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The VA Center: Tomorrow's Technology Today
By Ginny Cook Forget Superman and his x-ray vision. The radiologists at the Baltimore Veterans Affairs Medical Center would put the man of steel to shame. They can peer into the bodies of patients 50 miles away and diagnose pneumonia and bone fractures or pinpoint tumors and calcifications. How? They use x-ray vision that comes compliments of a remarkable computerized x-ray system that uses no film. Known as the Picture Archiving and Communication System (PACS), it transmits body images via a high-speed line from an x-ray machine to a computer work station -- in this case from the VA in Perry Point to the VA in Baltimore. What's more, patient images taken in the Baltimore VA can be brought up on more than 40 computer screens throughout the hospital. PACS not only delivers rapid, high-quality images but accelerates the speed of the medical consult. For example, a radiologist on the first floor and a surgeon in the operating room can simultaneously view the same image and confer to make medical decisions. As the first hospital in the world with a filmless radiology department, the Baltimore VA Medical Center is riding into the next century on a crest of research and development. From filmless radiology to diagnosis and treatment of patients via a two-way video camera (see the following article, Is There a Doctor on the Set,), the Baltimore VA conducts some 35 major research programs. In fact, last year with $11 million, it climbed from 26th to number one in research funds among the 132 Veterans Medical Centers in the country. The three veterans hospitals in Maryland have undergone a metamorphosis since 1995, restructuring three institutions under one administrative roof, says Dennis Smith, director, VA Maryland Health Care System. Now the Baltimore VA provides tertiary care, Perry Point focuses on mental health and Fort Howard houses rehabilitation beds, he says. The change consolidates programs, cuts down on duplication of services and employs utilization review, all efforts to reduce costs, he explains, changes which have been "painful because each hospital was independent." "Yet we've been able to downsize without laying off a single employee," Mr. Smith adds. The cuts came through attrition, he says. There's still much work to complete, however. The VA is committed to improving access to care by a better use of resources and expanding outpatient presence, says Mohamed Al-Ibrahim, M.D., chief of staff. "In St. Mary's City in southern Maryland, for example, we've increased our health screening and counseling at veterans centers." "We've also been active in women's health," he says, making a concerted effort to add amenities such as on-site OB/GYN services and a 10-bed female wing at Perry Point. Like all major health care institutions, the VA Maryland Health Care System is polling its market to determine what veterans need. "We recently completed a detailed survey of 2,000 veterans in Maryland," says Dr. Al-Ibrahim. Results indicate the Maryland VA reaches about 8 to 10 percent of the veteran population.
Far-reaching ResearchLike the rest of America, the veteran population is aging, with 40 percent over age 65, he adds. "Thus our research efforts revolve around aging, cholesterol, obesity, stroke, hypertension, diabetes and heart disease, he says. As home to one of the VA's 16 Geriatric Research, Education and Clinical Centers, the Baltimore VA was involved in a notable study published in 1995 in the Journal of the American Medical Association. It found that losing weight is more effective than exercise for reducing the risk of heart disease among heavy, middle-aged men. Other studies target vision and diabetes. The VA hopes to give "legally blind" people a chance to read with a Low-Vision Enhancement System. The system uses a specialized camera and mirrors to reflect images through prescription lenses and into the eyes. It could help up to 2.5 million Americans whose poor vision cannot be corrected by conventional lenses. Another study compared delivering insulin to 121 diabetics using an implantable pump versus multiple daily injections. Results of the study reported in a 1996 issue of the Journal of the American Medical Association showed the pump proved to be effective in reducing the occurrence of hypoglycemia, eliminating weight gain and improving the quality of life for diabetics.
Radiating changeInnovations in radiology departments at the Maryland VA have put the department in the international spotlight. It is reinventing a discipline that celebrated the 100th anniversary of the x-ray last year, says Eliot Siegel, M.D. '82, chief of radiology service and nuclear medicine at the Baltimore VA. "We're moving away from the constraints of putting a single image on celluloid," he says. Much like word processors and copy machines eliminating the need for carbon paper, computerized images generated and stored on a computer system are retiring x-ray film. Instead of forming an image on film, computed radiography creates a matrix image of numbers on a photo plate. "We can take that math matrix and have the computer optimize its quality," explains Dr. Siegel, who is also an associate professor at the University of Maryland School of Medicine. The technology has a laundry list of advantages available at the click of a mouse: the images appear almost instantaneously on a computer screen; radiologists manipulate the images on the screen rather than technologists printing out numerous films; there's no film to store or lose; images are stored on optical disks allowing for rapid retrieval of not only the most recently taken picture image, but of prior images for comparison. One optical disk holds tens of thousands of pictures, so "we've substantially reduced storage space and gone from five film file clerks to one," Dr. Siegel says. Studies taken four to five months ago are instantly retrievable and pictures put in long-term storage "can be automatically de-archived to short-term storage and retrieved," he explains. Once an image is brought up on a computer screen, radiologists can manipulate it with computer tools, changing the view, zooming in or enhancing the picture. "It has allowed us to make better and more accurate diagnoses," Dr. Siegel says. Radiologists now read scans within minutes and can help colleagues in other parts of the building or in other hospitals make medical decisions. "And we've become more efficient," he adds. "Radiologists are 15 percent faster using PACS than film." Dr. Siegel never expected to head the first filmless radiology department. As a fourth-year medical student, he'd attended a radiology meeting in Boston where experts predicted the technology was "imminent." Imminent proved to be more than a decade. Even the Baltimore VA, designed to be filmless when its doors opened in November 1992, had to wait until the following June for the technology to be delivered. "The vendor was not quite ready with the equipment," Dr. Siegel explains. "And we were in a bit of a quandary. We didn't even have any conventional view boxes." Yet those first months provided a windfall, giving Dr. Siegel and his colleagues baseline data to compare film with the filmless PACS system. "As a result, we've written the majority of the literature on filmless operation -- everything from economics to productivity studies to accuracy and physician satisfaction," Dr. Siegel says. "PACS has made us more productive. Our volume is up 70 percent without the significant addition of technicians or radiologists," he points out. What's more, the Baltimore VA almost never loses an image and rarely has to retake one. "Our lost film rate went from 8 percent to virtually 0 percent. And our retake rate -- films that were either too light or too dark, under- or over-exposed, went from 5 percent to .7 percent," Dr. Siegel adds. And he found, "somewhat to our surprise" that PACS is fiscally attractive. "It's significantly less expensive to operate a PACS, even accounting for a maintenance contract," according to a paper on the economics of PACS he presented to the Radiological Society of North America this winter. The Baltimore VA still ranks as one of only six or seven institutions in the world that can boast a filmless department of radiology. It recently extended its PACS network to Perry Point VA 50 miles north and Fort Howard VA 15 miles east. All their images are transmitted to Baltimore and archived on optical disks. "We're in the process of setting up connections to the Washington VA and Martinsburg VA," Dr. Siegel says, and the University of Maryland Medical System is also preparing to make the transition. A second PACS system, developed by the VA internally, serves not only as a backup system but will produce an image or a tracing of anything that can be captured visually. Dr. Siegel explains, "A health care provider with proper authority can go to a work station and in one sitting view all the radiology, all the nuclear medicine, any pathology. We'll have a whole generation of clinicians who have grown up being able to access that information at a work station." This has made the Baltimore VA "a model for the military and other hospitals that have tried to emulate our capability," he says. This is only the first step into the new frontier of radiology, Dr. Siegel says. The future could see hospital radiology departments linked to each other, sharing coverage and subspecialty expertise. And he says, the next decade will bring explorations in computer-aided diagnosis, where radiologists would "train" the computer to find and recognize lesions or pathologies and mark them for review, much like word processing programs now underline possible misspellings in text. Three-dimensional images and pictures of a cancer shrinking in response to chemotherapy grouped together in a movie loop all loom on the radiological horizon, he says. Ginny Cook is a frequent contributor to The Bulletin. Is There A Doctor On The Set?By Ginny Cook Move over George Clooney. Telemedicine is putting genuine physicians on the tube. Recent studies at the Veterans Affairs Medical Center in Baltimore have used two-way video cameras for exams and diagnosis in the dermatology clinic. The technology could revolutionize the practice of medicine, putting specialists in underserved areas and expanding access to care. Researchers wanted to know whether the patient or physician would be as comfortable with telemedicine as they are with old-fashioned, face-to-face office visits. Patients first saw a doctor on a television screen after being introduced by a nurse escort. The physician was in another part of the VA building, although the two-way video camera is designed for use in remote areas, says Mark Lowitt, M.D., assistant professor of dermatology at the Veterans Affairs Medical Center in Baltimore. "Afterwards, patients saw a real, live, in-the-flesh physician, who also took a history and exam, and made a diagnosis," he adds. Then both patients and physicians completed questionnaires. "We wanted to know how they felt, if they made eye contact, could they hear -- overall were they comfortable," Dr. Lowitt explains. Physicians had to list their diagnosis and their degree of confidence in it, he adds. Results from 100 patients studied showed that although most said they preferred a live visit, they were still highly satisfied with seeing a doctor via a television camera. Physicians, too, were extremely happy with a 90 percent confidence level in their diagnosis when the video camera transmitted images over a T1 line, a high-speed and expensive transmission. When the transmission dropped to 1/4 T1 -- meaning the image on the television set was not as sharp -- physicians were less pleased and their degree of confidence dropped to 80 percent, according to Dr. Lowitt. "One of our next steps is to get more information and find the minimum transmission which would be acceptable," he adds. Dr. Lowitt and his colleagues also compared the diagnoses of the in-person versus video visits to see how well the groups of physicians concurred. "We found the physicians agreed 80 percent of the time," he says. But he didn't know, what no one knew, is how often physicians agree on a diagnosis anyway. So, "we did a second study to determine the agreement in diagnosis if two dermatologists do separate, face-to-face exams of the same patient," he explains. Researchers are still crunching numbers but physicians appear to agree about 77 percent of the time. "Physicians disagree not because video gets in the way but simply because as a rule they have different opinions," Dr. Lowitt explains. And in the first study, he adds, the discrepancies mainly involved the types of benign tumor. The next step is to repeat the live versus video study and examine the outcomes -- how well patients fared, what tests were ordered and what therapies were recommended. Seeing patients via video has broad implications for underserved areas and populations, Dr. Lowitt points out. It could open up access for patients at the Perry Point VA where the dermatologist is overwhelmed. And it could be a cost-effective method employed in prisons. Right now, dermatologists at the clinic see about two prisoners a day. Transportation and security guards put the cost for each visit at about $1,000 per patient. Seeing inmates at the jail via video could add up to huge savings that would quickly offset the price of setting up the high-speed transmission line, he says. Psychiatry and ophthalmology are among the medical specialists who are also exploring telemedicine, he adds. And each specialty will have its own criteria for use. Already alternatives to live two-way videos have been proposed. Images could be stored and forwarded to be examined later by a specialist in much the same way radiologists read x-ray films. "It is less expensive but I'm inclined to lean away from this use as it drastically alters the age-old model of doctor/patient interaction," Dr. Lowitt says. Telemedicine can prove to be extremely valuable but Dr. Lowitt cautions, "we have to be responsible and evaluate outcomes before we embrace the technology." Kappelman's Career-Kid Stuff!
Teaching, consulting, writing and supervising residents. Dr. Kappelman continues to work in the Department of Pediatrics, where most recently he was chief of the division of behavioral and developmental pediatrics. He began working in the area of behavioral pediatrics long before a recognized specialty existed, long before anyone thought it was necessary. "When I submitted my first abstract in 1959, it was on learning disabilities," says Dr. Kappelman. "They turned me down because they said it was not important." In 1969, however, he published his first article on learning disabilities in the second issue of the Journal of Learning Disabilities. He has since written numerous articles and chapters on the subject. "I got into this area because I was interested and trained, to some degree," he says. "We had no fellowships (in this specialty) in those days, so I put together my own training." Dr. Kappelman had some training in child psychiatry-he later became professor of psychiatry in addition to his pediatrics' appointments-and served in a behavioral pediatrics clinic in Germany during his tour in the Armed Forces. After returning from the service, he worked in the comprehensive evaluation clinic at UMAB, where he saw a number of children, most of whom were disadvantaged, with attentional problems. In his own pediatrics practice, Dr. Kappelman also saw that divorce and adolescent sexuality were issues that pediatricians would have to deal with more and more often. He drew from his clinical experience and his experience as a board member for Planned Parenthood of Maryland (where he later served as president) to pen another book, The Pediatrician as Sex Educator and Counselor. His advice to other pediatricians? "Be available, non-judgmental, and confidential." To date, he has authored, or co-authored, six books about children for parents, two medical education books, and three novels. Now that he is partially retired, he is planning another book. "I want to discuss attitudes toward parenting because many parents have walked away from parenting," says Dr. Kappelman. "Parents would rather be friends with their children than parents, but children need parents." He should know. Dr. Kappelman and his wife, Joan, raised four children of their own, all of whom are now settled into successful careers. Even Dr. Kappelman's novels tend toward children's issues. His first novel, The Child Healers, is based on his personal experiences and observations of pediatricians and the relationships they develop with their patients. One reason he wrote the book was to show "the humanity of medicine," a theme he later carried over into his role as associate dean of medical education and special programs. In fact, in 1972 he founded the Office of Medical Education at UMAB, one of the first programs in the country. "We offer services for educational programs for students and faculty, such as academic support and faculty development as teachers." The Office also helps faculty learn to teach new things, such as problem-based learning, and introduces new concepts into the medical curriculum. Recently, through the efforts of other faculty members, the school accepted a proposal that weaves literature and medicine together. "The students have short readings that they discuss in relation to specific cases. It helps show that medicine is not an isolated subject," says Dr. Kappelman. One of the accomplishments that gives Dr. Kappelman the most satisfaction is the School of Medicine's new curriculum, which was fifteen years in the making. "We needed it, and it is successful so far," he says. "It's more student-friendly. They spend more time in independent study and in interactive learning in small groups and with instructors, and less time in big class settings." He adds, "Today's medical students are outstanding. When they go out for senior electives or internships, we often hear back they're among the best-trained clinicians -- which is a joy to hear." "It's been wonderful watching the school grow to such national stature in research and training," he says. "Over a period of years it's become one of the finest medical schools in the country." Dr. Kappelman's work with medical education and children's issues have earned him a number of awards, including the Richard J. Cross Award for distinguished contributions to sexuality from the Robert Wood Johnson Medical School and the Merrell Flair Award for outstanding contributions in medical education from the Association of American Medical Colleges. He also has held appointments at several other Baltimore-area hospitals, including Sinai Hospital and the Johns Hopkins School of Medicine, is a founding member of the Society for Developmental and Behavioral Pediatrics, and is on the editorial boards of the Journal of Developmental and Behavioral Pediatrics and Academic Medicine. Dr. Kappelman has worn many hats, but it has always been his interest in children that fueled his activities. "There is nothing as great as dealing with children. They give back so much more than you give," he says. "And watching them grow from baby to teenager -- it's exciting, very dynamic, and great to be a part of that process." "I don't know why everyone isn't a pediatrician." Courting the Criminal Mind
As a physician, Dr. Rappeport's interest in criminal and violent behavior goes beyond punishment and includes making sure that mentally ill criminals receive treatment that could stop them from committing crimes again. Rappeport is one of the nation's foremost authorities on forensic psychiatry, which explores the mental illness and psychiatric component of legal disputes from criminal cases to child custody to contracts. The law requires that people who are accused of certain crimes or are involved in illegal business transactions have the mental capacity to understand what they are doing; the forensic psychiatrist helps the court determine if the party has that required mental capacity or whether the person is mentally ill. Since first testifying in a sanity hearing in the 1950s, Dr. Rappeport has worked in courtrooms across the country, and provided psychiatric consultations in many high-profile criminal cases, such as the case of John Hinckley (who shot President Ronald Reagan), Sara Jane Moore (who shot at President Gerald Ford), Arthur Bremer (who shot Alabama Gov. George Wallace), and most recently John DuPont, who was convicted of killing Olympic wrestler Dave Schultz. In retirement, Dr. Rappeport plans to withdraw from providing forensic psychiatry consultations and court testimony, but will write, edit, teach and continue the study of forensic psychiatry. "We need to support and assist in some research into the whole criminal behavior world," Dr. Rappeport said. "I think there is a role for us as long as there is a mental issue in the law and as long as the courts believe that our testimony can help the judge or jury reach their decision." Dr. Rappeport is disappointed that the public still doesn't fully understand the role of the forensic psychiatrist, especially with regard to the hot button issue of the relationship between criminal behavior and the insanity plea. "It bothers me that the public has such an uninformed opinion on the insanity plea." The data shows, according to Dr. Rappeport, that it is rare that an attorney enters an insanity plea, it is rare that someone is acquitted by reason of insanity, and most people who are found not guilty by reason of insanity spend more time in mental hospitals than if they had been convicted. All of the recent notorious killers who pled insanity -- like Arthur Bremer, the Son of Sam, John Wayne Gacy, and Jeffrey Dahmer -- were imprisoned. And defendants who are found insane are sent to mental hospitals where they stay until they can prove they are no longer dangerous. Dr. Rappeport said studies show that mentally ill criminals don't commit crimes when they are cured of their mental illness. "We do a much better job in preventing recidivism than the criminal justice system." Dr. Rappeport said that while the practice of forensic psychiatry isn't foolproof, the chance that someone is faking a mental illness or using a fake mental illness in order to get away with murder is rare. In the end, Dr. Rappeport said, the psychiatrist can work with the mental illness that causes a person to commit a crime, but can't cure someone who wants to commit a crime. "We don't cure criminal behavior, we cure mental illness." Dr. Rappeport began studying the relationship between psychiatry and law in the early 1950s, the formative days of the specialty, and over the years, has taken his study of mental illness and criminal behavior into countless courtrooms to aid lawyers, judges, and juries in assessing criminal responsibility and competence. Through Dr. Rappeport's work, the medical profession has recognized forensic psychiatry as a subspecialty. "I was a late bloomer," Dr. Rappeport said. "I'm not the world's leading philosopher and intellect. I think I've accomplished more than you would expect from someone who graduated in the lower third of his medical school class." Dr. Rappeport traces his interest in medicine and psychiatry to his neighbor, Dr. Manfred Guttmacher, the first chief medical officer for the Supreme Bench of Baltimore City. As a teenager, Dr. Rappeport babysat for Guttmacher and read in Guttmacher's library. After medical school, Dr. Rappeport attended the American Psychiatric Association Meeting in St. Louis, where Dr. Guttmacher invited him to sit in on the Committee on Psychiatry and the Law. Dr. Rappeport served his internship at Michael Reese Hospital in Chicago from 1952 to 1953, moving to the University of Maryland Hospital in 1953 and Sheppard Pratt Hospital in Baltimore in 1954 for his residency training. During his residency at the University of Maryland Hospital, Dr. Rappeport became interested in the reasons why some patients assaulted staff members. This led Dr. Rappeport to study dangerousness and the prediction of dangerousness. At the time, no forensic psychiatry training programs existed and little research had been done on dangerousness since the 1930s. After his residency, Dr. Rappeport joined the staff of Spring Grove Hospital, where he had the opportunity to examine patients and was asked to testify in criminal cases. Later, he was asked to supervise the maximum security unit at Spring Grove. In 1959, Dr. Rappeport established the first Office of the Court Psychiatrist in Baltimore County and opened his own clinical practice. In 1967, several forensic psychiatrists met informally at the American Psychiatric Association meeting. During the next two years, the informal meeting grew until, in 1969, the American Academy of Psychiatry and the Law was born. Dr. Rappeport was one of the group's founders and was its first president, serving from 1969 to 1971. He also served as the Academy's medical director from 1981 to 1995. In 1972, Dr. Rappeport received a grant from the National Institute of Mental Health to run a treatment clinic for sex offenders and violent offenders at the University of Maryland. The clinic treated selected second-time sex offenders in group therapy and intense probation. Only 25 to 30 percent of those treated committed another sex crime, compared to 60 to 80 percent of incarcerated but untreated people who go on to commit other crimes. In the mid 1970s, Dr. Rappeport was instrumental in setting up Maryland's Pre-Trial Screening Program through the Maryland Department of Health and Mental Hygiene. Before the pre-trial program was introduced, a person accused of a crime could be sent to a mental hospital for psychiatric evaluation, sometimes for as long as 30 days. Dr. Rappeport said studies showed that 80 percent of those people were found competent to stand trial and did not need to be held that long. The Pre-Trial Screening Program reduced the number of people who were referred to mental hospitals, cut costs to the state, and provided some helpful evaluations for the court. Throughout his career, Dr. Rappeport has been a prolific writer, publishing articles and book chapters on courtroom testimony, ethics in forensic psychiatry, capital punishment, and forensic psychiatry practice. |
