Chester County Medicine Winter 2022 by Hoffmann Publishing Group

YO U R CO M M U N I T Y R E S O U R C E F O R W H AT ’ S H A P P E N I N G I N H E A LT H C A R E

SPRING 2022

CHESTER COUNTY

P u b l i s h e d

b y

P e n n s y l v a n i a ’s

F i r s t

M e d i c a l

S o c i e t y

The Art of Chester County

Presents

Vaughn stadtmiller PracticeBeat: Can Patients Find You?

Steps for Improving Your Online Presence PAGE 6

The Secrets to Long Life A Cardiologist’s Perspective PAGE 11

Contents OFFICERS 2022 President

Bruce A. Colley, DO President-Elect David E. Bobman, MD Vice President Mahmoud K. Effat, MD Treasurer Winslow W. Murdoch, MD

5In Every Issue 3 President’s Message 16 The Art of Chester County

Features

Past President Mian A. Jan, MD, FACC

20 The Experiences of a Physician Advocate in the Political World

Board Members Norman M. Callahan, DO Heidar K. Jahromi, MD John P. Maher, MD Manjula J. Naik, MD Richard O. Oyelewu, MD Christina J. VandePol, MD

24 The Coroner’s Office: Time to Build for the Future

David A. McKeighan Executive Director Chester County Medical Society 1050 Airport Road PO Box 5344 West Chester, PA 19380-5344 Website – www.chestercms.org Email – chestercountymedsoc@gmail.com Telephone - (610) 357-8531

PracticeBeat - Endorsed for CCMS Members - Can Patients Find You? Steps For Improving Your Online Presence

10 Notice to CCMS Members 11 The Secrets to Long Life A Cardiologist’s Perspective 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.

SPRING 2022

27 Even Something Small Helps 28 Poliomyelitis 30 What to Know About the COVID-19 Virus and Vaccination in Pennsylvania Children

14 Mysteries of Medicare: Who Can Help Demystify Medicare?

Letters to the Editor: If you would like to respond to an item you read in Chester County Medicine, or suggest additional content, please submit a message to chescomedsoc@comcast.net with “Letter to the Editor” as the subject. Your message will be read and considered by the editor, and may appear in a future issue of the magazine. Cover: New York New York by Vaughn Stadtmiller.

Read more in The Art of Chester County on page 16. PUBLISHER: Hoffmann Publishing Group, Inc. 2669 Shillington Rd, Box #438, Reading, PA 19608

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For Advertising Information & Opportunities Contact: Tracy Hoffmann 610.685.0914 x201 tracy@hoffpubs.com

PR E S I DE NT’S M E SSAG E

Spring 2022

BY BRUCE A. COLLEY, DO PRESIDENT OF CHESTER COUNTY MEDICAL SOCIETY

am compelled to write a few words about Mary Wirshup. And it will be just a few words, as to try to share in any meaningful way even a brief review of her biography would require this entire issue. Most of my fellow physicians in the county knew her or knew of her and I know they understand. Thank you for allowing me this personal luxury to speak about Mary. I was lucky to have been able to practice alongside of Mary for many years. Though I never worked with her in an office setting I spent many, many hours over many, many years when making rounds at the hospital and admitting patients from the ER at all hours while Mary was doing the same.

D r. B r u c e A . C o l l e y

To contact Dr. Colley send email to: bacolley828@gmail.com

continued on next page >

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I first met Mary early one morning in the newborn unit. I was just finishing up a circumcision when Mary burst or waltzed or brought forth her grand positively charge persona, or, well, you all know Mary – into the nursery proclaiming loudly, “Where is that newborn of mine?” Taken aback, I thought, did she just deliver? Or, what? I quickly learned that all her patients, newborn or nursing home, were spoken of as part of her family. Over those approximately 15 years of rounding in the hospital I can say that I never, ever saw her do anything but smile and be a force of nature. She expected the best from everyone around her, fellow physicians, nursing, and desk staff. The last time I spent time with Mary was at a Family Practice meeting last year on St. Patrick’s Day. She came to the meeting dressed as a leprechaun sharing Irish biscuits fresh from her oven. We discussed, of course, the trials and travails we face attempting to care for our patients. But also, she shared her vision of starting a Family Practice Residency at Chester County Hospital. Always an optimist and something new and challenging. And so, Mary, you are no memory or past tense. But every day as I enter the exam room, I continue to brush up beside you as we did in years past on rounds and remember the short “prayer” you taught me. (Lord, be in the room with my patient and me and guide us to a path of healing.) Mary, you are wisdom, you are grace, you are guidance. I know Mary, I hear you. “Let’s go! Next patient up.”

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EVERY DAY we lose 10 Pennsylvanians to substance use disorder. . Substance use disorder impacts each and every Pennsylvanian. Discover

how you can better navigate the complexities of this public health crisis by joining Quality Insights for one or more complimentary CME sessions. Key topics include: • Safe and effective opioid prescribing • Strategies to identify/address substance use disorder • Referral workflows and resources Quality Insights professional trainings feature expert faculty, offer no-cost opioid education CME credit, and are available to any member of PA’s health care community. Schedule or register for a training today by scanning the QR code or by contacting Amy Porter at aporter@qualityinsights.org. These activities have been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through partnership with the PA Department of Health Office of Drug Surveillance and Misuse Prevention and the University of Pittsburgh. The University of Pittsburgh is accredited by the ACCME to provide continuing medical education for Physicians and Physician Assistants. The University of Pittsburgh designates each module for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Developed by Quality Insights on April 11, 2022. Publication number PADOH-PDMP-0-41122

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Endorsed for CCMS Members

Can Patients Find You? Steps For Improving Your Online Presence

n the past, accessing medical care has been difficult for patients, with issues ranging from limited availability to choosing which provider is best for them. As an independent medical practice, it’s important to make sure your patients can get the care that they need without the hassle. In order to ensure that new patients look to you for quality care over the leading hospital systems, your practice should be easy to find and communicate with. The creators of PracticeBeat, an all-in-one practice growth platform, have outlined the six steps of the patient journey and how you can utilize them to grow your independent practice.

Step One: Attract Patients Through Search Engine Marketing (SEM), Listings Management & More The “attract” stage of the patient journey is all about how patients will find you. In this day and age, if someone is feeling an ailment or seeking a healthcare provider, the first thing they will do is use a search engine to find a provider near them. In fact, 80% of patients use internet searches to find a medical provider and 70% of them start from Google. 6 CHESTER COUNT Y Medicine | SPRING 2022

If you want your practice to be the one that they find, then you need a strategy that will include things like: • Search Engine Optimization (SEO): Search is the #1 driver of traffic to content sites, beating social media by more than 300%. Using SEO tools and best practices helps to put your practice on the map. • Listings Management: With listing management, information such as your address, hours, and more are accurate and up to date. Nearly half of all Google searches consist of users seeking local information. Additionally, reviews make up 15% of how Google ranks a business in search results. • Social Media & Advertisement: Social media presence is a bare minimum requirement for successful practices. It is important to go further than just posting and have an effective strategy that is created for your target audience. Advertising and engaging with your target audience on multiple social media platforms can increase your potential for patient acquisition.

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Step Two: Convert; Turn Visitors Into Patients Securely and Effortlessly

Step Three: Engage with Potential Patients Through Social Media

The “convert” stage is where you can take your well-designed, optimized site a step further. Even if you have a high-performing website that is ranking highly in search, you need to seal the deal by getting your patients to schedule appointments. 45% of patients prefer to use digital methods to request an appointment online. You can achieve this by utilizing HIPAA-compliant tools such as scheduling, reminders, chat, call tracking, and record-keeping. Check out PracticeBeat’s comprehensive patient acquisition platform and learn about all the different tools you should be using to convert users to new patients.

Engaging more consistently and effectively with all of your patients through social media can capture the attention of potential patients even before they visit your site. Your online presence should make patients feel like they will be supported if they become a patient, or strengthen the loyalty of existing patients. This is where social media comes in to help you continue engaging with your patients. With outreach strategies like social media engagement, text and email broadcasts, and automated email campaigns, your practice will reach potential patients while maintaining unique patient-provider relationships.

With a universal scheduling tool, your patients can make appointments with ease whenever it’s convenient for them. After they have scheduled, confirmations and automatic reminders can help to ensure your patients actually make it to their appointment and get the care they need. A call tracking tool can also help you to keep track of all of your call metrics and better understand the workings behind your patient acquisition process. Having these tools in your pocket will reduce your staff’s workload while giving your patients a quick and easy scheduling process.

By engaging with your audiences on social media, you can increase your practice’s reputation. Platforms such as Facebook, Instagram, Twitter, and LinkedIn are a great way to attract new patients and cultivate a sense of community. With automated email campaigns, you can put your practicespecific news, offers, and expertise right in your patient’s inbox. Scheduling recurring email campaigns for both new and existing patients can keep your patients informed without requiring any work from either of you. continued on next page >

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PracticeBeat – Endorsed for CCMS Members: Can Patients Find You? Steps For Improving Your Online Presence continued from page 7

Step Four: Activate Your Success by Building & Managing Your Online Reputation After you’ve established a good reputation and strong online presence, you still need to keep track of your patients BY EVAN TULL and your progress. With your patients spreading their praise for your practice, you will be able to consistently bring in new ones. In fact, 94% of healthcare patients use online reviews to evaluate providers. It’s so important to monitor your online reputation, SEO optimization, and most importantly, turn your patients into proud advocates for your practice. Managing your online reputation is vital to your practice’s success. By utilizing a reputation management tool, you’ll be able to watch as your patients do all of the promoting for you. You can make it easy for patients to leave reviews on positive experiences and boost your practice up to a five-star rating. Not only can patients leave positive reviews, but with patient satisfaction surveys, you can customize surveys for your patients and receive the specific feedback you were looking for. By utilizing online reputation management reporting and analytic tools, you can see in real-time how these efforts are helping your practice’s growth. By monitoring your progress and making it easy for patients to share their satisfaction, you can show new patients the impact you have made as a provider.

In Summary Many healthcare practices and organizations have hired marketing design firms or even a family friend to build their website and online presence. While these sites may look beautiful and have good content to influence on-page SEO, they likely don’t function or perform optimally in patient Google searches because they lack the other critical technical SEO elements created by software engineers. Online performance depends on technical engineering criteria and on page content SEO. When a patient searches for your type of care, the results they see are determined by the Google Search Algorithm. This algorithm has nearly 75 technical components that have everything to do with how your online presence is engineered combined with your onpage content. The Google Search Algorithm is also modified several times a month, so this must be actively managed and not just a one-time fix. And yes, your online reputation and what you do on social media are also important to creating search ranking consistency.

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www.CHESTERCMS.org

The solution to this problem is to find a healthcare technology provider with strong engineering experience combined with talented designers to be your digital partner. PracticeBeat is that partner.

Final Thoughts for Having Success During the Patient Journey To grow your practice and offer exceptional care to your patients, you will need to keep the list of tools and strategies we discussed above on hand. By keeping your high-performing site optimized and easy to find, you set yourself up to rank higher on search engines. Simplifying scheduling, keeping your patients informed, and maintaining an open line of communication with patients and other providers through various platforms will allow you to grow your practice and continue to offer the best care possible.

If you are ready to attract and acquire new patients, boost engagement and communication, and enhance your overall care, PracticeBeat can help digitize the patient care journey and help independent practices grow by providing the tools and expertise necessary to outperform the competition. By delivering an effective, convenient care experience for patients, PracticeBeat helps your practice reach its full growth potential and stay competitive in the changing healthcare landscape. PracticeBeat will diagnose your online presence and share specific data on how Google sees your web presence in a free one-hour consultation. Reach out to your medical society to learn more about how PracticeBeat is assisting physicians like you, making life easier for patients, and innovating marketing in the medical field. Note: If you are interested in scheduling an appointment to learn more about PracticeBeat please call CCMS staff at (610) 357-8531.

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Notice to CCMS Members

he Officers and Directors of the Chester County Medical Society are hoping to include several additional members in the leadership of the society. There are presently several openings for additional members of the society’s Board of Directors and Delegation to the

Pennsylvania Medical Society. CCMS Board members participate in six meetings per year and set policy for the society; assist in planning special events; act as “ambassadors” with local medical staffs and physicians in various practice settings; and help other physicians throughout Chester County to see the value in membership. The CCMS Board meets bi-monthly on the first Tuesday evening of the month from 6:00 pm – 8:00 pm. The meetings include a light dinner and frequently feature guest presentations. The CCMS Delegation to the PAMED includes Delegates and Alternate Delegates who participate in the Annual Meeting of the PAMED’s House of Delegates (HOD) in late October. The HOD is the state society’s policy-making body and its proceedings are conducted with representatives of each of the county medical societies, specialty associations and “sections.” The Medical Students Section, the Resident and Fellows Section, the Early Career Physicians Section, the International Medical Graduates Section and the Women Physicians Section also hold an annual meeting in conjunction with the House of Delegates. No experience is necessary; we’re looking for physicians who are interested in working together to help us support, protect, and advocate for our physicians and our patients. Direct patient care is not a requirement; we recognize that many physicians are involved in a wide variety of positions in medical/ hospital administration, with research and pharmacy and in many varied businesses. To learn more about present opportunities please contact our staff at (610) 357-8531, email chescomedsoc@comcast.net or speak directly to any of our officers/directors.

Thanks! We hope to hear from you!

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The Secrets to Long Life A Cardiologist’s Perspective BY MIAN A. JAN, M.D., F.A.C.C., F.S.C.A.I., AND SURAJ JOSHI

§2. What to do.

“It is our duty, my young friends, to resist old age; to compensate for its defects by a watchful care; to fight against it as we would fight against disease; to adopt a regimen of health; to practise moderate exercise; and to take just enough of food and drink to restore our strength and not to overburden it… greater care is due to the mind and soul; for they, too, like lamps, grow dim with time, unless we keep them supplied with oil.” (de Senectute §11) You may have heard the above from a doctor (without the flowery language). But it’s actually from Cato Maior de Senectute, an essay on aging written in 44 BC by the Roman rhetorician Cicero. Cato the Elder, 83 years old, advises two 30-year-olds who heard terrible things about old age. They demanded that Cato explain how he survived so long. Arguably, Cato’s response is the best prescription for longevity even now.

(Image: NIH News in Health) Eat healthily; eat less. Eating a balanced diet full of fruits, vegetables, and diverse protein sources adds up to 13 years to your life (Fadnes 2022). But it can be difficult to keep all the diet recommendations straight. The Harvard Crimson has an excellent rubric for portioning foods throughout the day.

Of course, medical wisdom has progressed since Cicero, especially in the last century. In 1900, people in the US lived on average to 47 years (CDC). Now, it’s up to 81 years – almost double. If we double it again in the next century, we’ll live to over 150. Yet in many ways, the best advice has stayed the same. With few modifications, the Harvard Health blog agrees with Cato above, recommending that people avoid smoking, challenge their minds, exercise every day, and eat healthily. The Princeton Longevity Center also recommends regular preventative medical exams like colonoscopies, cardiovascular stress tests, and immunizations. Staying on top of all this can be daunting, but it’s never too late to commit to a longer, healthier life. In §2 and §3, we’ll review the best medical recommendations for prolonging life. We’ll cover some new research on prolonging life in §4. We’ll conclude with the key takeaways in §5.

As a general rule, green plants and vegetables are good (spinach, kale, green peppers). Margarine-based foods and white bread/pasta are bad due to their highly processed nature and high carbohydrate content. continued on next page >

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The Secrets to Long Life continued from page 11 Exercise. Most professionals recommend 150 minutes of moderate exercise per week. And we don’t have to spend all this time at a gym or fitness center. David Fein at the Princeton Longevity center remarks that the US has more gyms than any other country, yet obesity rates have doubled since 1980, making the US one of the most obese countries in the world. People around the world walk to work, walk to lunch, walk during work, and walk afterwards to social activities and home. They spread out their exercise; we can too. We can take 5-minute breaks for brisk walks, or squeeze in ten push-ups while watching TV during commercial breaks. Intermittent moderate-intensity exercise can get us up to 150 minutes easily. Avoid stress. Heavy, chronic stress can lower life expectancy by 3 years or more (Härkänen 2020). It’s important to practice healthy ways of reducing and coping with stress. Eating right and exercising help in this department, but any relaxation strategy works.

(Image: VeryWell / Joshua Seong) A striking 2019 study (Lee 2019), summarized in Table 1, corroborates these recommendations. The study found that optimism about life contributes up to 12 years (11-15% extension) towards life expectancy. The results were found to be independent

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of socioeconomic status, health conditions/behaviors, and mental health conditions. Finally, Stay on top of your tests. Start getting colonoscopies at least once every decade from age 45. Take a cardiovascular stress test and EKG if you have abnormal heartbeats or experience abnormal breathing. Get vaccinated for the flu, COVID-19, Tdap, and shingles. §3. What not to do. Don’t smoke. Smoking kills. Figure 1 shows up to a 7.5-year decrease in life expectancy from smoking, but recent data from the CDC indicates a 10-year difference between smokers and nonsmokers. Smokers increase one’s risk of dying by lung cancer and bronchitis by more than 12 times.

Good news: in 2018, more than half of adult smokers tried to quit in the past year (CDC). 7% succeeded, indicating quitting was difficult. But it’s still worth striving to break the habit. Don’t drink heavily. Heavy drinking is defined as consuming more than 14 drinks per week for men, or more than 7 drinks per week for women. Heavy drinking can take up to 5 years off your life, and is the third leading cause of preventable death in the US (NIAAA 2022).

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§4. What’s the limit? Jeanne Louise Calment lived to 122 years, achieving the longest lifespan of any human in history. She died in 1997. It’s natural to ask if we can beat that record, and by how much. Recent studies have suggested the limit is 150 years (Pyrkov 2021). After that, theoretically, the body can no longer repair age-related tissue damage.

It doesn’t stop there. We stand on the precipice of growing entire new organs using stem cells via “bioprinting” them into an organ scaffold in a 3D printer (Al Idrus 2020). Previous efforts to do so failed due to an insufficient understanding of organ architecture, but we understand it much better now. Grow a million stem cells, induce them to differentiate into your cell types of choice, put them into an organ scaffold, and you’ll have a new organ. Artificial organ transplanation involves significant risks of rejection reactions. But if we succeed at it, we will have to completely rethink the limits of aging.

Jeanne Louise Calment (Image: Reuters) But recent research on stem cell therapy suggests we could extend life even further. Stem cells are the building blocks of our body. They can develop into almost any type of specialized cell, be it blood, liver, bone, or skin cells. They can renew and replicate themselves. They also play a critical role in repairing damage to our organs by “filling” in for dying tissue after differentiating into the requisite cell type.

(Image: adapted from The Scientist staff 2020)

§5. Key Takeaways. Key Takeaways for a long life

Unfortunately, as we age, so do our stem cells: their powers of self-renewal and differentiation diminish. Up until recently, efforts to hijack and reverse this process have progressed slowly. But now, major clinics like the Penn Institute for Regenerative Medicine have begun exploring methods to transplant young stem cells into aging patients, allowing them to rebuild healthy tissue. Stem cell therapies tend to follow this outline: 1. extract stem cells from a compatible donor; 2. enrich the extract for young stem cells; 3. intravenously transplant the young stem cells into the patient’s bone marrow. We don’t know how long this can extend life, but such procedures have been shown to attenuate multiple age-related symptoms such as fatigue, pain, and immobility (DVC Stem 2021).

You don’t need stem cell therapy or advanced technology to live long. For the most part, Cicero has already covered the basics. I give my patients this brief advice: “Eat less, do more, try not to worry, avoid bad habits, and you can live a long, healthy life.” This article was written by Mian A. Jan, M.D., Chairman, Department of Medicine, Penn Medicine Chester County Hospital, and Suraj Joshi, an intern at West Chester Cardiology, who intends to join an MD-PhD program in 2023.

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Mysteries of Medicare: Who Can Help Demystify Medicare?

he State Health Insurance Assistance Program (SHIP) is a national program set up to assist those eligible for Medicare as they navigate Medicare enrollment, coverage, issues, and other options. In Pennsylvania this program is called Pennsylvania Medicare Education and Decision Insight (PA MEDI). Until July 2021, the PA program was called APPRISE. The Chester County PA MEDI program is staffed with a coordinator and volunteer counselors. Our local program coordinator and volunteer counselors operate within the Chester County Department of Aging. The counselors provide free, unbiased, confidential guidance with oneon-one counseling. Counselors are the key to the program. To become a PA MEDI counselor, the volunteer must pass a background check and go through a certification process that includes online training modules, two days of classroom instruction or four days of virtual training, a competency exam, and a period of working with a mentor before counseling clients on their own. Once certified, training continues with monthly meetings, webinars, and semi-annual regional updates. The counselors come from varied backgrounds and areas of expertise. (Comment from client who received one-on-one counseling): “Michael was phenomenal in helping me get my Medicare coverage in a very timely manner after I was having communication issues with Social Security Administration.”

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When can Medicare enrollment take place? Individuals have three different opportunities to enroll in Medicare. It is important to know the enrollment timelines for Medicare. People who have been collecting Social Security benefits before turning 65 will automatically be enrolled in Part A and Part B of Medicare upon turning 65. After the 24th month of Social Security disability, Medicare enrollment is also automatic. Otherwise, enrollment is required and should occur within the 7-month period surrounding the 65th birthday (3 months before, the month of the 65th birthday, and 3 months after). This is the Initial Enrollment Period (IEP). There are two other opportunities for Medicare enrollment. These are SEPs and the GEP. A Special Enrollment Period (SEP) is available if leaving employer coverage after working beyond Medicare eligibility. If a beneficiary misses the IEP and an SEP, there is a General Enrollment Period (GEP) each year from January 1 – March 31. With this option, coverage will begin July 1 and there may be a late enrollment penalty. Each enrollment period has different rules, which can be confusing. PA MEDI counselors are acquainted with these enrollment periods and the rules for each. Counselors can help beneficiaries understand what applies to their individual situations.

With Medicare, what else is needed? There are still some important decisions to make even when Medicare enrollment has been completed. At the time of Medicare eligibility beneficiaries may want to consider other

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options for help with medical expenses, such as a Medigap policy, a Medicare Advantage Plan, and a Part D Prescription Plan. PA MEDI counselors can provide detailed information on all these options. Counselors have access to an actuarial website that provides important Medigap considerations, such as pricing, that are not usually included in the advertising brochures flooding your mail and inbox. During personalized, one-on-one counseling sessions, clients are routinely screened for eligibility for government assistance programs such as Medicaid, Extra Help, Medicare Savings Program, and PACE. Counselors will provide assistance with applications for these programs, if needed. “I’m researching Medigap and Part D plans for my sister and have some questions as the medicare.gov is a bit confusing.”

When do PA MEDI counselors schedule appointments? In-person, one-on-one counseling has generally taken place at local senior centers or other community sites. Since the beginning of the pandemic, counseling has been done mostly by phone or Zoom. In-person counseling is now available on a limited basis. Some of the senior centers are beginning to open to the public. Counseling is available year-round, but the busiest time is during the Annual Open Enrollment Period (AOEP) from October 15 to December 7. One-on-one sessions during the AOEP include a review of Prescription Drug Plans and Medicare Advantage Plans using the Medicare website Plan Finder tool. These reviews may help beneficiaries find a new plan that can save hundreds, even thousands, of dollars over the course of the year. (Comments regarding assistance during AOEP) “For the past two years you have been of great assistance with helping me to enroll in Medicare Part D Prescription Plans. Your assistance has saved me at least several thousand dollars this past year.” “Thanks so much for all your time and patience with us as we navigated the Medicare Part D world with you. Your knowledgeable assistance is the reason we are able to save money and understand the process so that we can make the necessary decisions -- we can’t thank you enough.”

What are some special situations when PA MEDI counselors can assist Medicare beneficiaries? Counselors help clients with all kinds of issues and questions related to Medicare coverage: understanding a bill, what procedures are covered, how to change plans when moving, how to file an appeal when a service has been denied, how to apply for some of the assistance programs. Quite often PA MEDI counselors are asked to help with troublesome, critical, difficult situations. These might

involve issues of lost coverage, inadequate coverage, inability to get coverage. The beneficiary may have tried unsuccessfully to resolve the issue on their own. As a program, PA MEDI has direct contact with the Social Security Administration, the County Assistance Office, and Medicare. Having these contacts along with state and national recognition is critical for the success of PA MEDI work with Medicare beneficiaries. (Quote from client): “I am beyond frustrated. I have been unsuccessful after multiple times trying. At one point it (the Social Security website) locked me out.”

Does PA MEDI have outreach programs for the community? Group presentations are also available in the community at local libraries, churches, and senior centers. Attendance at these presentations is by reservation only. There are “Medicare 101” and “Medicare 102” programs available virtually or, where public health protocols allow, the meetings will be in person. The schedule and instructions for registration are available at https://www.chesco. org/calendar.aspx?CID=22. You can also call the Help Line for information. “Medicare 101” is a presentation for individuals becoming eligible for Medicare and provides a great opportunity to learn the basics of enrollment and coverage. People who attend a Medicare 101 presentation ask more informed questions at their one-on-one sessions. “Medicare 102” is especially informative for those already enrolled in Medicare. “Medicare 102” presentations include such topics as Medicare-covered preventive services, outpatient therapy, home health services, medical equipment, diabetic supplies, fraud prevention, and more. “Medicare Open Enrollment – Fine Tune Your Medicare” presentations help to make beneficiaries aware of changes that can be made during the Medicare Annual Open Enrollment Period to get the most out of Medicare during the next year. (other comments about the presentations): “You have such a great way of presenting the information which really helps to reduce one’s anxiety over trying to figure out the complex world of Medicare.” “Very thorough.” “I know what to do now.” “Better than expected.”

How can I contact PA MEDI? The overriding goal for our PA MEDI program is to educate and provide information that gives Medicare beneficiaries the tools to better understand and navigate their medical coverage – ultimately to have best access to their care. Contact for PA MEDI can be by phone on our Help Line (610-344-5004, Option 2) or by email (smilam@chesco.org). Counselors pick up these messages daily and return calls within one business day. The website www.chesco.org/477/PA-MEDI has a collection of articles and newsletters with information on many topics relating to Medicare.

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w w w.c h e s t e r c m s .o r g

The Art of

Chester County

Vaughn Stadtmiller BY BRUCE A. COLLEY, DO

New York New York (On the cover)

Gulkana Run

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aughn Stadtmiller grew up in Latrobe, Pennsylvania but has lived in Chester County for the past 40 years. He described his interest and love of art beginning from his earliest memories. “I cannot remember a time in my life when art was not the reason for my being.” Vaughn shared a beautiful story crediting his father for fostering his interest and talent. His father, a shipping supervisor at a local manufacturing plant, also loved art since his boyhood, but needing to provide for his family never pursued art in any other way but as an evening hobby. His dad, who never lost his passion for drawing, ran across and advertisement in TV Guide for art classes via the Famous Art School, a post-war correspondence school. His dad would order art classes in the mail and lovingly complete them in his few off hours. Vaughn’s most precious memories of his father were of him working on his art, allowing Vaughn to sit with him and when older help complete the projects. Though Vaughn spoke of their relation tangentially, it was clear to me his father recognized Vaughn’s artistic bent and championed his pursuit of a career in art. Though passing at age 56 and never living to see Vaughn’s stellar career I suspect he knew full-well of his son’s talents. Yes, this memory Vaughn shared with me of his father’s love of his son brought tears to me.

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Moon of the Great Horned

Great Egret

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After graduating from the Hussian School of Art in Philadelphia, Vaughn moved to West Chester as he accepted a job offer from the Lasko Metal Products Company. They hired him as a graphic artist and there he designed, drew, and made models of the various metal products made by Lasko, including lamps and fans. During his 42 years as a commercial graphic artist Vaugh also worked for the Lenox China company, Bradford Exchange, and many years at the Franklin Mint as well as a private commercial art consultant. Vaugh used his considerable artistic talents in a variety of artistic modalities, including product design, industrial models, painting, sculpture, wood carving and glass. Even though Vaughn’s occupation took him to a number of different companies and projects he remained in West Chester, as he found Chester County was his artistic home, and enjoys being part of the dynamic art community here in Chester County. Upon retirement Vaughn has pursued the fine arts full-time. He now concentrates on painting using watercolor and a modern egg tempera called acrylic gauche. Most recently Vaughn has been concentrating on rendering of wildlife and Chester County landscapes. Please take a moment to enjoy this small sample of his breathtaking art.

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White Throated Sparrow

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Artist Biography: Throughout my life I’ve maintained an active interest in the arts and the great outdoors. Having traveled to the western states and Alaska many times on fishing trips, I found time to sketch and photograph the magnificent wildlife and landscapes. Living in Chester County most of my life, I’ve developed a deep appreciation for its own charm, beauty and history. During the past years, I’ve focused most of my work on our feathered friends, especially paying attention to detail with all the things that surround us. Ellie at Hoopes

I’ve been drawing ever since I can remember, with my father as my first and biggest influence. I attended Hussian School of Art and graduated with an associate’s degree in design & illustration. I’ve made my career in the art field for the past 50 years. My wife and I had an exciting ride in the craft field for a number of years. Then I got into the commercial art market where I had accounts with the Franklin Mint, Lenox China, Bradford Exchange and numerious studios and agencies. Currently I’ve been participating in numerous galleries and shows on the East Coast. Watercolor & Acrylic are my choice of mediums.

Blue Bird & Apple Blossems

Vaughn Stadtmiller

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THE EXPERIENCES OF A PHYSICIAN ADVOCATE IN THE POLITICAL WORLD BY LARRY L. LIGHT

Rheum for Improvement

ull disclosure, I know Mark Lopatin, MD, the author of Rheum for Improvement, pretty well and, in fact, I have known him for many years. We’ve played golf together, and on that basis alone I consider him a friend. But beyond our friendship on the links, as a Pennsylvania Medical Society (PAMED) professional lobbyist I worked with Dr. Lopatin and numerous other physicians on the numerous and meaningful advocacy issues covered in his book. MOC, scope of practice, tort reform, prior authorization, etc.…. all of them and more. As a PAMED lobbyist what I did not have, and as a physician he did, was the benefit of thousands of physician encounters. This book is about those physician encounters, the related advocacy issues and his engagement as a health care and patient advocate. Knowing “ML” well meant that I was already very aware of his passionate engagement as a health care advocate. So, I knew upfront the direction this book was going to take. It did not disappoint me. Though I did notice an unforeseen consequence that quickly became apparent. From the first page, the words I read came back to me in his voice. At first that was a bit of a distraction. But as a I read his descriptions of patient experiences, at least in my mind, it gave his perspective and contention for physician advocacy engagement view a more meaningful quality.

In its entirety, Rheum for Improvement validates a long-standing tradition that was unwritten but still a core element of PAMED advocacy, established before and maintained throughout my tenure. When we went to the state capitol to give testimony before a legislative committee, something that happened several times a year, PAMED was always represented by a physician leader. It was never the PAMED Executive Vice President and never a lobbyist. My recollection is that the American Medical Association (AMA) operates under similar guidelines. Many

other professional associations in Harrisburg did not follow that rule. Their lobbyists were appearing regularly at public hearings. Their thinking being that having a familiar lobbyist carrying the message would work to their advantage and also save time for their busy member leadership. Our thinking was that a physician presenter guaranteed that the clinical aspects of the health care issue and the value of the patient-physician relationship would become part of the dialogue. I’ve always embraced that viewpoint. The series of patient case studies or experiences related by ML strongly supported the PAMED physician only policy. Quite simply the physician leader or another physician from the relevant specialty had the benefit of clinical knowledge. As lobbyists we could not come close to matching the depth of the patient-physician relationships that would be impacted by the policy change being debated. Even more clearly, we didn’t have the clinical training to present as an expert on the subject. There was no doubt, a physician was the only option and that was always the right choice. The depth of concern for his patients’ wellbeing related by ML validates that theory and becomes the de facto most persuasive argument in his book. Rheum for Improvement takes the reader on the author’s journey through his private practice of medicine and allows him to relate his genuine concern for patient care in the context of the numerous health care policy challenges that physicians have unhappily navigated in their struggles to provide quality care. His frustrations with those policy issues, he later discovers, often run parallel with the issues high on the policy agenda of groups like the AMA and PAMED. For any practicing physician, outside of tort reform, those issues are primarily restrictions to physician autonomy either in statutory law or insurance rules. As described by ML in the plainest terms, those frustrations are always palpable and clearly become an ongoing source of professional frustration that also impacts his personal life. continued on next page >

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The Experiences of a Physician Advocate in the Political World continued from page 21

For ML, ceding control over clinical decisions in patient care was obviously not an acceptable outcome. And for the reader, given an inside view of his patients’ clinical circumstances, that is a welcome consequence. For his own professional satisfaction, personal peace of mind and most importantly for the benefit of his patients the logical course of action was engagement as a health-care advocate. He embraced the goal of having physicians’ “skills and clinical judgement be the driving force for health care decisions rather than bureaucratic mandates.” Given the state of health care in the United States and the power of insurers, trial lawyers and others, he quickly had a lot of issues on his plate. I would suggest that ML expand his application of “grassroots advocacy.” His perspective in Chapter 11 is that grassroots advocacy is engagement outside of the organizational advocacy campaigns undertaken by professional membership organizations less structured than PAMED and the AMA. He relates grassroots advocacy only to his own later involvement in a wide variety of more aggressive and focused groups such as PAPA and PPA. In reality, he was engaged in grassroots advocacy from his first letter to the editor, if not before! In healthcare advocacy, grassroots physician engagement is always valued. Like all advocacy, if done with respect for the policy maker and with a message of asking for help rather than directing an action, an effective level of aggressive reasoning can impact policy decisions. Because of their clinical foundation in the patient-physician relationship, physicians have that capacity. The value of advocacy also emerges from ML’s initial exposure to election politics. He walked the walk by sharing his views and seeking support from the larger physician community. And he learned that political choices are often not simple. The caution is to realize that across the broad spectrum of political issues such as taxes, the environment, tort reform, the many aspects of health care and numerous other important policy problems it is unlikely that the candidate and the physician political campaign supporter will find unform agreement. That is unless the physician steps up to become the candidate. Policy makers at all levels, the news media, political candidates, and the public in general all respond positively to the advocate wearing a white coat. It’s a strategy embraced by those non-physician providers who wear them to lobby at the capitol. They fill the capitol rotunda with white coats, just as physicians did to lobby for tort reform, because they want a piece of the patient-physician relationship.

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They want to help their patients and provide care at the highest level of their clinical training. Fortunately, it would be nearly impossible to find a physician who did not embrace those same values while bringing significantly more education and training to the examination room. My perspective is that ML gives appropriate attention to the value of personal involvement, relationships and local connections in the political universe, all important elements of grassroots advocacy. But I believe he misses the point that individuals engaging on behalf of themselves, the basic feature of grassroots advocacy, and also for their professional associations can produce the same high return from their local and personal connection with the advocacy target. He’s correct, it is the “core of politics” and the most important component of any effort to achieve “meaningful change.” After I purchased Rheum for Improvement and accepted the challenge of this review there was one ironic point that I knew was obviously going to be my closing thought, even before I started reading the book. A PAMED President I worked closely with, John Lawrence, MD, in 1999 proposed that medical schools include a course on politics and the politics of health care in their curriculum. Having developed personal relationships with a group of legislators and government officials, he knew the benefits would follow. As it happens, Dr. Lawrence was also a rheumatologist. I was anxious to connect those dots and, quite happily, I discovered that they were connected for me when ML includes a short paragraph with the same recommendation (p. 179). I feel confident that Rheum For Improvement would be at the top of Dr. Lawrence’s syllabus for those courses. It also should be there for any physician advocate seeking to make a difference.

Larry L. Light retired from the staff of the Pennsylvania Medical Society as the Senior Vice President for Physician and Political Advocacy.

Larry L. Light

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Chester County Medicine, the official publication of the Chester County Medical Society for many decades. CCMS members receive a subscription to our quarterly magazine for their own reading and we encourage physicians to share the magazine with patients in their waiting rooms. CCMS members are also encouraged to contribute articles for It’s been a challenging year so we’re giving youpublication complimentary access to and to purchase advertising to help promote their practices! Chester County this $500 discount savings program - no membership, or userongoing series focusing on the art and artists of Chester Medicine activation features a popular County. The current and archived editions are available for readers on the society’s fees - to thank you for reading our publications. website: www.chestercms.org. Advocacy – the CCMS The PA Alliance of Professional Associations (PAPA) is affiliated withis an active supporter on many important local and regional task Join Us! forces, work groups coalitions such as the Chester County Immunization Coalition; thousands of leading appa apparel, electronics, jewelry, and furniture and retailers, the Regional Overdose Prevention Task Force; the Chester County Suicide Prevention Task Established in 1828, Chester County Medical attractions and the museums, overnight and destination travel, and 57,000 Force; the Pennsylvania Coalition for Civil Justice Reform and more. Society, Dr. William Darlington, M.D.,and service local,founded regionalbyand national restaurants providers. of thislegislative dinner program is an opportunity for the The Clam Bake – Use our annual is thought to be the oldest county medical society card affords attractive savings, discounts or cash back on every shopping, physicians of Chester County to meet and enjoy a casual evening of great food and in the State. Thetravel Medical Society isand involved in dining and purchase, it supports local community initiatives. conversation with elected officials. The event also features the presentation of two all aspects of healthcare policy, practice, and scholarships to West Chester University pre-med students. education and serves to advance the health of PracticeBeat – an outstanding member benefit offering practices a chance to enhance the community and to protect and expand the their on-line presence, improve patient satisfaction and ensure practice communications healthcare resources available to its citizens. andActivate scheduling requests are IPAA compliant. PracticeBeat offers CCMS members a of your FREE e nc lia Al a ni Pennsylva significant discount off their monthly base fee. Data-based insight is also provided relative ns tio The Chester County Medical Society works cia PAPA™ benefits today. Professional Asso to the competitive landscape in your specialty and geographic area. collaboratively withgra them Pennsylvania Medical Click the QR Code, or visit Savings Pro Leadership opportunities available – the CCMS leadership is eager to continue Benefits https://travnow.com/, Society, but our focus is on our local community. ings on $500 Discount Sav representing our membership and opportunities are available to serve for medical vel Tra & then click on ‘Just Got a Card’, ing TheSho Society’s role in Chester County is to support, Din pping, students, residents and fellows, early career physicians and our “full active” members enter code HPT500, and start protect, and advocate for our physicians and our T500 Practice management assistance – contact CCMS staff with questions about a wide ivation Code: HP Act saving today! patients. We look forward to growing an important w.com array on “business” matters pertaining to your practice. Our experienced staff at the Activate @ travno healthcare service for our community that will local and state level offer outstanding assistance. Participate in our in-person and virtual y unt Co ery om ntg Mo and we look forward to hearing Benefit benefit uss all, programs to help guide your practice on issues such as reimbursement, credentialing, ves ial Initiati fromSoc you. recruiting and many more important aspects of running a practice.

in The Chester County Medical Society

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THE CORONER’S OFFICE Time to Build for the Future BY CHRISTINA VANDEPOL, M.D.

healthy young woman becomes ill while working from home in 2020 and dies within hours of being brought to the Emergency Room. She does not have COVID. A husband and father in his early fifties is found dead at home at the end of a trail of blood. A high school athlete collapses during a workout and cannot be resuscitated. A pregnant woman goes into labor and dies in the ambulance en route to the hospital. A frail elderly woman dies within days after a fall at a nursing home. Each case is referred to the Chester County Coroner’s Office (CCCO), which is tasked with determining the cause of death, how it happened, and whether or not there was criminal intent or neglect in these and thousands of other deaths every year. Headed by an elected official, the Coroner’s Office is an independent county government agency, but its budget and resources are determined by the County Commissioners. As Coroner, I found the resources available to the CCCO, especially the infrastructure, grossly inadequate and outdated for the needs of a county of over 525,000 people. Despite years of lobbying, little changed during my four years in office. In a previous article in this magazine (VandePol, 2019) which reviewed the 334 years’ history of the CCCO, I decried the fact that the office had “failed an accreditation audit in June 2019 because of the dismal state of its morgue and autopsy space.” In response, Dr. Donald Harrop, Chester County Coroner from 1966 to 1990, wrote a Letter to the Editor of this magazine in Fall 2019, urging that “we need to provide active physician leadership on...establishing a proper facility to continue to professionalize the Coroner’s Office.” He recounted how, decades ago, Chester County physicians advocated for a county health department in the face of vehement opposition from the County Commissioners and some other elected officials. The physicians, including Drs. Bob Poole,

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Bill Limberger, and of course Dr. Harrop himself, succeeded in getting the decision on a county-wide ballot, which voters then approved. The Chester County Health Department was formed, and County Commissioners now tout its accomplishments and benefits to the community. Perhaps history will repeat itself if Chester County finally constructs the infrastructure necessary to bring our Coroner’s Office into the 21st century. Has the COVID-19 pandemic, which has taken over 1,000 lives in Chester County, brought any changes to the Coroner’s Office since the June 2019 audit? Let’s go back (reluctantly) to March of 2020, when the first COVID-19 death was reported to the CCCO. In April 2020, as the death count climbed at an alarming rate, hospitals, nursing homes, funeral homes, and the Coroner’s Office scrambled for morgue space. Chester County had no county morgue so the CCCO had been dependent on limited donated morgue space in our hospitals. Hospital deaths took priority over Coroner cases for morgue storage though, and cross-contamination between hospital staff/patients and CCCO staff/decedents was a constant worry. The lesson learned was that hospitals are not a good location for coroner operations. Recent hospital closures further highlight the risk of depending on forprofit facilities to provide infrastructure for public services. With little to no access to hospital morgues during COVID-19, the CCCO had to arrange for body storage at private funeral homes. To address this emergency need, in May 2020 the county used funding from the Coronavirus Aid, Relief, Economic Security (CARES) Act to quickly construct refrigerated storage space in an existing county maintenance structure. This temporary fix, which consists of 12 refrigerator and 3 freezer spaces, remains in use at this time, but it is not a long-term solution because it lacks privacy, adequate security, or space for projected increases in

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caseload. CCCO’s major functional areas are now scattered across three locations, with offices in one building, the temporary morgue in another, and an autopsy lab (Figure 1) at Chester County Hospital. This logistical inefficiency saps time, money, and energy. In 2020, as the temporary morgue was put into use (Figure 2), the county contracted with Crime Lab Design (CLD), an internationally-known planner of modern forensic labs (Figure 3), to perform a Needs Assessment for a centralized coroner forensic facility. The Needs Assessment (Crime Lab Design, 2020) concluded that the CCCO facilities were “decentralized, outdated, and insufficient for current and projected operations.” A centralized facility of 20,000 square feet, which would include administrative offices, refrigerated morgue capacity for up to 120 decedents (including surge capacity for mass fatalities), and at least three autopsy stations was recommended. An example of a modern forensic facility can be seen in Figures 3 and 4. The

estimated construction cost at that time was approximately $15 million for a facility that would serve the county for at least 30 years. This capital investment will save taxpayers money in the long run by eliminating current inefficiencies, bringing costly outsourced services like autopsies in-house, reducing the risk of injury to county employees, and achieving energy savings through green building design. The August 2020 report recommended new construction on county-owned land at the Public Safety Training Campus in South Coatesville. In early 2021, CLD provided the county with additional assessments of the feasibility of retrofitting two commercial properties available at that time. In December 2021, Chester County included $2 million in the proposed 2022 capital investment budget for a new coroner forensic facility. A county spokesperson was quoted (Rellahan, 2021) as saying that “the county ... will continue in 2022 to explore the options of purchasing a dedicated facility, or partnering with an organization that can accommodate and support the required resources.” The article noted that a coroner forensic facility had been “lobbied for by a succession of elected coroners, including outgoing coroner, Dr. Christine (sic) VandePol,” and that the proposed plans differed from the construction of a new 20,000 square foot facility on county property, as recommended in the Needs Assessment. Where do things stand now? A call to the County Commissioners’ Office on May 6, 2022 yielded the following statement: “The County has approved a budget of $14.9 million over three years for the new Coroner’s Office facility, and locations for the new premises are currently being evaluated. The County Coroner is apprised of current location options and County facilities staff will continue to work with her office as the project moves forward.” According to the Chester County website, approximately $2 million is in the 2022 budget. Future year budget plans are shown, but budgets are not formally approved in advance. continued on next page >

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The Coroner’s Office: Time to Build for the Future continued from page 25

Modern autopsy suite (photo courtesy of Crime Lab Design) Meanwhile, the receipt of $102 million in an American Rescue Plan Act (ARPA) grant offers a new funding opportunity. Allocation of the funding is to be determined by applications submitted to a County-appointed committee. The Chester County Medical Society (CCMS), recognizing the importance of coroner services to the community, has stepped up to advocate for a coroner forensic facility. Taking to heart Dr. Harrop’s call for “active physician leadership” on this issue, CCMS (2022) sent a strong letter of support to current Chester County Coroner Sophia Garcia-Jackson in support of an application to the ARPA Committee for funding the forensic facility construction. Coroner Garcia-Jackson responded by stating that “Chester County badly needs this critical infrastructure. Few county agencies have been more directly affected by the COVID-19 pandemic than the Coroner’s Office. A successful application for American Rescue Plan Act funding could help ensure the goal of a modern coroner forensic facility. I’m very grateful to the Chester County Medical Society for their support of this application.” The CCMS letter emphasized the many benefits of a modern centralized coroner facility to the medical community and the patients they care for, including “closer collaboration with treating physicians and hospital pathologists” when investigating why someone died, and educational and training opportunities for physicians in various stages of their education. The Medical Society also expressed its concern that “our patients and their families be treated with dignity and respect after death.” Sudden or violent death inflicts great emotional trauma, making “a dignified waiting room and a respectful, safe viewing room for families to view their loved ones” an important element of a coroner forensic facility. The CCCO currently has no family interaction space, and viewings are not permitted due to safety, security, and sensitivity concerns. The Coroner’s Office performs another important community function. It is the last resource for those who die unidentified or without next of kin, including veterans in our community. Without a proper facility, bodies must be cremated quickly, even while identification tests are pending or searches are still underway to find family or friends willing to make funeral arrangements.

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Is Chester County ready to recognize the essential public services performed by its Coroner’s Office by providing the critical infrastructure required to meet current and future public health, public safety, and criminal justice needs? Let’s not wait for the next pandemic or disaster. Let’s not rely on temporary fixes or kick the can down the road. This is the time to build for the future. Footnotes 1. Crime Lab Design. (2020). Chester County Facility Needs Assessment, August 4. Available at https://www.chesco.org/209/ Coroner. 2. Chester County Medical Society. (2022) Letter of Support to Chester County Chester County American Rescue Plan Act Funding Committee, May 3. Pending publication, https://www.chestercms.org/ index.html. 3. Rellahan, M. P. (2021, December 12). Chester County Budget includes no new taxes but funding for a morgue. The Daily Local News. Retrieved from https://www.dailylocal.com/2021/12/12/ chester-county-budget-includes-no-new-taxes-but-funds-for-a-morgue/. Accessed May 7, 2022. 4. VandePol, C. (2019). The Coroner’s Office. Then and Now 334 Years of History. Chester County Medicine. Summer 2019. Available at https://www.nxtbook.com/hoffmann/CCMSMedicine/ ChesterCountyMedicineSummer2019/index.php#/p/22. Accessed May 8, 2022. Christina VandePol, M.D., a retired internist, served as the elected Chester County Coroner from 2018-2021 and is a member of the Board of the Chester County Medical Society. She writes about medicolegal death investigation and its role in the health care, public health, and criminal justice systems. Further information or references on the subject of this article are available on request.

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Even Something Small Helps The war in Ukraine is distressing, with tragic stories of destruction and loss every day. Our county medical societies are not disaster response organizations, but we encourage our colleagues and friends to support organizations best suited to support direct relief. We all know that medications, supplies, and funding remain in short-supply, and we encourage everyone who wants to help to support organizations that are already on the ground near the crisis.

LOCALLY Maura E. Sammon, MD, an emergency medicine physician at Temple and Chief Medical Officer for Global Response Management (GRM), recently connected with us. GRM has partnered with the World Health Organization (WHO) to support relief efforts in Poland and Ukraine. GRM has an official seat at the WHO Emergency Operations Center in Rzeszow, Poland. Any funds donated through this will be spent solely on WHO sponsored activities in Poland and Ukraine. To learn more about GRC click here Global Response Ukraine. https://www.global-response.org/ukraine Kevin Sowti, MD, Chief of the hospitalist group at Chester County Hospital/Penn Medicine, recently returned from a trip to provide food and medical supplies to Ukrainian immigrants in Poland and Romania. Dr Sowti is active with the International Justice Mission (IJM), an organization working to end slavery and human trafficking. Dr. Sowti has set up a Go Fund Me page to help raise funds & provide food for Ukrainian refugees - https://gofund.me/552dc393

ADDITIONALY The staff of the Philadelphia County Medical Society continues to collate and post a resource list of organizations. https://philamedsoc.org/physician-resources-for-ukraine/

OTHER SUGGESTED LINKS TO CHECK World Central Kitchen (wck.org) United Ukrainian American Relief Committee, Inc. (uuarc.org) (Please note that this is for informational purposes only and is not a specific recommendation or endorsement regarding any one organization.)

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POLIOMYELITIS

AN ANCIENT SCOURGE, NEARLY ELIMINATED, BUT STILL LURKING IN THE SHADOWS? BY JOHN P. MAHER, MD, MPH

oliomyelitis (Polio) is an ancient, highly contagious disease caused by any of three serotypes of poliovirus. It is a member of the enteroviridae genus, family picornaviridae, which have an RNA genome and are acid stable, so that the three known types (PV1, PV2, and PV3) can transit the GI tract and be shed into the environment. Transmission is generally considered “oral-fecal” (via foods, liquids, direct contact, hand-to-mouth, etc.), the efficiency of which will vary slightly with the age, personal hygiene, environmental cleanliness, dose, and health status or susceptibility of the individuals involved in the transmission events. For all practical purposes, polio has been considered eradicated here in the U.S.A. Even when/if a case is imported, its further transmission is effectively prevented by the level of “herd immunity” among our general population – except of course if it would reach certain sub-population groups (e.g., Amish, Christian Scientists) who may avoid getting immunizations because of religious or deeply philosophical beliefs which constitute legal exemptions to state immunization laws/regulations. In third world countries, people may refuse vaccination due to fear, superstition, or pressure from political or religious extremist groups. So, in those settings, or where people and tribes may be extremely isolated and health programs unavailable, and since only humans are hosts to this virus, it is still conceivable that until/ unless the virus is completely eradicated there could still be a

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resurgence of paralytic polio, depending upon the world’s political, social and economic realities. From 1990 to 1999 there were 162 reported cases in the U.S., with an average of only 8 cases of wild virus polio per year reported here. Of those, six (6) were acquired outside the U.S., and two (2) were classified as “indeterminate” (meaning that no polio virus was isolated from the patients, and that they had no history of recent vaccination nor direct contact with a vaccine recipient). All of the remaining 154 (95%) cases were “vaccine-associated paralytic polio (VAPP) caused by the Sabin poliovirus strains in the oral polio vaccine” (more about this below). Because of the effectiveness of our American system of Public Health and the active participation of physicians, hospitals, parents and school systems, most Americans these days have had no real experience with epidemic or pandemic diseases with the current exception of the ongoing COVID-19 pandemic caused by the SARS CoV-2 virus. With the exception, perhaps, of the 10 Plagues on Pharoah’s Egypt which we pass over in silence (with apologies to Cicero and our old Latin teachers for the use of the praeteritio), all our combined histories would show only a handful of truly global prior pandemic diseases, namely: Plague, Yellow Fever, Malaria, Cholera, the 1918 Spanish Flu, and arguably Syphilis (or “the Great Pox”). The 1950s, when this author was a teenager, were full of fear and anxiety about polio – a disease whose cause and cure were

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By 1961, Albert Sabin had developed his trivalent oral polio vaccine (OPV) containing all three naturally occurring live attenuated viruses (now labeled wild polioviruses, or WPV 1, 2, and 3). This improved patient acceptability, ease of administration, and had the added benefit of preventing intestinal mucosal infection with WPVs. Following its introduction polio incidence plummeted to less than 1 in 10 million population. Because of widespread immunization and the WHO’s Global Initiative to Eradicate Polio, by the end of 2007, polioviruses were limited to only four countries which had not yet succeeded in interrupting transmission (Afghanistan, India, Nigeria and Pakistan).

unknown at the time and which reached epidemic and then pandemic levels across the globe, wreaking havoc with the health especially of young children. Polio was then said to be the thing Americans feared most, second only to the atomic bomb. In the first half of the 20th century polio killed millions of people globally and left legions of others permanently paralyzed and disabled. Despite the work of Karl Landsteiner and Erwin Popper whose 1908 experiments on macaque monkeys demonstrated the transmissibility of polio by the inoculation of an extract of nervous tissue from polio patients, it still took decades of research to produce workable, usable vaccines. Meanwhile, especially in the peak summer and fall seasons, all social activities came to a screeching halt as schools, churches, theaters, playgrounds, parks and athletic events were cancelled. By 1949, David Bodian (Johns Hopkins) identified the three types of polio virus (PV1, PV2, PV3). Jonas Salk (Univ. of Pittsburgh) subsequently developed a formalin-inactivated injectable vaccine. After some 58,000 polio cases were reported in 1952 in the US alone, in the mid-50s, Dr Salk announced the successful use of his injectable formalin-inactivated polio vaccine (IPV) and over the next five years 450 million doses were distributed, resulting in the national polio incidence declining from 18.8 per 100,000 population to only 2.2. Unfortunately, during the 1950s, a debacle occurred when the vaccines from two pharmaceutical companies (primarily the Cutter pharmaceutical company, and to a lesser extent, Wyeth) were not completely inactivated. Their use resulted in numerous polio cases, including 250 paralytic cases, a loss of public confidence, and a decline in the vaccination rates. In 1955, the NIH created a Technical Committee on Poliomyelitis Vaccines to test and review all polio vaccines and advise the USPHS as to which lots should be released for public use. [One might wish something like that had been instituted at the start of the SARS CoV 2 pandemic to prevent much of the ensuing political hype and posturing.]

In 2018, the WHO reported the incidence of wild polio cases had declined by 99% from 350,000 cases in 1988, to only 33 reported cases in 2018. They also reported that WPV2 had been eradicated in 1999, and that no cases of WPV3 had been found since 2012. But lest we get too complacent, it now seems that outbreaks of circulating vaccine-derived polioviruses (cVDPVs) are more troublesome. These strains are capable of spreading through susceptible populations and “becoming manifest” in non-vaccinated or incompletely vaccinated individuals. Published data indicate that OPV shed viruses may cause 3 doses of paralytic polio per million doses given, but that contrasts with some 5,000 cases of paralysis for every million cases of natural polio infection. In nations where immunization programs have effectively reduced the occurrence of paralytic polio, as in the U.S., consideration is generally given to making the choice of going back to the use of the IPV as the vaccine of choice. cVDPVs may be rare right now but they have been increasing in recent years in low-immunization rate countries, and by 2020 were the only form of poliovirus in the African Region. In February 2022, WHO listed 3 nations still with wild polio virus 1 (Afghanistan, Malawi, Pakistan), and 31 countries in Africa and the Middle East with cVDPVs, all currently with the “potential for international spread.” Thus it behooves health care personnel to be aware of the differential diagnosis, not just of cases of acute flaccid paralysis (AFP) but of compatible illness syndromes in patients recently arrived in the US from endemic or at risk countries, as well as those recently vaccinated or exposed to someone else who was recently vaccinated. Those interested in Medical History, or who wish to learn more about polio vaccines, the use of “iron lung” ventilators, Sister Elizabeth Kenney’s treatment, the March of Dimes, the Global Polio Eradication Plan, and the International Health Regulations governing these situations, can learn much more by Googling those topics and websites. Especially important for physicians and hospitals to be aware of are the CDC’s case definitions, mandatory reporting directives, and guidelines for lab testing and specimen collection, which may be found at cdc.gov/vaccines/pubs/surv-manual (and visit Chapter 12).

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www.CHESTERCMS.org

What to Know About the COVID-19 Virus and Vaccination in Pennsylvania Children BY RACHEL HAHN, MPH CHESTER COUNTY IMMUNIZATION COALITION

an children be infected with COVID-19 at the same rate as adults? What are the side effects of COVID-19 infection in children? Can they suffer from long-term COVID? Is the COVID-19 vaccine needed? These questions, along with many others, have been racing in parents’ minds since the start of the pandemic in 2020. With the Pfizer COVID-19 vaccine FDA-approved for children ages five and older and the vaccine approval for children under age five on the horizon, the side effects of COVID-19 and its vaccination is a topic that deserves to be addressed and clarified for parents in Chester County. Circulating unscientific reports give the impression that the side effects of the vaccination are worse than the effects of being infected with the actual virus. These reports are often propagated through avenues such as social media. For example, a common misconception is that myocarditis, inflammation of the heart

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muscle, is a likely side effect of the COVID-19 vaccine when in reality, it is more likely to develop from a COVID-19 infection. According to CDC data updated on May 4, 2022, the overall risk of heart conditions after a COVID-19 infection is sixty-nine times higher than the first shot. Taking all ages, genders, and both vaccine doses into account, the risk of a heart issue after a COVID-19 infection was anywhere from 2 to 115 times higher when compared to vaccination.1 In the U.S., children under age 18 are contracting COVID-19 at the same rate as adults. As of April 28, 2022, almost 13 million children have tested positive for COVID-19.2 The symptoms of the COVID-19 virus are similar in both adults and children, as is the risk of developing long-term effects from the infection. While the symptoms of the disease in children are mild in most cases, the side effects of the COVID-19 vaccine can be even milder and are shorter in duration.

www.CHESTERCMS.org

The side effects that occur from the COVID vaccination are no different from the side effects that amount from any other routine childhood immunization. These side effects can include a sore arm at the injection site, mild fever, headache, chills, nausea, and tiredness, and all typically subside 24-48 hours after receiving the vaccine. Children can also receive the COVID-19 vaccine simultaneously as their other routine immunizations, like the influenza vaccine. Another common question is whether to vaccinate your child even if they have already contracted COVID-19. The short answer – yes. Although contracting the virus provides a form of natural immunity, it does not last as long as the immunity provided by the vaccine. People who already had COVID-19 and do not get vaccinated after their recovery are more likely to get COVID-19 again.3 Not only does the vaccine provide stronger immunity, but vaccinating your child also decreases transmission from new variants. The virus transmits efficiently between unvaccinated children and adults – getting vaccinated reduces the virus’ chance of mutating into new, potentially more dangerous variants. Valuable vaccination work is undergoing worldwide that allows us to answer these questions and provide resources for county residents, including work that is being done right here in Chester County. Working underneath the umbrella of the PA Immunization Coalition (PAIC) and the PA American Academy of Pediatrics, the Chester County Immunization Coalition (CCIC) is an organization that promotes recommended immunizations for all Chester County residents across the lifespan. Chester County currently leads the state of Pennsylvania as the county with the most residents vaccinated against COVID-19, with over 91% of the residents partially vaccinated and 74% fully vaccinated.4 To improve these numbers, the Chester County Immunization Coalition (CCIC) is conducting various campaigns throughout the county. Currently, the coalition is advocating for COVID-19 vaccinations with billboard and bus advertisements (see photos on page 30 and the top of this page).

These advertisements will collect millions of impressions throughout their run and direct viewers to the COVID Resources page at LetsFightCOVID19.com. On this page, visitors can find scientific and reputable information about COVID-19, the COVID-19 vaccine, and how and where to receive their vaccine. In addition, the CCIC is advertising with commercials on Q102 Philly with ads airing every day that direct listeners to the same webpage as the billboard and bus advertisements. For more information on the CCIC, scan the QR codes to be taken to our webpage on the PAIC website or our Facebook page!

References: Spencer Kimball, “Myocarditis risk higher after Covid infection than Pfizer or Moderna vaccination, CDC finds,” CNBC News, April 8, 2022, https://www. cnbc.com/2022/04/01/myocarditis-risk-higher-after-covid-infection-than-vaccination-cdc-finds.html. 1

“Children and COVID-19: State-Level Data Report”, Critical Updates on COVID-19, American Academy of Pediatrics, last modified April 28, 2022, https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/childrenand-covid-19-state-level-data- report/#:~:text=Since%20the%20pandemic%20 began%2C%20children,hospitalizations%20and%20mortality%20by%20age. 2

“Getting a COVID-19 Vaccine”, COVID-19 – Vaccines, Centers for Disease Control and Prevention, last modified March 4, 2022, https://www.cdc.gov/ coronavirus/2019-ncov/vaccines/expect.html. 3

“COVID-19 Vaccine Dashboard”, Coronavirus Vaccine, Pennsylvania Department of Health, last modified May 4, 2022, https://www.health.pa.gov/ topics/disease/coronavirus/Vaccine/Pages/Dashboard.aspx 4

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Chester County Medicine Winter 2022

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