Lancaster Physician Fall 2023 by Hoffmann Publishing Group

Fall 2023

Sustainability I N H E A LT H C A R E

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DEMENTIA

AN ESSAY OF SORTS BY KRISTEN M. NEBEL, DO

THE LATEST VACCINATION RECOMMENDATIONS FOR CHILDREN BY PIA FENIMORE, MD, FAAP

HYPERTENSION

DEFINITION, GOALS, TARGETS, MEASUREMENTS, AND CONTROVERSIES BYJAMES GROFF, DO, MACOI

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contents 2022/2023 BOARD OF DIRECTORS OFFICERS Stacey S. Denlinger, DO

FALL 2023

COVER STORY

Sustainability in Health Care p. 26

President

Highlands Family Practice & UPMC Wound and Hyperbaric Center

Sarah E. Eiser, MD President Elect Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

Robin M. Hicks, DO Vice President UPMC Supportive Care & Palliative Medicine

Christopher R. Scheid, DO Secretary College Avenue Family Medicine

Stephen T. Olin, MD Treasurer Penn Medicine Lancaster General Health

Laura H. Fisher, MD Immediate Past President Lancaster Family Allergy

DIRECTORS Robert K. Aichele, Jr., DO Marco A. Cunicelli, DO | Resident Kendall R. Dempsey, MD | Resident Lena Dumasia, MD David J. Gasperack, DO Anna S. Goetze, DO | Resident James M. Kelly, MD Karen A. Rizzo, MD, FACS Susanne Scott, MD, MPH Danielle Rubinstein, DO

EDITORS

Best Practices 6 Robots Lend A Helping Hand To Penn Medicine Lancaster General Hospital’s Nursing Staff

10 Practice Management Insights: Retail Health Care

8 WellSpan Participates in Population Genomics Project

In Every Issue 5 President’s Message

30 Legislative Updates

13 Healthy Communities

32 Restaurant Review

23 Patient Adovcacy 24 Passion Outside of Practice

34 Medical Society & Foundation Updates

26 Perspectives

36 News & Announcements

Dawn Mentzer Beth E. Gerber Lancaster City & County Medical Society

Laura H. Fisher, MD Lancaster Family Allergy

Lancaster Physician is a publication of the Lancaster City & County Medical Society (LCCMS). The Lancaster City & County Medical Society’s mission statement: To promote and protect the practice of medicine for the physicians of Lancaster County so they may provide the highest quality of patientcentered care in an increasingly complex environment.

Content Submission The Lancaster Physician magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Lancaster City & County Medical Society. For more information or submission suggestions, please email bgerber@lancastermedicalsociety.org.

Lancaster Physician is published by Hoffmann Publishing Group, Inc. Sinking Spring, PA HoffmannPublishing.com 610.685.0914 SEE PAST ISSUES AT LP.HoffmannPublishing.com FOR ADVERTISING INFO CONTACT: Sherry Bolinger, Sherry@hoffpubs.com, 717.979.2858

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President’s Message

I hope this issue finds everyone feeling refreshed after an active summer and ready to begin another fall. Fall still feels like a “beginning” to me since I have a school-aged child. And while I love summer, I appreciate fall sunsets the most. Along with crisp nights and football comes the return to school and “flu season.” To me that phrase is — for all the distress it can cause —underwhelming. It’s important to remember that while these infections will circulate, there are things we can do to prevent their spread and severe disease. In this issue we have included an article that provides updated information on vaccines for children. Vaccines are just one way to prevent illness. As a family physician, I think prevention is the best strategy for promoting wellness and managing complications from diseases we may acquire. There are other preventive topics, including learning about what blood pressure numbers mean. Over time, with new information, recommendations may change or evolve. Staying educated and informed about current evidence in science and medicine allows patients and health care providers to have constructive conversations. I believe those conversations lead to understanding and trust, which leads to better care and disease prevention.

Stacey Denlinger, DO Highlands Family Practice & UPMC Wound and Hyperbaric Center Visit lancastermedicalsociety.org

While our local medical society spent the summer continuing to re-engage our membership community and reviewing applications for the scholarships our Foundation distributes annually to medical students from Lancaster County, the state medical society was busy preparing for the annual House of Delegates (HOD) meeting in October. For those of you who aren’t familiar with this event, it is a time when physicians come together from across the state to share ideas for how to improve the health of all Pennsylvanians. Many resolutions covering a variety of topics are proposed, discussed, and voted on in order to provide guidance to our state legislatures about issues facing our local communities. Stay tuned for more to come in our next issue about what was discussed at this year’s HOD event. As always, I sincerely thank you for your continued interest in the Lancaster City & County Medical Society. I hope everyone minds preventive care this “cold and flu season” and practices good hand hygiene along with distancing when ill, updating seasonal vaccines, sleeping well, eating well, and staying physically active. These are the best ways to support the immune system and strengthen our public health. Stay well!

Wondering how to keep up with important LCCMS and PAMED news and updates? Visit our website at www.lancastermedicalsociety.org

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best

pr ctices ALSO IN THIS SECTION • WellSpan Participates in Population Genomics Project • Health Care Practice Insights: Retail Health Care

ROBOTS LEND A HELPING HAND TO PENN MEDICINE LANCASTER GENERAL HOSPITAL’S NURSING STAFF “Roxy” and “Rosie” give nurses more time to focus on patients’ needs.

f you ask a nurse to name the best part of their job, running supplies back and forth probably won’t make the list.

The nursing staff at Penn Medicine Lancaster General Hospital (LGH) has some new helping hands in the form of two robot assistants. “Roxy” and “Rosie” help with routine non-clinical tasks, such as pickup and delivery of supplies, enabling nurses to focus on patient care.

“Roxy” and “Rosie” help the nursing staff at Lancaster General Hospital with routine non-clinical tasks, such as pickup and delivery of lab specimens and heart-monitoring equipment.

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Penn Medicine Lancaster General Health (LG Health) Interim Chief Nursing Officer Tim Zellers, MBA, MSN, CRNP, said the hospital’s nurses get pulled in many different directions during a typical shift. In fact, the robots’ creator, Diligent Robotics, estimates that 30% of nurses’ time is spent retrieving and

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gathering supplies, such as personal protective equipment, lab samples, and medications. “This is one way of limiting those tasks that don’t necessarily require a nurse but can help support them in their role,” Zellers said. “The robots allow nurses to actually focus on what they’re trained to do, and that’s to take care of patients.” Like other industries, such as restaurants and retirement communities, healthcare organizations are increasingly utilizing robots and other artificial intelligence to complete routine tasks. Diligent builds robots specifically to assist nurses and other members of the healthcare team. While its robots are in use in hospitals across the country, LGH is the first hospital in Pennsylvania to partner with Diligent. After several weeks of training by human technicians, Roxy and Rosie navigate the hallways of the 525-bed hospital autonomously — including the elevators — reaching a top speed of about 3 mph. They deliver and pick up routine lab specimens, such as urine samples or COVID swabs, as well as boxes that contain heart monitoring equipment. (Specimens that are deemed urgent or require special handling are carried by humans.) To request one of the robots to complete a task, a staff member uses an iPad kiosk located throughout the hospital, and pickups and deliveries are kept secure using a badge swipe. Each robot has three drawers of different sizes, making it possible to deliver several items, or to multiple locations, at once. The robot’s response time depends on the other tasks already in the queue. Roxy and Rosie are in service 22 hours a day, spending the other two charging on docking stations located throughout the hospital. They can also navigate to a docking station for a “nap” when not in use. Roxy and Rosie — who were named through a contest held by the nursing staff — are equipped with sensors to detect obstacles and will either stop or go around them. (They’re polite while doing so, saying, “Pardon me, may I get to that spot, please?” to announce themselves to passersby in the halls.)

The robots work beside hospital staff, helping the clinical team save time and do their jobs more efficiently.

The robots do not enter patients’ rooms or interact with patients. But with their blinking heart eyes, friendly “chirps,” and willingness to pose for selfies, they are a source of fascination and delight for many hospital visitors and staff alike. Zellers said the robots are not meant to replace people or fulfill jobs that are currently done by nurses or other clinical staff. Instead they work side-by-side to support clinical staff, helping them to save time and do their jobs more efficiently. “The robots assist our clinical team with tasks that take them away from the bedside, so they can devote more time to patient care,” he said. “It improves the experience, certainly, for our patients, who get to spend more face-to-face time with the staff taking care of them.” Allen Cubell, LG Health Executive Director of Innovation, said the year-long robot pilot is just one example of Penn Medicine’s continued investment in innovations that make healthcare workers’ jobs easier. The robots are a very visible example of those efforts, which also include initiatives to reduce the time providers spend on documentation and inbox management.

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“As a team, we are focused on ways that we can use innovation to reduce the burdens on our busy clinicians, which leads to improvements in their overall well-being,” he said. “The robots help our clinical staff to do more of what they love, instead of running around the hospital.” LG Health does not own the robots. Instead, the health system pays a subscription fee based on how heavily the robots are used. Just weeks into the pilot, Roxy and Rosie were already approaching their capacity for daily use, making a total of 70 to 80 deliveries per day, he said. The team is considering other possible uses for the robots, such as transporting patient care equipment during the overnight hours or delivering a utensil or condiment that is inadvertently missing from a patient’s food tray. “Based on the results of the pilot, it’s possible that we will add more robots in the future,” Cubell said. “Roxy and Rosie are high-tech, and they’re fun too. There’s no question that innovations like these are the future of health care.”

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Best Practices

Sonia Thomas (left), a WellSpan genetic counselor, and Becca Eberly, lead research nurse coordinator for the Gene Health Project, both submitted a blood sample for participation in the research project.

WellSpan Participates in Population Genomics Project GOALS ARE TO IMPROVE HEALTH, PROVIDE PERSONALIZED CARE, AND UNCOVER RISKS

hat if your patients could participate in a research project that will change the future of medicine, not only helping science but ultimately preventing disease?

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WellSpan physicians are asking their patients to do just that. WellSpan is joining with other health care systems — spanning, for now, more than 30,000 medical professionals and almost 500,000 patients from across the country in 10 health systems — partnering in a research project with a company called Helix. Helix is a leading population genomics company that works to enable health systems, public health organizations, and life sciences companies to accelerate the use of genomic data into patient care and public health decision making. Over the next four years, WellSpan will recruit at least 100,000 volunteers age 18 or older to participate in The Gene Health Project at WellSpan. Participants will provide a vial of blood, from which a DNA sample will be collected and analyzed by Helix. Initially the testing will focus on what the U.S. Centers for Disease Control has identified as “Tier 1 conditions,” because early detection of those diseases could significantly reduce deaths and illness. Nearly 2 million people in the United States are at increased risk for adverse health outcomes because they have genetic variants that predispose them to these conditions, which include: • A hereditary form of very high cholesterol known as familial hypercholesterolemia, which causes heart disease at an earlier age than is found in the general population. • A hereditary form of breast and ovarian cancer syndrome, specifically the BRCA1 and BRCA2 genes. • A hereditary type of colorectal cancer known as Lynch Syndrome. “We believe understanding what makes each of our patients unique is key to providing the most personalized, high-quality health care outcomes possible,” says Dr. Anthony Aquilina, executive vice president and chief operating officer of WellSpan Health.

This precision medicine research project is designed to integrate genetic insights into clinical care and research. Through analysis of the aggregate research gathered through the project, providers and scientists will be a step closer to learning the root causes of many diseases and the most effective treatments for them. It may also allow providers to tailor the care of many patients and better understand the health of the region. “I tell my patients that they may help advance science and help make discoveries that will benefit others,” says Dr. David Kann, medical director of precision medicine at WellSpan. “This project will collect trillions of pieces of data that will enable us to do research to understand disease, treat disease earlier, and develop medications that are tailored to specific conditions.” Tier 1 DNA results for each patient will be integrated into their electronic medical record, accessible to their personal physicians for the purpose of personalized treatment plans. The project first recruited participants from the WellSpan team. The system now is reaching out to 10,000 WellSpan team members and patients each week with an invitation to participate in the Gene Health Project. Blood sample collection can be done conveniently at any WellSpan lab. There is no charge to the volunteers for this testing. An extra benefit of the project is that participants also can learn about their regional ancestry and personal traits like gluten tolerance, caffeine sensitivity, and more, through the testing. Two early enrollees from Lancaster County are already deeply involved in the project and keenly interested in the results, both for personal and professional reasons. Sonia Thomas is a genetic counselor with WellSpan Maternal-Fetal Medicine in Ephrata. Becca Eberly is the lead research nurse coordinator for the project. “When this came along, I jumped at the chance,” Eberly says. “I am a WellSpan patient so if something came back positive on the screening, I have local physicians I

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can connect with and I know I can get the care I would need and want. I also have two young children at home and thought it was important to know for them, so they could get the care they might need down the road.” Both Eberly and Thomas had negative results for the genes in the Tier 1 conditions included in the project testing. Only about 1% to 2% (1 or 2 people out of 100) will be found to have a risk for one of these conditions. Thomas is excited to see the future of genomic medicine. During the nine years she has been a genetic counselor, she says the testing possibilities have advanced quickly due to genetic science. A simple example: when she first started, expectant couples used to have to wait 20 weeks to find out the gender of their baby via an ultrasound. That time has been cut in half, to 10 weeks, when a mom can have a blood test that looks at the baby’s DNA and reveals the baby’s gender. While the Gene Health Project is focused on adult screening, not prenatal results, this work will further expand what physicians can test for and discover in patients, she believes, improving care for all. “We may be carriers for genetic variants that make us predisposed to developing health concerns. However, we may not even be aware of it,” Thomas says. “With this work, we may know very early what to expect and start proactive surveillance and monitoring measures or even start treatment early.” Due to the wide swath and large number of participants from across the country, the research project has the potential to vastly change the way medicine is practiced, Eberly says. “They can look at trends and make correlations between a patient’s health history, their lifestyle, and their results on their genetic sequencing and learn from that and advance medicine,” she says. “What we are doing is moving medicine from a reactive state to a preventive state.”

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Best Practices

Practice Management Insights

ADDRESSING THE ISSUES, CHALLENGES, AND OPPORTUNITIES THAT IMPACT TODAY’S MEDICAL PRACTICES

Retail Health Care WHAT DOES A PRIVATE PRACTICE LOOK LIKE WHEN YOUR COMPETITION IS WALMART AND AMAZON?

HEATHER F. MODJESKY, COE,

Conestoga Eye

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Working alongside you to care for your patients with serious illness at home.

nyone that’s needed to purchase prescription eyeglasses in the last two decades knows the ophthalmology and optometry branches of medicine have been in direct competition with retail box shops for some time. Nearly every large department store or retail super store has an optical team (including an optometrist) seeing patients. With the rise of the online optical shop, the retail space is even more flooded. Retailers aggressively market their sub-par stock (e.g., frames and lenses), promising you can have it all — products that are fast, cheap, and good. You would think that after so many years, this market would be perfected — streamlined and ubiquitous. And yet, optical practices still exist. In maybe one of the best examples of quality over convenience, private optical offices continue to exist — and thrive — whether part of a medical eye practice or a routine set up.

• Specialist-level palliative care including an extensive interdisciplinary team • Pain and symptom management related to life-limiting illness • Goals of care discussion • Patient advocacy and care coordination • Caregiver support and education

Now, we are seeing the beginnings of medical retail: a minute clinic in Walmart and telemedicine and prescription renewal via Amazon. What does the world look like when our private doctors’ offices have to compete with the speed and convenience of a true “doc in a box”?

Quality care, quality of life. www.ChoicesHealth.org To make a referral, call (877) 898-0685 or email us at

We, doctors and supporting staff alike, must ask ourselves, “What are we?” Are we a single link in an integrated chain that prioritizes systems, or an innovator providing unique services with nuance? When we choose innovator, we begin to see how our services need to be communicated to potential patients.

choicesreferrals@choiceshealth.org.

THE LANGUAGE OF QUALITY BECOMES ESSENTIAL Our offices must become better at explaining the intersections between fast, good, and cheap. You can’t have all three, and it ultimately is up to the patient to decide which two options they want. We know what box chains will offer — fast and cheap.

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Anecdotally, patients who present with complex symptoms are going to need to see physicians outside of the medical retail space. Those locations won’t be set up for that. (We see this is ophthalmology/optometry now.) So why not bypass the “retail” step altogether?

• Comprehensive.

What we offer as private offices is good, quality, individual attention. If we can’t offer fast (either quick appointments or quick scheduling) and we can’t lower prices (completely understandable), then we need to make a case for why our quality is of greater value. What we say must align with the actual office experience our patients live.

• Personalized. • Concierge-style approach.

To develop language around this, I advise the Blue Ocean Strategy, which means not comparing yourself point for point with retail health care but explaining why you are different

Minnie Taw, MD Board certified in Internal Medicine, Pediatrics and Obesity Medicine

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Best Practices

Practice Management Insights

holistically. Focus on what you do best from the perspective of patients — and don’t use the word “excellence.” PROVIDER CONNECTION With the rise of urgent care facilities, a myth that patients just want to be seen and not establish a connection with their provider has permeated medicine. This “fact” is the result of several factors that force patients into situations that lead to this conclusion. In other words, when the patient’s copay is cheaper at an urgent care, or the hours they need are available at the retail office, a patient may have to choose an option that doesn’t foster connection. One of the best things our practices can do with patients is nurture a personal connection. This is true for both physicians/ providers and all your practice staff. Connection and rapport materialize in how your office makes people feel. The better they feel when speaking with your office staff or being in your office, the more likely they are to schedule future appointments. To create connection, it may mean some “patient-convenient” hours a few times a month, or even regular add-on slots, in your templates. If you want patients to choose you as the alternative to a doc-in-the-box, you have to be able to provide the structure for an enticing alternative. “CUSTOMER SERVICE” WILL ELEVATE YOUR PRACTICE I know, this is the soap box I yell on, too. The truth, as much as we want to rail against it, is that our office staff is providing customer service. And there are some things we can learn when we are willing to adopt the framework of this concept. I argue that customer service in a medical setting means you engage with patients in an authentic and present way. It means treating patients as individuals and not just another number to move through the clinic. There was an article that came out recently that said ChatGPT has greater bedside manner, on average, than physicians. While

One of the best things our practices can do with patients is nurture a personal connection. that’s a humorous anecdote, we have to do better than the technology we can utilize in our practices. When customer service provided by your staff improves, so does your communication throughout the practice. Additionally, your risk management improves. Customer service returns us to the question: “How do your patients feel when in your office?” When they feel heard and respected, they will stay, return for future visits, and recommend you to others. This is an infinitely better review than: “My last appointment was fast and cheap.” We must be able to find the ideal balance between seeing patients efficiently and forging those meaningful relationships and experiences with them.

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THE DEEP ADOPTION OF TECHNOLOGY One thing our retail realm competition has is technology fully integrated into their systems. It is the central axis their entire operation is built upon. From an administrative perspective, technology enables consistency, efficiency, and strong communication throughout the office when utilized properly. The approach for you and your staff is not to suffer technology, but to figure out how you can make it work for you to make your job easier and faster. Use the tools of your competition against them and get that tech up and running. Know that your patients (yes, even those Baby Boomers) are using technology, and many are open to its utilization in their care. Therefore, we have to know how to use it, explain it, and triage issues with it. The reality, whether you want to adopt technology or not, is to realize that your competition is adopting it; and they have the power of massive integrated systems behind them. Overall, retail medicine is closer on the horizon than many of us realize. It will be one more type of competition to press against in our very crowded field of medicine. Yet now is the time for us to get a step ahead. If we develop our strategies now, we will be at the forefront of these changes in the future. Let’s choose innovation. Let’s show them how to really make a difference in medicine.

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Healthy Communities

Dementia A N E S S AY O F S O R T S KRISTEN M. NEBEL, DO

Owner, PEACE OF MIND Aging & Wellness Specialists, PLLC, Geriatrician and death doula specializing in homecare for seniors, dementia care, caregivers, and end of life

WHAT IS DEMENTIA? I believe dementia is best understood by thinking of it as an umbrella term for anything that causes the brain to fail. If dementia were the heart, we’d call it heart failure. You can appreciate that just as there are multiple causes of heart failure, there are multiple causes of dementia. Each cause or type of cognitive impairment is given a specific name and falls under the umbrella of dementia. Types of dementia include Alzheimer’s, Lewy body, frontotemporal, vascular, multi-infarct, alcohol related, chronic traumatic encephalopathy, Huntington’s Disease, and others. There are often mixed types as well. (Image 1) I always describe memory as a spectrum with normal cognition at one end and end-stage dementia at the other (Fig. 1). In between, you have a range of cognitive diagnoses. Subjective cognitive impairment (SCI) is when changes are present that only the individual and those close to them observe. Individuals or families may observe subtle changes in affect, quick recovery from errors, or increase in anxiety. Mild cognitive impairment (MCI) is subjective and able to be quantified by testing. MCI is defined as impaired functioning of one cognitive domain WITHOUT interfering with daily life. The individual should still be able to maintain their job skills, bill paying ability, and complex negotiations. Dementia is defined as Continued on page 14

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image 1

impaired function of one or more cognitive domains WITH interference in daily life. The individual may lose their job or volunteer role due to performance difficulties, may have unexplained dents or scratches on their vehicle, or may withdraw from events or gatherings. It is important to note that MCI does not always progress to dementia, but dementia is chronic and progressive. WHAT ARE ITS EFFECTS? In dementia the area of the brain affected determines the symptoms one has. The most commonly recognized dementia symptom is forgetfulness or short-term memory loss, but there are actually five to eight different brain functions (or domains) that make up what is commonly referred to as “memory.” These different cognitive domains include: • Learning and memory, which controls short-term, intermediate, and long-term memories; • Executive function, which is responsible for planning, organizing flexibility, and decision-making;

• Language, which controls understanding, speech, and word-finding; • Social cognition, which allows you to understand and appropriately respond to others; • Complex attention, which allows for processing, sustaining attention, and dividing attention; and • Perceptual-motor function, which controls visuospatial and motor skills. Making a diagnosis can be especially challenging when either memory and language are retained, the individual is not well known to the examiner, or family is not present to verify the patient’s history. As I’ve learned by doing capacity and dementia evaluations, some individuals can be very convincing but completely inaccurate. A corroborated and detailed interview is essential to making an accurate diagnosis. Dementia has a wide variation in presentation leading to missed and late diagnoses. As you can imagine, an impairment in the language domain (trouble finding the right word or describing an

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item instead of naming it) would look very different from an impairment in the memory domain (being unable to recall conversations or appointments) which varies from social domain dysfunction (where changes in personality or lack of social graces are encountered). Another reason early dementias and mild cognitive impairment diagnoses are missed is because memory loss is incorrectly thought of as normal aging and ignored. Not surprisingly, symptoms of dementia usually present 5-10+ years before a diagnosis is made. Diagnosing dementia at a moderate or later stage means the individual is likely already needing some level of care. It is very common for one to think they can wait to plan for their future care needs, only to end up in an emergency situation where the hospital is their only option. Planning gets you on the years-long waitlist for senior living communities, gives you control and choice in a disease that doesn’t afford either of those benefits, and significantly reduces stress. Avoiding planning puts an incredible stress on one’s family and caregivers to provide a level of care that they didn’t anticipate and haven’t been trained for.

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NEXT STEPS AFTER A DEMENTIA DIAGNOSIS “What do we need?” is an important question to answer. First, the support of a medical professional who is familiar with dementia and the progression is invaluable. Second, find support that will come into the home. As dementia progresses, the individual and their family will have more trouble leaving home thereby worsening isolation and caregiver well-being. The type of support an individual requires will vary based on the cognitive domains affected and needs will continually change and increase as the disease progresses. On average, one has a life expectancy of 8-10 years after dementia is diagnosed with the last several years requiring constant supervision. Services may start with transportation for errands, house cleaning, and bill payment, and then progress to daily medication administration and meal preparation before the individual finally needs incontinence care, feeding, and lifting to be transferred from bed to toilet or chair. QUESTIONS TO GUIDE YOUR PLANNING • What care is needed? • Where will the care be received? • If the individual remains at home, who will be available to care for them (now and in the future when they require 24/7 supervision or nursing level care)? Will they even allow someone into their home to care for them? • Is there interest in moving to a community where their needs can be met (now or in the future)? If yes, start planning now.

Whatever can’t be done on their own needs to be done for them. There are resources for in-home caregivers, transportation, food delivery, medication delivery, medical equipment, and other services. However, the majority of these services are not covered by Medicare or other insurances. Long-term care insurance or senior care community products often cover some of these services. Planning is emergent if an individual does not have their safety or medical needs met as it increases their risk of abuse, injury, and death. If concerns exist in these areas, a report can be made to your local Area Agency on Aging Protective Services Division. The most important part of dementia care planning is an honest look at who, what, and where — who will provide the care, what level of care, and where will the care be provided. This is very difficult because an individual’s need for autonomy never goes away even as cognitive ability declines. Be honest, but don’t bully or force your viewpoint. It’s better to let your loved one believe their truth than create agitation. I often tell my patients’ families that there is a new language they must learn in order to communicate effectively in dementia. Its goal is honoring the individual by maintaining peace and their dignity. Above all it is gentle, patient, and compassionate, offering a supportive touch and eye contact to let them know they’re seen and heard. Without this new language, ego flares and self-defense prohibits even the simplest act of care because the perceived truth is that we are diminishing their independence.

• How soon do you anticipate more care will be needed? • What are all the anticipated needs of the individual daily, weekly, monthly, and yearly? Can they manage these on their own? • What do you observe about their capabilities and needs — even if they don’t agree? • Does the individual have financial resources to pay for placement or in-home caregivers? If you are unsure, contact your Area Agency on Aging to inquire about waiver program qualifications.

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JAMES GROFF, DO, MACOI

Hypertension & Kidney Specialists Division Chief, Nephrology, Penn Medicine Lancaster General Hospital

t is universally accepted that hypertension (HTN) is a leading and independent risk factor for heart disease, stroke, and chronic kidney disease. Unfortunately, there is little consensus regarding other topics related to HTN. Hypertension may be one of the most preventable factors resulting in disease and death. There are an estimated 116 million adults in the United States and 1 billion adults globally with hypertension. Continued on page 18

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Healthy Communities

The National High Blood Pressure Education Program (NHBPEP) was started in 1972 under the direction of the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. This led to the organization of a group of experts who authored the first report known as the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC). The first JNC report was published in 1977 at a time when healthcare providers did not fully understand the grave importance of lowering blood pressure (BP) to reduce cardiovascular, renal, and stroke events. Since that first report, the classification, definition, goals, and treatments have changed immensely — at times with controversy among the experts. In 2014, JNC published its final evidenced-based guideline for the treatment of HTN, in part due to controversy among the authors. This eighth JNC report increased the threshold to initiate pharmacologic therapy when the BP is 150/90 mm Hg or higher in adults 60 years and older or 140/90 mm Hg or higher in adults younger than age 60 and patients with hypertension and diabetes, regardless of age. The outcome was that NHLBI stated it would support medical societies in the development of hypertension guidelines moving forward and no longer publish its own report. Fortunately, the morbidity and mortality due to cardiovascular disease (CVD), renal disease, and stroke have dramatically improved over the decades. Since that first report, there has been increased awareness and education regarding the treatment of HTN. A landmark study, A Randomized Trial of Intensive versus Standard Blood Pressure Control, by the SPRINT Research Group was published in The New England Journal of Medicine. It led to the development of the American College of Cardiology (ACC)/ American Heart Association (AHA) blood pressure guidelines, which were released in 2017. These were based on the SPRINT trial that randomly assigned persons of age 50 and older with systolic blood pressure (SBP) of 130 mm Hg to 180 mm Hg and an increased cardiovascular risk (including

chronic kidney disease CKD with an eGFR of 20 or higher) but without diabetes or prior stroke into two groups. The first group had a SBP target of less than 120 mm Hg (intensive treatment), and the second group had a SBP target of less than 140 mm Hg (standard treatment). The SPRINT investigators standardized study BP measurements using this technique: participants rested alone in a room before BP was measured three times with an automated device and averaged, a process termed “automated office BP.” The ACC/AHA hypertension guideline classifies BP as: • Normal BP: SBP < 120 mm Hg and diastolic blood pressure (DBP) < 80 mm Hg • Elevated BP: SBP 120-129 mm Hg and DBP < 80 mm Hg • Stage 1 HTN: SBP 130-139 mm Hg or DBP 80-89 mm Hg • Stage 2 HTN: SBP >/=140 mm Hg or DBP >/= 90 mm Hg The 2017 ACC/AHA hypertension guideline redefined HTN and lowered the target BP to <130/80 mm Hg. This was supported by the SPRINT trial demonstrating intensive BP control led to lower morbidity and all cause mortality. It was noted that serious adverse events of acute kidney injury, hypotension, syncope, and electrolyte abnormalities were more common in the intensive control group compared to the standard control group. Injurious falls, bradycardia, and orthostatic hypotension were not more common in the intensive control group. Patients with elevated blood pressure (SBP 120-129 mm Hg) or hypertension (SBP 130 mm Hg or greater or DBP> 80 mm Hg) should begin lifestyle modifications with proven non-pharmacologic strategies to reduce blood pressure. These include losing weight, reducing dietary sodium intake, consuming a heart healthy diet, engaging in physical activity, increasing dietary potassium intake, and moderating — or ceasing — alcohol intake. Dietary sodium

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intake guidelines remain controversial as recommendations vary: • ACC/AHA – <1,500 mg/day • USDA – <2,300 mg/day • WHO – <2,000 mg/day • Kidney Disease: Improving Global Outcomes (KDIGO) – <2,000 mg/day The bottom line is that the American diet is high in sodium and reduction below 2,300 mg/day may result in significant improvement in BP. As per the 2017 ACC/AHA guideline for HTN, it is recommended to begin pharmacologic therapy in patients with an average SBP of 130 mm Hg or greater or an average DBP of 80 mm Hg or greater with clinical CVD, or an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher. In patients without CVD and a 10-year ASCVD risk of <10%, it is recommended to start pharmacologic therapy at SBP of 140 or greater or DBP of 90 mm Hg or greater for primary prevention of CVD. Compared to previous guidelines, JNC 8 and the 2017 ACC/AHA guidelines recommend that initial therapy for HTN should be limited to: angiotensin converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), calcium-channel blockers (CCBs) and thiazide type diuretics. Patients with chronic kidney disease (CKD) should be treated with an ACE inhibitor or ARB. ACE inhibitors and ARBs should not be used together in the same patient due to the increased risk of hyperkalemia. Beta blockers are not recommended as first line treatment unless there is a specific cardiovascular indication. In patients with CKD and HTN, KDIGO work group recommends a target SBP of <120 mm Hg using standardized office readings for most patients with CKD who are age 18+, do not have a renal transplant, and are not receiving dialysis. This is more aggressive than the 2017 ACC/AHA guideline which

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suggests a target of <130/80 mm Hg in patients with CKD and CKD. KDIGO is more aggressive than the European Societies and the National Institute of Health and Care Excellence (NICE). The lack of uniform recommendations is in part due to the multiple methods to measure BP. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-the-office methods to assist in the diagnosis and management of HTN. Manual BP measurements are prone to error; therefore oscillometric measurements are preferred. ABPM is not widely used or covered by insurances in the US, and HBPM is used to guide BP management. In KDIGO 2021, the work group added a chapter on how to measure BP. Routine office BP refers to BP measurements obtained without standard preparation or device and is referred to “causal BP.” Standardized BP measurement is vital for identifying patients with HTN and is the foundation for the target or goal BP. Standardized BP measurement utilizes the technique used in the SPRINT trial. It is widely accepted that routine office BP and standardized office BP are highly variable. It is recognized that home BP values and routine office BP values are higher than standardized BP values. Unfortunately, standardized office BP measurements are not the “standard of care,” and this technique can increase the burden to patients, health care providers, and health care facilities. It is suggested that automated oscillometric BP devices be used for standardized BP measurements. Observational studies have demonstrated a stronger association of cardiovascular and renal outcomes in all populations using out-of-the-office BP measurements than with office BP measurements. Successful treatment of HTN requires accurate office and out-of-the-office BP measurements. Patients need to be instructed on the proper home technique to measure BP. It is my opinion that given the controversies in the field of hypertension — including the definition, target BP and measurement technique — the realistic target BP is the BP agreed-upon by the patient and their physician, certified nurse practitioner, or

physician assistant. This includes consideration for tolerable adverse reactions, cost, poly-pharmacy, and social determinants of health using shared decision making.

THE PROPER TECHNIQUE TO MEASURE BP INCLUDES: A relaxed patient in a quiet room, sitting in chair with both feet on the floor and back supported for five minutes. The patient needs to avoid smoking, exercise, and caffeine for 30 minutes prior to the recording. The BP device should be validated and calibrated. Clothing should be removed where the cuff is applied (preferably the upper arm). The arm should be supported to the level of the mid-sternum or right atrium. The correct size cuff should be used; bladder of the cuff should encircle 80% of the arm. Neither the patient nor the recorder should talk. It is important to inform the patient of their BP as part of the team approach for BP management.

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REFERENCES 1. SPRINT Research Group. A randomized trial of intensive versus standard blood pressure control. N Engl J Med. 2015; 373: 2103-2116. 2. Kidney Disease: Improving Global Outcomes (KDIGO) BP Work Group. Clinical practice guideline for the management of BP in CKD. Kidney Int. 2021: 99(3S): S1-S87. 3. Carey R, Moran A, Whelton P. Treatment of Hypertension, A Review. JAMA. 2022; 328(18): 1849-1861. 4. Whelton P, Carey R, Aronow W, et al. 2017 ACC/ AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/ PCNA guideline for the prevention, detection, evaluation, and management of THN in adults: a report of the ACC/AHA Task Force on Clinical Practice Guidelines. Hypertension. 2018.

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Healthy Communities

The Latest Vaccination Recommendations

n e r d l i h C for PIA FENIMORE, MD, FAAP

Lancaster Pediatric Associates, LTD.

or adults over 65, it looks like “three for me” is going to be the answer to staying healthy this winter. Influenza, COVID, and respiratory syncytial virus (RSV) vaccines seem like they will be widely available for this population. These three forms of protection have also been approved for children, and while some questions remain unanswered, pediatric providers are hopeful the immunizations will be available and change the trajectory of recent viral seasons. The new monovalent XBB COVID vaccine is getting a lot of attention, but it is only one of the many developments in the world of preventive medicine.

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RSV Pediatricians are particularly excited about the approval of an immunization to protect our most vulnerable patients from RSV. RSV is the most common reason infants are hospitalized. Last year was a particularly difficult year with increases in both incidence and severity of infection across all vulnerable populations. RSV is a seasonal virus typically lasting from November to January (for most pediatricians, even saying the word “Christmas” makes us think of RSV). Last year, it showed up in late summer and did not relent until February.

THE DIFFERENCE BETWEEN VACCINATION AND IMMUNIZATION, ACCORDING TO THE WORLD HEALTH ORGANIZATION: Vaccination: The use of vaccines to stimulate your immune system to protect you against infection or disease Immunization: The process of making you immune or resistant to an infectious disease, typically via vaccination

In August 2023, the Food and Drug Administration (FDA), Advisory Committee on Immunization Practices (ACIP), and American Academy of Pediatrics (AAP) approved nirsevimab (under the commercial name Beyfortus) for all infants — newborn to 8 months old — during RSV season. It is important to note that nirsevimab is not a vaccine, it is a monoclonal antibody which gives the child a temporary boost in their ability to fight off RSV infection. Monoclonal antibodies are proteins made in a laboratory which mimic the way our immune system fights off germs. Basically, administering nirsevimab is like giving babies a specifically trained army of antibodies ready to fight RSV should they become infected. The one-time dose immunization has been shown to be very effective in preventing severe RSV illness. Each year an estimated 58,000-80,000 children younger than 5 years of age are hospitalized due to RSV infection. RSV also is the reason for 2.1 million outpatient visits of children ages 0 to 5 each year. Most of these children are babies at their

most vulnerable during their first RSV season. Giving them protection through nirsevimab greatly reduces their risk of serious infection. This immunization has also been approved for children up to 19 months of age who have medical problems, such as chronic lung or cardiac disease, that put them at higher risk for serious RSV infection during their second season. Therefore, some patients may get two doses, about a year apart. The most common side effects were rash, pain and swelling at the injection site. Nirsevimab is expected to be available in pediatric provider locations beginning in mid-October. Many hospitals are preparing to give it with the Hepatitis B vaccine during newborn hospitalization. It is unclear at this writing what insurance coverage will look like. It has been approved for the Vaccine for Children program, but commercial payers may balk at the approximately $450 per-injection price tag. The AAP, as well as pediatricians locally, are lobbying for full coverage. If gray areas remain in coverage, it may be difficult to achieve widespread use of the vaccine. Influenza The influenza vaccine continues to be recommended for everyone ages 6 months and older. This important vaccine should be given sometime between September and November to ensure the best protection against flu this season. This year’s vaccine has slightly different strains than before, adjusted to address the predicted strains in our country. Last year, the flu shot afforded around 40-70% protection against severe influenza disease. The biggest change this year is that the CDC changed recommendations for people with egg allergy. Since many of the flu vaccines available contain egg protein, it was previously recommended that people with egg allergy receive smaller doses or receive the vaccine in a physician’s office. However, research suggests that these precautions are not necessary. People with egg allergy should get the flu vaccine appropriate for their age, with no restrictions. S. Pneumoniae Not to be outdone by these shiny “new” vaccines…one “old” vaccine has gotten more protective. Prevnar, a vaccine against streptococcus pneumoniae (S. pneumoniae), is bulking up and getting stronger! Since 2000, we have been vaccinating children ages

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2 months and older for S. pneumoniae in the United States. S. Pneumoniae can cause meningitis, pneumonia, blood infection, sinus, and ear infections in children. The vaccine was developed in response to increasing antibiotic resistance in this bacterium. According to the World Health Organization, around 300,000 children die from invasive pneumococcal disease each year. Most of the deaths are in developing countries where the vaccine is not available. Since the introduction of this vaccine in the U.S., the rates of invasive pneumococcal disease have declined by 99%. The incidence of ear infections and ear tube insertion has also declined due to the vaccine. The vaccine has been shown to be very safe with minimal side effects, including pain at injection site, fever, and drowsiness. What has changed is the development of Prevnar 20, which increases the coverage to include more serotypes of S. Pneumoniae, giving more extensive protection without adding any side effects. The seven additional serotype protection added to the vaccine currently accounts for around 40% of pneumococcal disease. This enhancement will further reduce the disease burden of S. pneumoniae in children ages 5 and under. Hope for a Healthier Fall and Winter Season All these immunizations have been examined under the strict safety criteria of the FDA, with research and trials being thoroughly examined by the Centers for Disease Control and Prevention (CDC), ACIP, and the AAP. While all of them do have side effects, they are mild compared to the risks of severe infection. With these new developments pediatricians are cautiously optimistic for the upcoming winter season. We have lots of gratitude for the scientists who have placed a priority on infectious threats to our children. Upper respiratory infections, flu, and pneumonia cause countless days of missed work, school, and fun! Most importantly, these immunizations can keep our children out of the doctor’s office, emergency room, and hospitals. Resources www.cdc.gov https://www.aap.org/en/pages/podcast/immunizations-special-rsv-covid-pneumococcus-influenza/

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Healthy Communities

Over-the-Counter

Hormonal Birth Control SARAH EISER, MD

Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

Why is this big news? The anticipated arrival of Opill in early 2024 is big news because an over-the-counter birth control pill has never been available before. Many barriers stand in the way of preventing pregnancy, and 50% of all pregnancies are unintended. Improving access to reliable contraception by eliminating the need for a prescription and a clinician visit is one way to decrease this statistic. Patients without insurance stand to benefit from Opill, and patients with insurance but who face other barriers can also benefit from it due to the increased convenience of access. Patients may not want to go through their insurance company if the primary policy holders do not support their contraceptive choices (e.g., partners or parents). And an over-the-counter option can be beneficial for patients who run out of their pills while out of town or before they can get an appointment with their prescribing clinician. What is Opill and how does it work? “Opill” is a newly FDA-approved progesterone-only form of hormonal contraception. Opill tablets each contain 0.075mg of norgestrel. Progesterone-only pills work by suppressing ovulation about half of the time, by thickening cervical mucus — slowing movement of the egg through the fallopian tube, and by thinning the endometrium or lining of the uterus. Serum levels peak within two hours and after rapid distribution and

elimination they reach baseline (zero) level by 24 hours. For this reason, adherence to timing and a closely followed regimen are extremely important for optimizing efficacy. Is it safe? Studies have shown that people in need of contraception are able to use self-screening tools to determine whether hormonal contraception is a safe option for them. In general, the progesterone-only pill is safe for most patients and there are no age restrictions. This pill should not be used in patients who have breast cancer, are pregnant, or have liver disease. The Opill contains yellow dye, so patients with yellow dye allergy should avoid taking it. The pill does not significantly increase the risk of venous thromboembolism. The American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American Medical Association, and the American Public Health Association support over-the-counter access to contraception. What are some adverse reactions it may cause? A progesterone-only pill can increase the risk of ovarian cyst development, menstrual irregularities, and ectopic pregnancy. As with all hormonal contraception use, headaches, mood swings, acne, nausea, abnormal bleeding, or fatigue may occur. LLAANNCCAASSTTEERR 22 22 PPHHYYSSIICCIIAANN

What are the important things to remember? To optimize contraceptive efficacy, the pill must be taken at the same time each day. If the pill is taken three or more hours late, condoms should be used for intercourse during the next 48 hours. Also keep in mind that hormonal contraception does not protect against sexually transmitted infections. Future considerations How much will the pill cost? The average cost of hormonal contraception these days ranges anywhere from $0-50 per month, depending on whether or not the patient has insurance. While the benefit of not needing a prescription is of great value, out-of-pocket cost for the pill may pose a major barrier to access for some women. We remain hopeful that Opill will be available at low or no cost to the patient. Will other forms of hormonal contraception become available over the counter after Opill is on the market? That’s difficult to predict, but if the public health impact is positive, the FDA’s approval of Opill may open the door to other non-prescription contraceptive birth control pills. If you have questions about this new medication or other contraception options, please reach out to a health care provider.

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Patient Advocacy

PAMED Task Force Created to Address Emergency Department Overcrowding

mergency departments (EDs) are filling up across the country. While this isn’t a new problem, the COVID-19 pandemic only served to magnify the issue. With no measurable improvement on the horizon, Edward P. Balaban, DO, PAMED’s Chair of the Board of Trustees, created a task force to work to address this issue. President-elect, Kristen Sandel, MD, who is an emergency department physician, is the chair of the task force. She says there are several reasons emergency departments are overcrowded. “Over the years we’ve seen a decrease in accessibility to medical care,” Dr. Sandel said. “Whether that is due to hospital closures or increased needs, it all adds up.” She shared that this issue has been on the forefront of emergency medicine societies for a while, but it’s important for PAMED to make this a priority. While the issues didn’t begin with the COVID-19 pandemic, it certainly shined a light on them during that time. “At the beginning of the pandemic, emergency departments were empty,” said Stuart Brilliant, MD, an emergency medicine physician from Chester County and task force member. “Afterward, we saw a change in nursing and clinical staffing. The shortages have remained.” One issue that the task force has identified as a problem is boarding, the practice of

holding patients in the emergency department after they have been admitted to the hospital, because no inpatient beds are available.

across the state, with representatives ranging in specialty from emergency medicine to addiction medicine and psychiatry.

Dr. Brilliant said that during the COVID19 Public Health Emergency, hospitals were able to take advantage of a federal waiver that charged patients with a 72-hour stay at the hospital and then Medicare would pay for placement elsewhere, if needed.

Dr. Sandel said, “This is not just an emergency medicine issue, it’s a health care issue. It affects everyone in Pennsylvania.”

“The government wanted to make sure we were freeing up beds to avoid hospitalization of patients who may not need longer care. With that ending, we aren’t sure what we are going to face,” he said.

“It’s been interesting joining the task force,” he said. “I thought as physicians we all deal with the same problems, but we don’t.”

The issue of patients staying in the hospital for extended periods was an issue even before the pandemic. Dr. Sandel said, “A lot of times we have patients come to the ED because they don’t have anywhere else to go, which makes discharge harder because we don’t have the proper outpatient resources for them. We don’t want to just discharge someone back to their home without proper care.” Another issue affecting emergency departments is wanting care immediately; as Dr. Brilliant states, we tend to live in a “Wawa” society. “People want care on their own terms. And they don’t want to wait four or five days until their primary care physician is available.” PAMED’s Emergency Department Overcrowding Task Force is made up of physicians

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Dr. Brilliant shared being on the task force with different physicians is eye opening.

Not only does the task force want to create awareness for the problem, but its first mission goes right to the top — sending a letter to Governor Shapiro and asking him to create a statewide task force. Dr. Sandel said, “We want the governor’s team to look at this issue from a state level to see what can be done from a regulation standpoint. If there is a reportable metric we can look at for each hospital, we can see how access can be improved.” “Increased overcrowding puts our physicians in danger when you’re treating them from the waiting room and don’t have the ability to monitor them properly,” Dr. Brilliant said. “We need to look at it from a state level to improve the quality of care of Pennsylvania citizens.” To learn more about PAMED’s Emergency Department Overcrowding Task Force, visit www.pamedsoc.org/EDOvercrowding.

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Passion Outside of Practice

Tony Vanetesse, DO Center for Interventional Pain & Spine

It’s our pleasure to highlight a Lancaster City & County Medical Society member’s “passion outside of practice” in each issue of Lancaster Physician. Beyond their commitment to health care, LCCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature Tony Vanetesse, DO, and his passion outside of practice. How did you develop an interest in your passion outside of practice?

The Vanetesse family

I started golfing at the age of 12 or 13 as a way for my uncle and I to spend time together. From the first few rounds, the sport had a hold on me. I have typically been able to pick up a sport quickly and be serviceable at it, but golf was different as it is constantly challenging even for those who excel at it. When I was around 14 years old, my parents and I started going to Lake Raystown to water ski and wakeboard. We spent a lot of time on the water.

How long have you been participating in this activity?

I’ve been golfing for nearly 20 years and wakeboarding for 17 years.

Why is this pursuit special to you?

Whether I was playing golf with friends after high school, at college, or getting out for a rare round during med school/residency/fellowship, the sport has consistently been a way for me to have “me time” to detach from the stressors of school or work. Now golf has become an integral part of my life and allows me to be more present. I’m excited to soon start golfing with my toddler son and introduce him to this appealing sport.

Golf & Wakeboarding Would you briefly describe your passion outside of practice for those who might be unfamiliar with it? I have two passions outside of my practice: golf and wakeboarding. Golf is the wonderful, humbling sport of attempting to get a small ball into a small hole hundreds of yards away in as few tries as

possible. Wakeboarding is a water sport that is akin to skateboarding on water. The rider is fastened at the ankles to a specialized board and towed behind a motorboat. The goal is for the rider to go back and forth across the wake created by the boat and perform jumps and aerial maneuvers.

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My parents were avid water skiers in their 20s, so water sports like wakeboarding provided a great opportunity for us to enjoy a hobby as a family, even to this day.

What else would you like readers to know about this passion?

Both golf and wakeboarding are activities that allow someone to spend time outside in nature and unplug from modern life, which is becoming an ever-important and increasingly difficult goal to achieve.

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Offers Advanced Treatments to Relieve Pain from Diabetic Neuropathy Diabetic neuropathy is a serious complication that affects as many as 50 percent of all people who have been diagnosed with diabetes. The condition, which can be debilitating, often results in pain in the legs, feet, and hands. While there are medications available to treat this condition, many patients do not respond well to them, or they don’t achieve the desired results while taking them. Argires Marotti Neurosurgical Associates of Lancaster is offering two advanced treatments to relieve pain from diabetic neuropathy in patients who have not responded well to medications: prescription capsaicin patches and spinal cord stimulation. Dr. Jack Smith, an Argires Marotti provider who specializes in pain management, said patient response to both treatments has been extremely favorable. “This is a condition that can really have a negative effect on a person’s quality of life, and that’s why we’re so happy to have these treatments available for our patients” Smith said. “Response to both types of treatment has been better than what we expected. The treatments have done a for people suffering from this condition.” The Capsaicin Transdermal Patch Approved in 2020 by the U.S. Food and Drug Administration as a treatment for diabetic neuropathy, the capsaicin transdermal patch has brought relief to millions of people who suffer from the condition. Capsaicin is the compound found in chili peppers that makes them hot. In treating diabetic neuropathy, the substance acts on pain receptors in the skin by desensitizing and numbing nerve endings.

“It stimulates nerves to a point that they’re desensitized to pain,” explained Smith. “The patch works better than prescription medications for many people and typically has fewer side effects.”

About 80 percent of patients tested get 80 percent pain relief and are considered candidates to receive the spinal cord stimulator, a process that normally is covered by insurance.

Smith said results have shown about 70 percent of patients who receive the capsaicin patch experience about 60 percent relief from their symptoms. About half of patients prescribed nerve pain medication report about 50 percent relief from symptoms, while the other half say they realize no significant relief. Also, many patients taking medications complained of unpleasant side effects.

“This can be life changing for patients who have been suffering for a while,” Smith said. “It’s wonderful to see the relief a lot of patients are getting from this technology.”

Spinal Cord Stimulation Argires Marotti Neurosurgical Associates has been offering spinal cord stimulation to diabetic neuropathy patients for about a year, according to Smith, with positive results reported. “It’s been working well for a lot of patients,” he said. The stimulator, which is implanted during a minimally invasive procedure, consists of two parts: a small pulse generator that’s implanted under the skin, and two small, wire leads that are placed near specific nerves along the spine. The pulse generator and wire leads work together to block nerve pain. “It basically tricks the nerves into feeling less pain,” explained Smith.

Spinal cord stimulation has been used for decades to treat back and leg pain but was only FDA approved as a therapy for diabetic neuropathy in 2021. Trials showed that spinal cord stimulation can also help patients regain sensation in their feet. Numbness in the feet is a common symptom of diabetic neuropathy and can increase risk for falls, trips, and undetected foot wounds that can become infected, causing serious problems. While medications are still the first line of defense for diabetic neuropathy, Smith said he is grateful to have other options to offer patients who continue to suffer pain and other effects from the condition. “If the medications don’t work or don’t work well enough, our practice is able to offer these other therapies for our patients,” Smith said. “It’s nice to have options that are able to help people have less pain and improve their quality of life.”

Patients first undergo a trial to test the effectiveness of the stimulator. After receiving light sedation, a needle is inserted into the patient’s spine and a wire placed into the spinal canal for about 15 minutes – enough time to gauge whether the spinal cord stimulator will work to relieve pain.

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Perspectives

Sustainability I N

H E A L T H

C A R E

SUSAN SHELLY Writer

It is ironic that through its efforts to heal and promote health, the health care industry in the United States creates real and measurable adverse effects on the environment and consequently, the populations it serves. The health care industry is a major contributor to harmful greenhouse gas emissions, accounting for about 9% of total output. The amount of those emissions, according to the Yale Center on Climate Change and Health, has increased by more than 30% within the last decade.

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The system also generates an astonishing amount of solid waste each year. According to the AMA Journal of Ethics, a publication of the American Medical Association, hospital patients in the United States generate nearly 34 pounds of waste per person each day, resulting in about 6 million tons of waste annually. Of that waste, which includes metals, glass, food, paper, and other materials, about 20 to 25% is plastic, of which 91% is not recycled. The issue of waste was brought starkly to the forefront during the pandemic when millions of tons of personal protective equipment is thought to have ended up as waste. The good news is that leaders within the health care system are stepping up to address and remedy the problems of emissions and waste and working to improve sustainability efforts in a variety of areas. As sustainability in health care becomes an increasingly important and talked-about issue, Lancaster Physician reached out to the health care systems serving Lancaster County to learn what they are doing to address it. Representatives from WellSpan Health, Penn State Health, and Penn Medicine Lancaster General Health responded. WELLSPAN HEALTH WellSpan Health is taking an aggressive approach to improving its sustainability efforts, with goals of reducing greenhouse gas emissions by Keith Noll 50% by 2030 and being carbon neutral by 2050. The health care system has signed the U.S. Department of Health and Human Services Health Care Sector Climate Pledge and the Health Care without Harm Climate Challenge, sustainability pledges that commit it to making wide-ranging changes aimed at increasing sustainability. “We’ve been on this journey now for the past few years,” said Keith Noll, senior vice president and chief administration officer.

“We’re really accelerating our efforts to reduce our energy use and cut down on waste.” The system is working in three areas to reduce its environmental impact: greening of its operations, energy optimization, and sustainable procurement. Recycling is a major factor in greening of operations, Noll explained, and WellSpan is making great strides in that area. Reducing its use of single-use products is a priority, with changes occurring across the system. “Starting in our operating rooms, we’re looking at which products can be reused or reprocessed instead of used once and discarded,” Noll said. An example, he explained, is ablation catheters, which typically have been a single-use product. WellSpan located a company that cleans the catheters and tests them for safety, then returns them to be used again. The health system is working with another company that recycles blue wrap, the material in which surgical instruments are enclosed. “We used 36 tons of that wrap last year,” Noll said. “We used to throw it all away, but now we’re recycling it so it can be reused. We’re looking at doing a lot of things differently.” Another initiative unfolding in WellSpan’s operating rooms is reducing the use of desflurane, an anesthetic gas. An inhaled anesthetic, desflurane is popular because it’s generally easy to wake up the patients to whom it’s administered, but it has a disproportionately high impact on the environment because it’s vented out of operating rooms into the environment. In its efforts to optimize energy use, WellSpan is retrofitting or replacing old equipment, converting fluorescent lighting to LED, and updating all heating and cooling equipment to be more energy efficient.

The system’s new outpatient surgery center at CityGate Corporate Center in Lancaster, currently under construction, will use all energy-efficient equipment. In addition, WellSpan is working toward gold Leadership in Energy and Environment Design (LEED) certification for its York Hospital expansion project. Regarding procurement, leaders are making efforts to utilize more local and minority vendors and to find vendors who produce and deliver products in a sustainable manner. “That’s been a very purposeful change we’ve made,” Noll said. “It not only is it good for the environment, but using vendors close to home is good for our communities. Financially healthy communities are generally physically healthy communities, and our primary mission as a health care system is building healthy communities.” Noll is impressed and pleased regarding the way health system employees have stepped up and responded to WellSpan’s commitment to improving sustainability. A surgeon has taken on a project to reduce the use of desflurane, and housekeeping is driving recycling efforts. A physical therapist was the driving force in getting WellSpan VNA Home Care to switch from using one-use blue paper pads to a reusable, antimicrobial pad. “Our employees are leading the charge,” Noll said. “We’re not doing all these things because regulations say we have to. Our efforts right now are based on good people doing the right things for the right reasons.” PENN STATE HEALTH Sustainability was a watchword for Penn State Health as it planned and oversaw the construction of its two newest medical centers, said David Barto David Barto, vice president of facilities.

James Bitler

Penn State Health Hampden Medical Center opened Continued on page 28

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Perspectives

in Enola, Cumberland County in 2021 and Penn State Health Lancaster Medical Center opened in East Hempfield Township in October 2022. Both are state-of-the-art and feature energy-conserving equipment and practices.

The system also is working to reduce its use of certain operating room anesthetics that have negative environmental impacts and to improve the sustainability of its procurement system by trying to assess the environmental impacts of its major suppliers.

“Those facilities were designed and constructed with conservation and sustainability in mind,” Barto said.

While it has not yet signed onto a climate pledge such as the U.S. Department of Health and Human Services Health Care Sector Climate Pledge or the Health Care without Harm Climate Challenge, Penn State Health is committed to increasing sustainability by improving energy efficiency, reducing waste, conserving water, and taking other steps.

James Bitler, facilities manager for Lancaster Medical Center, praised the on-site central utilities plant that has the capacity to create steam and hot water using either fuel oil or natural gas. The plant contains four chillers that provide cooling, one of which is a heat recovery chiller that saves energy while operating in recovery mode; three emergency generators with the capacity to power almost the entire medical center for nearly a week, if necessary; variable frequency drives that enable motors to operate at lower capacities; and other features. “This building was built to the highest standards available,” Bitler said. “It’s exceeded my expectations and I’m ecstatic about how it’s performing.” Meanwhile, the entire medical center utilizes LED lighting with dimmer switches and occupancy sensors, has filtered water filling stations throughout to reduce the use of plastic bottles, and contains only energy-efficient appliances and equipment. “We’re really working to reduce our carbon footprint,” Bitler said. Systemwide, Penn State Health is currently assessing operations at all its hospitals to get a better understanding of where to target its efforts for improvements in energy efficiency, greenhouse gas emissions, and other issues. “It’s important to know where we stand so we can target our efforts,” Barto said. “This assessment allows us to compare our hospitals, both to others within our system and those outside of it.”

PENN MEDICINE LANCASTER GENERAL HEALTH For the past 30 years, Penn Medicine Lancaster General Health has worked alongside its community partners to identify and address Lancaster Alice Yoder County’s most pressing health needs. The health system’s most recent Community Health Needs Assessment identified a top priority of creating a Gregory Evans safe, healthy environment for everyone who lives, works, and plays in the community. LG Health Executive Director of Community Health Alice Yoder said that the environment can significantly affect an individual’s overall health and well-being, in either a positive or negative way. As the largest employer and an anchor institution in Lancaster County, LG Health recognizes that its actions and practices can have a considerable effect on that environment. Troy Hafer

The system has had a continuing effort for reducing its energy use for years and is looking at higher standards for greenhouse gas emissions, even though Pennsylvania does not have specific requirements for doing so. Those who work in the health care system are very aware of the system’s impact on the environment and are voluntarily taking steps to reduce that impact, according to Barto. Penn State Health is a member of Practice Greenhealth, an organization that promotes sustainable health care and offers environmental solutions to health care systems. It encourages members of the health care industry to work together to share ideas and practices to make the industry more sustainable, something Barto views as a common goal of health care organizations and facilities management professionals. “The facilities management industry wants to do the right thing for the environment because that’s part of our culture and something we aspire to,” Barto said. “The health care industry wants to do the right thing because it’s best for the people it serves. I think we’re all working toward a common goal of a better and healthier environment.”

“As a health system, our mission is to improve the overall health and well-being of everyone in our community,” she said. “We focus our efforts on the areas where we can make the greatest impact, which includes the environment.” LG Health’s efforts include the 2021 launch of the Lead-Free Families initiative, aimed at eliminating childhood lead poisoning throughout the county, as well as the related Healthy Homes Program, which works to minimize the health impact of hazards in the home, such as radon, mold, and moisture. As a health system, LG Health is in the process of assessing its own environmental impact and formulating a climate action plan to address it, according to Gregory Evans, corporate director of sustainability for its parent company, Penn Medicine. “We’re measuring our impacts in all areas to give us the information we need to develop an action plan,” Evans said.

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He expects that the necessary data will be collected by the end of the year, and a multi-year sustainability strategy will be developed in early 2024.

devices, as well as food waste. These actions not only reduce waste and the hospitals’ carbon footprints, but also result in cost savings, Evans said.

Exhaust from the electricity-producing turbine is captured and converted into energy instead of being released into the atmosphere, significantly reducing emissions.

People within the LG Health system, which includes four hospitals and numerous outpatient facilities, are studying a range of systems with environmental implications, including waste streams, procurement, energy use, emissions, and transportation.

Troy Hafer, director of facilities engineering at LG Health, spoke of efforts underway to reduce the environmental impact of Lancaster General Hospital, citing its downtown location as a factor in its efforts.

Yoder cited LG Health’s longtime efforts to improve community health through programs that address environmental concerns.

“We have to look carefully at all these areas to determine how to best develop a strategy for LG Health,” Evans said. “There are many carbon emissions aspects to consider.” In an effort to reduce medical waste over and above the traditional recycling program, Penn Medicine partners with several companies to collect and reprocess single-use medical devices, such as pulse oximeter sensors and a number of surgical

The hospital is working to reduce energy use by maintaining constant temperatures and employing night setback systems, as applicable, Hafer explained. The hospital has produced most of the electricity it uses since 2017, when it opened a power plant on its campus in Lancaster. The heat created by making electricity also produces steam that is used for humidification and sterilization.

“We’re very proud of the work we’ve done over the past several decades to promote a safe, healthy environment for everyone who lives in Lancaster County,” she said. “We recognize that we still have work to do, but we’re developing a pathway to make an even greater impact with our climate action plan, and we’re excited about that.”

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Legislative Updates

Looking Ahead

PREVIEW FOR FALL LEGISLATIVE SESSION

s we begin the fall legislative session, uncertainty continues as the legislature has yet to come to an agreement on the details of the state’s fiscal 202324 budget. Driving much of this uncertainty is the narrow democrat majority in the House of Representatives that recently went from 101-101 to 102-101 after Rep. Lindsay Powell was sworn into office in early October. Speculation is also building that democrat Rep. John Galloway may resign his house seat as he pursues a Common Pleas judgeship this November.

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YOUR CANCER WON’T WAIT. NEITHER SHOULD YOU. Should that happen, the control of the House would again be split at 101-101, creating legislative gridlock and possibly resulting in an extended House recess this fall. Despite these political rumors, PAMED is continuing to pursue several legislative issues ranging from restricted covenants to insurance credentialing to scope of practice. Legislation was recently introduced that would give psychologists prescribing privileges, a scope expansion that PAMED, along with a coalition of physician specialty organizations, will oppose. The bill, House Bill 1000, was introduced by Rep. Dan Frankel who is concerned about the lack of access to mental health services.

Hyatt P. (Tracy) DeGreen III, DO and Lena Dumasia, MD

Appointments & Second Opinions Available

Rep. Frankel also recently introduced House Bill 1633, a proposal to prohibit the use of restricted covenants in physician contracts. The bill is awaiting consideration by the House Health Committee of which Rep. Frankel is chair.

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In the Senate, Senator Michele Brooks is pushing a proposal that will void physician non-compete agreements if an employer severs the contract without cause. Her legislation, Senate Bill 521, would also require entities who dismiss a physician to provide patients with the provider’s contact information. Lastly, PAMED is working with Senator Ryan Aument to introduce legislation addressing the often months-long delay in getting physicians credentialed with health insurers.

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Though PAMED’s legislative priorities are broader than these three issues, the Society’s government relations staff works to take advantage of opportunities that potentially favor one issue over another. PAMED remains committed to such issues as telemedicine, venue reform, PBM transparency, and other pressing concerns affecting physicians.

For more information about any of the items mentioned above, please visit the Advocacy Section of PAMED’s web site at

www.pamedsoc.org/advocacy

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Restaurant Review

PER DIEM

IMAGES PROVIDED BY AND USED WITH PERMISSION OF PER DIEM

reviewed by

ABIGAIL WALTERS, DO Community Anesthesia Associates

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t’s a Thursday night and I finally had the foresight to hire a babysitter. Our schedules align…and it’s date night. But where do we go? Make a reservation? At this point, it’s too late. Perhaps drive into the city and find something new? Sounds amazing, but too adventurous after a long day of busy ORs, juggling a toddler and the laundry list of daily tasks to manage our busy lives. Ryan, my husband, will inevitably be walking through the door any minute with the question, “Where are we going?” If you were to dissect this question to its true meaning, it reads: “Where can we go close to home that will feel casual but elevated and allow us to escape the mundane, enjoy some tasty grub, and sip on a crafted cocktail?” I find that the vibe of a place is really what sets it apart from others. Yes, the food can be great and the drinks on-point, but if the atmosphere doesn’t land, then the dynamic of the experience can just feel “off.” Per Diem hits just right. Their seasonally inspired menus lure their guests into visiting time after time to enjoy just how perfectly pomegranate seeds can complement a Burrata Panzanella salad or how Fried Brussels pair with goat cheese. Their vision for the restaurant feels homey and comfortable, while also maintaining a cool and eclectic atmosphere.

at pool. Their bar area allows guests the flexibility to gather around a high top or relax in cozy booth seating. Whether enjoying a group gathering or just a quiet night for two, Per Diem creates an adaptable dining experience for any type of soiree. Per Diem’s menu boasts a diverse selection of items that range from a get-your-hands-dirty Tour Burger to a more refined fish entrée. Their array of starters and salads allows diners to explore locally inspired and in-season flavors. My husband and I tend to follow their pasta dishes rather religiously. Another favorite? From their summer menu, I highly recommend their Summer Salad, complete with delectable local greens, tomatoes, corn, crunchy masa chips, and a delicious adobo buttermilk dressing. At the time of this writing and as fall weather approaches, Per Diem plans to host their fourth annual Harvest Week, a week-long celebration of all things local. Their menu will feature in-season flavors sourced from many local farms and producers. We look forward to joining in on the fun — and using this review as a reminder to book a reservation (and a babysitter!) in advance! We have made Per Diem our place to quell the stresses of work and enjoy a delectable meal amid a fun, yet comfortable vibe. I encourage you to give it a try!

Several different spaces in the restaurant provide guests with an experience altered to their tastes. The outdoor dining space feels secluded amongst arbor vitae trees lining the sidewalks of the Hotel Rock Lititz. Their firepit welcomes diners to enjoy a beverage prior to savoring a meal. Feeling up for a little competition? The restaurant even offers an entertainment space with shuffleboard, billiards, and cornhole, creating a fun stop to grab a bite, watch a game, and slay

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PER DIEM

Hotel Rock Lititz | 50 Rock Lititz Blvd. Lititz, PA 17543 | 717-500-3436 perdiemlititz.com

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Medical Society / Foundation Updates

Marissa Witmer

Alexandar Lalovic

David Raubenstine

Vincent Vozzella

LANCASTER MEDICAL SOCIETY FOUNDATION 2023 SCHOLARSHIP RECIPIENTS ANNOUNCED Area Students Awarded $12,000 To Help Defray Medical School Costs

he Lancaster Medical Society Foundation recently announced that four students from Lancaster County will be awarded a total of $12,000 in medical school scholarships for the 2023/2024 academic year. The students were selected as part of a competitive process, which makes selections based on good character, motivation, academic achievement, and financial need.

Lalovic, also a Franklin & Marshall College graduate, currently in his second year at Liberty University of Osteopathic Medicine, received a $3,500 award. He explained that growing up in an immigrant family allowed him the opportunity to witness discrepancies in health care at an early age. Alex spent hours in physician waiting rooms, listening to his mother translate for other refugee families. He explained that the experience had a positive impact.

“The Foundation scholarship program was created to help some of Lancaster County’s best and brightest achieve their dream of pursuing a career in medicine,” said Beth Gerber, Executive Director of Lancaster City & County Medical Society and The Lancaster Medical Society Foundation. “We look forward to watching the students grow in their education and hopefully welcome them back to practice in Lancaster County in the years to come.”

“I saw how much empathy and compassion every single person — from the secretaries to the nurses and physicians themselves — had for all of these new immigrants. No language barrier could stop them from providing the best care possible.”

Recipients of this year’s award included: Marissa Witmer, of Quarryville; Alexandar Lalovic, of Lititz; and David Raubenstine and Vincent Vozzella, from Lancaster.

He added, “I was taught that the field of medicine is much deeper than just attaining a knowledge of pathologies and facts. Ultimately, I aspire to leave a positive impact on my future patients just as all these local healthcare providers impacted my family’s adopted refugee friends when they were in an extremely vulnerable place.”

Witmer, a research assistant and medical interpreter apprentice, is a Franklin & Marshall College graduate and a first-year medical student at Sidney Kimmel Medial College. She was awarded $4,500.

Raubenstine, student at Philadelphia College of Osteopathic Medicine and a graduate of Lancaster Bible College, was awarded $2,000. His path to becoming a physician was fostered by his experience in his previous roles as a behavioral specialist and mobile therapist.

She shared that her experiences have heightened her awareness of the challenges faced by underrepresented populations. “It has underscored the significance of culturally sensitive physicians who can adapt their approach to meet the diverse needs of patients, fostering trust and empowering individuals to actively engage in their healthcare journey. My mission is to address healthcare disparities and contribute to an equitable healthcare system in Lancaster County,” Witmer said. “My choice to pursue a career in medicine is driven by my genuine calling to serve underrepresented populations and my deep-rooted desire to make a meaningful impact in the Lancaster community and beyond.”

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“I headed back to the office at the end of a workday, wondering what else I could do to advocate for the kids on my caseload. It was in that office building basement that I began thinking about my role in helping to solve the problem,” Raubenstine explained. “Over the next several years, I began meeting with and observing psychiatrists who worked at many of the frequently utilized organizations in the county. Balancing school and my work responsibilities gave me a broader understanding of how the theory of medicine and practical

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life events intersect,” he shared. “Medicine can allow people to live through a cardiac arrest or traumatic brain injury. Medicine can also improve quality of living in several ways. One of the most fascinating is improving metal health.”

and research, I understand how critical the optimization of care can be for different patient populations to ensure healthy development.”

Vozzella, a first-year student at Philadelphia College of Osteopathic Medicine and a graduate of Juniata College, views medicine as existing at the crossroads of science and service — a philosophy he developed while still in high school.

Founded in 1991, the Lancaster Medical Society Foundation is a 501(c)3 nonprofit organization that was formed to grant scholarships to students from Lancaster County who are accepted at or continuing a medical degree at an accredited allopathic or osteopathic medical school.

“My call to medicine began with a two-week period of optimizing my standard swim lesson plan for a little girl on the autism spectrum. This seed grew into a desire to work with pediatric populations, as well as work with neurological and psychological composition of the brain as it develops,” he explained. “Through my experiences with both academia

The Scholarship Foundation is generously supported by the Lancaster County medical community, through hospitals and health systems, group practices, individual medical society members, local businesses and Lancaster-area residents. Since its inception, more than $294,000 in scholarships have been given to deserving local students.

OBITUARIES Dr. Joseph Hess, 91 Joseph B. Hess, MD, 91, of Lancaster passed away on Friday, August 25, 2023 at Pleasant View Retirement Community in Manheim, PA. He was the son of the late Joseph B. and Beulah B. Hess, of Akron, PA. Joe married Shirley Caulwell Hess in 1954 and will be remembered as a loving husband, father, grandfather & great-grandfather, physician and musician. A graduate of Lititz High School (1949), Gettysburg College (1953), and Jefferson Medical College (1957). After completing a two-year internship at Lancaster General Hospital he began working for the U.S. Public Health Service, relocating his wife and 6-month-old son (Joseph) to Gallup, NM for two years and treating patients from the Navajo Indian Reservation. His daughter (Julie) was born there in 1960. They returned to Lancaster in 1961, and he operated a solo medical practice east of Lancaster, on the Old Philadelphia Pike, from 1962 - 1998. Joe was a proud tuba player and charter member of the Auscultation Brass, as well as playing trombone with the Lititz Moravian Trombone Choir since 1947. His talents and interests were many! In addition to playing many musical instruments (self-taught), he enjoyed bird watching, hunting, fishing, leather work, sewing, volunteering at the Landis Valley Museum Gun Shop, and trains (having worked on the railroad in his youth). He is survived by his son, Joseph B., husband of Karen of Auburn, AL; daughters: Julie Lyons, wife of Jeffrey Lyons of Lancaster and Lori Hess, wife of Kevin Sollenberger, of Leola; grandchildren: Joseph and Tom Hess and Jeffrey and Jessica Lyons; and great-grandchildren: Joseph, John, and Abraham Hess. He was preceded in death by his wife, Shirley, in 2017.

Dr. Bill Grosh, 83

Vozzella was awarded a $2,000 scholarship.

Bill is also survived by his daughter-in-law Melissa B. Della Croce, DMD; sonin-law Brad deLeeuw; three grandchildren: Owen Wenner, Harrison Grosh, and Olivia Grosh; numerous nieces and nephews; his brother Dr. Joseph Grosh, Jr.; and his sister-in-law Carol Grosh, wife of brother Paul. He is preceded in death by his parents, late brother Paul R. Grosh, MD, and niece Regina Grosh. Bill was born on September 16, 1940 at Lancaster General Hospital to the late Dr. and Mrs. Joseph W. Grosh and Mabelle (Stultz) Grosh of Lititz, PA. Bill graduated from Warwick High School in 1958 and Moravian College in 1964, where he was a member of the Tau Kappa Epsilon fraternity and the tennis team. Growing up, Bill worked different jobs. In his late twenties, he began to think about his professional options. He applied to the Autonomous University of Guadalajara (UAG) after reading an article in Time Magazine citing the university as the oldest private medical school in Latin America. Bill returned to the U.S. to complete his internship and his three-year family practice residency training at Lancaster General Hospital in 1978. He distinguished himself as a hardworking, dedicated, empathetic young doctor. Upon completion of his residency training, he fulfilled his childhood dream of practicing and partnering with his father Joe in Lititz. Bill served as the team doctor for ELCO football beginning in 1978. In 1983, when Bill’s father retired from medicine, Bill became the Warwick Warriors’ team doctor. Bill merged his practice with Lititz Family Practice in 1993 and served as Deputy Coroner. He was affiliated with many hospitals including Lancaster General Hospital and the Heart of Lancaster Medical Center, now UPMC. He was an active member of the American Medical Association.

William “Bill” Benjamin Grosh, MD, 83, passed away peacefully on his birthday surrounded by family at Mount Joy’s Hospice and Community Care on September 16, 2023.

His legendary 30-year medical career ended in December 2007 when he retired from Lititz Family Practice and as the team physician at Warwick High School.

Bill was an accomplished physician, pianist, community leader, author, and avid sports fan. His greatest achievements were as a loyal husband to his late wife Janet (Messner) Grosh and a wonderful father to Jennifer Grosh, Holly (Grosh) Wenner, and Stephen Grosh.

In 2010, Bill came out of retirement to begin working at Heart and Family Health. He had five more wonderful years doing what he loved which was

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patient care. He finally retired for good in 2015 at the age of 75.

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News & Announcements

Frontline Group Spotlight

Lancaster Pulmonary & Sleep Associates, A Member of UPMC Pulmonary and Sleep Services

Massood Ahmad, MD

Chinenye Emuwa, MD

ancaster Pulmonary & Sleep Associates provides evaluation and treatment for patients suffering from respiratory illnesses, difficulty breathing, and sleep disorders.

In addition, our practice treats patients with sleep disorders, which can significantly affect an individual’s quality of life. We diagnose and address sleep apnea, hypoventilation, obesity hypoventilation, insomnia, parasomnias, nightmares, REM behavior disorder, narcolepsy, and other hyper somnolent disorders.

We specialize in pulmonary medicine focused on conditions and diseases of the lungs, treating shortness of breath, coughing, recurring chest infections, bronchitis, and chronic obstructive pulmonary disease (COPD), a disease that affects more than 11 million people in the United States. We also see patients suffering from conditions such as asthma, interstitial lung disease, pulmonary hypertension, pleural diseases, and lung nodules.

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Our multidisciplinary team of experts — including lung specialists Massood Ahmad, MD, and Chinenye Emuwa, MD — work together to provide an individual treatment plan for each patient, ranging from pulmonary rehabilitation to surgical treatment.

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Member Spotlight

News & Announcements

Where do you practice and why did you settle in your present location or community?

I see patients at Lancaster General Hospital (LGH), Suburban Pavilion, and the Ann B. Barshinger Cancer Institute as a member of Penn Medicine Lancaster General Health Physicians Surgical Group. I was born at LGH and have lived in Lancaster County for most of my life. I worked at the hospital as a teenager and through college as a nurse’s aide and unit clerk. My undergraduate degree is a Bachelor of Science in nursing. I continued my career in nursing at LGH after graduation from college and began the process of entering medical training. I moved to Philadelphia for my medical training for 10 years. I chose to return home to practice because I had the opportunity to work with my current group during residency and felt at home. I felt comfortable in the hospital and valued the organization. It was a supportive practice for a new surgeon, and I loved the variety. I find great satisfaction in serving my community with surgical care.

What do you like best about practicing medicine?

I love the challenge of surgery and medicine. Though I treat many common conditions, each patient is different both in interaction and in anatomy. This variety means that each day is different and allows me to expand my knowledge and skills continually. The ability to use my knowledge and expertise to change patients’ lives for the better in a concrete way provides me with great satisfaction. I enjoy educating patients and helping them through the process of surgery and recovery.

What are your hobbies and interests when you’re not working?

Kelly Janke, DO Penn Medicine Lancaster General Health Physicians Surgical Group

I find it important to balance work and its stresses with positive and enjoyable activities. I have three children — 17, 15, and 12 — who are developing into fantastic people. Much of my free time is spent with them, and it’s a great way to be encouraged. They have ever-changing views on life and bring me great joy. I also provide a home for three entertaining cats who are quite spoiled. Though I am content to spend time at home recharging and cooking, I have come to enjoy frequent travel. I travel independently and with my children to locations far and near, seeking new places and experiences. It has enhanced my life greatly to explore regions away from home. I also enjoy hiking, backpacking, yoga, live music, taking outdoor photos, creating photo books, reading, and cross stitch.

For what reason(s) did you become a member of the Lancaster City & County Medical Society and what do you value most about your membership? I received a scholarship from the LCCMS in medical school. This was helpful to me, and I was eager to join the Society when I started practicing. I wanted to participate in this organization that is supportive to local students. After I began participating in Society events, the value of networking across the county became evident. Physicians tend to spend time with colleagues in their own organization by default. LCCMS offers an opportunity to expand my horizons to colleagues across institutions and get to know fantastic physicians in the area. This has led to friendships and increased awareness of medical care in the community. The Society is well-organized, and the events are fun. I look forward to the various offerings throughout the year.

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News & Announcements

FRONTLINE GROUPS FALL 2023 Frontline Practice Groups have made a 100% membership commitment to LCCMS and PAMED. We thank them for their unified support of our efforts in advocating on your behalf and facilitating an environment for physicians to work collaboratively for the benefit of the profession and patients.

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New Members Zahid Asgher, MD Laleh Sarah Radfar-Baublitz, DO Iconic Medical Arts Trevor Jackson, MD Lancaster Orthopedic Group

 The Heart Group of Lancaster General Health  Hospice & Community Care  Hypertension & Kidney Specialists  Iconic Medical Arts  Lancaster Arthritis & Rheumatology Care  Lancaster Cancer Center Ltd  Lancaster Cardiology Group LLC  Lancaster Ear Nose and Throat  Lancaster Family Allergy  Lancaster Pulmonary & Sleep  Lancaster Skin Center PC  Manning Rommel & Thode Associates  Nemours duPont Pediatrics Lancaster  Neurology & Stroke Associates PC  Patient First – Lancaster P enn Medicine Lancaster General Health Physicians Diabetes & Endocrinology

P enn Medicine Lancaster General Health Physicians Family Medicine Lincoln

P enn Medicine Lancaster General Health

P enn Medicine Lancaster General Health Physicians Family Medicine Norlanco

P enn Medicine Lancaster General Health Physicians Family Medicine Red Rose

P enn Medicine Lancaster General Health Physicians Family Medicine Susquehanna

P enn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

P enn Medicine Lancaster General Health Physicians Specialty Medicine

 Pennsylvania Specialty Pathology  Randali Centre for Aesthetics & Wellbeing  Shady Grove Fertility-Lancaster  Surgical Specialists—UPMC  Union Community Care – Hershey Ave  Union Community Care – Water St  UPMC Breast Health Associates  UPMC Plastic & Aesthetic Surgical Associates  WellSpan Ephrata Cancer Center  WellSpan Family Health – Georgetown

Physicians Family Medicine New Holland

reinstatements Daniel Sandusky, MD Penn Medicine Lancaster General Health Physicans Pain Management Jilian White, MD WellSpan OB/Gyn – Stony Brook, York

LCCMS EVENTS 2 0 2 3 Friday, October 27 - Saturday, October 28

PAMED House of Delegates Hybrid Event www.pamedsoc.org/HOD

Harrison Kline student

Saturday, December 2

Calista Long student

Holiday Social & Foundation Benefit

Megan Morris-Murphy, DO Highlands Family Practice

6:30 p.m. | Lancaster Country Club

Safitaj Sindhar student Terra Spinuzzi Sloat, DO resident - UPMC Lititz

for more info visit www.lancastermedicalsociety.org

Justin P Vandermolen, DO resident - UPMC Lititz

LANCASTER

PHYSICIAN

AS WE KICK OFF THE HOLIDAY SEASON & CONTINUE ALL THROUGH DECEMBER.

Starting

NOVEMBER 2, 2023 SPECIAL WEEKEND HOURS: November 4 & 5, 11 & 12 Saturday 10 a.m. - 5 p.m. | Sunday 12 - 4 p.m.

Our store will be ﬁlled with holiday home décor, ﬂoral designs, wreaths, ornaments, reindeer, Santas, candles & more!

Featuring... Door Prizes & Specials

Beautiful themes & colors diplayed on 5 ﬁreplaces & 8 trees!

717-354-2233 1064 East Main St. (Rt. 23) | New Holland, PA Mon. - Fri. 10 a.m. - 5 p.m., Sat. 10 a.m. - 2 p.m.

www.HeritageDesignInteriors.com

Join us on SOCIAL MEDIA for Special Events & Sales

The leading cause of death

calls for leading treatments

UPMC Heart and Vascular Institute brings world-class cardiovascular care to Lancaster County. UPMC Heart and Vascular Institute provides world-class care in Lancaster County. Our experts offer a full range of services to prevent, diagnose, treat, and manage diseases of the heart using advanced minimally invasive technology close to home. Learn more and schedule an appointment at UPMC.com/CentralPaHeart.