Berks County Medical Society Medical Record Summer 2015 by Hoffmann Publishing Group

Medical record Yo u r C ommu n ity R esourc e f or W hat ’s Happening in Healt h Car e

BERKS COUNTY MEDICAL SOCIETY

SUMMER 2015

Mr. T.J. Huckleberry Named BCMS’s New Executive Director

Superbugs: How We Can Fight Back

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Editor’s Comments

Greetings! O

ur summer edition of the Medical Record may not make it to a list of top beach reads, but it is full of upbeat and useful articles worthy of your time. We especially welcome T.J. Huckleberry, our new Executive Director, who has included a memorable introduction of himself.

Christina M. Ohnsman, MD, Editor

Likewise, Dr. Aparna Mele has written an inspirational article about the difference between dieting and healthy eating, containing great food for thought (pun intended). She invites us to join her to explore healthy eating and well-being at Guts and Glory Digestive and Wellness Expo on Sept 19, 2015 at First Energy Stadium.

I’m most excited about Dr. Deb Powell’s article detailing the latest on antibiotic resistance. This topic has been my passion for the last eight years, since I learned about the mutant selection window (see my sidebar to her article). Since then, I have had the great pleasure of getting to know Karl Drlica, Ph.D., following his work, and editing his book, Antibiotic Resistance: Understanding and Responding to an Emerging Crisis.1 While becoming a fan of a microbiologist proves my husband’s point that I am a nerd, it has also inspired me to work toward averting the threat of a post-antibiotic era. Along those lines, I’ve been following the progress of Resistance: The Film from its inception through its Kickstarter campaign to its release last year. Stay tuned for information regarding an upcoming screening here in Berks County for medical professionals and the general public. For further information about what you can do in the fight against antibiotic resistance, check out the Alliance for the Prudent Use of Antibiotics (APUA) website at http://www.tufts.edu/med/apua/. n

Happy reading! 1. Drlica, K, Perlin, DS. Antibiotic Resistance: Understanding and Responding to an Emerging Crisis. Upper Saddle River, NJ: FT Press; 2011.

SUMMER 2015

BVNA_MedRcrd_3.625x4.9375_COMFORT_Layout 1 6/25/15 9:31 AM Page 1

Medical record BERKS COUNTY MEDICAL SOCIETY

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THE BERKS COUNTY MEDICAL RECORD Christina M. Ohnsman, MD, Editor

EDITORIAL BOARD

D. Michael Baxter, MD Lucy J. Cairns, MD Daniel B. Kimball, MD, FACP Betsy Ostermiller

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Lucy J. Cairns, MD, President Andrew R. Waxler, MD, President-Elect D. Michael Baxter, MD, Chair, Executive Council Michael Haas, MD, Treasurer & Chair, Finance Committee Gregory T. Wilson, MD, Secretary Kristen M. Sandel, MD, Immediate Past President T. J. Huckleberry, Executive Director Betsy Ostermiller, Executive Assistant Berks County Medical Society 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610 Phone: 610.375.6555 | Fax: 610.375.6535 Email: info@berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society. Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication.

The Berks County Medical Record (ISSN #0736-7333) is published four times a year by the Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610.

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Table of Contents SUMMER 2015 FEATURES

Berks County Medical Society BECOME A MEMBER TODAY!

Go to our website at www.berkscms.org and click on “Join Now”

Cover Feature

“Why Us? Getting to Know BCMS’s New Executive Director” Superbugs: How We Can Fight Back

A Newer Strategy for Treating Infections

BCMS Legislative Breakfast Report Dieting: A Gastroenterologist’s Perspective NLRB Guidelines for Acceptable Social Media Policies

10 14 17 20

PAMED Brings Clarity to the Medical Marijuana Debate…But Now What? 32

DEPARTMENTS

Editor’s Comments

President’s Message

Foundation Update

Members in the News

Legislative Update Alliance Update

Events Calendar

28 29 34

Mark Your Calendars! Wednesday September 16, 2015 Fall Golf Outing

Content Submission Medical Record magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Berks County Medical Society. Submissions can be photo(s), opinion piece or article. Typed manuscripts should be submitted as Word documents (8.5 x 11) and photos should be high resolution (300dpi at 100% size used in publication). Email your submission to info@berkscms.org for review by the Editorial Board. Thank YOU! Cover Photo: BCMS’S New Executive Director Mr. Timothy (T.J.) Huckleberry, M.P.A. Photographer: Dave Zerbe

“Why Us? Getting to Know BCMS’s New Executive Director” By Timothy J. (T.J.) Huckleberry, M.P.A.

know what you are thinking: “We waited all this time for a new Executive Director and we ended up with a guy named Huckleberry?” Don’t worry; I’ve heard it all before. At least you know two things from me already – no one will ever forget who your Executive Director is, and at least this guy must have a sense of humor.

On behalf of the Berks County Medical Society, I would like to personally thank my predecessor, Bruce Weidman, for his 27 years of service. I certainly have some big shoes to fill, but I look forward to building on the foundation he created.

I would also like to thank both the Pennsylvania Medical Society and the Berks County Medical Society (BCMS) Executive Council for giving me this exciting opportunity. I have many goals and ideas on how to further energize BCMS, and I look forward to meeting with as many of you as possible to discuss how I can better advocate for your concerns. As my experience as a candidate for this position has taught me, the first question that almost always seems to be asked is — “Why us?” This is an important and fair question. Not only does it provide you with an idea of the candidate’s sincerity and objectives, but it also gives you a glimpse of who the candidate really is. That being said, I think it would be advantageous to provide you all with my answer to the “why us” question. By way of background, I have been fortunate enough to have worked for two outstanding local legislators: the late Senator Michael O’Pake and Senator Judith Schwank. If there is one thing I learned from each of them, it’s the importance of advocating for things you truly believe in. As a whole, the medical profession represents a vast network of brilliant,

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dedicated minds concentrating on one enormously complex task — improving and saving lives. Being Berks County’s voice and advocate for this vocation is an honor. Secondly, and perhaps more importantly, I want to be at the forefront of our nation’s important issues. And if there is one thing for certain, while subject matter comes and goes, the medical field has and will always be an ever advancing and controversial subject. We have medical marijuana and the Affordable Care Act today. What will we have five years, 10 years, and even 20 years from now? The issues facing physicians and their practices are both exciting and incredibly important…and I want to be part of it. On the series finale of the popular sitcom (and one of my personal favorites) Parks and Recreation, Amy Poehler’s character Leslie Knope gave an incredible quote that seems to fit perfectly into my expectations of my role as your Executive Director:

“When we worked here together, we fought, scratched and clawed to make people’s lives a tiny bit better. That’s what public service is about: small, incremental changes every day. Teddy Roosevelt once said, ‘Far and away the best prize that life has to offer is a chance to work hard at work worth doing.’” I look forward to working hard for all of you on work worth doing! n

MOVING MEDICINE FORWARD Building on our commitment to your health. The Seventh Avenue Project will include: n

24 surgical suites, including six hybridcapable operating rooms eight minor procedure rooms 150 total private patient rooms

16 new emergency treatment rooms and five new trauma bays n

The Seventh Avenue Project, with completion in the Fall of 2016, will be a combination surgical and inpatient tower that includes seven patient-care levels and combines the hospital’s many surgical services into one of the most technologically advanced and sophisticated surgical centers in the region. The new 476,000 square foot building will add new surgical suites, private patient rooms, and an all-new “Green Roof” while paving the way for the existing Emergency Department and Trauma Center to be expanded by 21,000 square feet. With the addition of the Seventh Avenue Project to our main campus, our community is assured that Reading Health System will continue to provide the highest level of care for many years to come.

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President’s Message

Mr. T.J. Huckleberry Named Berks County Medical Society’s New Executive Director By: Lucy J. Cairns, MD

t gives me great pleasure to announce that Mr. T.J. Huckleberry has been hired as the Berks County Medical Society’s new Executive Director as of June 29. His experience in legislative affairs and constituent service, coupled with his high energy level and strong desire to advance the interests of the physician community, led to his selection by the Search Committee at the conclusion of a yearlong process. Thanks to all those who contributed to this process are in order. Being on the receiving end of expressions of gratitude sometimes generates conflicting emotions. While it feels good to have your efforts appreciated, most of us recoil from appearing to have too high an opinion of ourselves. I confess that I am one of those people who often tries to ‘duck and cover’ when someone thanks me for something I have done. My tendency is to avert my eyes and mumble some self-deprecating words, then change the subject. I’m always disappointed in myself, though, when I’m unable to curb this reaction because I recognize it as a form of false modesty that gives the other person the impression that their gratitude is not welcome. When it comes to expressing my thanks to others, however, I have no such neurotic conflicts, and there are several people I would now like to publicly thank for their contributions to moving the Berks County Medical Society forward during the first half of 2015. I hope and trust that none of these people will feel a need to avert their eyes!

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Dr. Kristen Sandel, our Immediate Past President, is first on the list for leading the search that recently bore fruit when we hired a new Executive Director. The year-long process set in motion by the retirement of Bruce Weidman involved numerous conversations, meetings, and decisions. Should we partner with PAMED in the employment process or continue to go it alone? Should we continue to have a full-time executive who works exclusively for the BCMS, or enter into a

sharing arrangement with another county society? What items would be most important in the background and skill set of a good candidate? With the help of the rest of the Personnel Committee, Dr. Sandel gathered the information and clarified the issues in a way that enabled us to navigate this process with great success. Thank you, Kristen! The other person whose contributions were crucial to our search for a new Executive Director is our Executive Assistant for the last 10 years, Betsy Ostermiller. We owe Betsy a huge debt of gratitude for her willingness to take on the additional duties and hours necessary to keep the BCMS functioning smoothly over the past 12 months. She has managed to not drop a single ball while juggling the many tasks necessary to coordinate our regular meetings and special events, keep our financial house in order, inform members of our activities, and respond promptly to requests from members and the public. Not only did she rearrange her work life to accommodate our needs, she did so for a prolonged period without a definite end-date, which enabled our search to continue until some truly outstanding candidates were identified and a highly qualified Executive Director was hired. Betsy’s flexibility and hard work have been a tremendous asset to our organization, and will not be forgotten. While it is too early to thank our new Executive Director, T.J. Huckleberry, for his (future) contributions, BCMS members can be thankful now that he accepted our offer to assume this important position. T.J. is a Berks County native who studied political science and history at Drexel University before earning a Master’s in Public Administration from Kutztown University. He held the position of Legislative Liaison with Senator Michael O’Pake’s office from 2006-2011, then joined Senator Judy Schwank’s Constituent Relations and Legislative Affairs team. T.J. therefore comes to us with an in-depth knowledge of state political affairs and extensive experience in community relations, which will serve him well as he advocates for Berks County physicians and works to focus our society’s energies on issues that matter most to our members. While T.J.’s experience to date has not given him a chance to develop an insider’s understanding of the dynamics of Berks County’s medical community, we have no doubt he will prove to be a fast learner. Energy and enthusiasm are two more of T.J.’s most prominent qualities, and his arrival bodes well for the future of our society. A super-sized Thank You to Senator Judy Schwank for so graciously supporting T.J. as he pursues his career at the BCMS. The employment agreement under which our new Executive Director was hired is new to the BCMS, so I will briefly explain its outlines. Under a formal Cooperation Agreement with PAMED, he is a PAMED employee insofar as PAMED is

responsible for the administrative aspects of his employment and provides training and support. This relieves the BCMS Executive Board of a significant administrative burden while allowing our Executive access to all the employee benefits of any PAMED employee. PAMED will be responsible for providing coverage during vacations and other absences. Performance evaluations will be done jointly by PAMED and BCMS, but the BCMS retains full authority over our organizational goals and policies, and the Executive Director is supervised by and serves at the pleasure of our county society. This Cooperation Agreement may be terminated with 30-day’s written notice, but it is the expectation of our Personnel Committee that the arrangement will prove to be entirely favorable. Thanks to PAMED for supporting BCMS and other county societies in this manner. One of the goals I set for my year as President is to improve our communications strategies, and our incoming Executive Director will be poised to hit the ground running in this area thanks to the good work done by John Fundyga, our spring semester college intern. While completing his final semester at Albright College, as a double major in Biology and Philosophy in the Honor’s Program, John evaluated our society’s communications needs and researched available digital platforms with potential to improve the way leadership physicians communicate with each other and to make it easier and more convenient for BCMS members to engage with their society. Follow us on Twitter, friend us on Facebook, and look for additional innovative developments in the near future. John feels strongly about the importance of a strong medical community and hopes to contribute in the field of bioethics. We wish John great success and thank him emphatically for bringing 21st century communications strategies to our organization.

Space does not permit me to recognize all the many other people whose contributions have been invaluable to making the Berks County Medical Society one of the very best in Pennsylvania. With the accelerating pace of change in the medical practice environment, however, there is no time to rest on our laurels. If the Society is to continue to provide value to members we must question the value of what we do and how we do it, and be ready to adapt to the changes around us. Personally, I’m feeling very optimistic about our future—thanks to all of the above! n

SUMMER 2015

Superbugs: How We Can Fight Back By: Debra L. Powell, M.D., M.S., Chief, Section of Infectious Diseases The Reading Health System and St. Joseph Medical Center Chairman, Infection Control Committee St. Joseph Medical Center

ntibiotic resistance has increased to crisis proportions for several reasons: inappropriate antibiotic prescribing in humans, agricultural use of antibiotics to promote animal growth, and lack of new antibiotics in the pipeline. According to a report by the Centers for Disease Control and Prevention (CDC), two million Americans acquire an infection by an antibiotic-resistant organism each year and at least 23,000 of them die as a direct cause of this infection.1

ANTIBIOTIC PRESCRIBING

Drug-resistant bacteria are continuing to evolve, causing increasing morbidity and mortality. These organisms are selected by antibiotic use, which kills susceptible organisms and allows resistant organisms to multiply and acquire further resistance. As we treat these resistant organisms with the first line drugs (see â&#x20AC;&#x153;A Newer Strategy for Treating Infectionsâ&#x20AC;? on page 18), more extensive resistant strains are selected that have limited antibiotic treatment options. These second- and third-line therapies may have more toxicities, higher cost, and often lower effectiveness. Drug-resistant infections commonly lead to longer hospital stays and complications. The cost to the U.S. health care system is extensive, estimated at $20 billion per year in direct health care cost and $35 billion a year in indirect costs, such as lost productivity.2 There are particular patients that are at a higher risk for multidrug-resistant organisms. They include patients on chemotherapy for cancer, patients who have undergone complex surgery, patients with rheumatoid arthritis on immune-modifying agents, patients on hemodialysis, and

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patients post-organ or bone marrow transplants.

This evolving resistance problem is not new. Penicillin was introduced in the early 1940s and the first penicillin-resistant strain of Staphylococcus aureus was found in 1942. By the late 1960s, 80% of strains were resistant to penicillin.3 Currently in our area, penicillin resistance in Staph aureus is > 90% and methicillin resistance in is 40%.4 Vancomycin was introduced in 1972 and resistance wasnâ&#x20AC;&#x2122;t reported until 2002 in Staph aureus and in 1988 for Enterococcus. Levofloxacin was released in 1996 and resistance was reported the same year.

The CDC lists three urgent threats, which include Clostridium difficile infection, Carbapenem-resistant Enterobacteriaceae (CRE), and drug-resistant Neisseria gonorrhoeae. C. difficile is included not due to resistance, but due to its association with antibiotic use and the increasing incidence in the population. It is estimated that 250,000 Americans require hospitalization each year for C. difficile infection and at least 14,000 die of complications from this infection. CRE is estimated to cause 9,300 infections in the U.S. per year and 610 deaths. Drugresistant Neisseria gonorrhoeae is estimated to cause 246,000 infections per year and <5 deaths. Serious threats that have become familiar to the general public through news reporting include Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus (VRE), and multidrug-resistant Mycobacterium tuberculosis.

Table 1: CDC Resistant Organism Level of Threat Classification

Urgent threats 1) Clostridium difficile infection 2) Carbapenem-resistant Enterobacteriaceae (CRE) 3) Drug-resistant Neisseria gonorrhoeae Serious threats: 1) Multidrug-resistant Acinetobacter 2) Drug-resistant Campylobacter 3) Fluconazole-resistant Candida 4) Extended-spectrum B-lactamase producing

Enterobacteriaceae (ESBLs) 5) Vancomycin-resistant Enterococcus (VRE) 6) Multidrug-resistant Pseudomonas aeruginosa 7) Drug-resistant non-typhoidal Salmonella 8) Drug-resistant Salmonella typhi 9) Drug-resistant Shigella 10) Methicillin-resistant Staphylococcus aureus 11) Drug-resistant Streptococcus pneumonia 12) Drug-resistant Mycobacterium tuberculosis

Concerning threats: 1) Vancomycin-resistant Staphylococcus aureus 2) Erythromycin-resistant Group A Streptococcus 3) Clindamycin-resistant Group B Streptococcus

Therefore, most pharmaceutical companies have abandoned research and development of new antibiotics. The GAIN act (Generating Antibiotics Incentives Now) signed by President Obama on July 9, 2012 extended the exclusive period that pharmaceutical companies can market their product protected from generic competition by five years. This increases the time the company has to recover their cost of development and creates additional incentives to companies to create antibiotics. Drugs that fall under this provision can undergo expedited U.S. Food and Drug Administration (FDA) regulatory approval. In December 2014, the Pew Charitable Trust reported that there were 37 antibiotics in development.6 Ten of these antibiotics were in phase 1 clinical trials, 18 in phase 2, eight in phase 3, and 1 with a submitted new drug application. Twenty-four of the 37 antibiotics were receiving benefits under the Generating Antibiotic Incentive Now (GAIN) Act of 2012 as qualified infectious disease products (QIDPs) for serious or life-threating infections. Two of these agents were considered novel agents with new mechanisms of action.

continued on next page >

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Agricultural Antibiotic Use Far exceeding the amount of antibiotics prescribed to treat people, 80% of antibiotics in the U.S. are used in the agricultural industry. It is estimated that livestock were given 63,000 tons of antibiotics in 2010 for growth and health purposes,5 leading to increased antibiotic resistance in these animals and in the people who consume them.

Bills addressing the use of antibiotics in food animals currently in U.S. Congress committees include: the Delivering Antimicrobial Transparency in Animal Act (DATA) H.R.820, which was introduced Feb. 26, 2013 to enhance the reporting requirements pertaining to use of antimicrobial drugs in food animals; and the Preservation of Antibiotics for Medical Treatment Act (PAMTA), which would ban non-therapeutic uses of medically important antibiotics in food animal production, which was reintroduced on March 24, 2015.

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The New Antibiotic Pipeline

The pharmaceutical industry has few incentives to develop new antibiotics. These drugs are used for short periods of time, generating low revenues in comparison with drugs for chronic conditions. Furthermore, bacteria evolve, potentially developing resistance and making the new antibiotic obsolete.

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SUMMER

2015

Superbugs: How We Can Fight Back continued from page 11

Eighty percent of these agents are being developed by small companies, and half by companies with no products currently on the market.

The Antibiotic Development to Advance Patient Treatment Act (ADAPT) was introduced in Congress on December 12, 2013 (H.R. 3742) and is currently in committee. Its purpose is to encourage development of antibiotics for serious or life-threatening infections and to lower the time and cost for developers. ADAPT and the GAIN Act are considered complementary, providing an economic incentive to pharmaceutical companies that bring new antibiotics to market and streamlining the regulatory process to allow testing of these antibiotics on patients who need them most. Taking Action

The National Action Plan for Combating Antibiotic-Resistant Bacteria was released from the White House in March 2013 and updated in September 2014. The goals of this plan are to slow the emergence of resistant bacteria, strengthen surveillance efforts, develop rapid identification methods, accelerate research and development of new antibiotics, therapeutics and vaccines, and to improve international collaboration.7,8

Most recently, on June 2, 2015, The White House Forum on Antibiotic Stewardship brought together more than 150 key Federal and private sector leaders to discuss ways to improve how we use antibiotics in both the animal and human health arenas. The plan calls for improved testing and reporting, establishing a DNA database of resistant bacteria, and supporting research for new antibiotics and vaccines. Major food producers are committing to decrease the use of antibiotics in food production.9

What can we do? Health care providers can improve how we use antibiotics. It is estimated that 50% of all antibiotics prescribed to people are not needed. These antibiotics are often prescribed for viral infections causing bronchitis, Viruses or Bacteria? What needs an antibiotic?1

otitis media, sinusitis, and pharyngitis. (See below â&#x20AC;&#x153;Viruses or Bacteria?â&#x20AC;?) We can encourage physicians not to use antibiotics inappropriately and educate the public when antibiotics are not indicated. Delayed antibiotic prescribing is an alternative prescribing strategy in which a patient is given a prescription and asked to wait for 24 â&#x20AC;&#x201C; 48 hours and fill it only if their symptoms worsen.

A survey by Medscape of 796 health care professionals (407 physicians, 200 Nurse Practitioners and 189 Physician Assistants) reported that 21% of providers prescribed an antibiotic when it was not absolutely necessary. The specialty which reported prescribing antibiotics with limited indication most frequently was Family Medicine (30%), followed by Emergency Medicine (20%), Pediatrics (18%), OB/GYN (16%) and Internal Medicine (14%). Twenty-eight percent of providers admitted to prescribing an antibiotic because a patient requested it. Patients (N=1174) were also asked why they requested antibiotics. Eighty-five percent believed that it would cure their illness, and 65% thought that they would get better more quickly due to the antibiotic. When given delayed prescriptions, 37% of patients reported never filling the prescription. Of those that fill the prescription, 37% fill it on the correct date and use it at that time, 12% fill it but save it for later, 10% fill it just in case but tend to discard it, and 2% fill it early and use it.

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Physicians noted that they would be better antibiotic stewards if they had: materials to hand out (58%); rapid tests to clarify what is causing the infection (54%); information about local antibiotic resistance patterns (47%); outcome data (45%); guidelines information (36%); more time to talk to patients about antibiotics (30%); and better data on how their own practices compare to those of other physicians (24%). Twelve percent of patients surveyed reported that they or a close family member had a resistant infection. When questioned about what would satisfy the patient if they were told that antibiotics were not required for their infection, patients replied that specific recommendations for symptom relief (94%) and guidance on when to seek follow-up medical care if their symptoms worsened (93%) were the top satisfiers.10

CDC manages the Get Smart about Antibiotics Program, which is a national campaign to improve antibiotic prescribing. There are tools and educational materials available online to improve antibiotic use and to educate the public about when an antibiotic is not needed.11 Hospitals are encouraged to have an Antibiotic Stewardship Committee review hospital antibiotic use. Antibiotic Stewardship Programs have been shown to reduce the use of high-risk antibiotics by 30% and lower the risk of C. difficile infection by 26%. We can prevent hospital infections by optimizing hand hygiene and using contact precautions in the hospital to avoid spreading infection among patients and the community. We must always remember that antibiotics are powerful drugs and should only be prescribed when warranted. Every antibiotic course runs the risk of allergic reactions ranging from rashes to anaphylaxis, C. difficile-associated colitis, and drug interactions, in addition to increasing the burden of antibiotic resistance. n

Remember the 5Ds: Right Diagnosis Right Drug against the right bug Right Dose Right Duration Appropriate De-escalation. 1 Centers for Disease Control and Prevention, Antibiotic Resistance Threats to the United States, 2013, http://www.cdc.gov/drugresistance/threat-report-2013/index. html. 2 Centers for Disease Control and Prevention, Antibiotic Resistance: Urgent Health Threat Jeopardizing Modern Medicine, 2015, http://blogs.cdc.gov/ safehealthcare/2015/02/20/antibiotic-resistance-health-threat-jeopardizingmodern-medicine/ 3 Rammelkamp, CH, Maxon, T. Resistance of Staphylococcus aureus to the action of penicillin. Proc. Royal Soc. Exper. Biol. Med. 1942. 51:386-389. 4 Reading Hospital Antibiogram, 2014. 4 Chambers, HF. The changing epidemiology of Staphylococcus aureus? Emerg. Infect. Dis. 2001. 7:178-182. 5 Van Boeckel, T, et al. Global trends in antimicrobial use in food animals. Proceedings of the National Academy of Science. 2015 112 (18) 5649-5654 6 The Pew Charitable Trust. December 31, 2014. http://www.pewtrusts.org/en/ research-and-analysis/issue-briefs/2014/03/12/tracking-the-pipeline-of-antibioticsin-development 7 White House, Office of the Press Secretary. March 2015. https://www. whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_ antibotic-resistant_bacteria.pdf 8 White House, Office of the Press Secretary. September 2014. https://www. whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf 9 White House, Office of the Press Secretary. June 2, 2015. https://www. whitehouse.gov/the-press-office/2015/06/02/fact-sheet-over-150-animal-andhealth-stakeholders-join-white-house-effo 10 Yox, S. Too Many Antibiotics! Patients and Prescribers Speak Up, June 27, 2014. http://www.medscape.com/features/slideshow/public/antibiotic-misuse#1 11 CDC Get Smart About Antibiotics. http://www.cdc.gov/getsmart/community/ materials-references/index.html SUMMER

2015

A Newer Strategy for Treating Infections By Christina Ohnsman, MD

urrent antibiotic dosing strategies are based on curing the individual, not on the preservation of antibiotics or the prevention of bacterial resistance.

In 2001, Xilin Zhao, Ph.D., and Karl Drlica, Ph.D., published a strategy to restrict the selection of antibiotic resistant organisms in infections. Since then, their mutant selection window hypothesis has been proven numerous times and accepted by scientists, but isn’t well known among physicians. This is a summary of their work. Any pathogen population will naturally contain a tiny subpopulation of resistant mutants. We “select” these mutants when we treat an infection with a dose of antibiotic high enough to kill the majority of the pathogens (the MIC90), but not all of the pathogens (the mutant prevention concentration, or MPC). If we instead dose to the MPC, we do not select these resistant organisms. The range of concentrations above the MIC90 and below the MPC is called the mutant selection window. Figure 1 shows a hypothetical pharmacokinetic profile, with the mutant selection window appearing above the MIC90 concentration. 14 | www.berkscms.org

This means that the conventional practice of dosing to the MIC90 is a direct cause of antibiotic resistance. Another way of thinking of this concept is this: if the concentration of antibiotic is high enough to kill all of the pathogens, none will remain to become resistant. Similar to MICs, MPCs are unique to each pathogen-antibiotic combination. If we cannot dose above the mutant selection window due to drug toxicity, then combination therapy is required to prevent antibiotic resistance. A corollary of the mutant selection window concept is that the correct antibiotic must be used to kill all of the bacteria. Therefore, antibiotic stewardship rules that mandate use of “first-line” antibiotics before restricted antibiotics may sometimes cause more harm than good. If the first-line antibiotic fails, then by definition, we have contributed to resistance, and failed to cure the patient.

Since many infections are treated empirically, it is especially important for clinicians to be aware of community rates of resistance and susceptibility. Reading Hospital publishes an annual summary of antimicrobial susceptibility testing to provide us with this crucial information. n

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BCMS Legislative Breakfast Report

he annual BCMS Legislative Breakfast was held Friday, May 8th with 52 members, guests and legislators in attendance. These included first term U.S. Congressman Ryan Costello (6th district), State Senators David Argall and Judy Schwank and State Representatives Barry Jozwiak and Jerry Knowles. Larry Light and Hannah Walsh represented the PAMED staff. BCMS PresidentElect Andy Waxler served as moderator, and as usual a spirited discussion occurred, with the most attention given to the topic of medical cannabis. There was general consensus with the PAMED position that legislation for legalizing medicinal use should first require a change in federal law rescheduling marijuana from a schedule I drug, and that further research needs to be done to define the value for certain diseases as well as the risks, benefits and proper dosing of medical cannabis. There is strong pressure on the legislature from the public to move on such legislation.

Other issues discussed included the legislation being considered which would allow independent practice for certified nurse practitioners in Pennsylvania. There is strong lobbying for this from the CRNPs, who point to the need for greater access to primary care — especially in rural areas. Several BCMS members pointed out that CRNPs practice in a distribution much as physicians do, with a relatively high proportion providing specialty care rather than primary care. The geographic distribution of CRNPs is also similar to that of physicians. PAMED is working with other physician groups to clarify these issues and to emphasize that health care is best provided in physician-led teams. The need to strengthen efforts to retain in our state more of the physicians who train here was also brought forward. Expanded loan forgiveness programs were suggested as one means to this end. Several legislators mentioned that Berks County is a center of the “property tax revolt.” As the Governor and the Republican-controlled House and Senate are all proposing some form of property tax reform, there is a sense that some plan will likely be adopted this year. Larry Light gave a brief overview of PAMED priorities and commented on the recent Mcare abatement refund, which is clear evidence of the value of organized medicine’s role in state governmental affairs. n

SUMMER

2015

Foundation Update

Foundation Offers Scholarships to Pa. Medical Students Applications Accepted July 1–Sept. 30, 2015

HARRISBURG, Pa. —The Foundation of the Pennsylvania Medical Society offers several scholarships available to Pennsylvania residents enrolled in fully accredited medical schools. “We recognize that medical students play a vital role in the future of medicine in Pennsylvania so we proudly administer scholarships to deserving students across the commonwealth,” said Executive Director Heather Wilson. Additional scholarships are offered throughout the year and information can be found on the Foundation’s website at www.foundationpamedsoc.org.

The following scholarships accept applications July 1 through Sept. 30, 2015: ACMS Medical Student Scholarship Application Available Allegheny County Medical Society (ACMS) Foundation, in conjunction with The Foundation of the Pennsylvania Medical Society, is offering a $4,000 scholarship to third- or fourthyear Pennsylvania medical students from Allegheny County. Applicants must be U.S. citizens enrolled full time in an accredited Pennsylvania medical school.

Allegheny County Medical Society’s mission is to provide leadership and advocacy for patients and physicians. The Foundation of the Pennsylvania Medical Society administers the fund for the ACMS Foundation, which encourages physicians to contribute to the scholarship to help area students offset the cost of medical education. In 2004, ACMS Foundation established the scholarship and distributed its first award in 2007.

Scholarships Available for Blair County Residents

Blair County Medical Society (BCMS), in conjunction with The Foundation of the Pennsylvania Medical Society, is offering two $1,000 scholarships to medical students who are residents of Blair County. These awards are available to second-, third-, and fourth-year medical students enrolled full time in an accredited U.S. medical school. BCMS established the fund in September 2013 with $50,000. The purpose is to assist Pennsylvania residents from Blair

18 | www.berkscms.org

County with the cost of attending medical school.

Scholarship Available to Lehigh County Residents The Foundation of the Pennsylvania Medical Society in conjunction with the Lehigh County Medical Auxiliary’s Scholarship and Education Fund, Inc. is offering its $2,500 LeCoMASE Medical Student Scholarship award. Medical students who are residents of Lehigh County are eligible to apply. Additionally, students must be enrolled full time in an accredited U.S. medical school.

The Lehigh County Medical Auxiliary’s Scholarship and Education Fund, Inc., established this fund within the Foundation to assist Lehigh County residents with the cost of attending medical school. Individuals are invited to contribute to the fund to secure its future.

Scholarship Available for Lycoming County Residents

Lycoming County Medical Society, in conjunction with The Foundation of the Pennsylvania Medical Society, is pleased to announce the availability of the 2015 Lycoming County Medical Society Scholarship. Multiple $3,000 awards are available to first- through fourth-year medical students who are residents of Lycoming County and enrolled full time in an accredited U.S. medical school. Lycoming County Medical Society established the scholarship within the Foundation and presented the first award in 2002. Contributions from Lycoming County physicians made the fund possible. The society provides education, networking, and legislative support for member physicians.

Scholarships Available for Montgomery County Residents

Montgomery County Medical Society (MCMS), in conjunction with The Foundation of the Pennsylvania Medical Society, is offering two $2,500 scholarships to medical students who are residents of Montgomery County. These awards are available to first-year medical students enrolled full time in an accredited U.S. medical school.

The awards are possible thanks to contributions from MCMS and area physicians. The MCMS mission is to represent and serve all physicians of Montgomery County and their patients in order to preserve the doctor-patient relationship; maintain safe, quality care; advance the practice of medicine; and enhance the role of medicine and health care within the community and across Montgomery County and Pennsylvania.

Foundation Offers Medical Student Scholarship to Berks, Lehigh, and Northampton County Residents

The Foundation of the Pennsylvania Medical Society is offering its annual $1,000 Myrtle Siegfried, MD, and Michael Vigilante, MD, Scholarship to first-year medical students who are residents of Berks, Lehigh, or Northampton counties. Requirements include full-time enrollment in an accredited U.S. medical school. To help local medical students offset the cost of education, former Foundation trustee, Elena Pascal, and her sister, Carla Vigilante, established this scholarship in 1999 in memory of their parents who were prominent Allentown physicians.

Scholarship for Students of South Asian Indian Heritage The Foundation of the Pennsylvania Medical Society is offering a $2,000 Scholarship from the Endowment for South Asian Students of Indian Descent. Students must be of South Asian Indian heritage and enrolled full time in their second, third, or fourth year at an accredited Pennsylvania medical school. Jitendra M. Desai, MD, and Saryu J. Desai, MD, Sewickley, Pa., initiated this scholarship within the Foundation in 2002 to provide an opportunity for South Asian Indian students who demonstrate academic excellence. They invite others to contribute to the fund to secure its future.

In 2014, the Foundation awarded 21 scholarships totaling $50,500. The Foundation provided $445,000 in loans to 78 students across Pennsylvania. Since 1948, more than $19.1 million has been awarded to nearly 4,450 students in the form of loans and scholarships to assist with education costs. For information about these scholarships, call the Foundation’s Student Financial Services office at (717) 558-7852, or visit www.foundationpamedsoc.org. n

The Foundation, a nonprofit affiliate of the Pennsylvania Medical Society, sustains the future of medicine in Pennsylvania by providing programs supporting medical education, physician health, and excellence in practice. It has been helping to finance medical education for nearly 60 years. The Foundation offers scholarships and lowinterest loans for medical students.

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S SUPMRMI N ER G 2015

Dieting:

A Gastroenterologistâ&#x20AC;&#x2122;s Perspective

By: Aparna M. Mele, M.D.

hen it comes to dieting, recidivism is a hopeless consequence for most. People on diets start to cultivate a love-hate relationship with food and extreme fluctuations of weight result. Why do we diet anyway? Our image of what constitutes our correct weight and body size, often dictated by a media and public obsessed with obesity, continues to drive us to diet in order to achieve the ultimate ideal appearance. But, from a medical standpoint, this should not be the main goal of altering oneâ&#x20AC;&#x2122;s food intake. Worse, there may be detrimental effects on health with extreme dieting. Some glum news to share: only four out of one hundred people are able to both lose weight and to maintain their post-diet weight. Studies looking at low carbohydrate and low fat diets have shown that adherence is poor and attrition is high, with a high probability of regaining 50% or more of lost weight in 1-2 years.

The reason that diets often fail is not always related to a lack of will power and self-control. When there is reduced caloric intake, our metabolic rates decrease so that the body can still function. This process conspires against sustained weight loss, creating a vicious cycle in which it becomes more difficult to lose weight, as the dieterâ&#x20AC;&#x2122;s body uses food more efficiently and draws less from its fat reserves. Extreme diets create a starvation state in the body, forcing the body to store fat for energy. Severe weight loss from dieting induces catabolism and breakdown of vital protein stores and normal body tissues, leading to muscle loss. Many current diets focus on cutting carbohydrate intake (while reducing the total number of calories), but carbohydrate reduction can cost us. Carbs are needed for optimal body functioning. Although we can cut them out of our diets 20 | www.berkscms.org

temporarily to lose weight quickly, over the long term, low carb intake can have disastrous consequences, especially in individuals who actively exercise and need carbohydrates for energy substrates. Detrimental effects of low carb intake can include decreased thyroid function, decreased testosterone levels, increased cortisol output, impaired mood and cognitive function, muscle catabolism, and suppressed immune function. Many dieters mistakenly look at dieting as a form of deprivation, and agonize over every eating-related decision, and this can take an enormous toll on their emotional well-being. They torture themselves, refusing to indulge in foods they enjoy, even in small quantities, and eating loses its pleasure for many. They can become obsessed with weighing themselves, and become frustrated when their numeric weight does not dramatically change at a pace they expect. Furthermore, if you are always depriving yourself of your food favorites, or constantly restricting cravings, temporarily cheating, or falling off the wagon with your diet can lead to feelings of guilt, low self-esteem, and despair. This can then prompt not only abandoning the diet, but worse, comfort eating. Thus, dieting can be a major contributor to binge eating and eating disorders, produces an exaggerated reduction in metabolic rate when weight is lost, making regain of weight highly likely, and can produce cumulative adverse effects on physiological and psychological functioning, as weight is lost and regained repeatedly.

The lower the calories eaten per day, the harder it becomes to maintain daily requirements of important nutrients and vitamins. Also, because dieting lowers your basal metabolic rate (which means you can live on less food), when you do eventually return to your normal pre-dieting food intake, you can then gain weight even faster than before. continued on page 22

Dieting: A Gastroenterolgist’s Perspective

continued from page 20

From this gastroenterologist’s perspective, dieting does nothing to teach us about healthy intake. Healthy eating does not mean GOING HUNGRY, and we as a society should focus less on metrics, how much we weigh, and what we look like on the outside, and instead start focusing on how we look ON THE INSIDE.

Adopting healthy eating patterns, with regard to what we eat and how we eat, will not only curb weight gain, but most importantly, help us maintain a healthier body on the inside. Limited, while not overly restricted, daily caloric intake can help us live longer and healthier lives with reduced cholesterol levels, normalized blood sugars, improved stress response, and slowed aging. Healthy eating habits also allow us to pay attention to what we are putting in our bodies, by understanding the building blocks of nutrition, like how much protein and fiber we should be getting, and realizing how our bodies respond to certain foods. Reading labels is important, not only for helping us to stick to our goal calorie counts, but also helps us to ensure that we are getting the adequate protein, fiber, and other nutrients that we need to maintain health. Safe and sustained weight loss involves combining physical activity and a reduced-calorie diet, with healthy food choices and smaller portions. • Create and follow a healthy eating plan that replaces less healthy options with a mix of fruits, veggies, whole grains, protein foods, and low-fat dairy. • Minimize intake of added sugars, cholesterol, sodium, and saturated fat. • Eat low-fat proteins such as beans, eggs, fish, lean meats, nuts, and poultry. • Eat a rainbow of fruits and vegetables that fill half your plate and choose fruits and vegetables with vibrant colors that are packed with fiber, minerals, and vitamins.

When trying to lose weight, you can still eat your favorite foods as part of a healthy eating plan, but watch the total number of ingested calories in a day. Do this by reducing portion sizes, reading nutritional labels both to understand nutrient content and check serving sizes, and find ways to limit calories in your favorite foods. For example, you can bake foods rather than frying them, and use low fat alternatives. Most importantly, never skip meals. Skipping meals may make you feel hungrier and lead you to eat more than you normally would at your next meal, and there have been studies showing a link between skipped meals and obesity. Healthy eating is not about strict dietary limitations, staying unrealistically thin, or depriving yourself of the foods you love. Rather, it’s about feeling great, having more energy, improving your outlook, and maintaining your body’s normal functioning and vitality for longevity! 22 | www.berkscms.org

Create a tasty, varied, and healthy diet that is as good for your mind as it is for your body, but keep in mind that it is the overall dietary pattern that is most important. This means that switching to a healthy diet doesn’t have to be an all or nothing process. You don’t have to be perfect and you don’t have to completely eliminate foods you enjoy to have a healthy diet and make a difference in the way you think and feel. Come learn more about healthy eating and well-being at Guts & Glory Digestive and Wellness Expo 2015, being held at First Energy Stadium on Sept 19, 2015. For more information, visit www.mygutinstinct.org. n

Aparna Mele, M.D., is a Board certified gastroenterologist with Digestive Disease Associates in Wyomissing, PA since 2007. She came to the field of medicine with extensive experience and background in international relief work overseas and is actively involved in local philanthropic work directed towards community health education and promotion of societal health. In addition to her full-time job as a physician, she is the founder and president of My Gut Instinct, a 501(c) 3 nonprofit organization created to increase public awareness of digestive diseases and their impact on overall public health, and to advocate proactive and healthy lifestyle and dietary behaviors. In October 2014, through her nonprofit, she created Berks County’s inaugural and now annual Guts & Glory Digestive and Wellness Expo, a large scale free public health event designed to inspire the community to eat and live better, which was widely recognized and well-attended. Her biggest passion as a physician is to empower individuals to be proactive with their health and well-being to promote longevity. References Brownwell KD et al. Am Psychol . 1994;49: 781-91. Brownell KD et al. Physiol. Behav. 1986;38: 459-64. Foster G et al. New England Journal of Medicine (2003) 348: 208290. Heshka F, Journal of the American Medicine Association (2003) 289: 1792-98. Hyman F, Annals of Internal Medicine, (1993) 116: 681-87. Polivy J et al. Am Psychol . 1985;40: 193-201. Polivy J et al. Am Psychol. 2002;57 677-89. Ravussin E et al in VanItallie, TB ed. Treatment of the Seriously Obese Pt. New York: Guilford Press; 1992, p. 524 Samaha F et al. New England Journal of Medicine (2003) 348: 2074-81. http://www.niddk.nih.gov/health-information/health-topics/ weight-control National Institutes of Health, Methods for Voluntary Weight Loss and Control Conference, 1992

ensure that your organization maintains

National Labor Relations Board (NLRB) has recently claimed that many employer policies relating to employee conduct and social media are unlawful, which can result in terminated employees being reinstated and given back pay. Having an employment lawyer review the handbook can help your organization avoid costly litigation.

take FMLA leave to care for their spouses, regardless of where they live.

Employers should review and update their FMLA policies and procedures as necessary, and they should train employees who are involved in the leave management process on the expanded rules for same-sex spouses under the FMLA.

NLRB Guidelines for Acceptable Social Media Policies T he adoption of social media as a communication forum has greatly enabled organizations to reach end users and establish an online presence in our communities. However, maintaining a reputable presence is not an easy task in cyber space, especially due to employee participation in social media, which has attracted the attention of employers and governmental organizations. On one hand, employers are concerned about how their employees’ comments may affect their reputation and morale at the workplace. On the other hand, governmental organizations— such as the National Labor Relations Board (NLRB) and the Federal Communications Commission (FCC)—as well as state legislatures have been paying close attention to identify possible violations of employee privacy and protected activity rights.

CURRENT SOCIAL MEDIA LAWS

For some time now, employers have been screening applicants’ social media involvement to assess their character and fitness for employment. However, recent news coverage has alerted the public of employers that have gone as far as requesting an applicant’s username and password to logon to a social media profile. This practice has been condemned by many, and has even led companies like Facebook and Google to threaten lawsuits against those who request username and password disclosures. State legislatures have also reacted to this phenomenon by 24 | www.berkscms.org

passing and proposing legislation to prohibit this practice.

Despite the recent attention, there are still not that many laws or court decisions that address employers’ attempts to monitor and manage its employees’ participation in social media forums. However, the NLRB published a set of guidelines to help employers develop policies that protect employee rights under the National Labor Relations Act (NLRA). These guidelines are the result of an analysis of specific social media employer policies reviewed by the NLRB.

PROTECTED CONCERTED ACTIVITIES

Employee participation in social media may be protected under section seven of the NLRA, even for non-unionized employees. Section seven of the NLRA gives employees the right to form unions and to engage in protected concerted activities. Employees engage in protected concerted activities when they act for their mutual aid and protection regarding their terms and conditions of employment. The key to determine whether an employee has engaged in protected concerted activity is whether the employee was acting for the benefit, or on behalf, of others and not solely for his or her personal interest. Employees do not need to formally agree to act as a group or designate a representative to participate in concerted activities. Concerted activities can

include spontaneous, non-eventful actions such as a discussion of working conditions and wages or questioning a supervisor on a company policy. In that sense, the NLRA protects any employee who: • Addresses group concerns with an employer; • Forms, joins or helps a labor organization; • Initiates, induces or prepares for group action; or • Speaks on behalf of or represents other employees.

PROTECTED CONCERTED ACTIVITY IN SOCIAL MEDIA The line between personal interest and acting on behalf of others is blurry, and social media participation has only made the distinction more difficult. It is still unclear whether “friending” a co-worker is enough to establish a group or whether commenting on or “liking” a teammate’s post is sufficient to establish a group discussion. Instead of wrestling with these particular issues, the NLRB has taken the position that if an employer’s social media policy can be reasonably interpreted to include concerted activity, the policy violates the NLRA. The NLRB’s position is that broad, vague and ambiguous employer policies can violate an employee’s right to protected concerted activity because employees may believe that they are prohibited from participating in protected activities. In addition, the NLRB disapproves of policies that inhibit or intimidate employees from participating in protected concerted activities by expressly discouraging a protected practice, or threatening sanctions or disciplinary actions against those who participate in these activities. The NLRB also states that policies should not be adopted in response to previous concerted activities. However, the NLRA does not protect activities that are outrageously disgraceful or shameful conduct or reckless or maliciously untrue communications.

UNLAWFUL SOCIAL MEDIA POLICIES

In its analysis, the NLRB condemns any policy that is too vague or ambiguous. These policies, in the NLRB’s opinion, do not provide sufficient context, do not limit their scope and, as a result, overreach into areas protected by law. The NLRB also concluded that including a “savings” clause—stating that the policies must be interpreted in harmony with the NLRA—is not sufficient to limit a policy’s reach into protected activity. Some examples of vague and overreaching policies include policies that: Discourage employee participation in social media by threatening sanctions and policies against those that post disparaging or defamatory remarks regarding the employer; Encourage employees to not “friend” or reach out to one another using social media because they would stifle employee communications or possible efforts to initiate concerted activity;

continued on next page >

SUMMER 2015

NLRB Guidelines for Acceptable Social Media Policies

Prevent employees from releasing confidential information because they can be interpreted to restrict the discussion of conditions and terms of employment, unless the employer provides a narrow definition for what constitutes confidential information. This includes policies restricting the release of corporate financial information because such information can include data employees could use to negotiate improved terms and conditions of employment; Prohibit employees from contacting or answering to the media or governmental organizations because this could interfere with a legitimate investigation of employment terms and conditions;

Require employees to obtain authorization before discussing employer information in social media because they can inhibit employee discussion of conditions and terms of employment. These provisions also extend to a discussion of legal matters because this could be reasonably interpreted to include the discussion of potential claims employees may have against their employers; Require employees to obtain permission before quoting other employees or posting their image in social media outlets because it could be interpreted to include a restriction of posting the image of an individual working in substandard conditions to raise public awareness;

Require employees to report on another employee’s social media activity because they would inhibit employee discussion of employment terms and conditions. This aspect 26 | www.berkscms.org

continued from page 25

is particularly troublesome in cases where the employer is asking employees to either disclose their logon information to social media applications or to monitor social media forums in behalf of the employer; and

Require employees to report or ignore unsolicited communications because they can be reasonably interpreted to include an employee’s unsolicited request to other employees to participate in protected activity.

ACCEPTABLE SOCIAL MEDIA POLICIES

The NLRB’s analysis also provided several suggestions to employers that are looking to adopt or update their social media policies. The NLRB recommends that employers should limit the scope of their policies and include clear definitions of their policy terms to avoid ambiguity and misinterpretation. The NLRB also suggests that when employers include examples of both prohibited and acceptable practices, they can create a context for the reasonable interpretation of the policy and show how the employer’s policy harmonizes with labor practices and regulations. For example, the NLRB found that adopting a no-retaliation policy for employees that choose to report inappropriate social media activities is lawful because it does not impose a duty on employees to report social media activities but encourages employees to speak up, and this could improve employee discussion of working conditions because employees would feel that they could start a grievance procedure in safety.

In another instance, the NLRB found acceptable a policy stating that discriminatory remarks, harassment, bullying, threats of violence and similar inappropriate behavior that is not tolerated in the workplace is not acceptable in social media. The NLRB considered that this type of policy was a natural extension of compliance with acceptable labor practices, provided sufficient context and was sufficiently defined so that an employee would not reasonable interpret the policy to overreach into protected concerted activity. Other acceptable social media policies include statements that:

Forbid employees from impersonating the employer, making statements on behalf of the employer without authorization, or making statements that can be construed as establishing the employer’s official position or policy on any particular issue; Encourage employees to resolve workplace grievances internally with an invitation to refrain from posting comments and materials that could be viewed as malicious, obscene, threatening , intimidating or that could create a hostile environment on the basis of race, sex, disability, religion or any other status protected by law if they choose to address their grievance using social media; Request that employees do not disclose trade secrets, publish internal reports, provide tips based on inside information or participate in other activities that may be considered insider trading; and Restrict employees from accessing or using social media for personal purposes during company time with company equipment, unless they have secured prior authorization to do so.

REACTIONS TO NLRB GUIDELINES

Although the NLRB has issued some guidelines on acceptable social media policies, the reaction to this initiative has been mixed. While employers are grateful to have a list of “do’s and don’ts”, many question whether in its zeal to categorize employer policies as overreaching, the NRLB has issued an analysis of what could be reasonably interpreted as including protected concerted activity. Indeed, some believe that the NLRB may be trying to create relevance in a labor market where the power of unions is waning. Yet, employers would do well to understand the reasoning behind the NLRB’s analysis and may want to review their social media policies to avoid coming into conflict with the NLRB. n

SUMMER 2015

Legislative Update

The measure also calls for the creation of an advisory panel of subject matter experts, for which PAMED submitted recommendations, to advise the ABC-MAP Board in developing the program and carrying out its duties. Secretary Murphy indicated that the advisory panel has not yet been created.

State officials have indicated that the database is unlikely to be up and running by June 30, 2015, the kickoff date established by the law, due to funding concerns and logistical challenges. During the meeting, Secretary Murphy stated that she expects funding for the program to be included in the upcoming fiscal year budget, which begins in July. Gov. Wolf has included $2.1 million in his proposed 2015-2016 budget to run the program.

L-R: Michael Fraser, PhD, CAE, executive vice president of PAMED; PAMED President Karen Rizzo; MD, Physician General Rachel Levine, MD; Secretary of Health Karen Murphy, PhD, RN; and Board Chair David Talenti, MD, at a PAMED Board meeting.

State Seeks Best Practices in Creating Controlled Substances Database

n May 20, 2015, Karen Murphy, PhD, the state Secretary of Health, convened the second meeting of the ABC-MAP board, the group of cabinet-level officials who will oversee the state’s new controlled substances database. Chaired by Secretary Murphy, the board also includes the Secretaries of Human Services, Drug and Alcohol Programs, State, Aging, the Insurance Commissioner, the State Police Commissioner, the Attorney General, and the Physician General.

The primary purpose of the meeting was to hear from national experts Brandon Maughan, MD, and Marcus Bachhuber, MD, who are members of the Robert Wood Johnson Clinical Scholars program in the Perelman School of Medicine at the University of Pennsylvania, regarding operational best practices of prescription drug monitoring programs that are already operating across the country. In October 2014, then-Gov. Corbett signed a law that will give Pennsylvania physicians access to a statewide controlled substances database. The legislation is intended to give them better knowledge of prescriptions written for and filled by a patient, with the goal of reducing opioid abuse and identifying scammers.

28 | www.berkscms.org

PAMED Member Dr. Rachel Levine Confirmed as PA Physician General

ennsylvania Medical Society (PAMED) member Rachel Levine, MD, was unanimously confirmed by the state Senate as Pennsylvania’s physician general on June 9, 2015.

PAMED congratulates Dr. Levine, and looks forward to working with her on issues like tackling opioid abuse in Pennsylvania, which is one of her top priorities.

Dr. Levine is professor of pediatrics and psychiatry at the Penn State College of Medicine. She previously served as vice chair for clinical affairs for the Department of Pediatrics and chief of the Division of Adolescent Medicine and Eating Disorders at the Penn State Hershey Children’s Hospital-Milton S. Hershey Medical Center.

Some of her accomplishments include launching the Division of Adolescent Medicine at the Penn State Hershey Medical Center for the care of complex teens with medical and psychological problems. She also started the Penn State Hershey Eating Disorders Program, which offers multidisciplinary treatment for children, adolescents, and adults with eating disorders.

Dr. Levine graduated from Harvard College in 1979 and the Tulane University School of Medicine in 1983. She completed her training in pediatrics at the Mt. Sinai Medical Center in New York City in 1987 and her fellowship in adolescent medicine at Mt. Sinai in 1988. She was in the practice of pediatrics and adolescent medicine at the office of Edward Davies, MD, from 1988-1993, and was also on the faculty of the Mt. Sinai School of Medicine. Dr. Levine came to Pennsylvania as director of ambulatory pediatrics and adolescent medicine at the Polyclinic Medical Center in 1993. She joined the staff at the Penn State Hershey Medical Center in 1996 as the director of pediatric ambulatory services and adolescent medicine. n

Alliance Update

Another Hugely Successful Year Under the Leadership of President Lindsay Romeo

his spring, the Berks County Medical Society Alliance wrapped up another hugely successful year under the leadership of President Lindsay Romeo. With funds largely raised through the annual Holiday Card fundraiser, a total of $6,000 in philanthropic donations was made to organizations including: Aaron’s Acres, Children’s Home of Reading, We Agape You, Inc., Gilmore Henne Community Fund, and Western Berks Free Medical Clinic. A total of $5,000 will be awarded in scholarships to Berks County applicants preparing to enter the Medical or Allied Health field.

In May, Lindsay Romeo passed the baton to incoming President, Amy Impellizzeri, at an installation luncheon held at Golden Oaks Country Club in historic Oley. Alliance Regional Director, Kathleen Hall, was on hand to swear in the new 2015-16 Executive Board:

President: Amy Impellizzeri President Elect: Allison Wilson VP Health Project: Lisa Banco VP Membership: Kelly O’Shea and Jeane Serrian Treasurer: Kara DeJohn Assistant Treasurer: Amanda Abboud Recording Secretary: Meghan White Corresponding Secretary: Michelle Trayer Scholarship: Toni Calata Directors: Kathy Rogers and Lindsay Romeo

On May 20, 2015, many of the Past Presidents of the Alliance (and the incoming President) gathered at Berkshire Country Club for the annual Past Presidents luncheon, where the members updated each other on current news and happenings in each other’s lives, and also shared each President’s legacy from her year at the head of the Executive Board. It was a beautiful day celebrating the rich history of the Alliance, and especially honoring Toni Calata, who is celebrating her 25th Anniversary as President this year! For more information about BCMSA, please check out: http://berkscmsa.org or “Like” us on Facebook! n

SUMMER 2015

Members in the News Dr. William Clements Awarded the Jasper G. Chen See, MD Healthcare Professional Award at Caron’s 19th Annual Berks County Community Service Awards Breakfast held on May 28, 2015.

Dr. William Clements, a family physician located at Wernersville Family Practice, has been providing family and addiction medicine within his community for over 20 years. Dr. Clements’ holistic approach to patient care led him to developing an awareness of the toll an untreated addiction takes on the patient and the patient’s loved ones. In 1984 he began providing services to patients at the Caron Foundation and by 1987, Dr. Clements was certified by The American Medical Society on Alcoholism and Other Drug Dependencies. Through his family practice, he continues to provide compassionate care to those in all phases of addiction and recovery. Dr. Clements remains a staunch advocate and voice for those suffering from addiction, and his dedication to those he serves is truly exemplary.

Dr. Raymond C. Truex, Jr. was also recognized at the Awards Breakfast by the Berks County Medical Society as an unsung hero.

Lehigh Valley Business Names Dr. Sandel Among 2015 Women of Influence. Congratulations to Kristen Sandel, MD, Associate Director, Department of Emergency Medicine, Reading Hospital, who was recently recognized by Lehigh Valley Business as one of the publication’s 2015 Women of Influence. Dr. Sandel was cited for outstanding contributions to Reading Hospital, the Reading area community, and the healthcare industry. Dr. Sandel began her career 10 years ago at Reading Hospital. She is currently a member of the Board of Directors and serves on ten hospital committees, participating in the implementation of patient care procedures that ensure quality and safety. Dr. Sandel is also a member of numerous professional organizations, served as past President of the Berks County Medical Society, and serves on the Board of Trustees at the Pennsylvania Medical Society.

Dr. David L. George has been appointed governor of the Pennsylvania eastern chapter of the American College of Physicians, the national organization of internists. The areas of professional interest for Dr. George include medical education for students, residents and practitioners. Dr. George earned his medical degree from Harvard Medical School. He is chief academic officer at Reading Health and VP of Academic Affairs. He specializes in rheumatology, with certification in internal medicine and rheumatology. He is also a clinical associate professor of Medicine at Thomas Jefferson University. n

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PAMED Brings Clarity to the Medical Marijuana Debate…

But Now What? By: Heath Mackley, MD

he Pennsylvania House Health and Judiciary Committees met on March 24, 2015, and PAMED was there to provide much needed clarity to lawmakers and the public as they consider the legalization of medical marijuana. The white paper that presents PAMED’s policy position can be accessed on the Society’s website at www. pamedsoc.org/IsMarijuanaMedicine, and I encourage physicians and patients alike to read this well researched document. Like the AMA, PAMED believes the federal government should facilitate the study of marijuana and its chemical components so its safety and efficacy can be evaluated with the same scientific vigor as any other medication undergoing the FDA approval process. Additionally, PAMED believes the passing of medical marijuana legislation would be premature at this time.

The federal government’s position formally remains unchanged since the passage of the Controlled Substance Act of 1970, in response to the United States signing on to the multi-national Single Convention on Narcotic Drugs in 1961. Marijuana is a Schedule 1 substance, meaning it should not be studied because it has a high potential of abuse and has no recognized medical use. Both the AMA and PAMED believe this should be reviewed, while other medical societies have officially endorsed making marijuana Schedule 2 in order to facilitate its study. No physician-led society has endorsed the legalization of medical marijuana.

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However, the Pennsylvania State Nurses Association did so in 2014. The AMA believes physicians should be able to give patients unfettered information about the therapeutic use of marijuana without the fear of criminal sanctions, but does not go so far as to say that physicians should be allowed to prescribe marijuana under state law without fear of federal prosecution. Although the Pennsylvania legislation, in its current form, describes that providers “recommend” rather than “prescribe” marijuana, the risk that the federal DEA can sanction a physician for prescribing marijuana in a state that legalizes it remains real. Limited Studies

Marijuana has been studied in 27 double blind randomized trials subjected to peer review since 1990. Most are small and have short follow-up, and 10 were negative trials. Currently, the most promising conditions that merit further study based on positive trials are muscle spasticity for multiple sclerosis and neuropathic pain. As with all potential interventions, there is a risk of harm. There have been no reported deaths from the use of medical marijuana, but marijuana has well-documented acute and late toxicity, including the development of respiratory symptoms and diseases, adverse neurocognitive development in adolescents, and psychiatric disorders. Marijuana edibles run the risk of diversion because

of their attractiveness to children, and states with medical marijuana legislation have higher rates of recreational use and abuse in their populations. Furthermore, a type of “medical marijuana,” in the form of regulated prescription drugs, has existed since 1985. There are two FDA-approved THC derivatives: Marinol (dronabinol) and Cesamet (nabilone). Additionally, Epidiolex, a liquid form of CBD, is undergoing FDAapproved trials for intractable childhood seizures, and Sativex, an oral spray with THC and CBD, is being studied in the treatment of pain and ADHD. An Epidiolex trial is open at the Children’s Hospital of Philadelphia.

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An Emotional Argument

Although PAMED’s stance for more research is medically sound and intellectually honest, the chief sponsors of the legislation are not relying on a scientific argument. Many patients suffer from ailments we do not have effective treatments for, perhaps the most tragic of which are children with intractable seizures from Dravet syndrome and Lennox-Gastaut syndrome. The argument is that to withhold from them a product that has helped some patients is inhumane. Given that heartbreaking reality, it is not surprising that 11 states have legalized CBD for medical use, and 23 others to some degree have approved CBD and THC. Clearly, momentum is building nationwide, and this is no different in Pennsylvania, where multiple polls have shown overwhelming support for medical marijuana legalization. Stay Engaged

Although the future remains uncertain, Pennsylvania physicians should seriously consider what their individual position will be in the event that PA allows them to prescribe marijuana. Furthermore, PAMED will need to consider what its role should be. Should PAMED offer marijuana guidelines similar to the opioid prescribing guidelines (www.pamedsoc.org/opioidguidelines)? Our patients know we are concerned about their health, and they trust us to have informed opinions. Our patients and our legislators trust our organizations will have a similar concern for public health, and the ethical practice of medicine. In Pennsylvania, like many other states, if and when medical marijuana legislation passes, it will be a case of “the people have spoken.” But that will just lead us to a different conversation. So stay engaged, we’re going to need you! n Dr. Mackley is a radiation oncologist in the Penn State Hershey Cancer Institute and serves as the 5th District Trustee on the PAMED Board, representing physicians of York County.

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SUMMER 2015

Calendar of Events & Notes New Physicians, Residents and YPS Social Thursday, August 13, 2015 The Hitching Post, 2747 Bernville Road, Leesport, PA 19533 6PM-9PM RSVP 610-375-6555 or email info@berkscms.org

“Meet and Greet” our new Executive Director followed by our Executive Council Meeting Open to all members Thursday, September 3, 2015 6PM-7PM—Meet and Greet 7PM—Executive Council Meeting

The Family Medicine Fall CME Series will begin on Friday, September 11th, with Andrew Waxler, MD, presenting “The Role of Lipids and Diet on Coronary Artery Disease. Where Do We Go From Here?” All lectures are held in the Reading Hospital 5th Avenue Conference Center, Rooms 1, and 2, and begin at 8:00 a.m. The full fall schedule will appear in the next issue of the Medical Record.

NOTE: If you have not responded to the letter you received to update your listing in the 2016-2017 Directory of Physicians, please do so as soon as possible. If you have questions about your listing, please contact us at 610-375-6555 or email at info@berkscms.org

Berks County Medical Society

Mark Your Calendars! Wednesday September 16, 2015 Fall Golf Outing

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