In-the-Know Doctors

Margaret Marcrander, M.D.

Obstetrician and Gynecologist

Mercy Clinic

All of Dr. John Sopuch’s children were born at Mercy, including his daughter,Dr. Margaret Marcrander, who followed in her father’s footsteps. Sopuch has been delivering babies for 50 years, seeing three generations of some patients’ families. “I’ve been in practice so long,” he says, “growing up with these families, they are part of my family.” Today, he and Marcrander see genetic testing and new technology playing a key role. As Marcrander explains: “We are a society that has the benefit of the best and newest technology, procedures, and medication, and we want the newest and best. These are often expensive and can drain the system. It will be up to us as physicians and other healthcare providers, along with our patients, to determine if these new things are truly appropriate and have benefit in each individual case—really asking ourselves, ‘Just because we can, should we?’ If we do not ask these difficult questions, healthcare resources will not be available, and cost will continue to skyrocket.”

How do you keep compassion alive, in all the rush of caseload and logistics?

Marcrander: I remind myself each day that my patients are taking time out of their busy schedules to see me because they trust my knowledge and expertise. I try to be engaged in the moment I have with each patient while they are in front of me and we have time to work on the issues that they are presented with. It is an honor to be a physician and provide care and give advice to those at their most vulnerable times.

Sopuch: I’ve been doing it now for 50 years. I have patients now that I’m in the third generation that I’m delivering. For me, I just love it. I can see grandmothers, mothers, and I’m delivering for the daughters. I’ve been in practice so long, growing up with all these families, they are part of my family. I look forward to every day with that in mind. I enjoy teaching the residents. They keep me on my toes, and hopefully I keep them on their toes.

What’s the most fascinating case you’ve handled in recent years?

Marcrander: There are so many interesting cases over the years. One comes to mind in particular, because it illustrates the benefits of coordinated care with your colleagues and of a multi-specialty approach that benefits the patient. It also reminds me that you never know what diagnosis will walk through your door. Being an OB/GYN, many women use us as a first line for unusual  abdominal/pelvic pain. My patient came in with new onset flank pain for three weeks. She was not sure what it was, but thought I was a good place to start. She is not a complainer, and so I knew this was really bothering her. We ruled out gynecologic cause of her pain. I then referred her  to a urologist who did a work up for issues related to the [genitourinary] system, like a kidney stone. During this process, she was found to have large mass that was consistent with lymphoma in the space behind her kidney.  She was quickly referred to hematology/oncology for diagnosis and follow-up care. It was a rare and surprising finding.

Sopuch: Many years ago, the most interesting case was when the ultrasound missed the fact that a patient had triplets. We thought she was having twins. After I delivered the first two babies, I checked, and lo and behold, there was a third baby. A more recent case is of a patient who was pregnant with a set of twins. After the first baby was born at 25 weeks, we were able to tie off the cervix and keep the other baby in a little longer. The twins were born six weeks apart. Both babies are doing well now.

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Adrian Di Bisceglie, M.D.

Gastroenterologist and Hepatologist

SLUCare, Saint Louis University Medical Group

The chair of SLU School of Medicine’s Department of Internal Medicine and co-director of the SLU Liver Center, Di Bisceglie recently co-authored papers published in The New Eng-land Journal of Medicine about hepatitis C treatments. New drugs have made it possible to cure the disease in a fairly short period of time: “In the span of my 30-year career, we have gone from having a poorly understood disease called non-A, non-B hepatitis to discovering the hepatitis C virus to developing treatments that can cure almost all infected patients. This is a triumph of medical science, public-private partnerships, and the health-care system, all to provide direct benefit to the general public.”

What is the most pressing issue in medical ethics today, and why?

There are two big areas that are of concern to me. One is finding a way to allow all U.S. citizens to have access to good quality health care. As a physician, we see again and again patients who have severe or significant medical problems, but can’t have them taken care of because of lack of insurance or other resources. The Affordable Care Act (so called Obamacare) provided some suggestions on how to expand health care coverage, but it is not perfect and has unfortunately become a political football. Nonetheless, I think we as a society have to bear some responsibility for the health and care of those who are less fortunate and find a way to have them taken care of.

Another, but separate, issue is that of real or perceived conflicts of interest among physicians.  It is clear that some physicians have abused the trust that has been placed in them by having inappropriate working relationships with vested interests, such as pharmaceutical companies.  On the other hand, I see that there is considerable danger in completely abolishing communication and collaboration between physicians, particularly academic physicians or researchers, and pharmaceutical companies and device manufacturers that have worked to bring great medical advances to the U.S. public and to our patients

How do you keep compassion alive, in all the rush of caseload and logistics?

Keeping compassion alive is indeed very difficult as the workload and work environment for physicians has become increasingly busy, regulated, and burdensome—for example, by the introduction of electronic health records, which require very substantial increased time and effort by physicians to document their encounters with patients.  For myself, I do my best to get to know my patients in some way personally; knowing something about their work, home life, personal accomplishments, hobbies, etcetera allows me to keep patients real. For example, I know several of my patients are hunters, and we are always able to chat about their upcoming or last hunting season: What did they bag? What did they miss? Having this kind of conversation allows me to think of patients as real persons and keep my sense of compassion alive.

What’s the most fascinating case you’ve handled in recent years?

One of the things that I enjoy most about being a consultant physician is being able to solve difficult problems or come to a diagnosis on a patient that may have been missed or not appreciated previously. One example of a patient like this that comes to mind is a lady who is now about 60 years old and has been battling hepatitis C for more than 20 years. She failed multiple courses of treatment over this time. Unfortunately, her daughter also has hepatitis C, and we think my patient may have passed this on to her daughter at the time of her birth. The patient’s liver disease progressed. She eventually developed cirrhosis and then, some years later, liver cancer. This required her to have a liver transplant to treat the cirrhosis and liver cancer and then again developed recurrent hepatitis C after the transplant. However, we were finally able to treat her hepatitis C successfully using one of the newer antiviral drugs that has just become available. She is now free of hepatitis C for the first time in many, many years and is doing well.

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Ellen Lockhart, M.D.

Anesthesiologist

Barnes-Jewish Hospital

As a mother and an expert in obstetric anesthesia, Lockhart knows her patients are dealing with more than health-related matters: “As I drive in to work, I am thinking about my caseload, in addition to what my children are doing after school and what I am going to cook for dinner. Honestly, as soon as I see the hospital from Highway 40, my thoughts immediately turn to my patients. Some are having major procedures, some are dealing with a new cancer diagnosis, some are having babies, and all of them deserve my best. Many have a story beyond what you read in the medical record. The healthy patient having a very minor procedure may be dealing with a loved one in hospice. These realizations are humbling, make me very grateful for my family and friends, and remind on a daily basis why I chose a career in medicine: the patients.”

What is the most pressing issue in medical ethics today, and why?

I think that one of the most pressing ethical issues is examining how we address medical care at the end of life. This is an important issue because of the tremendous economic implications. A significant amount of healthcare dollars are spent on intensive measures at the end of life. There are important questions to answer: Will these interventions provide meaningful benefit? What are the patient’s wishes and expectations about their quality of life? What type of data-driven evidence can we provide to patients about potential outcomes? Deciding which therapies are beneficial is not always straight-forward, and it involves difficult conversation between patients, families and medical care teams. These topics are also challenging because they are interwoven with cultural, social, religious, and certainly political threads. Regardless of the difficulty, this is an important ethical issue for us to tackle. It is more than an economic concern: It will benefit our patients.

What’s the most fascinating case you’ve handled in recent years?

While I don’t want to get into specifics of a particular case, for me, the most fascinating cases are those involving high-risk pregnancies, which is my area of expertise and interest. This could be a woman with severe heart or lung disease, cancer, or even major trauma during her pregnancy. Not only are we caring for the mother, but we also need to consider the effects of our anesthetic management on the baby. These cases are intellectually and medically very challenging, and I enjoy the interdisciplinary collaboration that is involved. While you have to remain focused on delivering the best possible care to these patients, you also have to respect the emotional toll that these situations are taking on patients and their families.

What recent finding or trend do you believe will significantly shape your field in the years to come?

As anesthesiologists, we have a presence not only in the operating room, but are involved in preoperative assessment and planning, in the critical-care arena, and in treating acute and chronic pain. This breadth of experience provides us with a tremendous opportunity to better understand our patients, how to better assess their risk, and how our intraoperative management affects their short- and long-term outcomes and quality of life. Our department is actively engaged in using informatics and research to discover and implement solutions aimed at improving the outcomes of surgical, critically ill, and chronic pain patients. An important challenge facing anesthesiologists and other acute care physicians will be to use emerging evidence to mitigate perioperative risks and to optimize postoperative outcomes.

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Keith Mankowitz, M.D.

Cardiologist

Heart Health Specialists

At St. Luke’s Hospital, Mankowitz is director of the Hypertrophic Cardiomyopathy Center, where he specializes in diagnosing HCM, a condition associated with abnormal thickening of the heart that can cause sudden death, including in athletes: “Often, you have to spend a lot of time listening to patients’ stories and really hearing what they say… I recently saw a healthy-looking guy in his forties, who was younger than me. He wanted to play basketball, and his wife said, ‘You know, the last time you played, you just looked terrible. You came back and looked ashen.’ I proceeded with an evaluation and found he needed bypass surgery. If we hadn’t done that surgery, I’m not sure he would have made the next game.”

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Amy Mosher, M.D.

Radiologist

Missouri Baptist Medical Center, Midwest Radiological Associates

After completing a diagnostic radiology residency at Mallinckrodt Institute of Radiology and a neuroradiology fellowship at Massachusetts General Hospital at Harvard Medical School, Mosher began practicing with Midwest Radiological Associates in 1991. Today, she often reminds herself of why she chose to practice medicine and radiology: “Behind every imaging study I interpret is a person. I try to give each the attention I would a member of my family. I try not to forget what brought me to medicine. I treat others as I want to be treated. Empathy is important, in medicine and in life.”

What is the most pressing issue in medical ethics today, and why?

The debate continues over end-of-life decisions and their cost. A 2011 study showed Medicare spending of $554 billion. Twenty-eight percent of that was spent on the patients' last six months of life. The issues are complex. As our population ages and the cost of technology continues to grow, the costs, ethics, and concerns about end-of-life care will remain an active conversation.

What’s the most fascinating case you’ve handled in recent years?

Recently, a gentleman was referred for a CT scan of the brain after a relatively minor head injury. While there was no finding related to trauma, a subtle abnormality was seen and a brain MRI was obtained. The MRI  revealed a very early brain tumor. Examination by my colleagues, a neurologist, and neurosurgeon did not reveal any corresponding abnormality in his neurological examination. His early-stage brain tumor was discovered before he had developed any symptoms, allowing him to obtain early treatment and a potential cure.

What recent finding or trend do you believe will significantly shape your field in the years to come?

The escalating cost of healthcare is the most pressing challenge to medicine and society. The Affordable Care Act mandates affordable, universal healthcare coverage. Implementation will be challenging.I'll offer an example in my specialty of neuroradiology. Patients with headaches are unlikely to have serious intracranial pathology. The yield on neuroimaging (CT scans and magnetic resonance imaging) in patients with chronic headaches is very small, similar to patients without headaches. The use of neuroimaging in headache patients nearly tripled  from 1995 to 2010. A billion dollars is spent each year in the U.S. evaluating headaches, though many guidelines do not recommend it. Beyond the direct costs are the indirect costs of further evaluation of incidental findings and the issue of unnecessary radiation exposure with CT imaging. The overuse is driven by patient demand,  physician desire to reassure patients, and  by defensive medicine reflecting medical legal risks.This is but one example of myriad factors driving healthcare costs. We will all participate as we attempt to contain costs as we expand healthcare coverage.

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Arturo Taca Jr., M.D.

Psychiatry

INSynergy

The founder of INSynergy, a drug-and-alcohol rehab center, Taca sees a growing epidemic of addiction: “Heroin has made a strong comeback and is more popular than ever, especially in middle-class suburbia. More people are overdosing and dying on prescription painkillers versus car accidents, and for the first time in history, benzodiazepines are among the most prescribed group of medicines. Further, legalizing cannabis in some states has strong implications for addiction providers like me. And of course, alcohol and nicotine addictions have clear health risks leading to injury and death. Despite obvious need for addiction treatment, barely 8 to 9 percent of patients are offered evidence-based therapies, including a number of newly developed FDA-indicated medications.

 In recent years, there has been more research to support the fact that addiction is a brain disease and can be treated with medication along with behavioral modifications. A recent article in the Journal of the American Medical Association found that treatment for alcohol-use disorders may be aided by using medications. Unfortunately, some feel that treating a disease like alcoholism with medication is ethically wrong. 'Treating a drug addiction with another drug' is what we commonly hear. This misconception has led to a tremendous burden to the healthcare system, leading to chronic relapse and hospitalizations. There are treatment options available that are non-addictive and proven to be effective, like extended-release naltrexone. I’ve seen it save and transform lives of my patients. 

Society needs to overcome the stigma of addiction as a 'lack of will' and be more open to medication-assisted treatment. If someone has diabetes, people don’t say, 'It’s ethically wrong to take medication, and you should be able to overcome it by losing weight, eating healthy, exercising, etcetera.' Typically, a person with diabetes is taught to have a healthier lifestyle, but may take medication in addition. That’s similar to addictive disorders. Some people may need medication to help treat addiction, while at the same time going to counseling and attending support groups, etcetera. The truth is that medication assisted treatment in addictions can help enhance the counseling experience by reducing or eliminating cravings to use drugs or to drink alcohol.

How do you keep compassion alive, in all the rush of caseload and logistics? 

Believe it or not, it’s actually really easy to keep compassion alive in my field, amid the chaos, because I work with people who suffer from mental illnesses like depression, bi-polar disorder, schizophrenia and addiction—all of which are horrible diseases that devastate people’s lives and those of their families. In terms of addiction, I’ve worked with patients who have been addicted to prescription pain pills and heroin for years. While stereotypes exist that those addicted to drugs had neglected childhoods or were from poverty, many of my patients were happy and successful individuals before they became addicted. In many cases, they tried to seek help, but nothing worked until they received proper treatment. And access to treatment for addiction these days is very limited. In treatment centers, beds are full and there are long waiting lists for help. If you go to the emergency room with a heart attack, they don’t say there’s a six-week wait to be treated, but that’s how it can be with someone with an equally deadly addiction. There’s a double standard, so knowing the struggles they face, I never lose compassion.

What’s the most fascinating case you’ve handled in recent years? 

A middle-aged executive came to me for his addiction. He was very successful and hid his addiction for about a decade. He started smoking pot out of college, got married, had kids, started drinking more until he was having blackouts. He got injured and quickly got addicted to painkillers. He continued to lead his company while secretly struggling. He used his vacations in attempt to detox himself and actually a few times checked himself into expensive private rehabs. He would get discharged he would do well for a bit but would give in to cravings and relapse. His binges were getting more and more intense and reported that he may have had a seizure. When his doctors refused to give him any more narcotics for his previous injury he discovered heroin. He became a heroin addict. A real-life, suburban junkie. He came to me for help when his family got involved. For him, he had a misdiagnosed and untreated mood disorder. This was treated, and he slowly began to feel better. As for his specific addictions, a once-a-month injection of extended release naltrexone helped him reduce his cravings for drinking alcohol or using heroin and opiate pain medications. He did well in the program and still gets his monthly injection and is involved in intense family counseling focused on trauma that he experienced as a child. He has been sober for about two years now.

What recent finding or trend do you believe will significantly shape your field in the years to come? 

Addiction medicine relies on innovations from several medical and psychological specialties. There is continued research on the nature and treatments for specific addictions. The FDA approval a few years ago of the only once monthly, non-addictive treatment to prevent opioid and alcohol dependence relapse will help change the treatment paradigm. It helps reduce cravings, which is a huge component of addiction. And because it’s once monthly, patients are more likely to adhere to their treatments. Novel approaches such as long-acting medications, vaccines, and even brain stimulation are in the works. Advancements in the field of pain management will help address the growing problem of prescription pain pill addiction. New treatments in the field of psychiatry, such as transcranial magnetic stimulation for depression will be useful for persons not responding to traditional anti-depressant medications. Advancements in the field of genetics can often predict response to medications. Innovations in laboratory toxicology now can screen for metabolites of illicit drugs and even detect metabolites of alcohol up to 80 hours of the last drink. Technology and innovation from several disciplines is the key to a more predictable and successful addiction treatment program. We are in the early innings of the addiction medicine specialty. It has truly been a privilege to witness its evolution.

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Susan Myers, M.D.

Pediatric Endocrinologist

SSM Cardinal Glennon Children’s Medical Center

At Cardinal Glennon, Myers treats children with rare conditions like McCune-Albright syndrome and Turner syndrome, as well as more common diseases like diabetes: “We’re seeing a lot of Type 1 diabetes in much younger kids than we used to. It used to be we’d see a peak at school entry and again at adolescence; now, we’re seeing a lot of kids who are not quite a year old… [But] we are making tremendous progress, with better subcutaneous-insulin regimens, better insulin pumps, and continuous glucose assessors. And Cardinal Glennon’s Diabetes Transition Program is helping patients 17 or 18 years of age transition from our practice to endocrinologists who treat adults.”

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Thomas McKinney Jr., M.D.

Pediatrician

St. Louis Pediatric Associates

After two decades of seeing patients at St. Louis Pediatric Associates, McKinney understands the importance of listening to patients and their families: “A few years ago, a teenage boy whom I had known for years came to see me because of a small swollen gland in his neck… Even though the patient looked very healthy, the fact that his mother was very concerned swayed me to have him seen by a hematologist. A diagnosis of lymphoma was made, fortunately early, and the young man is now in remission and doing well. His mother’s advocacy for him played a major role in his good outcome.”

What is the most pressing issue in medical ethics today, and why?

We have tremendous resources in this country in regard to medical care. In spite of this fact, many Americans do not have ready access to quality medical treatment. Good medical care should be a right, not just a privilege for the more fortunate. Finding a way to remedy the health disparities in this country is the most pressing medical ethics issue today, in my opinion.

How do you keep compassion alive, in all the rush of caseload and logistics? 

My patients and their families are, first and foremost, individual people, all with their own interesting life stories and experiences. The “business” side of medicine is not always fun, but the person-to-person interactions that are part of the job remain rewarding. It is easy to feel compassion for families whom you grow to know and care about.

What recent finding or trend do you believe will significantly shape your field in the years to come?

The concept of “medical home” is one that I believe will help shape pediatrics over the next few years. Using the medical home model, the practicing pediatrician becomes essentially the “quarterback" for the medical providers and ancillary services involved in the healthcare of the patient. The goal is to improve continuity, thereby raising the quality of medical care; while at the same time controlling costs by improving efficiency.  Use of “evidence-based” medicine—strategies and treatments proven to be effective—is another important facet of the medical home concept.

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Jacqueline Saito, M.D.

Pediatric Surgeon

St. Louis Children’s Hospital

At St. Louis Children’s Hospital, Saito has watched as the tools of her trade have evolved: “When I was a medical student, laparoscopy was just emerging as a new technology. The equipment was clunky and awkward—think first-generation cell-phones. For many years now, we have had smaller, more delicate instruments, analogous to a flip cellphone, that can be used in infants and children. Even so, there are limits to what can be done laparoscopically, with surgical procedures performed through small incisions with a telescope. In adults, instruments are being developed that are ‘steerable’ to perform incisionless procedures. In the future,I anticipate downsizing of these devices to be usable in the smallest babies. This will hopefully enable pediatric surgeons to do even more diagnostically and therapeutically, with less pain and easier recovery.”

What is the most pressing issue in medical ethics today, and why?

One of the greatest challenges is how to ethically advance medical care and technology. This is not a new issue, but I think awareness on the part of the public and those involved with medical research has greatly increased. For many diseases in children, the best treatment is not known; either there are many treatment options with the safest or most effective treatment not known, or problems which still lack any effective treatment at all. To me, the issue is two-fold: First, how do we improve the care we provide for children while minimizing risk to those who participate in medical studies? And second, how do we ensure that every child, regardless of personal circumstance, has access to the best medical care once identified?

How do you keep compassion alive, in all the rush of caseload and logistics?

Seeing kids and their families keeps compassion a priority for me—from the stress and worry when a child is ill to the relief and gratitude when he or she recovers. Children are incredibly resilient and rapid healers; I don’t feel like my job is done until I see a child as fully healed as possible, feeling better, and back to being a kid. In contrast, it’s really frustrating when I care for a child who suffers from a problem that I can’t help improve. It is humbling to realize that modern medicine cannot solve all problems, but this also serves as motivation to continually improve care.

What’s the most fascinating case you’ve handled in recent years?

Because St. Louis Children’s Hospital is a referral medical center, I regularly see unusual cases. Some require more thought outside of the box because of a rare problem or unique circumstance. This unpredictability and variety are among the many reasons I chose to become a pediatric general surgeon. The most challenging surgical problems that I see in children require teamwork: coordination of effort with other surgeons or specialists. I am fortunate to work with incredibly talented, dedicated, compassionate staff and colleagues: physicians, nurses, therapists, child-life specialists... The list goes on. 

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John DiPersio, M.D.

Medical Oncologist and Hematologist

Washington University, Center for Advanced Medicine, Alvin J. Siteman Cancer Center

Every year, DiPersio and his team invite former bone-marrow trans-plant patients and donors to Siteman Cancer Center: “It’s almost a religious experience, because you can lose sight of your purpose in life until you see people that were so sick—almost near death—dressed up like you or I and happy with their families… The most incredible part of the event is when the recipients meet the donors. They’re so appreciative, but also the donor doesn’t get a real sense of what they did until they see the person. For all of us that take care of these patients, it gives us a concrete, absolute, no-doubt meaning for what we do.”