Lehigh County Health & Medicine Summer 2023

About Tick Time

UNDERSTANDING LYME DISEASE

BLACK MEN IN WHITE COATS

OSTEOPOROSIS: THE SILENT DISEASE

2022 HUMANENESS IN MEDICINE AWARD

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Hidden

LEHIGH COUNTY MEDICAL SOCIETY

P.O. Box 8, East Texas, PA 18046 610-437-2288 | lcmedsoc.org

2022-23 LCMS BOARD OF DIRECTORS

Rajender S. Totlani, MD President

Oscar A. Morffi, MD Treasurer

Charles J. Scagliotti, MD, FACS Secretary

William Tuffiash Immediate Past President

CENSORS

Howard E. Hudson, Jr., MD

Edward F. Guarino, MD

TRUSTEES

Wayne E. Dubov, MD

Kenneth J. Toff, DO EDITOR

David Griffiths

Executive Officer

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 Lehigh 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.

Well, the weather is getting warmer, so summer is here. This issue covers a range of topics, from Osteoporosis, information on Lyme disease and the transition of care. We hope you will read about our annual Humaneness in Medicine recipient. We also discuss the American Medical Women’s Association and Physician advocacy.

“The Domino Effect of Physician Advocacy” offers an interesting view on advocacy between physicians and policy makers. We are reminded that physician advocates have tremendous potential to have a significant impact on any health care policy. But we learn about the many things, good and bad, to think about in this process.

Are you familiar with The American Medical Women’s Association (AMWA)? Learn about its beginnings in 1915, and their journey to today.

Most of you are familiar with Osteoporosis, but how much do you know about it? Read “Osteoporosis: The Silent Disease” to learn more about it, how it affects the quality of life, how it can be diagnosed, and about treatments.

For several years Lehigh County Medical Society has chosen a recipient of their Humaneness in Medicine award from nominations of local residents or fellows. This award is presented to who has best displayed the Lehigh County Medical Society’s ideals of outstanding compassion in the delivery of care, respect for patients, their families, and healthcare colleagues, as well as demonstrated clinical excellence. Read the article to learn about this year’s recipient.

We hope you read “Transitions of Care.” Many of us have experienced transition of care either ourselves or through a family member. They are challenging times. Learn more about what can be done to help get better results for the patient’s care.

As we head outside in these warmer months, a great article to read is “About Tick Time.” Since our winter was warmer than usual, the bugs are more prevalent this year. Read on to learn all you need to know about Lyme disease.

We hope that you enjoy the magazine and find it both educational and relevant to your interests. If you wish to see past issues, they can be found at https://lcmedsoc.org/ our-publication. Thank you for reading.

GENERAL MEMBERSHIP MEETING

with 2.0 CME*

September 19, 2023

Homewood Suites

3350 Center Valley Parkway, Center Valley, PA 18034

*This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Pennsylvania Medical Society and Lehigh County Medical Society. The Pennsylvania Medical Society is accredited by the ACCME to provide continuing medical education for physicians. The Pennsylvania Medical Society designates this Live Activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The Domino Effect of Physician Advocacy

LARRY LIGHT SENIOR EXECUTIVE OF THE PENNSYLVANIA MEDICAL SOCIETY

The domino effect of physician advocacy is somewhat nuanced. Certainly there are exceptions, for example tort reform, but in many cases the end goal of physician advocacy is to protect the clinical ability to treat patients and improve health outcomes. Holding an unrestricted license to practice medicine, physicians don’t need to advocate for an expansion of their scope of practice. Filling their waiting rooms with more patients isn’t often the priority, especially in times of well publicized physician shortages. As a result, the goals of advocacy campaigns to reform insurers’ prior authorization restrictions, reduce the cost of prescription drugs, promote the availability of telemedicine services, ban smoking in public places and a host of other policy initiatives are far more altruistic.

Particularly in health care the “domino effect” can be surprisingly impactful. An example from health care, although not related directly to physicians, would be American Association of Retired Persons (AARP) advocacy for the $35 cap on insulin prices for Medicare patients. The AARP victory resulted in a projected savings of $25 billion in out of pocket costs for seniors. In addition, a result of the 2022 prescription drug law and subsequent positive actions taken by drug companies, is that savings will be extended to the much broader community of patients through reduced drug prices. There will also be savings for taxpayers and hospitals as the lower insulin costs and broader reduction in prescription drug costs lead to improved health care for patients. The out of pocket dollar savings are dramatic but the domino effect savings are just as real. Also quickly evident will be the positive changes for physicians who are clinically helping patients to manage their care as the domino effect takes hold. AARP engaged in advocacy to achieve an important win for their members and along with other advocates accomplished much more.

The real challenge of physician advocacy is how to do it successfully, and that challenge is significant. In many cases negative consequences are self-inflicted. Physicians can be especially prone to advocate with an approach of telling policy makers what actions and changes must be undertaken. At all levels of the political universe, especially in situations with strongly divergent partisan forces, demands for change that might seem obvious to the advocate are really not politically practical. The politicians have to consider a broad spectrum of factors, including funding concerns, how the change will be interpreted and implemented and how the action might affect other interests. The aggressive advocate is often just focused on what must, in their eyes, be accomplished to solve their problem.

Another factor that makes physician advocacy challenging is the broad scope of issues that can clutter the advocates’ agenda. Clinical issues should always be a priority, but sometimes those can be pushed aside by a concentration on social issues that while appropriate have the effect of diluting the

advocacy message. And from the clinical perspective, different messages and demands from the crowded field of medical specialties can make it difficult for policy makers to prioritize the viable issues. In those instances the dilution of physician advocacy messaging often leads to the relevant issues being set aside for further study.

A very important factor is that physician advocates cannot participate in health care policy discussions without bumping into the very aggressive and well funded advocacy campaigns of other stakeholders. For starters there is no requirement that the wide array of health care providers will have any level of unanimity on any and all issues. All sorts of factors come into play, including how an allied health profession may or may not be impacted by the issue and even how they want to strategically engage relative to a possible scope of practice confrontation with the physician community.

But in health care policy discussion, physicians and other providers are just some of the relevant stakeholders. Policy makers can expect to hear from disease specific interest groups, the AARP and a wide range of groups created primarily for focused but high profile advocacy activities. In addition, trial lawyers, hospitals and health systems, health insurers, nursing homes, pharmaceutical companies and a whole host of other special interests crowd into health care policy debates. Their advocacy campaigns are always well funded and always aggressive. And many competing advocates have what might seem a minor advantage in that they don’t have to juggle their advocacy work with patient appointments. Hospital leaders are paid to engage on behalf of their employer.

From a more positive perspective, within the very wide and fairly crowded spectrum of health care advocacy there is a special respect among policy makers for the potential that can be reached by physician advocates. Whether it is encouraging support for a political candidate on election day or supporting passage or defeat of legislation, physician advocacy has several positive predictors of success.

Physician advocates begin their engagement on an issue with some built in advantages. It’s a given that they are well educated, both generally and especially with respect to their profession. Sometimes a reminder is necessary, but it is accepted that their education and training outpaces any other health care provider. In many situations, physicians and physician advocacy organizations then find strong allies among other provider groups.

Successful physician advocacy highlights the sanctity and intensity of the patient-physician relationship and then promotes it as an unbreakable bond. Contemporary health care provider organizations and lobbyists have learned to follow the same tact in regard to policy issues. The patient-centric focus serves as a foundation for not only physician advocacy, but across the health care policy spectrum for the strong allies who contribute to health care policy discussion.

Policy makers are particularly responsive to the clinical focus that physicians can insert into policy debates. Many of the health care issues on the policy docket present the opportunity for consideration of a clinical aspect. The obvious advantage is that this is foreign territory for most legislators and reporters. While they can certainly obtain relevant information online or from other health care providers, the physician advocate perspective gains credibility. Like every episode of the hit television series MASH, relating the issue to a clinical procedure or diagnosis serves to enhance the policy discussion.

It is a given that physician advocates always have tremendous potential to have a significant impact in any health care policy discussion. You won’t win every vote, pass every bill or even get every amendment adopted. But everyone in the discussion will realize the importance of your engagement in the political process.

Larry Light is a retired lobbyist and Senior Executive of the Pennsylvania Medical Society.

tales from an anesthesiologist

HOWARD E. HUDSON, JR., MD

Iam a retired Anesthesiologist from Lehigh Valley Health Network who shared an experience with the Northampton Chapter of the American Wine Society (March 2023). As a beginning Anesthesia resident at the University of Pennsylvania, I attended the national convention in San Francisco in September 1969. The keynote speaker was Robert Dripps, MD. The topic of his speech was “The Importance of Serendipity in Patient Outcomes.” Three years later I would experience how important. In my third year of residency, I was working in a lab with no call, no weekend duty and no holiday call (life was good, I could finally catch up on lost sleep).

I took a 24 hr. call in the emergency room of the Delaware Hospital in Wilmington, Delaware. In early September on a Saturday, I parked in the hospital lot and walked into the emergency room. The clerk of the ER greeted me with “We are getting a child from down state...in “status epilepticus.” I asked the clerk to page the pediatric resident. In minutes the pediatric resident arrived and asked are the parents with the child? Do we have a contact number? He got the parents and a good tentative diagnosis. The parents were from Central America and spoke no English, but the pediatric resident was Spanish. He next called the hospital librarian and requested the most up to date treatment for lead toxicity, both drugs and dosage. Next he called the pharmacist and requested the pediatric size and dose of chelater and diuretic.

The child arrived and was seizing. I gave oxygen and when the seizure stopped, I started the appropriate size jelco. When the next seizure started, the pediatric resident produced a syringe of amital and began to titrate the amital through the IV. The seizure stopped. I asked the resident to count respirations and he replied zero. I gave three breaths and inserted the appropriate size endo-tracheal tube. The assembled group took the child and equipment through the hallway and up the elevator to the pediatric ICU.

When the ER became quiet in the afternoon, I asked the clerk how to get to the pediatric ICU. To my astonishment the little boy, who arrived in “status epilepticus,” was pushing his IV pole, walking to all the other childrens’ beds and handing out toys and huggies, talking up a storm. This little guy invented the job description of Play-Lady decades before smart adults did.

So why were three NC members of the AWS interested ? All three chemists are working on Pennsylvania State safety and health standards for the fifty-thousand PA employees who work with heavy metals daily. In 1969 a group of complete strangers came together to treat acute lead toxicity (in the only hospital available to that child). In 2023 three Northampton chemists are working on safety and health standards to protect the 50,000 PA employees who work with heavy metals daily. Was the Delaware Hospital event part of my “learning curve” or “serendipity”? Let archivists and historians decide!

Foundation Partners with WellSpan to bring

BMWC Youth Summit to Fruition

Changing the vernacular from “I want to be …” to “I am going to be …” is a first step on a journey of becoming a physician according to WellSpan Vice President and CMO, Women & Children, Carlos Roberts, MD, at a summit to guide and inspire diverse high school students toward a future profession in medicine.

Foundation of the Pennsylvania Medical Society shared in an exciting partnership with WellSpan Health to bring a Black Men in White Coats Youth Summit to William Penn High School, York, in March.

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PHOTOS BY SELA FUHRMAN, WELLSPAN HEALTH

“It was an exceptional day.  We filled a room with physicians and healthcare professionals from historically underrepresented groups so that students holding those same racial and ethnicity identities could be inspired to consider a career in medicine,” says Karla Tolan, manager, Diversity, Equity, and Inclusion for WellSpan Health. “More than 150 students, parents and caregivers, and 77 volunteers, participated in WellSpan’s inaugural event, a fantastic turnout for the first year!”

The genesis of the Black Men in White Coats campaign started in 2013 with the aim of increasing the number of black men pursuing careers in the medical industry. This initiative was founded by Dr. Dale Okorodudu in response to an AAMC report highlighting the decreasing number of black male applicants to medical school.  The summits invite students, parents, educators, clinicians, and community leaders together to “uplift our communities. The goal of the summits is to inspire our youth to consider careers in healthcare while laying the foundation for success via mentorship and networking,” according to its website.

Foundation of the Pennsylvania Medical Society Executive Director Heather Wilson says that establishing a support system to strengthen the diversity of physicians is a goal of the non-profit’s scholarship programs.  “We strive to gain more students who authentically look, speak, and understand the communities they will serve,” she says.  In the last five years, the foundation added additional scholarships to advance the commitment to include more diverse cultural composition of the medical school student body.

“Registrants for the day-long healthcare career exploration program represented 50 different high schools and seven states –some rising early to travel together by bus to hear from WellSpan’s expert physicians and medical professionals, who live and work in the region and represent racially diverse identities and lived experiences, through keynote presentations, Q&A panels, and breakout sessions,” says Tolan.  “One

physician told us that the first time he saw another black doctor was in medical school, so this shortens that timeline exceptionally for many kids.”

Keynote speaker Russell Ledet, MD, PhD, MBA, Indiana University School of Medicine Triple Board Resident Pediatrics/ Psychiatry/Child Psychiatry, entered the stage with a white coat, basketball sneakers and a baseball hat. His indelible stage presence served to encourage students. He said that even though he came from humble beginnings, his hard work, mentorship, and passion launched him into a successful medical career. When he realized what he was capable of he pursued it. Currently he has

eight letters behind his name emblazoned on his white coat.

Breakout session facilitator Raymond C. Truex, Jr., MD, FACS, FAANS, medical director, Physicians’ Health Program, Foundation of the Pennsylvania Medical Society, volunteered to participate in breakout segments on bleeding control and mental health self-care, for practical student experiences during the day.  “The students heard in the summit that the pursuit of medicine is challenging on all levels. Although they can achieve their goals, it is not without a great deal of discipline and hard work.”

Dr. Truex says the students were counseled on the importance of caring for themselves and recognizing stress indicators in their friends and classmates.  They learned about resources and how students can find help. “Medicine is a shared experience and mentors are here to help each and every one of these attendees,” he says.

Foundation Board Member Lynda Thomas-Mabine, MD, FCPP, Division Chief of Gynecology at Chestnut Hill Hospital and Section Chief for Robotic Surgery at Temple Health, travelled from Philadelphia accompanied by members of Medical Society of Eastern Pennsylvania to participate in this historic summit.

Dr. Thomas-Mabine said, “The successful event can be replicated in other areas to harness the momentum and provide shadowing opportunities.  We have brought together these role models to mentor these bright students so that they can envision a successful career in medicine.”

Tolan agrees. “It was a great day that culminated in a call and response. The kids roared into the chant, ‘I can do anything! I can pursue anything!’”

The mission of the Foundation of the Pennsylvania Medical Society is to provide programs and services for individual physicians and others that improve the well-being of Pennsylvanians and sustain the future of medicine.

The genesis of the Black Men in White Coats campaign started in 2013 with the aim of increasing the number of black men pursuing careers in the medical industry.

the American Medical Women’s Association

The American Medical Women’s Association (AMWA) is the oldest, national multi-specialty association for women in medicine. It was founded in 1915 by Dr. Bertha Van Hoosen at a time when women physicians numbered less than 6% of the physician population. From the outset, some questioned the need for a separate organization for women, but when World War I broke out and women physicians were turned away for service by the U.S. military, AMWA became a platform for the unified voice of women physicians. This work laid the foundation for the American Women’s Hospitals Service (AWHS), AMWA’s longest lasting program. AWHS began as humanitarian relief efforts in the war-ravaged areas of Europe and has continued since to provide aid most recently through raising funds for Ukraine, Pakistan, and Turkey relief efforts. Learn more about the founding of

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AMWA Meeting 1936

AWHS through the short documentary, At Home and Over There, American Women Physicians in WWI.

Over the next few decades, AMWA would grow as an organization and advocate for equitable opportunities for women in medicine. Because many hospitals would not take on women for post-graduate practice, AMWA’ published lists of female-friendly programs. AMWA also worked to improve women’s health, including support of the 1921 Sheppard Towner Act that would lay the foundation for maternal and prenatal care programs which still exist to this day.

Throughout this time, AMWA’s mission was to advance women in medicine and improve women’s health. As such, AMWA played a key role in the 1990s in promoting women’s health as a specialty and ensuring the integration of women’s health education within medical school curricula. In more recent years, this focus has broadened to encourage an approach to medical care within a sex and gender lens.

With the increasing numbers of women entering the medical profession, now

comprising just over 50% of matriculating students, one might assume that the work of AMWA is finished. But in fact, organizations like AMWA are needed more than ever before.

Take leadership. For over two decades, there has not been significant change in the leadership gender gap within the top tiers of academic medicine. Likewise, women attain less than 30% of the top positions in healthcare leadership overall, and the number of women from underrepresented groups is far lower. There is still much to be done to address pay disparities, gender and sexual harassment, implicit bias, and occupational gender segregation.

AMWA’s goal is to support women in medicine at every stage of their career, by providing mentorship, sponsorship, advocacy, education, and mentoring. In addition, AMWA works with a broad coalition of strategic partners ranging from academic institutions, government agencies, industry, and media—with a goal of uniting women physician leaders across all sectors. AMWA’s current initiatives have also expanded to include public health

campaigns against gun violence, human trafficking, opioid addiction, nutrition, and obesity prevention—in addition to our signature leadership development programs, AMWA Elevate and AMWA Evolve, and our longstanding work in gender equity.

As an association within the Medical Women’s International Association (MWIA), AMWA promotes awareness of global health issues. During the COVID-19 pandemic, AMWA hosted a series of webinars bringing together women physicians from around the globe to discuss strategies for COVID-19 mitigation and prevention. AMWA membership confers membership in MWIA and access to a global network of professional colleagues.

For over a century, AMWA has been the vision and voice of women in medicine. We work at the forefront of women’s health, reproductive rights, sex and gender specific medicine, and women’s leadership, equity, and advancement. A growing portion of our membership also includes our allies in this work—and as such, membership is open to all genders.

Learn more at amwa-doc.org.

AMWA Hosts the 100th Anniversary Congress of the Medical Women’s International Association

About Tick Time

UNDERSTANDING LYME DISEASE

RUTH SMITH COMMUNICABLE DISEASE INVESTIGATOR ALLENTOWN HEALTH BUREAU

As the weather changes and temperature and humidity levels rise, chances of outdoor encounters with the small parasitic arachnids we know as ticks increase as well. Lyme disease is one of the most common vector-borne diseases in the northeast region of the country and although its reach has expanded and has been reported across all states, its incidence decreases in the southeastern regions due in part to tick density and environmental conditions but mostly due to variable tick-host associations with the shifting of availability and selection of an efficient reservoir host for the tick.

The bacterium that causes Lyme infection in the US, the pathogenic spirochete Borrelia burgdorferi, gets transferred from an infected wildlife host, generally a rodent like the white-footed mouse, to a blacklegged tick: Ixodes scapularis in the northeastern, mid-Atlantic, and north-central areas, commonly known as deer tick; or Ixodes pacificus in all areas west of the Rocky

Mountains. Once inside the tick, Borrelia can be found dormant in the midgut, eventually migrating to the tick’s salivary glands where it gets passed on to humans after a bite and subsequent feeding occurs. In order for any Lyme bacteria to be transmitted, an infected tick needs to remain attached to the host for quite some time. According to CDC, at least 36 to 48 hours of attachment are needed for a tick to be able to transfer the bacteria that causes Lyme disease (Borrelia mayonii has also been found to cause Lyme but rarely).

The immature form of the tick, called a nymph, is responsible for the majority of bites and since at this stage it is only about 1mm, the size of a poppy seed or a pin head, the bite is rather painless and most likely to go unnoticed. Many people do not realize they are infected until symptoms start showing.

One manifestation of infection observed in about 70-80% of people within 3 to 30 days after a tick bite is an erythema migrans

rash. While most people are familiar with the well-known guideline of recognizing its bull’s eye appearance; the rash could be quite variable in size, location, and shape, and not everyone with an active infection will develop a rash. Flu-like symptoms such as fever, chills, fatigue, headache, muscle and joint aches, and swollen lymph nodes may appear as well regardless of the presence or absence of a rash. Nonetheless, as the majority of Lyme symptoms are also common in many other infections, people can often be undiagnosed or misdiagnosed with other conditions. When this infection is not treated accordingly, there may be subsequent damage to joints, nervous system, and heart. In such cases, treatment may vary depending on the severity and manifestation of the infection in the affected tissues.

In the majority of cases, Lyme infection can be cured with oral antibiotic treatment, generally doxycycline, during a number

Continued on page 14

of days or weeks depending on symptom manifestations. However, there seems to be a measure of medical controversy on the standards of care, particularly in late diagnosis of Lyme disease, as two divergent approaches from different medical societies are available that could prove confusing or frustrating to patients when they are seeking treatment. In summary, one approach considers shorter treatment with antibiotics and preventive strategies for the patient to be effective with not much emphasis on persistent infections or chronic conditions associated. The other approach recommends longer antibiotic treatment and supports retreating in appropriate clinical situations. These divergent guidelines are mainly based on different interpretations after revaluation of clinical trials results and risk-benefit assessments.

Since Lyme disease could be considered a multistage and multisystem infection, it may be somewhat difficult to diagnose in a timely manner. Isolated serological testing cannot accurately determine the difference between an active infection or a previously treated one because it is measuring antibodies present in blood. Additionally, since antibodies may take a couple of weeks to develop, those with very recent infections may not get a positive result if testing is performed too early. The gold standard remains a 2-tier testing algorithm that involves two immunoassay protocols; modified versions of the same 2-step testing practice have become available in recent years and higher sensitivity during early infection has been observed which is key to achieve a more accurate interpretation of results and a better approach to patient care.

Several factors are important for providers to consider when making an assessment for Lyme infection: signs and symptoms, the history and probability of exposure to an infected blacklegged tick which is determined by the area of residence, the possibility of other infections that may share similar symptoms, and the serological test results if indicated when there is clinical and epidemiological support for a diagnosis and when performed at appropriate times after infection or in case of observation of additional manifestations of disseminated disease.

It is important to also note that some people may still experience symptoms like pain or swelling of joints, insomnia, fatigue, depression, and some cognitive dysfunction that could last several months after they have completed treatment. While there is controversy about the possible cause of this symptom persistence, either lingering bacteria or an auto-immune response, and how close, or if at all, it is related to the initial infection; it is not exactly known why some people develop it and some do not, but it has been observed in as many as 20% of patients after treatment and it is referred to as post-treatment Lyme disease syndrome.

While the only Lyme vaccine available was discontinued in 2002 due to insufficient demand, increasing number of cases and public awareness have prompted more recent efforts for projects of new vaccines, currently at different stages of development. One vaccine is focused on directly delivering a monoclonal antibody to convey immunity quickly; another one on inducing the creation of multiple antibodies to block specific proteins of the bacteria, preventing it from leaving the tick when it bites a human. A different type of vaccine aims to cause an immune response with a noticeable reaction on the site of a bite that would prevent transmission of any bacteria by interfering with proper tick attachment. These are all promising yet still years down the road as trials are ongoing.

Although only the blacklegged tick, or deer tick, is responsible for transmission of Lyme bacteria to humans, other species of ticks may carry other infectious agents. Reducing chances of tick encounters and tick bites is always the best practice especially during the warmer months; wearing bright colored clothing when spending time outdoors to facilitate tick spotting, tucking in shirts and pants when able, spraying EPA-registered repellent on clothing, shoes, and gear before hiking excursions, laundering of clothing worn outdoors with hot water and drying in high heat afterwards, and performing a thorough body check all around yourself, children and dogs when back indoors; even though dog ticks are different than deer ticks

and do not transmit Lyme bacteria, they can carry many other tickborne pathogens. Prompt removal of any tick within the first 24 hours is important in decreasing any chances of infection. If an attached tick is found, it is recommended to use fine tweezers to steadily and slowly pull the tick straight up without twisting, thoroughly cleaning with rubbing alcohol, or soap and water, and carefully disposing of the tick by taping it or placing it in a sealed bag. Taking a picture of the tick may be helpful for identification, and while there are available centers offering testing of ticks for pathogens, most scientific organizations find several issues associated with this practice and do not consider the results to have definitive evidence or benefit for the treatment of patients.

Remember not all ticks carry the bacteria responsible for Lyme disease and not all ticks carrying the bacteria will be able to transmit it to humans. Testing of patients that do not show symptoms that are typical of Lyme disease, or whose risk of exposure is low, is not encouraged. As important it is to properly diagnose someone who has Lyme disease, it is equally important to avoid misdiagnosis and treatment of someone who may be suffering from a different condition with similar symptoms.

Even though some recommendations and treatment guidelines available regarding Lyme disease may seem conflicting at first glance, research keeps allowing better tools for clinicians to be developed, testing sensitivity continues to be improved, and ultimately it comes to the importance of effective and trusted communication between a skilled provider and the patient, the value of the use of clinical judgement when some evidence may seem uncertain, the need for individualized patient-centered care and the role of patient medical preferences while making decisions concerning their

Transitions of Care

The delivery of health care continues to evolve. Unless critically ill, today’s patients usually do not experience extended hospital stays and there are often multiple providers taking care of them. Both of these trends have given rise to an increased focus on transitions of care (TOC): movement from one level of care to another, among multiple health care team members, and across settings, such as hospitals to homes.

“In much of the nation, the model of one primary care physician tending to his or her patients throughout their entire stay in the hospital as well as managing all of their outpatient medical needs has evolved,” says Joseph Habig II, MD, Medical Director at Valley Preferred, the provider organization associated with Lehigh Valley Health Network. “Medicine today is complex and specialized. Admitted patients are seen and cared for by hospitalists. Patients are discharged, often while still in the recovery phase of their illness and are cared for in the ambulatory setting. The concept of ‘shared’ or ‘collaborative

care’ and a team-based approach with other providers requires efficient, effective communication and reliable transitions of care.”

SYSTEMIC CHANGE CREATES NEW CHALLENGES

A few illustrative examples of potentially complex transitions include going from the operating room to the ICU, the emergency department to a specialist, or hospital to their home. Patients and their caregivers may be anxious or overwhelmed, they may not understand what they need to do or to expect, they may be confused about their medications, or not know how to address their needs. Poorly executed care transitions can lead to adverse events, reduced quality of life, unneeded use of resources, and unnecessary or necessary readmissions.

In fact, on average, TOCs harbor a 1 in 5 chance of readmission to the hospital or a visit to the emergency department. (2) Readmissions are potentially drivers of cost and inefficiency and can affect clinical outcomes positively or negatively depending on how they are managed. Therefore, readmissions are used by insurers and health care institutions to measure transitions of care. Most use 7 or 30 days and many insurers, including Medicare, charge penalties for

patient readmissions of 30 days or under. For those occurring under 30 days, there can be incentives.

It means that TOCs impact everything from patient well-being to insurance reimbursement and health care organization reputation. These factors have put the spotlight on TOCs as areas that need attention and improvement.

STARTING OFF ON THE RIGHT FOOT

One of the most logical and valuable ways to reduce readmissions – and therefore improve transitions – has been found in the role of the primary care physician (PCP). Readmission reduction associated with in‐person physician visits (compared to none) was seen early after discharge, with 67.8 fewer readmissions per 1,000 discharges if physician visit occurred within 7 days, and 110.0 fewer readmissions for those seen within 21 days. (3) It’s just a fact: The PCP knows the patient and their family better than anyone and can notice if something is awry.

“For patients on Medicare, PCPs must wait to bill for their follow-up services

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“$26 BILLION IS SPENT ON POOR TRANSITIONS OF ACUTE CARE MEDICARE PATIENTS PER YEAR.”(1)

HOW TEAMWORK AND COMMUNICATION SMOOTH THE JOURNEY

MARK WENDLING, MD PRIMARY CARE PHYSICIAN AND EXECUTIVE DIRECTOR, VALLEY PREFERRED

until 30 days after discharge with the goal of reducing the chance of readmission,” says Dr. Habig. “PCPs are also encouraged to follow up after a patient visits the emergency department (ED) to assist with resolution of the medical problem and reduce the need for repeat ED visits and possible admission. There is also emphasis on reducing unnecessary ED visits. Many problems can be safely handled in the PCP office, which can be better for the patient and less expensive than an ED visit.”

To make sure this timeframe is met, some hospitals have instituted “discharge teams,” to assist in the discharge and transition process. The staff on these teams will make an appointment with a patient’s PCP for them, having direct access to physicians’ schedules. They’ll also help navigate the transition. “Bridge” or transition clinics are ready so that if a patient doesn’t have a PCP or the PCP is not available, the patient will be able to see a doctor within that 7-day window.

TEAMWORK IS THE NORM

Even when patients can see a PCP, there are additional considerations that have an impact on TOCs. Organizations have had to rethink their workflows, their personnel, and their very structures. Much of this transition management is covered by care coordination teams when providers or health systems have them in place. These teams assist in a wide variety of areas including behavioral health referrals, pharmacy consultation, and social work. Once patients are back home, care coordination assists with home care and visiting nurses or whatever else the patient needs to continue following their doctor’s care plan.

The importance of this coordination is illustrated in the study, “Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too,” from the January 2022 issue of The Joint Commission Journal on Quality and Patient Safety. (4) Researchers collected data on nearly 8,000 patients across 42 participating hospitals to evaluate the association of different combinations of

TOC strategies with patient-reported and post-discharge outcomes.

The group “hospital-based trust, plain language, and coordination” was the only group associated with lower 30-day rehospitalizations and emergency department visits within 7 days, among all the patients studied. This group encompassed the following TOC strategies:

• Communicating in plain language that patients can understand.

• Treating patients compassionately, as people, and building trust with the patient.

• Having a designated person responsible for conducting medication reconciliation and clarifying the medication list with outside sources when needed.

• Ensuring clinician access and conducting a post-discharge follow-up to reinforce education.

• Identifying high-risk patients (medical, behavioral, and social) and initiating intervention if appropriate.

• Creating a transition summary document containing key information for family caregivers.

Making certain patients and their families (i.e., multiple listeners) were engaged in the transition was an important key to success in the study. That’s why clear communication from patients and caregivers as well as from providers is the first strategy listed above.

COMMUNICATION ESSENTIALS

Many sources agree that the hallmark of successful transitions of care is good communication. Part of that involves technology and the ability of providers and facilities to “talk” to each other via an electronic medical records system (EMR). These systems ensure that all those involved with the care of a certain patient are connected and can share medical information, which increases efficiency, accuracy, and timeliness.

The information caregivers need for TOCs has to be specific and up to date. They need everything from descriptions of remarkable hospital events; written orders for medications, treatments, activity level and diet; recent and pending laboratory test results; and accurate descriptions of functional and cognitive status to pertinent social information such as preferences and unique needs. (5) The National Transitions of Care Coalition has identified various opportunities to use communication as a tool for conveying this important information. Here is some of what the coalition reported:

Communication surrounding medication. Strategies to ensure safety in this area include:

• “Teaching back” to be certain that there is a clear understanding of the medication plan by all involved.

• Reviewing each medication with the patient and caregiver, explaining purpose, how to take it, and side effects to watch for, so there is a more in-depth understanding.

• Creating a medication management plan in cooperation with the pharmacist that covers how to get the medications.

Communication can be optimized with planning. This is made possible through the guidance of an experienced navigator or care coordination team. These items are part of that step:

• Standardized transition documentation.

• Assessment of the home environment and social determinants of health.

• Patient and family education, including self-care and expectations in simple language.

• Counseling of the patient and their family so they can participate in care decisions.

• Explanation of “red flags” and what to do about them.

• Communication to ensure follow-up care. This includes knowing how to obtain timely access to providers. To improve transitional success, this should involve:

• Scheduling and confirmation of appointments including a PCP visit within a 7-day period, and sometimes sooner depending on the risk of the patient being readmitted.

• An RN follow-up call immediately post-discharge to monitor the patient’s condition.

• Access to a 24-7 help line.

• Frequent contact to help detect subtle changes in patients’ conditions and quick reactions to changing medical and psycho-social problems.

PART OF VALUE-BASED CARE

In 2022, the Centers for Medicare & Medicaid Services introduced the Star Rating measure to promote better care coordination during care transitions. While this is critical for Medicare patients, it’s necessary for all patients to be able to recover and thrive even as health care models and organizations change to adapt to the times.

“Hospital care is very expensive for the patient and patients do better when they can finish recovery at home while working with their PCP,” says Dr. Habig. “The framework for value-based care – looking at health outcomes rather than how many times a patient visits the doctor – is seated in more ambulatory care when patients can be effectively and safely discharged. To make the entire process successful, you need excellent communication and attentive teams to facilitate a safe and satisfactory TOC.”

SOURCES

(1) https://transitionsofcare.org/

(2) https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791965

(3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232431/#:~:text=In%E2%80%90person%20physician%20visit%20that,any%20 physician%3B%20full%20sample)

(4) https://www.jointcommission.org/resources/news-and-multimedia/ blogs/improvement-insights/2022/01/effective-care-transition-strategies-reduce-burden-on-patients-families-and-caregivers/#.ZDa1qnbMKUl

(5) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714367/

OTHER SOURCES

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/ measure1.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5656252/

2022

HUMANENESS IN MEDICINE AWARD from LEHIGH

COUNTY MEDICAL SOCIETY

LEHIGH VALLEY HEALTH SYSTEM MEDICAL RESIDENT MICHAEL BRACCIA, D.O., TO RECEIVE LEHIGH COUNTY MEDICAL SOCIETY’S

2022 HUMANENESS IN MEDICINE AWARD

Every year, the Lehigh County Medical Society (LCMS) presents its Humaneness in Medicine Award to one or more Lehigh County medical residents or fellows who have best displayed the ideals of outstanding compassion in the delivery of care, respect for patients, their families, and health care colleagues, as well as demonstrated clinical excellence. LCMS is proud to announce that Michael Braccia, D.O., has been selected as the 2022 Humaneness Award recipient.

Dr. Braccia is a resident in Internal Medicine at the Lehigh Valley Health Network. He is known for his compassionate and caring approach to patient care. An example of his dedication to and compassion for his patients is a story of his approach to a nonverbal patient with

cerebral palsy. In addition to noticing an acute process underlying the patient’s admission, Dr. Braccia also personally found time to care for the patient’s hygiene and provided help to the nursing staff.

As noted in his nomination letter, Dr. Braccia has a philosophy of “going above and beyond, and taking ownership” of patients even when it came to issues outside of medical care. He exhibited this when establishing a relationship and convincing a long-time IV drug user with empyema to stay so that he could check his chest tube and provide treatment.

LCMS is proud to have Dr. Braccia as the recipient of this important award.

Located in Allentown, PA, LCMS represents physicians of all specialties on local issues. In coordination with the Pennsylvania Medical Society, LCMS also works to address health issues at the state capitol.

The Silent Disease

Osteoporosis

HEALTH

According to the Bone Health and Osteoporosis Foundation, over 54 million Americans have been diagnosed with osteoporosis or low bone density also known as osteopenia which increases one’s risk for fracture. Why is osteoporosis known to be a silent disease? Many people do not know they have osteoporosis until after they fracture which leads to further increased risk for subsequent fractures in addition to disability from chronic pain or complications from the fracture(s). Osteoporotic fractures most commonly occur from a fall, but depending on how fragile your bones are, you can fracture from sneezing, coughing, or simply stepping off the curb. It is a fragility fracture that is a red flag one may have osteoporosis and should be screened to prevent future fractures, disability, and death.

Continued on page 20

MARIE SPEVAK O'BRIEN, DO MHA RHEUMATOLOGIST AND

SYSTEMS DOMAIN LEAD FOR USF MORSANI COLLEGE OF MEDICINE

Quality of life is greatly reduced in patients with fragility fractures. Many patients hospitalized with osteoporotic fractures do not get discharged back to their homes but are transferred to a rehabilitation center or a nursing care facility for further recovery or permanent residence. Up to twenty percent of hip fractures result in death in one year because of complications from the fracture, or surgical repair of the fracture, increased immobility, decreased ability to perform activities of daily living, higher risk for subsequent falls, or even worse, they develop another fracture. According to the Bone Health and Osteoporosis foundation over 740,000 people lose their lives to hip fractures each year. As a result of the COVID-19 pandemic, identification and management of osteoporosis has been severely affected with further delays in patients getting diagnosed and treated appropriately.

Osteoporosis occurs more commonly in women than men and risk for osteoporosis increases with age. One out of two women and one out of four men over the age of 50 will break a bone due to osteoporosis. This disease causes about two million broken bones annually. Osteoporosis can occur in any race and is more common in whites and Asians. In women, osteoporosis risk increases the first five to seven years after menopause. It is important for women to be screened after menopause and men and women need to be screened if they

have significant risk factors or have had a fragility fracture.

It is important to know the risk factors for osteoporosis. Family history is a strong risk factor such as a parent with a history of a hip or fragility fracture. Certain chronic medications are also a risk factor including warfarin, steroids, anti-seizure, or certain psychiatric medications. Reflux medications such as proton pump inhibitors affect absorption and have also been associated with low bone density. Smoking, increased alcohol use, low body mass index, conditions that affect absorption such as inflammatory bowel disease or celiac, and immobility are also significant risk factors as well. It is important for your primary care doctor to screen everyone over the age of 50 for osteoporosis in those patients with secondary risk factors.

As a rheumatologist, assessing bone health is a key component of all our patients visits. Many of the diseases we treat or care for affects bone density. For example, active rheumatoid arthritis accelerates bone loss and commonly steroids are used to treat flares of different autoimmune or inflammatory diseases which also affects bone density. We treat many patients with osteoarthritis, the aging arthritis, which not only can cause joint pain but can increase risk for falls. Therefore, we evaluate their bone health and determine if

osteoporosis screening is warranted. Within our practice at Lehigh Valley Hospital and Health Network, osteoporosis screening is one of three quality metrics measured and followed assessing appropriate screening for osteoporosis.

How is someone diagnosed with osteoporosis? Screening for osteoporosis is done by a bone density test also known as a DXA (dual energy x-ray absorptiometry). It is a noninvasive test consisting of an x-ray of your lower back, total hip, neck of the hip and sometimes forearm to calculate bone density and risk for fracture. Low bone density is reported as a T-Score and there is a scoring system in which 0 to -1.0 is normal, -1.0 to –2.5 is osteopenia or the stage before osteoporosis, and scores less than -2.5 is osteoporosis. Patients who have osteopenia, treatment is determined based on another scoring system called a FRAX score. The FRAX score is a fracture risk calculator that should be reported on your DXA scan if you have osteopenia. It takes in account your femoral neck (hip) t-score and other secondary risk factors as well as age, sex, and BMI. If your 10-year probability of having a major osteoporotic fracture (spine, hip, shoulder, forearm) is greater than or equal to 20% or if your 10year probability of having a hip fracture is greater than or equal to 3%, you should be on therapy to prevent fractures. Screening with a DXA scan should take place if you

are female 65 years or older or a male 70 years or older, 50 years old with osteoporosis risk factors, or someone with a fragility or nontraumatic fracture.

There are a variety of treatments for osteopenia and osteoporosis. Treatments vary from oral weekly or monthly medications to annual once a year 15-minute infusions. There are a variety of injectable medications used for preventing osteoporosis or osteopenia and some injectable medications are used to treat severe osteoporosis. Medications are dependent on many variables including other comorbid conditions and the severity of one’s bone loss. In addition to prescription medications, it is important to exercise regularly and make sure your vitamin D levels are within normal range. If you are vitamin D deficient, anti-osteoporosis therapy may not be effective. Many clinicians can treat osteoporosis including primary care physicians, gynecologists, endocrinologists, rheumatologists, orthopedics, and other specialists.

At Lehigh Valley Hospital and Health Network on average there are ninety hip fractures admitted to the Cedar Crest Campus each month. As a result, they are announcing the launch of a Bone Health/Fracture Liaison program for the facilitation of timely transition of care for patients discharged from the hospital with osteoporosis. This program will enhance the transition of care post discharge and improve ambulatory access to timely care. This is a multidisciplinary program under the direction of Dr. Scott Sexton, Orthopedics, in collaboration with Dr. Phillip Dunn, Rheumatology, and Dr. Mal Homan, Endocrinology. This program will be focused on the proper diagnosis of osteoporosis, education on risk factors and lifestyle modifications, treatment options and prevention of future fractures.

For more information visit www.bonesource.org

LCMS NEWS

NEW MEMBERS

David Patrick Adams

Elizabeth Aziz, DO

Sam Baird, MD

Justin Craig Becker, MD

Raul Davaro, MD

Aaron Bond Deutsch, DO

Daniel Adrian Fernandez Felix , MD

Sarah Teresa Fish, DO

Curtis Patrick Flaherty, MD

Kenzie Lynn Glassburn, MD

Ursula M. Hoffmann, MD

Jasmine Chou Hwang, MD

Patricia Faye Kandle, MD

Emilee E. Kurtz, DO

Darshan Lal, MD

Jacob Damian Lebamoff

Kevin Liu, DO

Crystal Rose Magno, MD

Mahrukh Shahab Malik, MD

Amed Natour, MD

Colin O’Hara, DO

Neil Patel, DO

Carolyn Mae Peterseim, MD

Casandra Verlene Roldan, MD

Lauren Nicole Schwartzberg, DO

Kumar Seelam, MD

Mark Thomas Shephard, DO

Chris Sielski, DO - Psychiatry

Vincent Duong Tang, MD

Michael Villeneuve, MD

Minami Watanabe, MD

Charles Dante Wowkanech, MD

Kateryna Yevdokimova, MD

Adnan Yousaf, MD

Wen Zhang, DO

RE-INSTATED MEMBERS

Travis Craig Dayon, MD

Meghana Ganapathiraju

Danny Le, DO

Emily Chea Mceldrew, DO

Puja Dinesh Patel, DO

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Rue was born a year ago with two tiny holes in her heart. Our Pediatric Cardiologists keep her healthy and happy by monitoring her condition. She’s one of hundreds of kids being cared for by St. Luke’s Pediatric Specialists. Parents will find a complete range of pediatric care from orthopedics to neurology to general surgery that’s all close to home and family. So whatever care Rue needs, we’re here to help keep her going strong all through childhood. sluhn.org/pediatrics

Thanks to pediatric cardiology, there’s no telling how far Rue will go.