Top Doctors 2010: The Evolution
Medicine keeps moving forward, thanks to practitioners such as these.
(To download the complete 2010 Top Docs list, click here.) (932KB)
The bad news: Conditions such as diabetes, high blood pressure and heart disease—not to mention a fair amount of mental stress—are on the rise. The good news: They’re more manageable and treatable than ever. Here’s what several of the most respected physicians in the state have to say about our health and their help. It should make you feel much better.
(Note: The physicians named in the Top Doctors list earned the greatest number of nominations in a survey of their medical peers. Physicians profiled received the most votes in their respective categories. Many excellent practitioners did not make the list. Their exclusion should not diminish their fine reputations.)
With 25 nephrologists and 11 nurse practitioners, Nephrology Associates is one of the largest practices of its type in the Mid-Atlantic. Named an exemplary practice in 2008 by the national Renal Physicians Association, Nephrology Associates is led by Robert Cox.
Perhaps the biggest change in Cox’s 30-plus years as a nephrologist has been the growth in the number of patients on dialysis. “When I first started practicing, there was one outpatient and one inpatient dialysis facility to cover the entire state, and there were only 100 patients on dialysis,” Cox says. Today more than 1,300 Delawareans are on kidney dialysis. There are 20 outpatient units, and every hospital in the state has an inpatient unit.
Why the dramatic increase? Reasons include a better understanding of kidney disease, greater availability of dialysis and more older patients choosing dialysis. But the biggest reason is an epidemic of chronic kidney disease in the United States that is related directly to the dramatic increase in diabetes, much of it caused by obesity.
According to Cox, of the 20 million Americans who have chronic kidney disease, 350,000 require dialysis. A number of advances have been made to treat these patients. Delawareans, for example, can now have kidney transplants at Christiana Care Health System through a program started with Nephrology Associates several years ago.
New, smaller dialysis equipment makes it more feasible for patients to dialysize at home, an option Cox expects more people will choose. Home dialysis not only allows a patient more freedom, it also encourages compliance, he says.
Cox expects that as soon as 2015, “wearable artificial kidneys” will begin to eliminate the need for cumbersome dialysis machines. The patient will be able to strap on the WAK and go about his or her normal routine while dialysis is performed continuously for eight to 12 hours.
All such advances in the treatment of advanced kidney disease are wonderful, but the real goal of Cox and his fellow practitioners is to keep patients healthy enough to avoid the need for dialysis or transplant in the first place. High cholesterol, high blood sugar and high blood pressure all contribute to kidney disease, so it is vitally important to control these conditions. Newer, improved drugs for these conditions help tremendously, Cox says—if people take them.
Page 2: Gilbert Leidig Jr. | Cardiology
Top Doc Gilbert Leidig Jr. of Cardiology Physicians in Newark and Wilmington believes that a doctor’s life experiences have a huge effect on how he practices medicine. One of Leidig’s most significant experiences was his 12 years as an Army doctor, when he learned both the drawbacks of single-provider health care (lots of waiting in line) and the benefits (doctors working hard with highly motivated patients to provide cost-effective, quality care).
The Army’s medical system, he says, instilled a can-do attitude in him. “You want to do your best for the service members because of what they give for our country,” he says. Though his current patients are civilians, Leidig continues to focus on prevention and on connecting with those in his care. “The better the listener, the better the physician,” he says.
The good news in heart health is that fatalities from heart attacks are down and patients with heart disease are living longer, more productive lives. Leidig points to several improvements in testing and treatment that have made those results possible.
One of the biggest has been the introduction of drug-eluting stents, he says. Stents are implanted to open blocked arteries. In the past, there was a 15 percent to 20 percent chance of scar tissue building at the implant site, which meant the procedure had to be repeated or a bypass operation done. Implanting stents coated with drugs has reduced the incidence of scar tissue to about 2 percent of cases. Another new development allows doctors to accurately measure fractional flow reserve, or pressure in the artery, so that they can determine which blockages are problematical enough to require a stent. That test has led to fewer unnecessary stent procedures.
He also points out that today’s cholesterol-lowering drugs are safer and more potent, which lowers the risk of heart attack and stroke. Now that there is long-term evidence of the safety of these drugs, he adds, doctors feel more comfortable using them to treat young patients aggressively.
Leidig stresses to his patients that they need to be stewards of their own health.
Page 3: Marciana Filippone | Gastroenterology
Marciana Filippone’s patients often visit her because of abdominal pain and bowel discomfort or irregularities. Such vague symptoms require Filippone to play detective by questioning her patients “to tease out the underlying reason he or she is presenting with these symptoms” and to identify the most appropriate course of evaluation and treatment.
Filippone sees many patients who suffer from gastroesophageal reflux disease, which is commonly known as heartburn or acid indigestion. Though treatment with acid-reducing drugs known as PPIs and H2 blockers is usually effective, GERD is an illness that in many cases can be controlled or avoided by eating a heart-healthy, low-fat diet, maintaining an appropriate weight, and avoiding the excess use of alcohol and anti-inflammatory drugs.
Filippone spends more time educating patients these days, especially those who have done reading on their own that raises concerns or anxieties about their illnesses and medications. “I try to dispel misconceptions and put their disease and treatment risks in perspective,” she says.
She is seeing a welcome upswing in patients being proactive about colon-cancer screening and colonoscopies, a trend she attributes in part to improvements in methods of sedation for the procedure.
She notes several other advances in the testing and treating of gastrointestinal disorders. For example, laboratory blood testing for celiac disease (an intolerance to gluten) is now more reliable and readily available. Virtual colonoscopy, which examines the colon by CT scan, is now available for cancer screening in selected patients who cannot or choose not to undergo traditional colonoscopy.
Wireless capsule endoscopy, also known as a capsule camera, is a new alternative to traditional endoscopy for looking into a patient’s small bowel.
People who suffer from moderate to severe inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis are benefiting from biologic therapy drugs introduced in the past decade, including the intravenous drug Remicade and new self-injectable drugs such as Humira and Cimzia.
“These drugs have really improved the quality of life for significant numbers of patients and allowed them to avoid surgery in many cases,” she says.
Page 4: Janis Chester | Psychiatry
Americans are having a tough time these days. Already troubled by our own personal foibles and relationship problems, we also have the added worries of war, terrorism and an economy that seems out to get us—personally. “It’s as if our own insecurities and inner conflicts are writ large in society,” says psychiatrist Janis Chester. “Americans feel like they are being pushed over the edge.”
Chester, chair of the department of psychiatry at Bayhealth Medical Center, has practiced in Delaware since 1998, after she finished a fellowship in geriatric psychiatry at Cornell University Medical Center and directed an inpatient unit at Thomas Jefferson University Hospital. In addition to teaching at Jefferson Medical College, Chester splits her time about 25/75 between caring for institutionalized geriatric patients and counseling patients in her private practice.
As a traditional psychoanalytically oriented psychiatrist, Chester is a bit of a throwback to the mid-20th century, before biologic psychiatry became the prevailing mode. Or maybe she’s ahead of the curve on a return to more traditional approaches that balance the tendency to seek a quick-fix with medications.
“Most psychiatry is still biologically based, but there’s a little push back now,” Chester says. “People are beginning to recognize that even for biologically based illnesses such as panic disorder, psychotherapy combined with medication works better.” Still, the prevailing mode in mental health is what Chester calls “split treatment”: the psychiatrist prescribes the medications and a psychologist, social worker or other counselor provides the therapy.
It’s not that Chester shuns medication. Most of her geriatric patients suffer some sort of dementia, so those treatments are mostly biologically based. And about half of her private practice patients are on psychiatric meds. But Chester prefers traditional psychoanalytic psychotherapy—delving deep into a patient’s past to find the root cause of today’s problems. “Psychotherapy is not a quick fix,” Chester says. “It usually takes three to five years to really resolve the issues.” It’s not something that many patients can or want to pay for, she adds. For those who do? The goal is changing lives.
Page 5: Anthony Sciscione | Maternal Fetal Medicine
“When it comes to patients, my job is to be an educator and an advocate and to make sure that they get the best care possible,” says Anthony Sciscione, director of the Delaware Center for Maternal and Fetal Health of Christiana Care since 2006.
The center cares for women whose pregnancies are considered to be high-risk, which can mean everything from pre-term labor and multiple gestations to a mother who has diabetes or is simply over age 35. Sciscione estimates that the classification applies to as many as 40 percent of the 7,000 births that take place at Christiana each year.
The primary way most of those women encounter the center is through its imaging services, which are among the most advanced in the region. Targeted sonography, for example, allows for a detailed physical exam of the baby’s anatomy at early gestational ages. It is even possible via ultrasound to diagnose anemia in a baby so that a life-saving blood transfusion can be done in utero.
Sciscione, who also directs the OB/GYN residency program at Christiana Hospital, describes himself as the sort of person who will not settle for less than excellence. His goal is to make Delaware a premier site for state-of-the-art obstetrical care, both because of the doctors and staff, and because of the imaging, medical and surgical options available to women. He is pursuing—and attaining—grants for participation in several maternal fetal health studies, including one for a recent study by the National Institutes of Health on fetal growth curves. Christiana was one of only five hospitals selected in the country.
“We are now starting to get a national reputation. We are getting referrals from out of state, including those who in the past would have been sent to Johns Hopkins or Penn,” Sciscione says.
He points to several areas in maternal fetal health where Delaware is making strides, including increased availability of first-trimester fetal screenings for chromosome abnormalities and structural defects, and access to fetal echocardiography, which allows for the diagnosis of heart problems in utero.
Page 6: Ginger Chiang | Pain Managment
Low back pain ranks second only to colds for the number of doctor visits it prompts, so it keeps pain management doctors like Ginger Chiang busy. Chiang typically sees patients who are referred to her when their primary care physicians are unable to alleviate pain with anti-inflammatory drugs, physical therapy, or other therapies such as chiropractic care or acupuncture.
Intractable problems such as these call for a multidisciplinary approach, says Chiang, who practices at Delaware Back Pain & Sports Rehabilitation Centers in Wilmington. “I take a traditional medical history, physical exam and imaging studies or other studies and look for the pain generator,” she says. Chiang says she treats the whole patient, not just the location of the pain. “Sometimes back pain is complicated by depression or fibromyalgia. If the patient is not also treated for these problems, then the pain won’t get better.”
In addition to low back pain, Chiang treats other back pain, neck pain, and pain in the shoulders, elbows, knees and other joints. One of the more unusual pains she deals with is coccydynia, or tail bone pain. “Most traditional pain treatments won’t work with coccydynia, so patients need to see a pain specialist,” she says. She also sees patients with complex regional pain syndrome, a debilitating disease that can cause swelling, burning, and pain in an entire limb or just hands, fingers, feet or toes. Typical treatment is sympathetic nerve blocks combined with physical therapy and pain medications.
Injection techniques have also improved, Chiang says. In radio-frequency denervation, for example, Chiang places a needle on the facet nerve to burn it and cut off the source of the pain.
Among the newer pain medications are Cymbalta, which treats pain and depression, and Lyrica, designed for nerve-related pain. Also new is FlectorPatch, a nonsteroidal anti-inflammatory pain relief patch that delivers relief directly to the site, bypassing the gastrointestinal system and preventing such side effects as kidney damage.
Page 7: Peter Panzer | Dermatology
Peter Panzer started as a solo practitioner, but over the past three decades his Newark dermatology practice, Panzer Dermatology & Cosmetic Surgery, has grown to eight doctors and six physician assistants.
“The different doctors and providers bring to our patients different subspecialties and different personalities,” Panzer says. Four of the doctors are general dermatologists. Subspecialists include a facial plastic surgeon, two surgeons who are board certified in Mohs micrographic surgery for skin cancer removal and the latest addition to the staff, a dermatopathologist who can analyze biopsies. Because the practice is large, Panzer has the support staff necessary to work with insurance companies to help get treatments covered, he says.
Multiple staff for patients’ multiple needs is in keeping with Panzer’s philosophy of practice: Be as patient-friendly as possible and offer as many state-of-the-art treatments as possible in both medical and cosmetic dermatology.
As a general dermatologist, Panzer sees the traditional dermatological cases—psoriasis, acne, warts, skin cancer, and spider veins, to name a few. He’s also adept at diagnosing difficult rashes.
He cites the introduction of self-injectable biologic treatments for severe psoriasis as one of the big developments in dermatological care. “These therapies are incredibly effective at clearing and controlling severe psoriasis,” he says.
Though biologics have been available for six or so years, he adds, not all patients are aware of the option. In fact, of the millions of people with psoriasis, about half have not seen a dermatologist. That’s unfortunate, Panzer says, because there is now a range of effective treatments, including topical creams and ointments for mild psoriasis.
A recent introduction to the acne arsenal is Isolaz, a patented device that uses suction and intense pulsed light to treat persistent acne. Five to six weekly treatments are usually required, but insurance plans do not cover it, Panzer adds.
Thankfully, most people are now aware of the need to use sunscreen to prevent skin cancer, Panzer says. Yet not everyone uses sunscreen properly. It should be applied 15 minutes before sun exposure so it can penetrate the skin. Today’s sunscreens are more effective than ever at protecting against cancer, he says. Those with UVA blockers are even more helpful at preventing photo-aging from the sun. In the near future, Panzer says, look for sunscreens that give protection ratings not only for UVB rays, as they do now, but also for UVA rays.