SHEDDING LIGHT ON CATARACTS
CAUSES, SYMPTOMS, TREATMENT, PROGNOSISBY ZACHARY LANDIS, MD
SHEDDING LIGHT ON CATARACTS
CAUSES, SYMPTOMS, TREATMENT, PROGNOSISBY ZACHARY LANDIS, MD
PERSPECTIVES ON WHAT LOCAL HEALTH CARE SYSTEMS HAVE LEARNED
RHEUMATOID ARTHRITIS (RA)BY MAMTA SHERCHAN, MD
DIABETES DRUGS USED AS WEIGHT LOSS MEDSBY MINNIE TAW, MD
Stacey S. Denlinger, DO President
UPMC Highlands Family Practice & UPMC Wound Healing Center
Sarah E. Eiser, MD President Elect
Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women
Robin M. Hicks, DO Vice President
UPMC Supportive Care & Palliative Medicine
Christopher R. Scheid, DO Secretary
UPMC College Avenue Family Medicine
Stephen T. Olin, MD Treasurer
Penn Medicine Lancaster General Health
Walter L. Aument Family Health Center
Laura H. Fisher, MD
Immediate Past President
Lancaster Family Allergy
Robert K. Aichele, Jr., DO
Marco A. Cunicelli, DO | Resident
Kendall R. Dempsey, MD | Resident
Lena Dumasia, MD
David J. Gasperack, DO
Anna S. Goetze, DO | Resident
James M. Kelly, MD
Karen A. Rizzo, MD, FACS
Susanne Scott, MD, MPH
Danielle Rubinstein, DO
LancasterPhysicianis a publication of the Lancaster City & County Medical Society (LCCMS). The Lancaster City & County Medical Society’s mission statement: To promote and protect the practice of medicine for the physicians of Lancaster County so they may provide the highest quality of patientcentered care in an increasingly complex environment.
As I review the amazing topics and titles for Lancaster Physician’s summer edition, I think it’s evident that “survival times” can be in our rear-view and we can move forward into the growth-phase of the present and future. How do we learn from the past? As a medical society, we are continuing to grow. We are experiencing growth in membership and in the understanding of each other and the needs of the people we serve. We’re also growing by making connections with newly elected legislators across the state. These relationships give us a voice in the policies and laws created at the state level. As individuals we come together with many shared experiences, but we also have personal experiences and stories. Being together, sharing those stories and experiences, makes us better able to serve the diverse Lancaster population.
Growth in medicine has continued and evolution of disease management in the areas of rheumatology and endocrinology over the last two decades is apparent in the types of treatments discussed with patients every day in our medical practices. We are offering treatment that manages the underlying problem of diseases and preventing complications from those diseases so much better than in the past. For example, this issue features an article about how medications for type 2 diabetes are helping patients manage excess weight, which is the number one risk factor for developing insulin resistance that leads to type 2 diabetes.
In addition to the articles about best practices in medicine, please take the time to read about a few of the outstanding physicians named by PAMED as Top Physicians Under 40. We are so thankful to all the physicians in Lancaster County and want to congratulate these special individuals for their achievements!
Lancaster’s markets, farm stands, rail trails, and its many summer activities — from outdoor music to food festivals — are great ways to get out in the community and interact. Please take advantage of all the things our amazing county has to offer and THRIVE this summer!
For many years, we have managed through long months of survival. We have to move through the surviving — the languishing — and find a way to thrive. Reviewing daily news headlines still leaves me with a feeling of looming threats. However, if you look around Lancaster, many of our small businesses have weathered the storm and the inviting, invigorating feel has been revived. We are a resilient community. It’s up to us to find a way to learn from the past in a way that allows us to be successful in the future. The young people need to see that there is hope.
As always, thank you to the contributors, advertisers and readers of this magazine for your continued support. I hope you enjoy the articles presented in this issue and have a wonderful summer!
ALSO IN THIS SECTION
• Penn State Health Lancaster Medical Center’s Interventional Cardiology Team Provides Seamless Emergency Care
• Anesthesia Gases: How WellSpan Is Working to Improve the Environment
• Health Care Practice Insights: A Driving Force Behind Successful Operations
Penn Medicine Lancaster General Health’s NEW
When it comes to an emergency, advanced training and equipment can make the difference between life and death. Penn Medicine Lancaster General Health’s new physician response vehicle brings both directly to the scene, with a mission to save more patients’ lives.
Penn Med 1 is a large sport utility vehicle outfitted with the same life-saving equipment and supplies as a medical helicopter. It also carries medical expertise: Its driver, Brendan Mulcahy, DO, PHP, PA, FAAEM, is LG Health’s EMS Medical Director and an emergency medicine physician.
Dr. Mulcahy works in collaboration with local emergency medical services personnel to provide advanced therapy to patients at the scene of an emergency. Since May, Penn Med 1 has responded to vehicle crashes, cardiac arrests, work-site accidents, and a serious fall. The vehicle is owned and operated by LG Health and provided as a service to the community.
“With Penn Med 1, we are essentially bringing the care of the hospital, including medical expertise and specialized equipment, to the point of injury,” Dr. Mulcahy said. “Our goal is to elevate the level of pre-hospital care that is available in Lancaster County and enhance survival and outcomes in our patients.”
Typically, when an emergency occurs, fire and rescue personnel extricate a patient who might be trapped — for example, someone who is pinned under debris in a building collapse — and deliver them to on-scene EMS personnel for treatment. When Penn
Mulcahy works alongside EMS personnel, and they make patient care decisions together. His training and background enable him to initiate treatment without first moving the patient, even if it means entering a collapsed building or other confined space.
“We have seen that taking earlier and more aggressive care right to the patient at the point of injury can significantly alter the outcome for that patient,” Dr. Mulcahy said. “As an emergency physician trained in EMS, I can deliver many of the specialized procedures our trauma surgeons do, except in austere environments.”
Penn Med 1 carries advanced life support equipment, a hospital-grade ventilator and a LUCAS device for mechanical chest compressions. It also carries two units of whole blood for on-scene transfusions, which is not generally available on EMS vehicles.
The vehicle’s “physician bag” contains chest tubes, arterial and central lines, and the supplies necessary to perform an emergency caesarean section or a field amputation. Additional features include
an ultrasound unit, a safe to store controlled substances, a cardiac monitor and equipment specially designed for pediatric patients. A pop-up white board is available when it becomes necessary to establish incident command.
In addition to field response, Penn Med 1 is used to offer education to local police, fire and EMS providers about tourniquets, bleeding control, and the vehicle’s capabilities.
Michael Ripchinski, MD, MBA, CPE, FAAFP, FACHE, LG Health Chief Physician Executive, said bringing medical expertise and advanced life-saving equipment to the scene of emergencies ultimately will advance the level of care that is available to patients throughout Lancaster County, even before they reach the hospital.
“LG Health is pleased to provide this resource as part of our longstanding commitment to the communities we serve,” he said. “Penn Med 1 enables us to bring advanced life support capabilities to the scene of an emergency, where we can partner with our EMS providers to enhance the care we deliver wherever our community needs us.”
An interventional cardiologist, left, and a registered cardiovascular invasive specialist at Penn State Health Lancaster Medical Center examine an intravascular ultrasound in one of the hospital’s three cardiac catheterization labs. State-ofthe-art imaging technology allows the interventional cardiologists to perform minimally invasive tests and advanced cardiac procedures.
Don Farr believes he would not be alive if not for the efforts of the emergency medical technicians, emergency department personnel, and the highly skilled interventional cardiologists who treated him at Penn State Health Lancaster Medical Center after he suffered a heart attack and cardiac arrest in April.
“I most likely would have died if I had gone to any other hospital,” said Farr, 65, of Mount Joy. “I not only had a heart attack, I went into cardiac arrest once I got to the emergency room.”
Emergency department doctors had been in constant communication with the Life Lion EMS paramedics who treated Farr on the way to the hospital and were waiting for his arrival.
As an emergency team, led by Dr. Alex Siegal, worked to restart Farr’s heart, a Penn State Health interventional cardiology team was mobilizing, having been activated upon receiving the results of the patient’s EKG. Within minutes, Farr was moved to one of the hospital’s cardiac catheterization laboratories, where doctors located a fully blocked artery and inserted a stent.
Dr. Patrick Fitzsimmons, an interventional cardiologist who treated Farr, said the rapid response of everyone involved and the experience of the catheterization lab team were key factors in saving Farr’s life.
“Survival rates for someone who has both had a heart attack and suffered cardiac arrest are only about 10 percent,” Fitzsimmons said. “It speaks to the work of everyone involved that this patient not only survived but walked out of the hospital just a few days after arrival.”
He called the process of transporting patients to the hospital, having them treated in the emergency department, and getting them transferred to the catheterization lab “seamless,” noting that the “door-to-balloon time” at Penn State Health Lancaster Medical Center — the time it takes from when a patient enters the hospital to when percutaneous coronary intervention (PCI) is completed — is about 56 minutes. Current guidelines call for door-to-balloon times of 90 minutes or less.
Fitzsimmons also praised the state-ofthe-art equipment in Penn State Health Lancaster Medical Center’s three catheterization labs, including Impella heart pumps, which are tiny devices used to help maintain blood flow during high-risk PCIs.
Meanwhile, Farr, a retired union sheet metal worker, is following up with Fitzsimmons on his ongoing care and doing just fine at home. He said he experienced no negative effects from the nine minutes that his heart was stopped, crediting the care team for quickly administering oxygen to prevent further damage.
“It’s like nothing ever happened,” he said. “It’s hard for me to comprehend. I had a heart attack and cardiac arrest on Saturday, and I ate lunch at home on Tuesday.”
Farr has made some lifestyle changes to assure he stays in the best health possible, increasing his intake of fruits and vegetables and getting regular exercise. Meanwhile, he and his wife, Jane, are grateful for the expertise and experience of the Penn State Health professionals who got him to the hospital quickly and provided lifesaving treatment.
“I can’t say enough about the care I got,” Farr said. “Everybody was really on the ball, that’s for sure.”
You breathe in, you breathe out. It’s the way the body works. It’s the same with the anesthesia gases you receive during surgery. You breathe in gases like desflurane, which helps people go to sleep quickly and wake up quickly. And then you breathe out the unused gases into the environment.
Unused anesthesia gases exhaled by patients are potent greenhouse gases, contributing to global warming and accounting for 5 percent or more of a hospital’s carbon footprint. This is why WellSpan is seeking ways to reduce its use of certain anesthetic gases while also safely caring for and ensuring the comfort of patients.
“The real concern is that the anesthetic gases sit in the atmosphere just like carbon dioxide does,” says Dr. Andrew Shorb, a WellSpan ear, nose, and throat physician who regularly performs surgery in the operating room. “Most
people think of carbon dioxide as the biggest greenhouse gas. Desflurane is described as having a 2,500 times greater global warming potential than carbon dioxide.”
Dr. Shorb is part of WellSpan’s Physician Leadership Academy, which seeks to develop the next generation of physician leadership at WellSpan. A Leadership Academy team is working with others on WellSpan’s surgical administration, supply chain, environmental services, and sustainability teams on the anesthetic gas reduction project.
WellSpan has made a commitment to reduce its greenhouse gas emissions by 50 percent by 2030. The health care industry is a major contributor to rising greenhouse gas emissions, emitting 8.5 percent of all U.S. greenhouse gas emissions and spending about $8.3 billion in energy annually to support its operations.
“Reducing our greenhouse gas emissions is one of WellSpan’s sustainability goals,” says Keith Noll, WellSpan senior vice president and chief administrative officer, who is working with the Leadership Academy team on its efforts. “As a system, we have embarked on a variety of sweeping changes to become more sustainable by recycling, reprocessing, sustainable purchasing, and conserving energy. We know we have a responsibility to care for our neighbors in South Central Pennsylvania and also for our planet.”
WellSpan hopes to reduce the anesthesia footprint through several initiatives:
• Educating and informing anesthesia leaders. The team sent a letter to providers with information about gases, their environmental impact, and costs. The letter also had data on baseline usages at WellSpan.
• Promoting the use of more intravenous anesthetics.
• Promoting the use of more local anesthetics or regional anesthetics, like spinal blocks.
• Examining the current anesthesia gas system to ensure that valves are working and there are not a lot of leakages in the tanks or system emitting gases into the air.
Dr. Shorb said WellSpan is taking a cooperative approach.
“We are not telling providers that they need to get rid of a certain gas but asking them to consider when they use it and why. We’re hoping we can be on the leading edge of phasing out some of these gases,” Dr. Shorb says.
At the top of the list is desflurane, an anesthetic gas that lasts in the atmosphere for 14 years. Eight hours of using desflurane is comparable to driving a car 1,600 miles, in terms of its atmospheric impact.
Hospitals in Europe have banned or are in the process of banning the use of this gas because of its environmental effects. Fortunately, there are good alternatives, such as sevoflurane, which has a much lower impact on the environment.
Dr. Greg Katos, an anesthesiologist at WellSpan Ephrata Community Hospital, says that these environmental concerns are being discussed and implemented by anesthesiologists across the country.
“In our current practice, we have already taken steps to limit the routine use of desflurane. We more frequently use sevoflurane, which has an inherently lower carbon footprint,” Dr. Katos said. “We also continually update our best practices as new data and information become available, including recent guidance that suggests these medications can be safely used in a manner that further reduces environmental impact.”
WellSpan will track usage of certain gases and see if numbers are trending down. Providers have been positive about making the changes, while also remaining focused on offering the right type of anesthesia to comfortably care for patients who are undergoing surgery or procedures.
“I think we all have concerns for environmental changes,” Dr. Shorb says. “We see the weather pattern changes and we see things that are happening globally. The more you look at projects like this that are targeting sustainability and environmental impact, the more you realize we need to act now.”
Communication is critical in any relationship. This is especially true when it comes to patient care and practice management. Before an individual even sees a doctor, their first touch point is with the office staff. This is the cornerstone of why we work with patients and providers to streamline processes, operate efficiently, and deliver the highest level of care.
It may seem obvious that talking to one another about problems, processes, and procedures occurs regularly, yet the workdays are busy and filled
with tasks like scheduling, billing, and greeting patients. Phones are ringing and computer screens are populated with forms and fields that require focus and attention. Finding time to have a conversation — especially a difficult one — while trying to manage operations through multiple platforms can be daunting.
Although new to my current role, I served UPMC HVI for 15 years in various positions, which has helped me learn the nuances of the practice. And since no two days are the same, I must shift gears when necessary.
My job is multi-layered, and I can be pulled in any direction on any given day. Since I am responsible for managing all aspects of business through our practice, communication is of the utmost importance to eliminate error and frustration.
Practice managers oversee accounting, staffing, compliance, marketing, patient scheduling, information technology, and operations in their work. Given all the moving parts of the day, my philosophy is simple — it’s about the patients.
Making sure my staff is well trained and informed is instrumental, but creating a positive experience begins by greeting patients with a smile as soon as they enter our door. Reminding everyone that sharing a common goal and taking a collaborative approach is a recipe for success.
Still, challenges present themselves and talking about what may not be working is how situations get resolved. We listen and consider feedback from each other. Anything can be improved to make the workflow a little bit better. No one person has all the answers.
Each morning, I make a list of what needs to be accomplished. I also rely upon the support and knowledge of my colleagues and counterparts.
To streamline processes and be efficient, networking with the other managers in Central PA has been critical. I have that support system, so if there’s anything I don’t know or need, I can reach out to the other managers.
We attempt to make it easy for patients to get their procedures and follow-up care. Working closely with other teams provides the resources needed to do our jobs and remain focused on delivering the level of care patients deserve.
But when we encounter situations like temporary staff shortages and scheduling conflicts, leaning on that network of colleagues helps to accommodate patients and keep operations running smoothly.
• CULTIVATE STRONG LEADERSHIP SKILLS.
• STAY CURRENT WITH INDUSTRY TRENDS.
• EMBRACE TECHNOLOGY AND EXPLORE NEW SYSTEMS.
• FOSTER A PATIENT-CENTERED CULTURE.
• DEVELOP EFFICIENT AND COMPREHENSIVE OPERATIONAL PROCESSES.
• INVEST IN STAFF DEVELOPMENT.
• PRIORITIZE REGULATORY COMPLIANCE.
• BUILD STRONG RELATIONSHIPS AND COMMUNICATE.
In my experience, UPMC is an inclusive and welcoming health care system. One that believes by expanding knowledge in all aspects of care, everyone thrives. The organization’s ideology is rooted in its Journey to Excellence program, which fosters passion for providing patients with the best possible care through commitments to six strategic pillars:
Of course, these focus areas are applicable in many parts of operations and complement the system’s overall mission and values: caring and listening, dignity and respect, excellence and innovation, quality and safety, and responsibility and integrity. For myself and my staff, delivering effective care isn’t possible without this value system and patients recognize when they are implemented.
Patient experience is so important to us because we see the same people regularly. It matters that they feel valued in our care. It’s rewarding to hear that they appreciate the time the doctors spend with them and the concern from our staff.
In keeping with the commitment to demonstrate these values, all UPMC employees are required to complete online annual continuing education classes. Topics range from emergency situations to policies and procedures as well as diversity, equity, and inclusion. I encourage my office staff to explore all educational opportunities since it helps everyone with their jobs and relationships.
Additionally, senior leadership participates each year in what is known as the RiTE sessions (short for Reimagining The Experience). These sessions not only support leadership development and advancing skills, they also are designed to evaluate new ways of advancing patient-centered health care and enhancing the work experience.
The RiTE sessions essentially create an environment where people want to work and physicians aspire to practice. Through presentations and a collaborative forum, employees identify opportunities, create solutions, and strive to engage in positive change.
This is one of a few mechanisms that combines interdisciplinary service lines across the Health Services Division (HSD) to share best practices and spread them throughout the division. Team huddles as well as regular staff and provider meetings also help facilitate planning and executing goals.
For me, being an effective and successful health care practice manager requires a combination of leadership skills, industry knowledge, and a patient-centered approach. By cultivating relationships and staying current with industry trends, offices can operate efficiently and continue to improve upon patient care.
Executing different strategies and prioritizing communication among staff and patients allow those of us working in health care to navigate challenges and achieve long-term success within our practices and organization.
Acataract is a clouding of the crystalline lens of the eye. The lens is a biconvex structure that is transparent at birth. It sits just posterior to the iris and is held in place by thin collagen fibers (zonules). Its function is to refract light to produce a clear image on the retina. The crystalline lens also has the ability to change shape to focus images when looking at images up close (accommodation). Accommodation begins to decline after the age of 40, which is when people start to need reading glasses. The lens then gradually becomes cloudy due to a multitude of factors including oxidative damage.
Cataract is the leading cause of vision loss worldwide. The incidence of cataracts increases with age but can also occur in younger individuals secondary to trauma, ocular inflammation (uveitis), diabetes, high myopia (nearsightedness), and systemic medications such as steroids and chemotherapies. Rarely, cataracts can also be congenital.
Several different symptoms can develop depending on the type and severity of the cataract. Typical symptoms include generalized blurred and decreased vision, glare, and difficulty in low light environments. Difficulty with night driving is typically one of the earliest symptoms of cataracts. Cataracts can lead to blindness when they become very dense.
Cataracts cannot be prevented, and surgery is the only treatment. This is generally performed as an outpatient surgery with topical anesthesia and intravenous sedation. Modern cataract surgery uses
ultrasound energy (phacoemulsification) to break the cataract into smaller pieces that are then aspirated through the same handpiece. This allows for a small incision (as small as 2 mm) that rarely requires suture placement. An artificial intraocular lens (IOL) is then placed in the eye. The appropriate power of the IOL is determined by anatomic measurements of the eye that are obtained pre-operatively (biometry).
discussion with the patient to determine the IOL that will give that particular patient the best outcome.
Post-operatively, patients generally use a combination of antibiotic, steroid, and nonsteroidal anti-inflammatory drops for several weeks. Some of these medications can also be injected in the eye at the time of surgery, decreasing the need for post-operative drops. There is typically significant improvement in vision by post-operative day one, but it does take several weeks for the eye to completely heal.
Cataract surgery is very safe. Major complications such as infection are extremely rare, especially with the use of intracameral antibiotics. The goal of cataract surgery is to remove the crystalline lens while leaving the capsular bag intact. The capsular bag is a collagenous basement membrane that is as thin as 4 microns. Given how thin the capsule is, the most common intraoperative complication is a posterior capsule tear or rupture. When this occurs additional surgical steps are required, but patients can still have favorable outcomes.
IOL technology has increased tremendously in the past decade and newer technologies continue to develop. There are IOLs that can correct astigmatism and can also give patients a range of vision from distance to near; there is now even an IOL in which the power can be adjusted post-operatively using UV light. Depending on ocular comorbidities, not every patient is a candidate for these advanced technology IOLs. It is prudent for the ophthalmologist to perform a thorough pre-operative exam and have a thorough
Cataracts do not recur, but it is common for the posterior capsule to become cloudy after cataract surgery due to migration of lens epithelial cells. This is referred to as a posterior capsular opacification and is easily treated in the office with a minor laser procedure (YAG capsulotomy).
Cataracts cannot be prevented, and surgery is the only treatment.
Autoimmune disease arises due to loss of tolerance to self-antigen. A combination of genetic factors, environmental triggers, and various infections can lead to breakdown of the tolerance mechanism of immune system. Dysregulation of the immune system gives rise to activation of the immune cells to attack autoantigens, resulting in inappropriate inflammation and multi-organ damage.
Rheumatoid arthritis (RA) is one of the common systemic autoimmune diseases affecting 0.5-1 percent of the general population and is almost two-fold higher in females then males. Although the exact cause of RA is unknown, interaction of genetic and environmental factors certainly plays a role. Most influential genetic risk factors are the class II MHC haplotype of an individual. Among the environmental factors, most consistent is cigarette smoking. Also, viral infections, such as Epstein Barr Virus, have been implicated as possible risk factors for RA.
RA primarily affects joints and causes polyarticular inflammatory arthritis, which can lead to progressive joint damage. A characteristic clinical feature is symmetric involvement of small joints such as hands, wrists, feet, and ankles with morning stiffness lasting more than one hour in early disease. The cervical spine, most commonly C1-C2, is involved in 30-50 percent of RA patients. There are also other less common patterns of onset, such as monoarticular or
oligoarticular presentation with predilection for larger joints such as elbows, shoulders, knees, or hips. If left untreated, RA can lead to bone erosion, joint deformities, and irreversible damage causing substantial physical limitation. Extra-articular manifestations are also observed, including skin-rheumatoid nodules, lung-ILD, eye-episcleritis/scleritis, and heart-pericarditis. Those issues are more severe in uncontrolled long-standing RA.
Rheumatoid factor (RF) and anti-citrullinated petptide antibodies (ACPA) are the relevant antibodies for RA. In contrast to RF, ACPA positivity is highly specific. RF can also be positive in systemic lupus erythematosus; Sjogren’s syndrome; and viral infections such as hepatitis B, C, and HIV. Other lab findings supporting RA are elevated ESR, CRP, thrombocytosis, and mild normocytic anemia. Early in the disease, radiographs are often normal, but typical radiographic findings include periarticular osteopenia and marginal erosions.
RA is diagnosed on the basis of typical articular manifestation — pain, swelling of joints with prolonged morning stiffness — along with lab, radiographic assessment, and tools used for classification criteria for RA to aid in diagnosis. 2010 American College of Rheumatology (ACR)/ Europeon League Against Rheuamtism (EULAR) classification criteria include the presence of small joint arthritis, positive serum RF or ACPA, elevated acute phase reactants, and symptom duration of at least six weeks. These classification criteria were developed for clinical trial purposes to assist in making a diagnosis.
Disease-modifying anti-rheumatic drugs (DMARDS) are the mainstay of treatment for RA. These drugs modify the nautral history of RA by reducing progression and structural joint damage. There are two different kinds of DMARDS: conventional DMARDS (cDMARDS) and biologic DMARDS (bDMARDS).
Conventional DMARDS include methotrexate, leflunomide, sulfasalzine, and hydroxychloroquine. Methotrexate remains the first line therapy for RA and an anchor drug in combination regimen for treatment of RA.
Research and development of bDMARDS has revolved around RA pathogenesis. Though incompletely understood, cells of innate and adaptive immune system play a crucial role in RA through production of pro-inflammatory cytokines, chemokines, and autoantibody production. Biologic DMARDS drugs work by targeting cytokines, their receptors, or cell-surface molecules. They include TNF targeted therapies (e.g., etanercept, adalimumab, infliximab, golimumab), IL-6 inhibitors (tocilizumab, sarilumab), B-cell depleting therapy (rituximab), T cell Costimulation modulator (abatacept), and JAK inhibitors (tofacitinib, baricitinib, upadacitnib).
Glucocorticoids are rapidly effective and are used along with other DMARDS as part of intial therapy to gain rapid control of RA. They are aggressively tapered, due to their toxicity, as slower DMARDS starts to kick in. Glucocorticoids are ideally used as a bridge to effective DMARDS therapy.
Treat to Target can be measured by various disease activity measures such as the Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), Disease Activity Score in 28 joints (DAS28), and Routine Assessment of Patient Index Data 3 (RAPID-3). It includes various RA assessment components such as tender joint count, swollen joint count, ESR, CRP, patient global, and provider global.
With new innovations and great advances in therapeutic regimens in RA, we have been able to alter the course of RA from a severe painful, disabling disease to a much more managable disease. With earlier intervention we can put RA in remission or minimize disease activity so patients experience fewer physical limitations and enjoy an improved quality of life.
Patient education about RA and its chronicity is crucial. There is good data to support
that patients with a good understanding about their disease and medication, who take an active role in management of their chronic condition, have better outcomes.
Educating patients about arthritis self-management and stress management is effective in lowering measures of helplessness, improving the ability to cope with pain, and achieving a more favorable health status. Referring to physical and occupational therapy for regulated exercise to improve joint mobilty and increase muscle tone and strength will help patients perform daily routines, improve global assessment and moods, and decrease chronic pain.
Studies have also highlighted RA as a significant risk factor for cardiovascular (CVS) morbidity. Patients needs to be screened for traditional CVS risk factors such as hypertension, hyperlipidemia, and diabetes and be aggressively treated for these conditions. Smoking cessation should be regularly addressed.
The bond between patient and physician to treat chronic lifelong disease is very important to build trust and ensure compliance with treatment. Without that connection, it is difficult to achieve a treat to target stategy. The best care is attained when a rheumatologist, PCP, and patient work together as a team.
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2. Erickson AR, Cannella AC, Mikulus TR, O’Dell JR. Clinical feature of Rheumatoid Arthritis, Treatment of Rheumatoid Arthritis. Firestein’s and Kelley’s Textbook of Rheumatology
3. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid Arthritis Classification Criteria. Arthritis and Rheumatism 2010
4. Guixiu Shi, Jianying Zhang, et al. Systemic Autoimmune Diseases. Clinical and Developmental Immunology Volume 2013, Article ID 728574
5. Sompayrac L. How the Immune System Works. sixth edition
As healthcare providers, we are quite familiar with the statistics of obesity not only in the U.S. but also worldwide. Obesity is a complex and chronic disease that now affects more than 40 percent of Americans. Overweight and obesity are risk factors for type 2 diabetes. Obesity is linked to half of the newly diagnosed cases of diabetes yearly — and both conditions are strongly linked to cardiovascular disease.
The National Diabetes Prevention Program has shown that a relatively modest amount of weight loss through diet, exercise, and lifestyle changes can prevent or delay diabetes. With the FDA approval of semaglutide for weight loss, which was initially approved as a diabetes medication (and another, tirzepatide, on its way for FDA approval), this is an exciting and promising time for patients living with obesity and for the providers treating them. While prior anti-obesity medications helped people lose about 5 to 8 percent of their body weight, this newer class of type 2 diabetes drugs can help achieve up to a 15- to 21-percent reduction in body weight.
These particular diabetes drugs, glucagon-like peptide 1 receptor agonists (GLP-1s), mimic incretins, the gut hormones we naturally make in our bodies. Weight loss can vary depending on the specific GLP-1 and its dose. The first of its class to be approved by the FDA for weight loss was liraglutide under the name Saxenda in 2014 (after it was approved to treat type 2 diabetes as Victoza). GLP-1s work at several levels: in the brain by decreasing appetite; on the pancreas by stimulating the release of insulin when blood sugar levels start to rise; and in the gastrointestinal tract by decreasing intestinal motility and delaying gastric emptying — making one feel full faster and longer. At lower doses (1.8 mg injectable dose per day), liraglutide was approved to decrease blood sugar among patients with type 2 diabetes. Liraglutide 3.0 mg/day (injectable dose) was approved for the treatment of obesity. The average weight loss is between 5 to 10 percent, especially with the higher liraglutide dose.
Semaglutide (Wegovy) was approved by the FDA for weight loss in 2021. To help with blood sugar levels in those with diabetes, the injectable doses include 0.25-2.0 mg per week (as Ozempic) and oral doses of 7-14 mg per day (as Rybelsus). Dosing for obesity requires a monthly titration starting at a 0.25 mg weekly subcutaneous injection to the maximum and maintenance dose of 2.4 mg weekly subcutaneous injection. From the STEP research trials (Semaglutide Treatment Effect in People with Obesity), average weight reduction was about 15 percent. Comparing this to the older generation obesity drugs, these results were quite remarkable. Furthermore, with about a third of the subjects losing at least 20 percent of their initial weight, their results were close or comparable to some types of bariatric surgery. Interestingly, in the research trials, those with diabetes had less weight loss than those without diabetes — but they lost on average about 10 percent of their initial weight after one year on the medication (6 percent more than the placebo group).
The STEP trials also looked into what happens if the medication was continued or discontinued after one year. They found that those switched to a placebo regained much of their weight — whereas those who received semaglutide continued to lose weight and stabilize their weight loss at about 15 percent of their initial weight. A follow up study showed that semaglutide can sustain weight loss for at least two years (compared to placebo). This reinforces the fact that obesity is like any other chronic condition and medications should be prescribed for long term use.
Tirzepatide is a combination of a GLP-1 and a gastric inhibitory polypeptide (GIP) — both incretin-mimicking hormones. Like semaglutide, tirzepatide also works in the brain by decreasing appetite; it signals the pancreas to release insulin to lower blood sugar after eating and it slows gastric emptying in the GI tract— allowing for fullness and decrease in food intake. Tirzepatide (as Mounjaro) was approved in 2022 for the treatment of type 2 diabetes. The SURMOUNT-1 trial included about 2,500 participants who were overweight or obese with at least one weight-related condition but who did not have diabetes. The trial compared different doses of tirzepatide to placebo. Tirzepatide at weekly injectable doses of 5 mg, 10 mg, and 15 mg resulted in mean weight loss of 15, 19, and 21 percent respectively at 72 weeks. Currently, the FDA has granted tirzepatide its Fast Track designation to be reviewed for the treatment of overweight and obesity.
Like any medication, the GLP-1s come with potential side effects. The more common side effects like nausea, vomiting, diarrhea, constipation, and abdominal pain often improve as the medication is continued and titrated slowly to the maximum dose.
Hypoglycemia is a risk and should be carefully monitored especially if a GLP-1 is taken with other glucose lowering medications such as sulfonylureas and insulin.
GLP-1s are not recommended in those with personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia, a previous history of pancreatitis, or who have a known hypersensitivity to any of the medication components. It is also contraindicated in pregnancy.
The cost is a major concern, not just for this class of drugs, but for all prescription medications that treat overweight and obesity. For a medication like semaglutide, the cost of over $1,000 per month creates a barrier for many patients who can benefit. Currently, it is not covered by Medicare and many private insurers. Most people taking anti-obesity medications in general pay for them out of pocket. Providers may need to continue to look into less expensive options like the older generation anti-obesity medications (i.e. phentermine, phentermine/ topiramate, bupropion/naltrexone, and orlistat) in adjunct to recommending diet, exercise, and lifestyle modifications.
According to the Obesity Medical Association, anti-obesity medication treatment is one of the four nonsurgical pillars of weight management — in addition to appropriate nutrition, physical activity, and healthful behavior. Medications should be part of the discussion about comprehensive treatment options for our patients living with obesity or who are overweight with related health risks. There is no “one size fits all” model, keeping in mind that individuals vary in terms of their biological makeup and weight journeys. A personalized, patient-centered approach is key. Weight loss medications like GLP-1s (and more on the horizon) have changed the landscape for weight management — a breakthrough patients and providers alike have been waiting for. Studies have shown that weight loss with the help of anti-obesity medications can lower the risk of serious cardiovascular events — a reminder that obesity is among the most significant risk factors for preventable death in our country. Now, with more potent tools, we can better help our patients get to their “best weight” and live their healthiest and happiest lives.
With nearly all major markets posting positive performance year-to-date in the face of a growing list of concerns around the economy, investors couldn’t be faulted for giving some thought to the old stock market adage “sell in May and go away.” The S&P 500 is up over 10 percent so far in 2023 as of this writing, performance that’s in line with the longterm average annual return for stocks. With ongoing concerns about a potential recession in the back half of the year, moving to the sidelines and holding cash in a money market fund, where yields are close to 5 percent, may appear tempting. A look at market history, however, tells us that trying to time the market is far more damaging to long-term investment returns than remaining fully invested in the appropriate long-term asset allocation throughout the ups and downs of market cycles. As Terry Smith, the notable British investment manager, once said, “There are only two types of people: those who can’t market time, and those who don’t know they can’t market time.”
Despite the uncertainty of the nearterm outlook, investors are best served by continuing to keep their long-term goals in focus. Though admittedly this can sometimes prove difficult — especially now that cash offers a more competitive return than it has in over a decade — it is far more difficult to reliably get out of the market at just the right moment and then also get back in at the right time. Looking to market history is instructive. Going back to 1930, the average intra-year decline for the S&P 500 has been 16.3 percent. Looking at the years when the index experienced a double-digit drawdown, performance still finished the year in positive territory 69 percent of the time. Deviating from the long-term plan and being out of the market also has substantial costs. Looking at the past 30 years, missing the 10 best days in the S&P 500 reduced the annualized return by 2.4 percent, missing the 20 best days lowered the return by 4.1 percent, and the 30 best days by 5.6 percent. Extending the analysis all the way back to 1930 is even more eye opening. Despite a myriad of
events that wreaked havoc on markets like the Great Depression and World War II at the beginning and the Global Financial Crisis and COVID-19 pandemic at the end (and many more in between) throughout the nearly 100-year period, the S&P 500 returned an astonishing 17,715 percent through the end of 2022. Missing just the 10 best days each decade, however, would have resulted in financial catastrophe, reducing the price return to a mere 28 percent — a difference of 17,687 percent.
Timing the market is made even more difficult because the best days are more likely to occur in the middle of a bear market than during a bull market. March of 2020 provides a recent salient example. After the market finally bottomed on March 23, the next three days saw the S&P 500 rise by 17.6 percent, even as the news remained grim. Taking a longer-term view, 78 percent of the biggest up days for the stock market have occurred in the midst of either a bear market or during the first two months of a new bull market. As we’ve clearly shown, missing those days can be devastating to long-term returns. The odds are decidedly against an investor who attempts to time the market in this fashion.
So what is an investor supposed to do in periods of uncertainty like we are experiencing today? Designing a plan you will be able to stick with through thick and thin will drastically improve your odds of success. Start by defining your goals.
What does your personal definition of financial success look like?
What is the money for, ultimately?
What keeps you up at night?
From there, design a plan built around a diversified long-term target asset allocation
that maximizes the probability of achieving success, however you define it, and choose the right path to get invested in line with those targets. Finally, once your plan is implemented, stick to it. The best tool to manage risk is a diversified long-term asset allocation matched to unique goals and time horizons. One of the best additional tools available to manage risk in addition to investing in an appropriate asset allocation is rebalancing portfolios regularly and, more importantly, in times of market stress that cause major deviations from that long-term target allocation.
Volatility is a feature of the stock market, not a bug. So when volatility rears its ugly head again, which it inevitably will, remember that you’ve planned for it. History has shown that despite what the immediate future holds, investors will be best served by sticking to their long-term strategy and staying the course. Those who do will ultimately be rewarded in the long run.
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 Shanthi Sivendran, MD, MSCR, MBA, and her passion outside of practice.
How long have you been participating in this activity?
When I first started running in medical school, I was looking for a way to stay in shape but also stay centered. During my residency and fellowship training, my running goals changed. I found myself placing in my age group in local races, so I was chasing personal best times. It was also a great excuse for my fellow trainees and I to run a race and then go eat a huge brunch! When I moved to the phase in my life of having three babies, running was the way I slowly regained my fitness. Now with young kids, I find running is what keeps me sane and keeps me healthy enough to run after the three of them!
Why is this pursuit special to you?
Running has been a central, unwavering part of my adult life. It brings me focus, creativity, community, and motivation and influences all parts of my life. It is also a way for me to explore new places when I travel. Ultimately, running brings me joy.
What else would you like readers to know about this passion?
Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?
My passion outside of practice is running. I love that all I need is my own two feet and good running shoes. Nice weather is preferred but optional — I have run through wind, snow, rain, and hail!
How did you develop an interest in your passion outside of practice?
I started running with a friend in medical school just for fun. I have always been a “big goal” sort of person, so we set our sights on running a marathon. My first race was the Dublin Marathon in 2000. Since then I have done countless races of varying lengths, but my favorite distance is the half-marathon.
My current favorite reason to run is because my sixyear-old daughter is showing an interest in this passion. She recently watched me run my first half-marathon in a while and decided she wanted to run a race as well. We spent several weeks doing some training and cross training which was wonderful time together. On Mother’s Day, she made me so proud when she ran her first 5K — sprinting all the way to the end. There was so much joy on both of our faces!
In the United States of America, June is Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA+) Pride Month. This recognition provides space to recognize and celebrate the LGBTQIA+ community out loud. Sexual orientation and gender identity are generally an invisible attribute, in contrast to skin color, ethnicity, and language — thus the importance of space to openly be your authentic whole self. Without the ability to be openly authentic, the toxic politicization combines with this invisible element of ourselves and creates fertile ground for internalized stigma and unwarranted shame. I recognize how the past decades have been marked by US Supreme Court legal recognition of same sex love and marriage, as well as transgender identities. Yet this does not erase the current efforts around the country to ban discussions of sexual orientation and gender identity in schools, question the validity of transgender students’ identities, or abhorrently paint LGBTQIA+ adults as pedophilic “groomers.” Like any journey, we are not where we were, but we have not arrived.
Counter to proponents’ claims that they act to protect children by restricting LGBTQIA+ adults and children, we find that these efforts cause harm — not safety. Transgender students at baseline are at higher risk of experiencing physical, verbal, and sexual assault compared to their cisgender* peers (1). Because LGBTQIA+ students are more often targets than perpetrators, sexual assault is increased for transgender students if bathroom and locker room accommodations are not provided (2). We also see that students’ mental health is impacted negatively if there is apathy or restriction at the state (3) and school (4) policy level. This is not only impacting LGBTQIA+ students, but based on a very large study, policies that protect and validate LGBTQIA+ students positively impact cisgender heterosexual students as well (4). The journey forward involves not separation and exclusion but embracing our shared humanity.
As a physician, I can state confidently that I didn’t go to medical school to comment on state policy, write op-eds, or stand up at school board meetings. I devoted my years
of training to studying the human body, its diseases, and how to heal them. But what are we to do when we see the toll that these policies inflict on our LGBTQIA+ patients? An antidepressant will not cure the ongoing trauma my transgender patients encounter at school, at work, in the courts, and in life. As physicians we are tasked not only with reactive treatment of established disease, but also prevention. We vaccinate, we screen for cancer, we treat that high blood pressure — even in people who feel well. As a father of two young healthy boys, I want them to grow up into a world where we have taken steps to stop bigotry and prevent trauma to the LGBTQIA+ community. Advocacy is both prevention and treatment.
We have a voice as physicians and health care workers, and our words carry weight. Not just in meetings with policy makers, but also with our colleagues and with the patient in front of us. I seek more than policy change; I want health care to treat all LGBTQIA+ folks with equitable compassion. I want the new father to feel confident taking his husband with him to their newly adopted son’s well child visit
— without being asked if the baby has been tested for HIV. I want the mother getting chemotherapy for her recurrent breast cancer to be able to hold her wife’s hand in the infusion center — and not have to use her rationed energy to explain one more time that this is her wife, not her sister. I want the physician whose child just came out as a transgender boy to know that she can bring him to his office visit and know that all the phone calls she made to update the office about his affirmed name and gender made a difference. Will his heath team address his migraines, or will the whole visit be questions about his gender?
Unfortunately these are not theoretical worries. In 2022, about one in three LGBTQIA+ people reported at least one episode of discrimination or mistreatment from a health care provider, and more than one in five reported an event where a doctor refused to even see the patient — these numbers are even starker in LGBTQIA+ people of color and transgender individuals (5). This discrimination impacts not only the LGBTQIA+ community, but also those who care for and care about the people of the community.
The pervasiveness and scope of advocacy needed may feel daunting, but allyship and advocacy are journeys as well. The first step is to acknowledge there is injustice and to sit with this awareness. From there we can move through several steps on this path: self-examination, awareness, education, interaction, and action (6).
1. In self-awareness, we meet ourselves where we are. Self-examination can be uncomfortable, but the ability to think critically and objectively about our own attitudes gets easier with practice. The first step in addressing unconscious bias is becoming conscious of it.
2. After we learn to see it in ourselves, we naturally engage with a broader awareness of the community’s challenges. We begin to internally and externally note the presence and context of this community.
3. Education is a fundamental next step as we grow in allyship. Learning about the history, culture, and concerns of the community, as well as the laws and policies impacting it — this provides context. At the same time, balance your educational process with courtesy and respect for the community. Marginalized groups are by no means obligated to teach you nor represent their entire community to you.
4. At this point interaction becomes a natural part of allyship. Listen more than speak. An unfortunate part of being a member of a marginalized community is becoming accustomed to not being believed by people outside the community. Nothing humanizes a situation like another human. The work of self-awareness makes it easier to open ourselves to the challenge of learning things that don’t match our assumptions.
5. As we build on our internal and external awareness, our knowledge, and our open interactions, we overflow into action. This in an inevitable next step after seeing and understanding ongoing injustice. We all have spheres of influence and here we can choose to be a force for positive change. We cannot help but name injustice, yet at the same time we must compassionately nudge and correct our colleagues. We do a disservice if we use our voice to push away potential future allies by forgetting compassion for those who are not yet aware of these injustices. There is no shame in learning.
As an ally, this may become a major piece of your life and work, or it may be yet another facet to your life. You may simply take an open stance in support of communities and colleagues impacted by bias, stereotyping, and injustice. In some ways, allyship is being an open, aware, and compassionate person. Compassionately listening to a friend who doesn’t know how to feel about her daughter coming out. Happily celebrating a male colleague’s engagement to his boyfriend. Sharing at a meeting about how a policy might impact the LGBTQIA+ community. With some practice, common ground is not hard to find. We all want to be good parents,
supportive colleagues, and work in places that provide safe, equitable, and high quality care. Remember why we went into medicine in the first place: to help others. Advocacy can be a seamless piece of this same calling. Indeed, you may find that advocacy is simply natural growth of the same work you have been doing all along.
*Cisgender (adj) – having a gender identity matching that which was assigned at birth.
1. Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep 2019;68:67–71. DOI: http://dx.doi.org/10.15585/mmwr.mm6803a3.
2. Murchison, Gabriel R., et al. “School restroom and locker room restrictions and sexual assault risk among transgender youth.” Pediatrics 143.6 (2019).
3. Prairie, K., Kivisto, A. J., Gray, S. L., Taylor, N., & Anderson, A. M. (2022). The association between hate crime laws that enumerate sexual orientation and adolescent suicide attempts. Psychology, Public Policy, and Law. Advance online publication. https:// doi.org/10.1037/law0000360.
4. Kaczkowski W, Li J, Cooper AC, Robin L. Examining the Relationship Between LGBTQ-Supportive School Health Policies and Practices and Psychosocial Health Outcomes of Lesbian, Gay, Bisexual, and Heterosexual Students. LGBT Health. 2022 Jan;9(1):43-53. doi: 10.1089/lgbt.2021.0133. Epub 2021 Dec 17. PMID: 34935516; PMCID: PMC9003132.
5. Medina C, and Mahowald L. Discrimination and Barriers to Well-Being: The State of the LGBTI+ Community in 2022. 12 Jan 2023. Last accessed 30May2023. Accessed from: https://www.americanprogress.org/article/ discrimination-and-barriers-to-well-being-the-stateof-the-lgbtqi-community-in-2022.
6. School of Social Work - Tulane University. Allyship: What It Means to Be an Ally. School of Social WorkTulane University, 18 Nov. 2019, https://socialwork. tulane.edu/blog/allyship.
The federal COVID-19 public health emergency ended in May, with most people ready to declare the pandemic finished and put it behind them.
Studies, surveys, and reports, however, are confirming what health care workers, teachers, social workers, and others on the front lines already knew. Long-lasting medical, academic, social, economic, and cultural effects of the pandemic are still in play, and it appears they’ll continue to be for some time.
COVID-related deaths of nearly 7 million people worldwide have had devastating effects on families, communities, and entire societies. The Centers for Disease Control and Prevention reports that nearly one in five adults in the United States who experienced COVID19 continue to suffer from symptoms of “long COVID,” a condition that causes ongoing health problems and can interfere with one’s ability to work, attend school, care for family, or complete other tasks.
Academic achievement slowed dramatically for millions of students, while rates of mental health problems and substance abuse sharply increased. The world economy suffered as a result of the pandemic, with dramatic increases in inequality noted within and across countries. Rates of homelessness, domestic violence, and isolation among elderly people also increased.SUSAN SHELLY Writer
And yet, not every effect of the three-yearplus pandemic was negative. We witnessed heroic efforts by health care workers who worked to heal the sick and scientists who labored tirelessly to find treatments and develop a vaccine. We found different ways to work, for students to continue to learn, and to socialize. Many of those innovations remain in place, with lasting, positive effects.
Lancaster Physician reached out to the health care systems serving Lancaster County to learn how they were most affected by the pandemic, what they learned from the experience, and what lessons will be carried forward. We spoke with representatives from WellSpan Health, UPMC, Penn State Health, and Penn Medicine Lancaster General Health.
COVID-19 produced major challenges for WellSpan Health’s staff and systems, especially during the early, chaotic days of the pandemic, according to Dr. David Gasperack, vice president and chief medical officer for the East Region, covering Lancaster and Lebanon counties among others.
“No one could have predicted that something like that was going to happen,” Gasperack said. “I think everyone was in a state of shock.”
Attempting to contain the virus by limiting hospital visitors was necessary, but extremely difficult for family members who were unable to be with hospitalized loved ones. That experience was especially difficult for those in the Plain Community, Gasperack noted, who often lacked access to technology that would have enabled them to connect remotely with family.
“The visitation policy was probably the most challenging, as we could see how hard it was for families,” he said. “But we had to do those things to minimize the spread of the virus.”
Other challenges included figuring out where to place patients, as hospitals were overcrowded with very sick people, and once placed, how to locate enough staff to care for all those patients.
Health care providers also had to contend with frustrated patients who were confused about policies regarding masking, vaccines, treatments, social distancing, closings, and other pandemic-related concerns.
“There were a lot of patients who really dug in their heels, and that was tough to deal with,” Gasperack said. “It really came down to a lot of one-on-one conversations with patients.”
Despite those and other challenges, however, Gasperack said he and others experienced times of great satisfaction and pride as staff from throughout the WellSpan system and across other systems came together to look for answers and find better ways for treating patients.
“Our tagline here is ‘working as one,’ and during the pandemic I saw that enhanced here at WellSpan and for the first time happening across other health care systems in our region,” Gasperack said.
Staff members willingly deployed as necessary, filling in wherever they were needed, adjusting their shifts, and sharing in-demand supplies and equipment. Staff of every level worked together to figure out the best ways to care for patients.
In addition, WellSpan joined other health care systems serving Lancaster County to establish testing stations and a community vaccination center to care for as many residents as possible.
“We all really came together to work for the greater good of the community,” Gasperack said. “That was very rewarding to see. To me, it’s the silver lining of COVID-19.”
Challenges remain, he noted, as health systems contend with staffing shortages that were exacerbated by the pandemic and other issues. WellSpan is focusing on helping patients experiencing long-term COVID symptoms by offering care at its COVID Care Center in York, virtual support groups, and other measures.
The system will continue to address staffing shortages by stepping up its use of artificial intelligence; continuing to employ telehealth, as appropriate; and embracing technological advances that streamline work for health care providers.
“We still are dealing with some challenges, but we learned a lot during the pandemic that made us stronger,” Gasperack said.
Dr. John Goldman, an epidemiologist and vice president of medical affairs at UPMC in Central Pennsylvania, is already considering the possibility of another pandemic, although preferably without him on the front lines of battle against it.
“We do think about what might come next,” Goldman said. “Many people believe the pandemic was a 100-year event, however, so hopefully I’ll be retired before the next one.”
Goldman predicted there will be lasting effects from COVID-19, which he believes will become a seasonal disease for which annual vaccines will be available, similar to influenza.
“It’s something that will be around, and we’ll certainly continue to monitor it closely,” Goldman said. “But what I expect to see as it becomes less contagious are fewer cases of serious illness and much lower mortality rates.”
At the peak of the pandemic, UPMC was caring for 1,000 COVID-19 patients systemwide, with 300 of them in Central Pennsylvania. Currently, according to Goldman, there are about 40 COVID patients hospitalized systemwide, with about a quarter of them in Central Pennsylvania.
“And the people who are ending up in our hospitals now are much less likely to end up in the intensive care unit,” he said.
Some experts are concerned about the possibility of a variant that won’t respond to pre-existing immunity or a vaccine, but Goldman does not consider that to be a major threat.
“There are some models that show that, but I’m not particularly concerned about it,” he said.
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As UPMC Lititz and other hospitals have gone back to more normal operations, including a return of elective surgeries and removal of masking requirements for everyone, Goldman, who was a frequent spokesperson for UPMC during the pandemic, reflected on a troubling trend he observed.
“For whatever reasons, we had a lot of resistance to masking and vaccines for what I believe were purely political reasons,” Goldman said.
While he acknowledges the value of debate regarding decisions such as required masking and shutting down schools and business, that debate should occur within objective, accountable frameworks — not on social media platforms.
“I think it’s perfectly legitimate to discuss what is the right balance for protecting the public from the effects of COVID with the negative consequences of social isolation, but it needs to be done in an organized, intelligent manner,” Goldman explained.
He hopes research regarding these types of issues will continue, and that the public will recognize the value of relying on scientific findings instead of politically based opinions presented as facts.
“I think one of the lessons we learned from the pandemic is that Americans should not get their information from social media,” Goldman said.
While the worst effects of the COVID-19 pandemic have abated, signs of a “COVID hangover” remain, according to Deborah Addo, executive vice president and chief operating officer for Penn State Health.
That hangover is evidenced by ongoing staffing shortages made worse by the pandemic and continued disruptions in supply chains — both problems that have threatened the stability of health care systems across the country.
“We are still dealing with residual effects of the pandemic, and probably will be for a long time,” Addo said. “But we’re also able to look back at what we’ve learned from the experience and use that knowledge as we move forward.”
An assessment of regulations that were waived during the pandemic to accommodate changing needs resulted in modifications to how some of those rules are implemented, Addo explained. Officials realized the need for more warehousing of supplies instead of relying on a just-in-time supply chain strategy, in which supply chain partners move materials right before they are needed.
And a review of the strict visitation policies enacted during the pandemic caused officials to re-evaluate their actions in that area.
“That certainly was one of the most difficult things we were forced to deal with,” Addo said. “We had to do what we could to prevent spread of the disease, but I can’t imagine we would ever go back to a policy of no visitation. We all were very happy when families could visit again.”
Reflecting on Penn State Health’s response to the early days of the pandemic, Addo praised the manner in which various components of the health system worked together, pooling resources and sharing ideas and strategies for best practices. She also noted the partnership that flourished between Penn State Health and Penn State University.
“I think we capitalized on the best of everything we are,” Addo said. “We saw an overall strengthening of our entire system through research, invention, and innovation. We’ve definitely seen that education, research, and healing can all work together.”
That spirit of teamwork has continued, she said, to the benefit of the health system and the university.
Penn State Health will continue its review of policies and regulations as it continues to assess COVID-19 and deal with new cases of the virus.
“We will always care for patients with COVID, just as we every year see patients come to the hospital with the flu,” Addo said.
Meanwhile, she and other leaders are assessing practical, ethical, and moral issues as they continue to debrief about the pandemic and strategize over preparing for future challenges.
“I think there is so much we can learn,” Addo said. “And that’s always easier when you’re looking in the rear-view mirror.”
While the COVID-19 pandemic presented great challenges, it also resulted in beneficial changes that likely would not have otherwise occurred, said Dr. Michael Ripchinski, chief physician executive at Penn Medicine Lancaster General Health (LG Health).
His biggest takeaway when looking back at the pandemic, reflected Ripchinski, is the power that’s found in working together.
“We all learned we’re capable of overcoming great challenges, and we learned that we work best when we work as a team,” he said.
He observed teamwork among the members of LG Health’s medical staff, who worked together to employ scientific methods for the rapid implementation of new processes and procedures to ensure smooth operations of its hospitals and the best care for patients.
Ripchinski also spoke of teamwork among the four health care systems that serve Lancaster County, officials of county government, the Pennsylvania Department of Health, and private companies, such as TriStarr Staffing and Rock Lititz, a production community in Warwick Township.
Members of those organizations worked together to establish and staff a vaccine center in the Park City Mall and administer nearly a quarter million COVID vaccines. They formulated plans for alternative care
sites in the event that local hospitals could not accommodate all patients and communicated timely information to the public.
“There was a lot of cooperation and teamwork involved to ensure we would do our best for our communities,” Ripchinski said.
As a health care system, LG Health employed performance improvement initiatives to maximize its capabilities to care for patients in challenging circumstances. While masking and visitation policies put in place during the pandemic have been relaxed, others, such as increased use of telehealth, remain in place.
Ongoing challenges that concern him, Ripchinski said, are staffing shortages and the morale of workers who have remained in their jobs.
“The moral distress and burnout that have occurred among our health care providers have caused many to leave,” he explained. “It also has taken a toll on the providers who are still here taking care of patients.”
Many factors are responsible for employee burnout and low morale, but they can be partially attributed to a decrease in the public’s trust of health care workers, according to Ripchinski.
Polls show that trust levels dipped during the pandemic, and while they’ve partially recovered, they are not yet back to pre-pandemic levels.
Both patients and health care workers must work to re-establish that trust and make efforts toward shared decision-making, Ripchinski said.
“That lack of trust in medical professionals is hard to accept because we go into health care to be of service to people,” he shared. “It’s been difficult to see those trust numbers going down during the pandemic.”
Still, he said, the lessons learned, and knowledge gained as a result of the pandemic will help health care providers and staff respond to other types of challenges in the future.
“We know if we roll up our sleeves and work together, we can figure out how to solve problems and do what needs to be done for our patients and community,” Ripchinski said. “And that benefits everyone.”
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The legislative session comes to an end with a victory! PAMED was successful in restoring money in 2023-2024 state budget for the Primary Care Loan Repayment Program. The program provides loan repayment, up to $80,000, for a health care provider who commits to practicing in a rural or underserved area for three years. Gov. Shapiro’s initial budget proposal “zeroed out” the funding for this program. However, PAMED was successful in not only having these funds restored but also securing a one million dollar increase in the overall funding, bringing the program’s budget line to a little over eight million dollars.
PAMED continues to actively push for venue reform. The Pennsylvania Coalition for Civil Justice Reform (PCCJR) made a formal request to the Supreme Court’s Civil Procedural Rules Committee to conduct an immediate review of the impact of the medical liability venue rule that returned forum shopping to medical malpractice cases. Data from the first six months of the venue rule change shows a significant increase in medical liability cases in Philadelphia. These cases are seeing substantially higher settlements than similar cases throughout the Commonwealth.
The new venue rule imposes a requirement on the committee to review the impact of the venue rule change after two years. However, PAMED and PCCJR are asking for a review now before irreparable damage is done to physicians and the health care system over the next two years. PAMED is a founding member of the PCCJR and continues to lead the way on venue rule review. We will continue to update members on news regarding venue as this continues to develop.
Recently, at the annual meeting of the American Medical Association (AMA), PAMED leadership drove the passage of a resolution to address the need for permanent and meaningful Medicare payment reform. Leadership from the Pennsylvania AMA Delegation, in partnership with the leaders of the Florida and Texas state delegations, presented the resolution at the AMA meeting, stating that this type of reform is critical for physicians’ practice sustainability and to protect senior citizens’ access to care. The passage of the resolution empowers the AMA to build a multipronged campaign addressing the issue on a national level.
Below are details on legislation that PAMED has been following.
Primary Care Loan Repayment Program (PCLRP) – As it currently stands, the program provides loan forgiveness, presently up to $80,000, for physicians who choose to practice in a rural or underserved community for two years. Next year’s proposed budget does not include the PCLRP line item — providing no student loan forgiveness. PAMED was success in advocating to not only keep the Primary Care Loan Repayment Program in the 2023-2024 state budget, but also in advocating for a one million dollar increase in the overall funding.
Senate Bill 631 on POLST – Senator Gene Yaw (R-23rd District) introduced Senate Bill 631 for the codification of Pennsylvania Orders for Life Sustaining Treatment (POLST) to be used by medical professionals across all health care settings for patients who voluntarily wish to execute a POLST order. PAMED has supported previous legislative proposals on POLST and applauds Senator Yaw for introducing this most recent proposal.
Senate Bill 25 on Scope of Practice Expansion – Legislation was introduced that would enable the independent practice of certified registered nurse practitioners (CRNP) and remove the collaborative agreement currently require to practice independently from physicians. PAMED opposes this legislation and supports the need for physician oversight of all non-physician practitioners.
Co-Sponsorship on Reforming Insurer Credentialing – Legislation was introduced that would modernize the health insurer credentialing process. Senator Ryan Aument (R-Lancaster) has agreed to sponsor legislation that will, among other things, limit the time afforded to insurers to complete a physician’s application to participate in each health plan, though the bill does not require insurers to accept every applicant. PAMED supports this co-sponsorship memo.
PAMPAC plays a critical role in helping to advance PAMED’s legislative agenda. Although PAMPAC does not engage directly in legislative advocacy, PAMPAC’s support of legislative candidates helps to open doors for our members by developing positive and productive relationships with legislators and legislative candidates. Physicians are encouraged to support PAMPAC. Contributions can be made here: pamedsoc.org/laws-advocacy/PAMPAC.
For more information about any of the items mentioned above, please visit the Advocacy Section of PAMED’s web site at www.pamedsoc.org/advocacy
It was a long overdue dinner date after having our second kid. We have finally found an amazing and reliable babysitter; therefore we took the opportunity to check out Iron Hill Brewery & Restaurant. We were joined by another couple for an evening of catching up. Our babysitter was a little early, so we arrived at the venue slightly before our reservation. Just as it struck 5:30, we were escorted to our booth.
Walking into the place, we found it looks like what you would see at many other brewery/restaurants — a lot of dark stained wood, big windows, and sports on TV at the bar. It’s a very comfortable and casual atmosphere. They have options for indoor, outdoor, or bar seating.
Shortly after being seated, we were greeted by our server. The staff was professional and friendly. After being handed the menu, we started browsing while waiting for the other party to arrive. After John and Jenn joined us, we started with an appetizer and drinks. Iron Hill has a great beer, wine, and cocktail selection. The menu groups the various beer options into categories, such as Crisp & Clean, Hoppy, and Spiced & Fruity. I ordered Iron Hill Light Lager. It was definitely brewed to give a crisp, clean, refreshing taste with very subtle malt and hop flavor. My wife, Tina, went with a Strawberry Margarita, which was made just right. John opted for the Hometown Tap brew called The Diplomat, taking its name from the mascot of F&M college. Iron Hill also offers nonalcoholic beer, which is for some other time.
For our appetizer, we tried Philly Cheesesteak Egg Rolls with horseradish sauce, which hit the spot. For the main course, I ordered Herb Chicken & Linguine. It was the sherry wine butter sauce that did it for me. Tina, given her love for tacos, ordered Chicken Fajita Tacos.
There have been many instances where she wants to “share” food, but on this occasion, even after I offered to share, I was turned down. It’s safe to say she enjoyed what she ordered. Jenn unfortunately was dealing with a medical issue and went light with an order of Kennett Square Mushroom Soup and a side of Buttery Mashed Potatoes. According to her, she was not disappointed. John had the Char-grilled Ribeye Steak. The steak was cooked just how he wanted it to be. We were enjoying ourselves so much that we ended up ordering another round of drinks.
After two and a half hours of indulging in well-prepared food and catching up on kids, work, and upcoming trips, we were greatly satisfied but still ordered Triple Chocolate Hill — a double-fudge brownie with vanilla ice cream, peanut butter caramel sauce, chocolate sauce, and whipped cream — for dessert. This time, Tina did want to share, and since she is not a big peanut butter fan, we ordered it without the peanut butter caramel sauce. We should have ordered separately as Tina’s idea of “sharing” was a little unfair.
Overall, we had a great experience and enjoyed Iron Hill’s cool and casual environment. We will definitely go back to check out other items on the menu.
Throughout the commonwealth are talented early career physicians, who already are performing at a high level. Pennsylvania’s Top Physicians Under 40 recognizes the best of the best early career physicians each year.
This year’s recipients, including three from Lancaster County, were nominated by colleagues and selected by a committee of Pennsylvania Medical Society member physicians. We are pleased to recognize Abby Geletzke, MD, Christina Lawson, MD, and Shane Specht, DO.
Abby Geletzke, MD, is a board-certified general surgeon who specializes in breast surgery. Dr. Geletzke earned her medical degree at University of Toledo Health Science Campus. She completed her residency at Penn State Health Milton S. Hershey Medical Center and a fellowship at the Women & Infants Hospital.
Her nominator said, “Patients we have shared say she truly cares about them as a person, not just another cancer diagnosis. As a fellow
clinician and colleague, it is amazing to work with someone you can trust to do the best thing for the patient and who never hesitates to reach out and discuss cases.”
Christina Lawson, MD, is board certified in Dermatology and practicing in Lancaster County. She has a medical degree from Howard University College of Medicine and completed her residency in dermatology at Howard University Hospital where she served as chief resident during her final year.
Her nominator said, “She is very knowledgeable, kind, and caring, but most importantly, she is one of the humblest individuals you will ever meet. These characteristics are shown through her patient care, research, and service.”
Shane Specht, DO, is a board-certified internist and is affiliated with UPMC Community Osteopathic and UPMC Lititz. He received his medical degree from Philadelphia College of Osteopathic Medicine where he also attended
residency. He currently serves as the program director for osteopathic education at UPMC Community Osteopathic.
His nominator said, “Dr. Specht is a respected and trusted member of the hospitalist team. During the time he spends at UPMC Lititz he is responsible for the care of a wide spectrum of patients, including critical care patients in the open ICU, as well as patients on the acute medical and surgical floors. He goes above and beyond to provide evidence-based and personalized care for his patients while balancing his responsibility as a teaching attending.”
“We had a lot of great nominations, but these candidates stood out among the rest,” Dr. Kristen Sandel, Pennsylvania Medical Society president-elect and chair of the awards committee, said in a news release. “With their ambition and innovative ideas, they will shape and shine bright in the future of medicine.”
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Lancaster Family Allergy has been open for over ten years, and Laura Fisher, MD, and Amanda Bittner, MD, have been practicing in Lancaster for years before that. Lancaster County is a beautiful place to live but has high pollen counts and sometimes poor air quality. This spring was particularly challenging for residents.
Lancaster Family Allergy treats patients with environmental nasal allergies and asthma. We manage food allergies and allergic skin rashes like atopic dermatitis and allergic and irritant contact dermatitis as well as idiopathic urticaria. Our practice evaluates patients for insect allergies and immune deficiency, and our specialty treats some challenging disorders, such as mast cell activation disorders, hereditary and acquired angioedema, and alpha-1 antitrypsin (AAT) deficiency.
The immune system is fascinating. There are so many more treatment options for patients now versus past years. Monoclonal antibodies can treat some of the challenging conditions above without overloading patients with steroids. Safe and effective treatment options exist for babies as young as six months of age with extensive eczema, poorly controlled asthmatics, and those with genetic disorders.
We started the practice looking to focus on families. Allergy and asthma patients often get allergy immunotherapy to improve and
“cure” their allergies. This is very effective in most cases but involves a time commitment and frequent shots in the office. Children sorting through food allergies to ease their parents’ anxiety and improve their quality of life might spend an afternoon doing an in-office challenge. Testing for drug allergies and stinging insect allergies can take several hours. We wanted an environment where kids can play in a separate playroom and adults can relax while getting cutting edge care. Best of all, unlike so many other areas of medicine, most of our patients get significantly better.
For many of us as physicians, the last few years have been different. We have been busier than ever. Lancaster Family Allergy is a private practice group and has faced trials during the pandemic and the aftermath that followed. The community of physicians in Lancaster is truly unique. We are thankful to have so many other physician colleagues in Lancaster from otolaryngology, rheumatology, dermatology, pediatrics, pulmonology, obstetrics and gynecology, and primary care, and others to help with difficult cases, give mental support, and advice. Our practice faces the same staffing challenges as many others, but we have a core group of awesome and dedicated nurses and staff to really get to know our patients and care for them. We feel truly blessed to live and practice in Lancaster.
Where do you practice and why did you settle in your present location or community?
I am an anesthesiology resident at UPMC Lititz. The anesthesiology program provides me with excellent training in a close-knit, extremely supportive environment. I can’t say enough about how much I enjoy coming to work with such amazing attendings, co-residents, nurses, and other staff.
What do you like best about practicing medicine?
I knew I wanted to be a physician when I was very young. Finally finishing school and starting residency feels like the culmination of many years of hard work. It’s amazing to see how far I’ve come over the years and know that I am living the dream I’ve had since kindergarten.
Are you involved in any community, non-profit, or professional organizations?
I am a member of the American Academy of Family Physicians and the Pennsylvania Medical Society, and I’m an active supporter of World Vision International.
What are your hobbies and interests when you’re not working?
When I’m not working, you’ll probably find me at Orange Theory; playing with my dog, Aloo; or trying one of the many restaurants in the area. On weekends off, I often head to Baltimore to see my partner who is a psychiatry resident at University of Maryland. I also enjoy traveling and recently set a goal to visit all the national parks.
For what reason(s) did you become a member of the Lancaster City & County Medical Society and what do you value most about your membership?
I think it is very important to be involved in advocacy for our profession. Since I am new to the area, I am looking forward to getting to know other LCCMS members and getting more involved.
Alere Family Health LLC
Argires Marotti Neurosurgical Associates of Lancaster
Avalon Primary Care
Campus Eye Center
Carter MD Aesthetics
Community Anesthesia Associates
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
Iconic Medical Arts
Sheryl Arif, DO resident - UPMC Lititz
Samantha L. Bush, DO resident - Lancaster General Hospital
Theja Channapragada, DO resident - Penn State Health Milton S. Hershey Medical Center
Matthew Douglas student
Thomas Fisher, DO resident - UPMC Lititz
Asma Ghafoor, DO resident - UPMC Lititz
Miranda Ginder, DO student
Anna S. Goetze, DO resident - UPMC Lititz
Roxanne Kelley practice administrator - Union Community Care
Baasma Khan, DO resident - UPMC Lititz
Alexandar Lalovic, DO student
Christopher George McCarty, DO WellSpan Family Medicine – Terre Hill
Lancaster Arthritis & Rheumatology Care
Lancaster Cancer Center Ltd
Lancaster Cardiology Group LLC
Lancaster Ear Nose and Throat
Lancaster Family Allergy
Lancaster Pulmonary & Sleep
Lancaster Radiology Associates Ltd
Lancaster Skin Center PC
Manning Rommel & Thode Associates
Nemours duPont Pediatrics Lancaster
Neurology & Stroke Associates PC
Penn Medicine Lancaster General Health
Physicians Cardiothoracic Surgery
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 New Holland
Penn Medicine Lancaster General Health
Physicians Family Medicine Norlanco
Joshua C. Merris, MD WellSpan Occupational Health
Anthony R. Miller, MD resident - Penn State Health Milton S. Hershey Medical Center
Clayton W. Mohler student
Alexa Renee Neiderer, DO student
David Raubenstine, DO student
Caroline V. Ruiz student
Sonam T. Sherpa, DO Myerstown Family Practice P.C.
Ameera Zaynab Syed student
Vincent Joseph Vozzella student
Marissa Witmer student
Zachary Zook student
Penn Medicine Lancaster General Health
Physicians Family Medicine Red Rose
Penn Medicine Lancaster General Health
Physicians Family Medicine Susquehanna
Penn Medicine Lancaster General Health
Physicians Lancaster Physicians for Women
Penn Medicine Lancaster General Health
Physicians Specialty Medicine
Pennsylvania Specialty Pathology
Randali Centre for Aesthetics & Wellbeing
Shady Grove Fertility – Lancaster
Surgical Specialists – UPMC
Union Community Care – 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 Breast Health Associates
UPMC Plastic & Aesthetic Surgical Associates
WellSpan Ephrata Cancer Center
WellSpan Family Health – Georgetown
Megan Morris-Murphy, DO Highlands Family Practice
Laleh Sarah Radfar-Baublitz, DO Iconic Medical Arts
Wednesday, August 2 Docs On Call
Sunday, August 6 Early Career Physician Meet-Up
Wednesday, August 23 Docs, Drinks & Dialogue | Walk & W(h)ine
Thursday, September 21 Advocacy 101
Friday, October 27 - Sunday, October 29 PAMED House of Delegates
Saturday, December 2 Holiday Social & Foundation Benefit
for more info visit www.lancastermedicalsociety.org
Lancaster General Health is proud to have Westphal Orthopedics and their expert team of orthopaedic surgeons, advanced practitioners, physical therapists, and office staff join our health system.
The practice, now called Penn Medicine
Lancaster General Health Physicians
Orthopaedics, is led by surgeons with decades of experience and commitment to our community: Dr. Thomas R. Westphal, Dr. Carl E. Becker, and Dr. Brian T. Brislin. The practice provides compassionate, personalized orthopaedic care including joint replacement, arthroscopy, on-site physical therapy, and sports medicine surgical treatments.
2106 Harrisburg Pike, Ste. 116 | Lancaster 717-393-1900 | LGHealth.org
UPMC is one of the most experienced robotic surgery centers in the world, having reached the milestone of performing more than 70,000 specialized surgeries. Our skilled experts have access to the latest robotic technology, including the da Vinci Surgical System® which is a more precise and less invasive option. This means our patients can experience shorter hospital stays, less pain, and a quicker recovery. Learn more about robotic surgery at UPMC.com/CentralPa.