ACMS January 2025 Bulletin by alleghenycountyms

Allegheny County Medical Society

BULLETIN

Opinion

Editorial

• The Cure for What Ails You Deval (Reshma) Paranjpe, MD, MBA, FACS

Editorial

• My Second Act as "Thursday's Pap"

Anthony Kovatch, MD

Society News

• $644 Sara Hussey, MBA, CAE

Advocacy

• Advocacy in Action

Bruce Scott, MD — President of American Medical Association

ACMS News

• Specialty Group Updates

ACMS Staff: Nadine

Popovich, Melanie Mayer and Haley Thon

Articles

Article

• It's the Most Wonderful Time of the Year...Except When It Isn't Vint Blackburn, MD

Materia medica

• Epinephrine Nasal Spray (Neffy®) Sydney Lee, PharmD and Eva Stachler, PharmD, BCPS

Cover Photo by Ronald Lee Thomas, MD Ronald Lee Thomas, MD is a Retired Physician Dancing Penguins

2025

Executive Committee and Board of Directors

President

Keith T. Kanel, MD

President-elect

Kirsten D. Lin, MD

Secretary

Richard B. Hoffmaster, MD

Treasurer

William F. Coppula, MD

Board Chair

Raymond E. Pontzer, MD

Board of Directors

Term Expires 2025

Anuradha Anand, MD

Amber Elway, DO

Mark A. Goodman, MD

Elizabeth Ungerman, MD, MS

Alexander Yu, MD

Term Expires 2026

Michael M. Aziz, MD, MPH, FACOG

Michael W. Best, MD

Micah A. Jacobs, MD, FIDSA

Kevin G. Kotar, DO

Jody Leonardo, MD

Term Expires 2027:

David J. Deitrick, DO

Sharon L. Goldstein, MD

Prerna Mewawalla, MD

Raymond J. Pan, MD

Nicole F. Velez, MD

PAMED District Trustee

James Latronica, DO, DFASAM

2025 Board Committees

Bylaws

Richard B. Hoffmaster, MD

Finance

William F. Coppula, MD

Nominating

Kirsten D. Lin, MD

Women’s Committee

Prerna Mewawalla, MD & Meilin Young, MD

Bulletin

Managing Editor

Sara C. Hussey, MBA, CAE ACMS Executive Director shussey@acms.org

Medical Editor

Deval (Reshma) Paranjpe, MD reshma_paranjpe@hotmail.com

Bulletin Designer Victoria Gricks victoria@thecorcorancollective.com

The 2025 Bulletin Editorial Board will be announced after the February Board Meeting.

EDITORIAL/ADVERTISING

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The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication.

Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA.

Administrative Staff

Executive Director

Sara Hussey shussey@acms.org

Vice President - Member and Association Services

Nadine M. Popovich npopovich@acms.org

Manager - Member and Association Services

Haley Thon hthon@acms.org

Operations CoordinatorACMS & ACMS Foundation Melanie Mayer mmayer@acms.org

Manager - Operations and Finance

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Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted.

The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted.

Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products.

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The Cure for What Ails You

A Local Remedy

By:

Deval (Reshma) Paranjpe, MD, MBA, FACS

Happy 2025! This month’s column was an unexpected gift. During a routine morning of surgery, today, I overheard something not routine and quite amazing. The anesthesiologist was congratulating the CRNA on his grand opening. Being a nebby Pittsburgher, I couldn’t help but ask what had just grandly opened and how he was involved. What I discovered was a great feel-good story about beer, burnout, and physician wellness, and a great new brewery to try.

Local Remedy Brewing 531 Allegheny Avenue (former location of Oakmont Bakery) Oakmont, PA 15139

Wed-Fri: 4pm-10pm Sat: 12pm-10pm Sun: 12pm-7pm

The CRNA is Sean Williamson, one of the five founders of the new Local Remedy Brewery in Oakmont. Years ago, Williamson was working at St. Margaret’s Hospital as an ICU nurse where he first met and became friends with Matt Synan MD, a pulmonary and critical care medicine physician. They bonded over work, among other things, and a mutual love of good beer. Synan majored in biochemistry in college and was always experimenting with brewing beer in his basement for fun; eventually, he started a nanobrewery. He pulled in four others close to him to found Local Remedy: his friend Sean from work, lifelong high school friend BJ Swartzlander (curriculum director at Kiski High School), college friend and current head

brewer Joe Vikless, and sister-in-law Andrea Boswell, a graphic designer at a firm that works with the Pirates and the Steelers. At St. Margaret’s, he found a second family of friends in his work colleagues, many of whom would become investors in Local Remedy—25% of his investors are physicians. In addition, his friend Dan Silanoff (a former NASA engineer who worked on lunar rovers and now works on self-driving trucks for Aurora) runs the supply chain and operations for the business.

Synan’s wife Maria strongly encouraged Matt’s brewing hobby a decade ago. As she observed him going through fellowship and beyond, she witnessed signs of the burnout that affects so many of us. She urged him to get a hobby he truly loved as refuge and relaxation so that medicine would not be his only identity and focus. She has been the “backbone of the business” according to Synan, and functions as the manager of Local Remedy.

Local Remedy was founded as an enjoyable side gig for its five founders to combat burnout and to give back to the local community. “None of us are quitting our regular jobs,” Synan and Williamson said emphatically. Six years ago, the nanobrewery routinely entered its products into competitions and festivals, but then the pandemic happened. “The pandemic had us all re-evaluating how we were spending our time,” Synan noted. Joe Vickless wanted to open a brick and mortar brewery, and in 2023, the five friends committed to the idea. “We all agreed that the brewing business was never going to replace our real jobs, so there

was no hurry—we decided to wait for the right place and opportunity.”

Synan grew up 10 minutes from Oakmont. He and his wife later lived in Oakmont for 10 years and fell in love with the close-knit community. When the perfect location and opportunity arose in the original location of the Oakmont Bakery, the friends acted on their dream. The Oakmont Bakery had been so successful in this location that it had to move to a larger location to handle its booming business. Oakmont Bakery owner Matt Serrao has been “incredibly supportive” of the brewery endeavor, as has the borough. Synan jokes that this building which housed a bakery and now a brewery is lovingly called the “Cathedral of Carbohydrates.”

The brewery has a strong community focus, and aims to support other Oakmont businesses and establish a large philanthropic presence. To this end, Local Remedy has pledged to donate 1% of their quarterly gross income to deserving local organizations. While the brewery does not have an in-house dining program, it has relationships with local eateries Pittsburgh Taco Boys (next door) and Leone’s Pizza, both of which deliver food to the brewery.

And as for the beer? “We’re all beer nerds,” laughs Synan. “We love all beer styles. We’re mostly hop-forward but are also traditionalists with lager and barrel programs. We have 7 beers on tap today, including our 2024 PA State Homebrew Competition winner, a Bourbon-barrel stout.”. Local Remedy also features a few guest beers from other supportive local breweries, as well as ciders and ready-to-drink cocktails

Editorial

from area distillery Goodlander to round out their offerings.

“We want people to drink good beer. You become a family when you work together in hospitals. Even when you move apart geographically, this is a way to stay close.” Synan points out that friend and investor Jason Lamb, MD now practices in West Virginia but still stays close to the group through his involvement in the brewery. “We all face the same stressors—being part of Local Remedy gives everyone a revitalizing creative outlet.”

So drop by Oakmont and check out Local Remedy—you may find medicine for the soul and inspiration to embark on your own creative pursuits to combat burnout, regain your energy and rediscover the fun in your life.

My Second Act as “Thursday’s Pap"

By: Anthony Kovatch, MD

“There are no second acts in American lives.”

--American author F. Scott Fitzgerald

When I--aware that I was settling in on the “back nine” of my professional career--“picked up” a one-day-a week supplemental job 15 years ago with the compensation earmarked to help contribute to the cost of my sons’ graduate education, I could have never comprehended how the continuation of the job (with its attendant role as “Thursday’s Pap”) would help sustain my challenged mental health and existential integrity when I fully retired from my full-time job in private pediatric practice 3 long, and seemingly endless, years ago. With my grown children then accomplished and raising their own families in locations too far from the Steel City for my wife and I to babysit on Saturday nights, I found I direly needed some “surrogate grandchildren”—sometimes referred to as “grandfriends “--to fill the shoes of the dear little patients who for 40-plus years had unwittingly assumed that role. To the chagrin of my uber-patient wife and biological children, my mission statement as a pediatrician had been borrowed from a comment I had heard and integrated into my psyche as far back as medical school: A good doctor should be like a close family member who just knows a little more about medicine than you do! Amen.

When I had originally accepted the role as an independent contractor in 2009, fulfilling the duties of interim pediatrician for children housed at one of 3 facilities of a revered hometown psychiatric institution, I considered it

merely another day at the office--just another facet of my practice. Indeed, there was anxiety about my breaking loose from years of compliance and the dogmatic slumber of cynicism (now referred to as “burnout”) and venture “emotionally naked” into the “heart of darkness” of mental health at the institutional level. However, by the time I had reached retirement and had freed myself from my angst, I was able to embrace a deeper involvement in the social determinants of health of these vulnerable unfortunates. I sensed not only a calling, but a sacred obligation, to dance to the music from an inner chamber within my restless being.

The institution, like the ancient kingdom of Gaul which I had read about in high school Latin class, was divided into 3 parts. The hospital proper was a temporary haven of safety for children from preschool age to young adulthood with acute psychiatric disorders who basically had to be made aware that their condition was serious and lifethreatening, or whose deteriorating behavior required a psychological “tuneup” or an overhaul of their medications. My role often focused on trying to reverse the unrelenting juggernaut of obesity that accompanied the necessity of psychiatric polytherapy. Despite these obstacles, most of these children had the capability of eventually being the heroes of their own lives.

In contrast, one residential treatment facility (RTF) housed boys with uncontrolled Bipolar Disorder, combined types of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and the whole spectrum of conduct disorders

and sexual maladjustment. The rehabilitation of these patients was complicated by the fact that they were otherwise intellectually normal, were often hard-boiled and devious, and had families with the same problems (or worse); with months of intense therapy, they were generally capable of being the heroes of their own lives. I often argued to myself that their ultimate fate would only be determined by their past, as concluded in this iconic quote in “Requiem for a Nun” by American author William Faulkner:

“The past is never dead. It’s not even past. All of us labor in webs spun long before we were born, webs of heredity and environment, of desire and consequence, of history and eternity.”

I preferred to surmise, however, that more contemporary author Malcolm Gladwell had it more correct:

“Sometimes the past deserves a second chance.”

Just like old, retired pediatricians!

"A

house is not a home when there's no one there to hold you tight."

The second RTF, which I referred to at times within my spiritually confused soul as "The Lesser House of God," sheltered children of a wide variety of ages with Autism Spectrum Disorder of various degrees of severity, including those who were completely non-verbal. It was in this facility that I spent the lion’s share of my time off on the Thursday’s (hence, “THURSDAY’S Pap) while I was still in practice, and where I expended most of my emotional energy and connectivity (hence, “Thursday’s PAP”) during the dedicated time of 2 days during retirement; by that time, the census was expanding at that “sanctuary” (as it was at others throughout the country). Many would be residents for years until they were stable enough to be transitioned to an adult facility at 18 years of age or, if miracles were in the wind, were adopted or recovered enough “normality” to return home to their parents. I frequently mistakenly referred to this building as a residential “training” (rather than “treatment”) facility, not because of the education provided within, but because the commotion and chaos produced within felt like a “freight training running through the middle of my head.” Most of the staff—no matter how dedicated and empathetic--shared my feelings in this regard.

It is fair to say that none of these inmates would be the heroes of their own lives! And that is where we who cared for them all came in. I still wonder if the Beatles were right in their song “Across the Universe”: “Nothings gonna change my world,” or if the truth lies in the conviction of a nurse who once frankly said to me: “Most of all these poor children just need someone to love them!” I realized that this would have to be an experiment in progress.

The personalities of the boys in the RTFs were as diverse and egregious as their psychiatric issues and as intense as the pitiful Charles Dickinsesque psychosocial dramas--now politically-correctly referred to as social-determinants of health--

which had fashioned their destinies. Physical, sexual and emotional abuse was universal. Some had been abandoned or had survived attempts at extermination by their parents after birth. Many of the parents, stepparents, or paramours of the primary caretakers were incarcerated. The ages, extreme caretaking demands, and virtual or perceived unlovability of the lad’s made adoption or guardianship unviable for even the most compassionate of folks; however, as we will see, there were exceptions!

The wards were larded with the foul musty odor of soiled pull-ups, the foul language of altercations, the hollow shrieks of autistic attempts at communication, and the omnipresent aura of staff frustration and cynicism, as well as overriding existential despair. Into all this, emotionally ignorant I arrived, like an untamed wild animal, equipped only with the hope and faith that I might be able to shelter this lot of ragamuffins from further trauma that might deteriorate into the corrosion of all empathy and affection. At the very least, I argued, I could try to create a positive childhood experience (PCE) or 2 that might counteract the deleterious effects of the multiple adverse childhood experiences (ACE) that had befallen them through no fault of their own. The easiest PCE for us to accomplish was probably the most efficacious: Having at least two nonparent adults who genuinely cared. Most of my efforts went unrequited and unrecognized; however, my unspoken hope was that in the long run one trivial instance of empathy might tip the scale in favor of an outcome that would produce resiliency and improved mental health in the unfortunates’ adulthood. (1) Manipulation of nursing personnel by the higher-functioning, sly, foxy inmates was ubiquitous, generally for the purpose of gaining some individual attention. Oldtimers like myself might remember author Jack Kerouac’s description of his outrageous sidekick Neal Cassady in “On the Road,” the 1957 dissertation that launched the cultural

phenomenon that would be the “Beat Generation”:

"He was simply a youth tremendously excited with life, and though he was a con-man, he was only conning because he wanted so much to live and to get involved with people who would otherwise pay no attention to him…”

In contrast to the mandatory periodic mental health assessments (referred to as “treatment team”) by the psychiatrists which intimidated the inmates, sightings of the bespeckled, grey-haired pediatrician instantly produced an epidemic of physical ailments involving just about every organ system (as well as some not previously documented in the medical literature). “He’s here! Pass the word around, guys!” It was widely known that the naïve, dim-witted “Kovatch” was as easy to dupe and conn as shooting fish in a barrel! In spite of entreaties from the “Golden Girls”--the miraculous nurses who had acquired enough experience and savvy to see through the shenanigans and debunk the conn artists in their tracks--to abandon his “bleeding heart” ways, the pediatrician fumbled through (and continues to do so) week after week like a myopic fool--in the image and likeness of the venerable Mister Magoo. The non-verbal autistic boys quickly learned that simply by trailing after “Magoo” with their index finger pointing to their cheek as a gesture meaning “more,” they could swindle from him all the candy he carried hidden under his instruments in his old dilapidating black bag!

Although the overriding sentiment was “Nothing’s gonna change my world,” there was a sign--perhaps a promise-above the entrances to all 3 facilities which read:

We Create Miracles in This House. These “miracles” will be presented in the sequels to this overview.

Reference:

1. Daines, CL et al: “Effects of Positive and Negative Childhood Experiences on Adult Family Health.” BMC Public Health Vol 21 Article Number: 651 (2021).

$644

Understanding the True Value of ACMS Membership

By: Sara C. Hussey, MBA, CAE — ACMS Executive Director

An Active Physician Membership in the Allegheny County Medical Society (ACMS) costs $644 annually—$295 in county dues and $349 in Pennsylvania Medical Society (PAMED) dues. For many, this might seem like just another expense in a long list of professional obligations. But when you pause to consider the tangible and intangible benefits this investment brings, the value becomes evident.

The ACMS recently established a Membership Task Force to delve deeper into membership trends and explore ways to enhance the value our organization brings to the physicians of Allegheny County. This effort comes at a pivotal time, as national trends show a decline in member engagement with associations. For those who have recently renewed your membership, or for those weighing your renewal (due by the end of February!), I’d like to take this opportunity to share my perspective on the immense value packed into your $644 annual investment.

Advocacy That Protects Your Profession

One of the cornerstones of your membership is advocacy—both at the county and state levels. PAMED, supported in part by your dues, works tirelessly to protect and advance the interests of physicians and patients alike. Recent legislative victories showcase this dedication:

• Limiting Noncompete Agreements: The passing of House Bill 1633 curtails restrictive noncompete clauses in physician contracts. This ensures greater job flexibility for physicians and continuity of care for patients—a win for both

the profession and public health. Of course, we recognize this bill did not accomplish all that we had hoped, and we look forward to additional changes in the next legislative session.

• Protecting Physician-Led Care: PAMED has successfully opposed attempts to grant non-physician providers independent practice authority, preserving the integrity and quality of care delivered under the leadership of trained physicians.

• Enhancing Telemedicine Access: Advocacy for telemedicine legislation has ensured that insurers cover virtual care services, a critical development in improving access to healthcare, particularly in rural and underserved areas.

These achievements don’t happen by chance. They require dedicated teams of professionals, informed lobbying efforts, and collective member support. By being a part of ACMS and PAMED, you contribute to this advocacy infrastructure and ensure that the physician’s voice remains strong in legislative discussions.

Continuing Medical Education (CME): Elevating Your Expertise

Physicians are lifelong learners, and ACMS and PAMED make it easier for you to stay current with the latest in medicine while meeting licensure requirements. Some highlights include:

• Free Required CME Courses: Members gain complimentary access to courses on topics like child abuse reporting, opioid prescribing, and patient safety/risk management. These courses not

only help you maintain your license but also deepen your understanding of critical issues in healthcare.

• A Robust CME Library: Beyond the required courses, PAMED offers an expansive catalog of educational resources, including webinars and on-demand sessions. Whether you’re looking to refine your clinical skills or explore emerging healthcare trends, these resources are at your fingertips.

Your membership fee also supports the infrastructure needed to create, update, and deliver these learning opportunities. Without collective funding from members, these essential services would not be as accessible or comprehensive.

Building Community: Networking and Leadership Opportunities

In a profession that can often feel isolating, ACMS provides a vital sense of community. Membership connects you with colleagues, mentors, and leaders who share your challenges and aspirations. Opportunities include:

• Special Interest Groups: Engage with peers who share your professional focus through groups like the ACMS Women in Healthcare Committee, the PAMED Early Career Physician Section, or joining the ACMS Board or Delegation. These groups foster connection and collaboration while addressing unique challenges.

• Leadership Development: ACMS and PAMED offer programs designed to cultivate future leaders in healthcare. Whether you’re looking to enhance your leadership style or take on roles in organized

Society News

medicine, these programs provide the skills and support to excel. Networking isn’t just about making professional connections—it’s about finding a community that understands your work’s complexities and importance. The relationships you build through ACMS can offer guidance, inspiration, and camaraderie throughout your career.

Supporting Your Practice: Operational Resources

Healthcare is as much about efficient operations as it is about patient care. ACMS and PAMED provide tools and services to support your practice’s success:

• Practice Management Assistance: Whether you’re navigating regulatory changes, optimizing workflows, or managing staffing challenges, expert support is available to help your practice run smoothly.

• Discounted Compliance Services: Members receive discounts on compliance reviews, cybersecurity assessments, and other services that protect your practice and ensure adherence to legal requirements.

• Insurance Solutions: From professional liability coverage to employee benefits planning, ACMS and PAMED connect members with resources to safeguard their practices.

In today’s healthcare landscape, where administrative burdens often overshadow clinical care, these services can save you time, money, and stress.

Advancing the Profession: Your Dues at Work

While the benefits outlined above directly impact you as a member, your $644 also contributes to the broader healthcare community. Dues support the salaries of ACMS and PAMED staff, including advocacy teams, CME developers, and member support specialists. These professionals work behind the scenes to ensure your membership delivers maximum value.

Additionally, your contributions help fund initiatives that advance the profession as a whole. This includes outreach efforts to promote physician wellness, public health campaigns, and programs aimed at fostering diversity and inclusion within medicine.

Membership dues are not merely an expense; they are an investment in the future of medicine. Every dollar supports efforts to strengthen the profession, improve patient outcomes, and maintain the high standards that define physician-led care.

Association Membership Trends: A Broader Perspective

ACMS and PAMED are part of a larger ecosystem of professional associations, many of which are grappling with shifting membership trends. Key insights from association management research provide context for the value of your membership:

• Personalization is Key: Members increasingly expect tailored experiences that address their specific needs and interests. ACMS and PAMED have embraced this trend by offering diverse CME options, customizable practice resources, and specialized networking groups.

• Digital Engagement is Rising: The pandemic accelerated the adoption of virtual events and online resources. ACMS and PAMED have adapted by offering webinars, virtual conferences, and digital tools that make participation easier and more convenient.

• Advocacy is a Priority: Across industries, members value associations that champion their interests at the policy level. The legislative successes of PAMED highlight the importance of collective advocacy in protecting the future of medicine.

These trends demonstrate that ACMS and PAMED are not only keeping pace with member expectations but are also leaders in adapting to the evolving needs of healthcare professionals.

The Intangible Benefits: A Sense of Belonging

Beyond the concrete services and resources, membership in ACMS offers something less tangible but equally important: a sense of belonging. In a profession as demanding as medicine, it’s vital to know that you’re part of a larger community working toward shared goals. ACMS provides a platform for physicians to unite, support one another, and make their voices heard.

At first glance, $644 might seem like a significant investment. But when you break it down, the value becomes clear. Your membership provides education, advocacy, networking, and support that directly benefit you while contributing to the advancement of the medical profession as a whole.

As we continue to face challenges in healthcare, from regulatory changes to workforce shortages, the collective power of membership becomes even more critical. By staying connected to ACMS and PAMED, you are investing not only in your own success but in the future of medicine.

The next time you renew your membership, remember that your $644 is more than a fee—it’s a commitment to excellence, community, and progress. This is your organization. We are member-driven. We need to know what your priorities are and how we can be of help and relevance to you so that your dues are used to your best benefit. Please contact me at shussey@acms. org to provide feedback.

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It’s the Most Wonderful Time of the Year…

Except When It Isn’t

By: Vint Blackburn, MD

I am still surprised that people find it strange that depression and the holidays go hand in hand. As a psychiatrist, we see a distinct increase in the acuity of our patients in December and January. Statistically, these are the two highest months for suicide, and over 60% of people with mental illness report worsening symptoms during this time.

As physicians, we like to think we’re outside these statistics, but that’s not the case. Under the best circumstances, roughly 50% of physicians report feeling burned out, which increases in the middle of winter, surrounded by a society that seems to expect merriment and joy. In many ways, we are at a higher risk for depression during this season, as many of us don’t get much relief during the holidays due to the demands of work.

A few years ago, I was interviewed for a magazine article on why depression and anxiety are so prevalent during the holidays. As I pointed out then, there is a myriad of factors. As practitioners, we are familiar with seasonal affective disorder, which tends to kick in as the days shorten, the weather becomes gloomier, and our ability to spend time outdoors is curtailed. But this involves a much greater time span than December and January, so why the peak of depression and suicidal thoughts?

One important contributor is the expectation that this time of the year should be full of joy and family togetherness. For those who do not have significant family connections, this can be a stark reminder of just how lonely and isolated they feel. This is one of the reasons movie theaters thrive on

Christmas Eve.

However, it is not only people who are without family who find the season challenging and isolating. For many, it is very stressful to have a large group of family members gathered with the unrealistic expectation of family unity and holiday merriment, especially when they do not agree or get along under normal circumstances. Every year, patients tell me, “I can’t tell you how stressful it is during the holidays. It’s nothing but bickering and reopening of old wounds.” As an adolescent psychiatrist, I work with young LGBTQ patients who often find the holidays horrific, especially when they are expected to spend time with relatives who do not agree with and actively despise their choices. There is nothing like a family gathering to make the black sheep feel even more alone.

There is an amazing episode of The Bear that depicts the insanity of Christmas gatherings and just how uncomfortable they can be. Even if you don’t like the series, I highly recommend watching that episode, especially given the cameo performance. Though exaggerated, it reminds me of family dynamics I’ve witnessed in real life.

As caregivers, specifically physicians, we not only have to help our patients who are going through these difficult feelings during the holidays, but we also have to navigate our own struggles, which can include not being able to be with our family as much as we would like. Furthermore, given the confidential nature of our work, we cannot share much of what we go through, which means they often do not understand. Doctors are often different than many

of their family members who do not work in such demanding professions or perhaps do not share the same nuanced point of view that we have as physicians (think COVID-19). I know that I struggle with not being able to share or talk in depth about what I do on a daily basis with my friends and family, something my mother still struggles with.

All of this is really to say that depression and isolation, not to mention other mental health struggles, are generally exacerbated during the holidays and post-holiday season. This is as true for physicians as it is for anybody else, and maybe more so given some of the issues I have touched on above. The thing to keep in mind is, if you are struggling during this time of year, you are not alone. Feeling sad or depressed during this time isn’t a flaw, even though societal expectations can make it feel that way.

For all of these reasons, it is an excellent time to see what options are out there to help us through this rough time. More physicians are exploring therapy and mental support, including our own ACMS Physician Wellness Program. This can link you, completely confidentially, to a therapist specifically interested in working with physicians. Best of all, up to four sessions are covered by the ACMS Foundation (with no identifiable data ever).

Most people who have been engaged in some form of therapy find it extremely useful (including myself). But when we are really struggling, it can be lifesaving. So please remember, “Dr. heal thyself,” and take the steps needed to care for yourself so you can continue caring for others.

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Advocacy in Action

How the AMA is Tackling Medicare Cuts, Prior Authorization Reform, and Physician Burnout

Contributed By: Bruce Scott, MD — President of American Medical Association

Editorial Note – Sara Hussey, MBA, CAE

You asked, and we listened! Many of our members have expressed a desire for more insights into advocacy at the national, state, and local levels. In response, we are excited to announce that an Advocacy section will now be a permanent feature in the ACMS Bulletin. Look forward to contributions from the AMA, PAMED, and local legislators, addressing topics that are important to physicians and organized medicine.

The American Medical Association (AMA) has long stood at the forefront of advocating for the health and wellbeing of patients and physicians alike. With the rapidly evolving challenges in healthcare—ranging from policy shifts to systemic financial pressures—the AMA's advocacy efforts are more critical than ever. Our first advocacy article of the year delves into two major areas of focus for the AMA: its recent advocacy update and its urgent response to Medicare reimbursement cuts, both of which underscore the organization's unwavering commitment to safeguarding the future of American healthcare.

A Call to Action: Medicare Reimbursement Cuts

The AMA's advocacy efforts recently came into sharp focus with its response to proposed Medicare reimbursement cuts. In a statement from AMA President Bruce Scott, MD, the organization expressed deep concern over the potential consequences of these cuts for both physicians and patients.

The Issue at Hand

Medicare reimbursement rates have been a longstanding point of contention. For years, physicians have faced declining payment rates that fail to keep pace with the rising costs of providing care. The latest proposed cuts exacerbate this trend, threatening the financial viability of medical practices, particularly those in rural and underserved areas.

Dr. Scott's statement highlights the gravity of the situation: "Congress’ failure to address Medicare physician payment cuts is an unconscionable blow to the patients we serve and to the physicians who care for them. These cuts threaten access to care for millions of Medicare beneficiaries and place an undue burden on practices already struggling with inflation and pandemic-related challenges."

The AMA's Response

In response to these proposed cuts, the AMA has launched a robust advocacy campaign aimed at rallying support from Congress to reform the Medicare payment system. The organization is calling for a system that provides predictable and sustainable payment updates, ensuring that physicians can continue to serve Medicare beneficiaries without financial strain.

Key aspects of the AMA's advocacy include:

1. Engaging Lawmakers: The AMA is leveraging its extensive network to engage lawmakers and educate them on the real-world impacts of Medicare cuts. By amplifying the voices of physicians and patients,

the AMA hopes to build bipartisan support for payment reforms.

2. Grassroots Mobilization: The AMA is encouraging physicians and patients to join its advocacy efforts through grassroots campaigns. These initiatives empower stakeholders to contact their representatives, share their stories, and advocate for meaningful change.

3. Data-Driven Advocacy: The AMA is also using data to make its case, highlighting the economic and social consequences of reduced Medicare reimbursements. This evidence-based approach aims to underscore the urgency of the issue and the need for immediate action.

Implications for the Future

The proposed Medicare cuts serve as a stark reminder of the challenges facing the healthcare system. Without a sustainable payment model, the ability of physicians to provide highquality care will be compromised, and patients—particularly those in vulnerable populations—will bear the brunt of the impact.

The AMA's advocacy underscores the need for systemic reform that prioritizes the needs of both physicians and patients. By addressing these challenges head-on, the AMA aims to create a more resilient and equitable healthcare system for future generations.

AMA Advocacy Update: Elevating Physician and Patient Voices

In the final advocacy update of 2024, the AMA Advocacy team provided a sweeping overview of the organization's

Advocacy

ongoing initiatives to address key issues impacting physicians and patients. A central theme in the update is the AMA's multifaceted approach to tackling healthcare inequities, improving access to care, and ensuring that physicians can deliver the highest quality of care without unnecessary administrative burdens.

Addressing Prior Authorization Reform

One of the AMA's flagship advocacy efforts is the push for prior authorization reform. For years, physicians have voiced concerns about the excessive administrative hurdles imposed by insurance companies, which delay or deny medically necessary treatments. These burdens not only take valuable time away from patient care but also jeopardize patient outcomes.

In response, the AMA has worked with policymakers to introduce bipartisan legislation aimed at streamlining prior authorization processes. The "Improving Seniors' Timely Access to Care Act," for instance, has gained significant traction. If enacted, this legislation would require Medicare Advantage plans to implement electronic prior authorization systems, thereby expediting approvals and reducing delays.

Combating Physician Burnout

The AMA's advocacy also extends to addressing the epidemic of physician burnout. The organization recognizes that the well-being of healthcare providers is intrinsically tied to the quality of care they can offer. To that end, the AMA continues to champion initiatives that reduce administrative burdens, promote workplace flexibility, and provide mental health support for physicians.

For example, the AMA has been instrumental in advocating for changes to federal policies that currently impede physicians' access to mental health services. By eliminating barriers such as stigma and fear of professional repercussions, the AMA aims to create a culture where physicians feel

supported and empowered to seek help when needed.

Promoting Telehealth Expansion

The pandemic underscored the vital role of telehealth in expanding access to care, especially for vulnerable populations. Recognizing this, the AMA is advocating for the permanent extension of telehealth flexibilities that were temporarily enacted during the COVID-19 public health emergency. These include ensuring adequate reimbursement for telehealth services and addressing the digital divide that limits access for rural and underserved communities.

Through its ongoing advocacy, the AMA seeks to make telehealth a permanent and equitable fixture in the healthcare landscape. This effort aligns with the organization's broader mission to innovate and modernize the healthcare system.

Looking Ahead

The AMA's advocacy efforts—whether through addressing prior authorization, combating physician burnout, promoting telehealth, or tackling Medicare reimbursement cuts— reflect a comprehensive approach to improving healthcare. These initiatives are not isolated; rather, they are interconnected components of a larger mission to advance the art and science of medicine for the benefit of humanity.

As the healthcare landscape continues to evolve, the AMA remains a steadfast advocate for the needs of physicians and patients. Through collaboration, innovation, and unwavering dedication, the organization is charting a path toward a more just and effective healthcare system.

The challenges are formidable, but the AMA's advocacy demonstrates that progress is not only possible but within reach. By uniting physicians, patients, and policymakers, the AMA is helping to build a healthcare system that reflects the values of compassion, equity, and excellence.

Call to Action for Physicians

Physicians can play a pivotal role in supporting the AMA's advocacy

efforts. By staying informed, engaging with policymakers, and participating in grassroots campaigns, healthcare providers can amplify their collective voice and drive meaningful change. The AMA offers numerous resources to help physicians get involved, including advocacy toolkits, legislative updates, and opportunities to connect with like-minded colleagues. You can visit https://www.ama-assn.org/ to learn more.

Additional Resources

In November 2024, the AMA released its Advocacy impact report. This report provides updates on the organization's advocacy efforts. It highlights how the AMA is working to influence health care policy, legislation, and regulations at the national, state, and local levels. You can check out the full report by visiting: https://www.ama-assn.org/system/ files/ama-advocacy-efforts.pdf

Epinephrine Nasal Spray (Neffy®)

By: Sydney Lee, PharmD and Eva Stachler, PharmD, BCPS

Background

Neffy (epinephrine nasal spray) manufactured by ARS Pharmaceuticals was approved by the US Food and Drug Administration for use in adults and children ≥ 30 kg (66 pounds). It consists of two milligrams of epinephrine in a nasal injector. The approved indication is the management of Type I allergic reactions including anaphylaxis.1 Anaphylaxis is a severe and potentially life-threatening reaction affecting multiple organ systems, usually within minutes to hours of allergen exposure. Clinical presentation includes urticaria/ pruritis, angioedema, swelling of the mouth/throat including respiratory compromise, and gastrointestinal symptoms like nausea/emesis, or sudden acute hypotension. The estimated incidence is about 2.1 events for every 1000 person years, though hospitalizations have been increasing since the early 2000s. Rapid administration of injectable epinephrine is the standard treatment, and delayed treatment or failing to treat is associated with increased morbidity and mortality. Historically, it was only available via injection, which was undesirable in patients afraid of needles and which led to reluctance to administer therapy entirely. There are several commercially available injectable products including autoinjectors, and autoinjectors with audio functions that will narrate instructions. Upon administration, the patient experiences bronchodilation that restores the airway and increased blood pressure/reduced vasodilation from the beta-adrenergic and alphaadrenergic agonism respectively.2,3

Safety

Due to the nature of the emergencies in which it is used, there are no contraindications to epinephrine for anaphylaxis. When given at usual doses, patients may become agitated or anxious, dizzy, pale, or experience a headache, palpitations/tremors, or nausea and vomiting.1,2 The same nonspecific alpha and beta antagonism that give epinephrine therapeutic effect also leads to these adrenergic adverse effects. In one trial the manufacturers submitted to obtain approval, there was a statistically significant change in systolic blood pressure at all but the first time point for the first 120 minutes, with a peak of about 20 mmHg change from baseline vs 13 mmHg for the IM formulation (CI 4.55-10.06), and then declining at a comparable rate to the IM formulation. Initial changes in heart rate (13 vs 10 BPM) and diastolic blood pressure (9 vs. 8 mmHg) appear comparable.4 Notably, patients are recommended to seek emergency medical treatment as soon as possible for further monitoring and evaluation –this includes monitoring for response to therapy as well as adverse effects.1 Given the route of administration, clinical trials reported nasal discomfort, rhinorrhea, nasal pruritis, sneezing, nasal congestion, and throat irritation.4,5

Tolerability

This medication is reasonably well tolerated for a product intended for emergency scenarios and is the first needle-free epinephrine dosage form for emergency use. Incidence for adverse effects varies, but no adverse effect was associated with greater

than 20% incidence after two doses in clinical trials of healthy adults.1

Efficacy

The manufacturers completed various pharmacokinetic and pharmacodynamic assessments in different populations, including healthy patients, those with both infections and allergic rhinitis, and animal models designed to simulate anaphylaxis. While pharmacokinetic differences exist among product formulations, they have not revealed themselves to be clinically meaningful thus far. In a review of all the trials conducted so far using intranasal epinephrine spray, systemic epinephrine concentrations compared to injectable products are comparable, consistent with variability between approved epinephrine products.3 When compared directly to intramuscular epinephrine injected by a healthcare provider in a phase I randomized crossover study of 45 patients with a history of allergic rhinitis, nasal epinephrine spray concentrations were higher by a statistically significant amount at most of the 16 available time points within 360 minutes after the administration of either agent.4 Notably, time to maximum effect was shorter with nasal epinephrine than IM, (30 minutes (range: 6.0-240 min) compared to 45 minutes (range: 4.0-120 min)) though it was not statistically significant, and it reached a higher maximum concentration and exposure – there are insufficient parameters to determine significance. In patients experiencing nasal congestion and/or upper respiratory tract infections, there were no statistically significant difference in epinephrine

Materia medica

concentrations or effect.5 This is important to note for patients who opt for this epinephrine formulation as they may need it in acute illness or may have comorbid allergies. These trial results suggest that nasal epinephrine can be expected to work as well as intramuscular epinephrine, even if patients are experiencing rhinitis and active congestion. Currently, there is no published real-world data to support the use of epinephrine nasal spray –however this was consistent with the approval process for other epinephrine products.3

Pricing

This product became available in the United States at the end of September, and was expected to become available in Europe under the name EURNeffy® during the fourth financial quarter of 2024.6

There is minimal official pricing data available in regard to insurance coverage compared to other formulations of epinephrine. The listed cash price is $199, but there is a patient assistance program available where patients can receive the medication for no charge, and $25 dollar copay cards for eligible individuals with commercial insurance available through BlinkRx.6

Simplicity

The dosage form consists of a nasal injector with each unit containing one dose – do not prime or reuse it. After opening the package, patients or caregivers should place their pointer and middle finger on either side of the nozzle and insert it into the nose pointed straight at the back of the head. Do not angle the nozzle to any side. Using the thumb, press the cylindrical plunger until it makes a snapping noise, and patients feel a spray – educate patients to not sniff during or after the dose is given. If symptoms have not abated five minutes after the first dose, a second dose can be given into the same nostril as the first dose, and if liquid drips out of the nose, if there are no other adverse effects, a repeat dose can be given. While it should be stored at room temperature, it can be stored

at high temperatures for a few days, and if accidentally frozen it can be thawed and readministered. Notably, if actively frozen it will not administer medication and should not be used.1 This represents an advantage over other injectable epinephrine formulations, which cannot be frozen, must be kept at room temperature, and require protection from light. While there is not yet literature to support safety and utilization in pediatric patients weighing <30 kg, this is consistent with the epinephrine auto-injector prescribing information; currently, the manufacturers are applying for a supplemental new drug application for a 1 mg product to be used in patients weighing 15-30 kg, which is consistent with the original epinephrine autoinjector dosing, and would increase product utility, as a needle free dosage form may be especially attractive in a pediatric population.7,8

Bottom Line

While epinephrine nasal spray is a new dosage form, it is not a new medication and there is some evidence supporting its utilization due to similar pharmacokinetic and pharmacodynamic outcomes. Its safety profile is consistent with that of other epinephrine formulations, and as real-world data emerges it will likely demonstrate similar clinical efficacy, which is comparable to the approval process for other epinephrine formulations. The needle free device and ability to withstand temperature changes represent advantages over other dosage forms, and while data about financial elements and logistics will be evolving, this unique product brings a new approach to the management of anaphylaxis. In patients who are not willing or able to use an injectable dosage form, or who do not have reliable access to climate-controlled spaces (e.g., air conditioning), epinephrine nasal spray appears to be an appropriate treatment for the management of Type I allergic reactions and anaphylaxis.

Dr. Sydney Lee is a PGY1 Pharmacy resident at UPMC St. Margaret and can be reached at lees39@upmc.edu. Dr. Eva Stachler is a PGY2 Geriatric Pharmacy resident at UPMC St. Margaret and can be reached at stachlere@upmc.edu. Dr. Heather Sakely, PharmD, BCPS, BCGP, the Director of Clinical Pharmacy Services and Director of the PGY2 Geriatric Pharmacy Residency served as editor and mentor for this work and can be reached at sakelyh@upmc.edu.

References

1. Neffy (epinephrine nasal spray) prescribing information. San Diego, CA: ARS Pharmaceuticals Operations, Inc.; 2024 Aug.

2. Pflipsen MC, Vega Colon KM. Anaphylaxis: Recognition and Management. Am Fam Physician. 2020;102(6):355-362.

3. Ellis AK, Casale TB, Kaliner M, et al. Development of neffy, an Epinephrine Nasal Spray, for Severe Allergic Reactions. Pharmaceutics. 2024;16(6):811. Published 2024 Jun 14. doi:10.3390/ pharmaceutics16060811

4. Casale TB, Oppenheimer J, Kaliner M, Lieberman JA, Lowenthal R, Tanimoto S. Adult pharmacokinetics of selfadministration of epinephrine nasal spray 2.0 mg versus manual intramuscular epinephrine 0.3 mg by health care provider. J Allergy Clin Immunol Pract. 2024;12(2):500-502.e1. doi:10.1016/j.jaip.2023.11.006

5. Oppenheimer J, Casale TB, Camargo CA Jr, et al. Upper respiratory tract infections have minimal impact on neffy's pharmacokinetics or pharmacodynamics. J Allergy Clin Immunol Pract. 2024;12(6):16401643.e2. doi:10.1016/j.jaip.2024.02.038

6. ARS Pharmaceuticals Announces U.S. Availability of neffy® (epinephrine nasal spray), the First and Only Needle-Free Treatment for Type I Allergic Reactions, Including Anaphylaxis. Ars Pharmaceuticals. Accessed September 25, 2024. https://ir.arspharma.com/news-releases/news-releasedetails/ars-pharmaceuticals-announces-usavailability-neffyr-epinephrine

7. Epinephrine injection prescribing information. St. Louis, MO: Meridian Medical Technologies, LLC; 2023 Feb.

8. Auvi-Q (epinephrine injection solution) prescribing information. Richmond, VA: Kaleo Inc.; 2024 Feb.

Society News

Specialty Group Updates

January 2025

By: Nadine Popovich, Melanie Mayer and Haley Thon

Allegheny County Immunization Coalition (ACIC) — 2024 Chair - Patrick Hussey, PharmD, MBA: The Allegheny County Immunization Coalition (ACIC) has been actively working on several initiatives to enhance immunization efforts in the community. Recently, Sarah Hoover, a pharmacist and clinical director at ACORx gave a presentation on the latest advancements in immunization practices and the role of pharmacists in improving vaccination rates. She shared innovative strategies for increasing community engagement and highlighted successful case studies from ACORx initiatives. Additionally, the Outreach Committee had a successful community vaccination drive in November, which saw over 500 individuals receiving vaccinations. The committee is planning more outreach events for the upcoming year to increase immunization coverage in the county. ACIC is also focusing on grant prospecting and sustainability planning to explore new opportunities for growth and impact.

Allegheny County Immunization Coalition membership is free and funded by our grants. All healthcare professionals with an interest in vaccination are welcome. See our website for full details www. immunizeallegheny.org

American College of Surgeons Southwestern Pennsylvania Chapter (ACS-SWPA) — 2024 President –Richard Fortunato, DO, FACS: The council has been actively working on several important initiatives. It is collaborating with the National Chapter on the ACS Chapter Dues Billing Project and planning events for

2025, including 3 Residents programs: "Debates and Dilemmas" in March, "Most Interesting Cases" in May, and "Surgical Jeopardy" in October. New opportunities for networking and professional development for active surgeons are also being explored. The council is focused on filling leadership positions and strengthening its efforts to recruit new Fellows to become active in the chapter. On January 6, Michael Sutherland, MD, FACS, Senior Vice President, Member Services from the ACS National Office joined local ACS members and officers at the Capital Grille for a 2025 planning meeting to discuss growth and engagement opportunities.

ACS-SWPA Council members hosted Dr. Michael Sutherland, ACS Senior Vice President, Member Services, from the National Chapter, for a dinner meeting focused on advancements in member services and collaborative opportunities. Attendees included (L to R) Melanie Mayer and Drs. Richard Fortunato, Michael Sutherland, Kenneth Williams, Suzanne Schiffman, Kenneth Lee, and James McCormick.

Pennsylvania Geriatric Society Western Division (PAGS-WD) — 2024 President - Heather Sakely, PharmD, BCPS, BCGP: We invite you to attend the 33rd Annual Virtual Clinical Update in Geriatric Medicine conference

scheduled for April 24-25, 2025. Although the program is presented in a virtual format, the goal is unchanged: to help you provide superb care to older adults by ensuring that each lecture, symposium, and breakout session provides evidence-based “pearls” that you can immediately incorporate into your practice.

Join us from the comfort of your home or office for an outstanding agenda of lectures and panel discussions. This AGS award-winning course is a collaboration between The University of Pittsburgh, the AGS state chapter, and many healthcare organizations. Brochures will be available soon.

The PAGS-WD Annual Report is now available. Take a moment to review the 2024 Annual Report, which provides an overview of the events and accomplishments of the society. The report can also be found on the homepage of pagswd.org.

The Pittsburgh Ophthalmology Society (POS) — 2024 PresidentPamela P. Rath, MD: The Pittsburgh Ophthalmology Society (POS) held its January 9 meeting at the PNC Champions Club, featuring guest faculty Courtney Kraus, MD, Associate Professor at Wilmer Eye Institute. Over 55 members attended Dr. Kraus’s engaging presentations on pediatric ophthalmology, glaucoma, and cataract updates in children. Special thanks to Ken Cheng, MD, for inviting Dr. Kraus, and to New World Medical for supporting the event. Amani Davis, MD, a resident at the University of Pittsburgh, presented a case for commentary by Dr. Kraus.

Society News

Chair Dan Frankel Visits POS

During the January 9 Pittsburgh Ophthalmology Society monthly meeting, the Society was honored to welcome PA State Representative Dan Frankel, Chair of the PA House Health Committee. Rep. Frankel shared insights on critical legislation, including:

• The Patient Trust Act: Protecting providers and patients from government interference.

• The Prescription Drug Affordability Board Act: Aiming to reduce medication costs for Pennsylvanians.

The audience appreciated his updates and engaged with thoughtful questions about advancing patient care.

February Monthly Meeting – DATE CHANGE

Don’t miss Dr. Mark Westcott, MD, FRCOphth, on February 6. A leading expert in uveitis and glaucoma, Dr. Westcott has authored over 70 research papers and the textbook Uveitis: Understanding the Grape. His session promises valuable insights into inflammatory eye diseases and surgical advancements.

60th

Annual Meeting – March 21, 2025

POS’s 60th Annual Meeting and 45th Annual Ophthalmic Personnel Meeting will take place at the Omni William Penn

Hotel. Highlights include:

• Harvey E. Thorpe Lecturer: Ralph C. Eagle, Jr., MD, a worldrenowned ophthalmic pathologist.

• Esteemed guest faculty: Kendall E. Donaldson, MD, MS; Peter A. Netland, MD, PhD; and Mark A. Rolain, MD.

• Ophthalmic Personnel Meeting with up to 7 IJCAHPO credits (pending approval) and workshops on diabetic retinopathy, pediatric ophthalmology, and ocular emergencies.

Mark your calendars for these exciting events!

Left to Right: Ken Cheng, MD; Chair Dan Frankel; Donald Morris, DO; Pamela Rath, MD; Andrew Eller, MD

Left to Right Ken Cheng, MD, Board Member; Courtney Kraus, MD, guest faculty, Laurie Roba, MD, President-Elect, Amani Davis, MD Resident Presenter