Lancaster Physician Spring 2022 by Hoffmann Publishing Group

Spring 2022

Genetic Testing its role in cancer prevention and treatment BY LENA DUMASIA, MD, LANCASTER CANCER CENTER LTD.

plus PERSPECTIVES FROM LOCAL HEALTH CARE PROFESSIONALS

Health Systems and Community PartnershipS By Susan Shelly RESTAURANT REVIEW

MAX'S EATERY By Justin Overcash, MD, Lancaster Radiology Associates, Ltd.

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contents

SPRING 2022

2021/2022 BOARD OF DIRECTORS OFFICERS Laura H. Fisher, MD President

Lancaster Family Allergy

COVER STORY

Genetic Testing p. 14

Stacey Denlinger, DO President Elect

UPMC Highlands Family Practice & UPMC Wound Healing Center

Sarah Eiser, MD Vice President Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

Stephen T. Olin, MD Treasurer

Penn Medicine Lancaster General Health Walter L. Aument Family Health Center

Robin M. Hicks Secretary

UPMC Supportive Care & Palliative Medicine

Robert K. Aichele Jr., DO Immediate Past President

Penn State Medical Group - South Lancaster

DIRECTORS Marco A. Cunicelli, DO | Resident Lena Dumasia, MD David J. Gasperack, DO Lauren M. Hammell, DO | Resident James M. Kelly, MD Karen A. Rizzo, MD, FACS Christopher R. Scheid, DO Susanne Scott, MD, MPH Danielle Rubinstein, DO | Resident

EDITORS Dawn Mentzer

Best Practices 6 Penn Medicine Lancaster General Health is Addressing Childhood Trauma's Long-Lasting Health Impacts

10 Penn State Health: Lancaster Cleft Palate Clinic’s Renovations Bring Enhanced Technology and New Family-Friendly Features

8 WellSpan Health: Patients with Depression Say Transcranial Magnetic Stimulation is Life-Changing

12 Practice Management in a Mental Health Crisis

In Every Issue 5 President’s Message

26 Perspectives

14 Healthy Communities

30 Legislative Updates

23 Passion Outside of Practice

32 Restaurant Review

24 Patient Advocacy

35 News & Announcements

Beth E. Gerber Lancaster City & County Medical Society Robert K. Aichele Jr., DO Immediate Past President

Penn State Medical Group - South Lancaster

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 patient-centered 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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SPRING 2022

President’s Message

hile it may be a while before we truly get to take a pandemic break, as intermittent spikes will need to be weathered, I am enjoying the gradual transition to in-person events.

In the interim, I anticipate smaller group sessions.

Lancaster City & County Medical Society will continue to adapt to changing local circumstances. Every physician’s circumstance is different, just like every patient’s COVID-19 recommendations are different at this point. I find each office visit taking longer as we discuss in detail an individual’s exposures, underlying health issues, comfort level, family and school dynamics, and risks.

Our very own Karen Rizzo is the chair of PAMED’s Women Physicians Section. As a Lancaster-based group, we would like to provide an opportunity to network and socialize via Zoom, or in-person, to listen to one of PAMED’s speakers and possibly enjoy some wine.

We understand that some of you may not be able to join us “live,” so we will continue to provide some virtual and smaller group content. However, we will also move forward with some larger events this year. We appreciate all the support for our Spring Social on Saturday, May 7th at Lancaster Country Club, which is also an opportunity to raise money for aspiring Lancaster County medical students and residents. Please save the date of Thursday, September 15th for our Annual Dinner & Awards Celebration. An open area with improved ventilation has been designated for use. December 3rd marks the return of our annual Holiday Social and Foundation Benefit at Lancaster Country Club.

We are moving ahead to schedule a virtual event with legislators who have been very helpful in the past.

Laura H. Fisher, MD Lancaster Family Allergy Visit lancastermedicalsociety.org

As the weather warms up, we are looking for volunteers to host small gatherings of 10 or fewer physicians (hopefully including some that they do not yet know) for a discussion of a common interest topic in their home or backyard. Topics might include hobbies, like fly fishing; lifestyle trends, such as raising backyard chickens; or critical skills, like “how to survive a 2-year-old.” If you have an area of interest or expertise and are interested in hosting, please contact Beth Gerber. In conclusion, I look forward to actually seeing some of you in person soon. Vaccinate, vaccinate, vaccinate! And please get involved, even if only for a little bit. Our LCCMS membership can make a big difference when we work together and can rely upon each other.

LHF

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 Health: Patients with Depression Say Transcranial Magnetic Stimulation Therapy is Life-Changing • Penn State Health: Lancaster Cleft Palate Clinic’s Renovations Bring Enhanced Technology and New Family-Friendly Features • Practice Management in a Mental Health Crisis

ADDRESSING CHILDHOOD TRAUMA’S LONG-LASTING HEALTH IMPACTS Penn Medicine Lancaster General Health works with community partners to provide awareness and resources.

he patient’s troubled medical history finally began to make sense once he revealed a painful childhood secret.

His health challenges, including hospitalization and surgery, began in his teens. As an adult, he experienced a string of failed relationships, struggles with substance abuse, and poorly controlled diabetes. At times he was so paralyzed by anxiety and depression that he was afraid to leave his house, resulting in many missed medical appointments. He eventually sought care at Penn Medicine Lancaster General Health Physicians Care Connections, a clinic for people who’ve had multiple hospitalizations over a short period of time.

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When asked about any possible traumatic events in his past, the patient at first was reluctant to respond. After some gentle prompting, he described attending a family event as a young boy. An older relative took the boy to a location away from the others and sexually abused him. “My patient, who was now middle-aged, had never disclosed what happened to him,” his physician, Jeffrey R. Martin, MD, said. “As we talked about the secret he had kept since he was a young boy, a picture of the consequences of childhood trauma began to emerge.” Unfortunately, similar stories are all too common. Childhood trauma — or “adverse childhood experiences” (ACEs) — can cause significant, long-lasting impacts on mental, physical, social, emotional or spiritual well-being. These traumatic events may include abuse or neglect; violence, mental health problems or substance abuse in the home; or instability due to parental separation or incarceration. LG Health convenes community partners working to prevent and reduce the impact of trauma by increasing awareness and creating more places in the community where trauma survivors can feel safe, valued, and empowered. The health system’s efforts include offering training for medical providers and other community members. Recognizing and supporting survivors is an issue of growing concern for many communities across the United States. In a recent Centers for Disease Control-Kaiser Permanente study, nearly two-thirds of respondents reported at least one adverse childhood experience, while more than 20 percent reported three or more. Martin, Chair of the Department of Family & Community Medicine at Lancaster General Hospital, said medical experts recognize the well-established connection between childhood trauma and both risky health behaviors and chronic health conditions in adulthood. “Individuals who have experienced more than four ACEs are at a significantly higher risk for seven of the top 10 leading causes of death, including heart disease, diabetes, emphysema, and suicide,” he said. “Those with six or more

ACEs have a life expectancy on average nearly 20 years less than those without ACEs.” RECOGNIZING AND RESPONDING TO THE LASTING IMPACTS OF TRAUMA

Trauma can affect survivors in many different ways, with lasting adverse impacts that range from difficulty trusting others to irritability, anxiety, depression, and substance abuse. These effects may not surface until well into adulthood, and many survivors carry the burden alone in silence for years. To offer survivors more supportive services both in health care and across a variety of community settings, LG Health collaborates with many community partners to raise awareness of the pervasiveness of trauma and its impact on those who have experienced it. LG Health and its partners work together to provide education and training, as well as implement sustainable changes to policies and systems in order to support trauma-informed care. Mary Dorman, a health promotion specialist at LG Health, said completing a training can help individuals and organizations to better understand trauma, how it affects survivors, and how to best respond. In particular, understanding the impacts of trauma can help medical providers gain greater insight into their patients’ experiences and needs, while building a stronger therapeutic rapport and connection. Many survivors of trauma may be less likely to seek care due to fear and anxiety, she said. An invasive medical procedure could be especially traumatizing for those patients. “A provider may have a patient who doesn’t show up for appointments,” she said. “By learning more about a trauma-informed approach to care, you learn to shift your perspective from ‘What’s wrong with them?’ to ‘What happened to them?’’’ Since one in eight Pennsylvanians has experienced four or more ACEs, it makes sense to take a “universal precautions” approach when caring for patients, Dorman said. In addition, it’s important to note that ACEs do not paint the full picture. Research shows that positive childhood experiences (PCEs) can provide protection against adversity.

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LG Health encourages medical providers, as well as anyone in the community who interacts with individuals and families who may have experienced trauma, to take the free virtual training course, “Understanding Trauma, Resilience and Trauma Informed Care.” The self-paced course includes four one-hour modules that can be accessed anytime, from any location. To date, more than 7,000 health care and behavioral health providers, first responders, law enforcement and criminal justice professionals, educators, community volunteers, and others have completed the training, Dorman said. Community members can access the training at pacesconnection.com/g/lancaster-county-pa-aces-and-resilience-connection; medical professionals can find specific instructions on the page. In addition to completing a training, medical professionals can provide more trauma-informed care by assessing their practice environment and making fairly simple modifications to ensure that patients and staff feel both physically and psychologically safe, she said. For example, people who have survived trauma will likely feel more comfortable in an environment that is serene and calming, instead of a cluttered and chaotic waiting room. LG Health also has specially trained staff members in place in a variety of settings to care for patients who have experienced trauma, including the Emergency Department and Seraph-McSparren Pediatric Inpatient Center at Lancaster General Hospital, as well as Labor & Delivery at Women & Babies Hospital. “With awareness, knowledge and the right tools, we can create a supportive and safe community for everyone,” Dorman said. “This is a sensitive and challenging issue, but our shared success is necessary to ensure the health, well-being, and resilience of our community now and for future generations.”

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Best Practices Mary Haupt (standing) and Tanya Seprinski demonstrate what a patient experiences during a transcranial magnetic stimulation treatment. Mary is the TMS technician and Tanya is the TMS coordinator at WellSpan Philhaven.

Patients with Depression Say Transcranial Magnetic Stimulation Therapy is Life-Changing WELLSPAN PHILHAVEN OFFERS THIS NONINVASIVE, OUTPATIENT TREATMENT WHEN MEDICATIONS FAIL.

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ike Parker felt nothing, just a yawning emptiness. He did not want to get out of bed. He did not want to interact with his wife or play with his dogs. Diagnosed with depression, he tried medication but could not find any that was effective. He was hospitalized twice and had to quit his chef ’s job. “People think of depression as you’re sad. You’re not sad. You just don’t have the will to live. You’re just breathing. You don’t want to eat. You don’t want to get a shower,” he said. “It’s just a whole lot of nothing. A blank state of barely surviving.”

SPRING 2022

Mike Parker, shown here with his wife, Carrie, recently underwent TMS treatments, which he said made him feel “like a new person.”

Patients recline in a chair during treatments. The treatment device rests lightly on their head and delivers electrical impulses to a specific area of the brain. The patient is awake — in fact it is preferred they are talking, reading, or otherwise mentally engaged for maximum effect. “The treatment feels like a pencil eraser tapping on your head, for short bursts,” Mike said. “It’s not uncomfortable.”

Then Mike tried a treatment called TMS, or transcranial magnetic stimulation. TMS is a noninvasive, outpatient procedure that uses a device to stimulate nerve cells in the brain and improve the symptoms of depression. Parker recently completed six weeks of treatments offered by WellSpan Philhaven. “Within the first week, I could tell my mood had lightened a little bit,” said Parker, 43. “After six weeks, I felt like a new person.” Parker and his wife hosted family members over the holidays at their Berks County home. He actively participated in and enjoyed the visit, something he would not have been able to do without the treatment. “I made dinner, which I have not done in a while,” he said. “We watched a couple of Christmas movies and had breakfast Christmas morning. It was good.” Overall, 70 percent of patients treated with TMS at Philhaven have seen an improvement in their depression symptoms and 42 percent have had a complete remission of their symptoms. A DIFFERENT WAY TO TREAT DEPRESSION Depression is the leading cause of disability for people ages 15 to 44 in the U.S., according to the U.S. Centers for Disease Control. Medications and therapy are the first line of treatment, but they do not work for everyone, said Dr. Sehar Khokher, the associate medical director of WellSpan Philhaven. Khokher is trained to deliver TMS, which Philhaven has offered since 2019.

Cleared by the Food and Drug Administration, TMS is a part of a growing field of “neuromodulation” treatments that deliver electrical or chemical signals to targeted areas of the nervous system, acting directly on the nerves. Neuromodulation therapies include spinal cord stimulation to treat chronic neuropathic pain, deep brain stimulation for Parkinson’s disease and other disorders, and vagal nerve stimulation for epilepsy. TMS treatments deliver targeted magnetic pulses to stimulate mood-controlling areas of the brain that are underactive in people who have depression, lessening or eliminating their depression symptoms. TMS also is showing promise as a treatment for other conditions. The creators of NeuroStar, the TMS device used at Philhaven, are working toward getting approval for its use in the treatment of tobacco addiction and bipolar depression. TMS also is being investigated for the treatment of opioid or stimulant addictions, eating disorders, ADHD in children, and early dementia, among other conditions. Patients with depression must have failed one trial (typically a six-week period) of antidepressant medication to qualify for TMS. The treatment is covered by Medicare and most private insurances. THE PROCESS, AND ITS RESULTS Patients receive a 30-minute treatment every weekday for six to eight weeks at one of the two Philhaven locations that offer TMS: the Mt. Gretna campus in Lebanon County or the Meadowlands office in York.

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About 60 percent of patients may need another round of TMS treatments. Mike was in this group. His treatment at Philhaven followed treatment he received four years ago in North Carolina, where he used to live. He was taking medication but started to feel depressed again and sought out another TMS provider. Khokher said the treatment can be “life changing” for patients, who often talk about having hope for the first time in a long period. She recalls a particular woman who had not left her house in years, due to her depression. By the second week of treatments, the woman was driving places and walking around the block in her neighborhood. “I don’t think people realize how debilitating depression can be,” she said. “We just manage depression. We don’t cure it. I think this will change future treatment approaches, and I think the technology will get a lot more sophisticated as time goes on and continue to evolve.” For Mike, TMS “seemed like magic, like a switch had been flipped. My wife was thrilled. After the treatment was done, we started going outside and going on hikes. We bought kayaks. We started going to restaurants. We started living.” He adds, “I am not the same person, in a very good way. It was night and day for me.”

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Best Practices

Dr. Donald Mackay, center, discusses follow-up care with the parents of a newborn patient.

Lancaster Cleft Palate Clinic’s Renovations Bring Enhanced Technology and New Family-Friendly Features 2021 TRANSFORMATION ADVANCES THE CLINIC’S WORK IN IMPROVING CHILDREN’S LIVES

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s a medical student, Dr. Cathy Henry knew she wanted to be a pediatrician. Then she did a rotation with pediatric plastic and reconstructive surgeon Dr. Donald Mackay at the Lancaster Cleft Palate Clinic. “It was life-changing,” Henry said. “The clinic just felt special. They really took care of patients the way we wish we could in every aspect of medicine. I knew then I had to become a pediatric plastic surgeon.” Today, Henry is part of the pediatric surgery team at Penn State Health Children’s Hospital that performs cleft lip, palate, and other craniofacial procedures for the clinic’s patients. Roughly 1 in 700 children are born with a cleft, which can range from a small notch on the lip or palate to a significant one-sided or bilateral cleft. Normally, the tissues that make up a baby’s lip and palate fuse together in the second and third months of pregnancy. But in babies with cleft lip and cleft palate, the fusion never takes place or occurs only partway, leaving an opening. Many clefts are diagnosed prenatally via ultrasound. Researchers believe that most cases are caused by an interaction of genetic and environmental factors. In many babies, a definite cause isn’t discovered.

SPRING 2022

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The Lancaster Cleft Palate Clinic follows between 2,000 and 2,500 patients annually. About one-third of its patients come from Lancaster County and surrounding areas, while the remaining two-thirds come from throughout Pennsylvania and other states. It’s the only craniofacial center between Philadelphia and Pittsburgh. The clinic’s multidisciplinary team — which includes a feeding specialist, dentist, audiologist, hearing therapist, pedodontist (pediatric dentist), and social worker, in addition to an orthodontist, speech pathologist, and the plastic surgeons — cares for all patients regardless of ability to pay.

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Dr. Elizabeth Prada, pediatric dentist and executive director of the clinic, recently spearheaded a much-needed renovation of the Clinic. The newly renovated clinic opened in July 2021. Named the Sam and Dena Lombardo Pavilion it recognized Sam and Dena’s extraordinary service to clinic as well as their generous $750,000 gift that ensured the success of the $4 million development drive. The clinic used the funds to upgrade and replace computers and servers throughout the organization, improving staff efficiency and productivity. They purchased new diagnostic and treatment tools for hearing, speech and feeding along with improvements to the office’s electronic medical records systems.

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Renovations include a building-wide HEPA filtration system and negative-pressure units in every pediatric operatory and treatment space. The clinic moved also moved its main entrance from Lime Street to the rear, putting the door closer to the parking lot for convenience. Family-friendly enhancements include a play area and private rooms for conferences or mothers breastfeeding babies. Child-centered dentist offices feature ceiling-mounted televisions, hidden space for technology with the potential to frighten children. Three additional rooms increased capacity. The project also included upgrades to the orthodontic suite and team spaces.

YOUR CANCER FIGHT IS OUR CANCER FIGHT

Lancaster Cleft Palate Clinic serves as the lead research facility for the Americleft Project, a multi-institutional outcomes study that will compare the clinic’s treatment protocols to those of other centers worldwide.

H. Peter (Tracy) DeGreen III, DO and Lena Dumasia, MD

Cancer is an unexpected and unwanted illness. It will change your life forever in a way that no other illness can. Together, we found that treating the cancer as well as supporting the patient and their well-being, provides the ultimate outcome in winning the fight.

In addition to treating newborns and children newly diagnosed with craniofacial conditions, the Lancaster Cleft Palate Clinic performs pre-adoption counseling at no charge for parents who wish to adopt a child with a cleft.

New patients and second opinions will be seen within 24 hours, call 717.291.1313.

For Mackay, helping children and families with clefts brings great reward. “To make an impact on these children and families is a remarkable privilege,” he said. “These kids are very inspirational and so strong. And when we can help them just a little bit, it doesn’t get any better.”

703 Lampeter Rd. • Lancaster, PA 17602 LancasterCancerCenter.com • (717) 291-1313 On-site Laboratory | Physician Directed Dispensary | Support

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Best Practices

Practice Management Insights

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

Practice Management IN A MENTAL HEALTH CRISIS

RITA M. BOER, LCSW

Practice Manager, Community Services Group, Lancaster Outpatient Programs

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ith the advent of the COVID-19 pandemic, many physicians and other health care professionals were catapulted into service delivery that looked completely different from that of pre-pandemic days. Today, in spring 2022, we look back and see we have successfully adjusted in many ways. We are familiar and comfortable with PPE. We routinely use tele-conferencing to connect with patients and each other. For community mental health clinics, however, there is a second epidemic that will continue to impact and shape the way we work. The pandemic-induced mental health crisis in our country has created increased demand for services and new considerations for psychiatric practice management. Ahead of the State of the Union address, a statement from the White House recognized that the current mental health crisis in our country is unprecedented and is affecting people of all ages. Today, two out of five adults report symptoms of depression or anxiety. One in three adolescents report persistent feelings of sadness or hopelessness. While rates of depression and anxiety were rising prior to 2020, the losses, trauma, and physical isolation associated with the global pandemic have not only led to increased risk of mental health concerns among healthy people but also have worsened symptoms for those with preexisting psychiatric diagnoses. This unprecedented prevalence and severity of the mental health concerns in our communities has had a significant impact on the mental health industry. Though difficult and challenging, our collective experiences of the last two years are partly what is allowing our industry to adjust and work to meet the needs of the current mental health crisis. Psychiatrists and other mental health professionals have long known the stigma associated with mental illness creates barriers to accessing care. As instances of mental illness increase, so does awareness and understanding of these important health concerns. We have begun to see institutional, governmental, and public

recognition that access to mental health care is a bedrock to sustaining a healthy community. As a clinic, we are working to use that momentum to enhance the services we provide.

So, how have we adjusted? Expanding access through the establishment of a “hybrid” clinic. The days of our traditional site-based model for accessing outpatient mental health services are gone. While our initial move to providing telehealth was sudden and dramatic, today we are using virtual platforms to connect with patients as a part of routine care. We know that just as psychiatric presentations vary by individual, so do the individual’s needs and preferences for accessing care. Our regulatory bodies and payers have also recognized that providing multiple avenues for service delivery is necessary in order to address population needs. As such, we have confidently forged ahead in creating a new model for service delivery that includes the possibility for virtual care for our patients. Today, our psychiatrists and other mental health professionals are able to offer care in whatever way works best for our patients: in-person, via tele-conference, or even, at times, by phone. Opening access to care to include multiple modalities for service delivery has meant that as a practice we have adjusted how we handle referrals, schedule appointments, and manage follow-up care. We are using technology – including our Electronic Health Record, phone system, and video-conferencing platform – in new ways every day. We’ve focused inward. In a time of increased patient volume and acuity, we are focusing on those providing care. Our practitioners are not only managing the impact of the mental health crisis within their own caseloads, but also navigating a larger mental health system whose capacity is strained. The feelings of stress, frustration, and helplessness that we see in our patients are often present in our staff as well. Practitioner burnout is a significant concern. As a clinic, we emphasize the concept of self-care with our staff because we know that maintaining a healthy workforce is a vital part of high-quality service delivery.

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Supporting our staff has started with allowing for workplace autonomy and flexibility wherever possible. For some of our staff this has included being able to work from home during parts of the week. We promote staff taking planned time off from work, and we provide opportunities for training/clinical development. Many times, promotion of selfcare in this challenging professional atmosphere has meant assisting in managing professional boundaries. Expanded access to care and increased use of connective technology in our day to day work has required clarification of expectations around work hours, how we communicate with patients, and how we interact with each other so that physicians and other staff can purposefully “unplug” and take time away from the demands of the work. Growing our team. One of the biggest challenges in practice management during this mental health crisis is meeting the current demand for our services. As an industry, we are balancing the gains we have made in reducing stigma and increasing access with the day to day realities of our capacity to treat and care for the community. As a clinic, we have managed this in many ways including using waitlists, and, during times of extreme capacity shortages, temporarily closing to new referrals. We have found, however, that the best way to truly meet the needs of the community is to grow. Adding staff to meet demand has meant readjusting expectations and letting go of some “old” pre-crisis considerations. We have had to be creative with office space, schedules, and administrative support to make this work. While we hope for wellbeing, stability, and recovery for all we serve, we also strive to remain nimble and open to adjusting to meet the needs of the community which is calling on us for help.

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Healthy Communities

Genetic Testing Its Role in Cancer Prevention and Treatment

LENA DUMASIA, MD

Lancaster Cancer Center Ltd.

enetic testing is a type of medical test that identifies changes in genes, chromosomes, or proteins in the human body that can lead to a disease. The results of a genetic test can also confirm or rule out a suspected genetic condition. Genetic testing can also help determine a person’s chance of developing or passing on a genetic disorder. It plays an important role in determining the risk of developing certain diseases. In some people who have a significant family history of cancer, genetic testing can be used to determine if they carry a gene for a certain disease that could be passed on to their children.1 However, it can only demonstrate limited information about an inherited condition. It will not show symptoms of a disorder, how severe the symptoms will be, or whether the disorder will progress over time. 2 A cancer syndrome, or family cancer syndrome, is a genetic disorder in which inherited genetic mutations in one or more genes predispose the affected individuals to the development of cancers. It may also cause the early onset of these cancers. Cancer syndromes often show not only a high lifetime

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risk of developing cancer, but can also detect the development of multiple independent primary tumors.3 Most common examples of inherited cancer syndromes in the field of oncology are the hereditary breast-ovarian cancer syndrome and hereditary non-polyposis colon cancer (Lynch syndrome).4,5 Hereditary breast-ovarian cancer syndrome is an autosomal dominant genetic disorder caused by genetic mutations of the BRCA1 and BRCA2 genes. In women, this disorder primarily increases the risk of breast and ovarian cancer and also increases the risk of fallopian tube carcinoma and papillary serous carcinoma of the peritoneum. Additionally, in men, the risk of prostate cancer is increased. Other cancers that are inconsistently linked to this syndrome are pancreatic cancer, melanoma, and cancers of the uterus and cervix. Genetic mutations account for approximately 7 percent of breast cancer and 14 percent of ovarian cancer cases. BRCA1 and BRCA2 account for 80 percent of these cases. BRCA1 and BRCA2 are both tumor suppressor genes implicated in maintaining and repairing DNA, which in turn leads to genome instability. Mutations in these genes allow further damage to DNA, which can lead to cancer.6,7 Hereditary non-polyposis colon cancer, also known as Lynch syndrome, is an autosomal dominant cancer syndrome that increases the risk of colorectal cancer. It is caused by genetic mutations in DNA mismatch repair (MMR) genes, notably MLH1, MSH2, MSH6, and PMS2. In addition to colorectal cancer, many other cancers have increased in frequency. These include: endometrial cancer, stomach cancer, ovarian cancer, cancers of the small bowel, and pancreatic cancer. Hereditary non-polyposis colon cancer is also associated with an early onset of colorectal cancer. MMR genes are involved in repairing DNA when the bases on each strand of DNA do not match. Defective MMR genes allow continuous insertion and deletion mutations in regions of DNA known as microsatellites. These short repetitive sequences of DNA become unstable, leading to a state of microsatellite instability (MSI). Mutated microsatellites are often found in genes involved in tumor initiation and

progression, and MSI enhances the survival of cells, leading to cancer.5,8,9,10 Genetic testing is important in cancer patients because if a test comes out positive, they are more aware of their own personal health and the health of immediate family members.11 For example, a patient positive for Hereditary Breast and Ovarian Cancer would be a candidate to go through specific surgery: a hysterectomy to reduce the risk of ovarian cancer as well as a bilateral mastectomy to reduce the risk of breast cancer. This can add years onto the patient’s life expectancy.12 Another preventive measure is regular cancer screening and check-ups. If a person has Lynch syndrome, they should have a regular colonoscopy to examine if there is any change in the cells lining the intestinal wall. Regular check-ups have been proven to add an average of seven years onto the life expectancy of a person suffering from Lynch syndrome, as early detection means the correct preventive actions and surgery can be done quicker.13 Regular breast screening is also recommended for women diagnosed with BRCA mutations. In addition, recent studies show that men with increased risks of developing prostate cancer due to BRCA mutations can decrease their risk by taking aspirin.14 Aspirin is hugely beneficial in lowering cancer prevalence; however, it must be taken regularly over at least a five-year period to have any effect. 15 Recently, the field of oncology treatment has been evolving into a genetic-based model.16 This means that a specific gene is identified in the cancer cell, and then a specific medication shown to target that gene and cause the death of that specific cancer cell is used.16 Oncologists often look for specific mutations in a person’s tumor biopsy findings because they can represent an important target for specific treatments. Targeted gene therapy has been demonstrated to be more effective in certain cancers than traditional chemotherapy. Until recently, testing for mutations meant running a specific test to look for a single specific mutation, or possibly requiring several individual tests to look for a few specific targets. Research has led to a growing number of potentially important targetable mutations for many cancers. A newer, alternative strategy

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called next generation sequencing (NGS) allows physicians to test many genes of a cancer simultaneously. Next generation sequencing can be performed on material from a patient’s tumor that has been biopsied. In some cases, it may be possible to even test a patient’s blood sample for small amounts of tumor DNA that may be shed from the cancer. Through this test, there can be several identified molecular targets that are commonly seen and a possibility of identifying a mutation that represents a new treatment option. 17 Targeted gene panels have shown expanded usefulness across many cancer types, especially those for which more than one genetic variant may be responsible. Certain mutations present in the tumor tissue could lead to specific treatment recommendations as they would be effective with that genetic variant. As an example, a poly(ADP-ribose) polymerase (PARP) inhibitor could be considered in a patient with an identified BRCA1 or BRCA2 mutation as it has been shown to be effective in this situation.17 Another option would be the use of a medication for breast cancer called Piqray®, which would be effective in breast cancer patients who exhibit the PIK3CA gene mutation that would also be detected by NGS. In 2017, the monoclonal antibody pembrolizumab was approved by the FDA for the treatment of adult and pediatric patients with unresectable or metastatic solid tumors identified as being MSI-high (MSI-H) or MMR deficient (dMMR).18 This is significant because it was the first time a chemotherapeutic agent was approved independent of the anatomical site of origin for a cancer. Finally, as another common example, patients who have non-small cell lung cancer can harbor specific genetic mutations that can be detected via NGS testing – EGFR, ALK, ROS, RET, and PDL-1 to name a few that, if present, would qualify them for a targeted treatment instead of traditional chemotherapy. BRAF mutations are another gene mutation that can be detected in melanoma that would help guide the treatment plan. Besides these examples, there are several other genetic mutations in a variety of other oncologic diagnoses that have been discovered, and medications are being used and formulated to target these genetic alterations. In addition, if Continued on page 16

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a cancer patient has no other traditional treatment options remaining, NGS genetic testing can be used to guide treatment based on that patient’s specific genetic alterations as a last resort option.

9. ^ Kunkel TA, Erie DA (2005). «DNA mismatch repair». Annu. Rev. Biochem. 74: 681–710. doi:10.1146/annurev. biochem.74.082803.133243. PMID 15952900.

Genetic testing provides options and can affect a cancer patient’s treatment regimen though detection of certain genes. Patients who harbor certain genetic alterations would be candidates for certain screening modalities for prevention as well as other surgical options and specific medications. For example, there are certain treatments, such as PARP inhibitors, which are especially efficacious in cancer patients who harbor the BRCA gene mutation. There are also other treatments and strategies to help prevent and treat cancer in patients with certain other genetic mutations. Therefore, it is important for all cancer patients to be aware of their genetic profile and know if they are eligible for certain options that can be effective for their personal treatment plan to help improve their prognosis.

10. ^ Kastrinos F, Syngal S (2011). «Inherited colorectal cancer syndromes». Cancer Journal. 17 (6): 405–15. doi:10.1097/PPO.0 b013e318237e408. PMC 3240819. PMID 22157284. Neumann HP, Pawlu C, P

References

12. S chrag, D.; Kuntz, K. M.; Garber, J. E.; Weeks, J. C. (1997-05-15). “Decision analysis--effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations”. The New England Journal of Medicine. 336 (20): 1465–1471. doi:10.1056/ NEJM199705153362022. ISSN 0028-4793. PMID 9148160.

11. R obson, Mark E.; Bradbury, Angela R.; Arun, Banu; Domchek, Susan M.; Ford, James M.; Hampel, Heather L.; Lipkin, Stephen M.; Syngal, Sapna; Wollins, Dana S. (2015-11-01). “American Society of Clinical Oncology Policy Statement Update: Genetic and Genomic Testing for Cancer Susceptibility”. Journal of Clinical Oncology. 33 (31): 3660–3667. doi:10.1200/ JCO.2015.63.0996. ISSN 1527-7755. PMID 26324357

1. https://medlineplus.gov/genetics/understanding/testing/genetictesting/#:~:text=Genetic%20testing%20is%20a%20type,passing%20 on%20a%20genetic%20disorder. 2. W hat are the risks and limitations of genetic testing?: MedlinePlus Genetics

13. Newton, K.; Green, K.; Lalloo, F.; Evans, D. G.; Hill, J. (January 2015). “Colonoscopy screening compliance and outcomes in patients with Lynch syndrome”. Colorectal Disease. 1. 17 (1): 38–46. doi:10.1111/ codi.12778. ISSN 1463-1318. PMID 25213040.

3. Allgayer, Heike; Redher, Helga; Fulda, Simone (2009). Hereditary Tumors: From Genes to Clinical Consequences. Weinheim: Wiley-VCH. ISBN 9783527320288. 4. Clark AS, Domchek SM (April 2011). «Clinical management of hereditary breast cancer syndromes». J Mammary Gland Biol Neoplasia. 16 (1): 17–25. doi:10.1007/ s10911-011-9200-x. PMID 21360002. S2CID 21417924.

14. Cossack, Matthew; Ghaffary, Cameron; Watson, Patrice; Snyder, Carrie; Lynch, Henry (April 2014). “Aspirin use is associated with lower prostate cancer risk in male carriers of BRCA mutations”. Journal of Genetic Counseling. 23 (2): 187–191. doi:10.1007/s10897-013-9629-8. ISSN 15733599. PMID 23881471. S2CID 15371573.

5. Lynch HT, Lynch PM, Lanspa SJ, Snyder CL, Lynch JF, Boland CR (July 2009). «Review of the Lynch syndrome: history, molecular genetics, screening, differential diagnosis, and medicolegal ramifications». Clin. Genet. 76 (1): 1–18. doi:10.1111/j.1399- 0004.2009. 01230.x. PMC 2846640. PMID 19659756.

15. ^ Thorat, Mangesh A.; Cuzick, Jack (December 2013). «Role of aspirin in cancer prevention». Current Oncology Reports. 15 (6): 533–540. doi:10.1007/s11912-013-0351-3. ISSN 15346269. PMID 24114189. S2CID 40187047

6. Petrucelli N, Daly MB, Feldman GL (May 2010). «Hereditary breast and ovarian cancer due to mutations in BRCA1 and BRCA2». Genet. Med. 12 (5): 245–59. doi:10.1097/GIM.0b013e 3181d38f2f. PMID 20216074.

16. Cagle, P. T., & Chirieac, L. R. (2012). Advances in Treatment of Lung Cancer With Targeted Therapy. Archives of Pathology & Laboratory Medicine, 136(5), 504–509. https://doi.org/10.5858/ arpa.2011-0618-RA

7. ^ Smith EC (2012). «An overview of hereditary breast and ovarian cancer syndrome». J Midwifery Womens Health. 57 (6): 577– 84. doi:10.1111/j.1542-2011.2012.00199.x. PMID 23050669

17. https://jamanetwork.com/journals/jamaoncology/ fullarticle/2734828

8. Drescher KM, Sharma P, Lynch HT (2010). “Current hypotheses on how microsatellite instability leads to enhanced survival of Lynch Syndrome patients”. Clin. Dev. Immunol. 2010: 1–13. doi:10.1155 /2010/170432. PMC 2901607. PMID 20631828.

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18. Clin Cancer Resdoi: 10.1158/1078-0432.CCR-18-4070. Epub 2019 Feb 20.

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“O sleep, O gentle sleep, Nature’s soft nurse, how have I frightened thee. That thou no more will weigh my eyelids down, And steep my senses in forgetfulness?” ~ William Shakespeare, Henry IV, Part 2

IS MELATONIN

Whether from the disruptions to routine that remote work and virtual school have wrought, the financial stressors of a rapidly changing economy and growing inflation, or the public tension of a pandemic made political, America is not sleeping well. American Academy of Sleep Medicine (AASM) conducted an online survey in March of 2021 that found over half of Americans have experienced an increase in sleep disturbance since the beginning of the pandemic.1

AN EFFECTIVE REMEDY FOR THE

Desperate for sleep, many turn to over-the-counter supplements like melatonin. Even prior to the pandemic, Americans’ use of melatonin had rapidly increased. A recent research letter compared survey data from 19992000 to 2017-2018 and found a five-fold increase in prevalence of melatonin use and a three-fold increase in those using greater than 5 mg.2 The rapid rise in use and escalation in dose raises the question: Will all the melatonin we are taking help and at what risk?

SLEEP-DEPRIVED? pros and cons of this popular sleep aid

What is melatonin and what does it have to do with sleep? Melatonin is primarily made in the pineal gland of the brain and released into the bloodstream at night. While it is known to have other functions in the body, it is best understood for its role as a regulator of the sleep-wake circadian rhythm.

ELIZABETH DOHERTY, MD Penn Medicine Lancaster General Health Physicians Family Medicine Manor Ridge

Sleep researchers use a two-process model to describe sleep regulation. Process S, or homeostatic sleep drive, Continued on page 18

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builds up gradually in the absence of sleep and resets quickly after sleep onset. Process C, or the circadian alerting signal, reflects the “internal clock” of the body and drives wakefulness. Endogenous melatonin (produced by our bodies) begins increasing approximately two hours before habitual sleep onset when sleep drive and the circadian alerting signal are both high. As endogenous melatonin rises, the wake-promoting signals of Process C rapidly decline, and Process S is allowed to bring on sleep. Melatonin levels peak approximately five hours later when the influence of Process S has waned, but sleep is maintained because Process C continues to be suppressed. As melatonin levels decline in the two to three hours prior to habitual waking and with exposure to early morning bright light, inhibition of the wake-promoting signals of Process C drop and alertness increases. Does taking a melatonin supplement work? If endogenous melatonin helps suppress wake-promoting signals, would more melatonin mean better sleep? While melatonin supplementation does appear to mimic endogenous melatonin, research shows the effects are subtle. A recent systematic review showed melatonin produced statistically significant effects on sleep quality, but these effects were clinically minimal.3 Another meta-analysis found significant but small effects on other sleep measures.4 AASM does not recommend melatonin supplementation for chronic insomnia in part due to results like these. It is natural to wonder if effects are weak because studied doses are too low, but all melatonin supplementation results in higher than physiologic serum levels of melatonin. Furthermore, the higher the dose, the longer the high serum melatonin levels last, meaning high dose supplementation results in high levels of serum melatonin during the day when endogenous melatonin production is normally inhibited and physiologic levels are dropping. Not only do higher doses increase the risk of side effects, like drowsiness the next morning, the prolonged high levels uncouple melatonin production from the circadian rhythm. This may explain why higher doses of melatonin actually impair sleep compared to lower doses and over time reduce effectiveness.5

Melatonin has greater benefit as a chronobiotic (a phase shifting agent) than as a hypnotic (sleep inducing agent). It can help manage jet lag after travel across multiple time zones, especially when spanning five or more in the easterly direction6 and it may help with shift work.7 What are the risks? Melatonin is generally considered safe and well tolerated. Two of the greatest risks with melatonin supplementation aren’t necessarily specific to melatonin. First, difficulty sleeping, or excessive daytime fatigue, can be caused by many different health conditions, including sleep-related breathing disorders, depression, thyroid disease, and medication side effects. Individuals supplementing with melatonin as a sleep aid may delay diagnosis of a serious health condition. Second, like most over-thecounter supplements, melatonin is not closely regulated. A 2017 analysis of 31 over-the-counter melatonin supplements found significant variability and contamination of content in the products, raising questions about reliability and increased risk.8 Assuming what one gets in the bottle is actually melatonin and the pills contain the dose as labeled, melatonin is likely safe for most adults when used short-term at doses up to 8 mg daily.9 Regular use at higher doses or for longer periods of time have not been studied. Common side effects are mild and include dizziness, nausea, headache, and sleepiness. Driving or using machinery should be avoided for at least four to five hours after taking melatonin. However, there is some concern for rarer side effects, like increased seizure and bleeding risk, effects on blood pressure control, and immune stimulation. There also isn’t enough reliable information to determine if melatonin is safe for use during pregnancy or breastfeeding. Is there an alternative? In the short term, it may be easier or more practical to use a supplement like melatonin to improve sleep, but in the long term, harnessing the power of the mind to re-frame sleep has a clear and lasting benefit. The first-line treatment recommendation for insomnia by the AASM is cognitive behavior therapy for insomnia (CBT-I). Much more than counseling or sleep education, CBT-I combines cognitive and motivational therapy strategies

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with conditioning theory. It is a structured combination of techniques including sleep restriction, stimulus control, cognitive restructuring, and relaxation training. The combination has clinically significant effects lasting up to a year.10 CBT-I is not appropriate for everyone and is best for individuals with stable medical and mental health conditions, sufficient insight and cognitive ability to participate, and motivation for treatment. It can also be difficult to find a trained CBT-I provider 11 although virtual and technology-based options are growing. Conclusions There is great demand for a safe, non-habit-forming sleep aid, so it is not surprising that despite minimal evidence for efficacy, melatonin use continues to rise in popularity. It is widely available and generally well tolerated. Yet, melatonin is only one ingredient in the “recipe” for sleep, and, like any other recipe, more of one ingredient is rarely better. Sources

1. https://aasm.org/americans-struggling-good-nights-sleepduring-pandemic/ 2. Li J, Somers VK, Xu H, Lopez-Jimenez F, Covassin N. Trends in use of melatonin supplements among US adults 1999-2018. JAMA. 2022;327(5):483-485 3. Fatemeh G, Sajaad M, Niloufar R, Neda S, Leila S, Leila S, Khadijeh M. Effect of melatonin supplementation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Journal of Neurology. 2022. 269:205-216. 4. Ferracioli-Oda E, Qawasmi A, Bloch MH. Meta-analysis: melatonin for the treatment of primary sleep disorders. PloS ONE. 2013. 8(5): e63773 5. Vural EMS, van Munster BC, de Rooij SE. Optimal dosages for melatoning supplementation therapy in older adults: a systematic review of current literature. Drugs Aging. 2014;31:441-451. 6. Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database of Systematic Reviews. 2002; Apr 22. 7. Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen M, Isotalo LK, Ruotsalainen JH. Pharmacological interventions for sleepiness and sleep disturbances caused by shift work. Cochrane Database of Systematic Reviews. 2014; August 12. 8.Erland LAE, Saxena PK. Melatonin natural health products and supplements: presence of serotonin and significant variability of melatonin content. J Clin Sleep Med. 2017;13(2):275-281. 9. https://naturalmedicines.therapeuticsresearch. com/databases/food,-herbs-supplements/professional. aspx?productid=940#background 10. Van der Zweerde T, Bisdounis L, Kyle SD, Lancee J, van Straten A. Cognitive behavioral therapy for insomnia: a metaanalysis of long-term effects in controlled studies. Sleep Med Rev. 2019; 48 (Dec): 101208. 11. University of Pennsylvania Perelman School of Medicine’s Behavioral Sleep Medicine Program maintains a database of certified CBT-I providers: https://cbti.directory/index.php/ search-for-a-provider

SPRING 2022

muscle changes with aging I

f you close your eyes and imagine the process of aging, grey hair and wrinkles may be some of the first things that come to mind. Although these physical changes are among the most visible signs of aging, a far more insidious process begins about the same time. We reach our peak muscle mass by our fourth decade of life after which we begin to lose as much as 3 to 5 percent per decade. This age-related decline in lean muscle mass is known as sarcopenia and is a major component in the development of frailty.1 Unchecked, the age-related degradation HANNAH FANELLI, MD of muscle can result in a more than 50 percent reduction in muscle mass by the time Penn State Sports Medicine people reach their 80s. Continued on page 20

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Healthy Communities Sarcopenia is primarily the result of two physiologic processes: decreased muscle volume and change in muscle composition. A decrease in muscle volume is due to the loss of muscle fibers and changes in muscle fiber type. Type I muscle fibers are small, slow-contracting fibers that derive energy from aerobic metabolism. These fibers produce low power contractions and are slow to fatigue. In contrast, Type II muscle is composed of large, fast-contracting fibers that produce higher power contractions but fatigue quickly. Type II muscle fibers use anaerobic glycolysis as their adenosine triphosphate protein (ATP) source. Aging leads to a relative increase of Type I fibers compared to Type II.2 This relative decrease in Type II fibers is thought to be the result of the trophic influence of alpha motor neuron units leading to fiber type conversion.2 As humans age, they lose motor neurons. That motor neuron loss happens at a faster rate in Type II fibers. The denervated Type II muscle fibers are then reinnervated with Type II slow-twitch motor neurons. With a decrease in the larger type II muscle fibers, muscle volume and strength decreases.2 The decline in muscle mass is also due in part to an overall decrease in the rate of skeletal muscle protein synthesis. Metabolic changes associated with aging include decreased hormone levels of IGF-1, growth hormone, and sex hormones, which further contribute to a decreased protein synthesis rate.1 Other environmental factors including obesity and poor nutrition also play a role. Alterations in muscle protein synthesis ultimately lead to fatty infiltration of muscle through mechanisms that are poorly understood.1 Sarcopenia is a rapidly evolving public health issue, exacerbated by an aging population. Decreased muscle mass and strength contribute to fatigue, weakness and poor mobility, which in turn may result in falls, fractures, loss of independence and disability. People with sarcopenia are twice as likely to have a fragility fracture and twice as likely to be hospitalized than those without the condition. On a societal level, the estimated cost of hospitalizations in the U.S. in individuals with sarcopenia was $40.4 billion in a 2019 study.4 Typically, muscle is responsible for approximately 30 percent of resting energy

expenditure. Accordingly, decreased muscle mass lowers total daily energy expenditure promoting metabolic disease.3 While many features of aging are inevitable, research suggests that lifestyle interventions can reduce and reverse some of these changes in skeletal muscle.2 Exercise induces adaptive changes in muscle throughout life. It is, therefore, possible to regain muscle strength and composition lost due to aging. Muscle response varies based on the type of exercise, but the effects are the same regardless of age. Resistance exercise stimulates improved motor neuron recruitment and can help reverse the age-related decrease in Type II muscle fibers.2 The strength improvement from resistance exercise can occur after a few weeks due to motor neuron recruitment, whereas muscle cell hypertrophy may take six to eight weeks. Strength training also increases enzymatic protein production and capillary density. The synthesis rate of muscle proteins increases after two weeks compared with approximately four months following initiation of aerobic exercise. Cruz-Jentoft et al. suggest that the protein synthesis that increases with aerobic exercise primarily improves metabolic and cardiovascular function as opposed to resistance exercise which creates structural muscle proteins.1 To achieve the aforementioned benefits, the American College of Sports Medicine recommends strength training involving all major muscles groups a minimum of two times per week. This can be achieved in a variety of ways including the use of dumbbells, barbells, resistance bands, and bodyweight exercises. Patients should be counseled that each exercise should be performed for 8-12 repetitions while maintaining form throughout the entire range of motion. Traditionally, the last repetition performed should be challenging and once this becomes easy, patients should increase the weight or resistance. While resistance training is the most important for muscle health, both muscle health and overall health are enhanced when combined with aerobic activity. In addition to two days of strength training, patients should strive for 150 minutes of moderate-intensity aerobic activity per week.

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The maximal benefit from strength training will occur in tandem with sufficient rest and nutrition. Most of the rest the body needs to build muscle occurs during sleep. The American Academy of Sleep Medicine advises a minimum of seven hours of sleep per night, which helps to curb stress and mitigate the effects of catabolism on muscle. Adequate daily protein and an overall balanced diet with ample Vitamin D and high-quality fats also play a role in rebuilding muscle. Consuming one gram of protein per kilogram of ideal body weight can provide sufficient amino acids to maximize the muscle protein synthesis from resistance exercise.5 Sarcopenia is a common condition affecting our aging population that can decrease lifespan and quality of life. Resistance exercise is an effective way to prevent and reverse sarcopenia. Patients should be routinely counseled on these topics during preventive health appointments. REFERENCES: 1. C ruz-Jentoft AJ, Landi F, Topinková E, Michel JP. Understanding sarcopenia as a geriatric syndrome. Curr Opin Clin Nutr Metab Care. 2010;13:1-7. 2. S iparsky PN, Kirkendall DT, Garrett WE Jr. Muscle changes in aging: understanding sarcopenia. Sports Health. 2014;6(1):36-40. 3. F rontera WR, Hughes VA, Fielding RA, Fiatarone MA, Evans WJ, Roubenoff R. Aging of skeletal muscle: a 12-yr longitudinal study. J Appl Physiol. 2000;88:1321-1326 4. G oates, Scott, Kristy Du, Mary Beth Arensberg, Trudy Gaillard, Jack Guralnik, and Suzette L. Pereira. Economic Impact of Hospitalizations in Us Adults with Sarcopenia. The Journal of Frailty & Aging. 2019;2: 93-99. 5. B easley JM, Shikany JM, Thomson CA. The role of dietary protein intake in the prevention of sarcopenia of aging. Nutr Clin Pract. 2013 Dec;28(6):684-90.

SPRING 2022

spring activity

I NJ U RY PREVENTION

JOY LONG, MD

Lancaster Orthopedic Group PC

ith warmer weather in the forecast, many of us are excited to return to outdoor activities and perhaps even try new sports. As we age, though, we have different considerations for injury prevention compared to when we were younger.

First, preparing for anticipated activity change is important. Ensure that any underlying medical conditions are under appropriate control and that your proposed exercise program is endorsed by your physician. Goals can include regular cardiovascular exercise, resistance training, and weight bearing exercise for bone health. Seasonal sports such as golf, tennis, biking, and running outdoors will be more available in the next few months. Many people also engage in gardening and home maintenance. A gradual increase in any pursuit is always prudent to allow your body to acclimate. Nutrition is important for injury prevention, including adequate calcium and vitamin D for strong bones. Hydration is a consideration especially with outdoor activity in the heat. When the temperature is high, consider repletion of electrolytes from perspiration. Proper equipment for each form of exercise is necessary as well. Continued on page 22

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Well-fitting, supportive shoes that are in good shape are essential. Walking or running in worn out or inappropriate footwear can lead to pain and injury. With age, humans naturally lose flexibility; and daily stretching becomes necessary. Lack of flexibility is a risk for injury — tight calves can predispose to ankle sprains or even Achilles tears. Tight hamstrings are associated with knee pain and low back pain. Dynamic and static stretching can be incorporated into any exercise routine, and activities such as yoga and Pilates can also improve flexibility and balance. Core strengthening also improves balance, which aids in injury prevention. In choosing activities, variety is important. Avoidance of single sports specialization is a focus for young patients, but this advice applies to all generations. Varying the form of exercise avoids placing strain on the same muscle groups and bones repetitively and can decrease the risk of overuse injuries such as tendinitis and stress

fractures. The same logic applies to outdoor chores — it is unwise to try to complete two months of yard work in one weekend. Despite our best efforts to vary routines, build endurance, and stretch frequently, injuries can still occur. In general, an acute injury should be evaluated quickly if it causes significant pain and weakness such as inability to bear weight on a leg or raise an arm. Severe swelling, deformity, or neurovascular compromise warrant urgent evaluation. Often, though, the more subtle overuse injuries are ignored. Relative rest, ice, appropriate over the counter agents, and compressive wraps or braces are reasonable remedies if they allow recovery in a few days or weeks and then are no longer needed. However, pain that interferes with activities of daily living or lasts longer than two weeks should be evaluated. With age, overuse injuries can be more substantial. For example, an aged rotator cuff tendon may not require as much force to rupture or may tear gradually. Chronic issues, such as tendinitis, typically respond to physical therapy

programs and improve more rapidly the sooner they are treated. Arthritis is a consideration in the more mature athlete. If pain persists for several weeks and a diagnosis of arthritis is determined, then management is based on symptoms and activity modification. Patients with arthritis benefit from exercise, but the form of activity may need to be altered to avoid excess stress on the affected joints. For example, patients with knee arthritis will likely do better with doubles tennis rather than singles. Lower impact activities such as swimming, biking, and walking are less stressful on lower body joints than running or jumping. Whether you choose to pick up old favorite activities or try something new, remember to start gradually and stretch regularly. Be willing to modify or vary your routine as necessary. If you are unfortunate and have an injury, seek the advice of a trusted medical professional.

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Lancaster Office | 717.393.9721 domaniwealth.com

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SPRING 2022

Passion Outside of Practice

David J. Simons, DO, FAOCA Community Anesthesia Associates

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 Dave Simons, DO, FAOCA, and his passion outside of practice. and competition. I never swam, cycled, or ran as a youngster, so the sport of triathlon has been exciting and challenging. The technology, nutrition methods, and training have evolved over the years, which creates an additional appeal. Traveling to national and world competitions with my family and teammates has been very interesting and memorable. In 2017, I joined a triathlon team called Yoder Performance. The coach, Andrew Yoder, competed as an accomplished professional triathlete and has transitioned into coaching. His squad includes impressive professional and amateur athletes of all ages.

Why is this pursuit special to you?

L: Simons representing Team USA at the 2018 World Championships in Australia R: The Simons family showing their support at the 2021 World Championships in St. George, Utah.

Competing in Triathlons Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?

My passion outside of medicine is competing in triathlons — multisport endurance races with three activities, including swimming, cycling, and running over various distances. Triathletes compete for the fastest overall completion time, including the transition between each discipline. Male and female athletes are grouped in five-year incremental age classifications ranging from young to old. Event distances range from less than 20 miles (sprint) to over 140 miles (Ironman). The sport has been included in the Olympics since the year 2000.

How did you develop an interest in your passion outside of practice and when did you begin participating in it?

I have been a “gym rat” for my entire life and played basketball in high school, rugby in medical school, and tennis after moving to Lancaster. I was invited by a friend to participate in the Lancaster YMCA triathlon in the late 1980s. I really enjoyed competing in an atmosphere of camaraderie with participants and spectators. Everyone is welcome to compete regardless of ability or experience. I have been involved in the sport ever since. I grew up in State College, PA, with two older brothers, which instilled in me a love for sport

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The sport of triathlon is growing in popularity and is a fantastic way to motivate you to get in (or stay in) shape. Triathletes are an engaging community of health-oriented, optimistic, and enthusiastic individuals with the common goal of self-improvement, fitness, and having fun. The sport is an excellent outlet for stress release.

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

In 2018, I was privileged to be a member of Team USA and compete at the World Championships in Australia with my family by my side. In 2021 we traveled to St. George, Utah, for the Half Ironman World Championship. I was thrilled to place third in my age group. I will hopefully qualify this year to compete in the 2022 Hawaiian Ironman in Kona, Hawaii. I feel so fortunate to be healthy and able to continue to participate and share this sport with my family. I encourage anyone interested to come out and join us.

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Patient Advocacy

HOW TO B E A N ADVOCATE FOR SO M E O N E I N A PER SO N AL CAR E O R SK ILLE D N U R S I N G CA R E FACI LI T Y

KENDALL HUNSICKER Senior VP of Healthcare, Willow Valley Communities

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SPRING 2022

hen someone is admitted to any type of health care facility, it’s important that they have an advocate to oversee their care and details of their stay. An advocate does not have to have a “clinical” background, such as a nurse, therapist, or physician. Rather, an advocate is someone who knows the person well enough to speak up on their behalf and who will not be afraid to ask questions or provide information about the person’s history, particularly as it relates to their medical and/or mental health. An advocate is willing to collaborate with the health care facility and assist in making the resident’s transition and stay more enriching and tailored to their individual likes and dislikes. When a person makes a life change to receive personal care or skilled care, it is very normal for them to have a range of emotions. They might be scared, angry, in denial, very quiet, or not participating or helping in their transition. This change can be a bit like going off to college for the first time, except the individual is typically not young and change becomes more difficult as we age. Any move can cause much anxiety and depression. It can take several months for them to settle into their new environment. Often, the person has lost the ability to care for themselves and thus feels they have lost control of their life. In fact, many of the scenarios deal with “loss.” It takes true grace and acceptance for an individual to allow others to help with things they have always done for themselves. If they feel ill, it makes everything seem worse. After all, who looks at the world as “sunny and bright” when they are sick? It is not unusual for them to think about questions such as “Am I going to be here for the rest of my life?”, “What is my life’s purpose now?”, and “Do I matter to anyone?” So how does one become a good advocate for someone who is in personal care or skilled care?

First, it’s important that an advocate be present in the facility, as often as possible, to take notice of the following items: • The attitude and friendliness of the staff • Customer service, such as timely follow-up to questions, graciousness when there has been an error, and overall approach to problem solving • Odors such as urine or feces; these will occasionally occur but should not be a continuous issue • Frequency of being checked on by the staff • Grooming of residents (hair combed, nails clean, dressed in regular clothing that is neat and clean, shoes on, etc.) • Other residents’ demeanors (Do they seem happy and are they pleasant?) • Presence of an upbeat atmosphere/culture • Availability of enjoyable activities to participate in • Appetizing looking food (Is it hot? Are they getting what they want? Are there special things they love to eat that the facility can make sure they receive?)

As an advocate, the advantage of being in the facility fairly often is that you can observe for yourself and separate “fact from their mindset” if the resident complains about things. If you are unable to be in the facility regularly and you are hearing complaints, speak to the administrator of the facility about the resident’s concerns. A big part of being an advocate is the ability to successfully collaborate and strategize with a caregiving team, which often includes nurses, social workers, recreational therapy staff, facility managers, and administrators. If the resident is unable, it’s the advocate’s job to collaborate on behalf of the resident. At times, advocates look at the facility staff as the “problem” or “the enemy” if they are not perceived as doing everything the “right” way or in a timely manner. Customer service should always

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be a priority for every team member and facility. This does not mean that everything is going to be perfect all the time, even in the best facilities! If there is a problem, stay calm and try to look at the situation from various viewpoints. Ask yourself if your expectations are realistic. Sometimes circumstances occur for which there is no fault on anyone’s part. There is no one to blame. It’s important that you speak to administration about how you would like to see things done differently in the future. As you do, your approach is very important. It is best to politely but firmly speak about your concerns and suggest solutions rather than make angry and/or threatening demands. A facility is a congregate environment governed by many regulations, which means that attention is given to many people who require care, not strictly your loved one. Work with administration and staff on problem solving issues. Be an advocate not an adversary! It is true that “laughter is the best medicine.” A good hearty laugh lowers the blood pressure and loosens tense muscles. A smile takes less muscle effort than a frown. As an advocate, think about what things, services, and activities would make this person smile, relax, and maybe even have a hearty laugh. Yes, their life circumstances are different, but they are still who they are, and they still have a “purpose.” Another way you can be a good advocate is to help the facility’s team consider the following question: “How can you and the care team strategize with them to discover their ‘new purpose’?” Being an advocate is an incredibly important job that can make a huge difference in someone’s quality of life. The job of an advocate should not be taken lightly or be done half-heartedly. Depending on the circumstances, it can be a great deal of work. Advocacy can also bring some frustration as issues are identified, worked on, and addressed. Yet, there is tremendous joy and fulfillment when all parties are working together for the resident’s quality of life and helping to define their life’s purpose. After all, isn’t that what all of us would desire for our own lives?

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Perspectives

Health Systems and

Community Partnerships SUSAN SHELLY Writer

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SPRING 2022

he importance of strong partnerships between health systems and community organizations has been increasingly recognized over the past decade, fueled in part by the need to address progressively complex issues affecting the health of communities. Across the nation, health systems have teamed up with community groups, nonprofits, faith organizations, and others to address issues including substance abuse disorders, mental and behavioral health, homelessness, chronic disease management, preventative health practices, obesity, violence, access to health care, social determinants of health, and other social ills. In San Diego, Sharp Grossmont Hospital joined forces with 2-1-1 San Diego and Feeding San Diego to provide information, referrals, and meals for its most vulnerable patients. St. Vincent Healthcare and the Billings Clinic — the two main health care systems in the region of Billings, Montana — partnered with a Senior Corps organization to link at-risk children and teens with foster grandparents. The University of Vermont Medical Center in Burlington teamed up with the Champlain Housing Trust, an organization that buys and renovates motels to serve as free and subsidized housing for unhoused people in the Burlington area.

work together to address a variety of needs among residents of the Ephrata and Cocalico school districts. “It’s a very good system to have these agencies collaborating to benefit the community,” said Steve Batchelor, Regional Director of Community Health and Wellness at WellSpan. “We strive to be that trusted partner with this organization.” Operating under the umbrella of the Ephrata Public Library, Hub member organizations collaborate to provide health resources; food assistance; financial help; housing and utility assistance; transportation; business, career, and unemployment resources; childcare and education resources, tax assistance, and community resources to thousands of people each year. Having all these resources in place under one umbrella is extremely helpful, as it enables WellSpan staff to connect patients with all types of services, Batchelor explained. Patients are screened for food and housing insecurity, chronic disease, behavioral health issues, and other concerns, and referred to appropriate agencies as needed. “It makes it easy for us to connect our patients with these community partners,” Batchelor said.

Among the hundreds of health system-community partnerships in place across the country are those that benefit residents of Lancaster and surrounding counties. Health care systems and community organizations are working together to address problems ranging from food insecurity to opioid use disorder.

In addition to referrals, WellSpan provides services to benefit community members such as free mammograms from its mobile mammography unit, educational events, transportation to vaccine clinics, and others. As health care systems have become more proactive, it’s important for health care representatives to be visible and accessible in their communities, Batchelor said.

Lancaster Physician reached out to learn more about these collaborations, asking each health care system serving Lancaster County to highlight a relationship with a community partner.

“It’s a lot more about being proactive and reaching out to our communities than it used to be,” he said. “Let’s work together as community partners and make sure the patients we see have all the connections they need.”

WellSpan Health WellSpan Health is proud of its partnership with Northern Lancaster Hub, a group of about 20 organizations that

WellSpan also provides some funding for Hub member organizations through its Community Grants Program, which provides direct funding to organizations to address social determinants of health and barriers to

Steve Batchelor

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care. In 2021, WellSpan distributed more than $900,000 in grants to community partners. “We’re always looking for ways to support organizations working on behalf of the community,” Batchelor said. As an example of a health system-community partnership, Batchelor told of WellSpan dieticians who offer community education programs at the Ephrata library. Using vegetables grown in a community garden organized and tended to by Hub participants, dieticians explain the importance of incorporating produce in a daily diet and offer cooking demonstrations and food tastings to those looking to learn more about nutrition. “It’s all about relationships,” Batchelor said. “It’s about breaking down silos, working together, and sharing credit for successes.” Penn Medicine Lancaster General Health Penn Medicine Lancaster General Health serves as the Alice Yoder convener and coordinator for Lancaster County Joining Forces, a coalition founded in 2017 to address the growing problem of opioid use disorder. “The opioid epidemic is complex and requires a coordinated approach with many sectors working together rather than alone,” said Alice Yoder, Executive Director of Community Health at Lancaster General Health. “There were a lot of community organizations and partnerships doing good work, but there was no coordinated effort at that time.” With a mission of reducing deaths from opioids and other substances, Joining Forces is continuing to look forward as it moves into its sixth year of operation. The coalition is made up of partners including various county agencies, the Lancaster County Commissioners, the Lancaster Chamber, other health systems, behavioral health organizations, Compass Mark, Lancaster County Recovery Alliance, and others. Continued on page 28

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Perspectives

While working collectively has realized significant successes, there is much work still to be done. The number of overdose deaths in Lancaster County decreased dramatically between 2017 and 2019. However, the death rate increased by 44 percent in 2020, mirroring trends seen across Pennsylvania and in many other states, which are partly attributed to the COVID-19 pandemic. Statistics for 2021 are still being tabulated, Yoder said, but are expected to be similar to the 2020 death rates. Joining Forces is currently completing its strategic plan for 2022-2025. Long-term goals of the organization continue to evolve as additional information and resources become available. “We’re always looking for evidence-based strategies proven to reduce deaths from overdoses,” shared Yoder, who was instrumental in the formation of Joining Forces. The coalition employs the Continuum of Care model developed by the Institute of Medicine and SAMHSA (Substance Abuse and Mental Health Services) as the foundation of its framework for action. The continuum integrates all levels of health promotion, prevention, and intervention to prevent and alleviate substance use disorders and support long-term recovery and wellness. Among its accomplishments since its founding are the implementation of evidence-based prevention programs in area schools, 29 dropoff sites for unused or expired medication, a variety of educational events presented to the community, increased access to naloxone for first responders and community members, warm handoff programs established to enhance connections to treatment, increased access to medication-assisted treatment, a local prescription drug monitoring program, and education of health care providers on safe opioid prescribing practices. The coalition also launched Joining Forces for Children, a program serving children impacted by addiction. The coalition, in which more than 40 community organizations participate, is moving forward with eight strategies, as outlined in

its strategic plan. They are: • Strengthen evidence-based prevention and intervention initiatives • Continue to share messages and provide educational information throughout the community • Create lasting changes in the medical community that improve patient safety • Increase access to evidence-based treatment services • Promote recovery by providing trainings and sharing positive stories about the recovery process • Advance Trauma Informed Lancaster County • Pilot an overdose fatality review process • Advocate for legislative changes to permit utilization of evidence-based harm reduction strategies As the coordinating institution of Joining Forces, the role of Penn Medicine Lancaster General Health is to assess community assets, identify gaps in services, and continue to support participating organizations, Yoder explained. She is proud of what Joining Forces has accomplished and looks forward to continuing progress. “Our premise from the very beginning was that we were going to be able to accomplish more together than we could individually,” Yoder said. “And we’ve found that is, indeed, very true.” Penn State Health In an effort to assure more equitable and better care to members of Hispanic/Latino communities in central Sol Rodríguez-Colón Pennsylvania, the Penn State Cancer Institute’s Office for Cancer Health Equity (OCHE), part of Penn State Health, partners with the Spanish American Civic Association for Equality, Inc. (SACA) to provide education through a Spanish-language

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cancer educational webinar series called “Vamos a Educarnos Contra el Cáncer” (“Let’s Get Educated Against Cancer”). In 2018, the office also established an 18-member Hispanic/Latino Cancer Community Advisory Board (CAB), which serves as a bridge between the Cancer Institute and the Hispanic/Latino community in 28 counties of central Pennsylvania. “It’s crucial that we’re able to reach members of these communities since they know their communities best,” said Sol Rodríguez-Colón, research project manager for the OCHE. “Partnering with a community organization that already has the trust of its people enables us to build connections, to work in collaboration, and establish cancer priorities that ultimately can help reduce the cancer burden among those communities. Once you have those in place, things go well.” SACA representatives, which are part of CAB, work with the Penn State Cancer Institute to promote cancer prevention initiatives, advising on how to encourage members of the Hispanic/Latino community to take advantage of cancer screening clinics, education, and research opportunities. SACA’s efforts have been particularly helpful during the pandemic, explained Rodríguez-Colón. “With COVID it was incredibly challenging to get people to the clinics and to get us out into the community,” she said. “Having SACA open to helping us made a huge difference in getting the community educated about cancer during the pandemic.” The idea for the webinar series began in June 2020 when OCHE offered a Spanish-language webinar on cancer care within COVID-19 with an oncologist from Penn State Health. SACA, which has an active social media platform and its own radio station — WLCH Radio Centro — promoted the program, which was rated as “excellent” by 82 percent of viewers who responded to a survey and “very good” by the other 18 percent. “We weren’t sure what kind of response we would have, and we were pleasantly

SPRING 2022

surprised that so many people tuned in to that first webinar,” Rodríguez-Colón said. Supported by a Penn State Health community relations grant, webinars were presented monthly throughout 2021, covering topics including mental health and cancer, patient navigation, spiritual health and cancer, breast cancer and mammograms, colorectal cancer, human papilloma virus, and liver cancer. Topics are suggested by CAB members, who are in close contact with community members. “The whole webinar series was reviewed by the CAB, and we had a lot of input from the Hispanic/Latino community,” explained Rodríguez-Colón. “That definitely has helped make the series so successful.” Rodríguez-Colón reported that nearly 300 people have attended the webinar series, and thanks to the partnership with SACA, OCHE was able to reach more than 11,000 individuals through Radio Centro’s Facebook page. Recordings of the webinars have more than 3,100 views, including a national and international audience. While Penn State Health is appreciative of SACA’s support in publicizing the webinars and help in forging pathways in the Hispanic/ Latino community, Sandra Valdez, Chief Operating Office at SACA, said community members have benefited significantly from Penn State’s outreach. “We are grateful that Penn State has been willing the go the extra mile for our community,” Valdez said. “Residents appreciate the educational resources and the opportunity to reach out for more information and support.” Webinars, which can be viewed on Zoom or Facebook Live, will be offered every other month in 2022. More information about them and CAB is available online at sites.psu. edu/cancerhealthequity in the “Initiatives” section. Viewers also can connect to the webinars through WLCH Radio Centros’s Facebook page.

UPMC Dr. Sharee Livingston, chair of Obstetrics and Gynecology at UPMC Lititz, is deeply concerned about health disDr. Sharee Livingston parities that negatively impact women of color. In 2020, she decided to do something about it. With support from UPMC Pinnacle Foundation and other community organizations, she co-founded the Diversifying Doulas Initiative (DDI), a program that provides free training for women of color to become certified doulas and provide their services at no cost to pregnant women of color. The primary goal of DDI, Livingston explained, is to close the gap in health outcomes for pregnant people of color. “Black women are three to four times more likely to die in childbirth than White women,” she said. “That’s a very concerning statistic that needs to be addressed, and DDI is helping us to do that.” The program, which is part of Patients R Waiting, an initiative that works to eliminate health disparities by increasing diversity in medicine, has been enthusiastically received by clients and is continuing to grow. “When we founded DDI there was one Black doula in Lancaster County,” said Livingston, who started the initiative with Dr. Cherise Hamblin, an OBGYN physician at Penn Medicine Lancaster General Health. “Now there are 26 who have served more than 140 women of color in less than two years. There is obviously a desire for these services.” Doulas, who are non-medical birth assistants, are partnered with women who are pregnant to provide services during pregnancy, labor and delivery, and post-partum. In addition to being patient advocates, doulas provide emotional, physical, and practical support. Research has shown that women who use a birth doula are less likely to require induced labor, less likely to have a Cesarean birth, need less pain medication, have reduced rates of post-partum depression, are more likely to be

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breast feeding eight weeks after giving birth, are less likely to have low birthweight babies, and are more likely to rate their childbirth experience as positive than women who do not have a doula. “There’s no question that doulas are beneficial for families,” Livingston said. “People call me the doctor who loves doulas. And I do.” While the benefits they provide are numerous, hiring a doula can easily cost $1,000 or more. “So, there are a lot of people who wouldn’t be able to have a doula because of the expense,” Livingston said. “We’ve eliminated that cost barrier.” DDI, a nonprofit organization, is supported through grants and donations that pay the doulas for their services. The UPMC Pinnacle Foundation recently awarded a $250,000 grant to the organization over five years. “I know I’m an employee and department chair, but I really have to credit UPMC,” Livingston said. “They’ve really put their foot on the gas to support us.” DDI is not currently training doulas but plans to resume the 16-week programs in 2023. Pregnant women who are interested in learning more about the benefits of a doula can fill out a form on the Patients R Waiting website (patientsrwaiting.com/ddi). While DDI is thriving, Livingston remains concerned about health inequities and will continue to focus on the work of Patients R Waiting, which works to increase the number of health care providers of color by making education and training more accessible and supporting minority clinicians once they are in practice. “Health care inequity is a big issue,” Livingston said. “But with big issues come big solutions.”

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Legislative Updates

PENNSYLVANIA MEDICAL SOCIETY QUARTERLY LEGISLATIVE UPDATE QUARTERLY LEGISLATIVE UPDATE

he General Assembly returned to Harrisburg for legislative business in late March, having recessed while in the process of budget hearings. As a result of the 2020 census, new legislative district lines, thought to be more favorable to democrats, have been drawn.

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SPRING 2022

Around 23 legislators have announced their retirement this year, one most notably being PA State Representative David Hickernell, Chairman of the House Professional Licensure Committee. It remains to be seen who will take his place. Dr. Arvind Venkat, an ER physician and PAMED member from Pittsburgh, is running for the State House in a newly created district. Due to the redistricting of the “voter maps” in Pennsylvania, this is a brand-new district and has no incumbent running. The PAMPAC Board looks forward to supporting Arvind Venkat, M.D., and hopes that he will become the first of many physicians in the Pennsylvania State House. On the legislative front, there are several bills that have seen some movement since the beginning of the year: House Bill 253 – Introduced by Rep. Clint Owlett (R – Tioga County), allocates $225 million to health care workforce. These funds will be used to help retain and recruit health care personnel as the COVID-19 pandemic continues to place strain on our hospital systems. The bill also establishes a task force examining the impact that the opioid crisis has on children in the Commonwealth. Result: Gov. Wolf signed HB253 into law on Wednesday, January 26. House Bill 1420 – Introduced by Rep. Wendi Thomas (R – Bucks County), directs the Secretary of Human Services to create a public awareness campaign promoting mental health resources available to first responders, health care workers and their families suffering due to the COVID-19 pandemic. PAMED is supportive of this legislation. Result: HB1420 is headed to Senate Appropriations Committee after second consideration in the full Senate.

House Bill 1862 – Introduced by Rep. Keith Gillespie (R – York County), preserves a COVID-19 regulatory waiver allowing health systems to utilize physicians with institutional licenses throughout the system’s facilities. Currently, the Medical Practice Act allows for physicians to have institutional licenses at no more than two facilities. PAMED is supportive of this effort to amend the Medical Practice Act. Result: The House Professional Licensure Committee reported the bill from committee with a unanimous vote. HB1862 is now awaiting consideration by the full House. Senate Bill 956 – Introduced by Sen. Judy Ward (R – Blair), would amend the Pennsylvania State Constitution to prohibit the use of Medicaid funds for abortions in Pennsylvania. Efforts to amend the state constitution require adoption of the language in two consecutive legislative sessions, then approval by voters in the Commonwealth through a referendum. PAMED is opposed to this legislation. Result: The Senate Health & Human Services Committee reported the bill from committee along a party line vote (7-4). SB956 now awaits the second consideration of the full Senate.

of residency before applying for a PA license whereas, U.S. graduates only need to complete two years. It is looking positive that this will get done this session. This bill will bring parity for IMGs by only requiring two years. Telemedicine (Senate Bill 705) — This bill has passed the Senate and is awaiting consideration in the House licensure committee. The pro-life caucus in the House wants to amend the bill to prohibit the use of telemedicine for medical abortions, causing a hurdle to pass in the House. PAMED and other stakeholders continue to push for a remedy. On a positive note, we do expect the current telemedicine Covid-19 waivers to be extended through June. At the end of February, Wayne Crawford joined the PAMED legislative team as the Director of Legislative Affairs. He has been involved in government affairs for his entire career, most recently working for the Pennsylvania Association of Realtors. In March, PAMED launched its new legislative community platform. The platform is a way to get physicians more engaged with legislation and to provide an opportunity to keep up to date on regulation and calls to action.

PAMED is closely monitoring and engaging in the following: Prior Authorization (Senate Bill 225) – The bill is nearing the end of the drafting process and could be up for a Senate vote in the near future. PAMED will be doing a call to action but not until there is a date that the bill will be considered. IMG Licensure Parity (House Bill 245) – The bill passed in the House last year and is currently awaiting a final Senate vote. IMGs currently must complete three years

For the most up-to-date information on advocacy priorities and legislative issues, please visit

www.pamedsoc.org/advocacy

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Restaurant Review

Max’s Eatery

reviewed by

JUSTIN OVERCASH, MD

Lancaster Radiology Associates, Ltd.

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PHOTOS PUBLISHED WITH PERMISSION OF MAX’S EATERY

P)eanut Butter Cup Milkshake

SPRING 2022

Max’s Single Smash Burger with cheese tots and onion rings

Chicken and Waffles with hot pepper syrup

ax’s Eatery sits right downtown, around the corner from Central Market, the Fulton Theatre, and all the other attractions the city has to offer. This was my wife’s and my second visit to the soda hop-themed restaurant, and this time we had appropriate companions, our 11and 6-year-old daughters. We had tickets to The Sound of Music at The Fulton. The show started at 8 p.m., so we had been looking for a 6 or 6:30 reservation. The online app was all booked up for prime time, so we begrudgingly choose 5:30, knowing it could be the perfect meal out with the kids. We were greeted by a friendly hostess who took us right to our table. Our girls would have happily played in the friendly, window-front waiting room for a while, though! The decor is an updated take on a diner, complete with a lunch counter and cute pink neon signs. The restaurant was only about half full, but for some reason they seated us right next to the bathroom, which my wife, Carly, grumbled about. While we ate, we noticed many tables still vacant, so we also aren’t sure why we were not able to make later reservations. However, all these minor details became unimportant when we met our very friendly server. He immediately greeted the girls and gave them classic soda jerk paper hats to decorate. They have a contest, and when you finish your hat, it is hung on the wall, and you are entered in a contest to win a gift card. We loved that this gave the kids an immediate activity! The menu is small, and very focused on milkshakes, over 15 flavors for kids and alcoholic ones for adults, and many, many cocktails. You can see it is probably a very fun menu if you are planning a boozy brunch with friends! We swooned over our respective beverages, vanilla and mint milkshakes for the girls, a Mai Tai for Carly, and Max’s twist on an Old Fashioned for me. They all came colorfully garnished with plastic flamingoes and mermaids, and everyone was

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happy with their choice. The milkshakes are not thick, and our 6-year-old was able to sip on hers right away. The food menu is brunchy and a bit heavy. But there are trendy diner-like options for all. Lots of shareable apps, salads, burgers, and tots. I chose to order off the brunch menu and got the Chicken & Waffles. Carly uncharacteristically ordered the Mac & Cheese, which came with a nice salad and fresh sautéed veggies. My chicken was crispy and covered with scallions and a delicious hot pepper maple syrup. No complaints here! The kids’ menu clocks in with eight options. My girls went with classic picks: Mac & Cheese and Max’s Chicken Toes (their cute name for chicken tenders). They had plenty to choose from as sides. Again, everyone was pleased. Max’s does not have a true dessert menu, just lots and lots of milkshakes! Carly and I were “forced” to split the “Peanut Butter Cup,” a shake made with soft serve, peanut butter vodka, Reese’s peanut butter sauce, and Hershey’s chocolate syrup. It came with two straws — and don’t worry, we embarrassed our kids thoroughly by drinking it like 1950’s teenagers. In the end, we had a great time. Our take-away: While perhaps not made for a gourmet date night, Max’s is the perfect spot for a meal with the whole family. It was an excellent way to kick off our evening. There was also a great awning for us to wait under while we gathered our nerve to dash out into the rain to catch our show.

MAX'S EATERY

38 West King Street | Lancaster, PA 17603 717-984-6286 | Maxseatery.com

PHYSICIAN

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SPRING 2022

Member Spotlight

News & Announcements

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

I am a breast surgical oncologist with the Breast Health Associates at UPMC’s Hillman Cancer Center. I came to love the Lancaster area while doing my general surgery residency at Hershey Medical Center. After completing my fellowship in breast surgery at Women & Infants Hospital/Brown University, I felt lucky to be able to bring my training in oncoplastic breast surgery back to the area. I love the unique combination of the cultural diversity of the city, its fascinating history, and the natural beauty of the region.

What do you like best about practicing medicine?

I am so privileged to be part of this profession — I really love coming to work every day! I enjoy the technical aspect of being able to work with my hands as well as the fact that I get to form long-term relationships with many of my patients. I also appreciate how quickly the field of breast cancer treatment evolves. So many brilliant physicians and scientists are working to cure breast cancer!

Are you involved in any community, non-profit, or professional organizations?

I am a Fellow of the American College of Surgeons and a member of the American Society of Breast Surgeons. I am also a member of Lancaster First United Methodist Church, a church with a strong focus on community and global outreach.

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

I love spending time with my husband, two kids, and bull terrier — I especially appreciate being able to experience the world through my kids’ eyes. I enjoy cooking, trying new restaurants, gardening, traveling, music — both playing the piano and seeing live performances, as well as watching my Detroit Tigers. New experiences for me this year have included paddle boarding and horseback riding. I think learning the drums may be on deck.

Abby Geletzke, MD Breast Health Associates UMPC in Central Pa.

For what reason(s) did you become a member of the Lancaster City and County Medical Society and what do you value most about your membership? I truly appreciate the advocacy of this group for physicians and patients in our region. I also appreciate the opportunity to promote the great physicians in this area and the wonderful things they are doing in health care and beyond.

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News & Announcements

Frontline Group Spotlight

Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco

Our practice receives recognition year after year from the National Committee for Quality Assurance with an award for delivering patient-centered, coordinated medical care. Patients receive sick and wellness care, including immunizations, as well as in-office procedures, including skin biopsies, minor surgeries, implantable contraception, joint injections, and cryotherapy. We have state-of-the-art equipment for onsite COVID-19 testing, diabetic eye exams, and EKGs. Our practice also offers integrated behavioral health counseling, addiction medicine, and pharmacist services. Local employers enjoy access to pre-employment physicals, drug screens, breath alcohol testing, and hearing testing. Our campus offers easy access to urgent care, lab, radiology, imaging, cardiology, endocrinology, psychology, podiatry, sports medicine, physical medicine, and rehabilitation services.

enn Medicine Lancaster General Health Physicians Family Medicine Norlanco has served our community for nearly 50 years at 418 Cloverleaf Road, Elizabethtown. Drs. R. Clair Weaver, Stanley M. Godshall, and J. Kenneth Brubaker opened the practice in September 1973 with the goal of providing the Northern Lancaster County community with access to quality medical care. The practice has steadily expanded, with multiple building expansions and additional professional staff to meet the health care needs of our growing community. Our team includes 15 physicians and four physician assistants, who work side by side with our nurses and front office staff to provide a full spectrum of high-quality, comprehensive medical care. As part of the prestigious Penn Medicine health system, our team ensures that patients receive direct access to top specialists and advanced services close to home.

At Lancaster General Health Physicians Family Medicine Norlanco, patients find that we provide a culture of excellent care through trust and teamwork.

As a primary-care practice serving all members of the family, our goal is to deliver quality medical care at every age and stage of our patients’ lives. Our knowledgeable team enjoys providing newborn through geriatric care and believes it is a privilege and honor to assist patients with end-of-life care, when comfort and compassion are essential.

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W E I G H T LO S S F O R A H E A LT H I E R L I F E

Demetria, Sleeve Gastrectomy Patient

We offer non-surgical and surgical weight loss options. For your patients that struggle with their weight and related issues such as type 2 diabetes or sleep apnea, our Healthy Weight Management & Bariatric Surgery program has a successful track record for obesity treatment. Our team is dedicated to helping patients achieve sustainable weight loss and improve their health. From an on-site exercise center just for patients to nutrition counseling and on-going follow-up and support, we have the resources to help your patients succeed. Your patients can take the first step by signing up for our online seminar at LGHealth.org/HealthyWeight. If you would like to talk to our staff about our program, please call 717-544-2935. Bariatric Surgeons

Joseph McPhee, MD James Ku, MD

Non-Surgical Providers

Zachary Ichter, DO

Lawrence Wieger, DO Virginia Wray, DO

Andrea Girolamo, CRNP

Healthy Weight Management & Bariatric Surgery 2150 Harrisburg Pike, Suite 300 | Lancaster

Bariatric AD_LancasterPhysician_7.375x9.875_11-21_Demetria.indd 3

11/11/21 8:30 AM

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

News & Announcements is to help your patients live life “toMyitsgoalfullest and die with dignity. With

deaths

your trust, Hospice & Community Care will fulfill its commitment of providing meaningful and compassionate care to Lancaster County residents facing life-limiting illnesses. With a team of board-certified palliative medicine physicians and interdisciplinary team members, we are committed to providing quality symptom management and support to relieve your patients’ pain and suffering.

John J. Corcoran, MD

John Joseph Corcoran, MD, passed away peacefully at home on Tuesday, February 1, 2022, surrounded by his wife of 61 years, Madolyn “Mickey” Corcoran, family, and friends. John graduated from Georgetown University School of Medicine in 1961, served a one-year internship at Misericordia Hospital in Philadelphia, and then served his country in the United States Air Force from 1962-1970. Assignments included serving as a general medical officer at Walker AFB, Roswell, NM; completing his OB/GYN residency at Lackland AFB, San Antonio, TX; and serving as a member and eventual Chairman of the department of OB/GYN at Andrews AFB, Maryland.

”

– Dr. Lauren Smith Interim Medical Director

In 1970, John and Mickey chose Lancaster, Pennsylvania to raise their family and to open his specialty practice of OB/GYN.

We’re here when your patients need us.

A skilled clinician and surgeon, Dr. Corcoran dedicated his life and career to the health and well-being of his patients. He was a Fellow in the American College of OB/GYN and served as a staff member of Lancaster General Hospital and St. Joseph’s Hospital. John served on various committees at both medical centers, including Chairman of the Department at Lancaster General Hospital. Dr. Corcoran’s credentials were top notch, but it was his manner and commitment to caring for his community that set him apart.

(844) 422-4031 www.HospiceProfessional.org

In addition to his wife Mickey, he is survived by his children, John Corcoran, Jr. (Holly Timms) of Snowmass, CO; Christine Liona (Steven) of Westford, MA; Matthew Corcoran, MD (Jody) of Margate, NJ and his six grandchildren. Also surviving are his sisters Rosemary Newberry (Joseph) of Cos Cob, CT, and Nancy Monti (Thomas) of Liverpool, NY; and his brother William J. Corcoran (Eric Palladini) of Washington, D.C. John was predeceased by his sisters Alice Holmes (the late John Holmes, MD) and Jane Briggs (Graham).

Lancaster County

Plans of Safe Care for substance affected infants and caregivers.

LCCMS EVENTS 2 0 2 2 Saturday, May 7

Spring Social & Foundation Benefit Lancaster Country Club (outdoor)

Wednesday, May 11 SIP. SHOP. CME.

Lancaster County Women in Medicine & PAMED Women Physician Section, Athleta, The Shoppes at Belmont

Visit LancasterJoiningForces.org/LancMD or call 2-1-1

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Thursday, September 15 Annual Dinner & Awards Celebration The Inn at Leola Village Casa di Fiori

SPRING 2022

FRONTLINE GROUPS SPRING 2022 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.

 Alere Family Health LLC  Allergy & Asthma Center  Argires Marotti Neurosurgical Associates of Lancaster  Avalon Primary Care  Campus Eye Center  Community Anesthesia Associates  Community Services Group  Conestoga Eye  Dermasurgery Center PC  Dermatology Associates of Lancaster Ltd  Dermatology Physicians Inc  The ENT Center  Eye Associates of Lancaster Ltd  Eye Health Physicians of Lancaster  Family Eye Group  Family Practice Center PC - Elizabethtown  General Surgery of Lancaster  Glah Medical Group  The Heart Group of Lancaster General Health  Hospice & Community Care  Hypertension & Kidney Specialists

New Members Lindsey L. Perea, DO Penn Medicine Lancaster General Health Physicians Trauma & Acute Care Surgery Dawn Snyder Practice Administrator, Susquehanna Valley Women’s Health Care Matthew D. Torres, MD Penn Medicine Lancaster General Health Physicians Family Medicine Quentin

Reinstated Members John D. Affuso, Sr., MD Penn Medicine Lancaster General Health Physicians Surgical Group

                 

Lancaster Cancer Center Ltd Lancaster Cardiology Group LLC Lancaster Ear Nose and Throat Lancaster Family Allergy Lancaster Plastic Surgery Lancaster Radiology Associates Ltd Lancaster Skin Center PC Stephanie A Mackey MD Manning Rommel & Thode Associates Medical Cosmetics LLC Neurology & Stroke Associates PC Ouilikon Medical Associates PC Patient First - Lancaster Penn Medicine Lancaster General Health Care Connections Penn Medicine Lancaster General Health Physicians Diabetes & Endocrinology Penn Medicine Lancaster General Health Physicians Family Medicine Lincoln Penn Medicine Lancaster General Health Physicians Family Medicine Manheim Penn Medicine Lancaster General Health Physicians Family Medicine New Holland

Maria Monica R. Calderon, MD Penn Medicine Lancaster General Health Physicians Internal Medicine Scott C. Conley, MD Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco Glenda J. Cook, MD Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco Dwight O. Eichelberger, MD Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco Brandon E. Johnson, MD Penn Medicine Lancaster General Health Physicians Anesthesiology Jeffrey B. Rittenhouse, MD Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco

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 P enn Medicine Lancaster General Health Physicians Family Medicine Norlanco  Penn Medicine Lancaster General Health Physicians Family Medicine Susquehanna  Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women  Pennsylvania Specialty Pathology  Randali Centre for Aesthetics & Wellbeing  Retreat at Lancaster County  Union Community Care - Duke St  Union Community Care - Hershey Ave  Union Community Care - Kinzer - Church St  Union Community Care - New Holland Ave  Union Community Care - Water St  UPMC Express Care  UPMC Lancaster Arthritis & Rheumatology Care  UPMC Pinnacle Breast Health Associates  UPMC Pinnacle Manheim Pike Primary Care  UPMC Pinnacle Plastic & Aesthetic Surgical Associates

Hayley W. Ryan, DO WellSpan Family Medicine - Trout Run Mary G. Tierney, MD WellSpan Family & Sports Medicine - Cocalico Paul E. Vassil, MD WellSpan Family & Pediatric Medicine - Rothsville Ryan C. Wennell, DO Penn Medicine Lancaster General Health Physicians Family Medicine Crooked Oak Meijuan Yan, MD Penn Medicine Lancaster General Health Physicians Specialty Medicine Richard C. Yunginger, MD Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco

Lebanon Harrisburg Carlisle

York

Lancaster

Chambersburg

Gettysburg Hanover

Surrounded by expert primary care. Welcoming new patients. With more than 50 convenient locations across central Pa., it’s never been easier to find a primary care provider. Our providers offer wellness services and treatment for medical conditions that range from common to complex. To find a doctor or schedule an appointment, visit UPMC.com/CentralPaPCP.

Lancaster Physician Spring 2022

Articles inside

WellSpan Health: Patients with Depression Say Transcranial Magnetic Stimulation is Life-Changing

Penn State Health: Lancaster Cleft Palate Clinic’s Renovations Bring Enhanced Technology and New Family-Friendly Features

Penn Medicine Lancaster General Health is Addressing Childhood Trauma's Long-Lasting Health Impacts