YOUR COMMUNITY RESOURCE FOR WHAT’S HAPPENING IN HEALTH CARE CHESTER COUNTY SUMMER 2022 Published by Pennsylvania’s First Medical Society The Art of Chester County Presents Philip Lustig The Dangers of Going to the Medical Cannabis Dispensary Without a Guide PAGE 6 2022 Legislative Clam Bake PAGE 5
CitadelBanking.com/ Medical WELCOME TO BETTER Built for Your BANKINGBUSINESSPracticeWeunderstandthatstarting,running,andexpandingapracticeisnosmallfeat. Our team of Relationship Managers offers years of experience partnering with medical professionals to develop custom strategies that address their distinct healthcare business needs. Federally Insured by NCUA
For Advertising Information & Opportunities Contact: Tracy Hoffmann 610.685.0914 x201 firstname.lastname@example.org www.Hoffpubs.com Contents SUMMER 2022 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 email@example.com 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: Artwork by Philip Lustig. Read more in The Art of Chester County on page 16. 30 5In Every Issue 4 President’s Message 16 The Art of Chester County 5 2022 Chester County Medical Society Legislative Clam Bake 6 The Dangers of Going to the Medical Cannabis Dispensary Without a Guide 10 Situation Report: Monkeypox 12 2022 Tools for Success - Practice Management Mini-conference & Evening Social 14 The Real Story on Eye DropsSometimes Generics are not Acceptable Features 20 FINANCIAL FOCUSCrypto: Investment or Speculation? 21 988 Suicide & Crisis Lifeline 22 Adverse ExperiencesChildhood(ACEs) and the Chester County ACEs Coalition 24 All Eyes Are PennsylvaniaOn 26 “Excuse me, I’m Speaking”Combating Moral Injury with Activism 28 More Than Meets the Eye: The Psychosocial Benefits of Cosmetic Surgery 30 CVIM Launches Expanded Vision Care Services 5
ChesterCountyMedicineis 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. opinions expressed in these pages are of the individual authors and not necessarily those of the Chester County Medical Society. The ad material is the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Chester County Medical Society. President2022 Bruce A. Colley, DO President-Elect David E. Bobman, MD Vice President Mahmoud K. Effat, MD Treasurer Winslow W. Murdoch, MD Past President Mian A. Jan, MD, FACC 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 David A. ExecutiveMcKeighanDirector Chester County Medical Society 1050 Airport Road PO Box 5344 West Chester, PA 19380-5344 – www.chestercms.org #438, PA 19608
Email – firstname.lastname@example.orgTelephone-(610)357-8531 PUBLISHER: Hoffmann Publishing Group, Inc. 2669 Shillington Rd, Box
BY BRUCE A. COLLEY, DO PRESIDENT OF CHESTER COUNTY MEDICAL SOCIETY
Summer 2022 PRESIDENT’S MESSAGE To contact
send email email@example.com: 4 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
The Medical Society Board is also proud that our dues remain the same and our membership, despite the significant financial burdens placed on many physicians during the epidemic, has remained stable. Once again, a heartfelt thanks to all our member for hanging in there. We need every physician’s membership as there are always new challenges that will adversely affect our patients’ ability to access and receive good medical care.
The past three years were certainly unique. The challenges and destabilizing forces created by the COVID epidemic, and the closure of Brandywine and Jennersville Hospitals, approached overwhelming. The Medical Society responded by holding monthly Zoom conferences addressing all aspects of COVID. Expert and community-based physicians from the five-county Southeastern Pennsylvania region tuned in and shared observations and ideas relating to the diagnosis and management of COVID as well as practical strategies to help physicians continue caring for the wider community in a “lock-down” epoch.
The professional, social, and personal stressors as we all know were considerable. To address these pressures and added responsibilities our monthly informal Medical Society meetings evolved to what we now call SCRUMS (a rugby term that is quite descriptive of these events), where physicians can meet to discuss any and all issues relating to medical practice and as importantly lend support to each other. This mutual support, all physicians agree, is a powerful antidote for physician burn-out. The SCRUMS are held the last Thursday of each month (time and location on website).
The two most pressing current challenges are the loss of Brandywine and Jennersville Hospitals and the need to re-establish medical centers in central and southern Chester County.
Chester County continues to be the healthiest county in Pennsylvania. This propitious achievement has been and will be realized only by continuing the cooperation among the citizens of Chester County, medical professionals, businesses, and legislators that exists here.
The other is the possibility of a Venue Rule change. A seemingly obscure bit of legal trivia, which would allow court cases to be held in counties other than where the physician practices, if changed, would make the practice of medicine impossible for many physicians. Please contact your state legislators and let them know you support the amendment to our state’s constitution (HB 2660) that would prevent this from happening.
Dr. Bruce A. Colley Dr. Colley
So, time goes by. I end my three-year term as President of the Chester County Medical Society in September, and this is my final President’s Message. I thank the members of the Society for allowing me to serve as President and I acknowledge all the members and the Board for their full and complete support that allowed our Society to address significant issues. Without the cooperative efforts of the members, Board, our Past President Mian Jan, and our Executive Director David McKeighan we would have less to point to. Thank you, my friends, you are the best.
Fond Regards, Bruce
SUMMER 2022 | CHESTER COUNTY Medicine 5 www. CHESTERCMS .org 2022 CHESTER COUNTY MEDICAL SOCIETY LEGISLATIVE CLAM BAKE THURSDAY, SEPTEMBER 29, 2022 The Farmhouse at People’s Light, Malvern, PA 6:00 PM – 9:00 PM The annual Clam Bake is an opportunity for the physicians & elected officials of Chester County to meet and enjoy a casual evening of great food and conversation. Refreshments and hors d’oeuvres will be served at 6:00 pm followed by the Farmhouse’s outstanding array of chowder, “clam bake items,” carving stations with prime rib, chicken curry, & grilled vegetables. Also featuring presentation of scholarships for 2 West Chester University pre-med students. Business attire is suggested Please RSVP by September 16, 2022 Please register and make payment on-line at www.chestercms.org Or mail your check with completed registration form to: Chester County Medical Society 1050 Airport Road PO Box 5344 West Chester, PA 19380 Price: $59 per person Yes, I/we will be attending the Legislative Clam Bake on September 29th Name _____________________________________________________________ Guest Name ________________________________________________________ Phone _____________________________ Email __________________________ # Attending ______ Payment: ____ check enclosed ____ on-line payment Special dietary request: (please specify) ________________________________________________ Special seating or ambulatory request: (please specify) ____________________________________
Medical cannabis has been approved in many states as an adjunct therapy for the management of an array of medical conditions. In my experience, this has provided another treatment option for my patients with chronic pain, anxiety, insomnia, spasticity, and other painful conditions. It allows them to have another tool in their toolbox for use while they work on managing their own condition and optimizing their quality of life. Medical cannabis has become significantly more accessible to patients who could benefit from it, which is great progress.
BY ASARE B. CHRISTIAN, MD, MPH
My patient with fibromyalgia and anxiety, who was a first-time user, was given pills containing 10 mg of THC, which is a dosing more appropriate for those who have been using medical cannabis for a period of time. The patient took her pills on Saturday afternoon, again on Sunday morning and again in the afternoon
Because the delivery medium of medical cannabis varies, the time for the onset and duration of the drug effect and the impairment profile varies, too, depending on which type you use.
6 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
I have seen many side effects and accidental intoxication from patients who did not consult with a pharmacist or other medical professional directly about their medical cannabis use. A particular patient story comes to mind that details the harm that could be caused if proper research and guidance is not performed. As you may or may not know, cannabis used for medicine comes in different forms: pills, flowers, tinctures, edibles, vapes and more.
There are, however, dangers present for patients if they are not provided with education and direction from their doctors on what type of cannabis to try and what to expect during treatment. Though some dispensaries do have pharmacists who are able to provide some real clinical advice, many patients get their treatment recommendations from “budtenders,” or the employees who work at the dispensary who do not have a medical background. Nothing against budtenders, but some of my patients have had some very bad trips (literally and figuratively) from getting medical cannabis based on their recommendations.
The Dangers of Going to the MedicalWithoutDispensaryCannabisaGuide
SUMMER 2022 | CHESTER COUNTY Medicine 7 www. CHESTERCMS .org because she was not feeling any effects. Come Monday morning, she went to work where she was employed as a dispatch for a truck company. All of a sudden, the patient started feeling a bit uneasy. Her heart started pounding, and she started sweating profusely. She couldn’t focus and began to feel very paranoid as worrisome thoughts set in. She thought, “Oh my gosh, I’m very high, and I’m going to lose my job. Can everybody tell how impaired I am? Can they tell from my speech?” This patient was having a very bad trip. She was more anxious than ever and felt like she was having a panic attack. She was able to get to her car and lay down for two hours for things to calm down. These two hours were the most dreadful, longest hours of her life, she recalls. What happened here? This patient thought she was following the directions given on how to take her medical marijuana. This experience was a huge turn off for her, and she decided she would never use it again, even though she had few options for effective medications for her due to the side effects they wouldTherecause.are many lessons here to reflect on. First, the budtender did not take into account that this patient is not using cannabis for pain, but rather, was using it to manage her anxiety. Second, continued on next page >
Lessons Learned: 1. Go to a provider or doctor who understands and can educate you on what to get when you go to the cannabis 2.dispensary.Ifthedispensary offers you a “substitute” for what was recommended by your doctor, check with your doctor first to make sure it is similar, as there are many combinations of cannabis medicine out there.
These stories are very common in practice because most clinicians certifying patients for cannabis do not take the time to educate themselves on the proper dosing and titration of cannabis to prevent side effects. The patient is then left to the mercy of the budtender to advise them on dosing strategies, which we have learned, is not recommended.
BY EVAN TULL as her provider, I did write down exactly what I wanted her to get when she went to the dispensary (which was mostly CBD with a small amount of THC and terpenes to help with her anxiety), but this was substituted by the budtender because they didn’t have what I recommended in stock. Third, this story emphasizes that it is important for patients to understand that “feeling something” should not be equated to cannabis working. A lot of my patients will say, “I didn’t feel anything when I took it, so I don’t think it’s working for me.” Most people know of the psychoactive properties of cannabis and expect that for it to be working, they have to feel “high.” This is far from the truth when we are using cannabis for medical purposes. Most of the medical benefits of cannabis can be achieved without any “high” or impairment. In fact, most patients seeking medical cannabis therapy in my practice do not want to get high. They are usually adults, who have failed conventional therapy and are looking for something that can help them improve their pain and still be able to function.
Without a Guide continued from page 7
What happened in my patient case was a phenomenon called the first pass effect. When you take cannabis in forms such as via a pill or edible, it is metabolized through your liver. In the “first pass,” your liver then breaks down the 9-delta THC you have ingested into another molecule called 11-hydroxy THC. This intermediate compound can yield a strong sense of “being high.” The problem is that this conversion of THC to 11-hydroxy THC can take 4-6 hours and the drug effects can last for 24 hours. Because my patient took the pill and didn’t feel anything right away, she continued to take more. Her body was metabolizing the cannabis while she continued to take more, until 12 hours later, it all caught up to her, and she was so symptomatic she could not move and felt like she was floating.
The Going to the Medical Cannabis Dispensary
8 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
SUMMER 2022 | CHESTER COUNTY Medicine 9 www. CHESTERCMS .org Main AssociatesGastroenterologyLine Main AssociatesGastroenterologyLine Call USDH at 610-644-6755 or schedule online at usdigestivehealth.com. COLONOSCOPY CANCER It could be the choice of your patient’s life. IT’S YOUR #1 DEFENSE AGAINST ONE OF THE MOST LETHAL CANCERS. It’s fast. It’s painless. Most insurance will cover it for patients 45 or older. And it could save their lives. Colon cancer can be deadly when it’s not caught early. But it can be completely eradicated through early detection by colonoscopy. Now, thanks to a GI Genius™-enabled colonoscopy, technology aided by artificial intelligence, doctors at Main Line Gastroenterology Associates can diagnose colon cancer with unprecedented accuracy. DON’T PUT IT OFF. REFER YOUR PATIENTS FOR A COLONOSCOPY TODAY.
3. Ask to speak to a pharmacist, especially during your first time going in, so they can provide clinically sound judgment with treatment recommendations.
4. Not “feeling something” doesn’t mean your medical cannabis isn’t working unless you are looking to get high. Dr. Christian is the founder of Aether Medicine located in Wayne, Mainline Philadelphia. Aether Medicine focuses on what your impairments or pain prevents you from doing, easing unnecessary suffering, while making you the healthiest person possible. Aether Medicine believes pain management and rehabilitation starts with making individuals healthy and providing practical strategies to change habits. We provide pain management, rehabilitation and wellbeing medicine in an integrative manner combining conventional, complementary, and regenerative medicine with an individualized treatment plan and strategies. Aether Medicine emphasis stress management, exercise, nutrition, sleep, and social support as foundations for managing chronic pain. To learn more about Aether Medicine, visit www.aethermedicine.com.
10 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
Despite the near universal concerns over the ongoing repetitive new global waves of SARS CoV-2, Mother Nature, aided by the never-ending activities of human nature, has tossed us another curve ball. This time in the form of another contagious viral disease known as Monkeypox. Monkeypox is not a new entity for us. Many of our readers will recall the 2003 outbreak which occurred in the US midwest after 800 African mammals, including infected rodents, were imported from Ghana for sale, and passed their infection on to “pet prairie dogs,” resulting in 47 known human cases spread out among 6 US states (IL, IN, KS, MO, OH, WI). This was the first time any human cases had been reported outside of Africa according to the CDC. Until now, Monkeypox disease (hereinafter, MPX) had been considered a rare, tropical, viral zoonotic disease, caused by Monkeypox virus (MPXV), a virus from the same family as smallpox (genus: orthopoxvirus) but which is generally much less severe. The CDC website lists 12 separate orthopox viruses, including variola and vaccinia as well as several named for the specific mammals they target. Despite its name, monkeys are not considered the natural reservoir of MPX virus. The main reservoir is suspected to be local rodents, prompting some to conjecture that halting the “bushmeat” underground and gray market trade and consumption of wild animals might halt the ongoing exposures. Given their cultural and economic situations, that is unlikely to happen in PoxvirusesAfrica.are described as brick or oval-shaped viruses with large double-stranded DNA genomes which tend to result in skin lesions such as nodules, pustules, and/or disseminated rash which, in MPX, is frequently described as “ulcerative lesions.”
Until the current outbreak (epidemic, now pandemic?) MPX had been considered rare except in Africa where it has persisted endemically in two virus forms (“clades”): the milder West African, or Nigerian, clade; and the Democratic Republic of Congo (DRC) clade which is the more severe form and carries a greater case fatality rate there (estimates vary from 3.7% up to 10%). Little was heard about MPX for quite a while, despite a new outbreak in Nigeria in 2017 which got little world attention at the time despite the data showing over 440 suspected cases there spread among 30 of their states between September 2017 and May 2021. However, in July 2021, a US resident returning from Nigeria was hospitalized in Dallas, Texas, with MPX. This prompted a collaborative public health contact tracing effort by airlines, CDC, and state and local health officials to identify 200 of the patient’s fellow passengers from two flights, as possible contacts to the sick person. Around that same time, similar cases and response actions were happening in the UK, Israel, and Singapore. Officials were waking up to the fact that something was happening.
Still, the usual “keep calm and don’t create a panic” mentality continued in place, resulting in all the usual platitudes. Instead
BY JOHN P. MAHER, MD, MPH Situation Report as of early August, 2022
Caveat: This article is labeled as a “situation report (or “sit-rep”) for good reasons. When we started on it, we knew the topic, Monkeypox, was in its early phases of epidemiologic development, was dynamically changing day-by-day, and could have different outcomes depending on multiple variables. We did not realize, however, just how fast and how radically things could (and would) get out of hand, nor all the parallels with the very early days of the HIV/AIDS pandemic. And so, this is nowhere near the end of the story. Rather it is a report on the situation as we know it, in the last week of July while events continue to occur and be reported rapidly.
Not all of that has been definitively proven as yet. As cases continued to increase in Africa, the US CDC issued an official Travel Alert on 9/30/21 regarding the DRC outbreak and at the same time the WHO reported there were over 8000 cases in Africa in 2021. In November 2021, another US case was identified in a Maryland man returning from Nigeria. Then, in April 2022, a case was diagnosed in Massachusetts in a man returning from a trip to Canada. About that time, in England, a representative of the UK Health Security Agency (UKHSA) mentioned that “the high proportion of cases in the current outbreak in England that are gay or bisexual (51%) is highly suggestive of spread in sexual networks.” To anyone experienced in public health, the similar references to international travel should have been an early warning sign that these individual cases may have been “sentinel events.”
Case reports continued to come in and totals increased. Reports from various sources in different nations started to identify events which might now be labeled “super-spreader events,” e.g., international “raves” which were held in two European nations (Spain and Portugal), and a 4-day gay “fetish festival” held in Belgium in early May, 2022.
At this point we leave the further issues of elucidation of treatment, prevention, which antivirals and vaccines are available and what should be the public health/governmental approach to outbreak control, to those better qualified and more up-to-date in the indications, side effects, and contra-indications of those approaches. Readers are referred to the appropriate professional and online resources for specifics.
SUMMER 2022 | CHESTER COUNTY Medicine 11 www. CHESTERCMS .org of admitting they didn’t really know how this happened, or that there was insufficient information at that time to identify the method of exposure and transmission, the media and the public were basically reassured there was no danger, no need to worry, the disease is spread by exposure to rodents, it takes prolonged contact, not spread casually, it’s a mild disease, it will all be over shortly. It was reported that “people at risk for MPX are those who get bitten by an infected animal or have contact with the animal’s rash, blood, or body fluids or that it can also be transmitted personto-person through respiratory or direct contact, and contact with contaminated bedding or clothing.”
(b) which arrived in our in-box early this afternoon (7/24/22), announcing that: At a 7/23 news conference held by WHO Director General, Dr. Tedros Adhanom Ghebreyesus, held following a second meeting of their Emergency Committee under the International Health Regulations, at which he officially declared: “the global monkeypox outbreak represents a public health emergency of international concern” and announced a set of recommendations for 4 groups of member nations, varying somewhat depending on whether those groups had recent cases, active transmission (people-to-people or animalto-people), and/or the technological capacity to produce vaccines, antivirals, etc.
We will close, however, with two pieces of the latest “breaking news” on the topic: (a) the first arrived on Saturday, July 23rd, announcing the Biden Administration is reorganizing the federal health department to create an independent division that would lead the nation’s pandemic response, amid frustrations with the CDC — this 1000 person team known as Office of the Assistant Secretary for Preparedness and Response (ASPR), as a new separate division, will mobilize a coordinated national response more quickly and stably during future disasters and emergencies while equipping us with greater hiring and contracting capabilities.”
Two other aspects which need attention: there are reports of finding MPX virus in semen, saliva, and perianal tissues. No proof has been offered so far as we know, that these are live/active, infectious viruses, but the implications would be very important and need to be addressed. In addition, a small number of women, as well as a couple of babies, have been diagnosed with MPX, and at least one report has identified the environmental contamination by MPX virus in the homes/rooms of known patients. Again all these things need to be studied and answered.
The nearly asymptotic case report curve (q.v.) has been visibly very impressive, but as with all early data needs to be evaluated carefully. It is not uncommon for such a trend to be seen early in the history of a new disease, as people become aware of the signs and symptoms, seek medical care, and get diagnosed, and doctors develop a higher index of suspicion watching out for such patients. One problem is whether these are all new cases, as opposed to old or ongoing cases just now getting identified and reported. Also, on a global scale, how many nations have the sophisticated health lab technology to distinguish MPX from varicella, measles, syphilis, etc.? Still the numbers, and the rate of increase must grab one’s attention both because of the numbers themselves, because they are multi-national, and because they increased by nearly 7-fold each month between May and July this year.
The transcript and full details of his announcement are available at https://WHO.int/director-general/speeches.
2022 Tools for Success Practice Management Mini-conference & Evening Social
(L-R) 2nd District Trustee Mark Lopatin, MD; Laura Offutt, MD; Delaware County Medical Society President Joseph W. Laskas, DO; & Chester County Medical Society President Bruce A. Colley, DO Laura Offutt, MD – Everyday Hero
On Thursday June 23, 2022, the Chester & Delaware County Medical Societies presented an afternoon medical practice management conference and an evening social at the Waynesborough Country Club in Paoli. The afternoon program featured two outstanding guest speakers and a panel of practice administrators for an interesting and interactive session. Eight exhibitors provided financial support to the programs and allowed their staff to network with the practice administrators and physicians. These businesses included: Aether Medicine (Dr. Asare Christian); Choice Medical Waste (Matt Georgov); Edward Jones Financial Investments (Brendan Murphy); Healthcare Facilities Solutions (David Heaney); L H & W Insurance (Michael Whitcraft); M & T Bank (Julian Gentile); Premier Payroll Services (Ann Angelucci) and Tesla Payments (Drazen & NatasaHeatherCvijanovic).A.King, MHA, Director of Healthcare Operations PAMED, provided a presentation “Practice Management Update & Important Priorities” focusing on the “No Surprises Act,” COVID Waivers, Masking & Vaxxing at Practice Sites, Practice Policies, and a current legislative update.
12 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
Attorney George C. Hlavac, Esq., (a veteran of twelve previous “Tools for Success” Conferences), gave a captivating presentation “Hot Human Resources Topics for Medical Practices” with a focus on FMLA & ADA compliance, medical marijuana and implications for practice employees, and harassment in the workplace.
Jill Venskytis, CMM-PP (Practice Administrator – Drexel Hill Pediatrics), facilitated a panel discussion with four other practice administrators: Paul Brewer (Dermatology Ltd.), Deanna DiMascio (ENT Associates of Chester County), Dawna Gillespie (Penn Medicine Primary Care & OB/GYN), and Michelle Harper (PentaHealth Primary Care). This discussion addressed “Best Practices for Recruiting & Retaining Staff” and was very well received by the audience.
An evening social was attended by many managers as well as physicians from Chester, Delaware, Montgomery, and Philadelphia Counties. As part of the evening ceremonies, Laura Offutt, MD, was presented the PAMED Everyday Hero Award for her work in developing and implementing the International Adolescent Health Week program. It was noted that Adolescent Health Week is celebrated the 3rd full week in March yearly, as a grass-roots initiative for young people, their health care providers, their teachers, and their parents, to come
www. CHESTERCMS .org CHESTER COUNTY Reach Audience...Your Reach 35,000+ Engaged Consumers 3,500+Plus, ChesterThroughoutPracticeDentistsPhysicians,&ManagersCounty www.Hoffpubs.com Advertise in YOUR COMMUNITY RESOURCE FOR WHAT’S HAPPENING IN HEALTH CARE CHESTER COUNTY FALL2021 Published by Pennsylvania’s First Medical Society PAGE PAGE8 YouthPhilanthropy SowGoodNow Developments in PhysicianPeer Review The Art of Chester CountyPresentsLELE Galer Reach out to us today! Tracy 610-685-0914Hoffmannx201 (L – R) Kevin Sowti, MD, Bruce Colley, DO, Jay Rothkopf, MD, Manjula Naik, MD, Richard Oyelewu, MD, Heidar Jahromi, MD, and Mrs. Shaheen Jahromi together and celebrate young people and with an ultimate goal of working collectively towards improving the health and well-being of the over 1 billion adolescents across the globe today.
venue rule for professional liability lawsuits in
verdicts and awards are significantly higher in urban courtrooms and
PAMED Second District Trustee Mark Lopatin, MD gave presentation addressing the proposed change in Pennsylvania, which would plaintiffs’ it was plaintiffs’ the proposed change “high-risk”
may facilitate significant increases in the cost of liability insurance, especially for physicians performing
attorneys to file suit in county courts other than where the alleged malpractice occurred. In the ensuing discussion
Sometimes Generics Are Not Acceptable
14 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
As best we can tell doctors have little control over the costs of your medication. This is between you and your insurance company. They are in the business of selling you insurance and providing care for you at the lowest cost and highest quality they can obtain. But like anything; lower cost means lower quality, and this is most true with your eye drops. There is a state law that makes us allow substitution, meaning that if we write a brand name or a particular drug the pharmacy and you have the right to switch to a generic drug. It is our understanding that this has led to a distortion in the market and that large pharmaceutical chains are more able to negotiate price on generic drugs and therefore often choose those over brand names because it is more profitable for their business. The whole thing is distasteful, but it is how things are currently.Work with your doctor’s team to help you in your selection of any generic drugs or brand names that your pharmacy will not dispense or if there is undue cost. Doctors do not control these costs, we do not know what your copay is when we prescribe your medication, we go with the best drug possible and work from there. Doctors do not participate in any financial way with your prescribed drugs, which is against the law. Most doctors have sophisticated software that helps them choose the best drug for your condition that is allowed under your insurance. These systems are not foolproof
Our phone rings every day with calls from patients who are irate when they find that their copay is so high or that these tiny underfilled bottles are so expensive. The first part is they do not see them as drugs carefully engineered medications to be given topically on your eye but mere “eye drops.” Most doctors prefer branded eye drops. That is because they know what is in those brand name eye drops. Brand name eye drops are very studied and scientifically composed medications that not only carry the active ingredient but more importantly are in a special and specifically engineered vehicle. This “inactive” solution part of the drop is designed to help the drug reach the structure in the eye that needs the medication. In some instances, some drops seem to sting; this stinging is part of their activity of penetrating the surface of the eye with their vehicle or solution, which allows the active ingredient to penetrate the eye. This can often cause a superficial stinging when first given. That is a sign that they are working correctly. If they are too uncomfortable call your doctor. A different vehicle drop can be prescribed; remember, your doctor wants you to do well and they need you on their team to get feedback to set things straight.
BY STEVEN SIEPSER, MD, FACS
T he real story behind eye drops is of critical interest to you and your doctor. Let me explain. People think of eye drops as bottles of watery drops as though they were mouth wash they buy at the pharmacy. When an eyecare professional prescribes drops, they are very carefully engineered and powerful drugs that are delivered via dropper. Even the size of the drop and the tip of the dropper are precisely engineered to give appropriate dose size in the least amount of volume in the best products. In generic or inexpensively constructed dropper bottles, a massive drop of unneeded volume in these poorly designed dropper bottles ends up on your cheek. Most of the active ingredients either spill out of the eye or flow through a canal to your nose where they are absorbed systemically, where they can precipitate a host of unwanted side effects, besides giving you a runny nose!
Established in 1828, the Chester County Medical Society, founded by Dr. William Darlington, M.D., is thought to be the oldest county medical society in the State. The Medical Society 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. The Chester County Medical Society works collaboratively with the Pennsylvania Medical Society, but our focus is on our local community. The Society’s role in Chester County is to support, protect, and advocate for our physicians and our patients. We look forward to growing an important healthcare service for our community that will benefit us all, and we look forward to hearing from you. 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 publication and to purchase advertising to help promote their practices! Chester County Medicine features a popular ongoing series focusing on the art and artists of Chester County. The current and archived editions are available for readers on the society’s website: www.chestercms.org.
Advocacy – the CCMS is an active supporter on many important local and regional task forces, work groups and coalitions such as the Chester County Immunization Coalition; the Regional Overdose Prevention Task Force; the Chester County Suicide Prevention Task Force; the Pennsylvania Coalition for Civil Justice Reform and more.
The Clam Bake – our annual legislative dinner program is an opportunity for the physicians of Chester County to meet and enjoy a casual evening of great food and conversation with elected officials. The event also features the presentation of two scholarships to West Chester University pre-med students.
PracticeBeat – an outstanding member benefit offering practices a chance to enhance their on-line presence, improve patient satisfaction and ensure practice communications and scheduling requests are IPAA compliant. PracticeBeat offers CCMS members a significant discount off their monthly base fee. Data-based insight is also provided relative to the competitive landscape in your specialty and geographic area.
and often things change so quickly that your doctor can prescribe a drop one day and the price can change the next. There are a couple of things I would recommend that you do. When you find that your co-pays are too high or unreasonable or a drug that is prescribed is uncovered, please notify the Pennsylvania Insurance Commissioner that you are unhappy.
you get upset about a high copay or these ridiculously overpriced drugs please send a copy of the receipt to your congressperson. It is easy just take a picture of the bottle and receipt then e-mail it to them. You do not even have to buy the medication in question, take the photos and then copy it. They are not the ones who are on the hot seat. Patients blame the doctor and our technical team for these costs; we are here to care for you and we do not control the costs. If you are really concerned about this, the best way to make a meaningful change is by taking action to notify your Congressman, US Senator, and the Pennsylvania insurance commissioner.
Leadership opportunities available – the CCMS leadership is eager to continue representing our membership and opportunities are available to serve for medical students, residents and fellows, early career physicians and our “full active” members Practice management assistance – contact CCMS staff with questions about a wide array on “business” matters pertaining to your practice. Our experienced staff at the local and state level offer outstanding assistance. Participate in our in-person and virtual programs to help guide your practice on issues such as reimbursement, credentialing, recruiting and many more important aspects of running a practice.
OF FOCUS INCLUDE Cataract surgery, Refractive surgery – LASIK, PRK, Refractive Intraocular Lens, Eye Trauma Reconstruction & Primary eye care in The Chester County Medical Society Member Benefits Join Us!
www. CHESTERCMS .org SUMMER 2022 | CHESTER COUNTY Medicine 15
To learn more, join or renew, visit https://www.pamedsoc.org/ab out-pamed/Membership
Steven Siepser, MD, F.A.C.S. Has built a solid foundation of excellence in eye care over the last 40 years and continues to lead the eye care industry with innovations and new devices. Dr. Siepser specializes in helping patients with a wide range of refractive errors including astigmatism to see without glasses or contact AREASlenses.
BY BRUCE A. COLLEY, DO Sir Cecil Beaton Beaton talks to Joan Crawford Philip with Sir Cecil Beaton
This issue’s featured artist is one those, a gifted observer, analyzer, and commentator of our physical and cultural surroundings. Philip Lustig is a photographer, and multi-media artist and designer. Though all the artists and craftsmen we have featured are unique and breathtakingly talented, our featured artist for this issue is a talent for his generation, where many years of experiences has given him many insights as his career spans from 1950 to Philippresent-day.wasbornin Newark, N.J. and grew up there. His father was a cabinet maker and his mother was a noted New York fashion designer known as Countess Lustig. After high school he graduated from New York University with a degree in art. Then, following his mother’s footsteps Philip continued his schooling at Parsons School of Design. His entry into the fashion field was short lived due to its unsteady fluctuations. That gave him the incentive to return to an early passion for photography, which was a perfect fit.
The Art of Chester County Philip Lustig
www.chestercms.org 16 CHESTER COUNTY Medicine | SUMMER 2022
From time to time we meet people who are a bit more than interesting; and rarely a person who is skilled at being interesting.
www. CHESTERCMS .org SUMMER 2022 | CHESTER COUNTY Medicine 17 continued on next page >
The Art ofChester County
continued from page 17
The Art of Chester
18 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
By serendipity, Philip’s first job was at the prestigious Photography Place Studio in NYC where he worked with many of the country’s best photographers. And because of his talent he was chosen to work with Sir Cecil Beaton, at the time the most famous photographer and theater designer in the world (ie. My Fair Lady and court photographer for Queen Elizabeth). In fact, Beaton had been an idol of Philip’s, calling this chance to be his assistant an act of fate. While assisting Sir Beaton, Philip met and helped photograph many of the world’s illuminati, such as Joan Crawford and Charles Addams. Phillip then moved on to become the photographer at Hilty Studios in New York City doing album covers for the likes of Buddy Holly and Lena Horn among many more. Then having been offered a contract with a Hollywood studio, Philip moved to the west coast, working a short time for movie studios, where he soon became bored with the Hollywood fantasy. Seeking a major change, he bought an inch-thick book of airline tickets to travel around the world (something one could do in those days). While on his travels an advertising firm hired Philip to shoot the prize winning “Man On The Spot” series commissioned by Bank of America. During this time, he circled the world 4 times and was in 88 countries. During his travels he climbed to the top of the Cheops pyramid in Egypt, and in Katmandu, was given permission to photograph the Living Goddess of Nepal. Following his travel years, Philip became Director of Photography at Fingerhut, then moved to Chester County in 1976 and for 28 years was the senior photographer at the Franklin Mint until they closed. Since “forced retirement” he continues his artistic endeavors including photography, wood sculpture he terms contemporary folk art, sketching, whimsical paper cut-outs, painting, and digital art. Moreover, to “stay busy” he attended West Chester University taking writing and poetry classes. Philip has written more than fifty each of short stories and poetry. Please enjoy this small sample of Philip’s many oeuvres.
www. CHESTERCMS .org SUMMER 2022 | CHESTER COUNTY Medicine 19 We are one Living Goddess of Nepal “All trees are a work of art”
• Volatility – Cryptocurrencies are subject to truly astonishing price swings, with big gains followed by enormous losses –sometimes within a matter of hours. What’s behind this type of volatility? Actually, several factors are involved. For one thing, the price of Bitcoin and other cryptocurrencies depends heavily on supply and demand – and the demand can skyrocket when media outlets and crypto “celebrities” tout a particular offering. Furthermore, speculators will bet on crypto prices moving up or down, and these bets can trigger a rush on buying and selling, again leading to the rapid price movements. And many purchasers of crypto, especially young people, want to see big profits quickly, so when they lose large amounts, which is common, they often simply quit the market, contributing to the volatility.
FINANCIAL FOCUS Crypto: Investment or speculation?
BY BRENDAN MURPHY, AAMS, CRPS FINANCIAL ADVISOR
With cryptocurrencies so much in the news, you might be wondering if you should invest in them. But “invest” may not be the right word – because, in many ways, cryptocurrencies, or “crypto” for short, are more speculation than Butinvestment.what’sreally the difference between a speculator and an investor? Probably the main factor is the differing views of time. A true investor is in it for the long term, building a portfolio that, over many years, can eventually provide the financial resources to achieve important goals, such as a comfortable retirement. But speculators want to see results, in the form of big gains, right now – and they’re often willing to take big risks to achieve these outcomes.There’s also the difference in knowledge. Investors know that they’re buying shares of stock in a company that manufactures products or provides services. But many speculators in cryptocurrency don’t fully comprehend what they’re buying –because crypto just isn’t that easy to understand. Cryptocurrency is a digital asset, and cryptocurrency transactions only exist as digital entries on a blockchain, with the “block” essentially being just a collection of information, or digital ledgers. But even knowing this doesn’t necessarily provide a clear picture to many of those entering the crypto world. In addition to time and understanding, two other elements help define cryptocurrency’s speculative nature:
www. CHESTERCMS .org 20 CHESTER COUNTY Medicine | SUMMER 2022
This article was written by Edward Jones for use by your local Edward Jones Financial Advisor. Edward Jones, Member SIPC Brendan Murphy 520 S. Bradford Ave., West Chester, PA 10382
• Lack of regulation – When you invest in the traditional financial markets, your transactions are regulated by the Securities and Exchange Commission (SEC), and the firms with which you invest are typically overseen by the Financial Industry Regulatory Authority (FINRA). Other agencies are also involved in regulating various investments. These regulating bodies work to ensure the basic fairness of the financial markets and to prevent and investigate fraud. But cryptocurrency exchanges are essentially unregulated, and this lack of oversight has contributed to the growth of “scam” exchanges, crypto market manipulation, excessive trading fees and other predatory practices. This “Wild West” scenario should be of concern to anyone putting money in crypto.The cryptocurrency market is still relatively new, and it’s certainly possible that, in the future, crypto can become more of an investment and less of a speculation. In fact, Congress is actively considering ways to regulate the cryptocurrency market. But for now, caveat emptor – “let the buyer beware.”
326316-D Developed in collaboration with the Centers for Disease Control and Prevention
On July 16, 2022 the transition to 988 will happen across the nation. Moving to a 3-digit dialing code is a once-in-a-lifetime opportunity to strengthen and expand the existing National Suicide Prevention Lifeline (the Lifeline). The Substance Abuse and Mental Health Services Administration (SAMHSA) is the lead federal agency, in partnership with the Federal Communications Commission and the Department of Veterans Affairs, making 988 a reality for America. But 988 is more than just an easy-to-remember number it is a direct connection to compassionate, accessible care and support for anyone experiencing mental health related distress – whether that is thoughts of suicide, mental health or substance use crisis, or any other kind of emotional distress. Preparing for full 988 implementation requires a bold vision for a crisis care system that provides direct, life-saving services t o a ll in need. Chester County sees 988 as a first step towards a transformed crisis care system in much the same way as emergency medical services have expanded in the US. Chester County’s 988 planning process is being coordinated by the County’s Department of Mental Health/ Intellectual and Developmental Disabilities, with consulting support from Capacity for Change, LLC. As part of Pennsylvania’s effort to support counties in this transition, Chester County was awarded a $300,000 grant in September 2021 for the current 988-planning process. How is 988 different from 911? 988 was established to improve access to crisis services in a way that meets our country’s growing suicide and mental health related crisis care needs. 988 will provide easier access to the Lifeline network and related crisis resources, which are distinct from 911 (where the focus is on dispatching Emergency Medical Services, fire and police as needed). Until July 16, those experiencing a mental health or suicide-related crisis, or those helping a loved one through crisis, should continue to reach the Lifeline at its current number, 1-800-273-8255 Questions? 988Team@samhsa.hhs.govEmail:
In 2020, Congress designated the new 988 dialing code to operate through the existing National S uicide Prevention Lifeline.
Adverse Childhood Experiences (ACEs) and
“Six years ago, I worked at a small non-profit that assisted women and children experiencing housing instability, food insecurity and domestic violence. We realized that many of the families that grad uated from the program continued to struggle with so many issues and crises, it was difficult for them to function. Our dilemma led us to discover the ACEs study and prompted the creation of the coalition,” said Chelsea Melrath, the Chester County ACEs Coalition Coordinator and certified trauma specialist. “Understanding the core issues, which are often things that began in the mother’s childhood, was key to the families achieving their goals and long-term success.” the Chester County ACEs Coalition
ACEs Include: • Emotional Abuse • Physical Abuse • Sexual Abuse • Emotional Neglect • Physical Neglect • Mother Treated Violently • Household Substance Abuse • Household Mental Illness • Parental Separation or Divorce • Incarcerated Household Member
How is it possible that so many medical conditions in adulthood, from arthritis and heart disease to diabetes and chronic digestive problems, can be connected to our childhood adversity? It may seem like an unlikely connection, but research has shown that the trauma of our Adverse Childhood Experiences (ACEs) has a lifelong impact on our overall health and wellbeing. It is true that some stress and adversity in childhood is normal and can even help build resilience. But when childhood adversity becomes intense, prolonged, and frequent, and the child does not have the support of caring adults, it can be toxic. Experiencing emotional or physical neglect or abuse or growing up in a household with many difficult challenges change a child’s brain development and can wreak havoc on one’s body, activating physiological responses. Imagine the feelings of flight, fight, or freeze. When that stress response occurs over and over, it takes a toll on our body’s circulatory, digestive, nervous, and other systems. While one might think that only certain underserved populations would be affected by this type of adversity, statistics show that one in six American adults experienced four or more adverse childhood experiences. With the profound public health impact of ACEs, there has been a groundswell of interest and research on the topic in recent years. More information than ever before is available to help individuals, families and communities identify and prevent ACEs, build resilience, and support those who need it. The Chester County’s ACEs Coalition pulls together a network of local partners committed to increasing ACEs awareness and understanding as well as educating the community about prevention strategies.
The information about this trauma is not new, however. The original study of ACEs began almost 25 years ago with a survey of more than 17,000 middle-class adults. Created by Kaiser Permanente health maintenance organization, the study is one of the largest investigations of childhood neglect, abuse, and household challenges and how they connect to adult health. The survey tallied the number of ACEs experienced to create an ACE score for individuals. The results were groundbreaking, linking such adversity to an array of physical and mental health problems, including asthma, obesity, unintended pregnancy, alcoholism, depression. The impact is also cumulative; the more adverse experiences in one’s childhood, or the higher one’s ACEs score, the greater the possibility of disabilities and dysfunction as an adult. In fact, at least five of the top ten leading causes of death are associated with ACEs.
22 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
• Trauma & Resilience 101
SUMMER 2022 | CHESTER COUNTY Medicine 23 www. CHESTERCMS .org
As more people have learned about ACEs, the demand for train ings in both community and professional settings has resulted in the coalition growing exponentially. What began as a small, grassroots group formed by the small non-profit is now a county-wide program managed by the Chester County Health Department and financially supported by the Chester County Department of Children, Youth, andMelrathFamilies.says the Chester County ACEs Coalition has increased awareness through advertising and social media campaigns and hosting local events. The coalition also provides trainings, workforce development opportunities, workshops, film screenings with expert panel discussions, quarterly ACEs Community Meetings, and an opportunity for professionals and community members to be trauma-informed advocates (referred to as ‘Resilience Champions’).
The reach continues to grow, as Melrath and her colleagues have witnessed first-hand at some of their presentations and panel discus sions. Often, after community members watch a film screening and sit through a panel discussion, they will share personal experiences and express their complete astonishment over what they have learned.
The ACEs Coalition offers a panel discussion with local experts in the field following the film.
“The child may not remember, but the body remembers.”
• Becoming a Trauma-Informed Organization
• Connections: Trauma & Suicide
• Screenings for ACEs and Resilience: How to Approach Clients, Provide Resources and Follow Up
In the year 2021, the Chester County ACEs Coalition provided 43 trainings and trained over 1,300 people in Chester County. “These initiatives have helped foster hope to offset the cycle of trauma and contribute to long-term health benefits throughout the county,” Melrath said. “We’re proud of the expanded reach of the organization in recent years and look forward to continuing to reach more and more audiences around the county in the years to come.”
Schedule a screening of RESILIENCE, a one-hour award-winning documentary that delves into the sci ence of ACEs and the birth of a new movement to treat and prevent toxic stress. Now understood to be one of the leading causes of everything from heart disease and cancer to substance abuse and depression, extremely stressful experiences in childhood can alter brain development and have lifelong effects on health and behavior. The film chronicles the birth of a new move ment among pediatricians, therapists, educators and communities, who are using cutting-edge brain science to disrupt cycles of violence, addiction and disease.
• Promoting Resiliency and Developing Connections
To schedule trainings, contact Chelsea at firstname.lastname@example.org.
Trainings offered by the Chester County ACEs Coalition:
“We’ve often heard people say ‘Wow, I had no idea! I didn’t expect to learn so much and I didn’t expect to be able to relate the information to my own life,’” said Melrath. In the years since the first ACEs study, additional research has shown that frequent or prolonged exposure to ACEs affects a child’s ability to learn and function in school. ACEs can lead to difficulties with language and communication skills, attention, memory and recall, problem solving and organization, the ability to develop a plan and carry out goals, among other concerns. Students with high ACEs scores have lower standardized test scores, are more likely to be suspended from school and are more likely to fail a grade. But there is Researchhope.has also led to more understanding of the neuroplas ticity of the human brain, which has the ability to reorganize itself with new neural connections throughout the lifespan. Even serious adversity and childhood trauma can be offset by practices that build resilience and promote overall health. Given the right tools and support, children and adults can survive and thrive, despite ACEs. To learn more about ACEs and the programs offered by the Chester County ACEs Coalition, contact Chelsea Melrath at email@example.com. Visit the coalition website at www.ccacescoalition.com.
Some observers think that party polarization and well-defined top tier issues will have the opposite effect in the general election and result in a Democratic organizational movement to drive their voters to the polls on November 8th. But as voting day approaches, Republicans have narrowed the voter registration gap between their party and the Democrats to about 500,000. Not too long ago, the Democratic margin was over 1 million. In addition, Republicans are outpacing Democrats in registering new voters. To say the least, the political landscape is more complicated thanBeyondever. control of the US Senate, reproduction rights rises to the top tier of issues. With the recent ruling of the US Supreme Court in Dobbs v. Jackson it was immediately clear this would be a critical element in elections at both the state and national levels.
Politics & Medicine
In both national and local news coverage, political analysis, candidate fund raising messages and everywhere else the recurring theme is that “all eyes are on Pennsylvania” as the 2022 fall general election approaches. Another widely accepted opinion is that this will be a “watershed” election. It’s easy to understand why. The 8.7 million registered voters in Pennsylvania are at the center of the political universe. To start with, the political stakes are extremely high, and the candidates are, in a word, unique. PA voters on November 8th will have two incredibly important statewide elections on the ballot as they choose a successor for both term-limited Governor Tom Wolf (D) and retiring US Senator Pat Toomey (R). Those two statewide races will be not only at the top of the ballot, but they will also be closely followed by the national media and the most powerful politicians in the nation. The Gubernatorial race is critical for state party Democrats if they want to counterbalance the stranglehold that PA Republicans have had on control of the General Assembly. To retain control of the Governor’s mansion, Democrats will need to elect sitting Attorney General Josh Shapiro to the post. Since the two-term limit was imposed on Governors, a change of parties has been the norm so Democrat Shapiro succeeding Democrat Wolf is the first complication and just one reason that Democrats have a difficult task.Another factor is that the GOP nominee for Governor, State Senator Doug Mastriano, runs with the support of former President Trump and he proved in the GOP primary that he is anything but a conventional candidate. In the primary he defeated a crowded field of seven opponents by translating anger over the assertion that the 2020 presidential election was “stolen” to claim 44% of the votes and a win. Mastriano is well known as a participant in the events at the US Capitol on January 6, 2021 and will count on the conservative base of the state Republican party to fuel his victory. Voters studying the policy positions of Mastriano and Shapiro will find a very large gap and very little common ground.The other statewide race, to replace retiring Republican Senator Pat Toomey, is simply a centerpiece of the national level political discussion because it will be a key factor in determining political control of the US Senate for the remaining two years of President Biden’s term. Even considering that there are tightly contested races in a few other key states, many national observers consider the race in Pennsylvania to be the fulcrum that will determine control of the Senate, if you will, the “Keystone State” in real life. At the national level Democrats are looking at the Pennsylvania Senate race as the one they will need to “flip” from R to D to again secure their majority in the upper chamber. Democratic candidate John Fetterman surprised many by handily winning his party’s primary and the nomination while campaigning in his own unconventional style. He then stepped off the campaign trail to recover from a stroke he suffered just before the election. The Republican candidate, Dr. Mehmet Oz, is a celebrity physician who until recently lived in New Jersey. While Fetterman was slow to re-engage in campaign activities because of his health, it did not deter his early fundraising and at least thru most of the summer he was leading Oz in both the polls and funds raised.This election cycle has its underpinnings in issues that are sure to guarantee explosive headlines, creative media buys and more than likely high voter turnout. It was reported that voter turnout in the 2022 primary was a record for mid-term elections with more than 1.2 million voters from each party casting ballots. But in mid-term elections, based on the presidential cycle, historical voting data predicts there is less of an expectation for a similar dynamic in November. And history would also predict more success for the party not holding control of the White House, presenting an additional challenge for Democrats Shapiro and Fetterman. Without question, this means that the statewide candidates from both parties are campaigning in an unusual and difficult mid-term election environment.
24 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
BY LARRY L. LIGHT
All Eyes Are On
Last day to request a mail-in or absentee ballot: November 1, 2022 Ballots must be received by 8:00 P.M. Election Day is Tuesday, November 8, 2022 Polls are open on election day from 7 A.M. - 8 P.M.
A fourth issue, again well-known across the nation, is the battle over preserving 2nd Amendment rights in the face of the debate on gun control and the recurring instances of gun violence that seem to dominate our news cycles. And to cite the obvious, voter anxiety over economic uncertainty will come into play.
Another well-known issue, one debated at both state and national levels, is addressing climate change. Not surprisingly, the views of the candidates range from considering climate change a universal crisis to declaring it to be junk science.
SUMMER 2022 | CHESTER COUNTY Medicine 25 www. CHESTERCMS .org
In contrast, both Shapiro and Fetterman currently hold statewide offices. Shapiro is the Attorney General and Fetterman the Commonwealth’s Lt. Governor. They may not qualify as a “fresh face,” but they will benefit from a wealth of political acumen. But Oz and Shapiro also have the perceptual hurdle of running to succeed an office holder from their own respective party, Republican Senator Pat Toomey and Democratic Governor Tom Wolf respectively. In legislative races the “fresh face” element is supplanted by the advantage of being a local candidate well known to many voters. Given the political turmoil of the past few years it is an element that will be critical. As the Pennsylvania races for the US Senate and Governor bring both national attention and a barrage of television advertising, they will most certainly fulfill the political adage that elections are about choices and the future. The winners in Pennsylvania, John Fetterman or Mehmet Oz for the US Senate seat and Josh Shapiro or Doug Mastriano in the gubernatorial race, will be positioned to make important policies decisions in our national and state governments. Voting on November 8th in Pennsylvania could not be more important. It has been proven time and time again that every vote does count. Whether you vote by absentee or mail-in ballot or in person, it is important that you vote!
level, federal reapportionment required that Pennsylvania lose one seat in its House delegation. The decision of Democratic Congressman Conor Lamb to not seek re-election and to make a run-in his party’s primary for the nomination to the US Senate provided a bit of breathing room, but here was still delicate political process of having districts absorb new territory as the state delegation was reduced from 18 to 17 in number. It’s important to note that Pennsylvania did not lose a seat in the House via the reapportionment process because our state is losing population. In fact, the population of Pennsylvania has increased to more than 13 million. The problem is that Pennsylvania is not growing as fast as states like Texas, North Carolina and Florida. Reapportionment is a realignment process for the US House of Representatives for the next ten-year period, akin to shifting sand. The most populous state in our nation, California, lost 2 House seats in the most recent reapportionment process.Collectively
Last day to register to vote: October 24, 2022
Legislative races in Pennsylvania will also bear watching. Republican state legislators, tired of dealing with Governor Wolf and his veto pen, are anxious to write new law on matters ranging from election security to reproductive freedoms. The problem is that they face their own challenges in that they are running in newly drawn state legislative districts. A controversial reapportionment process, which was concluded only when the state Supreme Court determined the new boundaries, means more contested elections and more fundraising to stay competitive in moreAtdistricts.thecongressional
Finally, there is an element in the 2022 cycle that is particularly relevant to the statewide Senate and gubernatorial races. Polling and focus groups have captured the theme that “fresh faces” are needed in politics. With nominees Oz and Mastriano having not previously run for statewide office, that would seem to indicate that the GOP primary winners are better placed than their Democratic opponents. In fact, Oz has never been a candidate, while Mastriano has won election to the local State Senate seat.
the candidates from both parties in the 203 State House races, 25 State Senate races and 17 Congressional races have the challenge of finding campaign volunteers, fundraising contributors and media attention in the wake of the unprecedented contests for Governor and US Senator.
“Excuse me, I’m Speaking”
One of the most ominous examples came late at night on July 8th when the Pennsylvania Senate and House passed a bill that would ask voters to amend the state constitution to declare that there is no right to abortion and no guarantee that taxpayer funding can be used for abortions. Members of the Pennsylvania legislature are not defending or protecting us, they are actively and harmfully impeding our ability to perform our jobs safely and effectively.Atthis moment in history, we have the opportunity to use our exhaustion, outrage and moral injury to galvanize ourselves into action. The work can feel overwhelming, but advocacy is empowering and there is a lot we can do in each of our communities. A quote from the Talmud* summarizes it well: “Do not be daunted by the enormity of the world’s grief. Do justly, now. Love mercy, now. Walk humbly, now. You are not obligated to complete the work, but neither are you free to abandon it.”
A t the start of the COVID-19 pandemic, when healthcare workers were being hailed as heroes, some of our colleagues didn’t fall for it. They knew the accolades were short-sighted and would ultimately ring hollow. As the cheering faded, physicians who were already working within a struggling healthcare system, have seen it breaking further. We are beyond burnout and many of us are struggling with moral injury. Moral injury occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their longstanding, deeply held commitment to healing. Moral injury for physicians in 2022 is fueled by sexism, racism, gaslighting*, and white supremacy. We’ve continued doing our jobs while enduring sneers at the grocery store when wearing a mask or wearing scrubs. We’ve been vilified for sharing our expertise as physicians. Our voices as physician parents have been undervalued and/or dismissed by school board members when concerns about COVID mitigation, racial inequities and the children’s mental health crisis, which preceded the pandemic, have been raised. Physician perspective and input was absent from the Supreme Court majority opinion on abortion in Dobbs v. Jackson Women’s Health Organization. The opinion is not only a clear departure from precedent but goes further by using the derogatory term “abortionist” instead of physician, doctor, or obstetriciangynecologist. It’s demoralizing to see the U.S. Supreme Court engage in this toxic gaslighting, despite expert feedback from physicians. We are now living in a post-Roe America, where the constitutional right to abortion, upheld for nearly a half century, no longer exists. In the summer of 2022, we are at the convergence of multiple public health crises including child and adolescent mental health, gun violence, and COVID-19 all exacerbated by systemic racism. As physicians, we have put trust in our social infrastructure systems (public health, education, school boards, healthcare). We had hoped that elected officials, appointed officials or administrators would have our backs and share our Hippocratic Oath to do no harm. It has never been more clear that they are failing us.
26 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
BY MAURA DUNFEY HWANG, DO
COMBATING MORAL INJURY WITH ACTIVISM
2. Raise awareness with colleagues, family and friends — let them know that an abortion ban is on the horizon in PA.
This November we need to elect candidates in Pennsylvania for Governor and the US Senate who are committed to preserving our ability to be the doctors we want and need to be. Just as important, we need to support other candidates for election to the state legislature who will stand up for women’s reproductive rights, protect PA against an abortion ban, and support the health and well-being of PA children and families. Please consider the following action steps:
3. Know who your State House and State Senate candidates are and vote accordingly. Our physician voices will continue to be silenced and sidelined unless we raise them now and use them forcefully. This is our lane, and we will not stop speaking. We have been measured and reasonable, but we are increasingly enraged. We will not stop demanding action. We are literally fighting for our lives, the lives of our patients, and for the lives of our children.
1. Encourage patients, colleagues, friends and family to register to vote, in primary and general elections. Look into Vot-ER at your institution. This summer, the AMA declared voting a social determinant of health. Voting is essential to a healthy democracy, healthy patients and healthy families.
Maura Dunfey Hwang, DO, is a double board-certified child, adolescent and adult psychiatrist who is active with many advocacy groups including Physician Women with Democratic Principles (PWDP-PA); Philadelphia Healthcare Invested in Racial Equality (PHIRE) and PA Physicians for Healthy Families. She also serves on the Board of Directors of the Delaware County Medical Society. “Do not be daunted by the enormity of the world’s grief. Do justly, now. Love mercy, now. Walk humbly, now. You are not obligated to complete the work, but neither are you free to abandon it.” *Editor’s Notes: 1. The term gaslighting refers to the manipulation by psychological means into questioning one’s own sanity or attempting to sow self-doubt and confusion. 2. The Talmud (Hebrew for “study”) is one of the central works of the Jewish people. It is the record of rabbinic teachings that spans a period of about six hundred years, beginning in the first century C.E. and continuing through the sixth and seventh centuries C.E.
SUMMER 2022 | CHESTER COUNTY Medicine 27 www. CHESTERCMS .org
MORE THAN MEETS THE EYE: Our world has become an increasingly more visual place. In 2018, an estimated one trillion photos were taken.1 Other reports have shown that a significant portion of photos are selfies. Ultimately, we are constantly being bombarded by images of faces – including our own. With the COVID-19 pandemic and subsequent popularity of online video meetings, this effect has further been magnified and is likely responsible for the upsurge in cosmetic surgeries over the past two years. As this evolution has taken place, we have become both more aware of our physical features but also more critical of them. A spur-of-the-moment selfie may have drawn your attention to the size of your nose or a Zoom meeting may have you tugging at extra skin under your neck. According to the 2021 American Academy of Facial Plastic and Reconstructive Surgery survey, 79 percent of facial plastic surgeons identify patients seeking procedures for an improved appearance on video conferences as a rising trend, compared to only 16 percent in 2020.2 With the increased flexibility of remote work and the ever-decreasing stigma of plastic surgery, more and more individuals are opting to pursue surgical interventions for facial features that they dislike.
A meta-analysis of 37 studies suggests that patients have improvements in body image and quality-of-life after cosmetic surgery, especially those pursuing augmentation mammaplasty and aging face surgeries (e.g., face lifts).3 Another meta-analysis of 36 studies showed a positive effect of cosmetic surgery on “self-worth,” “self-esteem,” “distress and shyness,” and “quality of life.”4 Finally, a third meta-analysis of seven studies showed improvement in body image; however, no improvement was observed with regard to self-esteem, anxiety, and depression.5 Unfortunately, most of these studies suffer from small sample sizes, lack of diversity, the role of body dysmorphic disorder (BDD), and short-term follow-up; however, there is still inherent value in the questions they ask.
Anecdotally speaking, cosmetic procedures do seem to play a positive role for most patients undergoing them. Our selfperception of attractiveness seems to strongly correlate to our overall sense of happiness. In my experience as a facial plastic surgeon, the three most common anatomic areas with the greatest psychosocial improvement are periorbital rejuvenation (e.g., upper BY SINEHAN B. BAYRAK, MD
Additionally, individuals are, on average, living longer. More importantly, most individuals are maintaining careers and active social lives well past the traditional age of retirement at 65. Unfortunately, our physical bodies have continued to age at the same rate, and our increased social and professional longevity only adds pressure to maintain an appearance of youthfulness. Per the AAFPRS, an estimated 1.4 million surgical and non-surgical procedures were done in 2021, with plastic surgeons performing an average of 600 more procedures than they did in 2020, a 40% increase.2Butdoes putting a fresh coat of paint on change anything beneath the surface? A variety of studies suggest that it might.
THE PSYCHOSOCIAL BENEFITS OF COSMETIC SURGERY
28 CHESTER COUNTY Medicine | SUMMER 2022 www. CHESTERCMS .org
Frontal, profile, and oblique pre- and post-surgical views of a neck lift patient.
Sinehan B. Bayrak, MD, is a Facial Plastic Surgeon, practicing at Subbio Plastic Surgery in Newtown Square, PA. Dr. Bayrak is an active member of the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Otolaryngology – Head and Neck Surgery, and The Triological Society. Patient that had a temporal brow lift, upper blepharoplasty, lower blepharoplasty, and periorbital CO2 laser resurfacing.
www. CHESTERCMS .org SUMMER 2022 | CHESTER COUNTY Medicine 29 and lower blepharoplasty, brow lifts, etc.) and cervical rhytidectomy (i.e., neck lift). Patients who undergo these rejuvenative procedures seem to have the most significant gains when it comes to body image and selfesteem.There is truth to the old adage of “eyes are the windows to the soul.” Eye-tracking studies have shown that most people exhibit gaze patterns that follow the eye-mouth gaze continuum.6 Simply put, during face-to-face conversation most participants alternate their gaze between the other individual’s eyes and mouth. The adoption of masking during the COVID-19 pandemic drew increased attention to the periorbital area – the intersection of the brow, upper eyelid, and lower eyelid. While upper blepharoplasty has been performed for functional vision impairment due to dermatochalasis, cosmetic upper blepharoplasty patients often present with complaints of looking tired, appearing older than their actual age, or feeling a sensation of heaviness on their upper eyelids.Women, specifically, often endorse difficulty applying eyeshadow or mascara. Descent of the eyebrow or brow ptosis can often accompany excess skin of the upper eyelid, further exacerbating the complaints listed above. With regard to the lower eyelids, candidates for lower blepharoplasty typically have physical exam findings of lower eyelid dermatochalasis and fat herniation. They often complain of “crepiness” of the lower eyelid skin and “bags” under their eyes. Periorbital procedures like brow lifts and upper and lower blepharoplasties can address all of these concerns and complaints. Lightening the “load” on the upper eyelid not only manifests physically as increased eyelid space and a well-defined supratarsal crease; the decrease in hooding and the sensation of heaviness makes patients feel more well-rested. Similarly, addressing the undereye “bags” due to intraorbital fat herniation frequently results in a decreased perception of tiredness. Essentially, when we look less weary, we tend to feel less weary.The popularity of virtual meetings via platforms like Zoom, Microsoft Teams, etc., has undoubtedly increased the amount of time we spend looking at ourselves. The neck, in particular, has received a spike in attention, likely exacerbated by the typically suboptimal angle of most webcams (i.e., angled upwards on laptops). Moreover, most of us are not as diligent when taking care of the neck. For example, think of all the times you’ve put sunscreen on your face but not your neck. Unfortunately, nonsurgical anti-aging treatments for the neck are limited when compared to the face. In my practice, there has been a distinct uptick in the number of patients bothered by the redundant skin and muscle dehiscence of the cervical region. Like most aging processes, this is commonly due to a tincture of factors, including genetics, environmental exposure, time, and gravity; however, there is some thought that the increased use of handheld electronics (resulting in the advent of “tech neck”) has amplified these physical changes. Thanks to our cell phones, tablets, and smart watches, we spend far more time looking downwards than our parents and grandparents.Whilenon-surgical therapies like neurotoxin injections, hyaluronic acid injections, and radiofrequency skin-tightening devices exist and may be appropriate options in the younger patient with realistic expectations, results achievable with these interventions are often underwhelming and, frankly, inappropriate in the older patient with moderate-to-severe skin laxity and platysmal banding. Patients often come in with stories of seeing a candid photo of themselves taken from the side (i.e., a profile view) and being bothered by this visual. Events like these lead to magnified self-consciousness regarding that particular feature. After a surgical neck lift, these patients often report high levels of happiness regarding their surgical results and their newfound freedom from their previous insecurity regarding their appearance. When we feel good about how we look, we feel good about other aspects of our lives as well. Positive body image translates into positive interpersonal relationships, increased productivity, and a higher quality of life. It is worth mentioning, of course, that cosmetic treatments and procedures do not treat BDD or other deep-rooted psychological issues. In these situations, therapy and medication under the guidance of a mental health professional are paramount. In the absence of these circumstances, peer-reviewed studies and personal experience suggest that the effects of plastic surgery are more than skin deep.
C arlos, a patient of Community Volunteers in Medicine, had experienced blurred vision for many years. He had never had an optical exam, and was eager to attend a recent eye exam event held at the healthcare center. Carlos was amazed when the doctor adjusted the lenses of the exam equipment to allow him to suddenly see sharply and in focus. A landscaper by trade, Carlos spent his entire life working in the sun, which resulted in a case of pterygium—also called “surfer’s eye,” a growth that forms in the conjunctiva due to prolonged exposure to the sun. Until this exam, he was unaware that wearing sunglasses could have protected him from this condition, as well as preserving his vision. He and many others like him at the two-day optical care event were elated when the simple exams they received free of charge resulted in improved vision and free eyeglasses.
BY JANET JACAPRARO, M.D. CVIM MEDICAL DIRECTOR
30 CHESTER COUNTY Medicine | www. CHESTERCMS .org
The group of volunteers from Salus included three members of the optometric faculty, five optometric student interns, and one optometric technician. These volunteers identified 33 patients who require follow-up care from CVIM volunteer ophthalmologists. Additionally, 74 patients will get eyeglasses, which are being provided to the patients free of charge.
Community Volunteers in Medicine (CVIM), a local nonprofit full-service health care center that provides free, high-quality healthcare to low-income, uninsured Chester County residents, launched our expanded vision care program in June with a twoday optical exam blitz. On June 23 and 24, volunteers from Salus University’s Pennsylvania College of Optometry arrived at CVIM’s West Chester healthcare center with their vision van, a specialized mobile unit outfitted with optical exam equipment. In that van, as well as in CVIM’s brand-new, state-of-the-art eyecare lane, nine Salus volunteers helped address our eye care waiting list by performing 76 eye exams for CVIM patients. Volunteers and employees who helped work at the event get tears in their own eyes when discussing it. “It was like Christmas,” said one interpreter, who got emotional when recalling the joy of helping patients receive their first-ever eye exams.
“CVIM is where the community comes together to address a community need. Together, our caring network of volunteers, donors, and partners form a healthcare safety net for our vulnerable neighbors.”
Maureen Tomoschuk, CVIM President and CEO
While these partnerships and the grant money have been an incredible benefit for our patients, the need continues. We are still seeking additional partners, as the eye exams often reveal issues that require referrals for specialized care, such as procedures and surgeries. Like Carlos, many patients have pterygiums due to the time spent outside working in the landscaping and agricultural industries. Some patients seen during the kick-off event need follow-up care for cataracts and glaucoma. Many CVIM patients have diabetes, which puts them at increased risk for diabetic retinopathy and related issues such as diabetic macular edema (DME).Therefore, it is crucial that we are able to provide our patients with regular eye exams and referrals for follow-up treatment to ensure their continued vision health. Currently, we have community partners at Levin, Luminais Chronister and at Siepser Eyecare who provide this specialized care. However, the need is growing, and CVIM is looking for more ophthalmologists who are willing to see patients in their offices for special procedures and surgeries. If you can help, please contact me, Dr. Janet Jacapraro, at firstname.lastname@example.org.
About CVIM Founded in 1998, Community Volunteers in Medicine (CVIM) delivers free, comprehensive, high-quality medical services, dental care, behavioral healthcare, and prescription medications to more than 4,000 individuals and families among the working uninsured in the region. Services are provided by 350 volunteers who donate their time and professional services. Area healthcare institutions contribute diagnostic services and advanced care that cannot be offered in a primary care setting. Virtually 100% of CVIM’s revenue comes from philanthropy. Beyond providing direct care that improves the health of the overall community, CVIM is an expression of our highest ideals as a society: compassion and equity for everyone.
SUMMER 2022 | CHESTER COUNTY Medicine 31
The Role our Partners Play CVIM relies on philanthropy, volunteerism, and strong relationships with community partners to advance our health equity mission. In addition to volunteer providers for primary care, we do have volunteer practitioners offering 15 specialties from cardiology to rheumatology. Our local hospital partners provide charity care services for CVIM patients. Chester County Hospital Penn Medicine provides free laboratory testing, and Main Line Health’s Paoli Hospital provides diagnostic imaging, surgery, and even cancer care. But we still rely on partner practices within the community for donated services that are needed by our patients but not possible at CVIM. Strong partnerships with community-based organizations including hospitals, universities, social service organizations, and private healthcare practitioners make possible the full complement of our services.
When it comes to MRI providers, there is a difference. MRI Group has a long tradition of excellence: Accurate image reading. Collaborative, highly trained physicians. Exceptional patient experience. Affordable rates. • Images read by local radiologists • Radiologists available 24 hours a day, year round, to read images and provide consultation • All MRI Group locations are ACR accredited • All radiologists are board certified by American Board of Radiology • Experts in various radiology specialties including cardiovascular, interventional, neuroradiology, vascular, musculoskeletal, and pediatric imaging • Evening appointments available MRI scans performed at our Parkesburg location • Abdomen • Brain • Chest • Extremity • Joint • (MRA)AngiographyResonanceMagnetic • Pelvis • Spine Phone: 717-291-1016 Fax: 717-509-8642 MRIGroup.com Several locations in Lancaster County and Chester County CHESTER COUNTY LOCATION: 950 S. Octorara Trail, Parkesburg (Intersection of Routes 30 and 10) We are located at the Penn Medicine Lancaster General Health Parkesburg outpatient facility.