Central PA Medicine August 2016 by Hoffmann Publishing Group

Your Community Resource For What’s Happening In Health Care

AUGUST 2016

Central PA

Official Publication of the Dauphin County Medical Society

THE END OF THE ANTIBIOTIC ERA? Women’s Issues

BREAST CANCER SCREENING

PASSION O UTS ID E OF PRA CTICE PHOTOGRAPHY OF

Joseph Gascho, MD

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Contents

AUGUST 2016

Features Dauphin County Medical Society

777 East Park Drive, PO Box 8820, Harrisburg, PA 17105

(717) 558-7849 • dauphincms.org

The End of the Antibiotic Era?

Breast Cancer Screening

What is Multiple Myeloma?

2016-2017 DCMS BOARD OF DIRECTORS Mukul L. Parikh, MD President Robert A. Ettlinger, MD Immediate Past President

Community, Health & Wellness

Jaan E. Sidorov, MD President-Elect

ProduceRx

Heath B. Mackley, MD Vice President

Silently Suffering: A Closer Look at Sickle Cell Disease

Shyam Sabat, MD Secretary-Treasurer

MEMBERS-AT-LARGE Lawrence L. Altaker, MD Bryan E. Anderson, MD Joseph F. Answine, MD Michael D. Bosak, MD Leonardo A. Geraci, DO

Practice Management 20

The Role of a Humanities Program in Medical Education

What a Patient Needs to Know About Preparation for Surgery

Quality of Life

Everett C. Hills, MD Andrew J. Richards, MD Andrew R. Walker, MD

EDITORIAL BOARD Heath B. Mackley, MD, Editor-in-chief Connie Benson, Editor Susan Neville, Executive Director Joseph F. Answine, MD Robert A. Ettlinger, MD Mukul L. Parikh, MD

The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Dauphin County Medical Society. All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the publisher or editor.

In Every Issue From the Editor . . . . . . . . . . . . . . . . . . . . 4

Restaurant Review . . . . . . . . . . . . . . . . . 24

President’s Message . . . . . . . . . . . . . . . . 6

Legislative Updates. . . . . . . . . . . . . . . . 26

Passion Outside of Practice . . . . . . . . . 14

DCMS News. . . . . . . . . . . . . . . . . . . . . . 34

Central PA Medicine is published by Hoffmann Publishing Group, Inc., Reading, PA HoffmannPublishing.com | (610) 685.0914 FOR ADVERTISING INFO CONTACT: Kay Shuey, Kay@hoffpubs.com, (717) 454.9179

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From the Editor

Balance Billing:

WE CAN DO BETTER

Heath Mackley, MD, FACRO Central PA Medicine Editor-in-chief

facebook.com/dauphincms

Dauphin@pamedsoc.org

Dauphin County Medical Society 777 East Park Drive, PO Box 8820 Harrisburg, PA 17105

4 August 2016 Central PA Medicine

s is often the case, it takes a New York Times article for a health care issue to enter the public consciousness. On Sept. 2, 2014, an eye-catching headline of, “After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know” told the unfortunate story of Peter Drier, a 37-year-old bank technology manager who needed a neck surgery1. He went to an orthopedic surgeon in his health insurance network, and had an operation at a hospital that accepted his insurance. However, his surgeon needed the assistance of a neurosurgeon on the case—a physician Mr. Drier had not met previously and was not in his network. The result was a “full bill,” and not a negotiated fee, charged to him. This was 19 times the fee his orthopedic surgeon, the primary surgeon, received for his part of the procedure. Not surprisingly, this was given the pejorative “drive-by doctoring,” likening it to highway robbery. This is clearly not fair to the patient. But what do we do to stop this from happening?

HOW DO INSURANCE COMPANIES ARRANGE FOR CONTRACTS WITH PHYSICIANS AND HOSPITALS? It’s a balance of competing interests. The insurance company wants to drive down the fee so they can charge a smaller premium than their competitor and still make a profit. The providers also want to collect a fee that gives them a reasonable profit for the service provided. Providers can decide that a fee schedule is too low to be profitable, and decline participation with an insurance company. This makes the insurance company’s product less desirable as fewer physicians participate, but it means there is a population of insured patients that will not likely go to that provider, hurting their market share. In a fair playing field, this balance of interests will encourage providers and insurers to innovate and become more efficient, keeping costs at a minimum for patients, and providing a fair profit for all parties involved.

What if, as the insurance companies would The article further describes some hospitals prefer, physicians are forced to accept the and physicians in a very negative light, suggesting in-network reimbursement even if they are that they are deliberately seeking out these op- out-of-network? How then will physicians be portunities to “stick it” to unsuspecting patients. able to negotiate with insurance companies? Somewhat surprisingly, the article portrayed What if, as the hospitals would prefer, to be on the insurance companies as the defenders of the medical staff of a hospital, a physician must the patients’ interests, often paying for the accept the insurance policies that the hospital exorbitant fee on behalf of the patients even accepts? This would incentivize the hospital to though they didn’t have to. As would be expected, negotiate contracts with insurance companies the author proposes a solution: a New York that are good for the hospitals at the expense state law, which went into effect in 2015, that of the physicians. Is that good for the system as absolves patients of personal responsibility for a whole? Finally, what about the physicians of unforeseen, out-of-network charges beyond what all specialties, who unlike insurance company they would have paid in-network, and directs managers and hospital administrators, stand the insurers and providers to negotiate directly or on the front lines, seeing patients at all hours enter mediation. This sounds reasonable, until of the night and on weekends and holidays? the unintended consequences are fully realized. They do not check the patient’s insurance status before they engage in the medical care that the patient needs. Don’t those physicians deserve

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some bargaining power, to be able to negotiate balance beyond a very high deductible. How can their own fee schedules, and to choose which that be called “health coverage” at all? A Robert insurance policies to participate in? These are Wood Johnson Foundation and University of thorny issues, to be sure, but that is why we Pennsylvania analysis suggests that 41% of health need PAMED, with an engaged membership, networks are narrow, only including 25% or to be active in any state-level discussion about less of the office-based physicians practicing insurance legislation or regulation. in the area2. Additionally, the elephant in the room here is also the inadequacy of “narrow networks.” The fundamental reason for surprise billing is that there aren’t enough in-network physicians to provide the care the patients need. Patients want to pay lower insurance premiums, and insurance companies want to charge them lower premiums, but if this low-cost premium exists because only a few physicians will accept the low fee schedule the plan offers, then the patient will end up paying for a plan where they can’t find an in-network physician! They are then “forced” into seeing out-of-network physicians, and the insurance company either doesn’t have to pay for anything, or only has to pay for the

The AMA has created a thoughtful national model policy addressing this issue, calling for state regulators to enforce network adequacy requirements3. Insurance plans should be required to report quarterly on network adequacy measures to ensure compliance is maintained. Patients need financial protections when seeking necessary out-of-network care. Finally, the public needs full disclosure on the criteria of how health plans choose which physicians participate in their network. On the state level, recently PAMED has been communicating with Insurance Commissioner Teresa Miller, expressing concerns about access

to care and out-of-pocket costs consumers face. This is one of countless ways that PAMED is important to physicians and patients alike. So stay involved, this issue isn’t going to be resolved fairly without our active involvement! Dr. Mackley, a Radiation Oncologist at the Penn State Cancer Institute, is the 5th District Trustee of the Pennsylvania Medical Society representing physicians of this county.

RESOURCES

1. http://www.nytimes.com/2014/09/21/us/ drive-by-doctoring-surprise-medical-bills. html?_r=0 2. http://www.rwjf.org/content/dam/farm/reports/ issue_briefs/2015/rwjf421027 3. http://www.ama-assn.org/ama/pub/news/ news/2014/2014-11-10-ama-policy-protectpatient-choice-access-care.page

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President’s Message

WHY I BECAME A PHYSICIAN

here are as many answers as physicians to the title of this article. We all wrote an essay during the selection process for admission to medical school to answer the question, “Why I want to become a doctor.” Some of these were authored by ourselves, and some plagiarized from prior essays by successful medical school entrants. To this day, many of us may not be able to completely articulate a good answer to why. In my case, the simplest answer would be that my Dad wanted me to become a physician, and as an obedient son I complied (I had no choice)! I followed his wishes and have never regretted the decision. Recently, my father passed away after a brief illness. He quoted something once to me about being a physician that has made a deep impression in my mind and conscience. Maybe it was someone else’s quote but nonetheless here it is: “In the practice of medicine surgery rarely, medicines sometimes, but COMPASSION ALWAYS.” Mukul Parikh, MD, DABA President, DCMS

I truly believe now that most physicians have the trait of compassion as a foundation for the many other reasons they espouse for becoming a physician. In the grueling years of medical school, residency and the rigors of practice, the element of compassion may get masked by other necessary priorities, but it is still at the root of everything we do. Every now and then, it comes to the forefront of our patient interactions and gives us that immense satisfaction reminding us of why we chose to become physicians in the first place. As Dalai Lama said on many occasions, “Compassion is a natural human trait. Whenever and however we express, it leads to happiness, the primary goal of any endeavor or life for that matter.” As physicians, we naturally encounter many situations that require compassion and have many ways to express it. There is no greater antidote for physician burnout other than being compassionate to the suffering of our patients and their genuine gratitude for our help. COMPASSION ALWAYS.

6 August 2016 Central PA Medicine

As fellow clinicians—

what inspires you, inspires us. penn State Health’s MD Network serves as a resource to referring providers at any stage of the referral relationship.

For the families you serve Now, one call is all you need to get into the Milton S. Hershey Medical Center system via MD Network:

for more information, please visit the MD Network web page at PennStateHershey.org/mdnetwork.

1-800-233-4082

MD Network is reserved for clinicians and office support staff only.

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Features

THE END OF THE ANTIBIOTIC ERA? By DR. JOHN GOLDMAN

8 August 2016 Central PA Medicine

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Pennsylvania woman was recently found to have a urinary tract infection with what was reported to be a “superbug:” a highly antibiotic resistant bacterium that was resistant to one of the “last ditch” antibiotics. The bacteria was described as being “untreatable” and its discovery heralded “the end of the antibiotic era” and could portend the start of the “post-antibiotic era” when common infections might become resistant to all known antibiotics.

In fact, much of the media coverage was exaggerated. The bacterium was not an untreatable “superbug”. However, it did contain a set of genes for antibiotic resistance that, if they were to spread to other more resistant bacteria, would make them much more difficult to treat. The bacterium itself was actually easily treatable. The bacterium was an E. coli (a type of bacteria that is commonly found in the gut and the urinary tract) that was resistant to colistin. Colistin is an old antibiotic that previously had not been widely used because it had more side effects than most of the antibiotics in use today and was particularly toxic to the kidney. The fact that it is not used frequently, likely prevented most bacteria from developing resistance to it. Consequently, colistin is often one of the antibiotics “of last resort” in highly resistant bacteria.

different species of bacteria. Consequently, the antibiotic resistance that was found in this bacterium had the potential to be transferred to other E. coli or to other types of bacteria. If this resistance were to spread to other, more resistant bacteria, it could create much harder to treat infections. It is feared that this colistin resistance could be transferred to a class of highly resistant bacteria called carbapenem resistant enterobacteriacae (CRE). This type of bacteria is usually resistant to most of the commonly used antibiotics including the carbapenems that (until recently) almost all bacteria were susceptible. CREs are typically found only in extremely sick, chronically hospitalized patients. These patients typically have multiple medical problems, have had prolonged hospitalizations (weeks or months) that include stays in the intensive care unit and extended course of broad spectrum antibiotics. These infections are most commonly found in nursing homes or other long-term care facilities that have the sickest and most debilitated patient. Consequently, CRE’s are almost never found in patients who acquire their infection in the community or during or after a short hospitalization.

mortality that is due to their underlying disease. They do not typically infect healthy people.

If this resistance were to spread to other, more resistant bacteria, it could create much harder to treat infections. How can we protect ourselves from becoming infected with these highly resistant bacteria? First of all, because they are an uncommon source of community-acquired infections, people who are not hospitalized are unlikely to become infected with these bacteria and do not have to take special precautions. However, most people are hospitalized at some point in their lives. It is unclear if there is anything that can be done while you are healthy to make these infections less likely. It is common sense that minimizing your pre-hospital exposure to antibiotics by not taking any unnecessary antibiotics and practicing good hand washing to minimize your exposure to both bacterial and viral infections are likely to make resistant infections less likely.

Even in the absence of colistin resistance, However, this E. coli was still sensitive to CREs have been very difficult to treat. These other commonly used antibiotics. Specifically, bacteria require treatment with more than one In summary, the bacterium found in Pennit was sensitive to the carbepenams (a class of antibiotic. If colistin is used as a single agent, the sylvania was not a true superbug. It was still intravenous antibiotics that is used to treat hos- mortality of the infected patient is approximately treatable with commonly used antibiotics. pital acquired infections) and nitrofurantoin (an the same as if the infection is not treated at all. However, this bacterium was resistant to a last oral antibiotic that is used to treat urinary tract Successful treatment usually requires using ditch antibiotic: colistin. If this resistance were infections). In other words, currently available two or more agents to which the bacteria is to spread, it could create very resistant, very hard and regularly used antibiotics would have worked susceptible. Consequently, colistin resistance to treat bacteria. Fortunately, these bacteria are to treat an infection by this “superbug.” will clearly make CREs more difficult to treat. unlikely to be a source of community-acquired However, they have always required other active infections and will likely be limited to the The E. coli contained a set of genes called antibiotics for successful treatment. sickest, chronically hospitalized patients. The mcr1 that encoded resistance to colistin. These detection of this new resistance does not herald genes were contained on a plasmid. A plasmid The infections are also difficult too because “the end of the antibiotic era” but warns us that is a circular, highly mobile set of genes that can the patients are so ill. In fact, it is often hard to there is clearly the potential for some infections be transferred from bacteria to bacteria both distinguish the morbidity and mortality that is (particularilly hospital-acquired infections) to within the same species of bacteria and between due to their infection from the morbidity and become much more difficult to treat.

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Features

Women’s Issues

BREAST CANCER SCREENING By KATHRYN PEROUTKA, MD

t’s hard to consider women’s health be done every other year from age 50 to 74. without discussing breast cancer. The There is “insufficient evidence” to support diagnosis touches nearly all of us in routine mammography prior to age 50 and some way, since the lifetime risk for beyond age 75. this cancer is one in eight women. Early detection, along with improved therapies, However, other organizations’ guidelines has led to improvement in survival rates. differ from the USPSTF. For example, the American Cancer Society (ACS) recommends Let’s look at three questions about screen- that the average risk woman should have yearly ing for breast cancer and try to answer them. screenings between the ages of 45 – 54, then every other year beyond that. They also suggest that screening should be started at age 40 and QUESTION ONE: continued annually after age 55. WHO KEEPS CHANGING THE

RULES ON MAMMOGRAMS?

It seems like we hear about a new set of guidelines, then hear about the controversy it has stirred, then when it seems like it’s over, there is an announcement of another set of recommendations and more comments by the experts. Most recently, the US Prevention Study Task Force (USPSTF) published a set of guidelines which again differ somewhat from our current practice patterns. The USPSTF has said that for women with no increased risk, routine screening should 10 August 2016 Central PA Medicine

Another organization, the National Comprehensive Cancer Network (NCCN), recommends that the average woman have yearly mammograms starting at age 40. So, for the average-risk woman, we have one organization that suggests yearly mammograms and another that does not. It is surprising that there is no consensus here. How can something so important, so common, and so intensely studied not have a common standard for screenings? What gives? Everyone agrees that surviving breast cancer

is an important goal. Everyone wants to drive down the mortality rate. Perhaps the reason for these differing recommendations is that the same information may be interpreted differently by different groups. Here are some facts to consider. The USPSTF looks at breast cancer survival data and notes that early or more frequent mammography doesn’t impact survival. Furthermore, there is a concern that mammogram abnormalities that lead to biopsies are more often negative for cancer than positive. These are called “false positives.” Going for a biopsy is anxiety provoking and if done unnecessarily, is a problem. An argument can also be made that cancer found early might not have a worse prognosis if found later. After all, most cancers are curable. The approach which supports starting early and doing yearly studies reinforces our intuitive instinct that the sooner we find cancer, the better the overall chance of a cure. Most women, if told they might unnecessarily need a biopsy, but that screening yearly finds cancer earlier, are willing to take the chance on an “unnecessary” biopsy. The thought is the earlier cancer is detected, the lower

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the risk for spread which could minimize additional therapy such as chemotherapy. Overall, women should know that there are benefits and limitations to screening and that guidelines are simply guidelines. However, if a woman is at increased risk, she will need increased screening.

QUESTION TWO:

WHAT IS A 3D MAMMOGRAM? Another ‘new’ type of mammography is a 3D mammogram or mammography with tomosynthesis. For the patient, the clinical experience will not seem different than a standard mammogram. These 3D mammograms include more imaging which is joined with the same 2D imaging which was done before to give a more detailed view of the breast. This has been available for a few years now and many mammography units in our area now offer this.

IS IT A BETTER STUDY? It does seem to offer a better view of the breast, particularly when there is a “dense breast” issue. Data generated so far show that when a 3D mammogram leads to a biopsy, it is more likely that cancer will be found (fewer false positives). Also the number of “call backs” after a mammography for more testing decreases. However, when we go back to the prime consideration of whether there is less breast cancer mortality with the use of this type of mammogram, we are left with the fact that survival data doesn’t yet show that a 3D mammogram is more effective. Certainly, in the future with longer patient follow-up, this may change, but we aren’t there yet with survival statistics.

mammogram and it takes longer. There is no radiation exposure.

What is beneficial is that the image that is produced is quite detailed. This is both its strength, and one could say, its weakness. While the MRI results show things in great detail (good sensitivity), it can also display QUESTION THREE: more benign abnormalities (less specificity) DO I NEED AN MRI? and lead to biopsies of noncancerous lesions Another kind of imaging study is a breast (those “false positives” again). Nevertheless, Magnetic Resonance Imaging (MRI). An in certain circumstances, especially when MRI can be done on many parts of the body. cancer has already been found, it is of great With the MRI, you lie face down in an MRI use. It is also appropriate for screening for pamachine. It is a different experience from a tients with genetic predisposition and other

unique situations. For screening, however, MRI’s are not part of our recommendation for the average-risk patient.

CONCLUSION The good news is that most women who have breast cancer, beat breast cancer! There are a variety of screening options for patients with average risk and for increased risk. We can look forward to more good news as research and studies lead us to the inevitable conquer of this disease.

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Features

WHAT IS

MULTIPLE MYELOMA? Multiple Myeloma is a cancer arising from plasma cells. Plasma cells are a type of white blood cells found in the bone marrow, which produce antibodies. Multiple Myeloma is also known by other names including plasma cell myeloma, Kahler disease, and myelomatosis. There were an estimated 26,850 new cases of Multiple Myeloma in the United States in 2015. It is commonly diagnosed among people aged 65-74.

By SARITHA RAVELLA, MD & KATHRYN PEROUTKA, MD

12 August 2016 Central PA Medicine

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ormally, a plasma cell is polyclonal tests, skeletal X-rays and in most cases a bone (different clonality and is able marrow aspiration and biopsy test. to produce different kinds of antibodies as per the bodyâ&#x20AC;&#x2122;s need). HOW IS MULTIPLE In Myeloma, plasma cell becomes monoclonal MYELOMA TREATED? (same clonality and produce same kind of abnormal proteins) and starts multiplying abnormally. There are several categories of treatment Myeloma cells make abnormal antibodies called options which are usually used in combination. Monoclonal (M) proteins. These proteins The treatment options fall broadly into the accumulate in the bone marrow, blood, urine, categories of chemotherapy drugs like melphalan, and in other organs causing end-organ damage. cyclophosphomide, doxorubicin, liposomal As myeloma cells increase in the bone marrow, doxobucin, vincristine, bendamustine, etoposide, they outnumber the normal cell lines in the cisplatin; steroids like dexamethasone and

abnormal blood work and urine tests start showing improvement as they show response to their treatments. Usually, most patients (including elderly patients) are able to tolerate the newer treatments very well with clinical, biochemical and radiological responses. Treatment responses are periodically monitored by the treating hematologist/oncologist with relevant blood work, urine tests, radiologic tests, and sometimes bone marrow aspiration/biopsy test. Multiple Myeloma (Plasma cell myeloma) is one of my areas of interest in hematological malignancies because the disease pathology is interesting, with lot of available treatment options which yield very good clinical responses. Multiple Myeloma, although not curable at this time, is very treatable, just like high blood pressure. A patient with Multiple Myeloma needs ongoing treatment to keep the disease under control. When the disease is well controlled, most patients have a high likelihood of living a full thriving life.

Photo Courtesy: National Institute of Health, http://www.cancer.gov/types/myeloma/patient/myeloma-treatment-pdq

bone marrow causing a decrease in cell counts. Sometimes, myeloma cells cause damage to the solid part of the bone. These damaged areas appear as lytic lesions in the bone. Myeloma cells not only affect the bone marrow and solid part of the bone, but also cause kidney damage in most cases.

prednisone; immunomodulatory drugs like lenalidomide, thalidomide, pomalidomide; proteasome inhibitors like bortezomib, carfilzomib, Ixazomib; Histone deacetylase (HDAC) inhibitors like panobinostat; monoclonal antibodies like daratumumab and elotuzumab. Other therapies also include autologous stem cell transplant in eligible patients. Adjunctive Clinically, Myeloma is suspected when therapies commonly used include bisphonates symptoms and signs like anemia, kidney dys- (zoledronic acid and pamidronate) and radiation function, bone pain, bone lytic lesions, increased therapy. Other less commonly used therapies calcium levels, frequent infections, abnormal include IVIG and plasmapheresis. Patients need protein levels on blood work, etc., arise in a certain prophylactic (preventive) therapy (like patient. Usually it is suspected by primary care antimicrobial prophylaxis, and/or anticoagulant physicians and nephrologists, among other prophylaxis) based on the type of primary specialists. Upon clinical suspicion, patients are Myeloma treatment drug. referred for further hematological work-up to a Hematologist/Oncologist. Diagnostic work-up In our experience, patients feel significant includes specific types of blood work, urine symptomatic relief from bone pain, and their

Photo Courtesy: National Institute of Health, http://www.cancer.gov/types/myeloma/patient/ myeloma-treatment-pdq

Dr. Ravella joined Andrews and Patel Associates in November 2014. Dr. Ravella completed her Hematology and Medical Oncology fellowship training at Lankenau Medical Center in Wynnewood, PA. She is a member of the American Society of Clinical Oncology, American Society of Hematology, and Pennsylvania Society of Oncology and Hematology. Dr. Ravella has clinical research publications and poster presentations in the topics of Lung cancer, Prostate cancer, and CML. Dr. Peroutka is a hematologist at Andrews and Patel and is affiliated with multiple hospitals in the area, including Community Medical Center and Holy Spirit Hospital. She received her medical degree from University of Maryland School of Medicine and has been in practice for more than 20 years.

LEARN MORE Please visit www.andrewspatel.com for additional information and patient resources. Central PA Medicine August 2016 13

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Passion Outside of Practice It’s our pleasure to highlight a Dauphin County Medical Society member’s “passion outside of practice” in each issue of Central PA Medicine. Beyond their commitment to health care, DCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature the photography of Joseph Gascho, MD.

PA S S I O N OU TSI DE OF PRACTICE

Photography of Joseph Gascho, MD 14 August 2016 Central PA Medicine

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or me, photography is about seeing. Seeing something unusual or unique. I don’t have to go to the North Pole or Tasmania—I can go outside my front door into our little courtyard and see something that catches my eye that is amazing, that I want to photograph. My eyes are attracted to pattern, texture and color which is different than the color many people see, I suppose, as I am color blind! Our brains work to take the lines and colors and arrangements of patterns of something and put them together into the object that it is—a wagon, a flower, a house. It’s an essential task—we need to be able to realize in a flash that the combination of bits that meet our eye is really a car hurtling towards us and we need to get out of the way so we won’t be killed. But for the sake of photography, it’s important to go back to an earlier stage of development, the stage when we did not yet know the names of objects. An exercise for the photographer is to stare at an object “until it has no name.” If one can get to that point, then one can become enamored by the shadows of a tree on a sidewalk, on the windows of a twenty-story apartment building with a red flower in one window. The step beyond that then is trying to duplicate faithfully what is seen on film so that one can go back and look at it and relive the wonder of that moment.

“Swan”

or the image sharing something with me. I have a strong, left-brain part of me, and there was a time when the mathematics of shutter speed and aperture size and film speed appealed to me, but that is not where I am now. When I take photographs I lose track of time. I come away from a photography stint refreshed and renewed and invigorated. So it is good for me, and I want to go back to it.

HOW LONG HAVE YOU BEEN Seeing is such an important part of medicine— DOING IT?

seeing with echocardiography, the vegetations on a mitral valve in someone with endocarditis or seeing the collaterals that come in late after a coronary injection. Despite our best efforts, we as physicians too often miss what is right there in front of our eyes. I suppose that this importance of seeing has carried over from my career as a cardiologist into my avocation as a photographer.

HOW DID YOU DEVELOP AN INTEREST IN YOUR PASSION OUTSIDE OF PRACTICE? That’s so hard to answer. No one seems to ask a pediatrician who golfs why she developed an interest in golfing. My mother loved to make photographs. I like to “make photographs” rather than “take photographs”—I see photography not as “capturing an image” or “shooting something”; I see it as receiving something from the image,

I’ve been making photographs for a long time. I remember going to Lyndon Johnson’s inauguration in 1965 and making a photograph with a little Brownie camera through binoculars! The photograph will not win any awards, but I cherish it. I remember a couple of years before medical school, going to a store in downtown Philadelphia and buying, after careful research and careful counting of dollars, a used rangefinder camera. Almost 15 years ago my wife surprised me with a then, state-of-the-art Nikon digital camera. The camera cost $2,000 then, but you couldn’t probably even sell it on EBay today. It was not necessarily that much better than the camera I was using, but it was a beautiful tool—the kind of thing one could put on the coffee table as a conversation piece even if it was never used for what it was designed to do. Having a beautiful camera in some indescribable way elevated my photography

to a higher level, I think.

WHAT MAKES IT SPECIAL TO YOU? Just as photography is about seeing, poetry to me is about seeing. I divide my time between poetry and photography. A poem for me is putting words into a new way of seeing something that shows others, ‘look, doesn’t this make you think differently about this idea or emotion when you hear it in the way these words are arranged?’ I enjoy combining my photography with poetry. I often create portraits of my patients and combine their photos with a poem about them. A Photographer Writes a Poem Three times I went. to make the photo. It was never right. The light was too high. There were no shadows. And then the fourth time: the light at 6 o’clock. A poem. Central PA Medicine August 2016 15

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Community, Health & Wellness

ProduceR by SARAYNA SCHOCK Global Health Scholar Medical Services Coordinator, LionCare

tarting this August, providers within the Penn State Health System in central Pennsylvania will be able to “prescribe” a weekly box of fresh, locally grown produce to patients identified as “high-risk” or “underserved” through a new innovative program called ProduceRx. This program is one of the first of its kind in the nation to involve all members of the interdisciplinary health care team in impacting health outcomes of a patient as research has shown that simply increasing access to fruits and vegetables is not enough to change eating habits. The program, ProduceRx, will consist of a nutritional education component in

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As Hippocrates said,

“LET FOOD BE THY MEDICINE AND MEDICINE BE THY FOOD.” collaboration with registered dietitians, dietetic interns, and medical students from the Penn State Milton S. Hershey

Medical Center. Participating patients will receive nutritional education through printed newsletters and YouTube cooking videos. The YouTube videos may feature guest physicians, community members, health administrators, and other health care workers to increase community-connectedness with the project. Local farmers will also be included and encouraged as the initial source of the quality nutrition that is contributing to their community health with this project. The program will also strengthen the local tax base. This holistic community-centered approach will facilitate connectedness and solidarity between the health care system and those it serves, and has the potential to set a

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precedent for other health systems across the country.

HOW IT WORKS The program follows a CSA, or Community Supported Agriculture structure, in which local farms offer a certain number of “shares” to the public. The initial partnering farm, Strites Orchard, will open up its pre-existing CSA delivery points across central PA to ProduceRx participants in order to increase accessibility of the program to patients who do not live within the immediate area of the medical center. In addition to Strites offering a slight discount on their CSA boxes for the program, grant funding will be used to discount the boxes down to a more affordable, weekly $10 “copay” for patients. EBT/SNAP benefits may be used

to pay this “copay,” The program will not be contractual. Instead, initial registration will allow the patient to return by the end of each week to order a box for the subsequent week, if so desired. Weekly boxes will consist of six to eight items of fruits and vegetables grown locally and harvested just prior to packaging. As an added bonus, participating patients will be able to visit Strites farm on open “Upick” days and pick additional fruit and vegetables at no cost while visualizing the growing process and seeing where their produce is coming from. ProduceRx aims to support patient health and improve patient outcomes, make quality produce more accessible and affordable to patients, and engender differences in longitudinal eating behaviors in ways consistent with the hospital’s wellness initiative.

ProduceRx will also consist of a research component to examine the program’s impact and influence on patients’ lives and eating habits and attempt to show the benefit of implementing a program such as this at similar health care institutions. This program has been designed with both patients and prescribers in mind. As so many clinic visits and comorbidities are associated with underlying weight and nutrition issues, it is essential that health care workers have time to adequately address these acute issues and be able to provide a means to address the pertinent underlying chronic issues of malnutrition and obesity.

LEARN MORE

please visit https://sites.psu.edu/producerx.

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Community, Health & Wellness

SUFFERING SILENTLY A Closer Look at Sickle Cell Disease

By JOSEPH ROBINSON JR

here are some things you ought never to forget: your mom’s birthday, your first kiss, a wedding anniversary, the pledge of allegiance, where you were during 9/11 and that some endure suffering through no fault of their own.

which is the inadequate supply of healthy red blood cells to carry oxygen throughout the body. However, the anemia is a byproduct of the disease which affects the structure of the red blood cells. These oxygen carrying blood cells take on the shape of a crescent moon or sickle, clogging the small vessels and depriving organs of vital nutrients. What results is a lifetime of chronic pain in oxygen starved joints throughout the body. Some have described the pain as equivalent to that associated with passing kidney stones or natural child birth.

to my home, as he has on so many occasions, I could handle it. The abuse would be the same, but I have weathered the storm alone many times…I decide I should leave because I can’t bear to break down in front of these people. In the next 5 minutes, I have what I know to be the onset of tremendous pain on the side of my left knee…If he attacks me further in the parking lot, in my car, or at home, at least no one will see him doing it. After all these years, I still can’t explain this. No one would believe me anyway. They never see him. They just see me, and when they see me again, I am as good as new.

All around us are nearly invisible families, friends and neighbors silently suffering with the genetic disorder, Sickle Cell Disease. Imagine being born with a disease marked by chronic pain that routinely escalates to “crisis level” requiring emergency room treatment with a battery of high dosage One adult sufferer from Dallas, Texas, narcotics, followed by an extended hospital Shirley Renee writes about it in her book, Since 1994 The South Central PA Sickle stay of 3-10 days. The worst effects of this The Stranger Within Me. She equates the Cell Council (SCPASCC) has provided disease include stroke and organ failure. The painful attacks to those of an assailant who supportive services to children, adult clients most extreme cases result in premature death. periodically shows up unannounced to strike and their families in 26 counties throughout and subdue, leaving in his wake recurring north, south central and northeast PA. DeContrary to the common perception, feelings of shame and embarrassment: spite its undeniable devastation to families, Sickle Cell Disease and the Trait can be found we in the Sickle Cell Disease community on almost every continent, affecting Italians, The stranger came to visit me today. I haven’t call this the “forgotten disease” due to the Greeks, Middle Easterners, Latinos, West been bothered by him this way in several months. limited public awareness of its prevalence Indians, Asians, Africans and Blacks. Sickle I was at the gym for my usual workout…As and seeming disinterest in its eradication. Cell Disease is caused by a genetic defect I notice the stranger from a distance, I say a To address this public recognition gap, our that affects the red blood cell, a centuries prayer to myself that no one else will see him. He statewide PA Sickle Cell Provider Network old adaptive mutation in response to malaria. has my mind so controlled, that I immediately annually conducts a day of advocacy at the It is often mistakenly referred to as “anemia” panic when approached in public. If he came state capitol, meeting with members of the 18 August 2016 Central PA Medicine

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legislature from both parties to raise their awareness and explore paths to a stable funding base.

and pain relieving medication.

Locally our Council provides clients with family and individual counseling, In order to help us better serve those adult and children support groups, annual living with Sickle Cell Disease, the Sickle psychosocial assessments, assistance with Cell Disease Association of America, located school Individualized Education Programs, in Baltimore, MD, launched our first awareness presentations to employers, schools, ever national patient registry. This registry medical providers and community partners, allows those with the disease to input their utility and transportation assistance, summer vital medical history information into one camp experiences and an annual Christmas repository that is accessible to them any- Holiday party with gifts provided by Toys where in the world. Because of the limited for Tots. Until a cure is found, today’s care experience most physicians have with Sickle is focused on managing pain, strokes, heart Cell Disease, it is of tremendous value to the attacks and coping with the hopelessness and patient, admitting themselves to a hospital fear that results from this disabling disorder. emergency room in a rural part of the country or the world, to be able to access September is National Sickle Cell Disease their medical history information, instantly Month. One way the Council is bringing and provide it to the attending physician. awareness to Sickle Cell Disease, as well The alternative has been to suffer, sometimes as, augmenting the funding received from hours, before gaining admittance to a bed the Pennsylvania Department of Health

OSS Orthopaedic Urgent Care Owned & operated by OSS Health physicians.

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is through our 5th Annual Golf Outing, occurring Friday, September 2, 2016 at the Valley Green Golf Course, Goldsboro, PA. Our platinum sponsor is PinnacleHealth. Aside from a great golfing experience, the day includes breakfast by Panera Bread, dinner by Carrabba’s Italian Grill and over 100 raffle prizes! Information about the event can be found on our website, www.scpascc.org. Please take time to browse our site and get to know us a little better. We also encourage you to stop by our office at 2000 Linglestown Road, Suite 103, Harrisburg, to meet the staff and permit us to show you more of the future events we have planned. Join us in our effort to remember and serve the gallant individuals and families living with this disease. Joseph Robinson Jr is Executive Director of the South Central PA Sickle Cell Council.

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Central PA Medicine August 2016 19

Practice Management

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THE ROLE OF A

HUMANITIES PROGRAM IN MEDICAL EDUCATION By CONNOR ZALE

ealth care is changing rapidly with requirements of the Patient Protection and Affordable Care Act (PPACA) or Affordable Care Act (ACA). Health care providers are experiencing fatigue and burnout from the increasing demands and expectations of new government regulations and insurance mandates. A recent study from the American Medical Association (AMA) and Mayo Clinic that was published revealed that up to 54.4 percent of physicians reported at least one sign of burnout in 20141. The medical education curriculum is also evolving to address the new roles of physicians in health care. Across the country, medical schools are implementing health care system courses. Medical schools are also focusing on humanities courses to preserve physician empathy throughout medical training.

Penn State College of Medicine was one of the earliest schools to incorporate a humanities program into the medical school curriculum and Penn State College of Medicine was the first medical school with a Humanities Department. Students at Penn State College of Medicine complete humanities courses during all four years of their medical education. First-year students are paired with a patient of the medical center for the ‘Patients as Teacher’ course. They visit with the assigned patients to learn their story and to gain a greater understanding of how a disease impacts their entire life. Students also attend classes once a week for large group or small group discussions on various humanities topics throughout their first two years. Humanities classes allow students to read and discuss poetry, literature and art. These courses provide a chance for students to step away from studying medical science and learn about the patient and family’s management of a disease or diagnosis, such as a patient’s resilience with a chronic condition or struggle with the loss of a family member.

As health care delivery becomes driven by evidence-based medicine and systemsorganized care, physicians are beginning to feel removed from a patient’s perspective and more toward efficiency and cost-effective care. Even student and resident empathy decreases throughout training especially During a recent art class that was offered during the third year of medical school2. to medical students by the Humanities Workload, stress and the hidden curriculum Department, the art instructor impressed are major factors that affect student and the importance of not becoming too focused. resident empathy. Humanities programs are He suggested that you take a break and walk being instituted in order to retain student away from your artwork. Maybe, look at the and resident empathy. artwork in another form of light which may then allow you to find a new idea or plan for

your painting. Studying medicine is similar in some aspects to creating a painting. We enter medical school with ideas and hopes for helping patients and then we begin our first year of school. We suddenly become entrenched in studying the medical sciences as we work through each organ system. We become entirely focused on our tests and covering all of the medical material. Engaging in Humanities Program activities will provide physicians and students with a break from clinical and academic responsibilities. These escapes from clinic duty or studying pathology chapters allow a physician or a student to clear themselves of stress or worries temporarily. It may provide them with a new perspective for a patient case or a new approach to a problem. The artists can then return to their work in order to correct an error or to complete a newly discovered plan as they find new meaning in the painting.

REFERENCES

1. S hanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023. 2. N eumann M, Edelhäuser F, Tauschel D, et al. Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents. Acad Med. 2011;86(8):996-1009. doi:10.1097/ ACM.0b013e318221e615.

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Practice Management

WHAT A PATIENT NEEDS TO KNOW ABOUT PREPARATION FOR SURGERY By JOSEPH F. ANSWINE, MD

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s a patient, you will be asked to do many different things in preparation for a surgical procedure and anesthesia. Many seem repetitive and sometimes feel unnecessary, but they are all meant to help achieve a successful and hopefully stress-free procedure.

You will be given many instructions on what medications to take and not take, and when you can or cannot eat or drink prior to surgery. It can be complicated because the dosages of some may be changed temporarily and new medications added for pain control or to decrease nausea and surgical side effects. Furthermore, when you can eat and/or drink is changing from the old days of nothing after midnight to allowing a more “liberalized” oral intake because newer studies show that some food or more commonly carbohydrate drinks may decrease dehydration and malnutrition during surgery and in the healing phase. Keep in mind, again, the rules will be different for different individuals and surgeries so make sure you understand your particular instructions. Write them down because again, they can be confusing. Not following the instructions could potentially cause your surgery to be delayed or cancelled.

You will likely be asked to visit your primary or family doctor. Your family doctor knows you and your health history better than anyone else. First, it keeps them “in the loop” with your surgery because they will most likely be the ones caring for you during your later recovery. Furthermore, it will be important for them to make sure all of your chronic illnesses are in control or as we like to call it, optimized. These illnesses include but are not limited to common ones such as heart disease, emphysema, diabetes and hypertension. All, if not under control, can have a negative impact on the success of your surgery. For example, poor blood sugar levels not only have been associated with an I can’t stress enough the importance of making those lifestyle increased risk of infection, but also a decreased overall survival changes I mentioned above such as stopping smoking which clears rate from major surgery. Also, heart problems can become worse carbon monoxide and chemicals from your lungs and improves while under anesthesia or shortly after. Your doctor will encour- lung function even if done for a couple weeks or a few days. age you to stop smoking and lose weight if you are overweight The loss of a few pounds decreases the stress that your lungs and before surgery because both have been associated with potential heart are under during anesthesia, and decreases our “struggles” complications and slow recovery. Your medicines that you take as anesthesiologists with your airway. It also improves your sleep chronically may be adjusted as well if they feel it is needed. Lastly, apnea symptoms. Getting those sugar levels as close to normal you may be asked by your family doctor to visit specialists before as possible even for a short time balances the electrolytes and surgery such as a cardiologist, endocrinologist or pulmonologist fluids in your body and, again, lowers your chance of an infection. to help understand and treat particular illnesses more thoroughly. How your surgical pain will be treated has also changed with a It is important to make sure a complete list of all medications movement from narcotic pain medications to non-narcotic regimens you take regularly is available and known to all those involved in based around acetaminophen (Tylenol) and non-steroidals such as your care prior, during and after surgery. This includes all vitamins ibuprofen (Advil) along with pain blocks using local anesthetics. and “herbal” medications because they truly are medications with Narcotics won’t be completely removed but we are learning that effects and side effects as well as interactions with other drugs the side effects slow your recovery and lead to complications. you currently take or will be given during surgery. For example, many herbal medications “thin your blood” and increase your Lastly, know exactly what is going to happen to you and what risk of bleeding. Some also interact with the medications used is expected of you before and during your procedure and hospital to raise and lower your blood pressure and heart rate while under stay. As I wrote in the last edition of this magazine, you are now anesthesia. Make copies of your list of medications and hand them an active part of the peri-operative care team. Actually, by far, you out especially if the list is long or dosing regimens are complicated. are the most important person on the team. If you prepare properly for surgery, , there will be no surprises when you are asked to get Believe it or not, you may be asked to exercise based on your up, move around, eat, drink and get back to your life. abilities because this has been shown to improve your “stamina” to undergo the stress of surgery. This may include short walks, stationary bicycling or just deep breathing exercises. Any little bit counts and even small gains improve your chances of success.

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Restaurant Review

THE GARLIC POET By DR. ROBERT ETTLINGER

ronting the Clarion Hotel in New Cumberland, The Garlic Poet is the creation of Jennifer Delaye of JDK Catering. As garlic is the universal seasoning, and poetry the universal language, she named her eatery in recognition of the strong union between people and food. An evening there is guaranteed to be a worthy culinary experience, just minutes away from Harrisburg city.

The décor is welcoming, with a literary theme throughout. Paintings of Oscar Wilde and Victor Hugo are accompanied by a bust collection above the bar; see how many you can name. The library section of the restaurant is cozy if you prefer privacy, and the adjoining Grain and Verse Bottle House has the funkiest pizza selections around. 24 August 2016 Central PA Medicine

Executive Chef Kurt Wewer, son of local Garlic Poet features ingredients from physician Dr. William Wewer and self- local purveyors, including not only the taught in the restaurant business since his typical meat/cheese/produce items, but teens, developed an inventive menu with also spices, ice cream, and beer. Delectable unique selections. His imaginative choices starters include bay scallop ceviche, a pale for his diners have a common thread of ale fondue for two, and burrata (a housecomplexity. Virtually all of the items have pulled mozzarella on tomato and basil, with multiple layers of flavor to enjoy. Our a plum/balsamic reduction). I enjoyed a party was pleased with our selections. As unique calamari, with fig, fennel, pea shoots an example, one of the chef ’s most popular and a perfectly spicy chili glaze. A regular dinners, the five-hour braised short ribs, cast of soups and bisques, each containing isn’t just slopped with the usual tomato-y about a dozen well-matched components, barbecue sauce. Instead, the locally-har- is joined by daily specials. Fried peaches vested angus beef is dressed with a stout and smoked duck soup, containing pickled demi-glace, and is accompanied by grilled watermelon rind and aquaponic flowers, sweet corn with za’atar seasoning, a leak/ surely didn’t come from a red can! fennel/hemp seed hash, and granny smith and lemon-cardamom kale slaw. The burger and sandwich board is anything but run-of-the-mill; selections In virtually all of the selections, The average about a half-dozen gourmet layers

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on ciabatta, brioche, and naan. (Personally, I’ve penciled in the malt-roasted pork and kimchi tacos for my next trip there.) A selection of three different specialty fries will appeal to the most discerning of carnivores. Like many up-to-date establishments, entrée selections are offered as <smalls> or <biggies>, both for those with small appetites and those who crave variety. My dining guest had a small plate of bacon and pastrami-infused chicken that was quite generous in size. Served with a purple potato/bacon/roasted garlic mash, stone fruit salsa, and chevre and leek foam, it was a hit. Other choices include daily changing farm, seafood and vegan entrees, and a generous pork porterhouse at a neighboring table that looked tempting. I was well pleased with my veal roulade, adorned with citrus

fennel, herb de provance, and a locally-grown red stone fruit puree. Mixologist Ajay Cheney offers a balanced beer and wine selection, as well as one-of-a-kind specialty cocktails inspired by authors throughout history. Desserts include a daily changing crème brulee, and puffies (a reverse-shaped waffle with homemade ice cream and chocolate granache). For elegant dining in a fun, casual atmosphere, The Garlic Poet is a local masterpiece.

THE GARLIC POET 148 Sheraton Drive New Cumberland, PA 17070 717-774 5435 Open Daily From 4-10 P.M.

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Legislative Updates

Pennsylvania Medical Society Quarterly Legislative Update August 2016

ith final passage of the 20162017 state budget, the Senate and House of Representatives recessed for the remainder of the summer. Both chambers are expected to reconvene in the fall for a limited number of session days prior to the November General Election.

education in pain management or in the prescribing practices of opioids for licensure renewal. The education could be completed as a portion of the total continuing education required for biennial renewal, and it would not apply to physicians who do not possess a DEA registration number to prescribe controlled substances. House Bill 1805 is nearly identical to SB 1202, except that it requires the two hours of continuing education to be completed in pain management, identification of addiction, or in the prescribing practices of opioids. HB 1805 was approved by the House unanimously on June 23. The Pennsylvania Medical Society (PAMED) has expressed support for both bills.

sufficient to treat a patient for seven days and any practitioner who violates this provision will have committed unprofessional conduct and be subject to penalties. The Pennsylvania Chapter of the American College of Emergency Physicians (PAACEP) and PAMED originally opposed the bill. However, both PAACEP and PAMED took a neutral position after the bills was amended to allow for exceptions to the seven-day limit if, in the professional medical judgement of the health care professional, more than a seven-day supply of an opioid drug product is required to treat the patient’s condition and there is a notation in the patient’s medical record.

The number of bills that have been introduced this session to address the current epidemic of opioid abuse facing the state continues to grow. Recently, a number of those bills have received action.

HB 1698 and HB 1699 were also approved by the House on June 23. HB 1698 would require health insurance plans to provide coverage for abuse-deterrent opioids (ADOs) that are harder to crush, cut, dissolve or inject, and apply cost-sharing provisions for these products at the same level as cost-sharing applied to other brand and generic drugs covered under a plan’s formulary. PAMED supports this legislation.

Senate Bill 1202, which passed the Senate unanimously on June 15, would require licensed prescribers and dispensers in Pennsylvania to complete two hours of continuing

Legislation will also be introduced in the near future that would require medical schools in Pennsylvania to implement mandatory Safe Opioid Prescribing Curriculum. State funding would be dependent on implementation of the curriculum, which would focus on four areas: pain management, multimodal treatments for chronic pain that minimize the use of opioids, identification of risk for addiction to opioids, and management of substance abuse disorders as a chronic disease. PAMED has not yet taken a position on the proposed legislation.

HB 1699 would impose limitations on the prescribing of opioids within emergency departments and urgent care centers in PennsylOn June 23, members of the House of vania. It would limit prescribing to a quantity Representatives held a press conference in the

As usual, budget deliberations during June were accompanied by a flurry of action on other legislative initiatives, including a number of health care related measures. Following is an update on recent legislative activity that is of interest to the Society. Opioid-related legislation

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Capitol Rotunda to call on Gov. Tom Wolf to call a special session of the General Assembly to combat the opioid crisis. So far, there have been nearly three dozen bills introduced to address this issue. Gov. Wolf has also made it one of his own priorities to provide a $34 million appropriation to create 50 Centers for Excellence across the state to treat Medicaid recipients for opioid addiction. It is unclear whether the appropriation will be part of the final spending plan approved by the legislature in the coming weeks. Telemedicine With a growing number of services being provided via telemedicine technologies, there is an obvious need for a set of safeguards and standards to support the appropriate coverage of and payment for telemedicine services in Pennsylvania. PAMED believes that patient safety and quality of care must be the guiding principles behind any use of telemedicine. For several months, PAMED has been working with other stakeholders to draft legislation addressing the use of telemedicine in Pennsylvania. Senator Elder Vogel (R-Beaver) is expected to soon introduce a bill in the Senate, and Rep. Marguerite Quinn (R-Bucks) has agreed to introduce a companion bill in the House of Representatives. The legislation will define what telemedicine is, offer guidelines outlining who can provide telemedicine services, and provide clarity around insurance company reimbursement for these services.

through the use of telemedicine technologies. PAMED has not taken a formal position on the legislation and Pennsylvania’s participation in the Compact. CRNP Independent Practice

Requiring a minimum number of years or hours of work experience in an unstructured setting with highly variable experiential learning does not replace the expertise and support that comes with physician oversight. PAMED continues to strongly oppose the legislation and encourage physicians to reach out to their legislators and urge opposition to the bill.

The Senate Consumer Protection and Professional Licensure Committee approved PAMED strongly supports a physician-led, SB 717 on May 18. The bill was amended team-based approach to patient care, which by the Committee to require nurse practi- emphasizes increased collaboration and integrationers (NPs) to have a minimum amount of tion among health care providers, rather than In addition, legislation that would authorize post-licensure experience under a collaborative provider autonomy. With the complexity of Pennsylvania to join the Interstate Medical agreement with a physician before they may our health care system ever increasing, patients Licensure Compact passed the House of practice independently. While well-intentioned, need both physicians and nurse practitioners, Representatives unanimously on June 15. PAMED believes the logic of this amendment coordinating care and sharing information for At the time of this writing, HB 1619 awaits was flawed. The stipulation on independence the benefit of the patients. The collaborative consideration by the Senate Consumer Pro- requires just three years and 3,600 hours of agreement serves to ensure that patients have tection and Professional Licensure Committee. practice experience, while completely lacking direct access to a physician when their care The overarching purpose of the Interstate meaningful details. There is no required requires a more highly trained professional. Medical Licensure Compact is to streamline curriculum for the completion of those hours/ Eliminating this network of support would the licensure process for physicians interested years, no assurance of the quality of mentors not only be contrary to proven concepts of in becoming licensed in multiple states. HB and oversight, and – unlike the 3 to 7 years team based medicine, but has the potential 1619 is thus being promoted as a way to of heavily supervised residency training that to jeopardize patient care. increase access to healthcare for individuals a physician must complete – no accreditation in underserved or rural areas and allow pa- or inspection of the “training” sites of NPs. tients to more easily consult medical experts Central PA Medicine August 2016 27

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Practice Management

QUALITY OF LIFE By CHARLES YANOFSKY, MD 28 August 2016 Central PA Medicine

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y daughter and I had been caring for her spirited terrier named Jefe before the little guy accidentally jumped off a balcony and broke his spine. He was a full-breed dog with a genetic liver shunt that caused him to have gout, and hepatic encephalopathy. Jefe did well on allopurinol, plus lactulose and metronidazole. He was vivacious but frail and my daughter Eve, with my help, kept him going for about 10 years—not a bad lifespan for a dog. Eve couldn’t have loved Jefe more even if he had been healthy. In the end, seeing Jefe in pain and unable to move his legs was too much for her and him and she had to let go, staying with him until his last moment of life.

more impaired than expected. A localized never surrender their joie de vivre. The problem like shingles infection can have difference is what’s inside. unexpected permanent consequences, either because it is more widespread than Given that disease is not the sole deterit seems, or happens in an elderly person minant of quality of life, it has occurred without much functional reserve. It means to me to address the following: one can’t know all about the disease process looking at disease measures alone and en- 1. Look for paths around disability as courages vigorous disease prevention such in devices that preserve function. as vaccination and blood pressure control. Stephen Hawking couldn’t have survived, Many patients thrive after major setbacks let alone used his brilliant mind or exsuch as what seems to be severe cardiac pressed his thoughts, if not for extensive dysfunction yet snap back while others use of devices that made his full life lives are a shambles, seemingly without possible. measurable pathology. What accounts for such resilience or lack thereof? 2. Consider altering mental states. In addition to antidepressants, a simple talk One widely used and reported quality can change a patient’s outlook, focusing of life scale, developed by John Flanagan on experiencing pleasure and one’s best Reflecting on this and the 2014 movie, and modified by Carol Burkhardt, has 16 life in the present. It is even possible that “Theory of Everything” about Stephen components rated by a person on a 1-7 one day, computers will be used to usher Hawking moved me as a physician and scale from ‘terrible’ to ‘delighted.’ Of a disabled persons, and everybody else, into neurologist to the spectacular case in possible total of 7 X 16 = 112 points, a imaginary worlds that can be used for point of something I’d observed for quite person might score 90. Health is under- rehab or life enhancement. a long while. It’s about the human spirit. represented as only a single dimension on Humans are capable of living full lives this scale, on par with having close friends If you really desire to improve quality despite great impairments, sometimes and participation in the community, and of life—work with the brain. Given the right up to illness that affects mobility, self assessment of independence, even if fact that all experience is represented there, breathing and even the brain. health affects other measures. Obviously, it is the final arbiter of perceived quality these scales measure sentiment and attitude of life. The brain feeds back onto disease Clinicians are incentivized to look more than anything. mechanisms. A simple stimulator in the beyond treating disease to Health Related appetite center of the hypothalamus can Quality of Life (HRQAL) measures. It’s hard for clinicians to accept that be used to control the disease cluster of Medical therapies are being scrutinized for disease is only one of the horsemen of the obesity, metabolic syndrome, diabetes and their impact, not only on direct disease apocalypse. We think disease is everything, atherosclerosis and other co-morbidities. measures, but where the rubber-meets-the but human suffering comes in many For now, even if I can’t lessen an illness road and quality of life. The best example forms: repression and loss of autonomy, directly, I will find it beneficial at times of this is the New York Heart Association lack of shelter, being despised by others to alter a patient’s focus away from their (NYHA) functional measure. The ejection and subject to natural and man-made ailments, to a renewed appreciation of their fraction of the heart, a measure of disease, threats. A catastrophe anywhere, such as life. Thus it seems the best clinician will isn’t necessarily the best guide for therapy, sickness, can blacken one’s view of all the broaden obsessive emphasis on disease, to but rather how the patient functions. Case others. Yet humans are multi-dimensional the ecosystem in which the disease develops in point—just because you have a readily and complex, particularly in their social and thrives, quality of life. available measure, doesn’t mean it tells relations. That there is more to the human you what you want to know. condition than simple physical well-being has been profoundly expressed by Viktor Nowadays, we have an array of func- Frankl in “Man’s Search for Meaning.” We tional measures in all specialties. They see people who have everything, throwing reveal surprising things. After a TIA or it all away, while others living in miserable minor stroke, people turn out to be far circumstances, in gulags and prison camps,

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DCMS Happenings

Dauphin County Medical Society in the Community DCMS President’s Inaugural Dinner On Friday, April 29, nearly 100 guests gathered at the Clarion Hotel & Conference Center, Harrisburg, West to celebrate the 150th anniversary of DCMS. The President’s Inaugural Dinner was hosted by DCMS President Mukul Parikh, MD, and the theme was dedicated to recognizing all the living past presidents and the history of DCMS. Longtime physicians and guest speakers Dr. Raymond Grandon and Dr. George R Moffitt Jr. both spoke about their time in medicine and the changes they have seen over the years

DCMS Night at The Vineyard and Brewery at Hershey Friday, July 8th, The Dauphin County Medical Society got together for a relaxing, fun-filled evening at The Vineyard and Brewery at Hershey Decked-Out Live Entertainment Series.

From left: Jihua Cheng, MD; Michael Wilson,The Vineyard at Hershey’s Vice President of Marketing & Outreach; DCMS Vice President Heath Mackley, MD

From left back row: Drs. Mukul Parikh; Bernard Margolis; Stanley Smith; Richard Patterson; Kenneth Conner; Everett Hills; John Goldman; Lawrence Altaker; Andrew Richards From left front row: Drs. George Moffitt Jr.; Raymond Grandon; Domingo Alvear; Mary Simmonds; Gwendolyn Poles; Robert Ettlinger.

A SPECIAL THANK YOU TO OUR SPONSORS AND PATRONS FOR HELPING TO MAKE THE PRESIDENT’S INAUGURAL DINNER and DCMS 150th ANNIVERSARY HAPPEN.

PATRONS Everett C. Hills, MD Mukul L. Parikh, MD From the Kiran and Anandi Patel Family Fund of The Foundation for Enhancing Communities on behalf of Anish and Rupal Patel Thank you to Janet Bowen from the Historical Society of Dauphin County for providing DCMS historical photos and books.

30 August 2016 Central PA Medicine

It's 5 o'clock somewhere! Join DCMS at the Vineyard in Hershey Sept. 30 for wine, friends and Jimmy Buffet music. The first 50 RSVPs are free! Watch your email for registration and details.

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DCMSA News

Dauphin County Medical Society Alliance QUARTERLY N EWS The Dauphin County Medical Society Alliance (DCMSA) would be delighted if you would be our guest at one of our upcoming meetings or events. DCMSA membership is comprised of physicians, residents, medical students and their spouses. Please contact Holly Mackley at dcmsalliance@gmail.com if you would like more information regarding these events or to join the DCMSA. Find us on Facebook at www.facebook.com/ dauphincountymedicalsocityalliance/

*If you are interested in joining the DCMSA or any of the hospital auxiliaries events can contact Holly Mackley at dcmsalliance@gmail.com and I can forward you more information.

Calling all DCMSA Members:

It is that time of year again to renew your membership. You can reach out to Holly Mackley at dcmsalliance@gmail.com for more information.

Ongoing Volunteer “Hands-On” Opportunities: • Hands are Not for Hitting: Program for first graders that operates in two Harrisburg Schools. • Community Check-Up Center: Volunteers read to local children in Harrisburg. Please Contact Holly Mackley at dcmsalliance@gmail.com if you would like more information regarding these events, volunteering or to join the DCMSA. Find us on Facebook at www.facebook.com/ dauphincountymedicalsocityalliance/

DCMSA had another successful Spring into Fashion show and luncheon on April 19, 2016. We were able to donate over $12,000 to charitable organizations in Dauphin County that support our mission of improving community health, supporting medical education and engaging in charitable activities. We are already planning our 2017 luncheon and fashion show and hope to see some news faces in attendance. May 10, 2016 DCMSA members gathered at the Tavern on the Hill in Enola for our annual Gavel Club and Installation of new officers. We said a fond farewell and thank you to Judith Dillon, our outgoing president. We installed the following board members for 2016-2017: President Elect: Wendy Hammaker Membership Secretary: Alex Anastasio Treasurer: Holly Mackley Recording Secretary: Karen Daughtry Correspondence Secretary: Ronni Scher On the evening of July 23, 2016 DCMSA members and their guests gathered at Dr. Andrew and Karen Bloschichak’s home for a summer mixer. A fun time was had by all.

Upcoming Count y Events ( County

Level)

Association of Family and Friends of Penn State (AFF)

-9/28/16 Third Annual Joint Auxiliary Luncheon and Program at the Hershey Garden Conservatory 11:30 am -9/14/16 AFF Fall Coffee at the home of Carol Schneidereit 9:30-11:30 -Monthly Getting to Know You Lunches will resume in September

Holy Spirit Auxiliary

-August 30-31 2016 Jewelry Sale at Holy Spirit Hospital -September 8, 2016 Membership event

PinnacleHealth Auxiliary

-October 21, 2016 - The PinnacleHealth Auxiliary will be presenting their 19th Annual Chic PHantastic Fall Fashion Show and Luncheon to be held at the Sheraton-Harrisburg-Hershey. Fabulous fashions will be provided by SAKS FIFTH AVENUE! Doors open at 10:30 a.m. More information can be obtained at pinnaclehealth.org/auxiliary or by calling 717-231-8080. -November 17, 2016 - PinnacleHealth Auxiliary Board and General Membership Meeting - guests are welcome! Join us at Mangia Mangia Italian Grill, 2981 Elizabethtown Rd., Hershey for a noon luncheon and wine pairing presentation by Bernie Strackhouse of North American Spirits & Wine. For more information, please call 717-231-8080.

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HELPING FINANCE PHYSICIAN EDUCATION

he Foundation of the Pennsylvania Medical Society, a nonprofit affiliate of PAMED, sustains the future of medicine in Pennsylvania by providing programs that support medical education, physician health, and excellence in practice. It has been helping finance physician education for more than 60 years.

“We recognize that medical students play a vital role in the future of medicine in Pennsylvania, so we proudly administer scholarships to deserving students across the commonwealth,” said Heather Wilson, the Foundation’s executive director. Applications for several scholarships will be accepted July 1–Sept. 30, 2016. Allegheny County Medical Society Medical Student Scholarship. Residents of Allegheny County can apply for a $4,000

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award. Applicants must be enrolled full-time at a Pennsylvania medical school as third- or fourth-year students. Blair County Medical Society Medical Student Scholarship. Blair County residents attending a United States medical school may apply for the $1,000 award. Applicants must also be enrolled full-time as second-, third-, or fourth-year students. Endowment for South Asian Students of Indian Descent Scholarship. Pennsylvania residents of South Asian Indian heritage may apply for this $2,000 award. Additionally, applicants must be enrolled full-time as second-, third-, or fourth-year students at a Pennsylvania medical school. Lehigh County Medical Auxiliaryâ&#x20AC;&#x2122;s Scholarship and Education Fund Scholarship. Lehigh County residents attending a US medical school full-time may apply for this $2,500 award. Lycoming County Medical Society Scholarship. Lycoming County residents attending a US medical school full-time may apply for a $3,000 award. Two recipients will be selected. Montgomery County Medical Society Scholarship. Montgomery County residents attending a US medical school as first-year students may apply for this $1,000 award.

Scott A. Gunder, MD, DCMS Presidential Scholarship. Second-year students at Penn State University College of Medicine who are Pennsylvania residents may apply for this $1,500 award. Postmark deadline: April 15. To find out more about scholarships, call the Foundation at 717-558-7852, or visit the Student Financial Services page at www. foundationpamedsoc.org. Since 1948, more than $19.6 million in loans and scholarships has been awarded to nearly 4,500 students. Thank you to the generous contributors who have made these scholarships possible! If you would like to donate to the future of medical education through any of these designated funds, make your check payable to The Foundation of the PA Medical Society, and indicate which scholarship you would like to support in the memo line. Mail your gift to the Foundation of the Pennsylvania Medical Society, 777 E. Park Drive, Harrisburg, PA, 17105. If you have questions regarding support of student scholarships, please feel free to contact Marjorie Lamberson, CFRE, via email at mlamberson@pamedsoc.org or by phone at 717-558-7846.

Myrtle Siegfried, MD, and Michael Vigilante, MD, Scholarship. Students residing in Lehigh, Berks, and Northampton counties and entering their first year at a US medical school may apply for the $1,000 award. Additional scholarships are available each year with alternate deadlines: Alliance Medical Education Scholarship. Pennsylvania residents attending a Pennsylvania medical school as second- or third-year students may apply for a $2,500 award. Multiple recipients will be selected. Postmark deadline: Feb. 28.

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DCMS News

FRONTLINE GROUPS

NEW MEMBERS

The Dauphin County Medical Society thanks the following groups for their 100 percent membership commitment:

 Central PA Surgical Associates Ltd  Cocoa Family Medicine  Family Practice Center PC – Halifax  Healthy Starts Pediatrics  Hershey Kidney Specialists Inc  Hershey Pediatric Center  Pediatrix Medical Group

 PHCVI-Pinnacle Health Cardiovascular & Thoracic Surgery Assoc  PinnacleHealth Cardiovascular Institute Inc  PinnacleHealth Internal Medicine Union Deposit  Pulmonary & Critical Care Medicine Associates PC  Saye Gette & Diamond Dermatology Assoc PC

 Sollenberger Colon & Rectal Surgery Ltd  Tan & Garcia Pediatrics PC  The Arlington Group

 Heather Johnson

 Urology of Central PA

 Laura Hershey Brubaker

 Women First Obstetrics & Gynecology PC  Woodward & Associates PC

 Sarayna Schock  Christopher B. DiCroce  Andrea Aldinger  Yuxia Jia, MD  Yanfang Guan, MD  Sabina Yvonne Miranda, DO

WE CAN MAKE A DIFFERENCE

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