Central PA Medicine, Summer 2016

Your Community Resource For What’s Happening In Health Care

SUMMER 2016

Central PA

Official Publication of the Dauphin County Medical Society

and

Pregnancy

30 Stories for 30 Years

PA S S I O N

OUTSIDE Photography of

Chris Dicroce

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Central PA

{ Contents }

SUMMER 2016

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

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Zika Virus and Pregnancy

12

Fighting Opioid Abuse in Pennsylvania

14

30 Stories for 30 Years

(717) 558-7849 • dauphincms.org

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

Community, Health & Wellness 16

The Snow is Gone & the Sun is Shining—Protect Yourself From Sun Exposure

18

What Am I Supposed to Eat? Debunking the Dilemma of the Diabetic Diet

24

Hepatitis Awareness

Heath B. Mackley, MD Vice President 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

EDITORIAL BOARD Heath B. Mackley, MD, Editor-in-chief Connie Benson, Editor

Practice Management 26

Match Day

27

Judgement Call: Protocols Need Human Supervisors

28

Physician Information for Medical Marijuana

30

What a Patient Needs to Know About Preparation for Surgery

32

Why Digital Health Technologies Matter

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 . . . . . . . . . . . . . . . . . 23

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

Legislative Updates. . . . . . . . . . . . . . . 34

Passion Outside of Practice . . . . . . . . 20

DCMS News. . . . . . . . . . . . . . . . . . . . . . . 36

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From the Editor

To Be, or Not To Be – The Role of the County Medical Society

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

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n Oct. 25, 2015, the PAMED House of Delegates adopted Resolution 15-501, requiring the Board of Trustees to create a task force to examine the feasibility of forming larger regional medical societies built upon the existing structure of the county societies, with the goal of continuing to provide appropriate representation of physicians’ local issues while providing increased member benefits through the pooling of resources. Consequently, on Feb. 9, 2016, the PAMED Board of Trustees approved the creation of a task force, to be chaired by Charles Cutler, MD, and the appropriation of funds to contract with a consultant that is highly regarded for work in the association and membership fields. The focus of the consultant’s work will be to look at the issue of dues pricing relative to value and willingness to pay as that will directly impact the cost analysis of the feasibility of regionalization. The task force, with the help of the consultant, will deliver a report to the Board later this year, which will then be presented to the House of Delegates on Oct. 22, 2016.

This is important work, and we look forward to reading the task force’s findings, but this begs a fundamental question that I wish to pose: What is the purpose of the county medical society? What has worked in the past, and what didn’t?

What works now and what doesn’t?

Where should we go from here? These are healthy questions for any organization undergoing change, and although PAMED

is an appropriate venue to discuss regionalization, it must be discussed locally in each county as well. Each county’s medical society is an independent professional association with its own history. They are not subsidiaries of PAMED, just as PAMED is not a subsidiary of the AMA. The relationships are best described as interdependent, as it is difficult to imagine a healthy state society without engaged county societies, or a vibrant national society without strong state societies. Although independent in one sense, the success of one is dependent on the success of the others. In short, this is a partnership, and any fruitful discussion of regionalization requires the participation of the counties.

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The Dauphin County Medical Society (DCMS), of which I am privileged to serve as vice president, has a rich history, being founded on Feb. 20, 1866. Its original mission, speaking broadly, was to help maintain the AMA and PAMED, which were founded in 1847 and 1848, respectively. More specifically, DCMS’s mission was to extend medical knowledge, advance medical science, elevate and maintain the standards of medical education, uphold the ethics and dignity of the medical profession, foster partnerships between physicians and the communities they serve, and promote public health and hygiene in the prevention and management of disease. Over time, a number of changes occurred. As a county medical society, DCMS is no longer focused on advancing medical science or improving medical education standards because those missions, although important, are not best suited to a county medical society. Today, DCMS’s mission is to uphold the ethics and dignity of the medical profession, elevate and maintain the highest standards of healthcare, promote and disseminate medical information to members and the public, and promote collegial relations among our members. I’m sure many of the other county medical societies have similar missions, and also have a history

of their missions changing as the needs of their members changed. A thoughtful discussion of regionalization requires deciding on a clear mission for those societies.

While organizations have official mission statements to publicly communicate their ideals and what they hope to achieve, it is also useful to look at the unwritten mission statement of an organization: What is it actually doing? What do its members want it to do? How do both of these match the formal mission? Broadly speaking, the activities of DCMS are focused on maintaining a community for physicians that crosses health systems and employment statuses, advocating for patient and physician causes in the legislative and regulatory spheres, offering continuing medical education on select topics, giving of ourselves in community outreach and philanthropy, and providing a conduit for Dauphin County members to become involved in the work of the Pennsylvania Medical Society (PAMED). I have had the good fortune of meeting and working with other county societies in the 5th district, including Berks, Lancaster, and York, and these county societies are also very active, making their communities and PAMED better in the process.

But not all county societies are active.

Even if they have an attractive mission statement, what message is that saying to the public, and what value are they providing to their members?

Would physicians in nearby counties with non-active county societies be better served by becoming a member of a regional society with a foundation of the active county societies? Or would this dilute the community that the strong county societies are trying to foster, and hurt membership by alienating members that appropriately cherish and take pride in the rich histories of the county medical society?

Let’s not forget the elephant in the room— money. Within the group of inactive county societies, some collect dues, and some do not.

For PAMED to continue to thrive, it has to consider adjusting its own dues structure, yet it has no direct control over county societies which set their own dues, and that is part of the price tag that physicians see. PAMED requires its members to be a member of a county society, but this is a choice, not a mandate. In 1995, PAMED ceased to require AMA membership for its members. While it is possible for PAMED to do something similar with the counties, it’s hard to see that become anything other than harmful to county membership. Would that be in PAMED’s best interest? “Softer” measures could include exerting influence over county dues rates by making PAMED’s collection of county dues on their behalf contingent on specific conditions. Given the likelihood that less than 100% of counties would be compliant, this would lead to a schism of sorts between the “cooperative” counties and the “uncooperative.” It is also worth noting that the majority of many county society’s budgets are for professional support staff, many of whom are PAMED employees.

Any effort that significantly decreases county income could lead to PAMED needing to either downsize or reassign those positions.

All of this underscores the interdependence of PAMED and its county societies, and their collective need to be partners in any process that considers major changes that effect both.

This article is not a sound of alarm about impending changes, nor is it a recommendation on adopting a specific policy. This is a call to open the lines of discussion as broadly as possible. I see the county medical societies and PAMED engaged in important work each and every day. But what do we need to do to thrive in the future? Let us know your thoughts! We need your involvement more than ever!

Dr. Mackley is a Radiation Oncologist at the Penn State Hershey Cancer Institute and 5th District Trustee, representing physicians of this county.

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President’s Message

PAST, PRESENT

FUTURE

t is said that the past is done and gone and the future is not here and hard to predict; therefore one should live in the present. It is also said that those who do not learn from the past are likely to repeat the same mistakes now and/or in the future. Both of these viewpoints have an element of truth to them.

I had the pleasure of reading a book about the first 100 years of DCMS history which was written in 1966 and I learned a lot about the issues and problems faced by the Society during that time. Kudos to the leaders of those times for facing the problems head on and coming up with solutions to tackle them. Our leaders in the last 50 years learned from the past and carried the Medical Society to its current state. Many other ancillary groups including hospital medical staffs arose from DCMS along the way. Some of them survived and others ceased to exist after serving their purpose.

Mukul Parikh, MD, DABA President, DCMS

DCMS today faces some very similar problems from the past including membership recruitment/renewal as well as attracting members to participate in various DCMS activities. The rise of specialty societies which rightly take up the causes for their respective specialties seems to suggest that DCMS and the Pennsylvania Medical Society (PAMED) may have diminished roles. In reality, it is quite the contrary. Specialty societies, without the backing of the entire medical community through county and state medical societies, would certainly fail in their specialty-specific endeavors. Government healthcare agencies and insurance companies would love to split our ranks and pit us against each other. It is for that very reason that all the specialty societies have a seat at the table at PAMED to guide it in its deliberations and seek support for their causes. DCMS, for its part, holds monthly executive committee meetings and quarterly board meetings to discuss local, state and national issues related to the practice of medicine. DCMS is extremely well represented both at the state and national levels through our 5th district representative on PAMED’s board, three specialty leadership cabinet positions and one American Medical Association (AMA) representative.

The future of DCMS, though hard to predict, I believe is in good hands with the young leaders in the ranks. It will continue to serve the needs of the medical community in many areas. To achieve that goal, all of us have to support it through our membership and participation.

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Features

and

Pregnancy Deborah J. Herchelroath, DO, FACOOG

“The thought of a pandemic virus that causes a severe fetal neurodevelopmental abnormality and for which there is no ready clinical diagnostic work-up, preventative vaccine, or antiviral therapy is chilling.”

– Dr. Charles Lockwood

T

he Zika virus is a mosquito-borne illness that has been around for many years. It was first identified in Uganda in 1947. Unfortunately, it has become more prevalent in the past year, especially in certain countries (http://wwwnc.cdc.gov/ travel/notices/). The virus is carried by Aedes aegypti mosquitoes. These mosquitoes bite not just in the evening, but all day as well.

At this time, there are no cases of transmission of the Zika virus by mosquitoes in the United States. However, there have been over 270 laboratory-confirmed cases (in the continental U.S.) among U.S. travelers to areas where Zika has been transmitted by mosquitoes.

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Features Continued‌

The symptoms of the virus may include fever, rash, arthralgia and conjunctivitis. Actually, approximately 80% of people infected with Zika have no symptoms. Of note, some Zika outbreaks have been associated with Guillain-Barre syndrome. The incubation time for the virus is three to 14 days. That means from the time the patient is bitten until he or she shows symptoms is three to 14 days. After the onset of symptoms, viremia lasts, on average, a few days to one week.

The major concern with Zika is to our pregnant patients. It can be transmitted from mother to fetus in any trimester and has been associated with microcephaly in the fetus and newborn. Microcephaly is defined as a head circumference two to three standard deviation below the mean, corrected for age and sex. (FYI, the most common infectious cause of microcephaly in the world is cytomegalovirus.) Pregnant women are not more susceptible to Zika compared to the general population. The risk is just higher to them because of the risk to the unborn baby.

The US Centers for Disease Control and Prevention (CDC) issued a health advisory and travel alert in January 2016 advising women who are pregnant to avoid countries where Zika virus transmission is ongoing.

Interim guidelines are released and updated frequently. As of completion of this article (March 2016), the following guidelines are in place:

1.

Antibody testing for Zika virus is now recommended for all pregnant women who have traveled to an affected area regardless of the presence of symptoms.

Testing can be offered between two and 12 weeks after pregnant women return from travel to areas with ongoing Zika virus transmission.

2. Antibody testing for Zika virus is now

recommended for all pregnant women living in an affected area regardless of symptoms.

3. Health care providers should discuss reproductive life plans, including

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pregnancy intention and timing, with women of reproductive age in the context of the potential risks associated with Zika.

4. Asymptomatic women with possible

Zika exposure should wait at least eight weeks before attempting to conceive.

5. Women of reproductive age with

current or previous laboratory-confirmed Zika should be counseled that there is no current evidence that prior Zika infection poses a risk of birth defects in future pregnancies.

Availability to test for Zika virus is limited at this time. If you have a patient who should be tested, the recommendation is to contact our state health department at 1-877-724-3258 or 717-787-3350.

We do not yet have a vaccine for Zika (although it is in the works). Therefore, prevention is key. Avoiding exposure is the best thing to recommend. When traveling to areas where Zika has been reported, we need to liberally use bug spray with DEET,

cover exposed skin, stay in air-conditioned or screened-in areas, and treat clothing with permethrin. The CDC website has free patient handouts and posters for patient education.

As for women who think they may have been exposed and are currently pregnant, the CDC recommends serologic testing for Zika virus infection. If testing is positive, recommendations are to obtain serial ultrasounds to evaluate for microcephaly, intracranial calcifications, and brain and eye abnormalities. If testing is negative, it is still recommended to obtain fetal ultrasound. If any signs of Zika infection are present, the patient should be retested for viral infection.

Rarely, reports of sexual transmission of Zika have been emerging. For now, the recommendations are to either practice abstinence (no vaginal intercourse, anal intercourse, or fellatio) or the consistent and correct use of condoms if a pregnant woman’s partner has travelled to countries in which Zika has been reported. Recently, the FDA discussed Zika and human cell and tissue products. This includes semen.

Therefore, they are recommending a deferral

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period of six months because the virus has been detected in tissues and body fluids after it is no longer detectable in the blood stream. Zika has been detected in semen possibly up to 10 weeks after the onset of symptoms. Specifically, if a male partner has been diagnosed with Zika or has symptoms of Zika, the couple should use condoms or practice abstinence for six months. If a male traveled to an area with Zika but did not develop symptoms, eight weeks of condoms or abstinence has been recommended.

(Personally, I have issue with this because, remember, 80% of people infected with Zika have no symptoms.)

Zika in breast milk has been reported in very small amounts and thought unlikely to be harmful to a newborn. The current thought is that the benefits of breastfeeding outweigh the risks and the mother should continue to breastfeed her baby.

Transfusion transmission events have also been reported. The FDA recommends the deferral of individuals from donating blood if they have been to areas with active Zika virus transmission, potentially have been exposed to the virus, or had a confirmed Zika virus infection.

The CDC has also released guidelines for the evaluation and testing of newborn infants with possible congenital Zika virus infection. These can be found at the following link: www.cdc.gov/mmwr/volumes/65/ wr/mm6503e3.htm#F1_down. These recommendations are updated frequently with “interim guidelines.”

Here is some good news: in the hardest hit area of Brazil, the attack rate is only 5.5 cases/10,000 inhabitants. The risks are still small, even if the disease process is devastating.

There is no treatment for Zika virus except for supportive care.

REFERENCES:  SMFM and ACOG, Practice Advisory: Updated Interim Guidance for Care of Obstetric Patients And Women of Reproductive Age During a Zika Virus Outbreak, Feb 12, 2016.  Lockwood, C. Zika virus and microcephaly.

Contemp Ob/Gyn. 2016;61(2):6-9.  FDA News Release: FDA issues recommendations to reduce the risk of Zika virus transmission by human cell and tissue products. March 1, 2016.  www.cdc.go Deborah J. Herchelroath, DO, FACOOG, is a seasoned obstetrician/gynecologist who practices at Woodward & Associates, P.C. with privileges at Pinnacle Health Hospital. She believes in communication, education, and leadership. She also has a heavy interest in aesthetics, nutrition, and wellness.

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Features

FIGHTING OPIOID ABUSE in Pennsylvania Introducing PAMED’s Innovative Educational Series and Other Resources Health Care Teams Can Use To Address The Opioid Crisis The Problem: Opioid abuse, misuse, and overdoses are increasing, both in Pennsylvania and nationally. While some requests for pain medication are legitimate, others are likely to be from pill scammers who have become addicted to opioids.

The solution: A multi-pronged approach that includes physicians, patients, and healthcare organizations like the Pennsylvania Medical Society (PAMED) working collaboratively to address this growing epidemic.

PAMED, in collaboration with the Pennsylvania Department of Health and 11 other healthcare associations, is creating a comprehensive online educational resource to help prescribers combat this problem.

“Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know” is a multi-part course that examines all the tools prescribers can use to identify patients with addiction issues and get them help.

The first session of the course addresses how prescribers can use the statewide voluntary opioid prescribing guidelines, and the second session takes a closer look at the state’s naloxone law. Both are available at www.pamedsoc.org/ opioidscme. Additional sessions are forthcoming.

This educational series features: • Videos and interviews with physicians, other prescribers, and state officials working on the front lines of the crisis • The latest statistics and data • Details on how to use opioid prescribing guidelines for physicians, emergency departments, and other providers 12 Summer 2016 Central PA Medicine

• Scenario-based learning to help implement the lessons into daily practice

This crisis spans nearly every state in the U.S., but has hit Pennsylvania particularly hard. Nearly 2,500 deaths were reported in Pennsylvania as a result of drug overdoses in 2014, and more people die from drug overdoses than in car accidents.

No one disputes the magnitude of the prescription drug abuse crisis in Pennsylvania and the nation at large. The question is, how do we combat the problem?

“I think that we have to understand this is a public health crisis and we all have a role to play in terms of solving this,” said PAMED member and Pennsylvania Physician General Rachel Levine, MD. “We need to get past the idea that these are somehow just drug abusers that are miscreants and throwaway members of our society,” says Dr. Levine. “This crisis hits everyone—our mothers, fathers, brothers, sisters, sons, daughters, rural, urban, suburban,” she said. “We have to get past the idea that this is someone else’s problem.

We have to get people into treatment and recovery. Addiction is a disease; we have to erase the stigma.”

PAMED’s education seeks to address the many layers and complexities of this crisis.

Learn more and get CME credit by visiting www.pamedsoc.org/opioidscme. Access additional resources such as prescribing guidelines in PAMED’s Opioid Abuse Resource Center at www.pamedsoc.org/ opioidresources.

“Opioid CME is not currently mandated by the state, but one way to ensure it stays that way is for Pennsylvania physicians to use the voluntary opioid guidelines and take this voluntary CME,” said Dr. Levine.

3 Ways

To Increase Your Confidence In Managing Opioid Therapy

1. Familiarize yourself with these stateendorsed, voluntary guidelines for opioid prescribers in Pennsylvania:

• • • • •

Chronic Non-Cancer Pain Emergency Department Pain Geriatric Pain Obstetrics and Gynecology Pain Pain in Dental Offices

2. Get involved with grassroots advocacy

and initiatives by having a discussion with the physicians in your county or region. Call PAMED’s Speakers Bureau at (800) 228-7823, ext. 2620 for details.

3. Have a conversation with your chronic

pain patients using PAMED’s Opioid Prescription Checklist to help facilitate the pain-management discussion.

Visit www.pamedsoc.org/opioidresources to access these resources and more.

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Features

Stories for 30 Years

The Foundation 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. Here are some excerpts from a few of those stories and outcomes.

The Physicians’ Health Program (PHP), a program of The Foundation of the Pennsylvania Medical Society, the charitable arm of PAMED, provides support and advocacy to physicians struggling with addiction or physical or mental challenges. The program also offers information and support to the families of impaired physicians and encourages their involvement in the recovery process.

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My Husband’s Alcohol Addiction

When my husband’s alcoholism came to light, he went into a rehab center and I went into a crisis. It felt like a hand grenade had gone off in my living room, and the pieces of my life were flying around me like shrapnel and debris. I honestly didn’t know what to hold on to, and what to let blow away. The counselor at the rehab center recommended that I get in touch with the PHP to learn about the voluntary monitoring program for physicians. Although I was reluctant to share our family secrets and to ask for the help that we needed, I found the phone number on the internet and called while my husband was still in inpatient treatment.

The reception I got from the PHP was warm and welcoming. I realized that I didn’t have

to find my own way, because others had gone before me on this path.

When I told the PHP counselor that my plan for my husband after his rehab discharge was to administer a breathalyzer test before he went to work, when he came home, before he drove with the kids, etc., I was quite wisely told that I couldn’t be a spouse and the sobriety police. What would I do if my husband kept drinking? How could I enforce these rules? What would happen with empty threats and ultimatums that might not work? I listened to the information about their program and started to have hope that I wouldn’t be alone to shoulder the burden of living with an alcoholic.

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Fast forward two years, and our family is doing well. I attend Al-anon meetings, and have found a whole group of people who understand this disease. I have learned that I am not responsible for anyone else’s drinking or sobriety. My husband is working a strong AA program and attends 5–6 meetings per week. He has maintained his sobriety by using all of the tools available, one of which is the PHP monitoring program. He has random blood and urine tests, and follows the program requirements of meetings and counseling. We don’t look at these program requirements as an intrusion or a punishment. Instead, they are a welcome means of accountability. It is a way to reestablish trust and prove that he can “walk the walk” as well as “talk the talk.” Alcoholism can’t be cured, but it’s a disease that can be managed with the right strategy. I am grateful to the PHP for helping us live with alcoholism.

My Story is a Miracle

On Oct. 12, 1988, DEA agents invaded my home in search of evidence regarding distribution of controlled substances. More than 70,000 doses of narcotics were registered to me and not accounted for. That day was the first time I ever admitted (to the agents) that I was a drug addict. This was the end of life as I knew it.

My Pennsylvania medical license and DEA registration were suspended/revoked, as were my hospital privileges. Felony charges were issued three years later. I had to stop using narcotics, and that for me seemed impossible.

On Oct. 14, two days later, knowing that my supply was frighteningly low, I made a plan to commit suicide. I prepared two syringes, one with Midazolam and one filled with Pavulon, and placed them in my top drawer. That same day, I called an old acquaintance of mine who had previously been in much trouble. He gave me a phone number and said, “You do not have to feel this way anymore. Life can be beyond your wildest dreams.”

reershysicians enjoy a C & s e v p ians. an 3,000 aving Li sful physic ed more th

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s has help be succe , the PHP ntinue to o rs c a d e y n a 0 l 3 o For the PHP alcoh t drugs or ibuting to u tr o n h o it c w y e b lif berson@ rence E, at mlam ke a diffe R a F m C , n n a o c mbers ow you ur gift to: arjorie La To learn h r, mail yo ontact M O c . t, 6 n 4 e 8 m -7 Endow 17) 558 ty c.org or (7 ical Socie pamedso ania Med aign nsylv nt Camp f the Pen ndowme dation o E n u m o F ra g e Th h Pro ns’ Healt Physicia e v ri D rk a P 777 East 0 2 8 8 x o P.O. B 5-8820 , PA 1710 Harrisburg

That phone number was for the PHP. I spoke somewhat honestly for the first time about my addiction. They sent a gentleman to my home to escort me to Marworth, a rehabilitation facility. Since then, and for the past 27-plus years, I have been involved with the PHP as a participant, monitor, and committee member with continuous sobriety since day one. PHP provided the framework for my recovery, monitoring, and letters of support whenever needed. I owe them my life.

My family and closest friends constantly remind me how much better I am since joining the PHP. The staff is very kind, and it is clear that they care about you and your well-being. My most memorable patient experience that reminded me how great the program has been for me was on my psychiatric rotation. I was talking to one of my patients, and another patient happened to be sitting at the table with us. I had never met her before and I felt a very unique connection and understanding with her.

I resumed practicing anesthesia in 1989 and have been professionally successful since that time. This is a direct result of PHP intervention. My story is a miracle. My path would not have been feasible without the support and guidance of PHP.

She mentioned that she no longer drinks because no one likes being around her when she drinks. This patient went on describing her story, and I was able to relate on a very personal level. I understood her intimately, as my family and friends have been telling me how great I am to be around since I’ve stopped drinking.

Grateful I Am a Better Person

Through the PHP, I feel like I am finally in a place where I have always wanted to be.

I feel happier than I have ever been before.

Mainly, I am grateful to PHP for making me a better person, and I know I will be a better doctor.

As a medical student, my experience in the PHP has been quite interesting. Initially, I was hesitant, mainly because I had never imagined myself in a program like this.

However, after almost a year in the PHP, I can honestly say that this program is the best thing that has ever happened to me.

Go to www.foundationpamedsoc.org throughout the year to read new stories every month and donate online.

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Community, Health & Wellness

– g in in h S s i n u S e h t The Snow is Gone &

M O R F

F L E S R PROTECT YOU Bryan Anderson, MD Penn State Hershey Dermatology

pring is finally upon us, the snow is gone and the sun is shining. As the days get longer, and we spend more time outdoors, please remember to protect yourself from excessive ultraviolet light exposure. Protecting yourself from sun burning is critically important to the health of your skin as well as your overall wellbeing. Ultraviolet light exposure has been linked to skin cancer as well as wrinkling, dyspigmentation, and an appearance of aged skin. It is therefore vital to protect oneself from the dangers of ultraviolet sun damage.

Skin cancer, including basal cell carcinoma, squamous cell carcinoma (both of which are often referred to as non-melanoma skin cancer) and melanoma, is the most frequent form of cancer in humans. Basal cell carcinoma skin cancer alone will be diagnosed more frequently than all other forms of cancer. In fact, one in five Americans will develop a form of skin cancer over their lifetime. The main preventable risk factor 16 Summer 2016 Central PA Medicine

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for all is ultraviolet light exposure. The good thing about this risk factor is that it is modifiable. In other words, we are able to avoid and protect ourselves from over-exposure to harmful ultraviolet radiation. The absolute most important aspect of sun protection is to avoid sunburns. Recent information has shown that having a history of five sunburns will double your risk of melanoma.

This is not only modifiable, but of critical importance for our overall health.

skin. A broad-brimmed hat and the use of sunglasses is recommended. One should also consider avoiding ultraviolet rays when they are most potent, during the hours of 10 am to 2 pm. A good rule of thumb is that if your shadow is shorter than you are, you should seek shade. When at the beach use an umbrella or find a shade structure that will dramatically reduce your exposure to harmful ultraviolet radiation.

Sun Protection

The importance of early detection of skin cancer cannot be overstated. The earlier skin cancer is detected the better the outcome.

Individuals with non-melanoma skin cancer will often present with a bleeding sore, or non-healing sore on the head and neck region. Although skin cancer can be seen at any location of the skin, the head and neck receives many more times the amount of ultraviolet light exposure over one’s lifetime, thus the head and neck are the most frequent areas of involvement.

The most common form of protection from the sun is sunscreen. More specifically, it is important to get in the habit of applying a broad spectrum sunscreen—one that protects against both ultraviolet A (UVA) and ultraviolet B (UVB) rays, and with a sun protective factor (SPF) of 30 or higher.

Also remember that sunscreen will not last for hours on end. The sunscreen will get diluted with heavy activity, swimming, or anything that individuals do that increases sweat production. Reapply your sunscreen every 2–3 hours. Don’t forget to protect your lips with lip balms containing sunscreen.

If you would rather not use sunscreen, there are many sun protective clothing products available which can accomplish the same goal as sunscreen without having to apply a cream or lotion to one’s

Detection

Non-melanoma skin cancer can present in many manners. A bleeding papule, or blood tinged crusted patch are frequently encountered. If you or a

loved one has an area of concern it is best to have it evaluated sooner than later. If caught early, nearly 100% of non-melanoma skin cancers can be cured with various surgical or medical techniques. Untreated skin cancers will enlarge over time, and if not treated, will eventually invade deeper structure and/or metastasize. Skin cancers that are diagnosed in later stages of disease can cause considerable morbidity and mortality. This is especially true for squamous cell carcinoma. If not treated squamous

cell carcinoma will eventually metastasize.

Therapy for larger skin cancers or those that have metastasized is much more difficult than for skin cancers that have been diagnosed at an early stage. This confirms the importance of prevention, self-screening and screening by your physician. When in doubt about a skin growth, have your family doctor or dermatologist evaluate.

Melanoma is much less commonly encountered than the non-melanoma skin cancers, however, melanoma has a tendency to metastasize thus reaffirming the case for prevention and early detection.

Approximately 80,000 cases of melanoma will be diagnosed this year. It has been estimated that one-half of all melanomas are self-discovered or discovered by a family member. This strengthens the argument for monthly self-skin examinations. The overall lifetime risk of developing melanomas in the United States now stands at 1 in 50. That means 2% of the population will develop melanoma skin cancer. The ABCDEs are a good rule for individuals to use for self-screening. A=Asymmetry, B=irregular Border, C=variation in Color, D=Diameter >= 6mm, E=Evolving or changing. Melanoma is often described as an asymmetrical flat area of the skin with an irregular border and color variation. Just remember that not all skin cancers read books and melanoma does not have to have all of these characteristics. In practice the obvious melanoma has all of these features.

Many melanomas will only have 1 or 2 of these criteria. As with all things in life, no criteria are perfect. I have found that one of the most important criteria is the evolving or changing mole or nevus. If the nevus changes in an asymmetrical manner, further evaluation with dermoscopy or via biopsy is warranted. The goal is early detection.

So as we move into the summer months, remember to protect yourself and your loved ones. Prevention is easy and beneficial. Keep in mind that early detection is critical. You do not need to hide from the sun, you just need to protect yourself from its harmful ultraviolet rays.

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Community, Health & Wellness

What Am I Supposed to Eat? Debunking the Dilemma of the Diabetic Diet

By Robert Ettlinger, MD

ometimes, it practically makes steam come out of my ears.

I often have patients with diabetes come to my office after being in the hospital. They tell me what the doctors, nurses, and sometimes even the dieticians told them about what to eat to help control their diabetes. “You are no longer allowed to eat sweets. If you eat a cookie or a piece of candy, you’ll burn in hell.” “If you drink a beer, you’ll have undone all of the hard work I’ve done to save your life.” “On Thanksgiving, you may eat mashed potatoes, sweet potatoes, corn, chestnut stuffing, and a few crescent rolls, but, if you eat one mouthful of pumpkin pie, the Lord Almighty will smite you down with a heart attack by halftime of the Detroit Lions game.”

And then, there’s the most vile, dastardly mythical advice of all that they tell you...“Orange juice is good for you.”

So just what are you supposed to eat?

To answer this question, I will relay not on my personal opinions, but essentially the advice given by perhaps one of the most authoritative sources of all—the American Diabetes Association. Their expert panel recently detailed their recommendations in the January 2016 issue of “Diabetes Care,” with an updated policy paper about the evaluation

and management of Type 1 and Type 2 Diabetes Mellitus. So, if after reading this, you still think that Oreos are inherently evil, you can look up what the esteemed endocrinologists said in that comprehensive review.

First of all, my dear diabetics, you gotta eat. Every day, several times a day. Food is not like cocaine or heroin or cigarettes, things we can live without. Even though we might feel like we have addictions or cravings for certain foods, food is necessary to survive, is as integrally necessary as your medicine to help prevent damage to your body from diabetes, plus it tastes great and makes us happy. Hence, don’t let anyone try to make you feel that you’re committing a crime by eating food.

Second, food does not contain molecules carrying little signs that say, “I’m good for you” or “I’ll kill you.” Whether you eat oatmeal, nachos smothered in melted cheese, cabbage, pepperoni pizza, beans or brownies, it all turns to faceless glucose (the “sugar” our body uses for fuel, repair and growth). Therefore, stop looking at food as an enemy. See it as a delicious, pleasurable thing that you should make a commitment to consume proportionally less of or more of.

One concept that’s important to understand is that of “glycemic index.” This is a measure of how quickly and how high a food will raise your blood sugar. It is well accepted that rapid spikes of blood sugar make your body’s insulin (whether made in the pancreas or injected from a syringe) less able to get it in your body’s cells for healthy processing, which increases overall health deterioration. Coca-Cola, a liquid (rapidly absorbed within minutes of ingestion in the stomach) with a high content of sugar, has a very high glycemic index. Brown rice, which has to get to the small intestine for slower digestion and absorption, has a lower glycemic index...so, ounce for ounce, it won’t raise your blood sugar as much or as quickly as soda.

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Not all that long ago, the American Diabetes Association had strict rules about diet, involving lists of food in a “1,500 calorie ADA diet” that involved reading and memorizing labels, measuring foods on your laboratory scale, and figuring out “food exchanges” (such as “one huge piece of boiled, bland flounder” equals “one quarter of a strip of bacon”). You had to go through this process every time you ate lunch, otherwise you were a bad, ungrateful patient. The ADA dropped this system, after discovering that every diabetic in America was totally ignoring it and laughing hysterically at the concept, except for Barney Heckelmeister of Gooberville, Nebraska, who, in addition to his diabetes, had severe obsessive-compulsive disorder.

The ADA now recommends an individual approach to diabetic diets, “based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes, and barriers to change.” They also acknowledge the inherent pleasure of eating (it’s no longer put on the same moral level as donating charity to the Taliban), recommend to healthcare workers to be more non-judgmental about patients’ food choices, and advise offering “practical tools for developing healthful eating patterns rather than focusing on individual macronutrients, micronutrients or single foods.”

They do acknowledge the benefit of weight loss, advising sustained, sequential drops of 5% from initial to ideal body weight.

This can be done by a general daily energy deficit of 500 calories (consuming less calories, and/or more exercise to burn them up), which translates to a pound a week. You’ll be looking like Channing Tatum or Beyoncé in no time flat!

Carbohydrate intake from whole grains, vegetables, fruits, legumes and dairy products should be emphasized, especially if higher in fiber or lower in glycemic load. One way of accomplishing this, without starving at dinner, is to fill half of your plate with “grown above ground” vegetables, with a quarter of the plate each made of starch and meat. Diabetics taking insulin should learn about carbohydrate counting, by a registered dietician if necessary, so that they can match their meals to their insulin doses. If insulin doses are fixed, meal planning should emphasize a relatively fixed carb consumption pattern, with respect to both time and amount.

While studies are not fully conclusive about dietary fats in diabetics, evidence does point to benefits of a Mediterranean diet high in monounsaturated fats (such as fish, nuts and vegetable oils). These foods, rich in omega-3 fatty acids, help to prevent cardiovascular disease, which is the most common cause of death in diabetics.

Evidence does not support a beneficial role for omega-3 dietary supplements. On a related note, there is no good evidence that vitamins, minerals (such as chromium), herbs, and spices (such as cinnamon) play a significant role in treating diabetes. In fact, there are concerns about long-term use of anti-oxidants such as Vitamin C, Vitamin E and carotene.

The ADA recommends that diabetics limit alcohol to one drink daily for women, one or two daily for men. As with the general population, limit sodium to under 2300 mg daily. Evidence about protein in diabetics whose kidneys are healthy is inconclusive, but is often said to be advisably comprising a third of daily calories.

Sugar-sweetened beverages should be limited, as they have a capacity to displace healthier, more nutrient-dense food choices.

Thus, diabetics of America, do what the experts say. You may eat every single food in the grocery store or the restaurant, guilt free without feeling like you’ve committed a mortal sin. Enjoy eating, and smile as it hits your taste buds and goes down the hatch. Just try to eat lesser amounts and frequencies of some foods, and more of others. One or two small changes in your diet can make a world of difference. Make decisions about foods you have problems controlling, and keep them out of the house. If this is not practical, then decide to lower their intake frequency, amounts per serving, or try to substitute something with a lower glycemic index or calorie content.

And, as for orange juice—it has more calories, per ounce, than soda.

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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 Chris Dicroce.

PA S S I O N OUTSIDE OF PRACTICE Photography of Chris Dicroce

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How did you develop an interest in your passion outside of practice?

Growing up in New Hampshire I found myself outside a lot as a child. Whether it was hiking in the White Mountains in the summer and fall or out skiing and snowshoeing in the winter, the mountains always seemed like my backyard. With the beautiful outdoors always surrounding me I think an interest in photography was natural, especially an interest in landscape and nature/wildlife photography. When I was young I would pore through National Geographic magazines looking at such amazing photos ranging from expeditions to Antarctica to rare wildlife in Africa or Siberia. As a kid I would collect postcards of different landscapes that would catch my eye, many of them landscapes, especially in the autumn when the New England foliage can be so breathtaking. I think my initial interest came in part from a desire to try to humbly imitate that style and simple detail to the best of my ability.

There is such beauty in the world and photography can capture it in so many forms. I think the skill of professional photographers and how they can make an image appear more real than your own eyes can is something that is underestimated when it comes to artwork. Take some of the works of Ansel Adams and Bradford Washburn, two of the greatest landscape and mountain photographers in the world. Their work is so powerful and ranges from a cluster of leaves on the ground to the seemingly unlimited heights of Denali in Alaska. You can be standing in front of a print of one of their works and feel like you have to step backwards to keep from falling in.

How long have you been doing it?

I’ve been taking photographs since I was about eight or nine years old. My very first photographs were from a now ancient phenomena known as a disposable film camera.

“A girl and her dog”

“Desert Moon”

From time to time my mom and dad would let me snap a photo with the family camera and encourage me to take photos on family hikes. Perhaps my first introduction to some of the technical aspects of photography came when I was a Boy Scout and decided to work on my photography merit badge. Some of the requirements really forced my twelveyear-old self to look more into the science behind setting a scene for a photograph.

Since then taking photographs has always been a passion of mine. Being active outside

through hiking and skiing means there is never a shortage of new areas and wildlife to take in. Nowadays with digital photography you can certainly cherry pick the shots you like and make real time decisions with the angle and perspective of the shot. Although it has always been more of an amateur hobby, I look forward to the day where I can devote more time to improving my own skill with the camera as well as take more time solely for photography.

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Passion Outside of Practice Continued…

that show my family in so many stages of life.

Pictures of holidays and family gatherings, life events and seeing the growth of persons and families. I really consider pictures to be a necessity along with spoken word and storytelling to pass down family history. It immediately gives you a sense of so many small details that are left out from a simple recounting of past events.

“Backroads”

“Perspective”

What makes it special to you?

The truly awesome power of photography to connect you to so many different things.

It could be a foreign landscape, flora and fauna you may have never seen before or have never seen in enough detail to appreciate. It could be connecting you to your past or to your family’s past. I still enjoy going through the many photo albums my grandmother has

I think equally fascinating is knowledge of the skill that is involved in photography.

There is so much that I have to still learn about the art and science of photography. I have come to realize that the keys to success are preparation, patience and persistence as well as a hefty amount of blind luck. There are so many factors that can go into a shot.

With landscapes the lighting is always so important and the most vibrant shots you get will typically come at sunrise or sunset.

Making sure you have the right shot, waiting for the perfect light and hoping for clear weather all means that sometimes it could take a few different tries on different days to get it right; persistence is a very necessary factor. Finally, sometimes you just get lucky, the clouds break at the last minute or the bird turns its head right when you snap the picture. That element of chance can make it so frustrating and yet so rewarding.

What else would you like to share about it?

We live in a pretty extraordinary time where a camera is such a readily accessible thing. Every cell phone has a digital HD camera that would put my disposable Kodak to shame. Combined with photography apps like Instagram we are really seeing a huge interest in photography from people of all ages. It is truly a fascinating time to be living and I’m looking forward to seeing the new work that is created.

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Restaurant Review

Vrai

photos from vrairestaurant.com

True Food

Robert Ettlinger, MD

hen it comes to dining out, the selection in Lemoyne has long underwhelmed the beauty of the town. Following a change in the town’s liquor license regulations, sophisticated dining has finally arrived at 1015 Market Street, a block east of the West Shore Market. VRAI (French for “true”) has a European feel, with a culinary concept based on the use of high-quality ingredients, unprocessed food without hormones, and an emphasis on locally-grown foods.

Word is getting out from its regular customers of the joys of its menu.

made in Hanover from recycled materials, gives VRAI a casual, café-like feel, topped off by an eye-catching Carrera marble bar top. The sweeping bar is well stocked, with a nice variety of wines and one-of-a-kind cocktails.

Starters, sides and salads were simultaneously light, yet hearty, and unique in their use of local produce. You can enjoy flatbreads with artichokes or asparagus, and a kale, farro and fennel salad. Our party was especially impressed with the wood-fired brussel sprouts with hazelnuts, and the roasted beets with goat cheese and pistachios.

VRAI, currently open for dinner on Tuesdays through Sundays with plans for a lunch menu in the works, is the dream and creation of Shelly Page. With an accounting background as the chief financial officer of a local medical group, the Millersburg, PA native switched gears four years ago and attended a prestigious culinary school in New York City to learn the ropes of the restaurant business. Following a few more years of research and contemplation, VRAI opened in February 2016 and has been busy ever since. An eclectic menu was created by her and her Executive Chef, Doug Shenk (formerly of Fraiche and The Cellar). Shelly’s husband, Dr. Michael Page, a respected local surgeon, contributes his expertise in the extensive wine selection. In addition to his duties as sommelier in residence, he has even been spotted washing dishes once in a while!

Nine varieties of wood-fired pizza use local Caputo Bros. creamery mozzarella topped with outside-the-box vegetable and light meat combinations—not a single slice of pepperoni or anchovy was to be found.

The open feel of the dining area, bar (backed by a wood-fired pizza oven), and ‘in-sight’ prep kitchen has its noise level tempered by a European foam wallpaper. The furniture, some of which is

Continuing our area’s recent trend of farm-to-table cuisine by East Shore newcomers like Harvest, Millworks and The Mill, VRAI is sure to keep diners happy in Lemoyne.

Unique entrees included pan-seared salmon on pilaf with pesto, and black bean sweet potato tortillas. On a recommendation, I went for the homemade ravioli filled with braised short rib, topped with horseradish cream and pecorino, while a dining partner was equally impressed with the butternut squash ravioli. Half and full orders are available for those who want to share or to try a variety of the flavorful dining choices.

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Community, Health & Wellness

HEPATITIS A W A R E N E S S Karen L. Krok, MD

he month of May is designated as Hepatitis Awareness Month in the United States, and May 19th is Hepatitis Testing Day. During May, the CDC and its public health partners work to shed light on this hidden epidemic by raising awareness of viral hepatitis and encouraging priority populations to get tested.

Hepatitis C Virus (HCV):

There are more Americans infected with hepatitis C than with breast cancer (2.8 million) and HIV (0.9 million). It is estimated that between 5,000,000 and 7,000,000 Americans are infected with hepatitis C and only 25% of patients may know that they are infected. In Pennsylvania alone there are at least 250,000 people with HCV. Approximately 75% of patients with hepatitis C are in the baby-boomer generation (born between 1945 and 1965) and it is estimated that 1 out of 33 baby-boomers are infected with HCV. For this reason, the United States Preventative Service Task Force (USPSTF) recommended in 2013 that all patients born between 1945 and 1965 be tested one time for hepatitis C. But, the new infections of hepatitis C are in an entirely different generation of patients—the young heroin and intravenous drug injectors. We are in the midst of an epidemic of hepatitis C in this patient population. There has been a 400% increase in HCV over the last 10 years in some states (in Pennsylvania there was a 100% increase in HCV), which mirrors a tripling of heroin users in this same time period. Amongst injection drug users, the prevalence of HCV is approximately 70%; within 3 months of injection drug use between 50 and 60% of people will develop HCV. This is also no longer just an inner city problem. Most new infections are in predominantly white people between the ages 24 Summer 2016 Central PA Medicine

of 18 and 29. There is an equal male and female predominance and it is equally prevalent in urban and non-urban settings.

There is no simple solution to preventing the spread of hepatitis C, as this will require a decrease in the heroin use. The rise of heroin has stemmed from the opioid use and it is predicted that as opioids are regulated more, there will be a rise in street heroin use. Unfortunately this is a very big problem in Pennsylvania—Pennsylvania is actually #1 for heroin overdose deaths in males between 18-29 years of age.

Not a time that you want to be #1!

Hepatitis C becomes chronic in 75% of patients who are infected with 1 out of 5 people developing cirrhosis. It was recently announced that the life expectancy of Americans has decreased slightly because of the rising deaths related to cirrhosis and end-stage liver disease.

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This is the time to check for hepatitis C. Since late 2013, we now have many new, all oral medications to treat hepatitis C. These are expensive, but they can cure hepatitis C in up to 97% of patients.

And unlike the previous treatments that were riddled with side effects, these medications are tolerated very well with few side effects (insomnia, fatigue and headache are the most common). I have personally treated hundreds of patients with these new medications and the biggest issue with the medication is getting it approved by insurance; patients tolerate these medications very well. I have seen overall quality of life improvement (improvement in fatigue, joint aches and mood) with eradicating a patient’s hepatitis C. It is a very exciting time to be a hepatologist!

To test a patient for hepatitis C, please order a hepatitis C antibody.

If this is negative, the patient has never been infected with hepatitis C. If it is positive, then there are three possibilities: 1) active infection; 2) prior infection and cleared either spontaneously or with treatment (a patient will never lose the hepatitis C antibody); or 3) a false positive antibody. In order to determine which it is, you need to order a hepatitis C viral load and a genotype. If you have all of this information prior to referral to a treatment physician, it will make that first office visit more productive.

Hepatitis B virus (HBV):

There are approximately 2 million people with chronic hepatitis B in the United States, with the majority of infections in immigrants.

Unlike HCV, there is a vaccine for hepatitis B and so hopefully there will be a decline in chronic HBV—they have seen this in China! If untreated one-third of patients can develop cirrhosis or liver cancer. HBV is associated with 80% of all cases with HBV world-wide.

It is recommended that many patient populations be tested for HBV: 

US-born persons not vaccinated as infants whose parents were born in regions with high HBV endemicity

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Persons with chronically elevated aminotransferases

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Persons needing immunosuppressive therapy

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Men who have sex with men

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Persons with multiple sexual partners or history of sexually transmitted disease

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Inmates of correctional facilities

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Persons who have ever used injection drugs

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Dialysis patients

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HIV- or HCV-infected individuals

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Pregnant women

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Diabetic patients <60 years of age

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Family members, household members, and sexual contacts of HBV-infected persons

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Persons born in high or intermediate endemic countries (please refer to the CDC website)

I would like to particularly draw attention to the diabetic patients as this is a recommendation since 2011—it is recommended that patients with diabetes be vaccinated for hepatitis B. In addition, it is important to remember to assess for HBV in patients whose parents were born in areas of high HBV endemicity.

I would suggest that all patients with HBV be referred to a HBV treating physician. There are also many good medications to treat HBV (although not everyone needs to be treated) and these guidelines are in flux. In addition, it is imperative that patients with HBV are screened for liver cancer, given the very high risk of developing HCC in these patients (particularly in patients who were infected as infants).

Hepatitis C is now easily cured and hepatitis B can be managed.

By treating these two diseases, we can decrease the burden of cirrhosis and end stage liver disease and prevent liver cancer. Please think about testing the populations at risk and refer to your local treating physicians with any positive test result. May is Hepatitis Awareness Month, but every day you see patients you should be thinking about ordering the simple blood tests to assess for these viruses.

Karen L. Krok, MD, is Associate Professor of Medicine, Transplant Hepatologist, Penn State Milton S. Hershey Medical Center.

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Practice Management

MATCH DAY Matt Tangel

T

he wait was finally over. March 18th had arrived and approximately 143 students were packed into the Hershey Club ballroom accompanied by their friends and family for 90 minutes of nerve-wracking anticipation. The entire venue was brimming with excitement as students, faculty, and alumni gave speeches addressing the class of 2016. Once the clock struck noon, all of the students collectively opened their envelopes and shrieks of joy reverberated throughout the room. After weeks of waiting and years of hard work, we all finally knew where we would be spending the next three to seven years of our lives.

This is the excitement thousands of medical students experience each year on Match Day. The event has grown to become a largerthan-life event where past medical school performance and future residency placements meet in a single dramatic moment. But it has not always been so.

Back in the early 1900s, before the Match, hospitals would individually seek out medical students and offer them residency positions. The students would have to respond to an offer within 48 hours so that the hospital could interview more applicants if necessary. This would prevent medical students from determining what other options were available and force competition among the hospitals to interview students earlier than their competitors.

During this period, several hospitals stated that they would not interview medical students until a certain time in hopes that other hospitals would do the same; however, their effort was futile. This competition eventually became so intense that hospitals started to send out interview invites as early as the beginning of junior year, before they could be aware of the student’s clinical performance.

The National Residency Matching Program (NRMP) was established in 1952 in order to alleviate the dissatisfaction with the process of finding a slot for residency. The NRMP dictated that there would be a period where students would interview and compile a a rank list of their favorite programs. In addition, each hospital would also rank their applicants. An algorithm would then 26 Summer 2016 Central PA Medicine

be run in order to match students to an appropriate program and come up with an appropriate match.

Things have certainly changed since the first Match Day in 1952.

Studies had to be done in order to make slight alterations in the algorithm over the years. Two scientists who study game theory (the study of mathematical models of conflict and cooperation among rational thinkers), Dr. Shapley and Dr. Roth, won the Nobel Prize in economics for their work over the years on the matching process. In 1995, the algorithm was re-evaluated since it was found that it tended to favor the preferences of institutions over the residents’ rank lists. The algorithm was changed so it favored applicants’ preferences. Today, the entire process is streamlined and done online. Waiting periods of about three weeks between submission of the rank list and receiving the results is the norm even though the algorithm takes seconds to run and maybe days to proofread for any issues. For applicants waiting anxiously on edge, three weeks feels like an eternity!

The Match this year was the largest on record. According to data made available on Friday, March 18, 2016, the Match saw record numbers of registered applicants, active applicants, and total residency positions. Just 10 years ago, there were 24,085 applicants in the Match worldwide, compared to 42,370 in 2016.

Out of all applicants, 35,476 were “active,” or submitted a rank list, and 26,836 were successfully matched. It was certainly an exciting day for many people. After all, to be matched means there is job security for the next three to seven years. For those who were not successfully matched, they will have to enter the Match again for fellowship positions.

I would like to congratulate the Penn State College of Medicine Class of 2016 on a successful match. Everyone has worked incredibly hard to match at excellent residency training programs both here at Penn State Hershey Medical Center, and elsewhere throughout the nation. I wish all of you the best of luck through residency training and beyond!

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Practice Management

Judgement Call:

Protocols Need Human Supervisors Charles Yanofsky, MD, Pinnacle Health Neurology

It is said that patients benefit when we follow protocols and that judgement gets in the way of best practice. Writings of Atul Gawande, MD, and others have cemented the importance of protocols in the mind of the physicians and non-physicians alike, enough for us to ask if there is any role at all for clinical expertise. Here are two cases that prove computers and protocols still need human supervision.

Case 1 A 60-year-old healthy man on no medication came by ambulance from his gym where he’d been lifting weights then ran on the treadmill.

He walked up to the desk at the gym having trouble expressing himself. Everyone thought he was having an acute stroke. He had passed a stress test only days ago with flying colors. He had modest right body and facial weakness, halting speech and a preference to look to his left—all signs pointing to problems with his left frontal lobe. A CT scan just done, showed nothing in the brain except that the left middle cerebral artery was opacified which can be a sign of an extensive clot. EMTs also reported he had complained of visual loss. Speaking haltingly, he let me know he did transiently lose vision in his left eye. Any pain? No. Well, last night I had a minor headache but that is about all. Any straining? He came in sweaty. He lifts 35 pounds at most.

Protocol told me he was a shoo-in for the clot busting i.v. t-PA therapy. But my clinical expertise made me pause. The left-eye vision loss didn’t make sense. He should have lost his vision, if anywhere, in his right visual field. No, he insists, it was his left eye.

Case 2 The next time I hear from the ER it is 3 a.m.

A poorly-controlled diabetic hypertensive man

comes in on account of vomiting when he eats, but mentions painless double vision that he has had for two days. Could he be having a brainstem stroke? He blames the double vision on his left eye because it is worst looking to the left. He had been covering one eye just to get rid of the double vision. He reported that he had a similar problem years ago which went away on its own. I was assured his pupils were equal or at least there wasn’t a blown pupil.

Comfortable that I knew his diagnosis, I told the ER doctor and asked that the patient have an MRI of the brain and an MRA of the circle of Willis to rule out abnormalities. I didn’t think the results were going to be abnormal and rolled over and went to sleep.

When I did get to examine the 3 a.m. patient a few hours later, he had a drooping eyelid on the right and his right eye was not following to his left. Pupils were equal. He had all the signs of a diabetic-related right eye third nerve palsy, a common benign entity. So, it was the right eye, not the left, and not a stroke. Protocol would have had us check for an aneurysm pressing on this nerve, but that is painful and pupils would not be equal. The vomiting turned out to be a separate issue. He told me he mostly vomits shortly after eating, something he had for a long time that pointed possibly to a problem with esophagus motion or structure or the gastroesophageal sphincter. The brain studies proved perfectly normal.

As for the healthy 60-year-old man from the gym, as soon as I got the history of the left eye, I looked with an ophthalmoscope for little clots on the retina that might have been thrown from his carotid artery. In minutes we had him in the CT scanner again to do a CT arteriogram which showed a left carotid occlusion likely from a tear in the vessel (dissection) from intense physical activity. Even so, the clot buster benefitted him as we could see flow higher up in the middle cerebral artery. All of his other vessels were pristinely perfect.

The moral of these stories which both involve the eyes, is we as physicians all have inner vision.

Thought is a path to the unexpected. Computers are very smart and in the future could even drive our vehicles in cities and superhighways. In the not-too-distant future computers will even do surgeries.

My own medical career started with simple calculators and the need to recall all the side effects of every drug and their interactions. The way I practice today is different. I can look these things up instead of having to memorize them.

Computers and protocols regularly make clinical decisions. Computers generate images I see every day and consider more beautiful than art, but they aren’t always right. I believe we are living in that short sliver of time when computers and protocols still need human supervision. I revel in that for now.

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Practice Management

Physician Information for

MEDICAL MARIJUANA Michael Siget, JD, MPA, Legislative & Regulatory Counsel, PAMED

 What is the status of the medical marijuana bill in Pennsylvania?

On April 13, 2016, the House of Representatives agreed to changes made by the Senate on Senate Bill 3, legislation that legalizes marijuana for medicinal use in Pennsylvania. SB 3 was sent to Governor Wolf who signed the bill into law Sunday, April 17.

 Am I required to participate in the medical

 Are there other limitations on my ability to certify patients for medical marijuana?

The Department of Health will monitor, with assistance from the Department of State, that a physician has a valid, unexpired, unrevoked, and unsuspended Pennsylvania license to practice medicine and whether the physician has been subject to discipline.

The inclusion of a physician in the registry is subject to annual review by the Department of Health to determine if the physician’s license is no longer valid, has expired or been revoked or the physician has been subject to discipline. If the license is no longer valid, the department shall remove the physician from the registry until the physician holds a valid, unexpired, unrevoked, unsuspended Pennsylvania license to practice medicine.

marijuana program?

No. Physicians are not required to certify any individual who seeks to obtain medical marijuana.

 If I want to participate, what do I need to do?

To register with the Department of Health, physicians must provide information to the Department that they have training or experience to treat a serious medical condition by providing documentation to the Department of credentials, training or experience. The Department will determine the necessary levels for DOH certification.

Physicians also will be required to undergo a 4-hour training program regarding the latest scientific research on medical marijuana, including the risks and benefits of medical marijuana, and other information deemed necessary by the Department. This training program may count as continuing education credits as determined by the State Board of Medicine and State Board of Osteopathic Medicine.

 Does that mean I can start recommending medical

 Who is eligible to obtain medical marijuana?

An individual must have one of 17 specific serious medical conditions as diagnosed by a Department of Health registered physician: Cancer; Positive status for HIV or AIDS; Amyotrophic Lateral Sclerosis; Parkinson’s Disease; Multiple Sclerosis; Damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity; Epilepsy; Inflammatory Bowel Disease; Neuropathies; Huntington’s Disease; Crohn’s Disease; PTSD; Intractable seizures; Glaucoma; Sickle Cell Anemia; Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain in which conventional therapeutic intervention and opiate therapy is contraindicated or ineffective; or Autism

marijuana to my patients?

 If I certify someone for medical marijuana,

No. It is estimated that it will take about 18 months for the program to be implemented.

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can I place a time limit on this certification?

Yes. If, in the practitioner’s professional opinion, the patient would benefit from medical marijuana only until a specified date, the practitioner may place such a time limit.

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 Can I certify a minor for medical marijuana?

Yes. If a patient is under 18 years of age, the patient must have a designated caregiver, such as a parent or legal guardian, an individual designated by a parent or legal guardian, or an appropriate individual approved by the Department of Health.

 Will physicians be publically listed as certified medical marijuana providers?

 Are there prohibitions for physicians under this law?

If my patients obtain medical marijuana, will their names be placed in a database?

A practitioner may not do the following: 1. A practitioner may not accept, solicit or offer any form of remuneration from or to a prospective patient, patient, prospective caregiver, caregiver or medical marijuana organization, including an employee, financial backer or principal, to certify a patient, other than accepting a fee for service with respect to the examination of the prospective patient to determine if the prospective patient should be issued a certification to use medical marijuana.

The names, business addresses and medical credentials of practitioners authorized to provide certifications to patients to enable them to obtain and use medical marijuana in the Commonwealth will be publically available. All other practitioner information will be confidential.

Yes. The Department of Health will maintain a database of patients and caregivers approved to use or assist in the administration of medical marijuana.

2. A practitioner may not hold a direct or economic interest in a medical marijuana organization.

3. A practitioner may not advertise the practitioner’s services as a practitioner who can certify a patient to receive medical marijuana.

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Practice Management

WHAT A PATIENT NEEDS TO KNOW

About Preparation for Surgery Joseph F. Answine, MD

s a patient, you will be asked to do many things in preparation for a surgical procedure and anesthesia. They may seem repetitive and unnecessary, but they are there to achieve a successful and hopefully stress-free procedure.

if they feel it is needed. Lastly, you may be asked by your family doctor to visit specialists before surgery such as the cardiologist, endocrinologist or pulmonologist to help understand and treat particular illnesses more thoroughly.

Visit Your Primary Doctor

List of Medications

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 be the ones caring for you after your early 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 in 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 increased risk of infection but also a decreased overall survival from major surgery. Heart problems can become worse while under anesthesia or shortly after. Your doctor will also be there to encourage you to stop smoking and lose weight if you are overweight before surgery because both have been associated with potential complications and slow recovery. Your medicines that you take chronically may be adjusted as well 30 Summer 2016 Central PA Medicine

It is important to make sure a complete list of all the medications you take regularly is available and known to all those involved in your care prior, during and after surgery. This includes all vitamins and “herbal” medications because they truly are medications with effects and side effects, and they can have interactions with other drugs you currently take or will be given during surgery. For example, many herbal medications “thin your blood” and increase your risk of bleeding. Some will also interact with the medications we use to raise and lower your blood pressure and heart rate while under anesthesia.

Make copies and hand them out especially if the list is long or dosing regimens are complicated.

Exercise

Believe it or not, you may be asked to exercise based on your 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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Follow the Instructions

You will be given many instructions such as 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 of your mediations may actually be changed temporarily such as your insulin dose. New medications may be 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 during the healing phase. But, 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 and not following the instructions could potentially cause your surgery to be delayed or cancelled.

Lifestyle Changes

I can’t stress enough the importance of making those lifestyle changes I mentioned above such as quitting smoking which clears carbon monoxide and chemicals from your lungs and improves lung function even if done for a couple weeks or a few days. The loss of a few pounds decreases the stress that your lungs and heart are under during anesthesia, and decreases anesthesiologists’ “struggles” with your airway. It also improves sleep apnea symptoms. Getting those sugar levels as close to normal as possible even for a short time balances the electrolytes and fluid in your body and again, lowers your chance of an infection.

Post-surgical Pain Management

How your surgical pain will be treated is changing; moving from narcotic pain medications to non-narcotic regimens based around acetaminophen (Tylenol) and non-steroidals such as ibuprofen (Advil) along with pain blocks using local anesthetics. Narcotics won’t be completely removed, but we are learning that the side effects slow recovery and lead to complications. By the way, make sure before you start Tylenol (acetaminophen) that the pain meds the doctor gave you for after surgery don’t already contain acetaminophen in combination with the narcotic.

Stay Informed

Lastly, know exactly what is going to happen to you and what is expected of you before and during your procedure and hospital stay. As I wrote in the last edition of this magazine, you are now an active part of the peri-operative care team. Actually, by far, you are the most important person on the team. Furthermore, there will be no surprises when you are asked to get up, move around, eat, drink and get back to your life.

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Practice Management

DIGITAL HEALTH TECHNOLOGIES

David Lee Scher, MD, FACP, FACC, FHRS

igital health includes wireless sensors and devices, mobile connectivity, the Internet, digital imaging, social media, and health information systems. For many physicians the electronic health record (EHR) represents the face of digital health technology. Unfortunately this has left a bad taste in the mouths of most, with studies showing physicians and support staff spending an average of 17 hours per week entering data into the EHR to meet quality metric requirements.

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An entire industry has sprung up (the medical scribe) to work around the evolved workflow which now has been shown to come between (literally and figuratively) the physician and patient. Andy Slavitt, the acting administrator of Center for Medicare and Medicaid Services, has declared Meaningful Use over. This incentive program accomplished the goal of widespread adoption of EHRs but has resulted in physicians â&#x20AC;&#x2DC;treatingâ&#x20AC;&#x2122; and spending more time with the EHR than

with their patients. With this, one can hope for the following; (a) The future design of EHRs to match clinical workflow, (b) The ability to capture data from remote patient monitoring seamlessly in the EHR, (c) The use of analytics which can filter out unnecessary data and present actionable data, the creation of patient portals which do more than furnish patients with test results, and (d) The ability for diverse EHR systems to talk with each other, something promised by all and accomplished by none. If properly utilized, digital health is something which can both make our lives as physicians better and empower our patients to take more control in their own healthcare management.

Tracking & Data Exchange

As private individuals, healthcare professionals sing the praises and utilize retail and finance technologies like Uber and Amazon apps and Apple Pay. Conversely, the adoption of these mobile apps in healthcare has lagged behind. Despite this lag, some advances have been made in the arena of mobile medical apps (MMAs).

Most apps and mobile technologies used today by physicians are reference apps to review drug doses, side effects, and specific disease diagnosis or treatment options. The vast majority of health and fitness apps (of

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which there are over 200K) used by patients are general wellness and fitness tracking.

They are used primarily by younger people who are generally healthy.

The future of apps lies in those which furnish patients with educational tools for management of chronic illness. Apps are an excellent way in which caregivers at a distance can track symptoms, health (via connected sensor devices), doctor appointments, and medication schedules/adherence.

To track medication ingestion, the company Proteus Digital Health has developed an FDA-approved physiologic microsensor (in use today) which is placed on a patient’s medication pill at the time of manufacturing.

It is activated by gastric juice and sends a digital signal to a Band Aid-like patch on the patient’s chest which then records the time in association with vital sign and geopositioning data obtained by the patch.

There are also apps associated with wireless transmission of data from insulin pumps and glucometers, blood pressure cuffs, smartphone ECG patches, and weight scales.

and reviewed after the doctor visit in a non-stressful home environment, with or sent to a caregiver, and translated into any language (by a company called SpeechMed).

This digital content can contain animations of discussions of diseases and procedures.

Another mobile app (ZocDoc) empowers both patients and physicians. The app provides information about a physician’s practice and insurance affiliations and allows the user to make or fill cancelled appointments in an automated fashion. This app has actually been proven to decrease no-show appointments.

Digital technologies will facilitate data exchanges between patients and physicians.

The key to successful adoption lies in their association with analytics technologies which will filter out the noise, prevent data deluge and deliver actionable trending data which will result in instructions which are either algorithmically derived or ordered by a healthcare professional to the patient and/ or caregiver. This will eliminate phone tag, escalation of clinical issues to critical levels and improved experiences on both sides.

A recent report by the President’s Council of Advisors on Science and Technology entitled “Independence, Technology, and Connection in Older Age” discusses how technology can benefit older people. This is going to be important as the vast majority of older people surveyed state that they want to age at home. The report highlights the role of technology in improving socialization of older people, in slowing cognitive decline, and in maintaining physical abilities. The AARP has established a $40M venture fund for the development of technologies to promote better aging at home.

There are many other aspects of digital health which have not been mentioned in this article. What is clear, however, is that technologies will continue to evolve and will address the pain points of healthcare on both the patient and healthcare professional sides. We just have to remember, it will take time.

David Lee Scher, MD, FACP, FACC, FHRS, is a practicing cardiologist and Director at DLS

Healthcare Consulting, LLC. He is a globally recognized thought leader in digital health technology and blogs at The Digital Health Corner.

Using Technology to Empower Patients

Mobile technologies also extend beyond the transmission of data and can help empower patients. Take for example a 20-minute office visit where a patient with a potentially serious health problem has to process everything the doctor has to say and make a decision about how to move forward with treatment. Making a decision on the spot or understanding all of the doctor’s verbal diagnosis can prove stressful. In fact, recent studies show that only 18% of people (22% of women and 14% of men) are health literate (as defined by the The U.S. Department of Health and Human Services (HHS) as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”). Technology can help the patient in this situation since digital content from that office visit can now be recorded, downloaded or emailed Central PA Medicine Summer 2016 33

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Legislative Updates

Pennsylvania Medical Society Quarterly Legislative Update March 2016

t the time of this writing, the House and Senate are in the process of completing their respective Appropriations Committee budget hearings. At these budget hearings, representatives from the judicial system, the attorney general’s office, and cabinet secretaries answer questions from legislators regarding their respective department’s operations and funding needs, and legislators delve into the Governor’s proposal for spending in the next fiscal year.

The budget impasse has had the effect of slowing legislative action in recent months; however, there have been a number of developments of importance to Pennsylvania physicians and their patients. Following are a few highlights.

Prior Authorization Reform House Bill 1657, recently introduced by Rep. Marguerite Quinn (R-Bucks), would streamline and standardize the process of prior authorization of medical services in Pennsylvania. PAMED worked closely with Rep. Quinn in crafting this much-anticipated proposal and welcomed her comments before PAMED’s Specialty Leadership Cabinet 34 Summer 2016 Central PA Medicine

meeting on February 9, 2016. In the coming months, PAMED will continue to build on a grassroots effort and encourage physicians to engage with their local legislators on this important legislation. PAMED will also be meeting with key House members to inform them on the issue and garner their support for the bill.

Mental Health Bed Tracking System Senator Camera Bartolotta (R-Greene) recently announced that she is introducing legislation to create a real-time, voluntary reporting system to identify available psychiatric beds across the commonwealth.

Sen. Bartolotta’s interest in the issue was sparked after a recent Pittsburgh Post-Gazette article which reported that beds in hospital psychiatric units in Pennsylvania regularly sit empty, even while emergency departments

struggle to find available services for patients in need of inpatient mental health care.

These patients may wait for hours or days to receive needed behavioral health evaluation and management, further exacerbating emergency department crowding.

The creation of a voluntary, shared bed tracking system would increase health care providers’ ability to ensure that proper mental health care is being delivered in an appropriate timeframe and in an appropriate setting. Specifically, the registry proposed

by Sen. Bartolotta would provide contact information and descriptive details for participating psychiatric facilities throughout the state; provide real-time information regarding the number of beds available at each facility, the type of patient who may be admitted, and the level of security; and identify appropriate facilities for

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detention and treatment of individuals who meet the criteria for temporary detention.

PAMED, along with the Pennsylvania Psychiatric Society (PPS) and the Pennsylvania Chapter of the American College of Emergency Physicians (PAACEP), support the development of a shared bed tracking system and have provided Sen. Bartolotta with draft legislation to address the issue. We anticipate a bill to be formally introduced in the coming weeks. Similar legislation was introduced this session in the House of Representatives by Rep. Dan Miller, but has not received consideration (HB 858).

Mandatory CME Legislation The state’s opioid abuse epidemic has continued to intensify, with significantly higher rates for drug-poisoning deaths in Pennsylvania than the U.S. average. A recent study by the Pennsylvania Health Care Cost Containment Council (PHC4) revealed a 225 percent increase in the number of hospitalizations for overdose of pain medication and a 162 percent increase in the number of hospitalizations for overdose of heroin from 2000 to 2014. From 2013 to 2014, Pennsylvania’s drug overdose death rate increased significantly, by 12.9 percent.

Department of Health officials recently announced that the administrative infrastructure for the state’s new prescription drug monitoring program—also known as ABC-MAP (Achieving Better Care by Monitoring All Prescriptions)—is in place and the system should be operational by August 2016.

Setting aside the fact that ABC-MAP is not up and running yet, the legislature appears eager to take further action to help combat the proliferation of misuse and abuse of opioids. Legislation was recently introduced in the state House of Representatives that would require physicians and other prescribers and dispensers to complete CME in the areas of addiction and opioid

prescribing as a condition of licensure (HB 1805). A similar proposal is expected to soon be introduced in the Senate.

Currently, physicians must complete 100 hours of CME for biennial licensure; twelve of those hours must be completed in the areas of patient safety and risk management.

PAMED’s position is that any new mandate for physicians to complete CME in pain management and opioid prescribing practices should satisfy a portion of these existing educational requirements for physicians to complete CME in the areas of patient safety and risk management.

Changes to the Child Protective Services Law

was to implement recommendations from the Governor’s Task Force on Child Protection, which was formed in the wake of the Penn State Sandusky investigation.

Amendments made to the CPSL in 2013 and in 2014 altered the scope of the child abuse clearance requirement. Those changes have resulted in some confusion as to how the law should be interpreted and which medical personnel are required to have a clearance. As a result of this confusion, legislation will soon be introduced in the state Senate to clarify who is covered under the child abuse clearance requirement in the CPSL. PAMED has provided input on the draft bill and will be monitoring its movement closely in the coming weeks.

Between the 2013-2014 and 2015-2016 legislative sessions, the Pennsylvania General Assembly passed more than twenty bills to update the Child Protective Services Law (CPSL). The goal of the package of legislation Central PA Medicine Summer 2016 35

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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

 Pediatrix Medical Group

 Cocoa Family Medicine

 Pinnacle Health Cardiovascular & Thoracic Surgery Assoc

 Family Practice Center PC – Halifax

 Pinnacle Health Cardiovascular Institute Inc

 Healthy Starts Pediatrics

 Pinnacle Health Maternal Fetal Medicine

 Hershey Kidney Specialists Inc  Hershey Pediatric Center  Patient First – Harrisburg

 Pulmonary & Critical Care Medicine Associates PC  Saye Gette & Diamond Dermatology Assoc PC

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 Sollenberger Colon & Rectal Surgery Ltd  Tan & Garcia Pediatrics PC  The Arlington Group  Urology of Central PA – Londonderry Rd  Watkin, Nipple & Assoc

W E L C O M E !  Thomas W. Allen, MD  Shelly Bansal, MD  Amy Suzanne Burns, MD  Emma Susan Dahmus  Eldra Warn Daniels, MD  Dorothy Ejeme Ebhaleme, MD  Yanfang Guan, MD  Shalin Prabhaker Patel, MD  Matthew Tangel

 Women First Obstetrics & Gynecology PC

 Stefanie Ann Woodard, DO

 Woodward & Associates PC

 Daniel J. Yutronich, DO

 Julie Lynn Worthington, MD

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DCMS News

Dauphin County Medical Society in the Community DCMS Recognizes Dr. Raymond Grandon for 70 Years of Service in Medicine

DCMS President and Past President at the Society of Diplomates Dinner

March 2, 2016, the DMCS Board presented Dr. Raymond Grandon with a plaque of Special Recognition of Distinguished Service and his dedication to the profession of medicine. Dr. Grandon practiced medicine for 70 years in Harrisburg, PA after receiving his bachelor’s degree from Dickinson College and his medical degree from Thomas Jefferson University, his internship at St. Luke’s Hospital and residency at Harrisburg Hospital.

He specialized in internal medicine and cardiovascular disease.

During the recent Society of Diplomates Dinner, DCMS President, Mukul Parikh, MD, spent some time with George Moffitt, MD, who was president of the Dauphin County Medical Society in 1968.

Dr. Grandon was extremely active in the community, mentoring and teaching many physicians and nurses over the years. He is a past President of the Dauphin County Medical Society and the President of the Pennsylvania Medical Society.

Doc Talk

Left to Right: Dr. Robert Ettlinger, Dr. Heath Mackley, Rep. Greg Rothman, Dr. Raymond Grandon, Dr. Mukul Parikh, Dr. Shyam Sabat

DCMS Members Cheered on the Hershey Bears

DCMS physicians, staff, and community health care professionals were available to answer questions about medical concerns from immunizations to medical marijuana to smoking cessation as they donated their services to the public from 11:00 a.m. to 2:00 p.m. on Saturday, April 9, at the Capital City Mall in Lower Allen Township. “Dauphin County Medical Society is always willing to help the public understand their medical issues and any questions they have through events like Doc Talk,” said Dr. Mukul Parikh, president of the Society.

Saturday March 5, DCMS members gathered at the Giant Center to cheer on the Hershey Bears against in-state rivals, the Wilkes-Barre Scranton Penguins. Over 45 DCMS members, residents and their guests came together to network and socialize. The Bears ended the game with a win, topping the Pens 6-2. We appreciate everyone who came out to enjoy a night of comradery and to support the team.

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DCMS News

Dauphin County Medical Society Alliance QUARTERLY N EWS DCMSA MISSION The DCMSA is organized exclusively for charitable and educational purposes.

To further these objectives, we are involved in:

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/

Upcoming Count y Events ( County

1. Improving community health 2. Supporting medical education 3. Engaging in charitable activities and contributing to charitable organizations on behalf of the medical profession.

• Hospital Auxiliaries • Association of Family & Friends of Penn State (AFF)

• 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/

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• Monthly Getting to Know You Lunches • Fall Coffee

Holy Spirit Auxiliary Events

Spring Festival

Adams Ricci Park May 21, 2016

Ongoing Volunteer “Hands-On” Opportunities:

Level)

Dates to be announced

Membership Event

Jewelry Sale

Holy Spirit Hospital August 30-31, 2016

September 8, 2016

Community Outreach As a result of various contributions and monetary donations, the hard work of the members of the Dauphin County Medical Society Alliance has significantly improved the lives of a considerable number of individuals living in the Dauphin County area.

Much of the money raised by the members of the Dauphin County Medical Society Alliance is returned to the community to support non-profits who serve people experiencing a variety of difficulties. For years, we have helped the Penn National Racetrack Medical Clinic by supplying them with health supplies and personal care articles. This year, we also provided over the counter medications to the Bethesda Mission Medical Clinic and packed healthy snack bags for participants in their Youth Program. In addition, items were donated to support the Mission’s Mobile Unit, which services the homeless population living on the streets of Harrisburg. The homeless were also assisted by donating bottled water and volunteering for “Project Homeless Connect” at the Farm Show. Beacon Clinic is being supported this spring with a financial donation to a fund to help pay for prescription medicine for their uninsured patients.

DCMSA helped children who were entering the Foster Care system by purchasing duffle bags, and boxes of disposable diapers were bought for babies whose families were unable to afford them. Toilet articles were given to an organization which serves families who have recently lost their homes. Also, canned goods, along with a financial donation to support the Central PA Food Bank, will help to provide hundreds of meals to those in need. If you are interested in assisting any of these programs please contact us for more information.