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THE ART of Chester County PROTECTING PATIentS IN CHESTER COUNTY FROM ONE-SIZE-FITS-ALL HEALTHCARE

SODIUM RESTRICTION: A TIME-HONORED DOGMA OR AN EVIDENCE-BASED PURSUIT?


oUr Family

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gateway medical associates, in Chester and now Delaware County, has been serving our community since 1996. Gateway strives to provide the highest quality primary and specialty care with a focus on our patients’ wellbeing and health. Our 43 physicians and nurse practitioners provide quality care from any of our 10 convenient locations. New patients are always welcome.

viSit oUr NEw PracticES:

Gateway Family Practice Newtown Square Newtown Business Center 4667 West Chester Pike, Newtown Square, PA 19073 610.356.7870 Maria DeMario, D.O. Tiffany Giltner, CRNP Gateway Brandywine Village Family Medicine 1229 Horseshoe Pike, Downingtown, PA 19335 610.873.2700

You can now schedule appointments online! gatEwaydoctorS.com

610.423.8181

Francis W. Brennan, D.O. Laurie A. Gallagher, D.O. Elizabeth M. Danielsen, CRNP Stacey Yantis, CRNP

NCQA Level 3 Certified Patient Centered Medical Home Practice Meaningful Use Recognized

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Contents WINTER 2014

2013-2016 CCMS OFFICERS President Winslow W. Murdoch, MD

President-Elect Mian A. Jan, MD, FACC

Vice President Michael J. Maggitti, MD

16 Physician Leadership...

Secretary Bruce A. Colley, DO

Treasurer David E. Bobman, MD

Board Members Mahmoud K. Effat, MD Heidar K. Jahromi, MD

17 THE ART of Chester County

Liza P. Jodry, MD

Presentation of a Case Study

John P. Maher, MD Charles P. McClure, MD Susan B. Ward, MD

Chester County Medicine is a publication of the Chester County Medical Society (CCMS). The Chester County Medical Society’s mission has evolved to represent and serve all physicians of Chester County and their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance the role of medicine and health care within the community, Chester County and Pennsylvania. The opinions expressed in these pages are those of the individual authors and not necessarily those of the Chester County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Chester County Medical Society. Chester County Medicine is published by Hoffmann Publishing Group, Inc., Reading PA 19608 HoffmannPublishing.com For advertising information, contact Karen Zach 610.685.0914 karen@hoffpubs.com

Features 6

11 6

“Healthy Pennsylvania” Expanded Medicaid Health Dollars: How Best to Use Them

10 Home Sleep Testing: Explanation and Implications 11 Presentation of a Case Study

In Every Issue 5 7 23

President’s Message PAMED Legislative Update Membership News & Announcements

14 Protecting Patients in Chester County from One-Size-Fits-All Healthcare 16 Physician Leadership: Why it Matters 17 THE ART of Chester County 18 CCMS Membership... Is it Right for You? 20 Physicians’ Health Programs Welcomes New Staff Members 22 Sodium Restrictions: A Time-Honored Dogma or an Evidence-Based Pursuit?

Chester County Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA I HoffmannPublishing.com I 610.685.0914 I for advertising information: karen@hoffpubs.com


EXCELLENCE. ONE OF THE TOP IN THE NATION. RIGHT HERE.

By focusing on quality care for patients and doing what’s right, we have received national recognition. The Joint Commission recognizes Brandywine Hospital* with the distinction of 2012 Top Performer on Key Quality Measures® for attaining and sustaining excellence in the following measure sets: Heart Attack, Heart Failure, Pneumonia and Surgical Care. So what does this recognition in using evidence-based care mean for you? Peace of mind in knowing that our local care is among the top in the nation. Find out more at BrandywineHospital.com.

It’s better at Brandywine. *Coatesville Hospital Corporation d/b/a Brandywine Hospital

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President’s Message

If there w as ever a time for us to come tog e th er as a profe ssion, this is it!

President’s Message

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hange is inevitable, sometimes for the better, sometimes for the worse. Healthcare costs over the last few decades in almost all developed countries, but especially the U.S., have become unsustainable. For the most part, patients are required to delegate their health care dollars to legacy third party payers (employer designated insurers, or government programs like Medicare and Medicaid) to act as intermediary. Physician quality and value are variables that have traditionally been hard to measure. Physicians are also trained to focus on the patient first, and not populations. Therefore until now, legacy third parties have been the ones who make policies and decisions that by default fall on healthcare providers to enact as the change agent. This creates disconnect by placing a third party between those requiring/requesting and ultimately paying for the services, and those who are providing it. It creates a market where there is very little price transparency. It poses a moral hazard for those with coverage, in that there is limited individual risk to demanding “bigger is better, no stone unturned… at every visit.” It creates barriers to care by limiting access (long waits, one problem per visit, multiple referrals, etc.). Lastly, it creates a top-down mandated structure that stifles innovation from those very

persons doing the day-to-day work. We are now entering a brave new world of high deductible healthcare plans and price transparency. Decades of data collection on physician activity and outcomes collected by the legacy players will increasingly become available and shared. In addition to legacy third parties, employers, and now venture capital investors, are starting to utilize data to create Clinically Integrated Networks of doctors. Their goals, to best meet the triple aim of: Cost, Quality and Service. Some will be winners, some not so much. Sliding co-pay price tiers will be established that will incentivize patients to utilize internally-selected physicians within narrower physician networks. These certainly are exciting times. There is potential for many of us to transform our professional lives in a positive direction, and increase our independence by employing creative problem solving, to improve our day-to-day practice lives. At the same time, there is great risk that these networks will be formed/funded and lead by the same legacy third parties that created this mess in the first place. Quality and outcomes data will be viewed through their lens. They still control the golden rule, those with the gold rule… If there ever was a time for us to come together as a profession, this is it! Instead of being at the table, we will be on the menu. I implore all practicing doctors in Chester County to join together in some organized fashion(s) to collaborate and pool resources. Having been involved at

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the county and PAMED state level for almost a decade, I have been exposed to a large energized group of very talented volunteer colleagues, and a small dedicated staff. They work tirelessly (and behind the scenes from most) on our behalf on a daily basis. Just as for our patients, in the long run, a proactive approach is much less costly and painful than a purely reactive approach. We need to focus our efforts into areas relevant to our day-to-day professional lives, utilize the resources and manpower that extend far beyond our personal reach, and create value within our profession. I invite all practicing doctors (regardless of membership status with CCMS or PAMED) and their significant other/ spouse to an informal meeting we will be hosting in May 2014 at the Applebrook Golf Club in Malvern, PA. I hope to organize some fun group brainstorming projects at the meeting and reinvigorate our sense of community and purpose as a profession. We will also announce the strategic plan that comes from the February 2014 PAMED board meeting and find common ground from which to chart our future. Watch for more information about this event and RSVP instructions in the next few weeks.

Happy New Year! I look forward to seeing many of you soon. Winslow W. Murdoch, MD Family Medicine West Chester, PA President of the Chester County Medical Society


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Mian A. Jan

Features

“Healthy Pennsylvania” Expanded Medicaid Health Dollars: How Best to Use Them T

he decision Pennsylvania makes on how to provide health coverage for its uninsured could make the difference between financial security and fiscal peril – a test we dare not fail. Right now, the federal government is offering to cover 100 percent of the cost to enroll more than a half-million Pennsylvanians in the Medicaid program. In future years, they will cover 90 percent of the cost. In later years, it will be less. This expanded Medicaid system would put a quarter of our population on government medical assistance. They would be a part of the state’s welfare system. No one in Washington is willing to say just how much this 10 percent share will cost Pennsylvania taxpayers down the road, just as they will not guarantee that we will eventually have to pay 50, 75, or 100 percent of the cost in the decades ahead. Whatever dollars we receive, we need to maximize. That brings us to Gov. Tom Corbett’s proposal called “Healthy Pennsylvania.” The plan has a lot of appeal, at least on paper, because it is not designed simply for the present but for the years ahead.

First, he would take the federal Medicaid dollars and have new enrollees use that money to purchase health insurance from private providers via the federal healthcare exchange. This makes sense on several levels: • Recipients will act as consumers, picking out the plan that best matches their needs. • Competition among private insurers will mean lower prices. • Instead of the stigma of government assistance, the new enrollees will have private insurance – the kind more readily accepted by top-flight physicians and specialists. The Corbett plan does not stop at the financial aspects. He proposes a holistic approach that includes expanding the use of telemedicine to make sure patients in remote or underserved areas of the state will have access via electronic hookups to top specialists in any part of Pennsylvania or the country. We have to make sure telemedicine does not become the norm, but is used for underserved areas where there is a limited availability of specialized care. Governor Corbett has proposed a tighter system to monitor the overprescribing of prescription painkillers, one of the leading causes of addiction. This should be supervised by a physician with expertise in addiction. He has also already succeeded in reauthorizing the state’s Children’s

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Health Insurance Program, eliminating a six-month waiting period for many new enrollees. I am not saying the plan is without flaws, and we are still waiting for the complete draft. But it does put in place some protection for paying customers and assures that social services will go to eligible and deserving patients. The Affordable Care Act is now a reality in the United States, but with the Corbett plan, the ACA does not have to be a grim reality. We can make it work using the efficiencies of the free market, healthy competition and the forward-looking approach that is “Healthy Pennsylvania.” Chester County has been the healthiest county in the Commonwealth, so we as physicians have done something right with our current resources, and change should not be for the sake of change but rather for the betterment of citizens. We as physicians should at least look more closely at Governor Corbett’s plan.

Mian A. Jan, M.D., is the immediate past president of the Chester County Medical Society and a practicing cardiologist in Chester County.


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PAMED Legislative Update

Scot Chadwick

Apology Bill Thanks in large part to physician advocacy, on October 25, 2013, Governor Tom Corbett signed into law legislation preventing most physician apologies from being used against them in a medical liability lawsuit. PAMED members sent more than 1,300 messages to the state legislature in support of this legislation over the course of the two-year campaign. The legislation, now Act 79 of 2013, will protect most physician apologies except for admissions of negligence, which will remain admissible. It removes a barrier to open communication between physicians and patients after a poor outcome, which is essential to maintaining the physician-patient relationship.

Pennsylvania Medical Society Quarterly Legislative Update By Scot Chadwick, Legislative Counsel, PAMED

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he state House and Senate both recessed until mid-January, closing the books on legislative activity for 2013. The fourth quarter of 2013 was a busy one, with action on several measures of importance to physicians and patients. Following is a summary of some of the highlights.

The new law does not take any legal right away from injured patients or impair their ability to file a personal injury action against a health care provider should they choose to do so. It also does not limit the amount that a patient can recover in such an action. The bill became effective on December 24, 1013. PAMED has put together a short webinar that goes over the nuances of the new law. It can be accessed on the Society’s website (http://www.pamedsoc.org/).

Controlled Substance Database A bill that would create a controlled substances database, giving physicians better knowledge of prescriptions written for and filled by a patient, is one step closer to becoming law. The House of Representatives passed House Bill 1694 on October 21, 2013, by a vote of 191-7. The success was the Continued on page 8

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PAMED Legislative Update

result of two years of effort by PAMED and its members, who recognize the value such a database would have in reducing doctor shopping and controlled substance abuse. Our “Pills for Ills, Not Thrills” campaign has played a major role in generating public support for the legislation. On November 18, 2013, Senator Pat Vance (R-Cumberland) introduced her own version of the legislation, Senate Bill 1180. The bill differs in several respects from the House-passed bill, HB 1694. PAMED is now working to reconcile those differences and get a final product to Governor Corbett’s desk to make this important tool a reality for Pennsylvania physicians.

Physician Assistant Bills Signed into Law Do you have a physician assistant (PA) with whom you have worked for some time, and who has impressed you with his or her competence? Has your confidence in that PA’s work reached the point where countersigning every one of his or her patient records has become an administrative burden rather than a necessity for patient safety? Could you be more productive, and do you believe patient safety would not be compromised if you were to countersign fewer of your PA’s patient records going forward? If you can answer yes to all of those questions, help is on the way. On November 27, 2013, Governor Corbett signed two bills into law that will permit the PA countersignature requirement to be relaxed under appropriate circumstances. The measures, House Bills 1348 and 1351, had the support of PAMED and the Pennsylvania Society of Physician Assistants, and became effective on January 26, 2014.

Under the new laws, physicians will continue to be required to countersign 100 percent of PA patient records during the first 12 months of a PA’s practice post-graduation and licensing; during the first 12 months of a PA’s practice in a new specialty; and during the first six months of a PA’s practice in the same specialty under the supervision of a new physician. After that, the PA’s approved physician could choose to review on a regular basis a lesser number of patient records completed by the PA. The physician will select patient records for review on the basis of written criteria established by the physician and the PA. The number of patient records reviewed must still be sufficient to assure adequate review of the PA’s scope of practice. That written agreement would then be submitted to the State Board of Medicine or State Board of Osteopathic Medicine for approval, the final step before the agreement would go into effect. It is important to note that entering into an agreement with your PA to countersign fewer than 100 percent of his or her patient records is purely optional. If a physician wishes to continue to review and countersign all of a PA’s patient records, he or she is free to do so. However, in appropriate circumstances, physicians now have a way to improve their efficiency and productivity without jeopardizing patient safety. PAMED believes this legislation is a good example of how physician-led, team-based care can be streamlined, ultimately increasing access to care.

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Child Protection Laws Strengthened On December 18, 2013, Governor Corbett signed into law a 10-bill package strengthening the state’s child abuse laws. The Sandusky scandal at Penn State revealed a number of weaknesses in Pennsylvania’s child protection laws and caused the General Assembly to establish a Child Protection Task Force to review the state’s existing statutes and recommend changes. The task force, headed by Bucks County District Attorney Dave Heckler, released a 427-page report in November 2012 recommending a wide range of reforms, which found their way into more than 30 House and Senate bills. While the 10 bills signed into law probably contain the bulk of the changes, there are still a couple more that will likely reach the Governor’s desk in early 2014. At least one of those will almost certainly have significance for physicians in their role as mandated reporters. Many of the changes enacted don’t go into effect until December 31, 2014, in order to give mandated reporters and others assigned new responsibilities an opportunity to be trained. PAMED is already at work planning the necessary educational materials for our members. Among the coming changes, the new laws will broaden the range of persons who can be found guilty of child abuse, and significantly lower the threshold for the degree of injury, pain or impairment needed to trigger a report of suspected child abuse. These are important things for physicians, who are mandated reporters, to know.


WINTER 2014

Scot Chadwick

Physician Leadership Day Held at Capitol With millions more Pennsylvanians potentially gaining health insurance as the Affordable Care Act goes into effect, their physicians want to be sure that care is teambased and physician-led. To spotlight physicians’ concerns, on December 10, 2013, PAMED leaders and members gathered at the Capitol in Harrisburg for a media event with Governor Corbett and Representative Matt Baker (R-Tioga), as part of PAMED’s Physician Leadership Day. Two bills that would help build a stronger framework for our health care teams have been introduced by Senator Judy Schwank (D-Berks) and Representative Baker. The bills, Senate Bill 1083 and House Bill 1655, propose a Patient-Centered Medical Home Advisory Council at the Department of Public Welfare to help nurture the growth and development of patient-centered care in the Medicaid program.

Governor Corbett also publicly announced his support for the establishment of a statewide controlled substance database and the proposed apology law. Not long afterward, the House passed a controlled substance database bill and the legislature enacted the state’s new apology law. Finally, the governor also announced his advocacy for health care technology and telemedicine. PAMED strongly supports the development of a statewide health information exchange (HIE), and is pleased that the Corbett administration and legislature are moving forward with this initiative. PAMED will be working aggressively with the governor and legislature over the coming months to advance this positive package of health care measures.

Following the media event, the physicians and physiciansin-training visited with their legislators to push for support of measures to help keep Pennsylvania’s health care teams strong, physician-led, and patient-centered. Member physicians also urged their legislators to support bills to improve access to care for the uninsured; retain and recruit the physician workforce, especially through student debt forgiveness and expanded residency slots; prevent prescription drug abuse through a controlled substances database; and improve access to health care technology in Pennsylvania.

Ask a Physician: If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to

Healthy Pennsylvania On September 16, 2013, Governor Corbett announced his Healthy Pennsylvania package of initiatives, and while his take on Medicaid expansion has grabbed all the headlines, the plan contains a number of other pro-physician, propatient measures.

admin@chestercms.org

Among those proposals, the governor endorsed increased medical student debt forgiveness, long a goal of PAMED. According to a 2012 report, the mean debt for graduates from the class of 2012 was nearly $167,000, not including premedical educational debt, driving many graduates away from primary care to higher paying specialties. The governor also proposed additional funding to increase the number of in-state primary care residency slots, a move that could help the growth of the physician population in medically underserved areas.

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with “Ask a Physician” as the subject. Your question will be forwarded to a physician and may be featured with an answer in a future issue of the magazine.

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Features

Brian Abaluck

Home Sleep Testing: Explanation and Implications By Brian Abaluck, MD

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ll major private insurers in our area now require prior authorization for polysomnography. Criteria for prior authorizations vary but have uniformly reduced in-lab testing and increased home sleep testing.

respiratory events. Such events fragment sleep, cause sleepiness, and increase cardiovascular risk. Lack of detection of arousal-associated pauses in breathing reduces sensitivity of home testing to sleep apnea, especially among the young and non-obese.

Given such low sensitivity, the American Academy of Sleep Medicine and I prefer the home sleep test in obese, snoring, sleepy patients who have overwhelmingly high pretest probabilities of sleep apnea. Unfortunately, insurance companies favor home sleep testing in all healthy adults, which creates many false negatives and enhances the importance of a full clinical sleep evaluation. After all, in some patients with negative home sleep tests, the likelihood of sleep apnea remains high: 40% of hypertensive patients, 70% of diabetic patients, and 90% of stroke patients have some degree of obstructive sleep Both home and in-lab studies detect respiratory events associated with oxygen apnea. desaturations. Unfortunately, lacking So what do these changes mean for EEG leads (or reliable EEG leads you? I saw an identical transition to even when present), most home sleep testing cannot record arousal-associated home sleep testing when I worked In-lab testing includes EEG, airflow, EKG, oximetry, chest and abdominal effort bands, and, on the chin and legs, EMG leads. Thus, in-lab studies detect periodic limb movements. EEG leads stage sleep and record arousals. Home sleep testing typically includes oximetry, airflow, and effort bands. There is generally no EEG lead to assess arousals. Home sleep testing requires the patient to come to the sleep lab, learn how to apply the sleep testing device, apply the device with its leads at home, record sleep period, and return the device to the sleep lab.

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at Brigham and Women’s Hospital as a fellow and staff member from 2009 to 2012. In 2009, Boston doctors traditionally referred patients directly for sleep studies. By 2012, as a result of prior authorizations, PCPs were sending patients for clinical consults so sleep doctors and sleep staff could handle prior authorizations, communication of sleep study results, patient follow-up, and CPAP when necessary (which it is not in many patients with sleep apnea). While sleep doctors struggled with this transition, referring physicians found conversations with sleep disordered patients shorter. No longer did your peer have to convince a patient to try to sleep in an unfamiliar place where a stranger would attach probes and perhaps apply a fighter pilot mask. Your peers would say, “I’m concerned about your sleep. Sleep problems can increase risk of stroke and heart attack. I’d like you to see a sleep specialist.”

Brian Abaluck, MD, is an independent sleep specialist.


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Features

Jan and Jan

Presentation of a Case Study: Woman with Takotsubo Cardiomyopathy, or Broken Heart Syndrome The author of the case study and research of the article is M. Kouresch Jan, who is finishing his third year at Drexel Medical School. He collaborated on the article with Mian A. Jan, MD, an interventional cardiologist at Chester County Hospital.

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middle-aged female was brought to the emergency room following two episodes of seizure activity. The patient appeared to be somewhat confused with slight slurring of speech, not unlike post ictal state. The patient’s vital signs were within acceptable range. Review of the system was significant for chronic anxiety, which had recently been compounded by both medical and personal issues. She was also recently separated from her significant other of many years. Social and family history was significant for forty-pack history of cigarette smoking, and there is no history of alcohol or drug abuse. Additionally, there is no family history of premature coronary artery disease or stroke. In the emergency room, the workup revealed a negative CAT scan of the head for an acute process. An EKG revealed no acute findings and was unchanged from the previous EKG. The patient’s white cell count was slightly elevated to 15.18K/uL. Serum chemistry, except for elevated random glucose of 173mg/dL, was unremarkable. A chest x-ray did not show any active disease. She was admitted to telemetry with a diagnosis of a breakthrough seizure of unclear etiology. An EEG carotid Doppler and neuro consult were ordered.

Forty-eight hours later, the patient suddenly developed acute shortness of breath accompanied by persistent chest pain, symptoms that were new to her. Consequently, a cardiology consultation was obtained and EKG and cardiac markers were ordered. The troponins were slightly elevated to .10. The EKG showed significant dynamic changes over precardial leads indicating subendocardial infarction or ischemia.

Initial EKG at presentation, unchanged from previous EKG of 2 years prior.

EKG during shortness of breath and chest pain.

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Features

An echo performed was of limited quality but revealed severe left ventricular dysfunction with estimated ejection fraction of 30%. There was mild to moderate mitral regurgitation seen. Patient’s coronary images with normal coronaries.

Classic presentation of Takotsubo cardiomyopathy by left ventriculography. At this time, a tentative diagnosis of stress-induced cardiomyopathy (Takotsubo) was made and the patient was treated with a beta blocker (Carvedilol) and ace inhibitors (Ramipril). A psychiatric consult was also obtained and the patient was placed on anti-anxiety and anti-depressant medication. The patient improved and was discharged in stable condition. A follow-up visit to the office showed significant improvement of her symptoms and improvement of her ejection fraction to within normal range of 55%. This was an atypical presentation to start with. The patient came with neurological symptoms but was accompanied by significant stress because of her separation from her spouse, as well as possible development of lung cancer and developed Takotsubo cardiomyopathy while in the hospital. The diagnosis was easily confirmed after cardiac catheterization.

A CT angiography revealed possible right lower lobe mass, bilateral pleural effusions, and evidence of pulmonary vascular congestion, and there was no evidence of pulmonary embolism. Due to dynamic change in the patient’s hemodynamic status with possibility of an acute coronary syndrome, the patient was taken to a cardiac catheterization laboratory. Essentials of her cath were as follows: • Normal coronaries. • Severely depressed left ventricular ejection fraction with apical ballooning and a hypo-kinetic apical and infra apical segments showing Takotsubo cardiomyopathy (TC) configuration. Ejection fracture was 20%. • Hemodynamic assessment revealed severely elevated LVEDP of 38mm and mean pulmonary capillary wedge pressure of 33mm. The pulmonary artery pressure was only mild to moderately elevated.

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Jan and Jan

Discussion

Diagnosis: A combination of EKG changes echocardiographic features with normal coronaries by coronary catheterization, which also shows typical apical ballooning and severe systolic dysfunction of LV.

Historical Prospective: Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy and broken heart syndrome, was first described by the Japanese in 1991. It was named because of its resemblance after octopus trap, called Takotsubo in Japanese.

Etiology: At this time, we know that Takotsubo cardiomyopathy results from sudden myocardial stunning, but is different from stunning that occurs with acute coronary occlusion. High levels of circulating epinephrine trigger a switch in intracellular signal trafficking from Gs protein to Gi protein signaling through the ß2AR. This change in signaling is negatively inotropic, and the effect is greatest at the apical myocardium in which the density of ß-adrenoreceptors is highest. There are less convincing hypotheses for the etiology, including intense epicardial coronary vasospasm. Even micro vascular spasm has been suggested. Another potential etiology mentioned is neurogenic stunned myocardium. Myocarditis leading to transient LV dysfunction has also been suggested.

Features of TC include: • Sudden development of shortness of breath, chest pain, and evidence of CHF following intense emotional stress (loss of loved one, separation, or severance of relationship with a loved one). Severe physical stress can also precipitate TC. • Electrocardiographic abnormalities resembling an acute coronary syndrome with mild elevation of cardiac markers. • No evidence of obstructive coronary artery disease. • Typical ballooning of the left ventricle with a severe sudden drop in ejection fraction.

Treatment: Treatment of TC is generally supportive. Since the disease is due to high catecholamine state, the patient should not be given inotropes for hemodynamic compromise. If needed, an intraaortic balloon pump or other supportive devices can be utilized. Agents like beta blockers and ace inhibitors should be utilized. Emotional stress should be combated on a permanent basis since there is 5-10% incidence of reoccurrence, especially in the first year with identical emotional or physical stress. Prognosis: Despite grave initial presentation, most patients survive the initial acute event. Although there is small initial mortality, the survival rate is better than 95%. In summary we presented a unique case of Takotsubo cardiomyopathy in a sixtyfive year-old female who presented with neurological symptoms and extreme physical and emotional stress and developed cardiomyopathy during her stay in the hospital. References Virani et. al. Takotsubo Cardiomyopathy, Texas Heart Journal. Sharkey et. al. Takotsubo Cardiomyopathy, Circulation.

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Features

Protecting Patients in Chester County from One-Size-Fits-All Healthcare A

s a Chester County board certified cardiologist and a physician practicing for more than 25 years, I see a diverse group of patients from a variety of backgrounds. No two patients are the same and I strive to give the very best care depending on the patient’s specific case. I apply a one-onone relationship model to the treatment and care of all my patients. It is for this reason that I recently participated in a healthcare forum at La Comunidad Hispana with a panel that included Congressman Joe Pitts

(PA-16) to discuss a new program – Academic Detailing – that is raising red flags in the medical community and is concerning to many physicians and patients alike. Academic Detailing is a U.S. Health and Human Services (HHS) program that promotes information gathered from research to help healthcare givers to make decisions based on research but also cost-effectiveness. In 2009, the Economic Stimulus Package allotted $1.1 billion towards Comparative Effectiveness Research (CER), research that essentially aims to figure out what works best in medicine. On paper, this sounds like money well spent. Unfortunately, as with most things in Washington, the devil is in the details and, as we have seen with the rollout of the Affordable Care Act, although much needed, the reality of

federal healthcare programs is that they do not always turn out the way they were promised or intended. To date, more than $30 million in CER stimulus funds have been spent on this program where government contractors or detailers visit physician offices, provide them with CER research, and try to convince the physician to make treatment recommendations based on the CER studies. While it is always helpful for physicians to have the latest research, it is not in the best interest of the patient for the physician to be told what kind of medicines should be prescribed for them based on onesize government research and costeffectiveness data. Abiding by Academic Detailing recommendations to make medical decisions is especially worrisome to

(L-R) Dr. George K. Avetian (Osteopathic Manipulative Medicine) and Andrew Spiegel (Global Colon Cancer Association) participated in a health care forum with Congressman Joseph Pitts and Dr. Mian A. Jan (far right) at La Comunidad Hispana.

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WINTER 2014

Mian A. Jan

physicians because the studies tend to be overly broad and do not take into account major factors such as age, race, or disability. CER studies are conducted to reflect what works best for the majority of people. However, the patients we see have specific medical needs and often-complicated conditions that must be dealt with on an individual case-by-case basis. Every single patient is different, which is why it is so critical that CER is never used to prevent any medical treatment in an effort to cut costs. Medicine should never be an assembly line. We must value the doctor-patient relationship and the trust that goes with it. New research data and information should be made available

to doctors and patients, but not in a manner that pressures physicians and obstructs a patient’s access to personal, individualized care. We simply cannot let government detailers replace doctors and patients as the ultimate healthcare decision-makers. As a physician we are very open to research data and information and appreciate any information we get regarding CER. If two treatments are similarly effective, there is no reason not to use the less costly treatment, but that decision should be based on research as it pertains to that patient and should be undertaken for the best interest of the patient and patient alone. If a physician wants to order a PSA test or a mammogram,

that decision should be based on the patient and the patient alone, not simply on data which may not address the patient’s sex, race, or ethnicity. In summary, we as physicians need to look at all available data, including comparative effectiveness, but the final decision should be based on what is best for our patients.

Mian A. Jan, M.D., is the immediate past president of the Chester County Medical Society and a practicing cardiologist in Chester County.

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Features

Tracey Haas

Physician Leadership: Why it Matters By Tracey Haas, DO, MPH, and Co-Founder of DocBookMD

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teve Jobs once said, “Innovation distinguishes between a leader and a follower.” I wouldn’t have known what he meant right out of residency, thrust into my first “leadership” role. What does it mean, after all, to be a leader in medicine? Many, like me, were considered a team leader by default, simply because of a degree. But as many have also learned, it takes skills and maturity to become a person others respect, listen to, want to follow – skills not necessarily taught in medical training. So then how can a doctor truly become a leader, and what does it really mean? Getting back to the quote, a leader can identify a problem and innovate to find a solution.

To continue in the spirit of Steve Jobs, “A leader leads by example whether he intends to or not.” Physicians are naturally in a position to influence others and be respected for their knowledge. Healthcare has become a marketplace, and those with a little business knowledge are often given positions to trump those with a lot of medical knowledge. This does not have to be the way of the future. Physicians and those who care for patients understand better than those in business how to save money in healthcare and how to innovate for better outcomes for their patients; they just need to be supported in these endeavors, and physician leaders support each other.

This may sound over-simplified, but the leap that it takes to go from naming a problem to doing something about it is a huge one. To take action and motivate others to do the same is really spectacular. But to build momentum and inspire impactful change in any industry takes something special, and this is where it gets exciting. Never has there been a bigger need for leadership in medicine. Never before has there been this much change or opportunity, and never before has it been more important for physicians to lead this change.

The idea for DocbookMD sprung out of a desire for better. We identified an issue that stimulated a desire for change, which in turn led to a passion, which developed into a technology that tens of thousands of doctors use today to help many more thousands of patients. Today we fight to keep physicians at the center of healthcare technology. We have a taste for this enigma that is business, and realize it is not another degree or something so removed from the practice of good medicine, as some would have you believe. It is applying common sense to areas where you have passion. Many specialty and state medical associations offer leadership training. It’s yours for the taking.

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WINTER 2014

Features

Bruce A. Colley

“Bedizened Shed” “‘Bedizened Shed’ is a local shed belonging to a friend. I’ve painted it many times because my friend grows prodigious amounts of ever-changing flowers in front. As so many of our outbuildings, this one too is slowly disintegrating.” –Emmy Krick.

The Art

of Chester County By Bruce A. Colley, DO, Chester County Medical Society Secretary

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mmy Krick has been a part of the Chester County art community since she and her husband moved to the Wanamaker Farm in East Bradford Township in 1951. She lived and farmed at Wanamaker Farm, as well as raised a family and taught art. She also learned from the children at the Upland Country Day School in Unionville. Emmy studied and painted with the likes of Tom Bostelle and Phillip Jamison. She has mastered most every art medium, including oil, water color, sculpture, wood block prints, and pen and ink. Many in the Chester County art community consider Emmy to be the most accomplished living artist in the United States. She regularly shows new work in all of the local shows. Recently, Emmy had a ninety-painting one-man exhibit at Jenkins Arboretum in Devon. CHESTER COUNTY

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Features

CCMS Membership… Is it Right for You? Building Better Practices and Stronger Communities One Member at a Time

PAMED and Chester County Medical Society (CCMS) membership supports you and your community in many ways. Membership in both Societies provides an indispensable resource for information, continuing education, distance learning, professional contact, and networking. PAMED offers practice management courses and refreshers on patient care. As leadership development is hard to find, PAMED presents webinars, online courses, conferences, and seminars for the benefit of its physician members. PAMED advocacy has an inside track on legislative and executive proposals on need-to-know issues so we can keep members like you fully informed. CCMS works collaboratively with PAMED, but its focus is on the local Chester County community. Some specific benefits of membership in CCMS include: • An opportunity to sign up for the PAMED “Find a Physician” program to promote your practice • Representation with local legislators • An annual meeting which provides you with the opportunity to impact your Society’s activities and goals • A legislative dinner, known as “The Clam Bake,” where you can meet with local legislators in an informal setting • An automatic subscription to Chester County Medicine magazine, the Society’s new twist on its longtime quarterly publication, and • Access to DocBookMD®, an exclusive HIPAA-secure messaging application for smart phone and tablet devices.

For additional information about becoming a PAMED and CCMS member, visit http://www.pamedsoc.org/membership and click “Join PAMED,” email admin@chestercms.org, or call (717) 558-7750 ext. 2699. To renew your current membership, visit http://www.pamedsoc.org/membership and click “Renew your membership.” Membership is available only for physicians licensed to practice in Pennsylvania.

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APPLICATION ___________________________________ County Medical Society (You may choose to be a member of the county in which you either live or work.) 777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820  717-558-7750 (Phone)  717-558-7840 (Fax) Full Name (Print): ___________________________________________________________________________________ Last

First

Middle

Home Address:________________________________________________________

_________________________

Office Address:________________________________________________________

_________________________

Email Address: ____________________________________________

_________________________

For mailing, please use:  Office Address  Home Address

Office Fax

Area Code & Phone Number

Area Code & Phone Number Area Code & Phone Number

Preferred Communication:  Email  Fax  Mail

BIOGRAPHICAL DATA Gender:  Male  Female EDUCATION

Date of Birth: ____________ Spouse’s Name:

INSTITUTION

LOCATION

DEGREE

BEGIN DATE END DATE

Medical

-

FOR RESIDENCY & FELLOWSHIP, YOU MUST GIVE ACTUAL OR PROJECTED ENDING MONTH & YEAR BEGIN DATE END DATE Residency__________________________________________________________________ Fellowships_________________________________________________________________ License: PA No. Date Issued

__________ -_________ __________ -_________

PROFESSIONAL DATA Present Type of Practice (Check Appropriately):  Owner of Physician Practice Group Name ___________________________________________________  Employed by Hospital/Health System  Employed by Physician(s) Group Name ___________________________________________________  Employed by Industry or Government  Independent Contractor  Other (specify) _________________________________________________ Specialty: Within the last 5 years, have you been convicted of a felony crime or is your license to practice medicine actively suspended or revoked? If yes, please provide full information. ___________________________________________________________

 Yes

 No

___________________________________________________________ ___________________________________________________________ DATE RETURN TO: ATTENTION:

SIGNATURE Pennsylvania Medical Society Member Services

QUESTIONS? Call (800) 228-7823

FAX: MAIL:

717-558-7840 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820


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Features

Physicians’ Health Programs Welcomes New Staff Members The Foundation of the Pennsylvania Medical Society Physicians’ Health Programs welcomed new case managers Tiffany Condran and Kendra Parry this year.

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he Physicians’ Health Programs (PHP) ensures physicians have the supportive resources and tools to stay healthy so they can continue providing healthcare for others. Physicians, like the rest of the population, are vulnerable to chemical dependency, physical disability or breakdowns in mental health. A physician who is having problems or who has concerns about a colleague (e.g. addiction, physical disabilities, or neuropsychiatric disorders) should reach out to the PHP.

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“We are thrilled to expand our PHP staff to better serve our participants,” said Foundation of the Pennsylvania Medical Society Executive Director Heather Wilson. “Tiffany and Kendra both bring a strong background in counseling and each provides a unique perspective on our core mission. Our program will continue to strengthen with their experience.” Tiffany, Pennsylvania State Board Certified Alcohol and Drug Counselor, most recently worked as a counselor at Gaudenzia Inc., in Mechanicsburg.


WINTER 2014

New Staff Members

“I have professional experience in both mental health and addiction therapy at multiple levels of care so I believe this will help me make appropriate referrals for treatment needs, build rapport with participants and their families, and have a solid understanding of the challenges and triumphs that individuals encounter through this process,” she said. When she is not at work, Tiffany enjoys kayaking, motorsports, going for walks, spending time with her family, gardening, and going to the movies. Kendra, Pennsylvania State Board Certified Alcohol and Drug Counselor, most recently worked as a counselor at Gaudenzia Inc., in Harrisburg. She earned her Bachelor of Science degree

Kendra said that after a short time working as a counselor, she found that one of the best ways to help someone is just by listening. For so many people who struggle with addiction they just need to know someone is there to listen and to care about what they are saying. “I always felt that one of my greatest strengths was my ability to listen and hear what others are saying, so it was a natural fit. My goal for the PHP is to become a contributing member of this already great team of people. I hope to be able to help make the program better in any way that I can. My coworkers are some of the hardest working and caring people I have met,” she said. When she is not at work, Kendra likes to spend time with her family and friends.

The PHP has restored careers, families and confidence by helping more than 3,000 physicians seek and receive the recovery care that enables them to remain a vibrant part of the physician workforce. CONTACT Physicians’ Health Programs 777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 Toll Free: (866) 747-2255 (in PA only) Phone: (717) 558-7819 Friday–Emergencies Only– 7:30 a.m. to 5 p.m.: (717) 558-7817 Email: php-foundation@pamedsoc.org www.foundationpamedsoc.org

Call us for a FREE HIPAA/EMR/IT/ICD-10 Assessment (a $350 value)!

Do you with ICD-10 Training and Implementation? Do you needneed help help with Computer/IT support, HIPAA Compliance, ICD-10 Implementation & Training, Billing, etc? CALL US ABOUT OUR FREE ICD-10 TRAINING PROGRAM CALL US ABOUT OUR FREE ICD-10 TRAINING PROGRAM. We specialize in healthcare IT. We have been helping many practices. We have expertise in EMR, Billing, ICD-10, HIPAA and practice management.

610.482.4359

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610.4 82.43 59

Tiffany decided to enter the addictions field after completing a semester internship at an inpatient dual diagnosis treatment program while completing courses for her master’s degree. Her main goal in regards to the PHP is to help support individuals through their recovery process so they can continue to practice medicine and contribute to society’s health and wellness.

Kendra joined the PHP staff because she felt it was a great opportunity to help others. “I love working in human services, especially in the field of addiction. Previously, I worked in addiction counseling, saw the chance to continue to challenge myself and to expand my knowledge and skill set,” she said. “I think being able to advocate for people is the best part of working for the PHP.”

She is recently married and loves to watch baseball and football, and go to as many Phillies and Ravens games as she can fit in. She also enjoys reading, crocheting and cooking.

you & Tra need help ining, Billing, with Com pu etc? CALL ter/IT supp We sp or t, US AB ecializ OUT HIPA A Co e in he We ha m OUR althca ve ex FREE pliance, IC re IT. pertise ICD-10 D-10 We in EM Impl TRAI R, Billin have been NING ementatio helpin g, ICDn PRO g man 10, HI GRA y prac M PAA an tices. d prac tice m anagem ent.

Tiffany joined the PHP staff because she was impressed with the philosophy and mission of the PHP and was interested in utilizing her clinical skills in a different professional environment while continuing to help people through the recovery process. “I enjoy having the opportunity to build relationships with our participants and having the privilege to be a part of their recovery journey,” she said.

in psychology from Messiah College, Grantham. Kendra volunteers with Keystone Human Service and the Paxton Street Home.

Call us Asses for a FR smen EE t (a $3 HIPAA 50 va /EMR/IT lue)! /ICD-1 0 Do

She also worked at the Roxbury Treatment Center in Shippensburg. Tiffany completed her coursework for her Master of Science, Applied Clinical Psychology and earned her Bachelor of Science in elementary and Kindergarten education, with a concentration in social and behavioral sciences from Penn State.


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Michael Lattanzio

Features

Sodium Restriction: A Time-Honored Dogma or an Evidence-Based Pursuit?

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his knowledge gap can have serious repercussions: poor medication adherence, increased mortality, and increased hospital readmissions and trips to the ER. Hypertension is a leading cause of cardiovascular morbidity and mortality in the U.S. There is compelling data that sodium restriction reduces blood pressure among diverse patient populations. These data provide the rationale for public policy programs advocating for sodium restriction within the U.S. and globally. Currently, most national and professional societies recommend less than 2300 mg/ day of sodium intake among the general population and less than 1500 mg/day within certain subgroups who may be at higher risk. These subgroups include African Americans, individuals over the age of 50, and individuals with hypertension, diabetes mellitus, and/or chronic kidney disease. Despite public policy efforts, the average American adult consumes 3400 mg/day of sodium, highlighting the challenge in achieving Na restriction goals. Despite its broad appeal as a public policy “target,” few studies have explored the association between sodium restriction and direct health outcomes, particularly incident cardiovascular disease (CVD). Moreover, some recent studies have suggested a paradoxical increase in CVD associated with sodium restriction. Within this context, the Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine (IOM) to perform a detailed assessment of the available data on dietary sodium restriction and health outcomes since its last publication in 2003. The following is a synopsis and analysis of the IOM’s findings published in the Sodium Intake in Populations: Assessment of Evidence in May 2013.1

By Michael Lattanzio, DO

day corresponds to the goal for individuals at high risk for BP-related CVD and is the goal set by the American Heart Association).2 The health outcomes included CVD and death, and did not include blood pressure. The committee made the following observations: • Evidence supports a positive relationship between higher levels of sodium intake and risk of heart disease. • Studies on health outcomes are inconsistent in quality and insufficient in quantity to conclude that lower sodium intake less than 2300 mg/ day either increases or decreases the risk of heart disease, stroke, or all cause mortality in the general U.S. population. • No evidence of benefit and some evidence suggesting risk of adverse health outcomes was associated with sodium intake levels in ranges 1500 2300 mg/day among those with diabetes mellitus, chronic kidney disease, or CVD. • Some evidence of harm was observed in individuals with moderate to severe CHF who were receiving aggressive therapies. The committee concluded that populationbased efforts to lower excessive sodium intake within the general population may reduce health endpoints, specifically CVD. There was limited evidence to support efforts to encourage lowering dietary sodium intake within the general population to 1500 mg/ day. Lastly, there was no evidence on health outcomes to support treating population subgroups differently from the general population.

Critics of the IOM committee findings point to the incongruous and inconsistent study findings as evidence for significant methodological flaws.3 The paucity of randomized-controlled trials included in The IOM committee was asked to focus the analysis weakens the strength of the on the health effects of sodium intake in findings. Additionally, the 24-hour urine the range of 1500-2300 mg/day (2300 mg/ collection used to determine daily sodium day corresponds to the 2010 U.S. Dietary consumption can be inaccurate. In regards to Guidelines for Americans upper limit for the harm observed in individuals with advanced general adult population, whereas 1500 mg/ CHF, critics of the study suggest reverse CHESTER COUNTY

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causality, the concept that lower sodium intake is a reflection of disease severity rather than a cause and effect phenomenon.3 What are the clinical implications of these study results? First, it is important to realize that 90% of Americans consume more than the recommended upper limit of sodium intake recommended by Dietary Guidelines for Americans. The current IOM committee results apply only to individuals consuming sodium in the 1500-2300 mg/day range. Therefore, the applicability of the study results to the majority of Americans is limited. The study confirms that curtailing excessive sodium consumption saves lives. The power of sodium restriction to reduce both primary and secondary CVD prevention has significant clinical implications. What remains uncertain is the lower limit of sodium consumption that should be recommended by health professionals. Further studies are required to elucidate the lowest amount of sodium consumption that engenders health benefits without adverse health, and whether lower targets confer additional health benefits. Tips to reduce sodium consumption: • Read labels • Avoid processed food products • Limit out-of-home eating • Eat fresh fruits and vegetables

References 1. Institute of Medicine (IOM). Sodium intake in populations: Assessment of the evidence. Washington, DC: The National Academies Press; 2013. 2. US Department of Agriculture, Department of Health and Human Services, Department of Agriculture: Washington, DC, 2010. 3. Appel, Lawrence. Whelton, Paul. Flawed evidence should not derail Sound Policy: The Case Remains Strong for Population-Wide Sodium Restriction. American Journal of Hypertension 26 (10) 11831185. 2013. No disclosures. Michael Lattanzio, DO, is a Clinical Nephrologist and Hypertension Specialist with Clinical Renal Associates of Chester County. He is Board-certified in Nephrology and Internal Medicine. He serves on the Board of the American Society of Hypertension Delaware Valley Chapter.


WINTER 2014

Membership News & Announcements Best Practices

Welcome New Members... CCMS is pleased to welcome the following individuals who joined the Society in 2014:

To publ i new CC sh photos of MS m physici ans, pl ember ease su digi bmit admin tal copies to @chest ercms.o rg

Orr Gill Barak, MD Mark E. Tantorski, DO

Frontline Groups Frontline Groups are truly special and significant for membership. Groups with 100 percent membership are recognized. They are 100 percent committed and we are thankful. This list reflects the Frontline Groups as of January 10, 2014

Academic Urology-West Chester Cardiology Consultants of Philadelphia-Paoli Cardiology Consultants of Philadelphia-West Chester Clinical Renal Associates-Exton Gateway Endocrinology Associates

Save the Date! The CCMS annual Clam Bake is an opportunity for the legislators and physicians of Chester County to meet and enjoy a casual evening of good food and conversation.

Gateway Family Practice Downingtown

Join us Friday, September 12, 2014 6:00 pm - 9:00 pm At the beautiful Radley Run Country Club Clubhouse Dining Room

Village Family Medicine Gateway Internal Medicine of West Chester Gateway Medical Colonial Family Practice Gateway Myers Squire & Limpert Wade Townend Pediatric Associates Levin Luminais Chronister Eye Associates Paoli Hematology Oncology Associates PC Plastic & Reconstructive Surgery of Chester County PC Brandywine Gastroenterology Associates Ltd. Great Valley Medical Associates PC Chester County Eye Care Associates PC Devon Family Practice LLP Main Line Gastroenterology Associates Medical Inpatient Care Associates

http://www.radleyruncountryclub.com/default.aspx

Refreshments and hors d’oeuvres will be served on the patio at 6:00 pm, followed by a delicious buffet of filet mignon, shrimp, crab, tilapia, chicken, fabulous desserts. . . and yes . . . clams! For more information contact admin@chestercms.org

Main Line Dermatology West Chester GI Associates PC Premier Orthopaedics & Sports Medicine-Chester County Division

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PMSLIC is committed to its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. For more information contact your agent, or call Laurie Bush at PMSLIC at 800-445-1212, ext. 5558 or email lbush@pmslic.com. Or visit www.pmslic.com/start for a premium estimate.

A NorcAl Group compANy

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Chester County Medicine Winter 2014  
Chester County Medicine Winter 2014