Central PA Medicine Fall/Winter 2016

Your Community Resource For What’s Happening In Health Care

FALL/winter 2016

Central PA

Official Publication of the Dauphin County Medical Society

MEDICATIONS FOR DIABETES a simple review

PASSION Plus PREVENTING ALZHEIMER’S DISEASE

O U TSI DE O F P RA CT I CE PHOTOGRAPHY OF

Yan Leyfman, Medical Student

Your cast comes off when You’re healed. why not your

heart 2001—Metal Stent

Today—Completely Dissolving Stent!

A leading-edge technology, the Absorb™ heart stent dissolves in the body naturally and safely after it has done its job of keeping a clogged artery open. As the artery heals, the stent dissolves, leaving behind nothing to restrict vessel motion or cause future complications. Safer and healthier.

PinnacleHealth is one of only 10 hospitals in the nation with Absorb available and was the first in Pennsylvania to place Absorb after FDA approval.

At the heart of your good health.

Talk to your doctor to see if the Absorb dissolving heart stent may be right for you. pinnaclehealth.org/heart

Central PA

Contents

FALL/WINTER 2016

Features Dauphin County Medical Society

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

(717) 558-7849 • dauphincms.org

8

Medications for Diabetes

10

As a Group, We Stand to Benefit from the Collective Experience

2016-2017 DCMS BOARD OF DIRECTORS Mukul L. Parikh, MD President Robert A. Ettlinger, MD Immediate Past President Jaan E. Sidorov, MD President-Elect Heath B. Mackley, MD Vice President

Community, Health & Wellness 14

Confronting the Peri-Operative Pain Paradox

16

Prostate Cancer Screening What it Means for You

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

Practice Management 24

Preventing Alzheimer’s Disease

28

The Foundation Celebrates 30 Years of Saving Lives and Careers

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 . . . . . . . . . . . . . . . . . 18

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

Legislative Updates. . . . . . . . . . . . . . . 20

Passion Outside of Practice . . . . . . . . . 12

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

daup h i n cm s .org

From the Editor

Pay It Forward:

The Joy of Mentoring

U 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

Fall/Winter 2016 Central PA Medicine

ndergoing the process of academic promotion in a university hospital is no small task, and in my case it includes distilling the last five years of work into a one to three page “personal statement.” A silver lining is that this forced reflection allowed me to put into words what I find the most valuable about my experience. In this process, I found myself writing recently. On a personal level, I have found mentoring to be one of the most rewarding aspects of my academic life at Penn State, and will continue to do that as much as I can.

Mentoring is not something that is only found in the halls of academic medicine. All physicians are teachers. We teach our staff, we educate our patients individually, and we inform society about public health issues in community groups of all shapes and sizes and in the media.

Organized medicine reflects this. One of the AMA’s founding principles was to set standards for medical education. The Pennsylvania Medical Society’s (PAMED) original and current mission statements include a commitment to advancing medical knowledge and promoting the public’s health. This is also found in my county’s mission statement (Dauphin), and I suspect this is found elsewhere throughout the other county medical societies of central Pennsylvania. Mentoring is a natural extension of this commitment to teaching.

PAMED, the only voice that represents all physicians in the Commonwealth of Pennsylvania, has a program called Mentoring Matters.

Their website says, “This volunteer program is designed to match physician mentees and physician mentors within common regions, specialties, or practice settings, based on the mentee’s needs and interests and the mentor’s abilities and experiences.” Although on some level, this program is “new,” it’s really more of a reboot. When I told Dr. Parikh I thought it was a good idea that PAMED was doing this, he smiled and said, “I remember taking part in

this in the 1980’s.” I’m sure our members with even longer institutional memories can described past mentoring programs before that as well.

Mentoring comes in many forms. Mentoring programs are a great start for people looking for advice, but I dare say a majority of mentoring takes place in informal relationships. Much of the best advice I received along my path have been in those settings, and I continue to seek out guidance during my “mid-career” as challenges and opportunities come and go. In some situations, I’m able to do something tangible for my mentor, but in most cases, I cannot. But I can “pay it forward.” I’ve personally had the good fortune of mentoring local high school students, undergraduate students, medical students, residents, fellows, and early-career attending physicians. All of those opportunities do not exist outside of university hospitals, but many of them do.

But what’s in it for the mentor? We’re all patients. We all benefit from investing in the medical community. It’s rewarding to encourage bright high school and undergraduate students to choose medicine, but it’s equally valuable for a learner to shadow in a clinic before applying for medical school. There is the occasional student that realizes after seeing clinical medicine that their best life decision is to go into something else that is often related, but that they will find more fulfilling. Likewise, medical students not only need to figure out which branch of medicine is best for them, but they also need specialty specific mentoring to help maximize their chance of matching into competitive programs. Residents, fellows, and early-career physicians have struggles related to work-life balance, establishing a successful practice in a region they want to live, and for some to establish a niche that they can leverage into an academic career. Mid-career and later-career physicians can struggle with work-life balance, the emotional impact of malpractice cases or physical illness, and developing leadership skills as some move

daup h i n c m s .o rg

up into management positions. End-of-career physicians have the challenge of navigating transition planning for their successful medical practice and the adjustment to the life change that comes with retirement. All students and physicians can benefit from mentoring, which means that all physicians of all ages could help by being a mentor. This means you!

So, I encourage everyone, but especially PAMED physician members, to consider: if I have benefitted from mentoring in my medical career, how can I pay it forward? You’ll be glad you did!

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.

Central PA Medicine Fall/Winter 2016 5

daup h i n cm s .org

President’s Message

The Practice of Medicine is Still a Business

Mukul Parikh, MD, DABA President, DCMS

T

he practice of Medicine, even if it is considered to be a noble profession, is still a business. In any business model, there are two basic entities — a buyer and a seller.

The seller has a product which can be physical goods or a service which he offers at a certain monetary value. The buyer ends up buying the product at that certain value if he needs it, and deems it to be fairly priced. The business of medicine was no different when it started.

Physicians offered their healthcare expertise to the people with illness and got paid in cash or kind. It was a fairly simple and straightforward business model.

Then, insurance companies entered the equation at some point of time to supposedly spread the risk and facilitate the transactions. In the beginning, they were non-profit, but soon they became a monstrosity in and of itself with shareholder owned, for-profit companies and enormous executive salaries with expensive real estate in prime locations.

While insurance companies provide beneficial services, they do not add any medical value.

They have made the whole business process extremely complicated and difficult to navigate for both primary stakeholders — physicians and patients.

Next, the legal profession entered the scenario. Again, while they provide a valuable service to patients who are wronged by the healthcare profession, the outrageous malpractice awards and the plethora of nuisance lawsuits added to the cost of healthcare without any medical benefit overall. In fact, the practice of defensive medicine added some unnecessary tests/procedures to the detriment of healthcare practice.

Let us look at the economics of this whole practice model. The physicians and lawyers charge for their professional services as a means of their livelihood. The insurance companies — whether for-profit or non-profit — are a business and need to make profits for their administrative support and real estate. For-profit companies have to make even more profits for their shareholders. The only party that always has to pay, is the patients (this includes doctors, lawyers and insurance company employees). We all do it through our insurance premiums (directly or provided by our employer) and/or by our taxes for the government-sponsored programs (Medicare and Medicaid).

The big question that needs to be asked of the current system we have created is: How much of the total healthcare dollars really go to providing healthcare directly to the patients which includes physician fees, medicines, lab tests, and hospital services? I bet we will be surprised to find that a significant percentage goes to the administrative structure and legal system with no medical benefit to the community.

Can we ever go back to the good old system — simple and efficient? I doubt it.

6 Fall/Winter 2016 Central PA Medicine

There is an alternative to invasive brain surgery. Penn State Health Milton S. Hershey Medical Center has upgraded to Leksell Gamma Knife® Icon™—the newest technology in cranial radiosurgery. Icon allows experts to target areas once considered too large or too risky even for radiosurgery. With this improved technology, 13 physicians on staff, and over a decade of experience performing more than 1500 procedures on patients with tumors, trigeminal neuralgia, AVMs and more—Penn State Health Milton S. Hershey Medical Center is the team for your patients’ radiosurgical needs.

To refer a patient and schedule a prompt appointment, call 717-531-8807, option 4. For more information and to view an informational video, go to PennStateHershey.org/GammaKnife.

NEU-10388-17-53623-0923

daup h i n cm s .org

Features

MEDICATIONS FOR DIABETES a simple review

By ROBERT ETTLINGER, MD

I

n a 2014 report by the U.S. Department a loved one are diabetic. This will permit of Health and Human Services, 29.1 you to be familiar with their intended and million Americans are afflicted with adverse effects, and help be more involved diabetes mellitus, with the prevalence with your doctor in self-management. expected to rise to 1 in 4 adults by 2050.

Many of them, especially the 95% that are To understand diabetes, it is essential to termed Type 2 diabetes, are overweight know how human nutrition works. Food and have elevated blood pressure and high is made up of carbohydrates (starches, blood fats. These lead to higher rates of which provide energy), proteins and fats serious conditions, including heart at- (for structural repair, as well as for reserve tacks, strokes, kidney failure, blindness fuel), and vitamins and minerals. The and gangrene. Thus, it is crucial to treat carbohydrates are absorbed through the this often symptomless disease seriously, to walls of the stomach and small intestine, prevent health disability and death. While where they are converted to the molecule, many cases of early diabetes can be treated glucose, commonly known as blood sugar. with dietary modifications, most diabetics The rate at which glucose levels rise in the eventually have to use medication to treat blood stream is related to its glycemic index. their condition. A vast number of drugs for Sugar immersed in water (such as soda diabetes have been invented since Banting or fruit juice) raises glucose levels highly and Best discovered insulin about 80 years and rapidly, whereas carbohydrate sources ago. A brief review of these medications, like beans (which take a longer time to be which are used both individually and in broken down to small molecules) have a combination, would be helpful if you or lower glycemic index, leading to a slower

8 Fall/Winter 2016 Central PA Medicine

and less steep rise of blood sugar. Proteins and fats are not used as fuel immediately, but are, instead, stored in the liver as a long chain of glucose called glycogen. Glycogen, which also stores unused blood glucose, can be thought of as being like honeycomb, compared to glucose being like liquid honey.

Glucose is used by the cells of our bodies by gaining access through the cell walls via the pancreatic hormone, insulin. Insulin is the key to the lock that is the cell wall, allowing fuel into the cells. While insulin lowers blood sugar, we get a rise in blood sugar by another pancreatic hormone called glucagon. Glucagon is necessary when we run out of the immediate fuel provided by our nutritional carbohydrates. It causes breakdown of glycogen in the liver, causing free blood sugar to rise, like honeycomb melting into usable liquid honey. In a nutshell, when people develop diabetes, they make too little insulin, too much glucagon, and can't suck

daup h i n c m s .o rg

the extra blood sugar into the cells, causing a wide variety of tissue damage.

Now that you're an expert in the multiple body processes that break down in diabetes, let's look at the selection of medicines that can correct these problems.

are used less commonly today due to their indiscriminate secretory action, working at equal rates both before and after a meal. This has led to increased rates of symptomatic low blood sugar, as well as weight gain (since lowered blood sugar triggers hunger and, thus, caloric intake). Also, their effectiveness tends to wane off over short time frames, due to eventual failure of self-production of insulin as the pancreas burns out over time.

The first drug invented for diabetes was insulin. Replacing insulin is needed when insulin is severely lacking or absent (termed Type 1 diabetes) or is deficient with decreased Metformin was a major boon to diabetic sensitivity at the cellular level (Type 2). pharmacology in 1995, as it was shown to Administering insulin increases disposal have the most impact among diabetic drugs of glucose into the cells, to be used as the on death and disability endpoints such as body's fuel, and decreases liver production heart disease, stroke and kidney disease. of glucose from glycogen by inhibiting its Metformin (brand name Glucophage) "enemy," the hormone, glucagon. Given inhibits glucose production from liver by injection (due to lack of GI absorption glycogen, decreases intestinal absorption at this point in human technology), it was of glucose, and improves cell sensitivity initially distilled from animal pancreas, until to insulin and body tissues. While up to a human recombinant genetic insulin was third of patients using metformin develop invented in 1982. This synthetic insulin transient GI side effects like bloating and improves stability, and decreases the tol- stool changes, only 2% of diabetics have to erance and allergies seen in animal insulin. stop it due to intolerance.

Many diabetics start with a basal insulin, which does not peak (an action needed Besides insulin and glucagon, a third right after eating) and, thus, lowers blood hormone, called incretin, is also involved in sugar all day long, especially while fasting carbohydrate metabolism. There are now two and when blood sugar comes strictly from new classes of drugs to work on that system. glycogen breakdown. Typically, this trickled The two incretin hormones, GIP and GLP-1, insulin is needed a few hours after dietary are secreted in the intestines in response to carbohydrate supplies are depleted. Exam- food ingestion. These hormones are involved ples include Levemir, Lantus, Tresiba and with stimulating insulin in the pancreas, Toujeo. Another type is ultra-rapid, which decreasing glucagon (the hormones that mimics the action for a healthy pancreas in produces sugar stored in the liver), slowing providing a quick squirt of insulin to lower stomach emptying, making us less hungry, sugar from just-eaten carbohydrates. Taken thus resulting in less overeating. The first right before meals, examples include Hum- of these drug classes, the DPP-4 inhibitors, alog, Novolog and Apidra. Less physiologic prolong the physiologic actions of GLP-1 forms, including extended (8-12 hour) and in the intestine, leading to lower blood rapid acting, are used less commonly these sugar. Examples include Januvia, Onglyza, days. Insulin is usually given via a pen, in and Tradjenta. A second group, given by about 90% of users (the rest use a bulkier self-injection just once a week, is called needle and syringe), with a tiny needle fed the GLP-1 agonists. Because of comparably through a dialable cartridge. For those who higher GLP-1 activity achieved, they have prefer to avoid needles, an inhaled form, better glucose-lowering activity than the Afrezza, is available.

DPP-4 inhibitors, and promote weight loss by increasing food satiety. While two older Sulfonylureas, invented in 1955, increases ones are given daily, the products Bydureon, insulin secretion rather than “squeezing” Trulicity and Tanzeum can be given once it out of the pancreas. While inexpensive weekly. Like insulin pens, the needles are in generic form, glipizide and glimepiride tiny, and surprisingly trivially uncomfortable.

In fact, over half of all diabetics take more than one drug for their management.

The TZD class of diabetic drugs currently only, for the most part, includes Actos.

Mainly working by increasing sensitivity of fat, muscle and liver to insulin, they also reduce glycogen breakdown. While not being a cause of congestive heart failure, they can exacerbate it if it develops, so they should be held in the presence of leg swelling or unexplained shortness of breath.

The most recently developed class of diabetic drugs are the sodium-glucose cotransporter-2 inhibitors, commonly known as the SGLT drugs. Available as Invokana, Farxiga and Jardiance, they cause the kidneys to leak unused blood sugar by decreased reabsorption of the small amounts of glucose unfiltered by the kidney. A welcome side effect of these drugs is weight loss, due to the dumping of unneeded glucose out into the urine. This urinary loss of sugar is accompanied by increased water to dilute it, so increased frequency of urination can be a problem for some. Trivially, increased rates of urinary and vaginal infections have been reported.

With few exceptions, these classes of medications can be taken in combination with each other, as they work at different levels in the diabetic process. In fact, over half of all diabetics take more than one drug for their management. If your diabetes is not in good control, or if you have any problems with medications you're already taking, lots of options are available through your doctor to keep you healthy.

Central PA Medicine Fall/Winter 2016 9

daup h i n cm s .org

Features

AS A GROUP, WE STAND TO BENEFIT FROM THE COLLECTIVE EXPERIENCE

By THOMPSON KEHRL, MD, FACEP President of the York County Medical Society

10 Fall/Winter 2016 Central PA Medicine

H

eraclitus, the ancient Greek philosopher, is credited with coining the term, “change is the only constant in life.”

As physicians in Pennsylvania, we are fortunate to have medical societies with long and distinguished histories – the Dauphin County Medical Society founded in 1866, the York County Medical Society in 1873, and the Lancaster City and County Medical Society in 1844. With longevity comes unique customs and traditions that are integral parts of the identity of each society. But, as always, change is upon us. We are faced with the stark realities of declining membership. With the significant financial implications this brings to member-fee driven organizations, we have the choice to change or wither into obsoleteness. After much discussion both internally and externally, our county medical societies have decided to consider the prospect of regionalization to address many of the hurdles ahead of us.

daup h i n c m s .o rg

The benefits of regionalization are innumer- as mentioned above, maintaining our inable and include consolidation of executive dividual county medical society traditions. and administrative services, increased clout on Further complicating the situation is the advocacy-related issues, combined educational unique financial and administrative founventures, and ultimately more benefit for our dation that each medical society is built on. members. The downside may be the loss of identity that our county medical societies need The next steps are already unfolding with to survive and continue to engage members. continued discussions between county boards, alignment of priorities, and getting down to The Delaware and Chester County the nitty-gritty details that will make this Medical Societies have already started to possible. It is unlikely that there will be a pave the way. They share a county execu- “one-size-fits-all� model. Early adopters of tive, David McKeighan, who was willing regionalization, however, will likely be able to to share his time and experience with provide a framework for other county medical my county medical society. We then met societies that are interested in following suit. with members of the executive boards as well as with the representatives from the I had the privilege of attending the President Pennsylvania Medical Society (PAMED) / President-Elect meeting at last year’s PAMED to discuss further direction. The key seems House of Delegates (HOD) during which to be finding a sustainable financial model time we heard all of the endeavors each county to meet the administrative and logistical medical society is undertaking. It really struck needs of the county medical societies while, me how much work is being done and how

We are faced with the stark realities of declining membership. important it is to have healthy, engaged county medical societies. I encourage each and every one of you to reach out to your board members and take part in this discussion. As a group, we stand to benefit from the collective experience, knowledge, and skills that our members bring to the table. You, your fellow members, and our patients deserve it!

Central PA Medicine Fall/Winter 2016 11

daup h i n cm s .org

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 healthcare, DCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature the photography of Yan Leyfman, Medical Student at Penn State College of Medicine.

PA S S I O N OU TSI DE OF PRACTICE

Yan Leyfman, Medical Student “America the Beautiful” 12 Fall/Winter 2016 Central PA Medicine

daup h i n c m s .o rg

“True Love”

HOW DID YOU DEVELOP AN INTEREST IN YOUR PASSION OUTSIDE OF PRACTICE? My passion for photography stems from my youth as I grew up in New York. New York City is the city that never sleeps and where interesting events arise at every corner. Wishing to capture its extravagant beauty and haphazard instances, I pursued photography as a medium to share the beauty that I saw on a daily basis.

HOW LONG HAVE YOU BEEN DOING IT? I have pursued this craft ever since my youth.

WHAT MAKES IT SPECIAL TO YOU? Photography is a unique medium that allows me to share the beauty of nature, architecture and mystique with those around me. My appeal is in the abstract ability to interpret a photo in many ways that can appeal to everyone observing it.

My clinical experiences have shown that a beautiful photograph can instantly alter a mood, change a perception, and even fortify the patient-physician connection. Patients can be very vulnerable and their ailments may cause depression, but a photograph has the ability to inject positivity and hope—something that is needed to lighten the mood and propel patients onto the road of recovery.

“Two Lives”

IS THERE ANYTHING ELSE YOU’D LIKE TO SHARE? I hope that my photography can bring smiles onto its viewers and inspire abstract thought about the profound meaning of every picture.

Central PA Medicine Fall/Winter 2016 13

daup h i n cm s .org

Community, Health & Wellness

CONFRONTING THE

PERI-OPERATIVE PAIN PARADOX

By JOSEPH F. ANSWINE, MD

This article has been accepted for publication in Anesthesiology News. It is reprinted here in order to expand the distribution of the information to patients and non-anesthesiology trained physicians.

14 Fall/Winter 2016 Central PA Medicine

daup h i n c m s .o rg

I

n the United States and around the world, we are striving to create a pain-free, peri-operative experience while limiting pain medications. This has motivated many institutions to attempt to utilize multimodal pain management with opioid avoidance.

This seems self-contradictory or a paradox. Pain medications, especially opioids, understandably have undergone intense scrutiny due to recent public concern over prescription drug abuse, as well as the known side effects of opioids limiting enhanced recovery programs such as somnolence impeding early ambulation and feeding, increased PONV, a higher incidence of ileus after colorectal surgery, as well as significant respiratory depression.

The problem is that major surgery comes with major pain and opioids are effective at treating major pain. Furthermore, when opioids are introduced after attempting to avoid their use, it is usually done “emergently” only after the patient is in extreme inconsolable pain disrupting recovery, and likely leading to larger doses given and the occurrence of the adverse events that all are trying to avoid. Add in that severe, acute pain is a risk factor for the development of chronic pain, sleep disturbance, changes in mood and behavior especially in children, poor wound healing, and delayed recovery. Avoiding the use of opioids in the face of intense pain and its potential short and long term negative effects has created what I call “the peri-operative pain paradox.”

(PCA) appears to be optimal because it minimizes the pharmacokinetic and pharmacodynamic variability among patients and patient populations, as well as being “on demand” based on the level of perceived pain and the cognitive ability of the patient. It also improves patient satisfaction by allowing immediate delivery and a sense of control. The American Pain Society’s post-surgical pain management guidelines also recommend IV PCA if PO opioids cannot be used. A transition then to PRN PO opioids in a time-limited manner while continuing multimodal pain control as patients progress can then occur, again emphasizing non-opioid modalities throughout. Other routes of administration can be considered such as epidural, intraarticular and transdermal depending on the procedure performed and the comfort level of those involved.

We are striving to create a pain-free, peri-operative experience while limiting pain medications.

Multimodal pain management is procedure and patient population specific, designed to maximize the beneficial effects of the different treatment modalities while limiting the unwanted side effects. This is an important statement because opioids are not the only medications with side effects. As doses rise, regardless of the mechanisms of action of the medications, the risk for unwanted or even life- threatening side effects increases as well. For example, local anesthetics have CNS and cardiac toxicities, acetaminophen has hepatic toxicity, and NSAIDs have hematologic and renal Therefore, to avoid the peri-operative pain paradox, multimodal toxicities, etcetera. Also, an over emphasis on neuraxial and pain management should be employed which includes opioids as regional techniques can cause muscle weakness and hemodynamic one arm of many used to control surgical pain. instability leading to delayed recovery.

It seems reasonable then, to move away from an opioid based pain management program to one that doesn’t remove opioids, but utilizes them as part of a coordinated protocol of opioids, non-opioid medications, physical modalities and education in order to provide optimal pain control and reduced opioid induced adverse events as well as those of other pain modalities.

How then should opioids be delivered since routes of administration are numerous? The most common route of post-operative opioid administration is intravenous (IV). It is most consistent from patient to patient in blood levels achieved, speed of delivery to the site of action, and duration of action; and the onset of pain reduction is relatively rapid. It also allows for more coordinated and efficient patient monitoring. IV patient controlled analgesia

Your First Choice for Quality

A Community Outreach of Homeland Center

717-221-7890

www.homelandhospice.org

717-221-7892

www.homelandhomecare.org

HomelandHospice.org • 2300 Vartan Way, #115 • Harrisburg, PA 17110 Central PA Medicine Fall/Winter 2016 15

daup h i n cm s .org

Community, Health & Wellness

PROSTATE CANCER SCREENING WHAT IT MEANS FOR YOU

By STEPHAN LEUNG AND TONY LIN

P

rostate cancer is the second most common cancer in men. In the United States alone, the average lifetime risk for developing prostate cancer is 1 in every 6 males (1). The risk of prostate cancer also increases greatly with age. The disease is also more common in African Americans and patients with a positive family history of prostate cancer.

Survival is related to the extent of tumor burden. The five-year survival rate for cancer localized to the prostate or for those with just regional spread is extremely favorable at near 100% (2). However, if the disease has spread beyond the local region of the prostate to elsewhere in the body, the five-year survival rate dramatically drops to around 30% (3). Therefore, diagnosing prostate cancer before it has spread is important. However, the rate at which localized prostate cancer progresses to disseminated prostate cancer is very low; hence, some urologists or family physicians may opt for a “wait-and-watch� surveillance period.

The prostate specific antigen (PSA) was originally introduced as a tumor marker to detect prostate cancer recurrence or disease progression after treatment (4). In the 1990s, the PSA was adopted for use by physicians as a screening tool which greatly increased the incidence of prostate cancer diagnosed in the adult male.

However, this had been controversial because the decision for adoption of the PSA as a screening tool was not based on data from randomized trials. Additionally, the use of PSA has led to an increase in the amount of aggressive treatments pursued for clinically localized disease, including prostate surgery or directed radiation therapy, which has led to more treatment related complications (5).

16 Fall/Winter 2016 Central PA Medicine

daup h i n c m s .o rg

Despite the prevalence of prostate cancer, screening guidelines have largely remained controversial. Before 2012, standard practice was PSA and digital rectal exam (DRE) every two years starting at age 50. However, the PSA test has been shown to produce many false positives and prevent relatively few deaths from prostate cancer. Hence, the risks associated with standard prostate cancer screening tests outweigh the benefits in the average patient. In light of this, the United States Preventative Services Task Force (USPSTF), an independent panel of experts in primary care and intervention, now recommends against PSA screening.

The American Urological Association (AUA) and the American Cancer Society (ACS) have also largely echoed the USPSTF recommendations. The AUA recommends against PSA screening in men younger than age 55, older than age 70, or has less than a 10-15-year life expectancy. For men between the ages of 55 to 69, there needs to be a discussion between the physician and the patient regarding the benefits and risks of prostate cancer screening. If screening is indeed decided to be initiated, the screening interval should be every two years. The ACS does not recommend routine screening in any age group. Instead, asymptomatic men with at least a 10-year life expectancy should be given an opportunity to make an informed decision with their healthcare provider after receiving information on the uncertainties, risks, and benefits of screening for prostate cancer. The ACS recommends that men should receive information at age 50 for those at average risk of developing prostate cancer.

Given this information, who exactly should receive prostate cancer screening? Dr. Joseph Y. Clark from the Penn State Hershey Medical Center Department of Urology says: “Screening for prostate cancer with a PSA blood test is very controversial; although screening with a PSA can reduce death from prostate cancer, the absolute risk reduction is small; one has to weigh the potential benefits of screening for prostate cancer versus the known risks of screening; the known risks of screening include a “false positive,” that

is having an elevated PSA without prostate cancer; these patients are subjected to the risks of prostate biopsy without any cancer found on the biopsy specimen. There is also the problem of over-diagnosis which is finding prostate cancer that would not cause the patient harm; most men in America are offered aggressive treatment for prostate cancer once detected; these men have anxiety from their diagnosis and are subjected to risks of aggressive treatment to include urinary symptoms, urinary incontinence, and erectile dysfunction which decrease quality of life.

Because urologists recognize these risks, many men who are felt to have low risk prostate cancer are now offered active surveillance which is avoiding or postponing immediate treatment of the prostate cancer; these patients are carefully followed (surveillance) and are offered definitive treatment when there is evidence that the patient is at increased risk for disease progression. Ultimately the decision to screen with a PSA is best made by the patient after a thoughtful discussion with his physician, but I feel that the most appropriate candidates for PSA screening are men between the ages of 55 and 70 who are relatively healthy and have at least a 10-15year life expectancy.”

Prostate cancer screening can be a very sensitive topic for some men. A thorough discussion between the patient and their provider regarding prostate cancer screening is important. That way, the patient can understand the potential risks and benefits and make an informed decision.

References: 1. Siegel R., Ward E., Brawley O., Jemal A. Cancer statistics, 2011: The impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011; 61:212.

2. Ries, L.A.G., Melbert, D., Krapcho, M., et al.

SEER Cancer Statistics Review, 1975-2004, National Cancer Institute, Bethesda, MD 2007.

3. Ries, L.A.G., Eisner, M.P., Kosary, C.L., et al.

SEER Cancer Statistics Review, 1973-1999, National Cancer Institute, Bethesda, MD 2002.

4. Lu-Yao, G.L., Greenberg, E.R. Changes in prostate cancer incidence and treatment in the USA. Lancet. 1994 Jan 29;343(8892):251-4.

5. Epstein, J.I. Pathology of prostatic neoplasia.

In: Campbell's Urology, 8th ed, Walsh PC (Ed), Saunders, Philadelphia 2002.

Central PA Medicine Fall/Winter 2016 17

daup h i n cm s .org

Restaurant Review

THE GREYSTONE PUBLIC HOUSE

By DR. ROBERT ETTLINGER

M

any local epicures sighed in disappointment when is now ample, in response to customer comments after the restauthe Mount Hill Tavern shut its doors last year. rant's opening days, and an outdoor patio provides a pleasant al Luckily, customers did not have to wait long for its fresco experience for the warmer months of central Pennsylvania. successor, The Greystone Public House, to fill the The nicely appointed upper floor offers smaller rooms for diners void. Investor John Frisch and popular local chef Jason Viscount who prefer a more intimate meal. renovated the beautiful, centuries-old stone building near the corner of Linglestown Road and Colonial Road, and have come Mr. Viscount, who most recently performed his magic at Bricco, up with a welcoming dĂŠcor and a progressive menu. Judging by has developed a menu in line with the agenda of many diners. the sizable crowds noted at each of my three visits there, the new To keep customers coming back regularly, he has offerings that eatery has earned its fans. are casual, family-friendly and affordable, as well as finer plates for more special occasions. "Hand helds," served with fries and Supplanting Mount Hill's multi-roomed dining area, Greystone's salad, include beef, bison and veggie burgers, crab cake and main floor is now open and spacious, with a modern industrial market-price fish sandwiches, and a house pastrami with smoke look accented by appropriate colonial lighting, fixtures and wall signal cheese and sour red cabbage. Combined with soups or decorations. A large central concrete bar is well lit by extensive apps, five salads can be served with chicken, salmon or crab cake windows and chandeliers resembling tree branches. Soundproofing to make a fulfilling dinner.

18 Fall/Winter 2016 Central PA Medicine

daup h i n c m s .o rg

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

Specializing in Patient Satisfaction.

Stepping it up a notch, our party enjoyed a selection of generously portioned appetizers, with top votes going to the half dozen mad house oysters, cleverly set on a ginger and citrus mignonette for flavorful crunch. The goat cheese pierogi haluski, with braised cabbage, onions and crème fraiche, was nearly a meal in itself. The charcuterie impressed by not having the usual cast of characters.

Greystone's braised beef short ribs, adorned with a red wine sauce, has reportedly become their signature dish. Day boat scallops and grilled yellowfin tuna are both served on a mélange of colorful vegetables. In addition to a selection of ever-changing fish, steaks, chicken and pork chops, you'll enjoy verdant parmesan-infused asparagus risotto, or a sage pappardelle with duck ragout, bacon and parmesan.

Still hungry? A must-have selection of cold brew coffees will go well with bourbon blueberry cobbler, a rich skillet carrot cake, or chocolate custard with roasted almonds, sea salt and coffee ice cream.

✓Faster Than the Emergency Room ✓The Sprain, Twist & Break EXPERTS ✓Legendary Patient-Centered Service ✓No Appointments Necessary ✓Open 7 Days a Week: Mon–Fri: 8am-8pm Sat & Sun: 9am-6pm

York and Mechanicsburg

OSSHealth.com

717.747.8315

Knowledge ..

Experience ..

Compassion

Make Greystone a 'must do’ on your list of dining plans.

Everything about it was a pleasure.

THE GREYSTONE PUBLIC HOUSE 2120 Colonial Road, Harrisburg PA, 717-829-9952, www.greystonepa.com

BREAST AUGMENTATION | TUMMY TUCKS | FACE LIFTS UPPER ARM LIFTS | RECONSTRUCTIONS | BREAST REDUCTIONS HAND SURGERIES | SKIN CANCER REMOVALS

Call 717.695.6553 today for your consultation 425 North 21st Street, Suite 405, Camp Hill Visit our website for More info including before & after photos

www.cosmeticplasticspa.com Dr. Theodore T. Foley

Central PA Medicine Fall/Winter 2016 19

daup h i n cm s .org

Legislative Updates

Pennsylvania Medical Society Quarterly Legislative Update September 2016

By HANNAH L. WALSH

W

ith passage of the 20162017 state budget in early July, the General Assembly recessed for the remainder of summer, not to convene again for regular business until September. When they do return, it will be for a limited number of session days before the two-year legislative session concludes at the end of November.

The House of Representatives has twelve scheduled session days remaining this year; the Senate has nine.

meeting to vote on bills after the election several years ago amidst sharp criticism and calls for reform.

While the General Assembly’s schedule this fall limits the amount of legislation action that can take place, there are a number of current issues that still have potential to move. Any bill that isn’t signed into law when the two-year legislative session concludes at the end of November will have to be reintroduced in the 2016-2017 session to begin the legislative process all over again.

The short schedule this fall is due to the fact that it’s an election year in Pennsylvania.

When voters go to the polls to cast their vote Opioid-related legislation for the next President of the United States in November, they’ll also have an opportunity to vote for their local Representative in the The state’s opioid abuse epidemic has state House and possibly their state Senator. continued to intensify, with significantly All 203 House seats and half of the Senate’s higher rates for drug-poisoning deaths in 50 seats are up for re-election in 2016. It’s in Pennsylvania than the U.S. average. A the weeks following the November election report released in July 2016 by the DEA that legislators are considered to be least indicates that 3,383 Pennsylvanians died of accountable to voters. Votes on legislation a drug-related overdose last year – up 23.4 during this time are made by either legisla- percent from 2014. tors who have retired or been defeated for re-election, or who don’t have to face voters In an effort to stem the crisis, many for another two to four years. Commonly states, including Pennsylvania, have enacted referred to as a “lame-duck” session, the mandates on use of a PDMP (Prescription General Assembly stopped the practice of Drug Monitoring Program), mandates on 20 Fall/Winter 2016 Central PA Medicine

prescriber and dispenser education, increased access for naloxone, and measures to expand treatment for substance use disorders. Some states – such as Massachusetts, Maine and New York – have taken a more radical policy approach by restricting the amount of opioids a clinician can prescribe to just a few days’ supply, with specific exceptions.

The Pennsylvania legislature is equally eager to take further action to address the proliferation of misuse and abuse of opioid prescriptions in our state. Until measurable reductions are seen in the number of opioid-related harms occurring across the Commonwealth, the number of legislative solutions proposed to this problem and the pressure to enact them will continue to grow.

At the time of this writing, over fifty bills have been introduced to address what has become the leading cause of accidental death in Pennsylvania, killing more people each year than motor vehicle accidents.

On September 16, Governor Wolf called for a Joint Session of the House and Senate to focus on the opioid epidemic. The Governor also identified several policy priorities that he is encouraging legislative leaders to accomplish during the remainder of the 2015-16 session. The proposals include requiring

daup h i n c m s .o rg

prescribers to check the PDMP every time they prescribe; increasing education about opioid and pain management for current and future medical professionals; limiting the quantities of opioids that can be prescribed in emergency departments; requiring health insurance plans to provide coverage for abuse-deterrent opioids; adding opioid misuse to existing public school curriculum on drug and alcohol abuse; and establishing a voluntary non-opioid directive form for patients who don’t wish to receive opioids in their medical care.

At the time of this writing, PAMED is in the process of reviewing legislation introduced related to the opioid crisis, including the proposals mentioned above, and is seeking feedback from physicians so as to best represent their interests.

Among the questions and comments HB 1141 addresses several issues with received, physicians have asked whether the information access and reimbursement that administration of a controlled substance, as often plague physicians who treat injured opposed to the prescription, necessitates a workers. For starters, the bill would ensure physician to query the PDMP; whether it that providers have access to information is permissible for prescribers and dispens- about the injured worker’s claim, including ers to talk to each other about a patient’s the claim number and the description of Prescription Drug Monitoring prescription history if the prescriber or the specific work-related injury for which Program dispenser suspects abuse or diversion of the insurer has accepted liability. Workers’ controlled substances by the patient; if compensation employers, insurers and their changes in dosage orders for the same agents would be required to accept bills On August 25, Pennsylvania’s new state- controlled substance is considered a first- electronically, enabling reimbursements to be wide prescription drug monitoring program time prescription requiring a new query; processed faster and with more accuracy. HB (PDMP) went live, enabling prescribers to are prescribers allowed to prescribe if the 1141 would prohibit a practice commonly view the prescribing history of their patients. PDMP is down or undergoing maintenance referred to as “silent discounting,” where a Prescribers are required to query the program and, if so, if there is anything they must health insurer or its “affiliates” pays providers for each patient the first time a patient is do for record-keeping purposes; and more. at a discounted rate – in other words, below prescribed a controlled substance by the the mandated workers’ compensation fee prescriber for the purposes of establishing In addition to questions, reports of tech- schedule – without their knowledge, approval a baseline and a thorough medical record, nical issues and suggestions for system or contractual agreement. It would also and if they believe or have reason to believe, improvements have also been communicated prohibit insurers from using coercive tactics using sound clinical judgement, that a patient to DOH. PAMED will share with physi- to compel a provider to accept discounted may be abusing or diverting drugs. cians any responses it receives from DOH reimbursements. Finally, the legislation regarding these matters and others. would increase penalties on payors who fail to In the weeks since the PDMP went live, timely implement updated fee schedules each PAMED has received numerous questions year; define “health care provider” to clarify from physicians regarding various aspects of Workers’ Compensation Reform that the term does not include an entity that the law and what it specifically requires of does not have a National Provider Identifier; them, as well as issues they have encountered and define “case management” according to with the PDMP system itself. PAMED has On September 13, the House Labor and national standards to include a variety of case shared these questions and concerns with Industry Committee held an informational management, care coordination, evaluation the Department of Health (DOH), charged hearing on House Bill 1141, legislation that and management services. with administering the program under the would institute a number of important law, and has requested official clarification reforms to Pennsylvania’s workers’ compenDuring the hearing, the Labor and Indusfrom the Department. sation system. Representative Stan Saylor try Committee heard testimony from a panel (R-York) introduced the bill this session. of individuals representing organizations Continued on page 22 Central PA Medicine Fall/Winter 2016 21

daup h i n cm s .org

Legislative Updates

which strongly support HB 1141—including the Pennsylvania Medical Society (PAMED) and the Pennsylvania Orthopaedic Society (POS)—followed by individuals testifying in opposition. Members of the insurance industry and the Department of Labor and Industry opposed legislation, stating that the bill would increase costs within the workers’ compensation system without necessarily improving care.

As the meeting was informational, the Committee did not hold a vote on HB 1141.

CRNP Independent Licensure On the evening of July 12, the Senate passed Senate Bill 717 – legislation which would allow CRNPs to practice independently and eliminate the requirement

22 Fall/Winter 2016 Central PA Medicine

that they collaborate with physicians – by a vote of 41-9. The bill now goes to the House of Representatives for consideration, where it has been referred to the Professional Licensure Committee.

Prior to Senate passage, SB 717 was amended to require CRNPs to have a minimum of three years and 3,600 hours of experience before they can practice independently. While well-intentioned, PAMED believes the logic of this amendment was flawed. 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, and is no match for a physician’s education and training.

PAMED has continued to express strong opposition to the legislation, which is being

supported by the Pennsylvania Coalition of Nurse Practitioners (PCNP), the Hospital and Healthsystem Association of Pennsylvania (HAP), and AARP Pennsylvania, among others. On September 16, PAMED sent a “Call to Action” to all physicians, asking that they call or email their state Representative and urge his or her opposition to SB 717.

If SB 717 fails to become law by the time the 2015-16 session concludes in November, the legislation will have to be reintroduced next session, which begins in January. The prime sponsor of SB 717, Senator Pat Vance (R-Cumberland), is not seeking re-election this year. A registered nurse by training, Senator Vance has for years been a strong proponent of advancing the scope of practice and role of the nursing profession in Pennsylvania during her tenure. At this time, it is unclear who will take up the cause and reintroduce the bill next year in the Senate.

Similar legislation was also introduced this

daup h i n cm s .org

session in the House of Representatives by Rep. Jesse Topper (R-Bedford) as House Bill 765.

Hepatitis-C Screening HB 59, which was signed into law on July 20, 2016, requires all individuals born between 1945 and 1965 to be offered a Hepatitis-C screening test when receiving health services as an inpatient in a hospital or when receiving primary care services in an outpatient department of a hospital, health care facility or physician's office. The bill provides for some exceptions to this requirement, such as if an individual is being treated for an emergency, has previously been offered or been the subject of a screening test,

daup h i n c m s .o rg

or lacks capacity to consent to a screening test. If an individual accepts the offer of a Hepatitis-C screening test and the result is reactive, the law ensures that a health care provider offer or refer the individual for follow-up health care, which must include a Hepatitis-C diagnostic test.

There's no doubt that HB 59—now Act 87 of 2016—is well-intentioned and that increased Hepatitis-C testing of this at-risk population would be beneficial. However, PAMED has consistently opposed legislation that mandates aspects of the physician-patient relationship. PAMED was successful in advocating that the final version of the HB 59 contained no penalties on health care providers.

regarding its implementation. PAMED sent a letter to DOH on August 31 requesting clarification on the requirements of the Act, which is set to take effect September 18, 2016, but at the time of this writing has not yet received a response. A Quick Consult has also been made available to PAMED members to provide guidance on some of the most frequently asked questions.

Hannah Walsh is the Pennsylvania Medical Society’s Associate Director of Legislative Affairs. Email her at hwalsh@pamedsoc.org.

Since the law’s passage, PAMED has received a number of questions from physicians

Advertise in...

Central PA Medicine

Your Community Resource for What’s Happening in Health Care

Central PA Medicine Fall/Winter 2016 23

daup h i n cm s .org

Practice Management

PREVENTING ALZHEIMER’S DISEASE

By CHARLES YANOFSKY, MD 24 Fall/Winter 2016 Central PA Medicine

daup h i n c m s .o rg

I

remember, when I was a resident, our dreaded Saturday morning case presentations with the chairman of neurology, a neuropathologist. (The chairman was volatile and a good teacher. When he expounded on anything you never forgot it.) In one case, we were discussing the causes of Alzheimer’s disease when one of my colleagues sheepishly brought up blood vessel disease. The professor firmly dressed down the hapless resident, “Alzheimer’s is not a vascular disease! Under a microscope we can prove that Alzheimer’s has nothing to do with circulation. Anyone who suggests otherwise has no place in this department.” The sheepish resident had good reason to whisper his theory. Medicines for dementia were then widely prescribed. They worked by dilating arteries to get more blood into the brain. Only later they were indeed found to be worthless.

It is true that you can see Alzheimer’s under the microscope. The progression is visible in plaques and tangles made of the proteins, beta-amyloid and tau. You needn’t go through the inconvenience of cutting open the head and examining brain cells. These toxins are measured on PET brain scans in living people.

With 5 million Americans affected in an aging population, researchers are racing to block the accumulation of the substances that seem to be the underlying cause of the disease. Antibodies and bio-engineered drugs have been deployed to block beta-amyloid and tau and are promising.

We have no definitive information on vitamins, resveratrol, anti-oxidants or anything that people are trying to sell you but we do know that a lot can be done to reduce your own chances of getting dementia—the major outcome of Alzheimer’s.

At least 1% of cases are familial presenting at a young age and caused by one of three genes. Half of late onset cases carry the APOE e4 genetic variant present in about 1/5 of us.

Carrying the e4 gene, a variant of a protein transporting fat, doubles the risk of developing typical Alzheimer’s disease. But most people with Alzheimer’s do not carry these genes.

Alzheimer’s usually starts with recent memory loss called mild cognitive impairment (MCI).

Mostly older people remember the distant past Continued on page 26 Central PA Medicine Fall/Winter 2016 25

daup h i n cm s .org

Practice Management

At least 1% of cases are familial presenting at a young age and caused by one of three genes.

26 Fall/Winter 2016 Central PA Medicine

daup h i n cm s .org

but not what just happened. It doesn’t mean you have dementia, but it is a risk factor for it. Non-memory functions have to be affected to make firm diagnosis of dementia.

Medicines available now help slightly in delaying the need for extra help at home and skilled nursing.

daup h i n c m s .o rg

The best way to prevent dementia, and maybe even Alzheimer’s, is to pay attention to your blood vessels.

Everyone wants to do what it takes to prevent dementia and on this score, it turns out my esteemed, vehement professor was wrong. The best way to prevent dementia, and maybe even Alzheimer’s, is to pay attention to your blood vessels. Many studies have found the risk factors for dementia BLOOD PRESSURE dementia or brain failure. It takes more are near identical with those for heart brain injury to induce dementia in a smart disease and stroke. Want to preserve your Blood pressure is especially instructive. person with a lot of cognitive reserve. Do mental capacities? Give up smoking, treat If your blood pressure is not under control, crosswords and sudoko puzzles and brain sleep apnea if you have it, avoid excessive you will build up tiny strokes in your white exercises prevent Alzheimer’s? Studies show alcohol and other substances that damage matter that are visible on MRI scans. De- at best a weak effect. Brain exercise is more the brain, control high blood pressure, mentia is the outcome of damaging a certain of a sign than a cause of brain health. blood sugar, body fat and cholesterol, and quantity of brain substance. People who do physical exercise. appear to have Alzheimer’s disease, have In anyone with a question of dementia, built up enough beta-amyloid and tau in it is the job of the neurologist to teach ALCOHOL USE the brain to suffer dementia. So dementia coping skills, to look out for and treat other is whole brain disease with damage adding insults to the brain, especially those that Alcohol use is interesting. People under- to more damage. affect blood vessels. The real task of a neuestimate it. There are folks who drink a lot rologist who is seeing someone suspected and don’t seem to lose too much mental PHYSICAL INJURY of Alzheimer’s is to look for everything function. But what if you have a little else, because those entities are ordinarily Alzheimer’s and are also drinking alcohol?

People suspected of having Alzheimer’s more treatable. That may change if tau or The fact is, the combo may do you in. It’s disease have other brain insults, often from amyloid blockers are detected. exactly the same if you have hepatitis and strokes and blood vessel disease. Nearly then drink excessively. That is foolhardy as everyone of a certain age suffers from the With Alzheimer’s the brain is like any you are more likely to destroy your liver. It’s combined effects of blood vessel or vascular other body organ. It has redundant funcall about cumulative injury. change and Alzheimer’s changes. Still another tion, but if injured enough in various factor appreciated in recent years is physical ways and repeatedly, the ability to think, DIET AND STAYING CONNECTED injury such as occurs in violent events such interact, solve problems and enjoy life, as accidents and repetitive sports head will be affected. You will have dementia.

The Mediterranean diet which is useful injuries. All these work together against Prevention is to revere the brain as you to prevent stroke and heart disease has been your brain. There is almost no such thing revere life. Take good care. shown to also prevent dementia. Staying con- as pure Alzheimer’s disease. nected, socially and intellectually engaged, being educated and curious, not giving up EXERCISE YOUR BRAIN your job, being married, seem to have an effect as well, though of less magnitude than Being educated, reading and solving physical factors. problems often, working as a professional, staying employed or having other interests, gives you cognitive reserve which protects you to some extent from having overt

Central PA Medicine Fall/Winter 2016 27

daup h i n cm s .org

Practice Management

The foundation celebrates

30 YEARS OF SAVING LIVES AND CAREERS

T

he Foundation of the Pennsylvania Medical Society, the charitable arm of the Pennsylvania Medical Society, celebrates the 30th anniversary of the Physicians Health Program (PHP) by sharing 30 Stories of how the program changed people’s lives.

and night just to give the appearance that I was normal and successful.

I had a DUI and was being investigated by the FBI, IRS, and DEA. No one else knew except my closest friend, who was also my attorney. On March 13, 1989, after having my home searched by the FBI, DEA, and IRS, Here are a couple of excerpts: I entered treatment for drug and alcohol abuse at the Mayo Clinic. When I got home, besides It was in February of 1989, and I appeared going to Alcoholics Anonymous meetings, I to be a very successful EM doc, but in my head, called the PHP, because I did not know how to I knew my life was in crisis. But I didn’t know deal with licensing issues, credentialing issues, what to do or how to get out. malpractice issues, legal issues, and many other situations that eventually would come up.

I knew I was an alcoholic and was using scheduled drugs to get through work and the I can honestly say that over a 25-year period, day. I was drinking and using drugs all day PHP has helped and supported me with every issue. In the beginning, I did not believe any of

28 Fall/Winter 2016 Central PA Medicine

the things I have now would ever be possible.

Because of the help, guidance, and support of PHP, I have a great and respected medical career. I am also happy, serene, and drug-free.

In short, I owe PHP my life and happiness.

Looking back, I wished I had done some things very differently in my professional and personal life. But if I could share one lesson I learned, it is never be afraid to ask for help — sooner rather than later. Asking for help is a sign of strength, being honest with oneself, and taking full advantage of what life has to offer.

It spares the pain and consequences loved ones must endure by not seeking help sooner. Not everyone will give you a second chance. But those who do will give you the hope.

daup h i n c m s .o rg

Emily Dickinson [wrote about in] a poem, which took me so many years to understand: “Hope” is the thing with feathers That perches in the soul And sings the tune without the words And never stops — at all.

Because of the help, guidance, and support of PHP, I have a great and respected medical career

In the past 30 years, the PHP has had many success stories. There is one, however, that impacted me personally. As the person who collects fees from our participants, I, at times, find the task to be daunting — especially when requesting payment of past-due fees prior to the mailing of an advocacy letter. This leads to my story.

There was a participant named Alice [name changed for anonymity] who was not the easiest person to talk with on the phone. Alice came into the PHP in the early stages of her recovery. She was usually combative, quick with a negative response, and resented being in the program. I was typically on edge when taking her phone calls, wondering if a simple question or request would be retaliated with a sharp rebuttal.

As it happens, Alice’s career took her to another state, where she enrolled in a second monitoring program. Her PHP file was eventually closed due to noncompliance.

However, several years later, she contacted the PHP in need of an advocacy letter. I was nervous about having to inform Alice of her past-due fees. All I could think of was our past exchanges and how negative they were. She immediately picked up on the hesitation in my voice and questioned it. I explained. Her response was remarkable: “Now that would not be good recovery.”

Wow, she was a totally different person! It was gratifying to see such a dramatic change in her. Alice was considerate, respectful and clearly in good recovery. Her transformation was heartwarming, and will remain a constant reminder for me of the positive impact programs like ours have in changing lives.

governing professional practice, and certainly the nature of the practice of medicine and For more than 25 years, I have had the dentistry. The stresses inherent in the pracprivilege of representing physicians, dentists, tice of medicine and dentistry have always and other health professionals. One of the been considerable — never more than today. most challenging and rewarding aspects of my Through it all, the PHP has been there. The practice has been the representation of health PHP has saved lives and has helped many professionals who have or may have a physical health professionals achieve a stable recovery or mental impairment. For my clients who have and continue working. For that, I express my connected with the Physicians Health Program gratitude and look forward to working together for help, the PHP has been a reliable, constant, in the years to come for the benefit of health compassionate, and knowledgeable resource at professionals in Pennsylvania. every step in the process — helping to obtain an evaluation, supporting and monitoring recovery, and advocating for the retention or Go to www.foundationpamedsoc.org reinstatement of professional licenses. throughout the year to read new stories every month and donate online.

Many things have changed in 25 years — the faces at the PHP, the laws and regulations

FOR MORE STORIES

Central PA Medicine Fall/Winter 2016 29

daup h i n cm s .org

Jim Brickman

Snarky Puppy

Fourplay

Keiko Matsui

March 31-April 9, 2017 Reading, PA

Brian Culbertson

Patti Austin

Marcus Miller

Spend 10 jazz- and blues-filled days and nights in the Greater Reading area!

Over 120 scheduled events, plus great shopping and dining in one area, make the 27th annual Boscov’s Berks Jazz Fest your perfect spring getaway.

For tickets, call Ticketmaster toll free at 1-800-745-3000 or visit www.ticketmaster.com to order online.

Tickets go on sale Saturday, Dec. 3, at 10 a.m.!

PATTI AUSTIN • GERALD ALBRIGHT • JONATHAN BUTLER • SNARKY PUPPY • WILL DOWNING • NAJEE • KEIKO MATSUI • RICK BRAUN • JIM BRICKMAN MARCUS MILLER • FOURPLAY FEATUIRNG BOB JAMES, NATHAN EAST, HARVEY MASON, CHUCK LOEB • PAT MARTINO ORGAN TRIO WITH HORNS BRIAN CULBERTSON • NEW URBAN JAZZ PARTY: BOB BALDWIN, WALTER BEASLEY, MARION MEADOWS, TOM BROWNE • NICK COLIONNE • ERIC DARIUS ADAM HAWLEY • LARRY GRAHAM & GRAHAM CENTRAL STATION • DR. LONNIE SMITH • TROKER • JEFF HAMILTON TRIO • JAREKUS SINGLETON TOMMY KATONA & TEXAS FLOOD • JON CLEARY • EVERETTE HARP & FRIENDS: CHANTE MOORE, PHIL PERRY, BRIAN BROMBERG JASON MILES PRESENTS CELEBRATING THE MUSIC OF WEATHER REPORT• BERKS GROOVE PROJECT • GERALD VEASLEY’S MIDNIGHT JAMS ERIC MARIENTHAL • FRANK DIBUSSOLO’S PHILLY REUNION BAND • GOSPEL ACCORDING TO JAZZ CELEBRATION: KIRK WHALUM, FRED HAMMOND, KEVIN WHALUM, JOHN STODDART AND THE DOXA GOSPEL ENSEMBLE • ANAT COHEN QUARTET • WEST COAST JAM WITH RICK BRAUN, NORMAN BROWN, RICHARD ELLIOT • THE ARTIMUS PYLE BAND: TRIBUTE TO RONNIE VAN ZANDT’S LYNYRD SKYNYRD • SHEMEKIA COPELAND AND MUCH MORE!*

berksjazzfest.com * LINEUP AS OF 10/30/16.

SUBJECT TO CHANGE 2016 Central PA Medicine 30 Fall/Winter

PROUD SPONSOR OF THE BOSCOV’S BERKS JAZZ FEST

Follow us on Twitter @berksjazzfest

daup h i n c m s .o rg

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/ 2016-2017 Board President: Marilyn Calaitges President Elect: Wendy Hamaker Treasurer: Holly Mackley Secretary: Karen Daughtery Correspondence Secretary: Ronni Scher Membership Secretary: Alex Anastasio

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/

Members gathered for the first DCMSA meeting of the year on 9/13/16 at Vision Resources of Central PA. Board members were able to view what the center was able to purchase with their 2016 DCMSA grant. We also approved our 2016-2017 operating budget. Members agreed to lend their support to Project Homeless Connect at the PA Farm Show Complex in October. We also agreed to send a memorial donation in honor of our past president, Ruth Christman, who recently passed away at the age of 94. Following the meeting was a luncheon and soap making program.

Upcoming DCMSA Events Holiday Party and Silent Auction December 13, 2016 | 10:00 am-1:00 pm Home of Marilou Cockroft 8th Grade Science Day Penn State Medical Center | Junker Auditorium DCMSA Annual Fashion Show April 18, 2017 | Westshore Country Club

Upcoming COUNT Y Events (COUNTY LEVEL) Association of Family of Friends Fashion Show | April 5, 2017 | Hotel Hershey

Central PA Medicine Fall/Winter 2016 31

daup h i n cm s .org

SCOTT A. GUNDER, MD scholarship essay

By EMILY GALLI Candidate at Penn State College of Medicine and 2016’s recipient of the Scott A. Gunder, MD, Dauphin County Medical Society Presidential Scholarship offered through The Foundation of the Pennsylvania Medical Society (PAMED)

EMILY GALLI’S WINNING ESSAY My inspiration to become a physician stemmed from an unusual source — my 100-year-old stock broker grandfather. He always encouraged me to "follow my passion" — a phrase with meaning I never truly grasped until I found medicine.

I matriculated to Penn State with enrollment in the integrated BS/MBA program with plans to enter the science industry after graduation. My diversified path to this discipline included a broad range of experiences spanning mastery of a foreign language, HIV research at Magee-Womens Research Institute of UPMC, an honors thesis in reproductive physiology and immunology, an internship where I learned about the governance of a business entity on Highmark's Corporate Development team, and an MBA in healthcare planning and finance. While all of those collegiate and professional experiences were positive, and surely would have afforded a successful career, none resonated with me. Realizing my uncertainty and noting the healthcare field as a common thread, I decided to volunteer at Penn State's University Health Services. It was there that I discovered what my grandfather truly meant by his statement.

Specifically, I realized that success is truly rewarding if you possess a passion for what you do. I had never felt as fulfilled as I did when I was interacting with and assisting patients at the health center, and I only hoped I brightened their days as much as they did mine.

32 Fall/Winter 2016 Central PA Medicine

daup h i n c m s .o rg

The path to becoming a physician requires determination, hard work, and a true passion for the field.

Striving to become the best physician I can be presents a perpetual challenge and motivates me daily to become a more complete and balanced representation of myself. Thus, when I am an attending, my advice to aspiring physicians will be exactly what my grandfather told me: Follow your passion.

For following your passion is simply about loving what you're doing, being excited to go to work, feeling like you are doing what you were meant to do, and having the realization that when you follow your passion, both you and those you help will be better for it.

Emily Galli is the recipient of the Scott A. Gunder, MD, Dauphin County Medical Society Presidential Scholarship offered through The Foundation of the Pennsylvania Medical Society. Galli, now a third-year medical student at Penn State College of Medicine, received $1,500 toward her tuition. Since 2000, the Foundation has awarded the Scott A. Gunder, MD, Dauphin County Medical Society Presidential Scholarship to a second-year medical student attending Penn State College of Medicine. Through this scholarship, the memory of Gunder, a 39-yearThe Foundation of the Pennsylvania Medold Harrisburg gastroenterologist, will continue. ical Society proudly serves as the 501(c)(3) The Foundation of the Pennsylvania Medical philanthropic affiliate of the Pennsylvania Society administers the Gunder Scholarship. Medical Society. The official registration Guidelines and applications for the scholarship and financial information of the Foundation are available at www.foundationpamedsoc.org of the Pennsylvania Medical Society may be under Student Financial Services. We hope you obtained from the Pennsylvania Department of will consider making a contribution to the Fund. State by calling toll-free, within Pennsylvania, To do so, visit https://webapps.pamedsoc.org/ 1-800-732-0999. Registration does not imply foundation/donatenow/donate_now.aspx and endorsement. enter the Gunder Scholarship Fund as your ‘Areas of interest within the Foundation’.

THANK YOU TO ALL CONTRIBUTIONS MADE TO THE FUND OVER THE YEARS!

Central PA Medicine Fall/Winter 2016 33

daup h i n cm s .org

DCMS News

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

NEW MEMBERS Renee Aboushi, MD

Daniel Lim, DO

Adeline Rose Answine

Steven Ma

Amarpreet Kaur Ahluwalia

 Central PA Surgical Associates Ltd

Eric Balaban

 Cocoa Family Medicine

Thiri Sandar Bickel, MD

 Family Practice Center PC – Halifax  Healthy Starts Pediatrics  Hershey Kidney Specialists Inc.  Hershey Pediatric Center  Pediatrix Medical Group  PHCVI-PinnacleHealth Cardiovascular and Thoracic Surgery  PinnacleHealth Cardiovascular Institute Inc.  PinnacleHealth Internal Medicine Union Deposit

Sean M. Baskin,DO

Melanio Bruceta, BS

GlendaAnn Cardillo, MD Benjamin B. Claxton Allen Joel Cwalina Luisa M. De Souza

Alcinda Emilia Flowers, MD Madison Force

Shaun Kenneth Geoffrey

Daniel James Goetschius Andrew James Groff

Patrick Charles Hancock, MD Stephanie Louise Harris, DO Brian Phillip Hertzberg, MD

 PinnacleHealth Kline Health Center

John Alexander Holbert

 Pulmonary & Critical Care Medicine Associates PC

Jeremy David Kauffman, MD

 Saye Gette & Diamond Dermatology Assoc PC  Sollenberger Colon & Rectal Surgery Ltd  Tan & Garcia Pediatrics PC  The Arlington Group  Urology of Central PA - Londonderry Rd.  Women First Obstetrics & Gynecology PC  Woodward & Associates PC

Mandar Jadhav, MD

Andrew Luo

Sarah Akhtar Malik Sarah C. McNatt

Nathaniel Lee Melton, MD

Irina Vladimirovna Mishagina, MD Gillian Rose Naro

Nicholas Noverati

Cassandra Lee Ondeck

Katsiaryna Paulovich, MD Kaitlin Lou Plummer, DO Hayley Nicole Price Farda Qayyum, MD

Dheera Adulla Reddy, MD Jennifer Saigal

Ambiga Samiappan, MD

Jason Benjamin Snavely Anam Tariq, DO

Thomas Joseph Watson, MD Mark Ford Wilkinson, DO Brendan Rich Wood

Dauphin County Medical Society in the Community DCMS RECOGNIZES 50 YEARS OF MEDICAL SERVICE Each year DCMS recognizes members of the Pennsylvania and Dauphin County Medical Societies who have reached 50 years of service since graduating from medical school.

September 7, DCMS recognized Dr. Charles Cladel, a psychiatrist from Hummelstown who practices in Behavioral Health Services at Holy Spirit Hospital.

Dr. Cladel graduated from medical school at the State University of New York Upstate. He went on to complete an internship in Indiana before going on to complete residencies in Indiana and Michigan.

Dr. Cladel is Board certified in psychiatry and child psychiatry.

DCMS also recognized 50 Years of Service members who were unable to attend Sept. 7. They are: Dr. Francis Duggan, Dr. Paul Fairbrother, Dr. Shashikant Patel, and Dr. Joseph Trautlein.

Congratulations on your service to the medical profession!

34 Fall/Winter 2016 Central PA Medicine

Specialists in the diagnosis and treatment of digestive and liver disease.

John P. McLaughlin, D.O., F.A.C.G., F.A.C.P. Kevin C. Westra, D.O., A.G.A.F., F.A.C.P. Michael A. Veliuona, M.D. Mark C. Friedman, M.D. Nicholas A. Mahoney, M.D. Cortni J.T. Brooks, M.D. Michelle R. Kostelac, MPAS, PA-C Lisa C. Brenize, MSPAS, PA-C

New patients are always welcome!

Specializing in the diagnosis and treatment of digestive and liver disease.

Treating symptoms such as:

Abdominal pain Heartburn Rectal bleeding

Constipation Jaundice Trouble swallowing

Diarrhea Nausea Vomiting

New Patients Are Always Welcome 4760 Union Deposit Rd., Suite 100 • Harrisburg, PA 17111

717-545-9811

Please visit our website at www.HbgGastro.com.

We participate with most insurance providers.

Please visit our website: www.hbggastro.com.

TAKE YOUR ASSOCIATE DEGREE

FURTHER.

TURN IT INTO A BACHELOR’S DEGREE. Healthcare Management* Nursing (RN to BSN)* Radiology Sciences* • Accelerated, 11-week terms • Fully-online format • Financial aid and scholarships available for those who qualify • Individualized career assistance for students and alumni

APPLY TODAY ENROLLING NOW!

RECEIVE A

$1,000

SCHOLARSHIP FOR TRANSFERRED CREDITS.** *Degree completion program **Available for those who qualify

Visit centralpenn.edu/med or call 1-800-759-2727.