Lancaster Physician Winter 2016

By Linda Myers, MD

2016 BOARD OF DIRECTORS

Contents

OFFICERS

WINTER 2016

James M. Kelly, MD President

Lincoln Family Medicine

David J. Simons, DO

Best Practices

President Elect

Community Anesthesia Associates

Robert K. Aichele, DO Vice President

Aichele & Frey Family Practice Associates

6 How to Talk to Patients About

Advance Care Planning

Paul N. Casale, MD Immediate Past President

The Heart Group of Lancaster General Health

Laura H. Fisher, MD Secretary

Lancaster Family Allergy

10 WellSpan Ephrata Community

Hospital Expands Lifesaving

Heart Care Services

Stephen T. Olin, MD Treasurer

Lancaster General Hospital

DIRECTORS Charles A. Castle, MD Stacey Denlinger, DO

12 Percutaneous Kidney Stone

Removal: A Team Approach

To Patient Relief

COVER STORY

Breast Cancer Risk Management The Factors That Matter Most (p. 22)

Robin Hicks, DO John A. King, MD Venkatchalam Mangeshkumar, MD Kathryn McKenna, MD Ashley Morrison, MD

In Every Issue

Karen A. Rizzo, MD, FACS

Editors:

4 President’s Message

30 Medical Society Updates

Dawn Mentzer

14 Healthy Communities

32 Restaurant Review

Susan Neville PAMED

20 Passion Outside of Practice

34 News & Announcements

22 Patient Advocacy

38 Foundation Updates

James Kelly, MD Lincoln Family Medicine

26 Legislative & Regulatory Updates Graphic Designer: Brittany Fry 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 klyons@lancastermedicalsociety.org.

Lancaster Physician is published by Hoffmann Publishing Group, Inc. Reading PA HoffmannPublishing.com 610.685.0914

For Advertising Info Contact: Kay Shuey, Kay@hoffpubs.com, 717.454.9179

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President’s Message

What Does PAMED Do For Me That My Hospital Can’t?

T James Kelly, MD President

his is a common question I hear from employed physicians when considering membership with our county and state medical societies. Information regarding ICD-10 education, insurance billing, and CME is readily available and seamlessly implemented in well-run hospital systems. So this begs the question—what else can PAMED offer to the employed physician?

For years we saw membership numbers of employed physicians decline. Thankfully, membership over the last two years is on the rise—especially in the employed sector, largely due to PAMED advocacy efforts. We have a dedicated and skilled lobbying team at the state level with several recent major victories benefitting all PA physicians. The MCare reimbursement monies, Maintenance of Certification (now being addressed at the national level), and taxation of physician services (Senate bill defeated on November 23) are recent advocacy wins accomplished by your PAMED team.

As we move into 2016, listed below are several areas where PAMED physicians and lobbyists are focusing efforts: 1. Insurance Credentialing – HB 1663, introduced in November 2015 with PAMED support, will streamline credentialing processes for new physician hires. A mandated single application form, provisional credentialing after 30 days, and reimbursement during provisional credentialing are the high points of this game changing legislation.

2. Prior Authorization – PAMED-advocated legislation should be coming soon with the goal of streamlining the cumbersome and frustrating prior authorization process (most commonly for advanced imaging) that delays patient care.

3. CRNP Legislation – Testimony by Lancaster’s own Karen Rizzo, MD, was instrumental in tabling legislation (HB 765, SB 717) granting CRNPs freedom from collaborative agreements. Keeping the health care team together under physician oversight is an ongoing effort at PAMED. 4. Telemedicine – Legislation is expected within the next year to address insurance coverage for telemedicine services, licensure required to provide services in PA, and liability protection when providing telemedicine services.

Visit lancastermedicalsociety.org

In addition to the above items, diabetes care in public schools, naloxone legislation, and medical marijuana are examples of recent PAMED victories on the public health front. Maintaining your local and state society membership is a way for all physicians to support these PAMED efforts.

Whether you are a silent voice or fronting our grassroots efforts, a PAMED membership recognizes the importance of physician political advocacy and funds goals that transcend employment status, hospital system affiliation, and specialty.

I invite anyone who has interest in organized medicine or who would like more information regarding membership benefits to contact the Lancaster City and County Medical Society main office at 717-393-9588.

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best

pr  ctices Advance Care Planning Expanding Lifesaving Heart Care Services Percutaneous Kidney Stone Removal

How To Talk To Patients About

Advance Care Planning

LEON S. KRAYBILL, M.D.

Chief, LG Health Division of Geriatrics

magine taking your one-year-old car to the garage for inspection. It is running well, and you can reasonably expect many more years of service. You give authorization to do any service the mechanics find necessary.

Now imagine taking your beloved 20-yearold car to the garage, expecting only an oil change. You return a day later to find the car with a new paint job, new wheels, a replaced transmission, and a digital dashboard display. The mechanic reports that he wasn’t sure what you really wanted, the car itself did not state a preference and he thought you would appreciate the changes.

You are incensed. You liked the previous color, did not want white-wall tires, knew the transmission allowed you to do the driving you enjoyed, and definitely saw that a digital display was incongruous with a 20-year-old car.

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Of course, we cannot compare cars and people, nor doctors and mechanics. But there are some similarities to advance care planning. We sometimes give more thought and considered care to our vehicles than we do to our health and future care. As medical providers, we often have a good sense of what is reasonable and appropriate for our patients, but we do not always welcome their input or choices about what is eventually done. And especially in our older patients with cognitive impairment, we do not always realize that they no longer retain the ability to appropriately make complex medical decisions.

What is advance care planning?

Advance care planning (ACP) describes the overall consideration of our health, options, preferences, and specific choices for intervention. Advance care planning often includes the following:

Winter 2016

• The advance directive (living will, 5 Wishes, etc.) is completed and signed by the patient and typically describes what care is desired in the narrow context of a confirmed terminal setting.

• The POA/Proxy names who should make decisions if, and only if, the individual is unable to do so.

• The code status/medical order (DNR, POLST) is an entry into medical orders by a medical provider, based on a discussion with the individual about his or her specific wishes. It is usually more “practical” than the living will, since it often includes directions for a broader range of medical change, and is not limited to a terminal situation.

Advance care planning done well results in high-quality care, with better patient outcomes and experiences, and often less cost.

The best ACP utilizes an understanding of the patient’s conditions and prognosis, a description of treatment options, a discussion with the individual about his or her understanding and preferences, a choice by the patient regarding future care, and documentation of these choices in the medical record.

Effective ACP is not merely getting a patient’s signature on a document. It is not just checking “yes” or “no” on an intake form.

Rather, it should be seen as a discussion process. It is an engagement with another human being about his or her wishes for life based on his or her viewpoint. It can be an opportunity to look through the eyes of another person at the world around them.

As medical providers, we can and should offer guidance, insight, perspective, and interpretation. But ACP is the decision of the patient, not the provider.

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How to start the conversation

Advance care planning is not necessarily complex or difficult, but there are skills that facilitate the discussion. When presented in appropriate context, individuals are rarely offended, demoralized or defensive. Many patients are relieved that the provider is honest, has opened that door to realistic discussion, welcomes the patient’s input, and demonstrates caring by considering ACP.

Advance care planning does not presume a final decision to limit care or establish a DNR status. Rather, it opens the question of what is best for the individual, based on an honest appraisal of the situation and the options, in light of the patient’s understanding. It is an opportunity for the provider to show great caring and compassion.

Continued on page 8

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Best Practices

How to Talk to Patients About Advance Care Planning

Examples of simplified patient discussions We have reviewed your current health situation. Now I’d like to have a philosophical discussion with you. You have four significant health conditions that could affect your health. Fortunately you appear stable now, but that can change. It would be very helpful to me if you can give me some guidance about how to respond if your health changes. If you are able to decide, I will always discuss things with you.

But if you are unable to have a future discussion, I’d like your guidance now for those future decisions.

Your recent health change is a significant medical condition. I really wish that we could cure this problem, but the chances are very small. I see three possible options. Option A is more invasive and has risk of immediate discomfort and decline, and a small chance of success. Option B seeks to address the concern with limited treatments that are less invasive. Option C focuses on only comfort and keeping you close to your loved ones.

What is most important to you as we look at these options?”

Personally, advance care planning has come to be one of the most rewarding personal and professional components of my work. My patients and families are almost universally appreciative of the discussion. I

feel like I can help to honor the wishes of my patients. I can help guide appropriate use of the available resources. I can help to limit futile care that results in discomfort and isolation. At the end of the day, I feel

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Leon S. Kraybill, M.D., finds advance care planning to be one of the most rewarding components of his work as a geriatrician.

that I have made a significant difference in the lives of my patients, I have assisted my hospital system and I have helped to prepare myself for my own future decisions.

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Best Practices

WELLSPAN EPHRATA COMMUNITY HOSPITAL

Expands Lifesaving Heart Care Services

With Cardiac Catheterization & Stenting

Comprehensive Heart Care Within The Local Community

eginning this year, the highly skilled specialists of WellSpan Cardiology (formerly Heart Specialists of Lancaster County) can treat narrowed arteries in WellSpan Ephrata Community Hospital’s new percutaneous coronary intervention (PCI) laboratory to help area residents live healthier, more productive lives. By now offering specialized cardiac treatments—such as heart catheterization and stents—WellSpan Cardiology can provide extensive care to patients requiring advanced, interventional cardiac care.

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Services available to patients include stress testing to diagnose heart disease, electrocardiograms (EKGs) to understand the heart’s electrical signals, electrophysiology services to treat heart rhythm irregularities, diagnostic catheterization to view blockages around the heart via a tiny camera inserted in the groin—and now catheterization treatments to open those blockages and help restore blood flow.

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Winter 2016

Expanding services to include treatment-oriented catheterization gives patients more care options with doctors they know and trust.

“We are a close-knit cardiology group offering highly personalized care,” explained WellSpan cardiologist Lokesh Gowda, M.D. “Our patients really appreciate what we do.

They grow attached to their cardiologists and want to see the same doctor they’ve seen in the past. It’s something we take great pride in at our practice.

“With the addition of the PCI lab, we do not need to transfer a patient to another facility to catheterize a second time. We can check for blockages and then perform any necessary intervention at the same time in most cases, making the experience much easier on the patient.”

WellSpan has also expanded its cardiology practice to accommodate these new procedures, including adding Patrick Fitzsimmons II, MD, to the practice’s roster of specialists. Dr. Fitzsimmons specializes in interventional cardiology, performing both angioplasty and stent placement in WellSpan Ephrata Community Hospital’s new PCI lab.

“We are a close-knit cardiology group offering highly personalized care.”

Expanding To Meet Demand

Because the demand for access to interventional procedures locally within the community is expected to grow rapidly, WellSpan Ephrata Community Hospital plans to open additional labs to offer patients more convenience and flexibility.

“This will significantly expand the number of patients we can serve with our existing single-camera lab,” Dr. Gowda says.

For his part, Dr. Gowda is pleased he no longer has to tell patients who need stents or other interventions they must go elsewhere.

“Patients don’t feel comfortable traveling long distances,” he said.

“I’m glad that we are now able to offer these important cardiac interventions right here in our own community, and that we will continue expanding our services to meet future needs.”

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Best Practices

PERCUTANEOUS

KIDNEY STONE REMOVAL:

A Team Approach To Patient Relief A Q&A With Robert Springer III, MD

Robert Springer III, MD, recently wrote a scholarly article about percutaneous stone removal for the prestigious medical journal Seminars in Interventional Radiology.

With stones in the urinary tract affecting nearly 12 percent of the population (according to the American Urological Association), we asked Dr. Springer to share more about the procedure and its benefits. If you or someone you know suffers from kidney stones, you’ll want to learn more about this innovative surgical procedure.

For what types of stones do you use the percutaneous stone removal technique?

Why do these kidney stones present a problem for patients?

The stones we are removing with this method are large kidney stones. “Percutaneous” refers to the approach used to get at the stones. It’s a Latin term, roughly meaning “from (or through) the skin.”

A large kidney stone is often a focus of chronic infection. It often causes at least partial obstruction of urine flow, which in turn raises the pressure in the kidney, causing damage. It can cause pain and bleeding.

How do you detect the stones?

Most often with simple X-rays, ultrasound or CT (computed tomographic) scans.

Could you explain how percutaneous stone removal is executed?

This is a team approach involving a radiologist and a urologist.

It starts from the skin surface of the flank. Very precise planning, guidance, and execution are necessary on the physician’s part to avoid nearby organs, pass through the intervening tissues and enter the kidney safely. It needs to be done from an angle and entry point, giving the urologist access that allows him or her to move freely inside the kidney.

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How is this approach superior to other approaches?

This approach is for stones too large to be destroyed or removed by drug therapy, shock-wave therapy (ESWL-Extracorporeal Shock-Wave Lithotripsy) or approached through the bladder.

What makes a patient a good candidate for this procedure? Is there anyone who wouldn’t be a good candidate?

As mentioned earlier, having large stones is the main criterion that qualifies patients for this surgery. This is a major surgical procedure—the more pre-existing medical problems (heart conditions, diabetes, lung disease) a patient has, the greater the risk.

What is involved in preparing to remove percutaneous stones in this way?

As with any surgery, the patient will have dietary and fluid restrictions prior to undergoing general anesthesia. There will be pre-procedure blood tests and administration of antibiotics to minimize the risk of infection, as well.

What should patients expect to experience after having this procedure? What is recovery like?

If everything goes well, the only discomfort a patient should experience afterward is diminishing pain at the approach site for a week or two. The incision is less than half an inch long, but the path to the kidney often goes through deeper muscles tissue, hence that recovery period.

About 70 percent of the time, we don’t have to leave a drain in after the procedure. When that’s the case, patients usually go home in a day or two. If there is enough bleeding that a drain is necessary, the length of the hospital stay is typically three or four days. Sometimes there are complications—such as infection, fluid buildup around the lung, or bleeding—that make it necessary for patients to stay in the hospital even longer.

Is it safe for patients to undergo this procedure multiple times if they have reoccurring kidney stones?

Yes, we have re-operated in this way on a number of patients. In general there is no more risk or difficulty the second (or third) time around. But it is uncommon for this to be necessary—even if a large stone recurs, it usually takes years and years for that to happen.

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Healthy Communities

Understanding The Multi-Faceted Impact Of

And How Physicians Can Help Patients Through The Process SUSAN SHELLY

ll of us experience grief during our lifetime.

behaviorally. It is a profound reaction to loss, and usually a difficult and arduous process.

We lose a loved one, and we grieve. We lose our ability to function independently, and we grieve. We lose a job, and we grieve.

We lose a long-held dream or expectation, and we grieve.

And, she explained, the depth and duration of grieving are directly correlated to the depth of caring for the person who has died.

Patti Anewalt, Ph.D., LPC, FT, Director of Hospice & Community Care’s Pathways Center for Grief & Loss in Mount Joy, has worked with thousands of bereaved people during her career as a grief counselor and mental health professional.

She explained that while grief is a guaranteed part of life, few people feel prepared for it.

Grief comes in all forms and takes on many shapes. It affects every person differently. It does not move in linear progression, but rather zigs and zags. It can show up when you least expect it, lingering for years, or an entire lifetime.

Grief, Anewalt said, affects people physically, emotionally, cognitively, spiritually, and

“No matter what it is that someone is grieving, the loss to them is real and intense,” Anewalt said. “And, people need to have safe places where they can be honest and have their feelings affirmed.”

Grieving Styles Vary Greatly From Person To Person

That doesn’t mean the father has gotten over his grief or the mother loved the child more; their reactions are simply different styles of grieving.

A common reaction to grief is feeling a need to do something. That’s why people set up memorials at the scene of a fatal crash site, or why many rushed to give blood after the deadly attacks on 9/11.

“Sometimes it doesn’t so much matter what they do, people just want to do something after a loss,” Anewalt said.

One thing is for certain: Everyone’s grief is unique. According to Anewalt, no two people grieve in exactly the same way, and there is no right way or wrong way to express grief.

Two hundred years ago, family members would dig a grave for a loved one and build a casket. Other than planning a funeral today, there often seems to be little to do, and that can seem frustrating to some.

While one person might retreat into silence, another cannot stop talking about the range of emotions he’s experiencing.

Expressing grief, however, is not always organized or visible.

A father who has lost a young child might choose to return to work shortly after the death, while the mother stays in her pajamas for weeks as she grieves for her child.

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One elderly man—a former literary agent—privately wrote love poems to his deceased wife, sharing them with close friends many months after his beloved wife had passed.

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Anewalt told of a man who lost his wife of many years and missed her tremendously.

He was quiet about his grief, but expressed it privately every afternoon at a certain time when he would play a CD of piano music he’d recorded as his wife played. As the music played, he wept.

“The point is, that everyone has their own style of expressing grief,” Anewalt said.

“Some people are very private, while others want to share. The range of grief expression is tremendous.”

Grieving Vs. Mourning

While we often use the words “grieving” and “mourning” interchangeably, they are not the same process.

Grief comprises a variety of reactions that occur following loss. While many of these reactions are emotional, such as sadness, anger, relief or guilt, they also are expressed in other ways.

It’s not unusual for a caregiver to become ill following the death of a loved one.

“It’s almost like the body is stepping up and saying, ‘Hey, it’s time for you to take care of me now,’” Anewalt explained.

Thomas Attig, who wrote How We Grieve: “Mourning, properly understood, is not a process of severing ties with those we love.

Rather, it is a transition from loving in presence to loving in absence.”

In some cases, however, mourning might be discouraged, or even forbidden.

Some cultures, including many members of the Pennsylvania German community, tend to be stoic and keep their feelings to themselves. They don’t see the point of expressing their grief or drawing out a period of mourning, and others within the culture may feel they have to follow suit, even if they would prefer another way.

“People need safe space in which to mourn, and not everyone finds that space,” Anewalt explained. “Sometimes families avoid mourning or sharing how they are struggling because they don’t want to upset each other, or they sense that another family member feels it’s time to move on.”

Generally, though, people who need to mourn find some way to do so.

Pathways Center for Grief & Loss in Mount Joy offers a wide variety of educational resources regarding grief. Anyone is welcome to access the materials on the Pathways website at www.pathwaysthroughgrief.org.

One of those handouts is a list of common reactions to grief, including physical, emotional, cognitive, spiritual and behavioral responses.

All of these reactions, and many others that may be experienced, are normal and natural, said Patti Anewalt, PhD, LPC, FT, who directs the Pathways Center, a part of the Lancasterbased Hospice & Community Care.  Intense sadness and crying at unexpected times  Numbness, as though the death didn’t really occur  Increased irritability  Lack of concentration—inability to follow through on routine tasks  Difficulty sleeping—dreams of the deceased  Anger at your loved one for leaving you  Anger around the situation of the death

Reactions to a loss also can be behavioral, cognitive, and spiritual.

“They may not understand exactly what they’re doing or be able to put a name on it, but most people actually find a way to mourn that works for them,” she explained.

“Grief isn’t just one reaction,” Anewalt said. “It’s a range of reactions.”

Mourning is not a linear process, but a series of ups and downs, Anewalt said.

 Guilt or anger over things that happened or didn’t happen in the relationship

Mourning, on the other hand, is what a person does with his or her grief reactions.

There will be times when a person feels she may be starting to adjust to her loss and adapt to the changes in her life. She may feel like she’s finally starting to cope, when all of a sudden she’ll hear a particular song or see someone in a crowd who reminds her of her loved one, and she’s thrown right back into grief.

 Sadness over lost hopes and dreams

“Many people describe the mourning process as an emotional roller coaster,” Anewalt shared.

 Physical discomfort such as emptiness in your chest, lump in your throat, neck tension

“They take three steps forward, then two steps back.”

Continued on page 16

 Exhaustion or feelings of fatigue

It is an act of mourning that motivates members of Mothers Against Drunk Drivers to express their grief by working to change policies about drunk driving. Members of MADD mourn their losses by taking their grief and anger and turning them into positive actions.

People look for ways of mourning that enable them to remain feeling connected to the person who has died, shared Anewalt.

She said she often refers to a quote regarding that sense of connectedness from author

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 Appetite changes—increased appetite or marked decrease in appetite resulting in weight changes

 Sensing the presence of your loved one – through sight, sound, scent or taste  Doubts or questions regarding spiritual beliefs  Dramatic mood changes over the slightest things

 A strong desire to talk with your loved one

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Understanding Grief

Healthy Communities How Physicians Can Help Grieving Patients

Physicians treating patients who have experienced a recent loss can be helpful resources.

Anewalt offered the following tips for physicians:

• Assess the patient’s relationship with the loved one who has died. This will provide a sense of the extent and depth of the patient’s grief. If the relationship was a complicated one, the grief process may be complicated, as well.

• Ask about other losses the patient has experienced. Loss can be cumulative, and previous losses can exacerbate the most recent one.

• Learn how the loss occurred. A patient who has lost a loved one suddenly or in a violent manner may have a very different grief reaction than a patient who has lost an elderly parent after many months of sickness.

• Assess the patient’s level of support. If the person will be living alone, how is she

getting groceries or keeping up with the house? Are there relatives or neighbors available to help? What would the patient do in the event of an emergency at home?

• Offer to write down instructions for the patient. Someone who is grieving may find it difficult to focus and retain information.

Even if he appears to be comprehending instructions, chances are that he won’t remember what you said. Ask the patient to repeat what you’ve directed him to do.

Many physicians in Lancaster County refer patients to the Pathways Center for Grief & Loss for care and support following a loss. That referral is helpful and appropriate when a doctor feels a patient would benefit from learning more about grief, and perhaps obtain support from a counselor or a support group. Some patients, however, need more than what the Pathways Center provides.

A patient who is clinically depressed or abusing drugs or alcohol, for instance, would be better treated with counseling

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and medication, and should be connected or reconnected with a therapist.

If there was trauma involved with the loss of the loved one, the patient probably needs the help of a mental health professional or community agency.

“We want to be sure that the patient is getting the appropriate help and the services that can best help him or her to move forward,” said Anewalt.

Because the staff members at the Pathways Center recognize not everyone will seek out their services for support, grief counselors are available to provide education to community professionals. Clinics, physician offices, and nursing facilities often feel more comfortable caring for and supporting bereaved individuals after an in-service visit from Pathways Center staff. Information is also available via resource materials on the Pathways website at www.pathwaysthroughgrief.org.

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Healthy Communities

FIGHTING OPIOID ABUSE i n Pennsy lvania INTRODUCING PAMED’S INNOVATIVE EDUCATIONAL SERIES AND OTHER RESOURCES HEALTH CARE TEAMS CAN USE TO ADDRESS THE OPIOID CRISIS

THE PROBLEM: Opioid abuse, misuse, and • The latest statistics and data overdoses are increasing, both in Pennsylvania • Details on how to use opioid preand nationally. scribing guidelines for physicians, While some requests for pain medication emergency departments, and are legitimate, others are likely to be from pill other providers scammers who have become addicted to opioids.

THE SOLUTION: A multi-pronged approach • Scenario-based learning to help implement the lessons into that includes physicians, patients, and health daily practice care organizations like the Pennsylvania Medical Society (PAMED) working collaboratively to address this growing epidemic.

This crisis spans nearly every state in the To help prescribers combat this problem, U.S., but has hit Pennsylvania particularly PAMED, in collaboration with the Pennsylva- hard. Nearly 2,500 deaths were reported in nia Department of Health and 11 other health Pennsylvania as a result of drug overdoses care associations, is creating a comprehensive in 2014, and more people die from drug online educational resource for prescribers. overdoses than in car accidents.

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

The first session of the course addresses how prescribers can use the statewide voluntary opioid prescribing guidelines, and the second session takes a deeper dive into the state’s naloxone law. Both are available at www. pamedsoc.org/opioidresources.

Upcoming sessions (Parts 3 and 4) will address the controlled substances database and the warm hand-off.

This educational series features: • Videos and interviews with physicians, other prescribers, and state officials working on the front lines of the crisis

FOUR WAYS

TO INCREASE YOUR CONFIDENCE IN MANAGING OPIOID THERAPY 1

Familiarize yourself with these state-endorsed, voluntary guidelines for opioid prescribers in Pennsylvania: • Guidelines on the Use of Opioids to Treat Chronic Non-Cancer Pain • Emergency Department Pain Treatment Guidelines • Prescribing Guidelines for Dentists

No one disputes the magnitude of the prescription drug abuse crisis in PennsylvaGet involved with grassroots advocacy nia and the nation at large. The question is, 2 and initiatives by having a discussion how do we combat the problem? with the physicians in your county or “I think that we have to understand this is a public health crisis and we all have a role to play in terms of solving this,” said PAMED member and Pennsylvania Physician General Rachel Levine, MD.

region. Call PAMED’s Speakers Bureau at (800) 228-7823, ext. 2620 for details.

3

Have a conversation with your chronic pain patients using PAMED’s Opioid Prescription Checklist to help facilitate the pain-management discussion.

“We need to get past the idea that these Access even more PAMED opioid are somehow just drug abusers that are 4 education and receive patient safety and risk management CME credits. Take miscreants and throwaway members of our PAMED’s six-part, online course designed society,” says Dr. Levine. “The substance use to educate physicians and other health problem and opioid problem touches all of care providers on the appropriate use of the families in our state and in the country.”

long-acting and extended-release opioids.

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

Learn more and get CME credit by visiting www.pamedsoc.org/opioidresources.

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

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Healthy Communities

CALCIUM SUPPLEMENTATION Does Protecting Against Fracture Risk Increase The Risk Of Cardiovascular Disease?

RICHARD W. REESE, MD

T

he last few years have emphasized a possible relationship between calcium deposition, coronary artery disease, and supplementation with calcium. One must look back at the origins of this thesis to understand how we may have come to a false conclusion.

In the past few years, what has become popular is using the CT scan to look for coronary calcification. Over time, it has become clearer as to how this calcification occurs. Coronary artery disease develops when the endothelium or lining of the vessel becomes damaged, whether from high blood pressure, smoking, stress, or elevated cholesterol. Sometimes the healing process does not take place quickly enough, and the artery forms a blood clot, which could cause a heart attack. In fact, about half of all heart attacks occur in a vessel that has less than a 50% stenosis at the time the heart attack occurs. As part of the formation of coronary artery disease, a plaque builds up, which can rupture. As part of the healing process, calcium is deposited. That calcification in the coronary arteries is actually the response, not the cause, of coronary artery disease and plaque rupture.

Initially, not much attention was paid to calcium supplementation, especially in people at risk for osteoporosis. The controversy really started with two studies published in 2008. Although they provided no statistical significance, those studies showed an upward trend in cardiovascular events in individuals supplemented with calcium. There were, in hindsight, significant difficulties with

both of these studies, including the major fact that in most studies a change in bone mineral density, not cardiovascular disease, had been the outcome measurements.

In 2010, there was a meta-analysis published, looking at the effects of calcium supplementation on the risk of myocardial infarction and cardiovascular events.

There was a total of 15 trials included, and essentially the bottom line was calcium supplementation was associated with about a 31% increase in myocardial infarction.

Curiously, when one looked at other endpoints including the risk of stroke, death, or a composite of all of the above, there was no significant increase. The study, however, hit the popular media and many questions abounded and phone calls were generated to the providers who were supplementing their patients with calcium. In hindsight, the major criticism in this article was that there was inconsistency in the validation for cardiovascular events and lack of information on adjustment for known cardiovascular risk factors. Subsequently, however, in 2012 at an annual meeting of the American Society for Bone Mineral Research, there were three new studies reported, all of which indicated appropriate calcium supplement use does not increase heart attack risk.

Combined, these studies looked at a pool of about 130,000 adults, most of whom were women older than 50. Some took calcium supplements and some did not.

When takers and non­takers were compared, all three studies concluded there was no association between calcium

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supplementation and heart attack risk. We may never have a perfect study of this issue since a double-blind placebo-controlled trial will likely never be done in this setting. From the standpoint of osteoporosis, it is fairly clear that adequate calcium and vitamin D intake is critical to reducing risk of bone thinning and osteoporosis. Vitamin D helps the body absorb calcium.

In any event, we should remain vigilant in the total amount of calcium recommended. It is by far best to have the majority of recommended calcium intake from the diet rather than through supplementation.

The current recommended calcium intake for women 51 years old and older is 1,200 mg. For men between the ages of 51­–70, the recommendation is 1,000 mg daily. For men 71 and older, the recommendation is 1,200 mg. The recommendation for vitamin D intake is 600 international units daily for those 70 and younger and 800 international units for those older than 70. Dietary sources of calcium have not been linked to any increased risk of cardiovascular disease, again justifying that as the primary recommended source of intake. It is important to keep in mind the fact that enough is enough. In other words, there is no data to suggest that more calcium is better.

Regarding the types of available calcium supplements, certainly calcium carbonate is the most widely available and has the greatest number of milligrams per pill of elemental calcium. It tends to be the cheapest and should be taken with food, not on an empty stomach, because it needs an acid environment to be absorbed. Calcium citrate is recommended in individuals at risk for kidney stones because it is less likely to cause stone formation. In addition, it tends to be better absorbed in an acid-free environment, such as one finds in the elderly and those on acid blocker medications.

With the data now available, we will be able to reassure our patients that appropriate levels of intake of calcium, particularly in the setting of low bone density, are not associated with the risk of coronary artery disease.

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Passion Outside of Practice It’s our pleasure to highlight a Lancaster City and 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 Christopher Shih, MD, FACG, who is not only a physician, but also an internationally recognized concert pianist.

family and a medical practice. Only about 10 years ago did I return to the piano, fueled by the opportunities I mentioned above.

4. Why is this pursuit special to you?

Christopher Shih, MD, FACG

Passion Outside of Practice: Concert Pianist

1. Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?

I have a minor side career as a concert pianist. I perform a handful of concerts each year.

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

When I was young, my parents started me on piano and violin. Over time, my interest in piano grew, and it became more and more serious as

I got older. In the past decade, there’s been an explosion of opportunities out there for serious amateur pianists. These competition and performance opportunities helped to keep my interest and passion alive.

3. How long have you been participating in this activity?

I’ve played piano since I was 5 years old. I continued playing seriously until the final year of medical school. Then I took a decade-long hiatus, during which I finished medical school, internship, residency, and fellowship, and started a

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I think balance is the key to almost everything in life, and music provides that balance for me. I would never want to be a full-time professional musician, saturated with music from morning until night every day. But the amount of music I have in my life, playing several concerts a year, provides a wonderful balance to my medical career and is just right for me. I also enjoy collaborating with other great musicians. In the past few years, I’ve focused almost exclusively on chamber and collaborative music, because for me this is the most fulfilling way to make music.

I’ve been very fortunate to have had countless opportunities in recent years to work with some of the world’s greatest artists and musicians.

5. What else would you like readers to know about this?

Please see my website www.christophershih. com for more information about me, as well as audio and video clips from my recent performances. I also have up-to-date listings of all my past and upcoming performances. Notable upcoming local concerts include collaborations with the string quintet Sybarite5 at the Trust Performing Arts Center in the spring and the Daedalus Quartet at the Ware Center in the fall.

Don’t miss those!

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Patient Advocacy

Brea

in a state or condition marked At Risk = by a high level of risk or susceptibility.

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Winter 2016

Breast Cancer Risk Management

ast Cancer

Risk Management:

The Factors That Matter Most LINDA MYERS, MD, FACS

s a breast surgeon, part of my job is to identify patients who are at risk for breast cancer. This information is gathered from the patient in multiple ways and is usually initiated by taking a thorough history.

Almost every aspect of a patient’s history is important and usually easily obtained. By asking the right questions, a woman’s hormonal history can be determined.  When was menarche?

In general, the longer the hormonal exposure, the higher the breast cancer risk.

The past medical history may reveal exposure to chest radiation for lymphoma or exposure to DES. A woman’s surgical history is also very important.  Has she had a hysterectomy and/ or oophorectomy? If so, at what age and for what indication?

 Does she have children?  At what age did she deliver her first child?  Did she breastfeed?  When did she go through menopause?  Has she ever used hormone replacement therapy, and if so, for how long and what type of hormones were prescribed?

 How many breast biopsies has she had and what was the pathology? It is critical to know if a “high risk” lesion was found, such as atypical ductal hyperplasia or lobular neoplasia.

Social history also provides necessary insight. Alcohol consumption is an important aspect to consider. Women who drink two to five drinks daily have a higher risk for breast cancer than women who don’t drink at all.

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Family history, however, is perhaps the most critical piece of the risk puzzle.

Obtaining an accurate family history can be time consuming, but using a simple questionnaire is an easy way to start. At Breast Health Associates, in conjunction with Lancaster Breast Imaging, we look for the presence of multiple cancers on the same side of the family, cancers diagnosed in younger patients, and rare cancers. When these red flags are noted during the routine screening process, we offer a more in-depth discussion with the patient to determine if genetic testing is indicated. While the BRCA 1 and 2 genes account for the vast majority of inherited breast cancers, there are other genes now known to be associated with high breast cancer risk: ATM, PALB2, CHEK2, STK11, PTEN, TP-53, and CDH1.

When a mutation carrier is identified prior to a diagnosis of cancer, aka “previvor,” the patient should be counseled about the options of increased screening Continued on page 24

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Patient Advocacy

Breast Cancer Risk Management

measures v. chemoprevention v. risk-reducing, prophylactic surgery. Finding a mutation in an unaffected person obviously has wider implications for the entire family, and they should be offered site-specific testing.

Another risk factor that has received extensive press in recent years is breast density. Breast density is determined by the ratio of the breast glandular and fibrous elements to breast fat, with dense breasts having more of the former. This is largely genetic, but is also related to age, pregnancy, and the use of replacement hormones or hormonal blockade. The risk for breast cancer is 1.2-2 times higher in women with dense breasts than women who have average breast density. Unfortunately, the ability to find breast cancer on

assessment is critical to determine the best plan for screening women at higher-than-average risk. Breast density is only one factor, and every woman with dense breasts may not warrant additional imaging. Conversely, women who do not have dense breasts may benefit from additional screening, such as whole breast ultrasound or MRI, due to other risk factors which put them at higher lifetime risk.

a mammogram is more difficult when the breast is dense.

While mammography is still the gold standard for breast cancer screening for the average risk woman, a more in-depth risk

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Fear of breast cancer is very common in women as breast cancer is such a prevalent malignancy. Being able to quantify a woman’s individual lifetime breast cancer risk is extremely helpful to her. It can relieve anxiety for those women whose risk is average or below average, and it opens the door to educating and making recommendations to those women who have a higher-than-average risk.

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

Legislative & Regulatory Updates

Pennsylvania Medical Society Quarterly Legislative Update December 2015

A

Public Hearing Held on CRNP Independent Licensure

s of this writing, Pennsylvania’s state government is operating in its sixth month without a state budget for the 2015-2016 fiscal year, which began July 1. Keeping up to date with the status of budget negotiations is no easy task, as things continue to be in a state of flux, even at this late date. However, there does appear to be light at the end of the tunnel and hope that the stalemate could end soon.

On October 22, the House Professional Licensure Committee held a public hearing on House Bill 765, sponsored by Rep. Jesse Topper (R-Bedford County). HB 765 would allow Certified Registered Nurse Practitioners (CRNPs) to practice independently and eliminate the current requirement that CRNPs have a collaborative agreement with a physician in order to diagnose, treat and prescribe to patients in Pennsylvania. PAMED is strongly opposed to the legislation.

After passing opposing spending plans earlier this week, House and Senate leaders are back to the table with Gov. Wolf trying to resolve differences and negotiate an end to the gridlock. The budget framework that is currently under discussion would include somewhere between $30.3 and $30.8 billion in state spending and rely on up to $2 billion in new tax revenues. The framework also includes a significant increase in funding for public schools—a key element for Gov. Wolf—and separate reforms to the state’s public pension systems and liquor system—both priorities of the GOP-controlled legislature.

Former PAMED President Karen Rizzo, MD, testified at the public hearing on behalf of PAMED. Also testifying in opposition to HB 765 were physician leaders representing the Pennsylvania Academy of Family Physicians, the Pennsylvania Chapter of the American Academy of Pediatrics, and the Pennsylvania Osteopathic Medical Association, and a PAMED member who had been a licensed CRNP before attending medical school and becoming a family physician. Additional testimony opposing HB 765 was provided by Ann Peton, MPH, Director of the National Center for the Analysis of Healthcare Data, who spoke about workforce migration trends nationwide and countered claims that nurse practitioners are more likely to practice in rural areas after gaining independent practice authority.

In the midst of the ongoing budget stalemate, there have been developments on a few measures of importance to physicians and patients this fall. Below are a few highlights on legislative activity.

Nearly two-dozen PAMED members attended the public hearing on HB 765, which was held at the State Capitol in Harrisburg. The House Professional Licensure Committee also heard testimony from a panel of individuals in support of HB 765 and the independent practice of nurse practitioners. Committee members then had an opportunity to ask questions of those who testified.

At this time, we are confident that we have a great deal of support in the House on this issue. We do not expect HB 765 to be scheduled for a vote in the near future. We are also closely monitoring the Senate version of the bill—SB 717, sponsored by Sen. Pat Vance (R-Cumberland County)—which is perhaps more likely to move.

Sen. Vance recently announced her intention to retire at the end of her current term.

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Winter 2016

PA Medical Society Quarterly Legislative Update

Medical Marijuana Legislation to legalize marijuana for medicinal use is awaiting consideration by the House of Representatives. SB 3, which passed the Senate overwhelmingly in May, is largely expected to be the measure ultimately voted on. At this time, over 200 amendments to SB 3 have been filed, both by House members who support medical marijuana and have specific views on what should be included in the legislation, and by members who remain staunchly opposed to the measure and are seeking to block its passage. Legalization of marijuana remains a contentious subject among House leadership.

Given the fragile state of budget negotiations, it is expected that consideration of a bill will be delayed until further into the new year.

Of the 200-plus amendments filed to SB 3, one particular amendment reflects recommendations issued by a House workgroup this past summer. The workgroup, which was comprised of legislators with varying opinions on medical marijuana legalization, was charged by House Republican leadership to come up with a compromise proposal that would garner enough support to pass the lower chamber. However, as evidenced by the number of amendments offered to SB 3, not everyone is on board with the workgroup’s product.

PAMED remains opposed to broad-based legalization of marijuana for medical use. PAMED’s 2015 House of Delegates reaffirmed this policy, noting marijuana’s ongoing status as a federal Schedule I controlled substance and the need for adequate and well-controlled studies of marijuana’s effects. Given that public opinion is overwhelmingly supportive of marijuana legalization, however, we expect the legislature to vote on the measure sometime in 2016.

Streamlining the Physician Credentialing Process Rep. Matt Baker (R-Tioga) introduced legislation in November that would improve the physician credentialing process in Pennsylvania, making it timelier and more uniform across insurers. The legislation is strongly supported by PAMED. HB 1663 specifically addresses the problem of unwarranted delays by health insurers in credentialing applicants for inclusion in their networks. Hospitals and physician practices routinely face the situation where a newly hired health care professional who is fully licensed and qualified to provide care is not reimbursed by insurers for months while the insurers work their way through an unnecessarily cumbersome credentialing process. This costs hospitals and physicians money, drives up the cost of health care, and limits access to care by keeping fully licensed and qualified providers on the sidelines until they are credentialed by insurers.

HB 1663 will establish a standardized process and timeline for insurer action on credentialing applications. The legislation

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introduced would require all insurers in Pennsylvania to accept the Council for Affordable Quality Healthcare (CAQH) credentialing application and provide for provisional credentialing of a provider when a determination is not made within 30 days of a submitted application. HB 1663 is currently awaiting consideration by the House Health Committee.

PAMED is also working closely with the Department of Human Services (DHS) to ensure more timely credentialing of physicians within the state’s Medicaid program. After discussions led by PAMED, DHS announced that beginning in 2016, Physical Health Managed Care Organizations (PH-MCOs) will be required to begin the credentialing process upon receipt of a provider’s application and must complete the credentialing process within 60 days.

Improving Prior Authorization Processes Rep. Marguerite Quinn (R-Bucks County) will soon be introducing legislation to streamline and standardize the prior Continued on page 28

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Legislative & Regulatory Updates

PA Medical Society Quarterly Legislative Update

authorization process in Pennsylvania. The legislation is strongly supported by PAMED.

Reauthorization of CHIP

Many health plans require physicians to obtain prior authorization for certain procedures or treatments before they can be administered. While the process is intended to minimize overuse of health care services, it often becomes an extremely burdensome process for physicians and their patients. Lack of transparency and standardization in prior authorization requirements not only makes the process difficult and time consuming, but can also result in delays in needed care for Pennsylvania residents.

The state House and Senate gave final approval this week to a bill that reauthorizes Pennsylvania’s Children’s Health Insurance Program (CHIP), which was set to expire at the end of 2015. HB 857, sponsored by Rep. Tina Pickett (R-Bradford County), extends the life of CHIP until the end of 2017 and also moves the program from the Pennsylvania Insurance Department to the Department of Human Services. The bill is currently awaiting the Governor’s signature to become law, which will likely happen in the coming days.

Rep. Quinn’s legislation would increase transparency and consistency in prior authorization criteria; establish standards and reduce the overuse of prior authorization; lessen manual processes and enhance the electronic exchange of information; develop a standard prior authorization form; and improve response times for prior authorization determinations. These steps will go a long way toward addressing administrative waste in our health care delivery system, resulting in both cost savings and improved access to care.

CHIP provides health insurance to children in Pennsylvania under age 19 who don’t qualify for Medical Assistance. In August, Gov. Wolf announced a number of changes to CHIP would take effect on Dec. 1, 2015, to ensure that the program meets minimum essential coverage requirements of the Affordable Care Act. The changes included the following: • All CHIP plans will cover certain preventive care services—such as oral hygiene education and dietary instruction—without cost sharing in the form of copayments, coinsurance, or deductibles.

PAMED sent a letter supporting Rep. Quinn’s legislation to all House members in early December, urging them to co-sponsor the bill.

• Annual and lifetime limits will be eliminated on the cost of some specific services and equipment like durable medical equipment, hearing aids, pediatric vision and dental service, including orthodontic services.

• Health plans must provide parity between mental health/substance abuse benefits and medical/surgical benefits.

In April 2015, federal funding of CHIP was extended for two years under H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015.

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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

Medical Society Updates

The Scope of the

“Scope of Practice” Issue

HEATH MACKLEY, MD, FACRO

O

n October 22nd, the Pennsylvania House Professional Licensure Committee received testimony on HB 765, a bill that would grant certified registered nurse practitioners (CRNPs) an unrestricted license to practice medicine in the commonwealth. PAMED was well represented, not only by then-President Karen Rizzo’s expert testimony, but also by dozens of physicians from near and far who showed up in their white coats. There were so many that everyone attending couldn’t be accommodated in the room!

The message of PAMED was articulate and compelling and can be found in their “Keep the Team” campaign materials. They include: 1) The best and most effective care occurs when a team of health care professionals with complementary, not interchangeable, skills work together. 2) The education and training of CRNPs falls significantly short of the education and training of a physician.

3) Current licensing standards serve an

especially important function in supporting critical safety and quality objectives. For these reasons and more, the majority of states still require a physician’s collaboration or supervision in order to practice.

The chief arguments of those in favor of the bill were also taken on with hard facts.

1) The collaborative requirement between CRNPs and physician supervisors enhances, rather than impedes, the ability of CRNPs to deliver quality patient care. 2) Granting unrestricted licenses does not significantly improve access in rural and underserved areas. 3) Ultimately, underserved areas need more physicians, and increasing the responsibility of CRNPs does not help that.

This debate, over who should be allowed to practice medicine, has been going on in America since medical licensing laws were instituted in the American colonies. During the 1800s, most of the laws were abolished, leading to the legal equality between

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“allopathic physicians” and “non-traditional physicians” of that time, such as homeopaths and eclectics. This also led to a proliferation of medical schools, many private and for-profit, of various quality and enrollment standards. The AMA, with its state-level partners such as PAMED, lobbied for the reintroduction of medical licensing laws with standardized testing for individual physician candidates and national accreditation of medical schools. Although there is clearly a public interest behind these measures, for public health and safety, and in support of a consumer’s right-to-know, it would be easy for a cynic to view this as a monopolistic tactic with self-interest at heart. But history tells us a different story.

Doctors of Osteopathic Medicine (DOs) became viewed as equal to Medical Doctors (MDs) when both sides could agree on the criteria for accreditation of medical schools, residencies, and medical licensure.

Other philosophies of medicine, such as homeopathy, are not illegal. Patients can

Winter 2016

The Scope of the “Scope of Practice” Issue

receive counseling and advice from those practitioners. So what does this history say to CRNPs, or Naturopaths, or anyone else?

If you create schools, tests, and post-graduate programs that are similar to what MDs and DOs currently have, we can work with you. If not, you do not have our support to practice medicine independently.

That being said, the debate, then and now, will always be influenced by economics. Large health systems have trouble filling the primary care “provider” (their word, not mine) positions they have, and hiring CRNPs for those positions might be easier if out of state CRNPs are attracted by an unrestricted license. That would certainly improve their bottom line for multiple reasons. While there is an added administrative cost to documenting the collaborative agreements, CRNPs command a lower salary than physicians. CRNPs also order more tests and make more specialist

referrals than primary care physicians, so that increases corporate revenue at the expense of global health costs. Mike Young, CEO of Pinnacle Health, while speaking in favor of the CRNP bill, bemoaned his institution’s inability to hire primary care physicians.

This is a real problem, one that can’t be fixed with a sound bite. But if giving CRNPs an unrestricted license is going to improve his institution’s ability to provide primary care, why not allow Pinnacle to also hire MDs from unaccredited foreign schools that can’t pass the United States Medical Licensing Exam (USMLE)? Wouldn’t that be a good idea too? If CRNPs aren’t expected to pass the USMLE or train in a residency, why should anyone be required to do so?

Medicine will always be delivered by a team, with the majority of the care being delivered to one individual patient at a time. PAMED feels that a physician, the most highly trained professional, should

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be the leader of the team. There are other alternatives. Mr. Young, near the beginning of his testimony, said, “I've heard a great deal of discussion today about who should lead the healthcare team. With all due respect, according to the Joint Commission and the Department of Health, <sic> the doctors and the nurse practitioners in this room, I, as CEO of Pinnacle Health, I lead the team.”

No one would argue that corporations need effective managers or that firms that engage in health care are businesses with bottom lines. But that isn’t what practicing medicine is. Practicing medicine is seeing a patient, diagnosing an illness, and prescribing a treatment based on scientific principles.

Managers don’t do that. Physicians do.

PAMED will continue to advocate to keep it that way.

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

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Restaurant Review

JoBoy’s Brew Pub 27-31 East Main St. Lititz, PA 17543 (717) 568-8330 www.joboysbrewpub.com JAMES KELLY, MD

JAMES KELLY, MD

O

ne thing I missed the most upon moving from North Carolina to Lancaster 13 years ago was Eastern North Carolina pulled pork barbeque. Back in Greenville, B’s Barbecue was right next door to the Brody School of Medicine. There was a line around the building every day for lunch, and they served until the food ran out. When I heard a native of North Carolina was opening a barbecue restaurant in Manheim, I was there within the first few weeks to give it a try. I immediately became a fan of JoBoy’s food and craft beer. Last year, JoBoy’s moved from Manheim to a much larger space in downtown Lititz. They now have three floors, including the larger main restaurant on street level, a banquet facility on the second floor, and a recently opened 50-person Speakeasy pub in the basement.

My wife Kim and I recently took our daughters to the new JoBoy’s location for dinner. It was a Saturday evening, and at 6 p.m. we had a wait of approximately 20 minutes. We were able to sit on stools in the front window overlooking Lititz Main Street while we waited, snacking on the incredible pulled pork nachos as an appetizer. The

nachos were crisp, had freshly melted cheese, and were topped with shreds of JoBoy’s own pulled pork. We would recommend sharing them with several people in order to save your appetite for the main course.

Once seated, we found the server friendly and knowledgeable about the food and craft beer selection. JoBoy’s serves its own craft beer with typically eight to ten choices and two additional brews on cask. For the non-beer drinker, they offer a wine list and typically have a cider on tap for gluten sensitive customers. Over the years, I have become a fan of their Oatmeal Stout on cask and Lititz Springs Lager. Manheim Red, an Irish Red Ale, is another popular choice. All beers are made on site, and you can purchase a growler to go if you find a beer you like.

The menu includes a selection of salads, seafood, and a hearty burger list. Their specialty, of course, is the barbecue—and options include pulled pork, beef brisket, baby back ribs, and chicken. We ordered the platter for two, which included a slowsmoked sampling of each of the above meats

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and a choice of four side items. In addition to fresh cut fries and potato chips, other side options include Jo’s mac and cheese, two types of cole slaw, hush puppies, fried okra, collard greens, and baked beans. Each meal also comes with a side of homemade cornbread. JoBoy’s serves two types of barbecue sauce with the meal—a more traditional “western style” tangy barbecue sauce or, my personal favorite, the Eastern North Carolina style vinegar-based sauce.

We thought the chicken was a little dry, but otherwise the pulled pork and especially the brisket were cooked to perfection.

JoBoy’s has a nice kids menu, with options ranging from chicken fingers to hot dogs to homemade macaroni and cheese to pulled pork sandwiches. Kids also get a freshly made chocolate chip cookie after their meal.

We didn’t have a chance to try dessert, but options again focus on southern specialties such as sweet potato and pecan pie.

As always, we left JoBoy’s with our bellies full and my craving for southern style pulled pork barbecue satisfied. I’m already looking forward to my next visit!

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News & Announcements

Member Profile

Robert K. Aichele, Jr., DO

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

Q: What do you like best about practicing medicine?

A: I was born and raised in Lancaster and loved growing up here and always

A: My favorite part of practicing medicine is interacting with the patients and

wanted to set up practice, settle down, and raise a family in the Lancaster area. When my partner and I finished our Family Practice residency program at Lancaster Osteopathic Hospital, we looked at the entire Lancaster County area and felt that the southern end was an ideal location due to its potential for growth and the number of family doctors in the area. We decided on Willow Street, and it was a great decision.

developing a relationship with them that hopefully translates into better health care as they develop a trust in my ability to guide them and help them make the right choices. Sometimes it is the gentle nudge that can make all the difference and that only happens if you have a good relationship with your patient.

For the majority of my medical career, I have been active in the training of medical students, Interns, and Residents both in the hospital and outpatient settings. I am not as active in that anymore, other than with an occasional medical student in my office. But it has always been exciting to watch their transformation into the medical profession.

Q: Are you involved in any community, non-profit, or professional organizations? If so, please list the groups: A: I have been involved with a number of community and professional organizations over the years including Red Rose Sertoma, and as a board member of Penn Manor Little League and St. Anneâ&#x20AC;&#x2122;s and Sacred Heart Elementary Parochial Schools. I currently serve as Vice-President of the Lancaster City and County Medical Society and am involved with a number of other committees as well. I am also a member of the ACOFP, AOA, POMA and PAMED.

Q: What are your hobbies & interests when youâ&#x20AC;&#x2122;re not working?

A: I enjoy reading and spending time with my wife and my four children (ages 16, 21, 23 and 24) in their various and sundry activities. We try to get out once or twice a year for a little skiing as well. I especially enjoyed the 10 years of coaching my four children and their teammates in Rec soccer. It was fulfilling helping them develop their soccer skills, as well as teaching them the importance of team work and sportsmanship. I was always amazed and thrilled at what they could achieve when they worked together.

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Winter 2016

News & Announcements

Frontline Group Spotlight

SouthEast Lancaster Health Services

For 41 years, SouthEast Lancaster Health Services has offered high-quality and compassionate medical and dental care to all in our community, regardless of economic status. The Health Center sees ALL patients, regardless of insurance. With a Sliding Fee Scale Discount Program, they offer a discounted rate on medical and dental services at their facilities. A patient can be eligible for this program if they do not have insurance or are under-insured. As expected, even with Medicaid expansion and the ACA, there are still people who fall between the cracks and are not eligible for health insurance.

The Health Center’s services include dental care, general family practice, prenatal, women’s health, refugee health, chronic disease management, pharmacy, insurance enrollment assistance, social services, and patient education.

SouthEast Lancaster Health Services is a nationally recognized Patient-Centered Medical Home because of their commitment to high-quality care through evidence-based medicine and systematic processes.

The Health Center has four sites: The two main sites—North Arch Street and South Duke Street—and medical offices inside of the Bright Side Opportunities Center and Reynolds Middle School, both of which act as a hub for refugee families new to the United States. They have providers and staff who are passionate about their work and who have diverse cultural backgrounds.

SouthEast Lancaster Health Services serves 21,000 patients with its 170 staff members, 4 facilities, 46 medical exam rooms, 13 dental operatories, and an annual budget of $15 million all focused on ONE mission: To deliver high-quality and compassionate healthcare to all— regardless of economic status.

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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

FRONTLINE GROUPS The Lancaster City & County Medical Society thanks these groups for 100% membership in the Medical Society.

Allergy & Asthma Center

Hospice & Community Care

LGHP–Women’s Internal Medicine

Baron Family Practice

Hyperbaric & Wound Care

Neurology & Stroke Associates PC

Brain Orthopedic Spine Specialists

Hypertension & Kidney Specialists

OBGYN of Lancaster

Internal Medicine Specialists of Lancaster County

Orthopaedic Specialists of Central Pa

Campus Eye Center Cardiac Consultants PC

Jeffrey H Chaby DO & Associates

Cardiothoracic & Vascular Surgeons of Lancaster Care Connections Clinic Community Anesthesia Associates

Conestoga Family Practice –Terre Hill Dermasurgery Center PC

Dermatology Associates of Lancaster Ltd Eastbrook Family Health Center Eden Family Medicine

Electrodiagnostic Medicine Group Ltd ENT Head & Neck Surgery of Lancaster Eye Health Physicians of Lancaster

Pain Medicine & Rehab Specialists

Keyser & O’Connor Surgical Associates Ltd

Patient First–Lancaster

Lancaster Arthritis & Rheumatology Care

Pennsylvania Specialty Pathology

Lancaster County Center for Plastic Surgery

Lancaster Family Allergy

Southeast Lancaster Health Services Inc

Southeast Lancaster Health Services–Arch Street

Southeast Lancaster Health Services–Hershey Avenue

Stephen G Diamantoni MD & Associates–Leola

Lancaster General Health Physicians Lancaster HMA Physician Management Lancaster Physicians For Women Lancaster Plastic Surgery

Family Medicine of Ephrata

Lancaster Skin Center PC Leacock Family Practice

Rehabilitation Medicine Associates of Lancaster PC Rothsville Family Practice

Lancaster Ear, Nose and Throat

Lancaster Retina Specialists

Highlands Family Practice

Red Rose Cardiology

Lancaster Cardiology Group LLC

Family Eye Group

Glah Medical Group

Pennsylvania Counseling Services–Lancaster

Lancaster Cancer Center Ltd

Lancaster Radiology Associates Ltd

Georgetown Family Health

Otolaryngology Physicians of Lancaster

Justin L Cappiello MD PC

Eye Physicians of Lancaster PC

General & Vascular Surgery of Lancaster

Stuart H Goldberg MD PC Surgical Specialists of Lancaster

The EMG Group at The Electrodiagnostic Center of Lancaster

LGHP–Lincoln Family Medicine

Trout Run Family Practice

LGHP–Manheim Family Medicine

WellSpan General Surgery–Ephrata

LGHP–New Holland Family Medicine

Welsh Mountain Health Center

LGHP–Susquehanna Family Medicine

Westphal Orthopedics

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Winter 2016

News & Announcements

Welcome…New Members

Upcoming Events

Mark your calendar so you don’t miss these 2016 events!

Marie Anderson Administrator, Otolaryngology Physicians of Lancaster

Mrinalini Meesala, MD The Heart Group of Lancaster General Health

Lindsay M. Castle, DO The Heart Group of Lancaster General Health

Sabrina Aileen Milhous, MD Southeast Lancaster Health Services

Daniel C. Connell, MD Regional Gastroenterology Assoc. of Lanc John Bassem Fileta, MD Eye Associates of Lancaster Ltd Rahul Jhaveri, MD The Heart Group of Lancaster General Health Navdeep Kaur, MD Hypertension and Kidney Specialists Christina Nicole Lawson, MD Jessica Mack, MD Lancaster Neuroscience & Spine Assoc

Michaela Mocanu, MD Hypertension and Kidney Specialists Marc Brian Perlman, MD Pediatrix at Heart of Lancaster Women’s Place James Stuccio Senior Vice President, Ambulatory and Physician Services of Lancaster General Health

April

16

Lancaster City & County Medical Society Young Physicians’ Social

M AY

11

Docs on Call at WGAL

JUNe

14

Lancaster City & County Medical Society Annual Meeting

DeC

9

Lancaster City & County Medical Society Holiday Social and Scholarship Benefit

Amit Varma, MD The Heart Group of Lancaster General Health Sandi Beth Verbin, MD Pediatrix at Heart of Lancaster Women’s Place

Congratulations...Reinstated Members Roddy Canosa, DO The Heart Group of Lancaster General Health Carmela R. Coppola, MD Women’s Place at Heart of Lancaster Neil A. Greene, MD LGHP Infectious Diseases David P. Hughes, MD Orthopedic Associates of Lancaster Ltd

Peter B. Murdock Administrator, Campus Eye Center Pawel Grzegorz Ochalski, MD Lancaster Neuroscience & Science Assoc Paul R. Sieber, MD, FACS Lancaster Urology Joseph A. Troncale, MD Retreat at Lancaster County

Joy L. Long, MD

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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

Foundation Updates

Lancaster Medical Society Foundation Awards Scholarships To Three County Residents The Lancaster Medical Society Foundation, a foundation of the Lancaster City & County Medical Society, is pleased to announce the recipients of the 2015 Foundation scholarships. These students have outstanding academic and leadership credentials.

Many thanks to the 2015 Scholarship Champions!

Platinum $2,000 or more

Kent Grosh

Christine Kreider

Karl Oberg

Kent Grosh graduated from Villanova University with a degree in Mechanical Engineering, but the idea of a career in medicine and service to others drew him to leave that field and begin a new career.

He is now studying at the University of Pennsylvania Perelman School of Medicine. As a physician, he hopes to transition from fixing mechanical systems to applying himself to understanding the intricacy of the human body’s systems and using that understanding to heal people.

Christine Kreider graduated from Eastern Mennonite University and is now studying at Penn State College of Medicine in Hershey. Her interest in developing creative health care solutions for patients has been nurtured by her involvement with LionCare, a student-run free clinic, as well as through her participation with the new patient navigation program for medical students with Lancaster General Health.

Karl Oberg graduated from the University of Scranton and is now in his final year of medical school at Jefferson Medical College.

He hopes to practice in Lancaster County or in a rural area where there is a shortage of practitioners.

In his practice, he would like to be able to build relationships and treat each of his patients in a holistic manner, taking into account their individual qualities, traits, and psychosocial makeup.

Lancaster, PA

Columbia, PA

Narvon, PA

Lancaster General Health * Lancaster General Hospital Medical Staff Heart of Lancaster Regional Medical Center Medical Staff Lancaster Regional Medical Center Medical Staff WellSpan Ephrata Community Hospital Medical Staff

Silver $1,000 – $1,499 Orthopedic Associates of Lancaster

Bronze $500 - $999 Benchmark Construction

The Scholarship Foundation is generously supported by the Lancaster County medical community, individual medical society members, and local businesses. These students were honored by Lancaster City & County Medical Society members and guests during a Holiday Social and Scholarship Benefit held on December 12, 2015 at the Lancaster Country Club.

Lancaster Medical Society Foundation Scholarships are given to residents of Lancaster County who are attending allopathic or osteopathic medical schools. Applicants must demonstrate academic achievement, exhibit good character and motivation, and show financial need.

Lusk & Associates Sotheby’s International Realty, Anne M. Lusk Neurology & Stroke Associates Regional Gastroenterology Associates of Lancaster * $10,000 Donor

Donations to the scholarship fund can be made to: Lancaster Medical Society Foundation, 480 New Holland Ave Ste. 8202, Lancaster, PA 17602

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