutes in health have benefited in an exponential way,” says Elizabeth McClanahan, who succeeded Dooley as chief executive officer of the Virginia Tech Foundation.

For its part, the City of Roanoke has designated a stretch of real estate as an innovation corridor, launched a digital platform to support collaboration among existing and prospective entrepreneurs and businesses, and supported the creation of RAMP, a business accelerator to mentor startups. The city manager meets regularly with Carilion and Virginia Tech leaders to explore what more they can do jointly. In addition, the region’s governments are working together to address transportation and housing needs to support the growth.

 “I believe the most significant changes of this century will occur at the intersection of health and technology,” Agee says. “Carilion and our region are well positioned to benefit from the many innovations that will ease the burden on providers, improve the quality of care they deliver, enhance access to care for patients, and ultimately lower the cost of care. The health care field is ripe for innovation, and I’m proud we’re helping to lead the way.”  

Written by Luanne Rife

Illustration by Señor Salme

Not infrequently, such traumas cause injuries to the network of nerves in the neck that send signals down the arm—a complex known as the brachial plexus. The damage disrupts critical communication between the spinal cord and the affected limb, potentially causing pain, impairment, decreased sensation, or even the loss of use of a shoulder, arm, elbow, or hand.

When these injuries happen, time is of the essence. Nerves have a limited ability to regenerate, and muscles will stop working over time if they don’t receive signals sparking them to action. That means there’s a ticking clock on efforts to fix the problem—as little as three to six months before the effects of the injury become irrevocable.

While prompt treatment is crucial, the complicated, specialized care that offers the best outcomes for brachial plexus injuries isn’t available everywhere. Too often, patients have to go to large and distant cities for state-of-the-art care—a practice untenable for many without the time, money, or transportation to travel.

Fortunately, these obstacles are no longer a problem for patients in southwestern Virginia. In 2017, several factors aligned, including the fortuitous recruitment of the right personnel and the vision of Carilion Clinic leaders, resulting in the foundation of the Brachial Plexus Clinic at Carilion’s Institute for Orthopaedics and Neurosciences.

“Our region sees a number of these traumatic injuries,” says Peter Apel, M.D., Ph.D., an orthopaedic surgeon at the clinic and an assistant professor of orthopaedic surgery at the Virginia Tech Carilion School of Medicine. “We established the Brachial Plexus Clinic to be a home for these patients, where they could get appropriate, timely, and, quite frankly, life-changing care.”

Tackling a “Whole-Life Problem”

The brachial plexus is crucial for both sensory and motor function of the arm. Damage to the network, inflicted when the nerves are overstretched, compressed, or torn, can have a range of consequences.

People who sustain such injuries can have trouble lifting a shoulder or bending an elbow, or even using the hand on their injured side. They might not be able to pick things up or bring a fork to their mouth. Putting on a shirt, reaching for a door handle, or scratching an itch can be a challenge.

Patients with brachial plexus injuries might even have what’s known as a flail arm—one that’s weak, senseless, essentially “dead weight.” The effects can severely limit an individual’s ability to work and necessitate support from family or friends. “A brachial plexus injury isn’t just a nerve problem,” Dr. Apel says. “It’s a whole-life problem.”

How patients are affected can depend on the severity and location of the injury itself—which and how many of the brachial plexus nerves are damaged, and where in the neck the injury occurs.

“Every patient is different,” says Cesar Bravo, M.D., an orthopaedic surgeon at the Brachial Plexus Clinic and a faculty member of the Virginia Tech Carilion School of Medicine. “Some injuries are more complex and some might present in a delayed fashion. Those differences change what we are able to do for treatment.”

Making the diagnosis—and developing and executing the right treatment plan—requires the input of specialists in many disciplines. Electromyography and nerve-conduction studies are needed to figure out which nerves and muscles are working or impaired. Physical and occupational therapy sessions are key to improving movement and mobility, as well as tracking progress in recovery of day-to-day function. In some cases, surgery is required to repair, reconstruct, or transfer nerves or tendons. Amid all this, patients need help with daily life issues such as addressing work situations, acquiring specialized equipment, and coordinating rides.

The entire process requires a dedicated crew and a multidisciplinary approach—a mindset that has been baked into the Brachial Plexus Clinic from the start. Modeled after some of the large centers in which Drs. Apel and Bravo conducted their medical training, treatment at the clinic relies on multispecialty involvement at every step. Patients make a single appointment to see their surgeons and therapists, the nerve specialists who conduct diagnostic tests, a social worker, and the nurse who coordinates their care.

 “It’s literally a team approach,” says Dr. Apel. “It’s not like a typical doctor’s visit. The entire medical team meets with the patient and family in a big room. Ideas are discussed. We encourage everyone, whether it’s the therapist, nurse, patient, or family members, to speak up. We talk through the injury, the situation, the plan—everything—because they affect everybody.”

The clinic runs monthly, and visits usually take an hour. “These aren’t rushed doctor’s appointments,” says Dr. Apel. “We’re dealing with life-changing injuries for these patients, and we take all the time needed to understand how patients are being affected and where they are in their recovery.”

The clinic’s dedicated physical and occupational therapists, who have expertise helping patients recover from brachial plexus injuries, are a critical part of the team.Patients work with these therapists exclusively throughout their time with the clinic.

“At each visit, we see how the patient is progressing,” Dr. Bravo says. “We assess how they’re working back into their professional and social life. Together we’re able to see where the patient has recovered—and what functions they’re not going to recover. That’s how we develop the treatment plan.”

If needed, that plan can involve surgery. But even in the operating room, brachial plexus injuries demand an especially team-minded approach. The operations for these injuries are delicate procedures that take several hours. Two surgeons with the highly specialized training are needed.

Dr. Bravo and Dr. Apel set aside one day a month to make sure they’re available to perform these time-sensitive procedures together.

Operating Shoulder to Shoulder

Several hours into such complicated surgeries, fatigue is bound to set in for the surgeons. The procedure can get frustrating. Maneuvering a tiny nerve fiber through a larger web of nerves, under a microscope, can be exhausting. Doing it when you know that the surgery is potentially life-changing—that the use of the patient’s arm hangs in the balance—adds to the stress.

It’s times like these that a surgeon truly appreciates the team approach. It helps to have a second surgeon there—a co-pilot on the journey—not just to help work through technical challenges, but also to provide emotional support.

“He knows my right hand and I know his left hand,” Dr. Bravo says. “Over the years we’ve gotten to know what the other is thinking. These are fairly extensive surgeries, so you need a partner you can trust, who has the right capabilities, so together you can provide patients with the best care.”

It’s also reassuring to know that the clinic’s team of experts have helped identify the exact problem, the nerve or nerves involved, and the proper procedure to ensure the best possible outcome.

Surgical options include nerve repair, reconstruction, and transfer. Repair entails a reconnection of fibers. Reconstruction involves removing injured or scarred tissue in the damaged nerve and replacing it with a graft. And, when a damaged nerve can’t be repaired, nerve transfer allows it to be replaced with a live functioning one nearby.

“In a nerve transfer, we’re basically taking a functioning nerve, rerouting it, and hooking it up to a nerve that’s not functioning. That provides that muscle, and by extension that extremity, with the connection it needs to work,” Dr. Bravo says. “It’s like taking from Peter to pay Paul. We’re redirecting the nerve and rewiring that person’s anatomy.”

The surgeons say finding that donor nerve—one that works yet isn’t essential to existing function—is particularly challenging. Then comes the chore of extracting it from surrounding tissue, an exercise akin to pulling a single thread from a rich fabric without damaging it. Then, finally, comes sitting down at the microscope and sewing the reworked or rewired nerve fibers together with sutures smaller than a human hair.

The operations can run eight hours, but the grind is worth it for the patients and families—and their doctors.

“We may not always get full return of function, but every bit can mean a great deal,” says Dr. Bravo. “It’s amazing to see how life-altering this type of procedure can be.”

Thinking Local

“What sometimes happens to patients in areas where this type of specialized care isn’t available is they get lost in the shuffle,” Dr. Apel says. “They’re seen somewhere where the condition goes unrecognized. They’re sent for tests or follow-up appointments they don’t need. Time slips by and they lose their opportunity for recovery. We created the clinic to have a means for capturing these patients and getting them prompt care so we can maximize their outcomes.”

To that end, the team has educated others in the Carilion system about brachial plexus injuries—to identify them early and refer them to the clinic. A gradual increase in patients year over year suggests their education efforts are working.

“With the help of clinicians throughout Carilion, we’re able to catch patients who weren’t being treated in a timely fashion,” says Dr. Bravo, who credits his early training at Mayo Clinic with helping to inspire the formation and multidisciplinary approach of the Brachial Plexus Clinic.

“My exposure to these techniques early in my training opened my eyes to the need for this type of medical access for patients with these types of injuries,” he says, noting that such specialization has too often been limited only to major health care hubs.

Dr. Apel agrees. “Our team is really proud,” he says, “that we’re providing what is, by all measures, world-class care for our patients here in little old Roanoke.”

Story by Veronica Meade-Kelly

For two months starting in late February 2020, her husband, David, was at a local hospital being treated for multiple complications arising from gastrointestinal bleeding from diverticulitis. Every other day, Dupree, 75, would drive an hour to the hospital to help fill an external infusion pump with treprostinil, better known as Remodulin, to increase blood flow through her husband’s lungs, which were damaged from the pulmonary arterial hypertension he’d developed six years before. “Administering his medication was very complex,” says Dupree of the multistep procedure.

But just when her husband was ready to be discharged, he tested positive for COVID-19. The nurses put Dupree in personal protective equipment before allowing her to see her husband and tell him the bad news.

“As soon as he heard, David said, ‘This is it,’” recalls Dupree. “He felt that COVID-19 was an automatic death sentence, especially after the medical ordeal he’d just been through. Nurses whisked him to an isolation ward so fast that all I could do was shout ‘I love you’ as the elevator doors closed.”

Two days later, Dupree’s husband of nearly 53 years was dead. In less than a week, Dupree would also test positive for COVID-19.

“My mom wasn’t eating or drinking and she slept a lot, but she was also mourning the death of her husband,” recalls DJ, Dupree’s son, with whom she now lives near Smith Mountain Lake, Virginia. But when she became too weak to stand, DJ called an ambulance to take Dupree to Carilion Roanoke Memorial Hospital. In the Emergency Department, Dupree, whose oxygen saturation level was normal, received a COVID-19 test, was treated for dehydration and exhaustion, and was released.

The next day Dupree learned she’d tested positive for COVID-19 and on May 4, five days later, she was admitted to a COVID-19 unit at Roanoke Memorial with a high fever, profound weakness, and difficulty breathing. Thus began Dupree’s three-week hospitalization for COVID-19, including 14 days in the intensive care unit.

“I was totally numb; I thought, I can’t lose her, too,” recalls DJ when his mother was admitted to the hospital. DJ also worried that his own symptoms of exhaustion and feeling winded were harbingers of COVID-19, but his test results were negative. And with international flights severely restricted, Dupree’s daughter, Diane, who lives in Ireland, had to remain thousands of miles away from her critically ill mother.

When infectious diseases specialist Ekta Bansal, M.D., saw Dupree on May 7, she privately worried that Dupree, who had severe respiratory failure and pneumonia in both lungs, might not survive.

“She looked so sick and she required a considerable amount of high-flow oxygen—up to 80 percent—in order to breathe,” says Dr. Bansal. Dupree’s age, coupled with her diabetes and hypertension, made her particularly vulnerable to severe illness.

“In early May, we didn’t have any specific therapies for COVID-19,” says Dr. Bansal. “We were still learning about the virus and could primarily offer only supportive care to treat symptoms.”

A day later, Dupree was transferred to the ICU. “Patients on high-flow oxygen can deteriorate quickly and require mechanical ventilation,” says Dr. Bansal. “Marcia was nearly at the threshold for intubation.”

Dupree was too weak to talk with her son over FaceTime, but physicians called DJ daily with updates about his mother. “I was pretty oblivious to what was going on around me initially,” says Dupree, “because I was so sick.”

Dupree received a transfusion of convalescent plasma. At the time, Roanoke Memorial was participating in the National Expanded Access Program for Convalescent Plasma, which was sponsored by the U.S. Food and Drug Administration and led by Mayo Clinic. Across the country, more than 35,000 hospitalized patients critically ill with COVID-19 were given plasma rich with antibodies from people who had already recovered from the virus.

Convalescent plasma has been used to treat infectious diseases for more than a century; many hoped that a treatment of antibodies from recovered patients might prevent progression of COVID-19 in those struggling to fight the virus on their own.

In May, Dupree became Roanoke Memorial’s first patient to receive the then investigational therapy for COVID-19. She felt results within 24 hours of receiving the infusion.

“My breathing became easier and I felt much better,” she says. “On day two I felt better still. That’s when I thought I would survive this.”

DJ also heard the difference in his mother’s voice. “She sounded stronger and had more pep during our conversation,” he says. “I was happy her physicians were trying experimental treatments like convalescent plasma.”

Dupree received one unit of convalescent plasma per the study’s protocol. Although the Mayo study was not a randomized, placebo-controlled trial,Dr. Bansal thought it was worth a try based on early, preliminary data.

“She required less oxygen after the infusion and her inflammatory markers showed improvement,” Dr. Bansal says. “While more recent trials have shown that convalescent plasma doesn’t benefit all patients, and other treatments such as monoclonal antibodies have since become available, we were very pleased with the progress she made after the infusion and other treatments we used.”

Dupree also received systemic corticosteroids for three days based on early observational studies that suggested improvement from short courses of steroids, as they temper the host immune response and decrease lung inflammation.

In addition, Dupree received therapeutic anticoagulation therapy, since she had elevated levels of D-dimer, a marker for blood clots, which are a risk for people with COVID-19. Elevated D-dimer levels have been found to correlate with severe disease and worse outcomes. Dupree also practiced self-proning—a method of lying on one side alternating with lying face down—in an effort to improve her oxygenation.

It wasn’t until Dupree left the ICU on May 19 and was back on a COVID-19 floor that she realized how sick she’d been.

“My vision was blurry,” she says. “I couldn’t write or feed myself well because my hand would shake, and I was so weak I couldn’t stand or get out of bed.”

But Dupree, a Michigan native, has retained her Midwestern grit and fortitude in the face of adversity. “There’s no sense in being miserable,” says Dupree, who spent 34 years as an elementary school art teacher in Michigan and Delaware, instructing as many as 1,100 students each week. “There are so many things in life to be happy about, or at least you can be content.”

Despite grieving her husband’s death and coping with the challenging effects of COVID-19, Dupree found comfort in a cardinal that repeatedly flew to her hospital window.

“I’ve long heard stories that cardinals are messengers sent from above to remind you of a loved one who has died,” she says. “I’ve no idea if that’s true, but looking for that cardinal every day gave me strength, and I felt my husband’s presence when I saw it.”

Her doctor won’t soon forget Dupree’s positive spirit and determination.

“From day one, she was a warrior and never gave up,” Dr. Bansal says. “She knew her situation was critical, but she said she would deal with whatever came her way. She had faith that she would make it, and she did.”

After leaving the hospital in late May, Dupree has been recovering at her apartment within DJ’s Virginia home. The fatigue she felt when she first returned home is easing, and her strength is slowly returning, though she finds her short-term memory is still impaired.

“I forget the simplest things, and I can’t add numbers in my head the way I used to,” she says. “My son has to remind me to do things.”

Over the summer, mother and son drove from Virginia to Michigan and back multiple times, hauling a trailer filled with three generations of antiques and family heirlooms as Dupree prepared to put her Michigan home of 16 years on the market.

“It’s in an isolated wooded area, and I wouldn’t be able to enjoy the house without David in it,” says Dupree. In time, she says, she will return to painting, sculpting, and designing clothes for herself. Dupree and DJ also plan to adopt two rescue greyhounds.

When Dupree reflects on her ordeal with COVID-19, it’s not without humor. She laughs when she relates how a physical therapist and an occupational therapist—both men—improvised a hair band from a surgical glove and worked together to tame her unruly hair before helping her walk.

“Everyone I met at the hospital was not only caring, but also kind,” says Dupree. “My doctors were so knowledgeable and I felt like I was treated as a family member.”

Story by Anita Slomski

A Center that Never Sleeps

With more than 40 full-time employees, the CTaC operates 24 hours a day. At peak times, more than 20 workers—including registered nurses and emergency medical technicians trained in critical care—sit before expansive flat screens generating a constant flow of data on everything from the location of helicopters and ambulances and the traffic levels in units throughout the Carilion system down to which patients are likeliest to be discharged soon. Serving as Carilion’s eyes and ears, it’s their job to ensure that patients enter and leave the system as smoothly as possible. And it’s their job to be there when physicians in remote locations call needing urgent care for patients on the brink of death. The nurse who fields the call about the woman with the clot in her brain becomes a sort of symphony conductor responsible for ensuring that professionals throughout the system, performing many different functions, operate as a unified team. “In certain situations, such as an aneurysm, ischemic stroke, trauma, or heart attack, a few minutes can save lives,” says Paul Haskins, M.D., emergency medical physician at Carilion and CTaC’s medical director. “You have to have the ability to arrange transport, have a place immediately ready to evaluate the patient, and intervene on their behalf.” The nurse’s first step is to alert the transport team and ensure that a helicopter is available and ready to go. As the only Level I trauma center in a 150-mile radius, Carilion operates a fleet of three rescue helicopters. In this case, the helicopter will replace a journey over winding country highways with a speedy flight lasting a few minutes. As the emergency crew prepares to take off, the R.N. turns her attention to ensuring the hospital is ready. In a traditional system, the first step might be to deliver the patient to the emergency room for evaluation—but that could cost precious time. Instead, she alerts Carilion’s specialized Stroke Center. Physicians from the Stroke Center’s neurointerventional team speak directly with the clinic doctor to discuss the patient’s condition. Meanwhile, the CTaC medic stays in touch with the helicopter crew about the weather conditions and estimated time of arrival. “That way, the physicians know what timeframe they’re dealing with,” says Melanie Morris, R.N., senior director of CTaC. The specialists will be waiting for the patient the moment the helicopter lands.

A Bed for Every Head

Behind the scenes, those precise operations are the result of years of training, new procedures, constant adjustments, and rethinking. The CTaC, located in Carilion’s Parkview campus, resembles nothing so much as “an air traffic control center for the hospital,” says Morris. Advanced tracking software plays a major part in the operations. The software helps Carilion manage the three helicopters, 44 ambulances and, crucially, 1,026 beds. While less dramatic than responding to a life-threatening emergency, bed management is every bit as vital to the quality of patient care. Like airplane seats, beds are at a special premium during busy times. Carilion’s bed occupancy, which hovers above 90 percent year-round, spikes during flu season and other periods. Leaving empty beds unfilled, or overbooking beds in a crowded unit, can lead to problems similar to those of a packed airport terminal at Thanksgiving, yet with the added pressure that the occupants of those beds are dealing with serious medical issues. In the CTaC control room, workers keep constant watch on the “bed board.” “We have a real-time view, refreshed every 30 to 60 seconds,” says Morris. “We have eyes on every bed in all of our hospitals on all campuses.” When a doctor writes a discharge order or transfers a patient, the system receives an alert that a bed will be opening soon. As soon as the bed is empty, the software system instructs the environmental services team to start cleaning. Back at the control center, Morris adds, “We can see what phase of cleaning the bed is in, and how close it is to getting ready.” The moment the bed is cleaned, another alert gives the CTaC the green light to send the next patient to it.

Emphasizing Human Cooperation

As impressive and useful as the technology is, the center could not function as it does without the close coordination of the humans who staff it. Indeed, the innovations around human behavior have as much or more to do with what makes the CTaC tick. One of the key concepts is called “distributed situation awareness”—an idea that has become increasingly prevalent among “high-reliability organizations” such as NASA, maritime navigation units, air traffic control centers, and other operations requiring pinpoint movement and precision timing. The idea, essentially, is that specialists can’t mind just their individual areas of expertise. For maximum efficiency and, in the case of a busy hospital, patient safety, they must remain fully aware of what’s going on in all areas, and be ready and able to communicate and coordinate with others. “Today’s health system is too complex to train humans on all the interactions they need to have,” says Paul Davenport, R.N., M.B.A., Carilion’s vice president of emergency services and care management. Thus workers must be encouraged to move beyond rigid checklists and procedures and develop the ability to understand and react in real time to the needs of those around them. “The more you can integrate teams using technology and dashboards,” Davenport adds, “the less you have to train a worker to notify someone else when something is happening.”

Breaking Logjams

Before CTaC, Carilion, like most busy health systems, struggled to adapt to ever higher caseloads. Despite their individual professionalism and desire to help patients, workers often created barriers and stress for one another. Some patients were staying longer than they needed to, or were admitted for conditions that might have been treated on an outpatient basis. And because patients might enter the system through multiple portals, potential logjams were often not detected until they had already occurred. That meant added wait times for patients and their families, and stress for busy physicians spending too much time dealing with logistics rather than patient care. “Our goal is to keep physicians off the phone and at the bedside as much as possible,” Dr. Haskins says. “If someone’s asking for a cardiologist when what’s needed is a cardiothoracic surgeon, that’s a delay. Yet if you can eliminate those roadblocks, you’ll have the right physician accepting a phone call from the transferring physician. They’ll know they have all the services they need available to them, and they can just acceptthe patient.” While the principles of distributed situation awareness apply throughout the hospital system, the nerve center and primary driver is the CTaC. One of the most important steps in achieving that level of awareness was to move the transfer staff and the communications staff (responsible for transporting patients), once located in different areas, into the same large room. “When we began to align these people and their functionality and teamwork, we began to have a more harmonious working environment,” Davenport says. “Yes, we can accept your patient, we do have capacity, we do have a helicopter in route to you now. We know the ETA back to the hospital and what treatments we should start. Within one phone call, we can answer all those questions and help those who are trying to send new patients or transfer patients throughout the system.”

A Beacon of Success

The results have been remarkable. Within eight years, the center has eliminated 30 minutes of wasted time for each patient—or an astounding 720,000 hours per year. A vastly improved alert system for the Emergency Department has cut the time it takes to put patients in rooms by half, Dr. Haskins notes. And the CTaC has contributed to a .3-day reduction in the time patients spend in intensive care. Such successes have caught the notice of the wider medical community in the United States and globally. Some 60 health systems from as far away as the United Kingdom and Singapore have made the trek to Roanoke in recent years. In early 2019, after sending a team to Roanoke, Ohio’s Kettering Health Network opened a $10 million, 17,000-square foot command center using many of the same procedures and advanced tracking software to move patients around its system more efficiently.

Buy-In from the Top

According to Davenport, one of the questions visitors most frequently ask is, “How do you get administrative buy-in for this?” In Carilion’s case, the thinking behind CTaC came from the top. More than a decade ago, Nancy Howell Agee, now president and chief executive officer of Carilion, formed a task force to investigate ways to better coordinate Carilion operations. The CTaC is a natural extension of Carilion’s commitment to constant improvement, informed by open and continuous communication across various medical disciplines and between clinicians and administrators. That’s the idea behind Carilion’s “dyad leadership” model, which pairs clinicians and administrators. “As long as you can keep open lines of communication between the providers who are seeing the patients and the administrators who are overseeing the hospital system, then we all have an idea of our goals,” Dr. Haskins says. “It’s important that we’re all moving in the same direction.”

Looking to the Future

While perfection is a goal, the CTaC remains a constant work in progress, Dr. Haskins says. And that’s not likely to change. Because health care is evolving so rapidly, solutions to today’s challenges may become outdated with breathtaking speed. And success breeds its own new complications. Thanks to CTaC’s efficiencies, Carilion in recent years has been able to accommodate a thousand additional patients each year in the same number of beds. Yet continued growth in patient volume will inevitably require ever-evolving solutions. Indeed, the focus is not just on finding better ways to bring more patients to Roanoke Memorial, but also on directing patients, where possible, to other hospitals and clinics within the system. Among the latest developments is a remote telemetry center, located just upstairs from the CTaC, that will soon be capable of monitoring at-risk patients at a central location. “For some patients, usually elderly, who are at risk of falling, we need to have people making sure they’re staying in the bed, staying safe,” Morris says. From the centralized location, tech workers acting as “virtual sitters” can keep track of up to 12 patients each—freeing busy floor nurses for other tasks.

Behind the Curtain

Those patients will likely have only the most tangential knowledge of all the personnel, technology, and planning being brought to bear to ensure their safety. So, indeed, will the stroke patient and her grateful family. Using interventional radiology techniques unavailable even five years ago, the team at the Carilion Stroke Center removes the woman’s clot, and she is out of danger, with an excellent chance of full recovery. The nurse who fielded the original call has alerted the intensive care unit, to make sure a bed is open and waiting so the woman can receive the postprocedural care she’ll need. For CTaC, Morris says, staying “behind the curtain” is part of the design. “Patients don’t need to worry about what we look like or what we’re doing,” she says. “They and their families just need it to feel right, and to know that they’re getting the care they need when they need it.”

By Charles Slack

“Caregivers see a seemingly innocuous injury on the soccer field, and the player winds up suffering from headaches and failing out of school,” says Damon Kuehl, M.D., an emergency medicine physician at Carilion Clinic and an associate professor at the Virginia Tech Carilion School of Medicine. “Yet someone who may have been knocked completely unconscious gets up, and an hour later is seemingly fine and has no ill effects—ever.

“The way I describe it is providers need a proverbial crystal ball to deliver quicker, more definitive diagnoses so we can get patients the care they need more quickly,” Dr. Kuehl adds. “The problem is we don’t have great tools right now for diagnosing mild traumatic brain injuries at the initial point of care.” It’s the concussion conundrum—how do you diagnose an injury that often has no signs or symptoms? It could be that the solution is small enough to fit in your pocket.

Game Plan

Work started in 2018 when Virginia Tech scientists—including principal investigators Michael Friedlander, Ph.D., executive director of the Fralin Biomedical Research Institute at VTC, and Stephen LaConte, Ph.D., an associate professor at the institute—won a $500,000 competitive grant to speed the development of a multi-modality system to aid in the diagnosis and management of mild traumatic brain injury. The effort involved BRAINBox Solutions, an early-stage startup biotech company that was developing a multi-modality concussion test to administer directly at the point of care.

“While our research was under way, the U.S. Food and Drug Administration granted ‘Breakthrough Device’ designation for the new diagnostic approach from BRAINBox Solutions,” says Dr. Friedlander, who also serves as Virginia Tech’s vice president for health sciences and technology. “The FDA recognized how important it was to accelerate this effort and to be able to accurately and rapidly diagnose mild traumatic brain injury in patients, especially those at greatest risk, including young people, athletes, soldiers, and the elderly.”

The device uses a biochemical test called an immunoassay that measures the presence of molecules in a solution. A small patient blood sample is placed in a container not much larger than a USB drive. The test hunts for specific proteins that have leaked from injury-damaged cells in the brain, entered cerebrospinal fluid, and from there crossed the blood-brain barrier. The proteins serve as biomarkers that can be measured at the point of care through an artificial intelligence–driven algorithm that integrates data from all the test’s components, which also includes validated neuropsychiatric testing. Cognitive assessments are included as well to determine the result of the biological and functional impact of the injury.

“This is a game changer,” says Donna Edmonds, a former critical care nurse and chief executive officer of BRAINBox Solutions. “The brain is extremely complex, and to understand what is going on during a head injury, it takes a multi-biomarker, multi-modality approach. Our method includes a test using a sample of whole blood placed on a cartridge or analyzed in a hospital-based laboratory. The point-of-care test will be plugged into a handheld device, and within about 30 minutes, you have a result.”

As part of a specific site sub-study, Dr. LaConte is deploying sophisticated structural and functional brain imaging technologies on patient volunteers in conjunction with Dr. Kuehl’s clinical assessments and venous blood draws to evaluate BRAINBox’s blood-based biomarker assay.

The objective of the research is to determine whether BRAINBox Solutions’ test is as accurate as clinical assessments and to demonstrate when to use magnetic resonance imaging. “Ultimately, the goal is to reveal what the brain is doing functionally in the context of results from neurocognitive and behavioral testing,”Dr. Friedlander says. “The profile of blood-borne biomarkers in combination with functional testing that reflect the injury and restoration processes under way in the brain provides a very promising approach to the process in its earliest stages, before the later manifestations occur at the level of behavior and cognition.

“When integrated with a battery of neuropsychological tests and through standardization across multiple sites,” Dr. Friedlander adds, “this approach offers an exciting new opportunity for the development of a true point-of-care objective assessment for diagnosing mild traumatic brain injury and providing a scientifically valid approach for personalized care for the patient.”

A Health Problem for All Ages

Just about everyone knows the Hollywood version of the concussion test. Someone gets cracked in the head and a helpful friend rushes to that person’s side, anxiously asking, “How many fingers am I holding up?” If the answer to the question is close to the mark—as it always is—the injured party jumps back into the fray. In real life, the script is not that much different. People really are eager to get back into the game, or to school or work.

After all, “mild traumatic brain injury” suggests the injury is, indeed, mild. Right? Not always. The potential side effects of concussions can be life-changing. The Centers for Disease Control and Prevention has concluded that concussions can affect memory, reasoning, sight, communication, and understanding. And multiple mild traumatic brain injuries have been linked to a range of mental health issues, including depression, anxiety, personality changes, and aggression. As a clinical condition, concussion has been recognized for more than 2,000 years, dating back to Hippocrates, who watched classical wrestlers lose their senses after receiving head blows. The father of modern medicine concluded that “no head injury is too trivial to ignore.”

The warning was visionary, but not necessarily heeded. And as a research subject, concussion hasn’t kept pace. In the 16th century, physicians coined the term commotio cerebri, referring to the shaking of the brain to describe the loss of mental function that concussion can cause. The development of the microscope in the 17th century allowed scientists to reveal the differences in brain tissue of deceased patients who have had concussions compared with those who have had severe brain trauma.

By John Pastor

“We talk about how they feel and how those feelings affect their recovery,” she says. But not everyone is ready to share. “If a patient doesn’t want to talk to me, that’s totally fine,” she explains. “But I keep showing up anyway and letting them know I’m invested in their care.”

That’s not just lip service. Like other certified peer recovery specialists, Hetzel isn’t just trained to provide support to patients struggling with substance use, mental health concerns, and other challenges. She’s drawing on her own lived experience to motivate and inspire them.

“I’m using myself as an example to show people in the throes of addiction that there can be a positive way forward,” she says. “I’m offering hope that even if they’re struggling now, they can work through it, too.”

An Unlikely Addiction

It’s a role Hetzel wouldn’t have imagined for herself just a few decades ago. A good kid from a supportive middle-class family, she was popular, did well in school, and was a cheerleader—even dating a football player in what she calls a clichéd but typical teenage romance. “I’d venture to guess that no one ever expected me to develop a problem with addiction,” she says.

Although she and her boyfriend experimented with prescription drugs as a way to relax and unwind occasionally, Hetzel says they were naive to their addictive potential and instead viewed pills as a mild alternative to alcohol. “We didn’t recognize this as risky behavior,” she says. “In my mind, it was similar to having a beer on the weekend. I never felt like I needed them.”

That began to change when, at 21, routine oral surgery left Hetzel in debilitating pain. After having her wisdom teeth removed, she developed searing chronic jaw and ear pain that had seemingly no explanation. The 60 daily milligrams of Oxycontin that her surgeon had prescribed barely alleviated it. When a specialist couldn’t identify the source of the pain, she left his clinic in tears.

“I distinctly remember the doctor telling my mother that I was seeking drugs and making the entire thing up,” she says. “Hearing these words devastated me and filled me with a sense of hopelessness and despair that’s difficult to describe.”

The next few years were filled with bone scans, physical therapy, and visits to pain management physicians—but the pain remained. Hetzel gradually began to misuse the opioids she was prescribed, desperate for relief and terrified the pain would get worse. Eventually, she was taking so much medication that she would run out of her monthly prescription in just three days. She found herself buying pills off the street just to avoid feeling sick—and to be able to pass the drug screens administered at the pain management clinic.

The Turning Point

Five years later, Hetzel was still showing up for appointments at the pain management clinic and passing those drug tests, hiding her reality of substance use while keeping up the appearance of a model patient. That all changed one morning in 2013, when a pregnancy test revealed that her symptoms of nausea and fatigue weren’t part of the withdrawal and addiction cycle to which she had become accustomed. She was five months pregnant and dependent on opioids. She knew she needed help.

But Hetzel wouldn’t find it from her pain management provider, who told her the clinic didn’t treat pregnant women and released her as a patient. Feeling guilty, ashamed, and alone, she made her way to a free clinic, and then a treatment program through Carilion Clinic that offered buprenorphine. “I knew I didn’t have a choice,” she says.

That July, her daughter was born, healthy and free of complications. “I stumbled my way into recovery because of her,” Hetzel says, “and the incredible providers who gave me a solution I didn’t know was possible.”

She went on to have a second child and found a new oral surgeon to address her dental problems without using narcotics. Now six years into recovery, Hetzel says that substance use has permanently changed her life, both for better and worse. After her children’s father died from his own addiction, she became even more determined to make a change.

“That gave me the shove to do something more,” she says. Previously a stay-at-home mother, she began doing her own research on the opioid crisis and learned about the role of certified peer recovery specialists in treatment. “I was ready,” she says, “to start giving back.”

A New Path

Certified peer recovery specialists are uniquely positioned to support people facing substance use disorder, mental illness, or other challenges, relying on their own personal experience while applying the skills they’ve developed through intensive education. Hetzel, who first heard about the profession from her own clinicians, underwent 72 hours of specialized training on how to work with people not yet in recovery. She also completed 500 hours of volunteer contact with patients—no easy feat for a single mother who lived an hour away from Carilion Roanoke Memorial Hospital. Yet it’s the perfect calling for Hetzel, who views her struggles with substance use as a benefit to the profession.

“I believe my experiences have gifted me with the unique ability to meet someone in their darkest moments and offer tangible hope,” she says, “because I can say ‘me too’ and ‘you’re not alone.’”

Indeed, a large part of the peer recovery specialist’s job is to act as a role model while helping to remove the stigma that still surrounds substance use disorder and mental illness. “I didn’t have a peer recovery specialist when I was in treatment, and I felt incredibly isolated and stigmatized as a pregnant woman,” says Hetzel. “That’s why I wanted to do this.” While she sees a wide variety of patients, she finds that she especially relates to expectant mothers with substance use disorder. “That’s my passion,” she says.

Although the position is relatively new to Carilion, certified peer recovery specialists can already be found throughout Carilion Roanoke Memorial Hospital, from the Emergency Department to the inpatient units. Hetzel and her colleagues also work with outpatient, in-group settings, and in the community. But they all have lived experience that no amount of training or education can replicate. And they all have the same goal: “We always try to take on the role of advocates,” Hetzel says.

That can mean helping people work to achieve goals for recovery, supporting their treatment, modeling healthy behaviors, serving as inspiration and motivation, and teaching them to advocate for themselves so they can obtain necessary services and care. They focus on helping people help themselves—all while treating their peers the way they would have wanted to be treated when they were in their shoes. They’ve been through similar situations, so they view relapse not as a failure, but as a bump in the road.

Persistence, says Hetzel, is key.

“People with substance use disorders get written off all the time,” she explains. “We want them to know that we want the best for them, and that we’re never going to give up on them—ever.”

By Jessica Cerretani

Lights were left on around the clock, and the hospital didn’t have the recycling programs she would have expected. Wohlford soon realized that she wanted to make it her life’s work to bring more environmentally friendly practices to Carilion Clinic. Yet it was hard to know where to start. At the time, only the largest health systems seemed to have the resources to address the issue, so there were few models to follow, and she wasn’t aware of degree programs that might train her for such a career.

Like others at Carilion and in the health care field more broadly, if Wohlford wanted to leave less of a footprint, she would, ironically, have to blaze a trail. Over the next decade and a half, Wohlford and her colleagues would do just that, forging a sustainability program that would, in a relatively short time, decrease medical supply and food waste by tens of thousands of pounds per year, and drastically reduce water and energy usage. It’s a journey that’s put Carilion on the cutting edge of a growing movement in health care.

An Exceptional Challenge

Carilion isn’t alone in struggling with this sustainability crisis. According to Practice Greenhealth, an organization that advises the health care community on sustainability, hospitals are second only to food service among commercial energy users, producing roughly 8 percent of the country’s greenhouse gas emissions. Hospitals also generate more than 4.67 million tons of waste every year and use 7 percent of the country’s commercial water supply. While some of these inefficiencies are an expected byproduct of volume—nearly 38,000 inpatients and an estimated 113,000 visitors pass through Roanoke Memorial’s doors each year—others can be traced to inescapable challenges peculiar to the health care industry.

Many of these revolve around patient safety. “We have many regulations we must match or exceed when we’re taking care of patients, because their well-being is our top priority,” Wohlford explains. “For example, any new recycling container has to be approved by life safety experts to make sure it meets fire code standards. It also has to be run by infection control because certain materials, like corrugated cardboard, can collect bacteria or dust mites—things that we absolutely cannot have here. So, when we introduce new programs, everything is a bit more complicated.” Nevertheless, to Wohlford and a growing number of health care professionals, sustainability is an effort worth investing in, especially considering the impact of environmental factors on community health. It was that connection that led Wohlford to enroll in a master’s program in public health at Virginia Tech. Concurrently, she started to work with Virginia Tech faculty and Carilion leaders to draft a business plan for sustainability, relying on advocacy organizations such as Practice Greenhealth and Health Care Without Harm for guidance in what were relatively uncharted waters. As she did, it became clear to all involved that running and advocating for any of the proposed programs would be a full-time job. Working with her boss, Vice President of Emergency Services and Care Management Paul Davenport, R.N., M.B.A., and other Carilion leaders, Wohlford drafted the sustainability manager position, a role she would formally move into in 2015.

Waste Watchers

Coming out of the gate, Wohlford and her advisors prioritized projects that were achievable and financially sound. They started recycling programs that emphasized reuse and donation, for instance. Five years later, Carilion boasts a single-stream recycling initiative that has cut the waste destined for landfills by 97,000 pounds per year. Carilion has also donated more than 53 tons of excess medical supplies to support medical education and international missions. Another early success involved a retrofit of light bulbs at Roanoke Memorial. The project, which was completed last year, saw more than 30,000 bulbs replaced by LEDs, an effort that has cut the energy used for lighting in half. Meanwhile, several other programs made their way to various stages of the project pipeline as teams across the health system worked with the sustainability team to build strategies and business cases for implementation.

The consistent thread through all of these efforts has been the commitment of employees to see them through. The success of the programs has relied not just on the sustainability team, but on the oversight of an Environmental Stewardship Council composed of executives and other leaders who offer guidance on the feasibility of individual programs, as well as the commitment of department heads willing to partner on sustainability. Perhaps most important are the thousands of nurses and clinicians who do much of the legwork, ensuring that the reforms are put into action systemwide.

For this, Carilion relies heavily on sustainability champions—roughly a hundred volunteers from departments throughout the system who help educate colleagues and oversee the execution of new initiatives. “I can put down recycling containers all day long,” Wohlford says, “but if the thousands of employees we have don’t know what belongs in each one, it’s all for naught.” Sustainability champions not only relay objectives and logistics; they also receive updates to share with their teams about how much waste they’ve reduced and when sustainability milestones are hit. Meg Scheaffel, R.N., M.B.A., vice president and chief nursing officer at Carilion, believes the feedback they provide to and from the sustainability office helps nurses and other health care workers appreciate the upside of their efforts.

“From an engagement perspective,” she says, “it helps nurses relate the sustainability programs to our overall mission of providing quality care.” Part of that care is stewardship, Scheaffel adds. Clinicians and nurses have a responsibility to use resources wisely. In addition to recycling, the sustainability champions have encouraged nurses to be more mindful of supplies taken into patients’ rooms. When rooms aren’t overstocked, fewer supplies have to be discarded and fewer new items need to be stocked. Carilion also reduced supply waste by working with infectious disease experts to develop policies on restocking and donating unused items. It was determined that in many cases, if items hadn’t been opened and weren’t visibly soiled, they could be reused.

“Supply return has been huge,” Scheaffel says, noting that it’s saved $61,000 in less than a year. “And it’s something nurses can relate to, understand, and control. There’s a lot of momentum out there to support our environment and keep things out of the landfill.”

Leaning Green

Food waste has been another key target for sustainability, and it’s another area in which teamwork made progress possible. Pat Bird, senior director of dining and nutrition services, joined Carilion just as the sustainability office was formally getting off the ground. It was fortuitous timing, as Bird’s department was looking to cut costs, and food waste pointed to possible inefficiencies. The timing was good on another front: Bird’s area had just partnered with the sustainability department to take on Adeola Adeoye, an efficiency and sustainability fellow with the time and drive to focus on the problem. Adeoye spent her first few months at Carilion researching what other health care systems were doing about food waste.

“Then we really needed to look at our patient menu, to understand what our patients actually wanted to eat,” Bird says. It was no small task given the variable duration of hospital stays, the nutritional needs of patients, and the logistics of serving patients, visitors, and employees.

For weeks, Adeoye monitored patient eating habits, measuring and tracking food that returned from patient areas. One pattern of waste that she uncovered was the volume of milk cartons and salads that came back untouched. Both items were served with meals as a matter of course, yet as much as 20 percent went to waste. Based on this and other observations, Bird’s team experimented with the menu, and milk and salad became optional items that patients could order. The team then further refined their menu using the feedback and data that Adeoye collected. Since adopting the new menu systemwide, Carilion has reduced food waste by tens of thousands of pounds and saved tens of thousands of dollars per year. A similar approach has resulted in savings on the public-facing, cafeteria side of Carilion’s food services as well. Additionally, Dining and Nutrition Services has started to convert from plastic and Styrofoam to more eco-friendly tableware.

“We’ve converted more than 40 percent of our Styrofoam products,” Bird says. “The added expense of the new products has slowed our progress, and yet I think eventually they’ll be entirely eco-friendly.” Bird is also excited about Carilion Cuisine, a new frozen-meal program that will benefit patients off-hours, in the Emergency Department, and in various clinics. The line—which will offer its own food jackets with nutritional information and cooking instructions—will provide more flexibility in feeding patients that should result in less waste.

Dropping Disposables

Carilion’s laundry services has also found ways to cut waste, drastically reducing water usage and supply costs over the past four years. In addition to tuning up equipment and tightening pipes to prevent leaks, the department has invested in a new tunnel washer and three new pony washers. The machines, which were installed in April 2019, have helped reduce water usage by roughly 35,000 gallons a day. And that’s not because the machines are washing less. In fact, while many hospitals opt for disposable bed pads, gowns, and other linens for the sake of convenience, Roanoke Memorial has committed to reusing every product that can be reasonably laundered. This is even true for operating room linen. “I have five kids. We used disposable diapers, so I understand it.
 

"It’s a lot more convenient than laundering diapers,” says Jim Buchbinder, head of laundry services. “In a hospital setting, it’s easier just to throw away all the mess that’s created—just put it into a plastic bag and send it to a landfill. It’s harder to wash it, but it’s definitely something we have the technology to do, and it benefits the environment and the hospital for us to do it.” Carilion’s efforts have seen linen expenditures drop by $275,000 year over year, which has helped offset the investment in new machines. But the potential savings aren’t the main reason Buchbinder feels strongly about the initiatives. “Many hospitals have opted for convenience maybe even despite the cost, but Carilion is committed not to do that,” he says. “I’m proud that I work for an organization that stands for that.”

Looking to the Future

As the climate discussion has taken on more urgency, Wohlford has seen it reflected at work. “More and more, physicians and nurses are coming to the sustainability team and asking, ‘where do we sit with this?’ I want to figure out how we can help with climate solutions through the lens of health, because the links are real,” she says, citing the connection between air quality and health and the dangers that come with weather emergencies, just to name a few.

With that in mind, Wohlford’s team organized Carilion’s first Climate and Health Conference in October. The event brought clinicians, nurses, and other health care professionals from across Virginia to discuss what health providers can do to educate the public, as well as patients and each other, about the impact of climate on health. It’s part of an ongoing conversation that will continue to unfold in the coming years. That discussion is sure to add to the growing list of initiatives Carilion is considering. Yet the fact that the journey is incomplete shouldn’t detract from the progress already achieved. “If you look back on where we were four years ago and where we are now, we’ve made tremendous strides on sustainability,” Bird says. “We’re not totally there yet, but we are on the cusp of greatness. We’re almost there.”

By Veronica Meade Kelly

Despite the stigma, opioid use in pregnancy is on the rise, with devastating effects. According to the Centers for Disease Control and Prevention, the number of women with an opioid-use disorder at the time of labor and delivery more than quadrupled between 1999 and 2014, reflecting the same pattern of prevalence in the general population.

For Virginians, those statistics hit close to home: Here, the number of infants born with neonatal abstinence syndrome—the withdrawal symptoms that result after a baby has been exposed to opioids in the womb—increased by 11 percent just from 2016 to 2017. The risks of opioid use are clear in new mothers, too. One recent study found that even though opioid overdoses decrease during pregnancy, they rise again during the postpartum period, particularly in the second six months after delivery. Women who do overdose tend to be younger, single, unemployed, less educated, and less likely to have received adequate prenatal care.

Indeed, the judgment surrounding substance-use disorders and pregnancy is especially strong, leading many women with opioid dependency to forgo prenatal care altogether. “Opioid-use disorder is a chronic disease that’s really put into focus during pregnancy, when you now have two lives at risk,” says Jennifer Wells, M.D., a physician in Carilion Clinic’s Department of Psychiatry. “But because of the stigma, women often feel ashamed and unworthy of help.”

To address this crisis, Dr. Wells and her colleague Kimberly Simcox, D.O., a physician in Carilion’s Department of Obstetrics and Gynecology, have established one of Virginia’s first office-based opioid treatment (OBOT) programs specifically for pregnant women. The Roanoke-based program—which opened its doors in February through Carilion Women’s—offers medications, counseling, and psychosocial and pregnancy-related support to expectant mothers.

“What makes us unique is that we allow women with an opioid-use disorder to come to a place that provides coordination of care, where the clinicians understand both substance use and pregnancy,” says Sarah Dooley, R.N., the program’s operations manager.

More than Medication

The OBOT model offers medication-assisted therapy (MAT), on-site behavioral health services, and care coordination. This treatment involves behavioral therapy combined with the use of FDA-approved drugs such as buprenorphine, methadone, and naltrexone to address the withdrawal symptoms and cravings that accompany opioids. When administered appropriately, the treatment can help opioid users safely sustain recovery. OBOT clinics integrate MAT into a comprehensive outpatient treatment plan that views opioid-use disorder as a chronic medical condition.

It’s an approach that aims to provide collaborative care without the stigma associated with addiction, while giving patients the tools they need to manage their disease. “We should be thinking of opioid-use disorder as we do diabetes or hypertension,” says Dr. Simcox. “It should be viewed like any other long-term chronic condition that requires treatment.”

Obstetrics-specific OBOT clinics tailor this model to the needs of opioid-dependent pregnant women. Like traditional OBOT programs, they offer MAT, but they also include information aimed at breaking down misconceptions about its use—reliance on medications, for example, doesn’t mean just swapping one drug for another. In fact, the American College of Obstetricians and Gynecologists recommends MAT as the preferred treatment for pregnant women.

Compared with MAT, medically supervised opioid withdrawal in expectant mothers is associated with higher relapse rates and worse outcomes, such as preterm birth and miscarriage. “There’s this idea that MAT is a crutch, that you’re not really in recovery if you’re on Suboxone or another medication,” says Dr. Wells. “That’s primarily a problem of not understanding the brain processes behind addiction. We try to educate women and their families about how critical MAT is for the safety of the fetus and for having a healthier baby—and that’s everyone’s goal.”

To that end, the Carilion Women’s OBOT goes beyond medication and counseling to include a spate of services focused on pregnancy and the postpartum period. “We’re not just seeing women coming in for medication and therapy, and it’s not your typical quick clinic visit,” says Leanna Stone, the center’s care coordinator, who also provides patients with psychotherapy services.

“It’s helping women apply for Medicaid if they need insurance and helping them find food banks if they lack access to good nutrition. We’re looking at each patient as a whole person, not just a pregnant woman or a woman with substance-use disorder.”

Birth and Beyond

That support continues beyond labor and delivery. Although the program doesn’t yet offer obstetric care, its clinicians work closely with patients’ obstetricians to ensure a safe and seamless experience.

“Our hope is to bring prenatal care to the program in the near future,” says Dr. Wells. “For now, our responsibility is to provide medication, psychological care, and overall support.”

The unique experience of the staff—Dr. Wells and Dr. Simcox are among a handful of physicians in the country both trained in obstetrics and board certified in addiction medicine—presents a significant opportunity to address all aspects of support.

“The advantage is that we’re knowledgeable about both pregnancy and opioid use, so we can talk to patients and their physicians about pain at delivery, neonatal withdrawal, and other concerns,” says Dr. Simcox. “We’re coordinating with obstetricians throughout the process so there are no surprises and everyone is aware of the care plan.”

They also work closely with Carilion pediatrician Jacinda Hays, D.O., to help prepare mothers for the withdrawal symptoms of neonatal abstinence syndrome—common in infants born to opioid-dependent women. These babies are not born addicted to opioids, but do experience the uncomfortable withdrawal process after birth. Babies diagnosed with neonatal abstinence syndrome are seen by Dr. Hays in a new transitional, low-stimulation nursery housed in Carilion’s Mother/Baby Unit. “We talk about how they can console their babies and use skin-to-skin contact, which is the best medicine for newborns,” says Dr. Wells. “We try to educate women as early as possible, so they know what to expect.” Because the months following childbirth can be particularly dangerous for moms, the OBOT program continues to offer support and resources for at least six weeks after delivery.

“Opioid-dependent women are typically abandoned in the post-pregnancy period, and most cases of overdose occur during this time,” explains Dr. Simcox. “We try to follow patients closely after delivery before transitioning them to long-term addiction care.”

Growing by Leaps and Bounds

The Carilion Women’s OBOT program has grown quickly since its inception. Within two months, the program was already serving about 15 patients at weekly appointments. “We’re growing every week, and we expect to expand even more within the next six months,” says Dooley, who adds that the plan is to offer prenatal care as well. Some patients come from other local programs, seeking consults.

Others arrive through word of mouth. But physicians play a crucial role in helping pregnant patients find OBOT clinics, too. “Some women come to their OB/GYN terrified that they’ll lose custody of their baby or be judged, so they try to hide their opioid-use disorder,” says Dr. Wells. “But with sensitive questioning and an open dialogue, they may feel comfortable enough to reveal their disease.”

Indeed, the American College of Obstetricians and Gynecologists recommends early universal screening for substance use as part of comprehensive obstetric care, beginning at a woman’s first prenatal visit. “We should be asking every patient, ‘Can I ask if you’re struggling with substance use?’—and then be asking again,” says Dr. Simcox. In the past, physicians were hesitant to question their pregnant patients, mainly because they felt they couldn’t provide guidance or treatment. Now, the establishment of the Carilion Women’s OBOT program gives clinicians the confidence to discuss opioid dependency with their patients.

“Providers used to be afraid to ask patients, ‘How can I help?’ because they didn’t have the answer,” says Dr. Wells. “Now they know that there’s a place for women to get treatment and support, so they feel more comfortable bringing up the issue.” The program, which is only expected to grow over time, already serves as a model that Dr. Simcox and her colleagues hope will be implemented in other areas as well. “We’ll be adding more resources as our patient population increases,” she says. “It’s such a unique opportunity for care.”

By Jessica Cerretani

Ultrasonography, a technique that uses the echoes of soundwaves to create images of what’s inside the body, is perhaps best known for helping obstetricians track what’s happening in the womb during pregnancy. Yet its use in medical practice is far-reaching. Since its introduction in the United States in the 1960s, ultrasonography has been adopted by fields as disparate as cardiovascular medicine, urology, emergency medicine, and dermatology to help make diagnoses and guide treatment. And, by ditching cumbersome machinery for more mobile, handheld devices, portable ultrasonography has opened up more applications for this powerful tool.

The portable devices can be dispatched in the field quickly—inside or outside the hospital—making them especially useful in critical care and emergency medicine, where cases are delicate or life-threatening and time is of the essence. The notion that portable ultrasonography devices, which were widely available by the late 1990s, were not being used to their full potential because of a lack of training was disconcerting. And it’s exactly the type of gap that CME, which is designed to keep physicians updated on the latest technologies and practices, was meant to address. To Dr. Dallas, it was a perfect opportunity for Carilion doctors to fill an unmet need in medical education.

“It’s one thing to do something that everyone else is doing and try to do it incrementally better,” Dr. Dallas says. “It’s another thing to do something no one else has done. It was exciting.”

There’s Always More to Learn

Mandatory CME programs began to pop up across the United States back in the 1930s, once it was recognized that the initial training of physicians wasn’t enough to sustain them through their long careers. Patients would be better served, it was thought, if their doctors continued to learn over the years. That philosophy has proven ever more relevant as the responsibilities of modern physicians have mounted. Physicians today not only care for the sick and injured, but also find themselves with additional responsibilities, most often as teachers, administrators, researchers, and advocates. Learning all these skills—on top of those needed to treat patients—would be impossible during the relatively short term of medical training. And new information and procedures always arise.

Without CME, it would be difficult for physicians to keep fresh and updated. Shari Whicker, Ed.D., director of the Office of Continuing Professional Development, of which CME is a part, looks at the issue from the perspective of health care delivery. “While it may be imperceptible to them, CME matters to patients,” Dr. Whicker says. “They expect the level of expertise that CME helps provide. When they come in, they expect their physicians and health care team to have answers. While providers are never going to be all-knowing, it’s absolutely critical for them to stay up with the latest technologies and information so they can provide the best possible care.”  

“One would hope that if you’re educating a physician on a new technique or practice,” Dr. Dallas adds, “then on the very next opportunity the physician has to see a patient with a relevant condition, there’s the potential that the patient will benefit.” He offers the emergence of new medications as an example. If a physician learns during a CME course that a new anticoagulant has come onto the market that causes less bleeding and is better at preventing clots than older therapies, then that doctor can immediately switch patients to the better agent. Similarly, if physicians learn that a new antibiotic is available, they’ll know they can prescribe it if other treatments fail. Carilion’s portable ultrasonography course provides additional instances.

Dr. Dallas notes that one student used the tool days after taking the course to identify the location of a dangerous clot. Anotherdiagnosed fluid buildup around the heart of a woman who was suffering from low blood pressure. “There have been cases,” he says, “where a physician has been able to help a patient in a significant way by having attended one of our CME courses.”

TEACH to Learn

With physicians’ responsibilities increasing, and with medical and scientific knowledge growing at exponential rates, CME has had to keep pace.Dr. Dallas reports that, in his time as CME director, Carilion has gone from offering 7,000 credit hours each year to more than 80,000 hours—an increase of about 20 percent each year.

Some of that increase can be traced to the growth of the Virginia Tech Carilion School of Medicine, which has brought more students, residents, and fellows into the system, creating an even greater demand for instruction. In tandem, and through collaboration with the Virginia Tech Carilion School of Medicine and Jefferson College of Health Sciences (now Radford University Carilion), Carilion has recognized the importance of support for quality teaching. That commitment is exemplified by the Teaching Excellence Academy for Collaborative Healthcare (TEACH). The program, which Dr. Whicker directs, brings together faculty and other professionals at Carilion united by the common thread of teaching within the health professions.

The academy provides organizational support, opportunities for networking and collaboration, and recognition for medical experts whose educational roles are too often overlooked. It’s hoped that some additional CME programming might continue to come out of the collaborations and training provided by the academy. Still more stems from existing trainings offered by individual departments.

“Almost every department has a requirement to teach residents and fellows. If their trainees can benefit from it,” Dr. Dallas says, “then we ask: why not make it so other physicians can benefit from it also and get CME credit?” Additionally, Carilion’s CME program offers various conferences and symposia, including a spring symposium that has, for the past 70 years, offered a concentrated mix of interdisciplinary training for interested Carilion physicians.

“We conduct regular needs assessments to see where our gaps are and what our faculty and professionals need to learn more about,” Dr. Whicker says. “Once we establish what those needs are, we seek experts who can provide that training internally and, if necessary, we’ll bring in outside experts to fill those gaps. This is true when it comes to teaching, as well as a variety of other developmental needs that reach our physicians and other health care providers.”

Dr. Whicker adds that topics include basic research, quality improvement, communication skills, team-building, well-being, and anything else that will improve the patient and learning experiences throughout the organization.

Crossing Borders

In Virginia, physicians are required to accrue 60 hours of CME every two years. Although requirements vary by state, it’s safe to say that demand for training nationally is high. Carilion is doing its part. While most of its offerings cater to physicians within the Carilion system, many courses allow physicians from all over Virginia, neighboring states, and the country to train as well. Past conferences have even attracted doctors from abroad. And Carilion has projected outward. Some courses—particularly those that are unique or in high demand—are taught outside of Carilion’s walls.

The portable ultrasonography course that Carilion designed—a detailed, hands-on, CME program first offered to critical care physicians at Carilion—proved so popular that it gained national attention. In addition to extending the program to primary care physicians and others, the experts who taught it were ultimately asked to design a portable ultrasonography course for the Society of Critical Care Medicine and, later, the American College of Physicians. Carilion faculty also teach courses nationally that weren’t developed through the CME program, yet depend on a faculty member’s unique expertise. Joseph Moskal, M.D., chair of Orthopaedics, for example, teaches courses on an anterior approach for total hip replacement surgery that he helped pioneer. Surgeons from across the globe have visited Carilion to learn the procedure, which allows access to the hip socket without cutting through major muscle groups, potentially speeding recovery. Dr. Moskal has also taught the technique in Europe. Similarly, Carilion’s chief of Otolaryngology, Benjamin Cable, M.D., is one of only three experts nationally who teach surgeons how to performsialoendoscopies in children.

The minimally invasive surgery has been shown to be a safe and effective treatment for obstructive salivary gland disorders. And the reach of Carilion’s program extends even further. Classically, CME has been defined as “by physicians, for physicians.” Yet the Carilion program has, over the past several years, committed to extending offerings to other health care professionals, such as nurses, physical therapists, and physician assistants.

“So many of the courses we offer are valuable for other health care professionals, and we don’t see a reason we should ever limit it,” Dr. Whicker says. She emphasizes that, as health care professionals increasingly work together on teams, it’s essential that they work from a shared knowledge base. “As health care evolves, interprofessionalism becomes even more critical to patient care, and if we’re not learning in the same way we’re practicing, we’re losing a lot,” she says. “It’s important to tear down the walls, engage in conversation together, and learn from one another.”

By Veronica Meade-Kelly

Family physicians would serve as the hub of a patient’s care, providing most of it themselves, emphasizing prevention, and coordinating referrals to other specialists. But to train this new kind of doctor in outpatient medicine as well as in the business side of running a medical practice, Roanoke Memorial needed to create something entirely new. It established the Family Practice Center, a medical office carved out of the hospital’s warehouse.

“The heart and soul of the family practice residency was this model unit, which was only the second such family medicine practice in the state,” recalls Francis Amos, M.D. The first graduate of the hospital’s family practice residency, Dr. Amos became associate director of the program. To jumpstart the Family Practice Center, Dr. Amos combed the hospital’s outpatient records and gave patients the welcome news that they could be part of the new practice. Making appointments would be much more convenient, waits would be shorter, and they would be able to establish relationships with their own personal doctors rather than seeing whatever physician happened to be on duty in the emergency room or in the hospital’s outpatient clinic.

Yet family medicine was so new a specialty that Dr. Amos and directors of the handful of other family practice residency programs nationwide had few guidelines to follow. Often they would gather at the American Academy of Family Practice’s headquarters in Kansas City to swap ideas on how best to train residents. With emergency medicine not yet a specialty, part of that training called for family practice residents to take shifts in the ER. If they needed help, they would call their faculty mentors, and Dr. Amos remembers a July 4 boating accident that landed eight people in the ER. “The resident and I sewed lacerations all night, splinted broken bones, and admitted those with internal injuries,” he says. “Working in the ER was an incredible learning experience for our family practice residents.”

A Magnet for New Physicians

But Carilion Roanoke Memorial’s pioneering work in family medicine was just one of many efforts, begun in the 1930s, to give new doctors the skills they needed to provide high-quality care to the community. Continuing that tradition, last summer Carilion Clinic, which now includes Roanoke Memorial as well as six other hospitals, welcomed 300 physician trainees to 26 residency and fellowship programs. During their training, these new residents and fellows will play an essential role in serving the health system’s one million patients in southwestern Virginia and southern West Virginia. They’ll also be trained according to standards set forth by the Accreditation Council for Graduate Medical Education.

“Training requirements for accreditation are now big documents, not the few pages that existed when I was a resident in the mid-1980s,” says Donald W. Kees, M.D., vice chair of pediatrics and designated institutional official for graduate medical education at Carilion. “All programs now have common training requirements that govern such issues as the number of hours a resident can work, patient safety standards, and how residents, faculty, and programs are evaluated.”

Many residents and fellows who have trained at the health system’s hospitals stay on after they complete their training, joining Carilion’s medical staff and establishing practices in underserved areas. “Every year, about 30 percent of our trainees remain with Carilion when they finish residency or fellowship,” says Dr. Kees. “Compared with other rural areas, we have a large number of primary care doctors and specialists available to our patients.”

Over the past several years some difficult-to-recruit specialists—including, for example, two child psychiatrists and an addiction medicine psychiatrist—have stayed to practice in the region after training at Carilion. The neurosurgery residency has brought four additional neurosurgeons to the community. Several graduates of the emergency medicine residency, a comparatively new addition to the hospital’s offerings, have chosen to practice at Carilion, eliminating the need for locum tenens emergency physicians in some of the system’s hospitals. At the same time, the residency programs have drawn many accomplished practicing physicians to the Roanoke area.

They come expressly for the opportunity to train young physicians. “If we didn’t have residents at Carilion, we wouldn’t have the quality of faculty that we have,” says Daniel Harrington, M.D., vice president for academic affairs at Carilion and vice dean of the Virginia Tech Carilion School of Medicine. Dr. Harrington, who established a psychiatry residency at RoanokeMemorial in 1990, led graduate medical education at the hospital for many years before taking his current position. Residents and fellows also affect the quality of care for Carilion patients through the research they conduct as part of their training. Most residents participate in quality and patient safety research projects with a faculty mentor. In recent years, those projects have resulted in quality improvements such as putting alerts in electronic health records to prevent the ordering of MRIs for patients with pacemakers and standardizing the placement of inferior vena cava filters in patients at risk of blood clots. Some residency programs and all fellowship programs at Carilion also require research in the physicians’ medical specialties.

Joshua Eikenberg, M.D., for example, recently received national recognition for a study he conducted of patients who had undergone Mohs surgery for their skin cancer. The dermatology resident found that physicians’ perceptions of their patients’ pain influenced their opioid-prescribing practices and that patients who received opioids were no more satisfied with their pain treatment than those who did not receive the addictive painkillers.

A History of Education and Service

The first interns at Roanoke Memorial Hospital arrived in 1933, but it wasn’t until 1946 that the American Medical Association, then the accrediting body for graduate medical education, put its stamp of approval on the hospital’s internship program. At the time, general practitioners could hang a shingle for their own practices after a one-year hospital internship. World War II had emptied medical schools, and practicing physicians were called to active duty, leaving Roanoke Memorial with just nine staff doctors and interns during the war. By the late 1940s, the hospital had four interns who were paid $90 to $150 a month, plus room, board, and laundry. In the 1950s, as medicine became more sophisticated and specialized, hospitals created residencies to extend and deepen the training of new doctors.

Roanoke Memorial established residency programs in surgery, pathology, internal medicine, and “crippled children’s orthopedics” between 1956 and 1961. In 1968, the hospital created a one-year general practice residency and the general surgery residency program expanded to four years. Then came the family practice residency. The hospital, as a leader in the new specialty, had no trouble recruiting physicians.

“We were in demand from the very beginning, because there were so few family practice residency programs,” says Dr. Amos. “And even though family practice residency programs at university medical centers had prestige, many young doctors preferred to come to Roanoke Memorial because community hospitals were a better fit for the medical experience and type of patients they wanted to care for.” Another drawing card for Roanoke Memorial was that the hospital’s specialists eagerly participated in teaching family medicine residents, and generalists practicing in the community routinely volunteered days off to train the young doctors in the Family Practice Center.

“Those senior physicians had invaluable experience and guided the residents, seeing patients right alongside them,” says Dr. Amos, who continued to supervise residents once a week after he established his own practice in Rocky Mount, 30 miles south of Roanoke. In anticipation of Dr. Amos’ retirement in 2014, a Carilion family medicine resident joined the practice to help smooth the transition.

A Continuing Commitment

The creation of the Virginia Tech Carilion School of Medicine, started in 2007 and opened in 2010, solidified Carilion’s path toward becoming a major academic medical center. The system’s hospitals have continued to add faculty and have expanded into new areas of subspecialty care. “Between 2006 and 2007,” says Dr. Harrington, “we had phenomenal growth in the number of residency and fellowship programs we offered.”

Yet Carilion’s continued development of residency and fellowship programs has required an exceptional commitment to the mission of educating physicians. The primary funders of graduate medical education—the Centers for Medicare & Medicaid Services and the Veterans Administration—subsidize residents’ salaries and pay hospitals to train young physicians. In 1997, though, CMS capped the number of residency positions it would support at each hospital, leaving the institutions to cover the cost of any additional residencies. Carilion stepped into the breach, and today, when those 300 new trainees start working at Carilion this summer, the government will fund the training of only 190 of the residents and fellows. Carilion will pay the remaining 110 physicians’ salaries and training costs.

“Training those additional physicians affects our bottom line,” says Dr. Kees. “But Carilion is committed to providing the region with high-quality primary and specialty care.” And the residents and fellows continue to repay that investment handsomely.

“I’m so impressed with the caliber of physicians entering residency and fellowship programs today,” says Dr. Harrington. “As U.S. medical schools have increased the standards required for graduation, these doctors have become increasingly well-prepared to practice medicine when they join clinical settings.” And just as trainees emerge from their time at Carilion’s hospitals as better doctors, having been educated by a multitude of specialists and subspecialists, the faculty benefit as well, with residents and fellows challenging them to become better teachers and communicators, adds Dr. Harrington. And most important, patients benefit from better and safer care when all of their physicians are at the top of their game.

Wellness for Residents

Nine years ago, neurosurgeon Gary Simonds, M.D., was worried about the seven residents in the neurosurgery training program at Carilion Clinic. Dr. Simonds, who established the residency program in 2006 and ran it until his retirement this year, knew these young physicians were under constant stress, and when he asked them to keep a tally of what happened to them in a typical day, the results were eye-opening. During each night on call, a resident might need to handle scores of urgent phone calls, and a week in the hospital often included at least a hundred interactions with patients who were seriously ill or dying. Conflicts with coworkers were common, and the residents rarely heard a word of praise. The survey responses confirmed Dr. Simonds’ suspicion that residency was taking an unnecessarily heavy toll on these doctors’ lives.

“Rather than assume that residents just needed to toughen up,” Dr. Simonds says, “I wanted to change our approach and arm them with techniques to mitigate the burden.” So, in partnership with clinical psychologist Wayne Sotile, Ph.D., an expert on resiliency and physician work/life balance, Dr. Simonds instituted monthly meetings with the residents and the entire neurosurgery team to develop and practice techniques for coping with stress.

“That Carilion supported and encouraged this intensive effort to improve resident well-being was unprecedented; no other medical center was doing anything like it,” says Dr. Simonds. Soon, other Carilion residency programs were consulting with Dr. Simonds and Dr. Sotile, and in 2015 the two published a guidebook of their techniques, which mostly involve small adjustments in attitude and outlook. Yet the changes seem to make a big difference in how residents perceive their training.

“Physicians are so focused on taking care of patients that they fail to recognize when they’re overstressed and fatigued,” says Dr. Simonds. Today, thanks to this training, Carilion’s neurosurgery residents seem happier and less stressed. Once subject to complaints from coworkers and patients for being short-tempered and abrupt, now they get compliments, and they’ve been recognized as the best consultants in the emergency room. “They are light-years from where they once were,” says Dr. Simonds.

By Anita Slomski

“When you’re starting from scratch, you have a big advantage,” says Daniel Harrington, M.D., vice dean of the medical school and vice president for academic affairs at Carilion Clinic. “You’re able to create something that is different.”

And it’s that word—different—rather than small or young, that perhaps best describes the school. In less than a decade since it welcomed its first class in 2010, Virginia Tech Carilion has earned national recognition for innovation. The medical school has reached for bold, new approaches to every aspect of creating new clinicians, from how it admits applicants to how it instructs them to how they interact with the community around them.  At a time when doctors must stay current with dizzying technological and biomedical breakthroughs, the need has never been greater for clinicians to be sensitive to the human side of medicine. The product of a partnership between Virginia Tech, a renowned research institution, and Carilion Clinic, a health care system with a long tradition of community-based medicine, the Virginia Tech Carilion School of Medicine seems almost uniquely qualified to produce doctors with abundant skills on both sides of that equation. The process begins with the application.

Finding the Best Candidates

From the start, the school’s leaders believed that traditional admissions benchmarks such as academic grades, standardized test results, and formal interviews—while important—failed to reveal key characteristics about which candidates have not just the work ethic and technical skills, but also the human skills required to be effective clinicians.

To help admissions officers gauge those vital qualities, applicants—who now average more than 4,000 for those 42 annual spots—undergo a “multiple mini interview” process, originally developed at McMaster University in Hamilton, Ontario. Virginia Tech Carilion was among the first U.S. schools to recognize its advantages. Applicants arrive in Roanoke over a weekend, where they have the opportunity to meet and mingle with faculty members, administrators, and current students and learn about the school’s patient-centered curriculum. But the heart of the weekend is a full Saturday of one traditional interview and nine decidedly nontraditional interviews.

For the nontraditional sessions, applicants rotate through interview stations. At each one, the applicants read a brief scenario that evokes a medical or ethical question. They then enter a room to have an eight-minute conversation with a member of the community to share their thoughts about the scenario.

 “The interviewer might be a faculty member, a minister, a retired physician, a teacher, or a shopkeeper,” says Dr. Harrington. “That person won’t have seen the student’s CV or background.”

All interviewers have an interest in the medical school and are trained in the interview process. Otherwise, though, the conversations are unscripted, without right or wrong answers. According to Richard Vari, Ph.D., senior dean for academic affairs, “This process gives the interviewer an inside look into the student’s ability to think quickly, reason through a problem, and perform under stress.” Questions and follow-ups can help determine how, for example, a student responds to being put on the spot—with equanimity, or by becoming combative. All of this amounts to much more than a feel-good exercise in community relations. Applicants who excel across the multiple mini interviews can rise to the top of the pool, in some cases ahead of those whose college grades and board scores are better.

The Human Side of Medicine

Once the interviews and the application process have yielded a carefully chosen class, the students begin their journey through the medical school’s four “value domains”—basic science, clinical science, research, and interprofessionalism. These form the basis of the school’s approach to medical knowledge and clinical skills, woven throughout all four years. A central tenet of Virginia Tech Carilion’s educational philosophy is developing compassionate and scientifically minded future physicians, and one way this happens is through problem-based, patient-centered learning.

“We teach clinical skills and clinical reasoning from the very first day of medical school,” says Dr. Vari. “It’s not saved for years three and four, as in some schools.”

Working in groups of seven, students meet three times a week to learn about actual patient cases. The focus at first is on science and clinical diagnosis. When the students are studying the cardiovascular system, for example, they may be presented with a case study of a patient dealing with a cardiac or systemic vascular condition.

“By examining the case, the students uncover all they know about the cardiovascular system—the anatomy, the physiology, the pharmacology,” says Dr. Vari. “More important, they uncover what they don’t know.”

Over the course of the week, the students research the condition on their own, then present back to the group, offering one another constructive feedback on the strengths and weaknesses of their reasoning. After a final team discussion on Friday, next comes a crucial step—the chance to meet the actual patient who has been the subject of the week’s study. According to Dr. Vari, it’s a chance to drive home to medical students that the enzymes, blood type, heart rate, biochemistry, and pharmacology they’ve been analyzing all week add up to someone with a life, a job, a family, and emotions.

“What they’re now exploring is the human side of this patient who happens to have this disease,” says Dr. Vari, who adds that less than 5 percent of medical schools are able to offer patient wrap-ups. “It puts the learning of their basic science, clinical reasoning, clinical skills, research, and interprofessionalism in the construct of a real human being.”

“It’s a wonderful way to learn,” Dr. Harrington says. “Our students have thrived with this model.”

Vital Community Connections

Members of the community play an important role in helping students learn how to interact with patients, ask questions, and diagnose conditions. The medical school’s 10 exam rooms serve as home for the standardized patient program, where students, starting in their first year, examine “patients” simulating conditions the students are currently studying. While the standardized patients undergo significant training in order to represent various conditions, they do not necessarily have medical backgrounds, says Tracey Criss, M.D., associate dean for clinical science, years 3 and 4.

“The program brings a sense to the community that our standardized patients are part of educating our students,” Dr. Criss says. “Community members really feel like a part of the school. They’re helping educate the students to be better caregivers, as physicians, when they graduate.”

As the students proceed through their years, the simulated situations become more complex, testing both their medical acumen and their ability to handle delicate and often emotional situations, including issues involving quality and safety. Dr. Criss describes one scenario in which a student must inform a patient and a family member that, due to medical error, a chest tube has been inserted on the wrong side of the body. In the tenseness of the moment, the fact that the patient and family member are playing roles seems not to matter.

“Our students don’t know, when they walk in the room, how that simulated patient and family member are going to react,” Dr. Criss says. “Sometimes they respond with calmness and sometimes with fear, anxiety, and anger. Students have to spontaneously react to the emotions of that patient.”

Research as a Core Requirement

Research, something not always prioritized at other schools, plays an integral role at the medical school. Regardless of the medical specialties they hope to pursue, all students must become “scientist physicians”—a term coined by Michael Friedlander, Ph.D., senior dean for research at the medical school, to describe both the primacy of the doctor’s calling and the essential role that research plays in it.

Research is central to all four years of training, totaling more than 1,200 curriculum hours. In years 2 through 4, each student is allotted $1,000 a year for supplies, and each is expected to produce an original research project starting in the first year, culminating with a final manuscript of publishable quality in the fourth year. The need for that emphasis may seem obvious for someone bound for a career at a major teaching hospital. But why so for someone hoping to serve as, say, a primary care physician in rural Virginia? As Dr. Friedlander sees it, training students in a scientifically rigorous context aims to create a more complete clinician.

“You approach all your patients and all medical situations from a human perspective, but also from a rigorous scientific perspective,” says Dr. Friedlander, who also serves as executive director of the Fralin Biomedical Research Institute at VTC. “You are versed in the most contemporary scientific understanding of the patient’s condition, and you have actually done biomedical research. Moreover, when you don’t know the most scientifically validated approach to a particular issue, you have the skills, confidence, and knowledge to find that information and deploy it on your patient’s behalf.”

Dr. Harrington adds, “By the time students graduate, they understand how to ask questions and are skilled in finding the answers.” That idea dates back a decade or more, when Dr. Friedlander, then a faculty member at the Baylor College of Medicine, served on a national task force of the Association of American Medical Colleges and the Howard Hughes Medical Institute dedicated to the scientific foundations of future physicians.

“Medical education was not keeping up with the scientific revolution in the biomedical science space,” he recalls. “There has been a revolution in molecular biology, molecular genetics, neuroscience, computational bioscience, and other areas. Even as advances were profoundly influencing how medical conditions are diagnosed, medical schools were still teaching medical students the same old way.”

Dr. Friedlander saw the opportunity to help forge new approaches to teaching at the foundational level of the nascent school. “From day one, students are exposed to possibilities for doing research,” he says. “They meet researchers from the Fralin Biomedical Research Institute and the main Virginia Tech campus in Blacksburg, research–oriented physicians from Carilion Clinic, and leading scientist physicians who visit from across the country to present the latest advances while aligning with the students’ current classes and patient case presentations.”

The results have been impressive, with students involved in nearly 60 published papers and more than 250 presentations at regional, national, and even international medical meetings. “We think we’re putting out something the country badly needs,” Dr. Friedlander says. “Even with all the new algorithms and electronic medicine, electronic health records, and computational capabilities, we need people who understand the science of medicine and are ready for the next big changes.”

Learning Across Professions

Even as Virginia Tech Carilion strives to create superior individual clinicians, a key driver of the school’s educational philosophy is that no doctor is an island. Studies have shown that flawed communication among health care professionals accounts for some 70 percent of medical errors. With that in mind, the school became the first in the country to integrate interprofessionalism across its entire, four-year curriculum. In conjunction with another pioneer in adopting shared learning—Jefferson College of Health Sciences, now known as Radford University Carilion—future doctors study with tomorrow’s nurses, physician assistants, and allied health professionals.

“They’re learning roles and scopes, conflict resolution, and team-oriented best practices,” says Dr. Vari. Teamwork, he notes, increasingly personifies “the art of medicine and the practice of medicine.” The students examine ethical dilemmas in health care, approaches to leadership, and strategies for overcoming personal biases and other issues.

“It’s preparing them for the real world of health care where they’re going to have to work with colleagues who aren’t physicians,” Dr. Vari says. In some cases, lessons in teamwork and empathy move beyond the confines of medicine. As one part of the program, for example, students work together to prepare nutritious meals for needy members of the Roanoke community. In one of the most intensive exercises, the medical students work with students in other health professions on disaster drills. Administrators may simulate the aftermath of a serious interstate accident, a terrorist attack, or a natural disaster. Students, given pieces of information, must respond in real time, assess the condition of trained “patients,” and, most of all, work together to solve problems and save lives.

“They’re paying a lot of attention to the patient, and at the same time they’re gathering information from other team members,” says Dr. Criss. “What you see is students recognizing the value of the team approach.”

Innovation Across the Board

These creative approaches to medical education foster a spirit of innovation that permeates the school. In 2010, for example, Virginia Tech Carilion, with the support of Sonosite, Inc., integrated advanced portable ultrasound machines into the curriculum, enabling students to master an evolving technology that will be essential to their ability to offer patients the best care. In 2018, the school purchased newer, state-of-the-art portable ultrasound equipment to enhance the students’ mastery of the skill.

The school is also one of the few in the country to make oral health part of the curriculum, thanks to philanthropic gifts and a partnership with Delta Dental of Virginia, amid growing awareness of the key role that oral health plays in a patient’s overall well-being. The drive to innovate is sure to continue under Virginia Tech Carilion’s new dean, Lee Learman, M.D., Ph.D., who sees the school’s size and youth as major advantages in advancing the mission of innovation guided by its goals to create new doctors for a new world. Where will this grand new experiment in medical education ultimately lead? Ever the researcher,Dr. Friedlander says, “We don’t have enough data yet.”

It may take 15 or 20 years to determine whether Virginia Tech Carilion’s innovations are truly helping to produce better clinicians. But what he does hear are stories—and they’re great. “We hear wonderful, wonderful things,” Dr. Friedlander says. “Our graduates are star residents in their programs, highly regarded by the physicians mentoring them. And residents from other medical schools are wowed not only by their knowledge, but also their ability to move facilely between scientific discovery and the delivery of quality clinical care.” Dr. Learman agrees. “I anticipate that, over the next decade, we will go from being one of the most outstanding new medical schools,” he says, “to one of the most outstanding medical schools in the country, period.” 

A New Dean, Building on Success

When Lee Learman, M.D., Ph.D., took over the helm of the Virginia Tech Carilion School of Medicine this summer, he began with the intention of listening. “One of the most important aspects of my first year will be to think deeply about the strategic planning process for the school of medicine with broad stakeholder input,” the new dean says.

He’s looking at how the school might expand while keeping in place what makes it special—the individualized attention for students, the focus on research and patient-centered learning, and the strong connections to the community. With 25 years as a leader in medical education, Dr. Learman is no stranger to helping young medical schools succeed. He most recently served as senior associate dean for graduate medical education at Florida Atlantic University’s Charles E. Schmidt College of Medicine, which opened its doors in 2011.  

“I’ve always been attracted by several elements I see as high priorities at the Virginia Tech Carilion School of Medicine,” Dr. Learman says. “These include humanism and professionalism in medicine, as well as the scientific basis of medical practice.” Dr. Learman adds that he appreciates the school’s emphasis on its connections with the community. “A top priority will be deepening my understanding of our community,” he says, “and by that I mean not only the Roanoke community, but the larger community of people who care about this medical school and want to see it grow and succeed.”

By Charles Slack