THE ART of Chester County WORKS OF
James “Sandy” Maxwell
PROTECTING PATIentS CHESTER COUNTY FROM theINONE-SIZE-FITS-ALL many faces HEALTHCARE F E AT U R E D O N PA G E 2 0
of SODIUM CeliacRESTRICTION: Disease
A TIME-HONORED DOGMA OR 7 Affordable Care Act Issues AN EVIDENCE-BASED PURSUIT?
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Chester County, PA Member of the Medical Staff at Brandywine Hospital
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2013-2016 CCMS OFFICERS President Winslow W. Murdoch, MD
President-Elect Mian A. Jan, MD, FACC
Vice President Michael J. Maggitti, MD
Pressure 10 Blood Control Adherence
Secretary Bruce A. Colley, DO
Treasurer David E. Bobman, MD
Board Members Mahmoud K. Effat, MD Heidar K. Jahromi, MD
20 THE ART of Chester County
Liza P. Jodry, MD John P. Maher, MD Charles P. McClure, MD Susan B. Ward, MD
Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evolved to represent and serve all physicians of Chester County and their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance the role of medicine and health care within the community, Chester County and Pennsylvania. The opinions expressed in these pages are those of the individual authors and not necessarily those of the Chester 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 Chester County Medical Society. Chester County Medicine is published by Hoffmann Publishing Group, Inc., Reading PA 19608 HoffmannPublishing.com For advertising information, contact Karen Zach 610.685.0914 firstname.lastname@example.org
Features 10 Blood Pressure Control Adherence: The Physician’s Role 12
Commentary: How the Two-Tier Healthcare System Really Works
In Every Issue 5 7 18 20 29 30
President’s Message PAMED Legislative Update Hospital Profile The Art of Chester County Membership News & Announcements Member Profile
New Leadership Says PAMED Has Your Back
14 Seven ACA Issues 16 The Many Faces of Celiac Disease 19 Looking to Hire a Physician? 21 Physicians’ Health Programs Offers Intervention Services 22 Frank F. English 24 Communication: The Glue for Accountable Care Organizations 26 CCMS Membership 28 New Leadership Says PAMED Has Your Back
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Regulatory Creep Are we a t a tippin point for g a patien t -c e revolutio ntered n in hea lthcare?
eeping up with the rapidly expanding complexity of the practice of medicine is a full-time job. Practicing physicians all spend several hours a week (or more), every week, learning about new treatments and diagnostic algorithms, as well as relearning the basics on tens of thousands of conditions that we do not encounter on a regular basis. This complex and academic challenge energizes us as we see our patients. We constantly apply our renewed and newfound knowledge every day. No doctor can
possibly know everything. So, we toil under the confines of our humanity, to add value to patients every day. Please excuse the following run-on list of regulations that we must comply with on a daily basis: HIPAA; OSHA; CLIA; ACA; ACO; MOC; MOL; JHACO; regulations on billing and balance billing; CME requirements; documentation requirements for E&M coding Byzantine requirement of ICD 9, now 10, diagnosis code labeling for getting paid for our work that force us to focus on piecemeal labels to get paid, as well as ordering routine outpatient lab, radiology, and diagnostic studies; a separate ICD 10 for hospital codes and services; prior
authorization for routine diagnostic studies and prescribing medication; review and signature of voluminous computer-generated care plans for home visiting nurses, hospice, and physical/ occupational/speech therapy; managing angry patients infuriated over denied payment by Medicare or insurer for routine lab testing; mandated observation status in the hospital and denied payment to doctors and then skilled nursing facility care; out of context disease guideline management enforcement; required specific CME (hours of study every year) for pet topics of legislators; electronic medical record mandates of “meaningful use (MU)” that interferes with our ability to communicate and diagnose; P4P and PQRS requirements to show and
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report often meaningless but easily measured quality indicators to avoid penalties and global reductions in reimbursement; MU attestation and submission of voluminous documentation to avoid payment reductions and penalties for not clearing the bar on EMR use; Sunshine Act; medical care billing and insurance denial of payment management; federal requirements and regular attestation and proof to become and maintain federal certification as patient-centered medical home.
multiple employees and administrators per physician to try to comply, thereby forcing the doctor to see more patients each day to cover growing overhead.
Hundreds of thousands of pages of bureaucratic federal, state, specialty society, and insurance regulations have been, and continue to be, written that pertain to a physician’s day-to-day practice. These rules have accumulated over several decades, usually as a legislative or insurance company’s response to one “never event” occurring. They often start as a knee-jerk way of dealing with public outcry. Over time, these new rules take on a life of their own. A self-interested bureaucracy evolves to measure and enforce them, often with handsome profits to those that administer. They are funded. They are mandated and they continue to evolve in complexity. With tight budgets, due to their bloated regulatory infrastructure, they are enforced mostly with sticks (which are potentially lethal to private practices, now clamoring to become employed by big hospital corporations) instead of carrots. Medical practices must hire
Do any of these help your doctor interview, examine, and educate you in a contemplative, thoughtful, and personalized manner? Do any of these really have a beneficial impact on the patient-doctor relationship? Are we at the tipping point for a patient-centered revolution in healthcare?
This is just the tip of the iceberg of the regulatory environment that we face daily. Your primary care doctor is not running a federally funded nuclear weapon, research, and testing facility, but it sure feels like it from our end.
Winslow W. Murdoch, M.D., practices family medicine in West Chester. He is president of the Chester County Medical Society. Contact Dr. Murdoch at email@example.com.
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PAMED Legislative Update
Controlled Substance Database Progress continues to be made on the Pennsylvania Medical Society’s (PAMED) drive to enact legislation establishing a statewide controlled substance database. As reported earlier, the House of Representatives passed House Bill 1694 on Oct. 21, 2013, by a vote of 191-7. The success was the result of two years of effort by PAMED and its members, who recognize the value such a database would have in reducing doctor-shopping and controlled substance abuse. Our “Pills for Ills, Not Thrills” campaign has played a major role in generating public support for the legislation.
Pennsylvania Medical Society Quarterly Legislative Update BY SCOT CHADWICK
overnor Corbett’s annual budget address is now in the books, and the House and Senate have completed their respective Appropriations Committee budget hearings. At these hearings cabinet secretaries pleaded their case and were cross-examined regarding the funding requested by the governor for their departments. The entire process (hopefully) will culminate with the enactment of a new state budget before the end of the fiscal year on June 30. The past few months have been busy, with action on several measures of importance to physicians and patients. Following is a summary of some of the highlights.
Subsequently, Senator Pat Vance (R-Cumberland) introduced her own version of the legislation, Senate Bill 1180. The bill differs in several respects from the House-passed bill, and PAMED has been working to reconcile those differences and get a final product to Governor Corbett’s desk to make this important tool a reality for Pennsylvania physicians. On March 19, 2014, the Senate Public Health and Welfare Committee approved Senator Vance’s bill unanimously, and as of this writing the bill awaits a vote by the full Senate. While PAMED supported the Senate committee action, we have a number of concerns about the Senate version, particularly in the area of patient privacy and law enforcement access to the database. At this point it is unclear whether the House bill or the Senate bill will ultimately be the one that reaches the governor’s desk, but in either case PAMED will continue to press for enactment of the best possible final product.
the understanding and treatment of disease. The billâ€™s fate is uncertain at this time.
Medical Marijuana There has been a surge of interest in legislation that would legalize medical marijuana in Pennsylvania, culminating in a Senate public hearing on January 28, 2014. Senate Bill 1182 is based on the premise that there is some evidence that marijuana may provide relief from nausea to cancer patients, and that it may aid in the treatment of glaucoma and post-traumatic stress disorder. There are also recent stories that oil derived from cannabidiol has aided some sufferers of Dravet syndrome, a rare form of epilepsy. PAMED testified at the hearing, where we expressed concern that much of the evidence is anecdotal, and that one individualâ€™s experience cannot be applied to others with any degree of confidence. In the absence of reliable scientific studies, we worried that there is no sure way to know whether the observed changes resulted from the administration of marijuana or from some other source or combination of sources. And might it be possible that two cases in which an individual benefited from marijuana were offset by three other cases where patients suffered harm?
PAMED also testified that serious questions remain even if one assumes that medical marijuana may benefit a certain class of patients. Was it the tetrahydrocannabinol (THC) that produced the result, or was it the cannabidiol (CBD), or a particular combination of the two? Or perhaps it was one of the dozens of other compounds in the particular strain that was used. What dosage or potency produces maximal efficacy, and how often should it be administered? And importantly, is there a dosage or frequency of administration that causes harm, and what are the longterm effects? Until these questions have been answered, PAMED testified that we cannot support the legalization of marijuana for medical use. However, PAMED believes a compelling case exists for a serious scientific examination of the potential medical use of marijuana, and four years ago joined the AMA in urging that marijuanaâ€™s status as a federal Schedule I controlled substance be reviewed, with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods. PAMED has also called for further adequate, well-controlled studies of marijuana and related cannabinoids in patients who have serious conditions for which preclinical, anecdotal, or controlled evidence suggests possible efficacy, and the application of such results to
Naloxone Bills Being Considered House Bill 2090 and Senate Bill 1299 would significantly expand access to naloxone, a drug used to counteract the effects of an opioid drug overdose. The bills provide for educational materials and training for law enforcement personnel, firefighters, and persons at risk and their friends and family members on how to identify a person experiencing an overdose, administer naloxone, and seek medical help. The scope of practice of EMS providers would be expanded to permit them to administer naloxone once they have received the necessary training. And importantly, prescribers would be authorized to prescribe and dispense naloxone to law enforcement personnel, firefighters, and persons at risk, along with their friends, family members, and others in a position to help them. Prescribers who prescribe and dispense naloxone in good faith would be immune from civil, criminal, and professional disciplinary liability for doing so, and persons seeking medical help for someone experiencing an opioid overdose would also be immune from criminal liability. While it is clear that naloxone saves lives, lawmakers are wrestling with the question of whether wide availability also encourages opioid abuse by reassuring potential abusers that an antidote is at hand.
Ban of Electronic Cigarette Sales to Minors PAMED has expressed its strong support for Senate Bill 1055, which would ban the sales of electronic cigarettes to minors. The bill was approved by the Senate Judiciary Committee on December 3, 2013, and is poised for a vote by the full Senate. PAMED believes that while electronic cigarettes may ultimately prove to be “safer” than tobacco cigarettes, a claim as yet unsubstantiated, they are far from harmless. Electronic cigarettes deliver nicotine, a highly addictive substance, into the body, and according to the American Medical Association’s Council on Science and Public Health, they also contain other toxins and carcinogens. PAMED is especially concerned that electronic cigarettes are attractive to minors, as evidenced by their availability in flavors such as bubble gum, chocolate, and even gummi bears. This is deeply troubling in light of a recent study of 76,000 Korean teenagers, which found that electronic cigarette use made them less likely to have succeeded in kicking the smoking habit and actually made them heavier smokers. The study, conducted by researchers from the University of California at San Francisco, concluded that: “use of e-cigarettes is associated with heavier use of conventional cigarettes, which raises the likelihood that actual use of e-cigarettes may increase harm by creating a new pathway for youth to become addicted to nicotine and by reducing the odds that an adolescent will stop smoking conventional cigarettes.” Attorneys General from 40 states have jointly submitted a letter urging the FDA to regulate electronic cigarettes in the same way that it regulates tobacco products, and since 2009 the FDA has banned e-cigarette imports on the grounds that they were unregulated medical devices. Yet under current law these devices can be freely obtained by children. PAMED is working aggressively to secure Senate passage of this important public health measure. Scot Chadwick is legislative counsel, state legislative affairs for the Pennsylvania Medical Society.
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Blood Pressure Control Adherence: The Physicianâ€™s Role BY MICHAEL LATTANZIO, DO
ADHERENCE IN HYPERTENSION
Dr. Michael Lattanzio, DO
dherence is a common roadblock to achieving optimal blood pressure control. Good adherence has been linked to improved blood pressure control and reduced health outcomes1. In regards to blood pressure, adherence applies to both pharmacological and nonpharmacological treatments. Factors influencing adherence with respect to hypertension range from patient-related factors to therapy- or condition-related factors (see table).
Poor Knowledge Poor Acceptance Adverse Drug Events Poor Drug Tolerability Expensive Regimens Complex Regimens Misconceptions of Hypertension Poor Insight into Medical Condition Expensive Regimens Poor Healthcare Access Lack of Trust Inadequate Follow-Up Poor Patient Education Clinical Inertia
THERAPY-RELATED CONDITION- RELATED SOCIO-ECONOMIC RELATED HEALTH-SYSTEM RELATED
With hypertension, like any chronic condition, patient education plays a pivotal role. Poor knowledge of the health risks associated with hypertension can result in poor adherence. It is the role of the physician to emphasize the cardiovascular benefits of long-term blood pressure control. The ability of the physician to educate and build trust with patients can have significant impact on improving adherence. Physicians should also aid patients in acceptance of their medical condition through reassurance and encouragement. Engaging the patient in their own medical care can empower patients to strive for better health. Lastly, the physician must address factors associated with adherence at each visit to avoid lapses in adherence.
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The choice of therapies to control blood pressure can have a dramatic impact on patient adherence. Complex regimens with poor drug tolerability can often derail blood control from the start. In general, simplified blood pressure regimens with well tolerated anti-hypertensive agents will aid physicians in achieving optimum blood pressure control. Combination pills can be useful to decrease pill burden and further enhance patient adherence. Addressing adverse effects from anti-hypertensive agents immediately can circumvent patient discouragement with the chronic condition. Lastly, the use of generic medications can help allay financial costs associated with blood pressure management.
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The issue of adherence is complex and requires a multidimensional approach on the part of the healthcare provider. Acknowledgement from the healthcare provider is critical to helping address the underlying issues related to poor adherence. Physicians must realize that most factors related to poor adherence are unrelated to the patients themselves. Physicians should collaborate with patients to implement plans to rectify poor adherence. The five E’s for improving blood control through improved adherence: • EDUCATE • ENGAGE • EVALUATE • ENCOURAGE • ECONOMIZE Reference 1. Lucher TF et al. Compliance in hypertension: facts and concepts. Hypertension, 1985, 3:S3–S9. Michael Lattanzio, DO, is a clinical nephrologist and hypertension specialist with Clinical Renal Associates of Chester County.
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How the Two -Tier Healthcare System Really Works BY STEVEN B. SIEPSER, M.D., FACS
“Doctor Siepser, how can you possibly charge me for my cataract surgery?” my patient asked. “I paid my insurance premiums. They told me I am covered and can see the best doctors and get the best care, and my insurance company said the services were paid in full. After all, it’s only a cataract.” I sadly look up, just starting to grasp the reality of the unintended consequences, I hope, of the zero-sum game of surgical disease insurance coverage. If you look at the healthcare delivery landscape, you mostly see economies of scale: more people covered, better coverage, and earlier intervention decreasing the overall costs of care. However, when you’re a surgeon sitting in front of patients looking for the best of care with the best products available, the truth of providing this becomes apparent. Our specialty no longer covers the costs for this type of superior service because it would break the system. The patient must pay, and the doctor is left holding the bag! Let me explain how those of us who must operate with the latest and greatest are squeezed into the position of explaining to the patient what real care will cost and why it is out-of-pocket. It’s simple economics. I would venture that the CMS knows exactly what it is doing, gaming the system to get a feel of what can be passed on to the patient. They know better than anyone what the prosthetic companies will abide and the great variability in product quality and cost of manufacturing. In ophthalmology we have the opportunity to offer products that improve the refractive outcome. This means that we can work through several choices, ultimately allowing the cataract patient to see without glasses. This is an offshoot of laser vision correction, considered to be a cosmetic procedure that is very rarely covered by insurance, save for our members of Congress who sometimes get coverage without reaching into their pockets. The insurance companies proclaim that they provide the best doctors and care, leading patients to be shocked to discover they are not covered for
the really good stuff. To give you some background, the best analogy would be an optical one. Many business vision plans cover basic eye exams and glasses. Frames and glasses covered by the plans are the least expensive and the quality is basic, but poor. Higher optical quality glasses, and intra-ocular implants used to replace the human lens after cataract surgery extracts the human lens, will involve out-of-pocket expenses for the patient. There are 3.5 million cataracts done a year in this country. It is one of the major line items for Medicare and most insurers. We are usually paid $750 for this procedure and up to $1200 for the facility fee. That includes everything, meaning the implant. Believe it or not, there are implants that can be acquired for $20 in certain deals. Using the cheapest thing available in volume can be done profitably. However, some people want and can afford the very best. The insurance companies have their “Cadillac” plans for these successful folks, but there is massive variability in quality and outcome. Coverage may not include implants delivering a close-to-perfect no-glasses outcome, as it is considered to be “cosmetic.” Insurance companies do this because the finest implants actually cost about $1,000, more than the payment
for the process in some cases. So, what do they do? They continue to “sell” the patient their policies and leave it to the doctor to explain the “yeah but” problem they have so neatly side stepped. It is high time that insurance companies start having disclaimers in their promotions somewhat akin to the word blast one hears at the end of car ads. Consumers need to be told up front that there are many products and services not covered, and getting the best care might involve dipping into their own pockets. This onerous task is placed on the surgeon who by default is made to look greedy and mercenary. In closing, I would suggest you ask your insurance company to fully explain what levels of care are being provided in their policies. Or, you may wish to ask your specialist to recommend types of coverage that may be beneficial to your current or future needs. There are many options. You just need to take the initiative. Steven B. Siepser, M.D., FACS, is a practicing ophthalmologist in Chester County.
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Seven ACA Issues for Chester County Physicians to Consider BY DENNIS OLMSTEAD
ith the Affordable Care Act (ACA) moving closer to full implementation in 2014, many Pennsylvania physicians continue to express concern over how the ACA will impact their practice and care of patients in the state. One of the biggest concerns about the ACA is the degree of uncertainty that it has introduced to an already complicated, competitive, and increasingly consolidated health care system. There are several unknowns related to ACA implementation in Pennsylvania, for example the state’s Medicaid waiver proposal to expand health insurance to over 500,000 residents of the state; and the insurance products that Pennsylvania insurers will offer in the state as part of the new marketplace. PAMED has a number of resources available to assist physicians in each of the areas of uncertainty identified below. Please contact your county representative or PAMED at 800228-7823 or ask your question at firstname.lastname@example.org.
#1. Practice Consolidation The trend toward the consolidation of independent physician practices into larger medical groups, including hospital and health plan purchases of physician practices, was clearly taking place in Pennsylvania well before the passage of the ACA. However, the ACA has driven an increase in practice consolidations for a number of reasons such as declining reimbursement rates, increased regulation of physician practices, complicated e-Health systems, new patient referral patterns, and a movement from “volumebased” payment models to “value-based” models.
#2. New Payment Models The ACA codifies what was once labeled an “innovation”– the trend toward physician payment based on population health or bundled services rather than feefor-service. While not universal, physician offices are now living in two worlds: payments based on fee-for-service and payments based on new models such as patient-centered medical homes or shared savings plans.
#3. Changing PhysicianInsurer Relations Because the central goal of the ACA was to expand health insurance coverage to uninsured Americans, much of the physician uncertainty about the ACA relates to specific issues concerning physician-insurer relationships. There are a number of issues related to the changing physician-insurer relationship. They include a downward trend in physician reimbursement rates, use of insurer contract language to require provider acceptance of lower rates, the creation of narrow and tiered provider networks, and an increase in patient outof-pocket costs that the physician must collect.
#4. New Penalties The ACA and other federal laws contain several penalties for physicians that do not comply with certain policies or procedures. For example, physicians who do not prescribe electronically after 2013 will face a 2% penalty in 2014. Likewise, physicians who do not participate in the
Physician Quality Reporting System (PQRS) as of 2014 will face a 2% penalty in 2016.
#5. Patient Demand
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One major uncertainty with regards to the ACA is the patient demand for physician services, especially primary care services, as the newly insured obtain coverage. PAMED will continue to work with partners at the state and national level working to address physician workforce issues, including the leadership of Pennsylvania’s nine medical schools.
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#6. Patient Insurance Changes or “Churn”
While patients currently change insurers on a periodic basis because their employer-sponsored coverage changes and/ or a provider is no longer “in network,” this issue could be compounded by the ACA. Under the ACA, small businesses may be able to shift their employees to Marketplace plans, rather than provide employer-sponsored insurance. If a physician is not in that patient’s Marketplace plan network they may have to terminate care to that patient because the patient will not be able to afford out-of-network costs of care.
#7. Quality Measures As the trend in reimbursement moves from “volume” to “value,” new measures will be needed to monitor the quality of care. Many existing quality measures and standards are based on a fee-for-service model. PAMED is working to assure that physicians are represented in statewide discussions on physician quality, especially as they relate to payment reform and reimbursement policies.
Uncertainty regarding the implementation of the ACA is a major issue for physicians across the state. These seven challenges clearly indicate that the ACA will impact physicians and patients. As the statewide advocate and resource for Pennsylvania physicians, PAMED will continue to share information and resources to members about the impact of the ACA and our work to address physician concerns moving forward.
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References Paige, Leigh. “How Insurance Exchanges Will Affect Doctors’ Income.” July 10, 2013 in Medscape, Business of Medicine, 2013, available at www.medscape.com, last accessed 12/18/13.
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Paige, Leigh. “8 Ways that the ACA is Affecting Doctors’ Income.” August 15, 2013 in Medscape, Business of Medicine, 2013, available at www.medscape.com, last accessed 12/18/13. Dennis Olmstead is chief strategy officer and medical economist at the Pennsylvania Medical Society.
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The Many Faces of Celiac Disease BY ASHISH CHAWLA, MD
ecently, I went to Iron Hill Brewery in West Chester to meet a friend from residency. While I was scouring the menu, he quickly asked the waitress about the glutenfree menu, which to my surprise, she provided. My friend explained that his wife had just been diagnosed with celiac disease, and he joined her in the diet as it helped with his GI distresses. Immediately, several questions came to my mind: Is celiac disease on the rise? Are we just missing it in our practice? What are the risks of celiac disease? Is there any scientific truth to “gluten sensitivity,” or is my friend just following a fad diet? Celiac disease is an autoimmune illness that can result in symptoms of chronic diarrhea, bloating, weight loss, malabsorption (symptoms similar to IBS) and has an estimated prevalence of approximately 1% in Western populations. Current studies actually indicate that celiac disease is on the rise. Researchers from Mayo Clinic
looked at blood samples from Air Force recruits from the early 1950s and compared them to age matched controls from 2011. Surprisingly, today’s men were 4 to 5 times more likely to have celiac disease (based on presence of antibodies) than their 1950s counterparts. In fact, meta-analyses have shown that for every patient identified as having celiac disease, seven to eight remain undiagnosed. Apart from the GI symptoms, celiac disease is associated with other conditions including iron deficiency anemia, type 1 diabetes, elevated liver enzymes, dermatitis herpetiformis, osteoporosis, infertility, recurrent miscarriages, and T cell lymphoma. The newest one to join this list is coronary artery disease (CAD). In a recent study from Cleveland Clinic, individuals with celiac disease were almost twice as likely to have CAD as compared with age-matched controls – in younger and older patients even in
the absence of standard risk factors. The authors hypothesized that the chronic inflammatory state in celiac disease can have adverse effects on heart health. Celiac disease occurs when genetically susceptible patients are exposed to dietary gluten. The vast majority of these individuals possess human leukocyte antigen (HLA)-DQ2 and/or HLA-DQ8, and these HLA haplotypes appear to play a major role in the pathogenesis by the presentation of gluten peptides to CD4+ T cells in the small bowel mucosa. The presentation of these peptides can result in the activation of intraepithelial lymphocytes that can ultimately lead to damage of the intestinal epithelium in the form of villous atrophy. Initial screening for celiac can be done by checking for serum TTG IgA and serum a IgA levels (approximately 5–10% of patients with celiac disease have selective IgA deficiency and can have false negative TTG results) while
the patients are on gluten diet. If the TTG is positive or IgA deficiency is noted, patients should undergo an endoscopy with small bowel biopsy. The genetic testing for HLA-DQ2 or DQ8 haplotypes is done when the biopsy results and serology are not concordant or for borderline cases (can be ordered via Quest labs). Treatment for celiac disease is gluten avoidance, but in refractory cases, steroids have been used after a search for secondary causes is exhausted (lymphoma, bacterial overgrowth, lactose intolerance). While I was surprised by some of the answers to my questions, surely my friend was not “gluten sensitive” and was just following a fad diet. Actually, the concept of non-celiac gluten sensitivity (NCGS) has gained significant interest from scientists and social media alike. GI symptoms of NCGS are similar to celiac disease, but patients also get systemic issues such as headache, “foggy mind,” joint pain, and numbness in the legs, arms, or fingers. NCGS is not an allergy or autoimmune condition, but felt to be driven by the innate immune response. The diagnosis of NCGS is made in cases with negative immunoallergy tests to wheat, negative anti-TTG serology, with normal duodenal pathology, resolution of symptoms when started on a gluten-free diet, and recurrence of symptoms when gluten is reintroduced. The estimated prevalence of this disease is much higher than that of celiac disease (approximately 6%). While initial studies have supported gluten withdrawal in these patients with resolution of their symptoms, a study in Gastroenterology found that patients diagnosed with NCGS responded best to a low FODMAP (fermentable, poorly absorbed, short-chain carbohydrates - fermentable, oligo-, di-, monosaccharides, diet, and polyols) and the symptoms were not noted with reintroduction of gluten. I think the jury is still out on NCGS. For me, I enjoyed my glutenfree appetizer guilt free. Ashish Chawla, M.D., is a practicing gastroenterologist in Chester County.
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Main Line Health: Providing Convenience and Excellence at the Exton Square Mall
he changing healthcare landscape encourages us to find new and innovative ways to deliver convenient care that fits into our patients’ busy schedules. This past January, obtaining medical care has become easier than ever at Main Line Health. Most recently, we have expanded our primary care network and specialty care services by opening the Main Line Health Center at Exton Square—right in the Exton Square Mall.
years, but this new center allows us to consolidate much needed services in a single, modern setting,” says Maria Flannery, director, Physician Practices/ Ambulatory Care Center for Main Line Health.
The outpatient center offers comprehensive care to meet all outpatient needs for every member of the family—even on nights and weekends. Additionally, our urgent care center is staffed by board-certified Main Line Health physicians, allowing patients to be seen by a doctor when they can’t get an appointment quickly with their primary care physician.
Main Line Health Center at Exton Square offers primary care, family medicine, pediatrics, hematology and oncology, urgent care, cardiology, and chemotherapy. Additional specialties will be opening soon, including gastroenterology, OB/GYN, orthopedics, podiatry, pulmonology, rheumatology, and sports medicine. The center features state-of-the-art imaging technology, including mammography, DEXA scan, CT scan, ultrasound, X-ray, and the county’s first Siemens 1.5T MAGNETOM Aera MRI. Laboratory and physical rehabilitation services are also available.
“Main Line Health has been providing excellent medical care in Exton for
Conveniently located near the Route 30 mall entrance, Main Line Health
Center at Exton Square has a designated entrance, complimentary valet parking, and dedicated parking spots. For patient convenience, the center provides extended hours and a centralized, onestop registration function to speed up the process and streamline paperwork. These are just a few of many features designed to offer exceptional service in comfortable surroundings. “We’re using innovative practices and a welcoming environment to give every patient a superior experience at Main Line Health Center at Exton Square,” Flannery says. “This new venue is the perfect setting for people to access the renowned team of Main Line Health providers. We look forward to a long, healthy relationship with the Exton and surrounding communities.” For information about the Main Line Health Center at Exton Square, please visit mainlinehealth.org/exton.
Looking to Hire a Physician? PAMED’s JobBank Can Help
he Pennsylvania Medical Society’s JobBank is an economical, online resource for Pennsylvania physicians looking for jobs and employers seeking candidates for medical job openings. Job seekers can post their resume and CV for free, set their own confidentiality level, browse and view jobs, and set up a job agent that will email you when jobs of interest are posted.
Ask a Physician: If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to
Employers get targeted access to physicians and other medical practice employees in Pennsylvania and across the nation. Because JobBank is part of the National Healthcare Career Network (NHCN), employers can gain access to 100,000 potential job applicants. The mega job boards charge upwards of $500 extra to search resumes of often less qualified candidates. With PAMED’s JobBank, the ability to search resumes is included in the cost of a job posting.
email@example.com with “Ask a Physician” as the subject. Your question will be forwarded to a physician and may be featured with an answer in a future issue of the magazine.
Visit www.pamedsoc.org/jobbank to create an account or learn more about these services. To find out about available discounts, call (800) 228-7823 or email Jeff Wirick at firstname.lastname@example.org.
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The Art of Chester County
The Art of Chester County BY BRUCE A. COLLEY, DO
or anyone who grew up in Chester County, that first day of fishing season was as magical as any holiday. James “Sandy” Maxwell grew up in the northern end of East Bradford Township in an area known as the Paradise Valley. And that it is. Take a drive, or better yet, bicycle along West Valley Creek from 322 to Boot Road and treat yourself to a uniquely beautiful part of Chester County that has changed little from the time it was settled in the early 1700s. Sandy spent countless days of his youth playing and exploring in this unique section of the Brandywine Valley, spawning his appreciation of its special beauty and his pursuit of fine art. In many of his works, his accomplished use of water colors captures the fauna and landscapes of Chester County and the “wild parts” of Pennsylvania. Sandy is nationally known in environmental and outdoor education as a pioneer of these programs at East Bradford Elementary School 40 years ago. He is now a professor of elementary education at West Chester University.
“Fly Fishing Upstate” “I have always been drawn to the streams found in upstate Pennsylvania. The awakening of spring unfolding into summer reveals the incredible rhythms found in life so dependent on clean water. Spring brings to the water’s surface the hatches of mayflies and stoneflies which trigger the awareness of song birds eager for a meal and the brook and brown trout that lie still in the currents. These waters are healing and centering to those who can escape the grind of day-to-day commitments and expectations.”—Sandy Maxwell “Lafayette’s Headquarters” “This painting of the Gilpin farmhouse used by Marquis de Lafayette for his headquarters during the Battle of the Brandywine emphasizes the rolling hills of Chester County and the field stone walls that dot the landscape. The rock removed from fields by early farmers to allow for planting, forms the many stone walls that separate property lines throughout the county as well as readily available building material for local homes.”—Sandy Maxwell Bruce A. Colley, DO, is the Secretary of the Chester County Medical Society.
PHP Offers Intervention Services
he Foundation of the Pennsylvania Medical Society Physicians’ Health Programs (PHP) is now offering intervention services to physicians and those who care about them. Senior Case Manager Lou Verna is certified in intervention services. Once thought of as a confrontational tool in treating addiction, intervention has developed into a “carefrontational” approach that demonstrates care and concern not only for the impaired individual, but also the family, friends, employers, and coworkers impacted by addiction or behavioral issues. Intervention is a way to address enabling behaviors and empowers those held hostage by addiction or behavioral problems and the challenges they present. People learn to utilize community resources and develop strategies for taking their lives back and returning to a healthy, productive lifestyle on a daily basis.
An interview will be conducted over the phone that will address the needs of the organization, family, employer, or coworker. The intervention process will be discussed as team members will be determined or eliminated. Those who continue to demonstrate enabling behaviors will be eliminated from the intervention team. A dialogue with concrete examples of the behaviors exhibited will be created and rehearsed. Finally a time and place will be determined for the intervention to take place and ultimately the recommendations for treatment to begin the process of resolution. Contact PHP for more information.
Those impacted by addiction quite often sit by helplessly witnessing and even contributing to the dysfunction. The process of intervention will allow those impacted to take charge of the situation, freeing them from being held hostage. The importance of recognizing, defining, developing, and implementing solutions is paramount. Early recognition cannot be stressed enough. Too often, the addictive patterns and behaviors are allowed to continue and go on unchallenged.
PHONE M O N D AY-T H U R S D AY
When determining whether an intervention is needed, some of the signs to look for are absenteeism, excessive sick leave, tardiness, and Friday / Monday absences. In addition, absences prior to and after holidays can be telling. Accident rates, poor work performance, or poor relationships or disruptive behavior in the workplace also are significant factors.
7 : 3 0 A . M . T O 5 P. M .
(866) 747-2255 OR (717) 558-7819 E-MAIL
P H P - F O U N D AT I O N @ PA M E D S O C . O R G ADDRESS
The process of coaching a team for the intervention can be initiated by a phone call to the PHP. This can be the start of a well thought out process that will help alleviate conditions and behaviors that have a far-reaching impact on the outcome. CHESTER COUNTY
P H Y S I C I A N S ’ H E A LT H P R O G R A M S 7 7 7 E A S T PA R K D R I V E P. O . B O X 8 8 2 0
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Frank F. English: A Forgotten Pennsylvania Painter
hortly after I finished my fellowship at Temple University, settled with my wife Amber in our home in Thornton, and joined a cardiology practice at Chester County Hospital in 1989, Ellie Egner, a patient who knew I was a fan of plein air art, invited me to a local auction. I spotted a plein air painting by Pennsylvania artist Frank F. English and instantly fell in love with his work. Despite my limited resources, I ended up with the winning bid and have continued to add to my collection when I could afford it, since his paintings come up for auction locally and nationally.
“Boat on the Shore”
“Girl and Boats in front of a Church”
“Delaware River Barge”
Frank F. English was born in 1854 and settled in Claymont, Delaware in the 1880s, working as an illustrator. During this time he was also associated with the Pennsylvania Academy of Art and studied under luminaries such as Thomas A. Eakins (1844-1916) and Thomas Anshutz (1851-1912). For five years English honed his art by attending evening classes at the academy. He also exhibited during the 1880s at the academy. He resided during that time on Arch Street in Philadelphia. In 1889 English exhibited in the Art Institute of Chicago and in 1910 at the Panama Pacific International Exhibition.
English lived the last 12 years of his life in Bucks County’s Village of Point Pleasant. His paintings during this time depicted the beautiful plein air scenery and nearby countryside. His colors became more luminous, and although the content remained pastoral, the work became more vibrant and mature. English died of stomach cancer on December 22, 1922. He and his wife Anna are buried at Point Pleasant Baptist Church. Frank and Anna had three offspring. The oldest, Frank Jr., died in 1975 with no children. The younger son died in Russia during World War I, and the daughter Ethel and her descendants’ whereabouts are unknown. “Girl With a Buffalo Cart”
With no heirs or descendants to speak for his exploits and no one to burn the flame in memory of the great artist, with time he will be erased from our memories. We as citizens of this great state need to preserve his art, his memory, and his name. When I started practicing in Chester County, I drove on some of the roads depicted in English’s paintings. Some of these miles and miles of beautiful countryside are gone forever, because of encroachment of both commercial and residential estates and urban sprawl. The paintings of Frank F. English chronicle this beautiful area that we have been blessed to live in. We must preserve and remember the life and times of the likes of Frank English before he is forgotten like the vanishing landscape that surrounds us.
“Horses by the River”
Mian A. Jan, M.D., is the immediate past president of the Chester County Medical Society and a practicing cardiologist in Chester County.
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Communication: The Glue for Accountable Care Organizations BY TRACEY HAAS, DO, MPH
magine your grandmother is hospitalized after suffering a heart attack. To everybody’s relief, she receives state-of-the-art medical care in a top-notch hospital a mere 10 miles from home. On discharge day, she receives a long list of instructions, new medications, and a recommendation that she follow up with her primary care doctor within the week.
A few days pass and she notices her feet begin to swell and even a little shortness of breath. She calls her doctor and books an appointment in three days, the soonest her doctor can see her. Fewer than two days later, however, her breathing becomes more labored. Not knowing what to do, she calls 911 for an ambulance trip back to the ER, where she is diagnosed with congestive heart failure, a complicated illness to treat. What’s the moral of the story? It’s that this situation, while fictitious, has happened and continues to happen to thousands of Americans. The root cause is much less about a failure of one person’s heart as opposed to the failure of a very procedureoriented and highly disconnected medical system. Enter the accountable care organization, or ACO, which is considered by some to be the medical system of choice in the (near) future. In an ACO, the same grandmother is given the same level of hospital care, but this time her primary care doctor is notified upon her release and given a brief synopsis of her hospital course and new medications. Courtesy of a secure communication platform used by physicians and support staff, the hospitalist even receives a “read” notification to ensure the message gets through to the primary care doctor. The next day the primary care doctor’s office schedules a followup visit for 48 hours later. At the appointment, her doctor notices a slight swelling of the feet, something the untrained
eye might miss. Her medication is immediately altered, and a home nursing visit is scheduled for the next day, and three times per week for the next two weeks. Using the same mobile communication platform as the hospital and family care doctor, the home health nurse sends timely updates about your grandmother’s new vital signs, weight, and other changes to her condition. Your grandmother is now able to start an in-home rehabilitation program. Even better, she has avoided a costly return to the hospital and prolonged illness. With just one mobile message and a single face-to-face visit, the primary care doctor was kept at the center of her care. What’s more, previously unreimbursed costs like the hospitalist and primary care physician providing transitional care from the hospital to home are now billable thanks to new current procedural terminology (CPT) codes, making non-face-to-face patient care financially sustainable for a family practice physician. The bottom line is that an ACO network must be able to communicate in a timely manner to coordinate care across loosely affiliated healthcare organizations if it hopes to ensure optimal patient outcomes and lower healthcare costs for patients and providers alike. This win-win-win scenario is actually already happening. The hospitals and payers save money by avoiding a readmission, the primary care doctor gets rewarded for good care, and most importantly, the patient is kept healthy. Ironically, the key to this success is deceptively simple: communication. In my experience, doctors are always motivated to do the right thing for their patients, but without good communication, they are simply not armed with all of the information needed to help their patients.
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Tracey Haas, DO, MPH, is cofounder of DocbookMD. CHESTER COUNTY
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CCMS Membership: Resources You Need Building
Communities One Member at a Time
PAMED and Chester County Medical Society (CCMS) membership supports you and your community in many ways. Membership in both Societies provides an indispensable resource for information, continuing education, distance learning, professional contact, and networking. PAMED offers practice management courses and refreshers on patient care. As leadership development is hard to find, PAMED presents webinars, online courses, conferences, and seminars for the benefit of its physician members. PAMED advocacy has an inside track on legislative and executive proposals on need-to-know issues so we can keep members like you fully informed. CCMS works collaboratively with PAMED, but its focus is on the local Chester County community. Some specific benefits of membership in CCMS include: • An opportunity to sign up for the PAMED “Find a Physician” program to promote your practice • Representation with local legislators • An annual meeting which provides you with the opportunity to impact your Society’s activities and goals • A legislative dinner, known as “The Clam Bake,” where you can meet with local legislators in an informal setting • An automatic subscription to Chester County Medicine magazine, the Society’s new twist on its longtime quarterly publication, and • Access to DocBookMD®, an exclusive HIPAA-secure messaging application for smart phone and tablet devices.
For additional information about becoming a PAMED and CCMS member, visit http://www.pamedsoc.org/membership and click “Join PAMED,” email email@example.com, or call ( (717) 909-2684. To renew your current membership, visit http://www.pamedsoc.org/membership and click “Renew your membership.”
Membership is available only for physicians licensed to practice in Pennsylvania.
APPLICATION ___________________________________ County Medical Society (You may choose to be a member of the county in which you either live or work.) 777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820 717-558-7750 (Phone) 717-558-7840 (Fax) Full Name (Print): ___________________________________________________________________________________ Last
Email Address: ____________________________________________
For mailing, please use: Office Address Home Address
Area Code & Phone Number
Area Code & Phone Number Area Code & Phone Number
Preferred Communication: Email Fax Mail
BIOGRAPHICAL DATA Gender: Male Female EDUCATION
Date of Birth: ____________ Spouse’s Name:
BEGIN DATE END DATE
FOR RESIDENCY & FELLOWSHIP, YOU MUST GIVE ACTUAL OR PROJECTED ENDING MONTH & YEAR BEGIN DATE END DATE Residency__________________________________________________________________ Fellowships_________________________________________________________________ License: PA No. Date Issued
__________ -_________ __________ -_________
PROFESSIONAL DATA Present Type of Practice (Check Appropriately): Owner of Physician Practice Group Name ___________________________________________________ Employed by Hospital/Health System Employed by Physician(s) Group Name ___________________________________________________ Employed by Industry or Government Independent Contractor Other (specify) _________________________________________________ Specialty: Within the last 5 years, have you been convicted of a felony crime or is your license to practice medicine actively suspended or revoked? If yes, please provide full information. ___________________________________________________________
___________________________________________________________ ___________________________________________________________ DATE RETURN TO: ATTENTION:
SIGNATURE Pennsylvania Medical Society Member Services
QUESTIONS? Call (800) 228-7823
717-558-7840 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820
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New Leadership Says PAMED Has Your Back
ichael Fraser, Ph.D., joined the Pennsylvania Medical Society (PAMED) as its new executive vice president in August 2013. With more than 15 years of public health agency and national association experience, he has supported and served healthcare organizations and federal, state and local public health agencies. Prior to joining PAMED, Fraser was chief executive officer of the Association of Maternal and Child Health Programs (AMCHP) in Washington, D.C., where he worked for six years. During his tenure, AMCHP was nationally recognized for its work in supporting state maternal and child health programs. Most recently, AMCHP received the Maternal and Child Health Bureau’s Director’s Award in October 2010 and the American Public Health Association’s MCH Section “Outstanding Leadership and Advocacy” award in November 2010. Fraser has published several research articles and professional publications and is on the adjunct faculty at the University of Maryland’s University College. He serves on several nonprofit boards and has worked as a strategic planning consultant and facilitator for many local, state, and national groups. With a little over six months on the job, Fraser has come to understand the challenging environment Pennsylvania physicians face. His travels across the state visiting with physician leaders have given him some insight to how PAMED can be a stronger advocate for their needs. Q: What significant changes have transformed the physician environment and how will PAMED address those issues? A: There are many, many issues impacting physicians across the Commonwealth including consolidation of physician practices, changes in the employment setting for many physicians, and the pressures and uncertainty introduced by the Affordable Care Act. We want PAMED to be the premiere physician advocacy organization for all PA physicians – we want physicians to know that despite these changes and transformations, we “got your back.” We also want PAMED to be the first place that physicians come to get useful information and helpful resources about what these transformations mean for their practices, the profession, and their patients.
Q: Name one change members will see right away under your leadership. A: You’ll see a revamped and revised communications strategy focused on getting the best, most relevant information to members as quickly as possible so they can make informed decisions and know what is impacting the practice of medicine in PA. You’ll also see a new, focused strategy to engage county medical societies and specialty medical societies in meaningful and collaborative ways both in advocacy and program development, and membership recruitment and retention. Q: Why should a physician remain a member of PAMED? A: Together we are stronger – when you join PAMED you are making a commitment to the profession and to your patients and supporting our advocacy for physicians across the state. PAMED is working hard to provide you with the best resources, tools, and technical assistance possible to help you sort through the uncertainty and change that is taking place in medicine today. We need your support to continue that important part of our work. We want to be your source for information and education as well – by taking advantage of our CME programs you can more than pay for your membership dues. Q: Why should a member join PAMED? A: If you are looking for a place to get relevant and timely information about the practice of medicine in PA, I urge you to join. If you are interested in being part of organized medicine, connecting and networking with physician colleagues from across the state, I urge you to join. If you want to be part of our advocacy on behalf of all Pennsylvania’s physicians and patients, I urge you to join. PAMED membership adds value to your practice in so many ways. We’d love to have you take advantage of our member benefits and be part of the PAMED family. Q: Where do you see PAMED in five years? A: You’ll see an organization that has transformed to meet the needs of members across the state; an organization moving nimbly to support all PA physicians. You’ll see members engaged in all aspects of our work, developing programs and resources that truly demonstrate value and relevance to our physician community. You’ll see an organization that supports our members through meaningful educational programs and leadership development with a robust catalog of offerings and CME resources. You’ll see us continue to maintain and increase our advocacy as the “voice” for physicians in Harrisburg and throughout the Commonwealth. Reprinted with permission from MCMS Physician, Winter 2014, and Montgomery County Medical Society of Pennsylvania.
Membership News & Announcements
Members in the News We would like your help in touting the accomplishments of Chester County physicians. If you receive an award or certification or have other good news to share, please submit it to firstname.lastname@example.org.
Frontline Groups Frontline Groups with 100 percent membership in CCMS are the backbone of the society. We are thankful for their total commitment to CCMS. This list reflects the Frontline Groups as of April 13, 2014.
Academic Urology-West Chester Brandywine Gastroenterology Associates Ltd. Cardiology Consultants of Philadelphia-Main Line Cardiology Consultants of Philadelphia-Paoli Cardiology Consultants of Philadelphia-West Chester
To publ i new CC sh photos of MS m physici ans, pl ember ease su digi bmit admin tal copies to @chest ercms.o rg
Mark Your Calendar! The annual CCMS Clam Bake gives Chester County physicians and legislators an opportunity to share a casual evening of excellent food and conversation Join Us Friday, September 12, 2014 6:00 pm – 9:00 pm Radley Run Country Club Clubhouse Dining Room
Chester County Eye Care Associates PC Chester County Otolaryngology & Allergy Associates Clinical Renal Associates-Exton Devon Family Practice LLP Gateway Family Practice Downingtown Gateway Medical Colonial Family Practice Great Valley Medical Associates PC
Levin Luminais Chronister Eye Associates Main Line Dermatology Main Line Gastroenterology Associates Medical Inpatient Care Associates Paoli Hematology Oncology Associates PC Plastic & Reconstructive Surgery of Chester County PC Village Family Medicine Wade Townend Pediatric Associates
Refreshments and hors d’oeuvres will be served on the patio at 6:00 pm, followed by a delicious buffet of filet mignon, shrimp, crab, tilapia, chicken, mouth-watering desserts…and yes…clams!
For more information, contact email@example.com
West Chester GI Associates PC
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Meet Your County Medical Society President
a daily basis, and having the ‘big picture’ perspective. I still regularly get that guttural buzz,” he says, “when I come to a tough diagnosis, receive thanks for a job well done, or for empathetic care when the only option left is always being there.”
stablished in 1828, the Chester County Medical Society (CCMS) founded by Dr. William Darlington, MD, is thought to be the oldest county medical society in Pennsylvania. CCMS is involved in all aspects of healthcare policy, practice, and education, and serves to advance the health of the community and to protect and expand the healthcare resources available to its citizens. Continuing in this tradition, Winslow W. Murdoch, MD, serves the residents of Chester County as the current president of CCMS. Here is a glimpse into the life of a Chester County physician. Name: Winslow W. Murdoch, MD Specialty: Family Medicine, Direct Primary Care “Concierge” Medicine Affiliated Physician at: Total Access Medical, 1450 E. Boot Rd., #300A, West Chester, PA 19380 Hospital Affiliation: Paoli Hospital, Chester County Hospital, and other area assisted living and nursing facilities. Dr. Murdoch also makes house calls. Medical School: Thomas Jefferson Medical College Residency: Montgomery Family Practice, Norristown. Dr. Murdoch was chief resident in his final year there.
On a Professional Note:
In May 2002, Dr. Murdoch was ranked by his peers as “Top Doc” Family Medicine in Philadelphia Magazine. Two years later, he was voted into “America’s Top Family Doctors.” Dr. Murdoch has served as a preceptor for family medicine residents and a teacher in family medicine for medical students from MCP*Hahnemann, now
Areas of medical interest
Dr. Murdoch has special interests in medical weight loss, type 2 diabetes, psychopharmacology, integrative/ alternative approaches to medicine, cardiovascular and general prevention, as well as the health management of patients with multiple or complex medical problems. part of Drexel University School of Medicine. In addition to his presidency at CCMS, in 2012 he was selected for a second four-year volunteer position on the Chester County Board of Health.
Why family medicine?
“A good ole Jefferson Medical College faculty member took me under his wing,” says Dr. Murdoch, “and encouraged me to pursue my interest in general medicine as a family doctor, not as an internist. Early on, I strongly considered ophthalmology as a choice, but during my rotations, it seemed that the focus was on one organ system and treatment of that organ. It was my observation that it was considered ‘inefficient’ to consider the whole person and work up underlying causes.”
What is most rewarding about your career? Dr. Murdoch believes that the most rewarding aspect of his career is “being able to figure out tough problems by taking time for a thorough history and exam, reading about pertinent topics on
On a Personal Note:
Dr. Murdoch and his wife, Donna, live in Malvern. Outside of medicine, Dr. Murdoch enjoys family dinners with his wife, and when around, their three grown children. Hikes with the dog through local parks are also a favorite pastime. Additionally, Dr. Murdoch cares for a “small collection of ‘cute as an iguana’ creatures” that inhabit the office waiting room.
Achievement of which you are most proud
“I am most proud of being able to successfully transition into a Direct Primary Care practice,” says Dr. Murdoch. “This model requires a huge commitment on myself and my family, but encourages creativity and provides the opportunity to fall in love again with the academic challenge of medicine and practice.”
If you could be anything other than a physician… “I would probably teach zoology,” says Dr. Murdoch, “or work at a zoo, sharing my passion for all living things.”
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Published on May 16, 2014