Percent Distribution of Active Physicians in Patient Care by Speciality, 2005

Internal Medicine = 15.0%
Selected surgical specialties = 10.8%
Family medicine = 12.3%
Pediatrics = 7.5%
Anesthesiology = 5.2%
Psychiatry = 5.1%
All other specialties = 38.5%

Median Compensation for Physicians, 2005

Anesthesiology = $320,000
General surgery $283,000
OB/Gyn = $247,000
Psychiatry = $180,000
Internal medicine (general) = $166,000
Pediatrics = $161,000
Family practice = $156,000

New River Carilion Staff

Don Halliwill, Vice President/Administrator	contact through secretary: Monica Mines 731-2508
Dennis Means - Medical Director	731-2250 or 731-2020
Sr. Director, Nursing	731-2506 or 731-2020
Kathy Kinder, Sr. Director, Clinical Support Services	731-2005 or 731-2020
Regina Pennington , Sr. Director Clinical Effectiveness	731-2588
Bill Copening - Sr. Director, Facility Support Services	731-2869
John Schneider, Manager, Human Resources	731-2504
Sharon Honaker, Director, Strategic Development	731-2185 or 731-2094
Donna Downs, Manager, Finance	731-2836
Shane Blanchard, Director, Cardiology/Vascular Services	731-2980

 

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Carilion Health System, now known as Carilion Clinic, is a large, Roanoke, Virginia-based not-for-profit health care organization. Carilion owns and operates eight hospitals in the western part of Virginia. The company also operates primary care clinics, residency and fellowship programs, laboratories, health clubs, an aeromedical program, and sub-specialty medical practices. Carilion originated with Roanoke Memorial Hospital, which is located at the base of Mill Mountain in southwest Roanoke. The hospital eventually expanded into related health care services and the acquisition of other hospitals. Most prominent was the acquisition of the competing Community Hospital of Roanoke Valley in downtown Roanoke. The deal took several years to complete because of anti-trust concerns by the United States Department of Justice that two of the three major hospitals in the Roanoke Valley would now be under the same ownership. In the early 1990s, Roanoke Memorial adopted the name Carilion for its consolidated health care business. Approximately 6,200 of Carilion's 9,600 employees are in the Roanoke Valley, making it the area's leading employer.In addition to traditional hospital-based services, Carilion has established the Carilion Biomedical Institute in Roanoke in association with Virginia Tech and the University of Virginia. The Institute is a business incubator designed to introduce advanced medical devices into the marketplace. A related goal is the development of a cluster of such firms in the Roanoke area. One such company is Luna Innovations, which is partially owned by Carilion and has oved its corporate headquarters to the Institute's business park. Carilion's management has warned that trends in the health care sector threaten to undermine the organization's financial position. Carilion has gross revenues of approximately $2 billion per year and ran a $93.6 million surplus in the last fiscal year. In response, Carilion has announced plans for a significant business reorganization which will change its emphasis from running hospitals to hiring more doctors in a larger number of medical specialties, with a primary goal of better coordination of patient care and an emphasis on medical education and research. There are currently no plans to sell its eight hospitals. The plan was developed after visits to the Mayo Clinic and other similar organizations. As part of the reorganization plan, Carilion has renamed itself Carilion Clinic. Some local doctors have expressed concern that their independence could be eliminated and that the scale of the reorganization, if it is not successful, could imperil the organization and the quality of health care in the Roanoke area and have formed the Coalition for Responsible Healthcare to express their concerns.As part of the Carilion Clinic's focus on education and research, Carilion and Virginia Tech recently announced plans to establish a small medical school in Roanoke. Carilion currently operates the Jefferson College of Health Sciences which offers a master of science in nursing and 13 associate and baccalaureate allied healthcare programs.

FORCES THAT IMPEDE CHANGE

Psychological Forces	Thoughts and Habits that Limit Change
Pain versus Pleasure	The immediate pleasure of the habit (gambling) is more powerful than the delayed pain (financial ruin).
Fear of failure	“If I don’t change, I will feel even worse than I do now.”
All or nothing thinking	“I must lose 50 pounds; losing 10 pounds is unacceptable”
Unconscious conflicts—unaware of problems	We may repeat maladaptive behavior because we fail to recognize the destructiveness of our acts.
Change is unpredictable	The discomfort of the status quo may be preferred over the anxiety produced by change.
Resisting authority	“I don’t like anyone telling me what to do.”
An undesirable habit may provide unmet needs.	Drinking relieves stress. Physical abuse provides attention. Eating fills a psychological void.

Psychopharmacology Update Cymbalta for Chronic Pain

October, 2004           PSYCHOPHARMACOLOGY UPDATE    Volume 4 Number 5

The Dual-Mechanism Antidepressant, Cymbalta, in the Treatment of Pain

Almost 45% of patients with major depression have at least one painful physical symptom including limb pain, backaches, joint pain, and headaches. Abnormalities of serotonin and norepinephrine in the somatosensory cortex and the spinal cord contribute to an increase of painful response in depressed patients. Painful stimuli are more actively conducted up the nociceptive neurons of the spinal cord in depressed patients.  In addition, the descending neurons of the spinal cord responsible for diminishing pain reception fail to work efficiently in depressed patients.    

Studies have shown that dual-mechanism antidepressants—medications that increase the neurotransmitters serotonin and norepinephrine—are effective in treating certain pain syndromes associated with major depression. The dual-mechanism antidepressant, Effexor, targets only serotonin at doses below 150 mg/day and begins to effect norepinephrine (and serotonin) at doses above 150 mg/day.

Cymbalta, (duloxetine), a recently approved dual-reuptake inhibitor, shows relatively equal affinity for binding to both serotonin and norepinephrine across the entire dosage range. This equal affinity for serotonin and norepinephrine seems to enable Cymbalta to be effective in treating a wider range of pain syndromes and have a more rapid onset of action than previous antidepressants.

In one study, Cymbalta proved effective in relief of diabetic neuropathic pain symptoms at a starting dose of 60 mg/day. Several studies of patients with major depression and chronic pain complaints exhibited significantly greater reductions in pain severity after only one week of treatment. Such a rapid improvement in pain severity suggests that Cymbalta has a direct effect on the nociceptive neurons and the somatosensory cortex. Other studies have shown that Cymbalta seems to have a more rapid antidepressant onset of action than other antidepressants making it unclear whether the relief of pain is related to the medication’s antidepressants effects or the pain relief comes from the medication’s direct effects on pain centers.

Regardless of the exact mechanism of action, Cymbalta appears to have several unique characteristics: 1) It is a rapid onset antidepressant; 2) It seems to be an energizing antidepressant; 3) It is more likely to induce full remission of symptoms rather than partial treatment response more commonly produced by other antidepressants; 4) It apparently treats pain syndromes unassociated with depression.

The usual starting and maintenance dose is 60 mg given in the morning. Taking Cymbalta after breakfast can reduce the risk of nausea, a mild side effect most commonly cited during the first week of treatment. Other side effects include insomnia, headaches, somnolence, dry mouth and sweating.  Food does not alter Cymbalta’s absorption but delays maximum concentration by about 4 hours. Cymbalta is metabolized by the 2D6 and 1A2 isoenzymes of the cytochrome P-450 system so that co-administration of beta blockers, quinidine, cimetidine, other antidepressants and antipsychotics could elevate plasma levels of Cymbalta or the other agents. Some men taking Cymbalta have more difficulty reaching orgasm. The agent is contraindicated in those patients taking MAO inhibitors, those with narrow-angle glaucoma, hepatic insufficiency and end-stage renal disease. Gradual reduction in the dose is recommended rather than abrupt cessation in order to avoid the occurrence of discontinuation symptoms. 

MAKING CHANGE

There are two types of pain:  1) imposed suffering – acts of flood, fire, famine – that comes from outside our psyche; and 2) elected suffering – a sense of rejection, shame, guilt, loneliness – that we inflict upon ourselves.  Imposed suffering protects from the elected kind. The despair of the concentration camp crowds out the loneliness of a dateless prom night.

            The patient with cancer illustrates both kinds of suffering. First there is the imposed suffering cancer induces, the pain and sickness the illness renders. The second type of suffering – the elected kind—comes from our own feelings about the cancer.

            Patient and surgeon read from a different book. The surgeon removes the tumor, but fails to relieve the sense of vulnerability the patient feels from the inflicted cancer.

WHY PEOPLE CHANGE

            The Lower Ninth Ward in New Orleans experienced calamitous flooding from Hurricane Katrina in 2005. The storm surge came from the east via flooded Saint Bernard Parish and from the west through two large breaches in the Industrial Canal flood protection system, creating violent currents that smashed homes and tore them from their foundations. The storm became the costliest natural disaster in U.S. history. At least 1,836 people lost their lives in Hurricane Katrina and many more thousands were rendered homeless.

            A College Station resident commiserated with one of the Hurricane evacuees temporarily housed in a local church:

            “That must have been the most terrible thing that ever happened to you. You lost your home. You lost your clothes and all of possessions. You have no money. You can’t get in touch with your relatives. Your friends have been displaced. What a tragedy. How will you ever recover?”

            The evacuee replied:

            “Surely that storm was a terrible thing. I was scared and pretty well knew I was going to die. Then a boat came and they took us to the Superdome, and it was like the devil himself had come down and was torturing us. We were all crowded together and squashed-up. People were yelling and crying. It was hot and dirty. And we all got thirsty and hungry. It smelled bad and it seemed there was no hope for any of us. But somehow, we got rescued and took care of. And now here I am in this nice church. We have food. And water. And air conditioning. And good people are helping us and looking after us.

            Yes, that Hurricane was a horrible thing and I never want to go through nothing like that again. But, you know, that Hurricane—no matter all the bad things that happened—was the best thing that ever happened to me and I am thankful for it.

            I’m not discounting the bad things that happened to so many people and all the dead people and people who never will find their families, but for me that hurricane was good. If it hadn’t been for Katrina, I would have been trapped in the lower ninth ward for life. Before the hurricane, I had nowhere to go. I had no idea how to go. I had no money to go. I was just there and that was my life. But the big wind came and blew me to a better way of looking at things. And now I have a new life, a new start on life. I’ve got possibilities. Yes, thank God for Hurricane Katrina. I’ve got hope.”

THE TRAGIC FAILURE TO CHANGE

            Some people have difficulty changing because they are caught in financial or geographical traps. Let us consider those people, however, who have every opportunity to change, but, nonetheless, continue to engage in self-defeating behavior despite ongoing negative consequences:

Ø    Smoking, obesity, and alcohol abuse can lead to chronic illnesses and premature death. Despite ominous health warnings that are more certain than storm alerts from the National Hurricane Center, surveys by the Centers for Disease Control and Prevention show that very few people are willing to stop their self-destructive unhealthy habits.

Ø    20% of American adults smoke

Ø    More than 30% of Americans are overweight

Ø    15% of Americans are binge drinkers

Ø    People are often noncompliant to medical treatments

Ø    50-65% of Americans fail to follow their doctors’ treatment recommendations

Ø    10% of hospital admissions among older adults result from failure to follow doctors’ directions

Ø    Almost one-third of patients visiting a physician fail to get their prescriptions filled

Ø    A Case Western Reserve University survey showed that 54% of glaucoma patients failed to use their eye drops as directed even though these patients knew they would go blind unless they complied with their doctors’ instructions.

Ø    70% of patients receiving treatment at a community mental health center dropped out of treatment before the third visit.

Ø    Most serious attempts to maintain behavior change are unsuccessful. A University of Scranton study found that only 19% of those who had made a significant change in a problem behavior maintained the change when surveyed two years later.

Ø    People continue to engage in patterns of behavior—anger, violence, nagging, dependency, and jealousy—that are destructive to their relationships and their well being.

REASONS FOR LACK OF CHANGE

            EMOTIONAL AMBIVALENCE. A woman complained vociferously about her husband who controlled her. He wouldn’t let her out of the house alone. He wouldn’t let her drive a car. He wouldn’t let her visit friends. When asked why she didn’t leave her husband, the woman replied, “I love him so much.” When the woman was seen two years later. She had the same complaints about her husband. She remained married.

            CIRCULAR EXCUSES. Common explanations for lack of change become circular arguments. People may blame their resistance to change on stubbornness, an addictive personality, or self-destructiveness. An explanation for refusing to improve a situation may go this way, “Because my situation is hopeless, I can’t change.” The behavior is then used to support the explanation, “I can’t change because my situation is hopeless.”

            REBELLION. Telling someone to change often exacerbates the situation. A highly directive approach causes a person to adamantly resist change. One study showed that the more alcoholics were directed to change the more they drank.

            INERTIA. Systems resist change. Physicists call this resistance to change “inertia.” The first law of motion indicates that people, like objects, tend to keep on moving if they are moving and remain standing still if they are still.

            BLAMING. It is easier to make excuses for our problems than it is to assume responsibility for our own behavior. The statement “If she didn’t nag me so much, I wouldn’t drink,” is an example of blaming others.

            LEARNED HELPLESSNESS. Put an animal in a cage. Apply a mild electrical shock all over the floor of the cage. When the animal discovers that escape is impossible, the animal lies down and passively in the corner of the cage and accepts the shock. Then the electrical shock is applied only to the corner where the animal is lying. The other areas of the cage are shock free. The animal continues to stay in the corner. Humans that are constantly exposed to conditions from which there appear to be no escape will eventually give-up and surrender to the situation.

TWO REASONS PEOPLE CHANGE

1.     Pleasure—realizing that new behavior patterns will produce more pleasure than maladaptive behavior patterns brings change. Believing that we can have a better life engenders different approaches. The power to visualize a successful outcome gives the courage to try new ways of doing things.

2.     Pain—understanding that maladaptive behavior causes intolerable distress stimulates an alternative lifestyle. Drastic environmental consequences may be required before inertia can be overcome. Imprisonment, financial ruin, homelessness, or the treat of death may be necessary before transformation occurs. Allowing a person to suffer may be the best way to generate change.

BENEFITS OF CHANGE

            We, as individuals, feel helpless in a sea of social turmoil where a single life raft offers little expectation for smooth sailing. A harmonious bulwark of social, cultural and spiritual safeguards provide the safest harbor from violent storms. A safe culture would provide:

1.     Children raised by two parents.

2.     A society that discourages a sense of entitlement.

3.     Recognition of individual uniqueness unassociated with power, beauty, and wealth.

4.     A spiritual foundation that offers love, joy, peace, kindness, and generosity.

5.     A culture that encourages and offers a work opportunity for each adult to provide sustenance for themselves and their families.

6.     A society that expects everyone to assume responsibility for his or her own behavior.

7.     More negotiation, less litigation.

8.     A society that recognizes that some people are more talented than others and at the same time a society that appreciates the less talented as much as the gifted.

9.     Respect, concern and the best of care for the mentally

10.  Entertainment that lifts the spirit and lightens the heart, rather than entertainment that celebrates violence and social deviance.

11.  Communities and small groups that regularly meet together to encourage one another and to stimulate loving friendship and good works.

12.   Cultivation of empathy and respect for others.      

 

Psychopharmacology Update August 2004

August, 2004           PSYCHOPHARMACOLOGY UPDATE    Volume 4 Number 4

Diagnosis and Treatment of Bipolar Disorder

In 1976 Dunner and colleagues proposed two categories of bipolar disorder (manic-depressive illness). These categories were named bipolar I and bipolar II.

Diagnosis of Bipolar I Disorder:

Bipolar I disorder is characterized by depressive episodes alternating with manic episodes.  A manic episode is associated with grandiose psychotic features and danger to the self and, perhaps, to others. The severity of the symptoms usually demands that the patient be hospitalized for treatment.

Diagnosis of Bipolar II Disorder

Bipolar II disorder is characterized by depressive episodes alternating with hypomanic episodes. There exists some confusion regarding the term "hypomania" (below mania). A hypomanic episode is unassociated with psychotic features. Instead, a hypomanic episode is characterized by a 4-day (or more) period of persistently elevated, expansive, or irritable mood. The symptoms of hypomania can be characterized by the acronym DIGFAST:

• D = Distractibility
• I   = Insomnia
• G = Grandiosity
• F = Flight of ideas
• A = Activity in unexplained burst of energy
• S = Speech that is fast, pressured, hyperverbal or interrupting
• T = Thoughtlessness that leads of risk taking behavior such as inappropriate sexual liaisons, spending more money than suitable or driving fast/recklessly.

Distinguishing between Recurrent Unipolar Depression and Bipolar II Depression

Because bipolar II patients often demonstrate several episodes of depression before an initial hypomanic episode, patients with bipolar II depression may be falsely diagnosed as having recurrent unipolar depression. When compared to unipolar depressed patients, bipolar II depressed patients are more likely to have the following characteristics:

1.     Family history of mania,  bipolar illness or substance abuse

2.     Earlier age of onset of depression (adolescence or early 20s)

3.     A higher number of depressive episodes 

4.     Mood swings

5.     Non-response or agitation on antidepressants

Rapid Cycling

Rapid cycling, defined as the presence of 4 or more mood swings in a year, is much more prevalent in bipolar II patients than bipolar I patients. Brief, frequent episodes of depression are highly suggestive of rapid cycling bipolar II disorder. Antidepressants can exacerbate rapid cycling. Antidepressants can also precipitate a manic crisis in depressed patients that have undiagnosed bipolar illness.

Treatment

Depakote possesses antimanic effects, but more moderate antidepressant effects.

Lamictal is effective in the treatment of depression in bipolar disorder. 

Lamictal + Depakote may be required in combination to stabilize rapid cycling.

Lithium functions poorly in rapid cycling patients; and because the therapeutic dose of lithium is close to the toxic dose, lithium treatment must be used with caution, if at all.  

Hitch Hiking to Seattle

I didn’t want to leave the orphanage, but if I had to go I thought I would go in style. I packed my suitcase. I also packed my trunk and I had a duffle bag full of clothes. Father Martin a tall, thin man with an Adam’s apple bigger than his neck drove me to the Highway 59 intersection with Timber, the busiest street in Ruskin. I stuck out my thumb and turned the suitcase with the sign

SEATTLE OR BUST

            I was nervous and somewhat embarrassed as cars whisked by. After about 10 minutes, I was about to think I would never get picked up. I laugh when I write this because later I would wait 10 hours and remain determined to stand out on the highway until I got a ride.

            A car pulled up. I remember President John F. Kennedy’s words: “We stand today on the edge of a new frontier—the frontier of the 1960s, a frontier of unknown opportunities and perils, a frontier of unfulfilled hopes and threats.” During the election of 1960, my friend Joe Clarke whose father was Chief Operating Officer of the Ample Paper Mill was for Nixon. I later learned the difference between Republicans and Democrats. Republicans favored business. They were for low taxes and small government. The Democrats were for the little man; high taxes on the rich, and making hard workers pay the way for ner-do-wells. I supported Kennedy for President because he was handsome and vigorous appearing. Joe Clarke talked about ideology. I didn’t know what to say except I liked Kennedy. I didn’t want to say that I liked him because he looked more Presidential and didn’t sweat on television so I just said, “I like Kennedy the best.”