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Winter 2017

OPIOID LEGISLATION

What should physicians know? Michael D. I. Siget, JD, MPA

Plus PREVENTING PRENATAL INFECTIONS

by Michelle Fegley, MD

WHAT IS A WARM HAND-OFF? by Robin L. Rothermel


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Contents

WINTER 2017

2017 BOARD OF DIRECTORS COVER STORY

OFFICERS

OPIOID LEGISLATION

David J. Simons, DO, FAOCA President

(p. 28)

Community Anesthesia Associates

Robert K. Aichele Jr., DO

Best Practices

President Elect

PAL South Family Medicine

Laura H. Fisher, MD Vice President

Lancaster Family Allergy

6 Postural Tachycardia Syndrome (POTS)

Stephen T. Olin, MD Treasurer

Retired/Consultant

8 LG Health Partnership With Children’s Hospital of Philadelphia

Stacey Denlinger, DO Secretary

Baron Family Practice

James M. Kelly, MD Immediate Past President

LGHP - Lincoln Family Medicine

10 Wellspan ReShape Program Offers New Weight-Loss Option

DIRECTORS Sarah E. Eiser, MD Robert A. Garvin, DO Robin Hicks, DO | Resident John A. King, MD Venkatachalam Mangeshkumar, MD

In Every Issue

Emily Miller, MD | Resident Lora S. Regan, MD Karen A. Rizzo, MD, FACS Rebecca M. Shepherd, MD Caitlin White, MD | Resident Kristy L. Whitman, MD

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

4 President’s Message

34 Medical Society Updates

12 Healthy Communities

36 Restaurant Review

24 Passion Outside of Practice

38 News & Announcements

26 Patient Advocacy 31 Legislative & Regulatory Updates

James Kelly, MD LGHP - Lincoln Family Medicine Lancaster Physician is a publication of the Lancaster City & County Medical Society (LCCMS). The Lancaster City & County Medical Society’s mission statement: To promote and protect the practice of medicine for the physicians of Lancaster County so they may provide the highest quality of patient-centered care in an increasingly complex environment.

Content Submission The Lancaster Physician magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Lancaster City & County Medical Society. For more information or submission suggestions, please email bgerber@lancastermedicalsociety.org. Lancaster Physician is published by Hoffmann Publishing Group, Inc. Reading, PA HoffmannPublishing.com 610.685.0914

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


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

President’s Message

T

he practice of medicine is dynamic, and as physicians we always need to be prepared for continued change. The challenge of managing this change must not distract us from our primary mission—caring for and serving our patients and the community. It has never been more important than now for physicians to step up and lead! Working together as a medical society, we can better advocate for our profession, speak to the citizens of Lancaster County, and inform our legislators who represent us.

David Simons, DO, F.A.O.C.A. President, LCCMS

The current opioid crisis, as identified by the increased number of prescription opioid medication and heroin overdose deaths, is an opportunity for our profession to both lead and educate. Opioid addiction has no socioeconomic, ethnic, or generational boundaries. It is heartbreaking to listen to the testimony of parents who are grieving the loss of their child and recognize that the addiction and overdose was potentially triggered by prescription medication. For the past 20 years, public policies compelled physicians to treat pain aggressively. We now know that we need to re-examine our prescribing practices. Presently, nearly 2 million Americans suffer from opioid use disorders and many die each year because of the tragic resurgence in heroin use. Our profession must re-examine prescribing practices and begin to individualize our treatment of both acute and chronic painful conditions. High-risk patients must be identified and carefully monitored for misuse of their medication. We must explore and exhaust non-opioid treatment options and work with federal and private insurance companies to enable access and payment for multidisciplinary treatment of pain as well as programs for addiction. This must be done without limiting or restricting the appropriate use of opioid medication in our efforts to treat patients with compassion and dignity. Attending to our patients’ needs in the face of overly restrictive public policies, limited reimbursement, and unreasonable expectations is no easy task. The South Central Opioid Task Force is working diligently to facilitate discussion to improve communication between physicians, pharmacists, dentists, insurers, and hospital networks. The Pennsylvania Medical Society (pamedsoc.org) has educational programs and information on opioid prescribing. The recently formed Pennsylvania Pain Society (papainsoc.org) will also offer education and advocacy. Most importantly, I urge everyone to register and use the recently implemented PA Drug monitoring program (PDMP). Thank you so much for your past and continued support of the LCCMS as we continue to grow and work diligently to serve our members. Please refer to page 44 for our 2017 calendar of events. Feel free to contact us with questions or feedback at lancastermedicalsociety.org. I wish you and your family prosperity in the New Year!

Visit lancastermedicalsociety.org

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There is an alternative to invasive brain surgery. Penn State Health Milton S. Hershey Medical Center has upgraded to Leksell Gamma Knife® Icon™—the newest technology in cranial radiosurgery. Icon allows experts to target areas once considered too large or too risky even for radiosurgery. With this improved technology, 12 physicians on staff, and over a decade of experience performing more than 1500 procedures on patients with tumors, trigeminal neuralgia, AVMs and more—Penn State Health Milton S. Hershey Medical Center is the team for your patients’ radiosurgical needs. To refer a patient and schedule a prompt appointment, call 717-531-8807, option 4. For more information and to view an informational video, go to PennStateHershey.org/GammaKnife.

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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

best

pr  ctices Postural Tachycardia Syndrome (POTS) LG Health Partnership With Children’s Hospital of Philadelphia Wellspan ReShape Program Offers New Weight-Loss Option

Postural Tachycardia Syndrome (POTS)

NEHAL D. PATEL, MD Cardiovascular Medicine; Red Rose Cardiology

P

ostural tachycardia syndrome (often known by the acronym POTS) has been gaining more recognition in the field of cardiovascular medicine during the past decade. I’ve been in practice for more than seven years, and I seem to be encountering more cases of it with each successive year. It’s a long medical term, but what exactly is this condition? To begin, it is a form of orthostatic intolerance, which seems to manifest in individuals during the younger and middle decades of life. Women are more

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WINTER 2017

Postural Pachycardia Syndrome

often affected than men. According to the Dysautonomia International Association, about 1 to 3 million Americans are affected. From a cardiac perspective, there is no underlying structural substrate when we conduct echocardiography or stress testing. In fact, the cardiac system “looks quite benign.” However, there is an abnormal physiologic response when formal tilt table testing is performed. In the upright posture, there is an abnormal increase in the basal heart rate levels. There also is a reduced return of venous blood flow to the heart. This abnormal response seems to be mediated by deficits in the autonomic nervous system. This abnormal physiology helps to explain the array of symptoms individuals with POTS experience: light-headedness, fatigue, “brain fog,” dyspnea, exercise intolerance, and GI disturbances, as well as temperature sensitivity. Cardiologists are increasingly beginning to diagnose this condition. They often work in conjunction with endocrinologists, rheumatologists, and neurologists when trying to make a formal diagnosis of POTS. Primary care providers are also beginning to refer cases that fit the symptom description to cardiologists as well. One factor that makes the evaluation more nuanced is the existence of primary and secondary forms of POTS. The former seems to have an idiopathic occurrence (meaning there is lack of a specific causal factor). At times, primary POTS can occur after pregnancy, major surgical intervention, trauma, or a significant viral illness. The exact mechanism is still not well known. However, research does point to denervation of the peripheral nervous system as well as paroxysmal over-activity of the sympathetic nervous system as possible explanations. Studies funded by the National Institute of Health are still trying to elucidate the pathogenesis of POTS. The secondary form of POTS seems to occur in the context of another disease state like diabetes mellitus, hyperthyroidism, amyloidosis, sarcoidosis, and certain

In the upright posture, there is an abnormal increase in the basal heart rate levels autoimmune disorders (like lupus). Cardiologists will often work in conjunction with other specialists when managing cases of secondary POTS. I have a handful of POTS patients who also have a rare inherited connective tissue condition called Ehlers-Danlos syndrome. POTS seems to overlap with this genetic condition, but we still don’t know the exact mechanisms. I’m often working with the specialists at Mayo Clinic or Johns Hopkins Medical Center for this subset of patients. The treatment of POTS includes a multimodal approach. Lifestyle modifications include increasing the intake of fluids, electrolytes, and salt in order to optimize the circulating blood volume. POTS is one of those peculiar cardiac conditions where we’ll have patients gently liberalize their salt intake. We also advise patients to curtail their intake of caffeine and alcohol (both of these substances can serve as diuretic agents in high doses

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and thereby lead to dehydration). There are also medications, like fludrocortisone and midodrine, which can optimize blood volume and facilitate blood vessel constriction, respectively. Certain SSRI agents (often known as antidepressants) can help in select cases. Beta-blockade agents can help when the sympathetic response in POTS is hyperactive. In addition to relying on pharmacologic therapy, we also stress the importance of certain forms of exercise. Activities that are semi-recumbent—like rowing, recumbent cycling, and swimming—seem to help nicely. Overall, POTS is becoming a more recognized condition within the field of cardiovascular medicine. The next time you encounter a patient with this constellation of symptoms, you may want to consider this condition during the diagnostic evaluation.


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

Best Practices

LG Health Partnership with

CHILDREN’S HOSPITAL OF PHILADELPHIA Expands Pediatric Expertise and Services Within Lancaster County LANCASTER

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L

ancaster General Health’s alliance with Children’s Hospital of Philadelphia (CHOP) is bringing world-class pediatric care closer to home for local families. Specialists from CHOP and pediatricians working with LG Health are working side by side at Lancaster General Hospital, Women & Babies Hospital, and the Suburban Pavilion to deliver advanced medical care in a growing number of specialties.


WINTER 2017

LG Health Partnership with Children's Hospital of Philadelphia

“The alliance supports the joint efforts of LG Health and CHOP to develop, support, and grow a high-quality pediatric program that services the needs of Lancaster County families for years to come,” said Michelle Schori, LG Health Executive Director, Women’s and Pediatric Service Line. “The alliance also enhances access to a broad spectrum of pediatric programs and services to improve continuity and quality of care, as well as convenience for local families.” CHOP is one of the country’s top-ranked pediatric hospitals. Attila Devenyi, MD, Chair of the LGH Department of Pediatrics, said CHOP’s team of nationally recognized experts brings the highest level of pediatric specialty care to local children and families. “LG Health’s alliance with CHOP will give families access to a nationally renowned institution for all of their child’s medical needs,” said Dr. Devenyi, a pediatric gastroenterologist. CHOP pediatric hospitalists provide around-the-clock inpatient care at LGH’s Pediatric Unit and Emergency Department. CHOP neonatologists care for infants in the 29-bed Neonatal Intensive Care Unit at Women & Babies Hospital. CHOP specialists in cardiology, endocrinology and diabetes, gastroenterology, and neurology see patients at the Suburban Pavilion’s CHOP Care Network Specialty Care Center. “Our community has a need for pediatric specialty providers,” Schori said. “CHOP specialists can diagnose a variety of pediatric conditions, then work with primary-care providers in our community to help families manage those conditions.” Local pediatricians also can initially diagnose a condition and request a consult

The alliance also enhances access to a broad spectrum of pediatric programs and services to improve continuity and quality of care, as well as convenience for local families. with a CHOP specialist. “CHOP and LG Health are developing a shared medical record to ensure that primary-care providers can readily access their patients’ records,” Dr. Devenyi said. The recently opened Diabetes Clinic is the newest addition to the CHOP center in Lancaster. The clinic’s multidisciplinary team, which includes a pediatric endocrinologist, nurse practitioner, registered dietitian, and certified diabetes educator, works with families to help educate and manage diabetes. In the past, many patients and their families had to travel outside the area for specialty care. Missed work or school and other inconveniences associated with travel could lead to missed appointments, ultimately affecting a patient’s ability to have timely checks, which can impact quality and outcome, Schori said. Many patients also experienced delays in making appointments for specialty care outside of the area. “Specialty medical care for children in our community has been fragmented, as patients are often seen by pediatric specialists from different institutions,” Dr. Devenyi said. “Access to pediatric specialists will be improved, and to the extent possible, care will be delivered locally to minimize disruptions to families.”

The LG Health/CHOP partnership will expand to include local allergy and asthma services in 2017. In the future, Schori expects that LG Health and CHOP will offer local access to providers in additional pediatric specialties as needs are identified. CHOP physicians also bring best practices to the local community, she said. For example, in the NICU at Women & Babies Hospital, the evolving treatment for an increasing population of infants with neonatal abstinence syndrome (NAS) follows a best practice protocol that is evidence-based. “Our alliance with CHOP provides the neonatologists at Women & Babies Hospital with the ability to work with other CHOP neonatologists in defining the very best practice in the treatment of newborns with NAS,” Schori said. Those best practice guidelines include education and reference materials with the most current data available, which also informs primary-care physicians involved in treating babies with NAS. “LG Health’s alliance with CHOP brings the best and brightest in specialty pediatric care to local families, which meets our goal of continuing to improve care to our community,” Schori said.

Physicians who have questions or would like to refer a patient to a local CHOP specialist may call 717-544-0375. LANCASTER

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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

Two Balloons, Six Months, 30 To 40 BMI WellSpan ReShape Program Offers New Weight-Loss Option

F

or some people, the surgery part of weight-loss surgery is a deal breaker. They are afraid of or don’t want to undergo surgery. Or they simply don’t meet the criteria for weight-loss surgery. Yet, they are looking for medical help in losing a significant amount of weight. An outpatient procedure at WellSpan Ephrata Community Hospital is offering these patients a new option. Performed by Dr. Jason Marone, ReShape is a nonsurgical, weight-loss, balloon treatment that produces an average weight loss of 30 to 50 pounds. ReShape has staying power. Seven months after the procedure, patients continue to lose weight, a study found. The study also showed that patients lost more than two times more weight with ReShape than with diet or exercise alone. ReShape is indicated for patients with a body mass index of 30 to 40. This makes it available to those who don’t qualify for bariatric surgery, which is indicated for those who have a BMI of 35 (and who have at least two obesity-related health problems such as heart disease or Type 2 diabetes) to over 40 (with no related health problems). During ReShape, patients embark on a year-long, three-phase process designed to

Dr. Jason Marone

reset their metabolism and to help them form and maintain healthy habits that will make the procedure successful over the long term. The first phase of the procedure involves a personalized evaluation and counseling that includes nutritional information, activity tracking, food logging, goal setting, community forums, and one-on-one counseling. The second phase is the outpatient procedure central to ReShape. Under light sedation, Marone endoscopically inserts two balloons down the patient’s throat and into his or her stomach, and then fills the balloons with a saline solution, a procedure that takes about 15 minutes. The two balloons conform to the stomach’s shape and make the patient feel full. The balloons stay in place for six months. “They act as a built-in portion control,” says Marone, who is currently the only physician in Lancaster County who performs ReShape. “While they are in the stomach, they help to re-set the patient’s metabolism.” The patient continues to receive support during this time. The third phase of the procedure includes continued personalized support after the two balloons are removed.

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Marone said he thinks several factors lead to the success of ReShape, which is not covered by insurance. The balloons help patients to feel full after eating less food and the other resources help them to form new habits to live a sustainable, healthier lifestyle. “The support is designed to be empowering,” he said. “People get reminders and encouragement that they are doing a good job.” Marone also performs other bariatric surgeries, including laparoscopic sleeve gastrectomy, gastric bypass, gastric band and revisions, as well as general surgery. New bariatric techniques are always on the horizon, says Marone, noting different types of balloons already have been approved in Europe. There is a reason that it is such a growing field. “Bariatrics is an evolving science because obesity has become such an epidemic in our country,” Marone says. “Treating obesity is important because you are treating multiple diseases: diabetes, high cholesterol, high blood pressure, joint pain, increased incidence of cancer and strokes.”

PHOTO BY STEPHEN MOYER PHOTOGRAPHY

Best Practices


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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

Healthy Communities

Pennsylvania

TEEN HEALTH WEEK One Of A Kind Nationally

G

overnor Wolf proclaimed January 9-13, the second annual Pennsylvania Teen Health Week, a week focused specifically on the important topic of holistic health in teenagers. Pennsylvania is the first and only state to have such a statewide proclamation and observance. Based on a successful Pennsylvania Teen Health Week in 2016, the week in 2017 was expanded and reached even more teens than the prior year. The American Medical Association passed a resolution to actively promote 2017’s Pennsylvania Teen Health Week, and then moving forward, to support development of a national Teen Health Week. The establishment of a Teen Health Week calls upon adults and health care and educational institutions to focus on the health needs of this special population. Pennsylvania Teen Health Week was developed by Laura Offutt, MD, FCPP. A member of the Delaware County Medical Society, Offutt runs a digital teen health resource called Real Talk with Dr. Offutt, in collaboration with the College of Physicians of Philadelphia and the Pennsylvania Department of Health. Many wrongly assume that teen health is synonymous with sexual health. However, teen health encompasses far more. Health behaviors resulting in illness later in life, that start or are reinforced in the teen years, include substance abuse, diet and exercise habits, violence, and mental illness. Specifically, worldwide, suicide is the third leading cause of death amongst adolescents, and as many as half of mental health disorders start by the age of 14; many are left untreated. Sexual development occurs during these years,

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and it is critical to teach youth means to reduce unwanted pregnancy and communicable diseases such as HIV and other sexually transmitted diseases. Health behavior patterns established during adolescence affect both the individual’s current and future health and have the potential to lay the foundation, either positively or negatively, for adult health. Thus it stands to reason that promoting healthy behavior in teens promotes a healthy population in general. In Pennsylvania, more than a quarter of youth are overweight or obese, and fewer than half of high school students report getting the recommended amount of daily physical activity. Teens account for nearly half of the cases of chlamydia and gonorrhea in Pennsylvania. Nearly half of students in 6th through 12th grades report having had alcohol, and one fifth of 12th graders report using marijuana in the past month. Depression symptoms and suicidal thoughts are increasing, with 15 percent of our teens reporting seriously considering a suicide attempt. It is often described that the adolescent brain develops reward pathways faster than it develops pathways responsible for planning and emotional control, but often what is less discussed is the remarkable capacity for the adolescent brain to adapt. It is recognized that exploring and experimentation are normal activities during teen years; but one should also consider that questioning, learning, and engaging with accurate health information will help adolescents develop the necessary skills to advocate for their own health. Since adolescents often are agents of change, including them in discussions and really listening


WINTER 2017

PA Teen Health Week

to what they have to say about improving adolescent health behaviors is critical. Pennsylvania Teen Health Week was and is intended to inspire adults and teens in our communities to work together to protect and improve the health of Pennsylvania teens. Individuals, schools, and other organizations became involved in many different ways. Each day had a specific broad health focus to serve as a suggestion or guide around which to focus activities: Healthy Diet and Exercise; Violence Prevention; Mental Health; Sexual Development and Health; Substance Use and Abuse. Guest speakers, special events, and educational materials were developed and shared at schools and through community health departments. Medical practices in the state shared patient information specific to each day’s theme. Numerous students and community members wore lime green, the official color of Pennsylvania Teen Health Week, to show support for teens and their well-being. Local libraries hosted specific teen-themed events, such as a teen healthy cooking class. Many suggestions

for activities were included in an official toolkit, which also had sample social media posts, and a variety of resources are grouped around the broad themes covered in the week. The week formally kicked off under the Capitol Rotunda in Harrisburg at the State Capitol Building with a formal presentation of Governor

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Wolf’s proclamation by students nominated from around the state of Pennsylvania as well as brief presentations from members of the Pennsylvania Department of Health and the College of Physicians of Philadelphia. The week closed out with a celebration at the MÜtter Museum in Philadelphia.


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

Healthy Communities

understanding and treating ENDOMETRIOSIS JOHN EICHENLAUB, MD, FACOG

Doctors Eichenlaub and May Obstetrics & Gynecology

SPECIAL SEGMENT: FOCUS ON WOMEN'S HEALTH In recognition of Cervical Health Awareness Month (January), International Prenatal Infection Prevention Month (February), and National Endometriosis Awareness Month (March), three Lancaster County physicians share their expertise on top-of-mind topics important to women in our community.

E

ndometriosis is one of those diagnoses that health care providers probably encounter far more often than they are ever aware. It can be in the form of some irregular bleeding or erratic menstrual pain that is readily dismissed if it is episodic or responds to NSAIDs or OCPs. Or it can be in the form of delayed fertility. But if treatment is minimal or even unnecessary, the diagnosis may never receive consideration. Unfortunately, it is this general assumption of “normal” that may result in a significant delay from when a woman first has symptoms until she is diagnosed and treated. Endometriosis affects an estimated one in 10 women during the reproductive years, which translates into 176 million in the world (1). Its prevalence in the U.S.A. is estimated to be 6-10 percent (2). It is over represented in infertile women (prevalence of 40 percent) and as much as 75-85 percent of women with chronic pelvic pain (3). Two modern factors may contribute to increased risk for the presence of endometriosis. One is that young girls are menstruating at an earlier age than ever before. The other is the decision to delay child bearing until later in life. Both of these subject women to a larger number of menstrual cycles that progress without hormonal suppression useful for controlling menstrual flow. Other risk factors include heavy menstrual flow and a genetic component in which a woman’s risk is 7 to 10 times greater if a first-degree relative is affected (4). There is also a strong concordance in monozygotic twins (5). A decreased risk is found among parous women and women who have increased length of lactation (6). Regular

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WINTER 2017

Understanding and Treating Endometriosis

exercise of more than four hours per week was also associated with a reduced risk of developing endometriosis (7). Diet has not been shown to have any role in preventing or controlling the disease. Understanding the pathophysiology is necessary to fully appreciate the insidious impact this disease can have during a woman’s reproductive life. Endometriosis is a condition in which the tissue from the uterine lining is found outside the uterus, producing a chronic inflammatory reaction that may cause an unpredictable amount of scarring. Key components in the development of endometriosis are local overproduction of prostaglandins by an increase in cyclooxygenase (COX-2) activity, and overproduction of local estrogen by increased aromatase activity. Progesterone resistance dampens the anti-estrogenic affect of progesterone and amplifies the local estrogenic effect. The pain, scarring, and infertility are due to the inflammatory cytokines, including tumor necrosis factor alpha and interleukins 1,6, and 8 (8). Most common areas for finding endometriosis include the posterior cul-de-sac especially along the uterosacral ligament, the ovaries and tubes, and the anterior cul-de-sac behind the bladder. This is responsible for producing the symptoms, which include painful menstruation, painful ovulation, pain with intercourse, heavy menstrual bleeding, chronic pelvic pain, fatigue, and infertility. Endometriosis may also be found anywhere in the abdomen including on bowel or in abdominal incisions, and in rare circumstances it has been found on the diaphragm and in the lung. Higher peritoneal levels of inflammatory cytokines can also affect sperm function including causing DNA damage to sperm (9). Diagnosing this disease is still dependent upon visualization using laparoscopy, with an overall sensitivity of 97 percent, and a specificity of only 77 percent (10). However because this is an expensive and invasive procedure, many studies suggest empiric treatment for three months with OCPs or GnRH (Gonadotropin releasing hormone) analogs to be preferable to diagnostic laparoscopy (11). Diagnosis using other modalities

such as pelvic ultrasound, MRI, or CA 125 is unreliable, and usually only helpful when there is an adnexal mass present. It should be noted that endometriosis might produce an abnormal elevated CA-125, which can confuse interpretation of an adnexal mass. Treatment of endometriosis consists of hormonal suppression or surgery. Medical suppressive therapies with continuous OCPs or GnRH analogs provide the mainstay of treatment for endometriosis. Overall control of pain symptoms can be achieved nearly equally with OCPs, progesterone (including the levonorgestrel containing IUD, oral norethindrone and IM medroxyprogesterone), GnRH analogs, and NSAIDs. The choice of treatment may be predicated on patient preference, tolerance to side effects, or cost. Dysmenorrhea has been shown to be most responsive to continuous use of combined OCPs to prevent any withdraw bleeding. Treatment of pain with Danazol (an androgenic drug) has been shown to be very effective, as well. However, the side effect profile from this drug frequently prohibits its use. While all these treatments may provide relief of the pain caused by endometriosis compared to placebo, large studies have shown they are ineffective for long-term treatment of infertility caused by endometriosis (12). Laparoscopic treatment of lesions has been shown to be superior in mild endometriosis only when infertility is a factor, with some studies showing a conflicted improvement in pregnancy rates. In a large prospective study, patients with all stages of endometriosis that had surgical removal of their lesions had a 21 percent, 47 percent, and 55 percent reoperation rate at two, five, and seven years of follow-up, respectively (13). Resection of an endometrioma or resection of severe disease has not been shown to improve fertility and can potentially risk compromising ovarian function if enough ovarian tissue is resected (14). Medical therapy does not resolve endometriomas (15). The FDA has only approved use of GnRH analog for up to 12 months, limited by the side effects (hot flushes and vaginal dryness) of osteopenia. Some studies suggest further

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use may be considered while using add-back estrogen or progestin therapy, as these greatly improve tolerance of the GnRH analog during the first six to 12 months of therapy. This treatment has been effective for control of symptoms only, as studies have not shown any improvement in fertility using GnRH analogs (16). Aromatase inhibitors such as letrozole and anastrozole have been studied for chronic pain of endometriosis with failure to respond to medical and surgical treatments in some observational trials (17). However, there are not sufficient controlled trials to advocate their use routinely, and they are not yet FDA approved for this purpose. Hysterectomy with bilateral salpingooophorectomy is still regarded as definitive therapy for treatment of endometriosis with intractable pain, and when medical therapy has failed. Conservation of the ovaries was associated with a 62 percent likelihood of recurring symptoms, and a 31 percent chance of requiring additional surgical treatment (18). REFERENCES Management of Endometriosis, American College of Ob-Gyn Practice Bulletin #114, July 2010, reaffirmed 2016. Up-to-Date, Endometriosis: Treatment of pelvic pain. December 15, 2016. (1)Rogers PA, et al. Priorities for endometriosis research: recommendations from an international consensus workshop. Reprod Sci 2009;16(4):335-46. (2)Giudice LC, Kao LC. Endometriosis. Lancet 2004;364:1789–99. (3)Verkauf BS. Incidence, symptoms, and signs of endometriosis in fertile and infertile women. J Fla Med Assoc 1987;74:671–5. (4)Malinak LR, Buttram VC Jr, Elias S, Simpson JL. Heritage aspects of endometriosis. II. Clinical characteristics of familial endometriosis. Am J Obstet Gynecol 1980;137:332–7. (5)Hadfield RM, Mardon HJ, Barlow DH, Kennedy SH. Endometriosis in monozygotic twins. Fertil Steril 1997;68:941–2. (6)Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL,Malspeis S, Willett WC, et al. Reproductive history and endometriosis among premenopausal women. Obstet Gynecol 2004;104:965–74.

Continued on page 16


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Understanding and Treating Endometriosis

(7)Signorello LB, Harlow BL, Cramer DW, Spiegelman D, Hill JA. Epidemiologic determinants of endometriosis: a hospital-based case-control study. Ann Epidemiol 1997;7:267–741. (8)Bedaiwy MA, Falcone T, Sharma RK, Goldberg JM, Attaran M, Nelson DR, et al. Prediction of endometriosis with serum and peritoneal fluid markers: a prospective controlled trial. Hum Reprod 2002;17:426–31. (9)Mansour G, Aziz N, Sharma R, Falcone T, Goldberg J, Agarwal A. The impact of peritoneal fluid from healthy women and from women with endometriosis on sperm DNA and its relationship to the sperm deformity index. Fertil Steril 2009;92:61–7. (10) Almeida Filho DP, Oliveira LJ, Amaral VF. Accuracy of laparoscopy for assessing patients with endometriosis. SaoPaulo Med J. 2008 Nov;126(6):305-8. (11)Ling FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstet Gynecol 1999;93:51–8. (12)Winkel CA. A cost-effective approach to the management of endometriosis. Curt Opin Obstet Gynecol 2000; 12:317-20.

(13) Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery [published erratum appears in Obstet Gynecol 2008;112:710]. Obstet Gynecol 2008;111:1285–92. (14)Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012; 97:3146. (15)Chapron C, Vercellini P, Barakat H, et al. Management of ovarian endometriomas. Hum Reprod Update 2002; 8:591. (16)Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database Syst Rev 2010; :CD008475. (17)Mousa NA, Bedaiwy MA,Casper RF. Aromatase inhibitors in the treatment of severe endometriosis. Obstet Gynecol 2007;109:1421 (18)Namnoum AB, Hickman TN, Goodman SB, Aehlbach DL, Rock, JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril 1995;64:898-902

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WINTER 2017

Healthy Communities

Cervical Cancer Screening & Prevention: BUILDING ON REMARKABLE ADVANCES

MELANIE L. STONE, MD OBGYN of Lancaster

T

he fight against cervical cancer is one of the great success stories of modern preventative medicine. Thanks to improved screening techniques and early detection, what was once the number one cancer killer of American women is now number fourteen. With the development of the HPV vaccine, we have the tools to reduce the incidence of HPV in both men and women. Unfortunately, 12,000 U.S. women are still diagnosed with cervical cancer annually, and 4,000 women will die of the disease each year. The decrease in cervical cancer that we saw over the last 30 years with the institution of screening and early treatment of dysplasia has now slowed. It is time to renew our focus on HPV-related diseases so that everyone can benefit from these major scientific breakthroughs. We need to ensure that all of our patients are getting recommended cervical cancer screening and receive the HPV vaccine if they are eligible. Cervical Cancer Screening – Is It Always Changing? Yes! Our scientific understanding of cervical cancer continues to advance, as do our screening regimens. With the invention of the pap smear test by George Papanicolaou in 1943, it became possible to identify patients with precancerous disease. Over the following decades, physicians and scientists learned more and more about cervical cancer and its progression from cervical dysplasia to cancer and developed effective

techniques to treat precancerous lesions. In the past 30 years, there has been a 50 percent reduction in cervical cancer in the United States thanks to the implementation of widespread cervical cancer screening. In the 1970s and 1980s, our understanding of cervical cancer expanded again with the discovery by 2008 Nobel Prize winner Harald zur Hausen that the HPV oncovirus causes almost all cases of cervical cancer. Commercial HPV testing became available in 1997 and was gradually adopted into cervical cancer screening protocols. As these discoveries were made, changes were made from universal annual screening to a risk stratified recommendation based on age. Recognizing The Patients We Are Missing Health care providers can sometimes get bogged down in the details of the different screening protocols. The most important thing is that women get regular screening of some sort and do not go for prolonged periods of time with no testing for cervical dysplasia. In women diagnosed with invasive cervical cancer, one half have never had a pap test and another 10 percent have not had one in the last ten years. The highest risk patients in the U.S. for being underscreened or never screened are those with limited access to health care, the uninsured, and women who have immigrated to the U.S. in the last ten years. It is vital that, when we do see these medically underserved patients, we offer them cervical cancer screening in addition to other health services they may be seeking.

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HPV Vaccination It is estimated that 75 percent of the reproductive-age population has been infected with one or more types of genital HPV. There are over 40 genital strains of HPV with types 16 and 18 being responsible for causing the majority of HPV-related cancers. There are currently three HPV vaccines: Cervarix, Gardasil, and Gardasil-9. Cervarix is only approved for females and covers 16 and 18. Gardasil covers four strains of HPV (16 and 18 and the two most common wart-causing types). Gardasil-9 covers nine strains (including 16 and 18). Gardasil has been the most widely used of the HPV vaccines. All HPV vaccines have been found to be >90 percent effective for the strains they cover when given prior to sexual activity. HPV vaccination is recommended for both males and female ages 9-26 with the major emphasis being on vaccinating 11and 12-year-olds. The vaccine requires three injections over a 6-month period, although the CDC has recently advised that children under 15 may receive just two doses. Only 50 percent of the eligible population has received these vaccinations. Not Just For Girls And Women HPV is responsible for genital warts and for cancers beyond the cervix, including anal, oropharyngeal, vaginal, vulvar, and penile cancers. Vaccination for boys and men is recommended not only to reduce the prevalence Continued on page 18


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Cervical Cancer Screening & Prevention

of HPV in the population, but also to reduce the incidence of HPV-related cancers in the men themselves. How Do We Increase Rates Of HPV Vaccination? The CDC recommends framing the vaccine as a “cancer vaccination” when counseling patients and families. The highest rates of vaccinations occur when HPV is treated as a routine vaccination like TDAP or hepatitis B. Parents often wait to make the decision about HPV vaccination after their child’s doctor initially brings it up because sexual activity seems far away to them. Many of these parents never get the vaccine for their child who later becomes sexually active without being protected. It is important to continue to readdress the vaccine after the initial offer. Often young people will seek out the vaccine on their own in their early 20s, but sometimes after beginning sexual activity when the vaccine is less efficacious. In my practice, we try and

vaccinate any eligible patients we see. I also try to discuss vaccination when I am seeing a woman with elementary-aged children for gynecologic care. I want her to know I feel this vaccine is safe and effective for her child. I stress the high prevalence of HPV in the population and the fact that condoms do not provide complete protection. If she has concerns about the vaccine, I try to explore from where she is getting her information and point her toward reliable sources of information. The Future Advances continue to be made in our understanding of cervical cancer and more changes will certainly come. For now, it is up to us as physicians to make sure all our patients are benefitting from proper screening and vaccination and to watch for the next important development.

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CURRENT ACOG SCREENING RECOMMENDATIONS: Ages 21-29:

Pap test every three years (preferred) Or Primary HPV testing q3y for > 25 years

Ages > 30:

Pap and HPV cotest every 5 years (preferred) Or Pap test every 3 years Or Primary HPV testing q3y for > 25 years

Age > 65:

Stop screening if two normal paps in last 10 years and no additional risk factors for cervical cancer


WINTER 2017

Healthy Communities

T

here are many infections that can lead to complications in pregnancy. The effects range from spontaneous abortion, growth restriction, preterm birth, malformations and fetal/infant death. This past year has renewed the public’s awareness with Zika’s effects becoming known and feared.

Infections that we are most concerned about in pregnancy include Zika, listeria, rubella, cytomegalovirus, toxoplasmosis, syphilis, herpes simplex virus, varicella, and influenza. Prevention is the key to a healthier pregnancy. Zika is primarily spread through infected mosquitos, but it can also be acquired through sex (oral, vaginal and anal). Congenital Zika virus infection is associated with severe congenital anomalies including microcephaly, facial disproportion, hypertonia/spasticity, hyperreflexia, seizures, irritability, arthrogyryposis, ocular abnormalities, and sensorineural hearing loss. We recommend that pregnant women do not travel to Zika-affected areas as determined by the CDC and not achieve pregnancy within six months of visiting one of these regions. If travel is necessary, use of DEET for skin and permethrin for clothing is recommended. Pregnant women should abstain or use condoms when having intercourse with a partner who has recently traveled to a Zika-affected region. The greatest risk appears to be with first trimester infection, but it can occur at any time during pregnancy. For a current list of places with Zika outbreaks, see CDC’s Travel Health Notices: http:// wwwnc.cdc.gov/travel/page/zika-travel-information.

MICHELLE FEGLEY, MD OBGYN of Lancaster

Listeriosis in pregnancy occurs most commonly during the third trimester. Listerial infection in pregnant women can lead to fetal death, premature birth, or infected newborns. We recommend pregnant women not drink or eat unpasteurized milk and avoid soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses or Mexican-style cheeses, such as queso blanco, queso fresco and panela. Also, avoid hot dogs and luncheon meats, unless they are reheated until steaming hot. Wash raw vegetables thoroughly before eating, and we also recommend thorough cooking of raw food from animal sources. We often receive calls from patients who have ingested a food implicated in an outbreak of listeriosis. It is reasonable to reassure the asymptomatic patient and only recommend cultures of stool and blood for patients with symptoms. Continued on page 20

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Preventing Prenatal Infection

Rubella infection of the fetus can be catastrophic, resulting in spontaneous abortion, stillbirth, congenital defects, and intrauterine growth retardation. Maternal-fetal transmission occurs via hematogenous spread and highest risk is in the first trimester and after 36 weeks gestation. Prevention is the most important aspect of management of congenital rubella. Preventive measures include immunization of girls before they reach childbearing age, testing pregnant women for rubella immunity, and providing counseling regarding avoidance of exposure to rubella for those who are nonimmune. Also, ensure that caregivers of children with congenital rubella syndrome in child care and hospital settings are rubella immune. Cytomegalovirus infection (CMV) can result in fetal growth restriction, microcephaly, ventirculomegaly, chorioretinitis, jaundice, hepatosplenomegaly, thrombocytopenia and petechiae. All pregnant women should be aware of CMV prevention measures, however, no actions can eliminate all risk for becoming infected with CMV. Practice good personal hygiene and avoid kissing children under the age of 6 on the mouth or cheek. Don’t share food, drinks, or utensils and properly clean toys and countertops. The classic triad of congenital toxoplasmosis consists of chorioretinitis, hydrocephalus, and intracranial calcifications. The main sources of maternal toxoplasmosis infection are ingestion of contaminated undercooked meat, soil-contaminated fruits and vegetables, and contaminated unfiltered water. Cats can become infected by eating infected rodents, birds, or other small animals. The parasite is then passed in the cat’s feces. It is recommended that pregnant women avoid changing the cat litter if possible. If no one else can, wear disposable gloves and wash hands with warm soap and water afterward.

stillbirth, neonatal death, preterm birth and congenital infection and anomalies. Penicillin therapy is effective for treating maternal disease and preventing transmission to the fetus. Herpes simplex virus (HSV) is transmitted to an infant during birth, primarily through an infected maternal genital tract. The risk of transmission is greater with primary HSV infection acquired during pregnancy. Most newborns with perinatally-acquired HSV appear normal at birth. HSV usually develops in one of three patterns: 1. Localized to skin, eyes, and mouth 2. Localized to the central nervous system 3. Disseminated disease involving multiple organs Women with known recurrent genital HSV should be offered acyclovir or valacyclovir suppression at 36 weeks’ gestation to decrease the risk of clinical lesions and viral shedding at the time of delivery. If a woman has prodromal symptoms or lesions present or a recent primary outbreak of HSV, a cesarean section should be offered.

The incidence of varicella infection in pregnancy is rare but severity of the disease appears to increase when acquired in pregnancy. Varicella pneumonia complicates 10-20 percent of maternal infections. Varicella can affect the fetus causing congenital varicella syndrome, which is associated with cutaneous scars and neurological, ocular, gastrointestinal and limb abnormalities. It is important to know that one can acquire varicella from persons with zoster, although the transmission rates are considerably lower. The CDC recommends all pregnant patients receive the inactivated influenza vaccine regardless of trimester and avoid contact with anyone known to have the flu. The best approach is to educate patients regarding the potential risks of infections during pregnancy. This can be accomplished through pre-gestational counseling and early education. Timely diagnosis of perinatally acquired infections is crucial to the initiation of appropriate therapy. Awareness of the features of the most common congenital infections can help to facilitate early diagnosis and tailor appropriate diagnostic evaluation.

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Treponema pallidum, the cause of syphilis, readily crosses the placenta and can occur at any gestational age and at any stage of maternal disease. The CDC reported an increased incidence of 38 percent from 2012 to 2014. All women should be screened at their initial prenatal visit and high-risk women should have a repeat screening later in pregnancy. Pregnancies complicated by untreated syphilis are at increased risk for intrauterine growth restriction,

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Healthy Communities

Clinical Trials A POWERFUL DEFENSE IN THE FIGHT AGAINST CANCER

H. PETER DEGREEN II, MD

Lancaster Cancer Center

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Clinical Trials

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he importance of cancer research cannot be underestimated. Findings from these studies have the potential to save thousands, even millions of lives. Clinical trials are an integral part of cancer research. They explore whether a medical strategy, treatment, or device is safe and effective for humans. Clinical trials are defined as a research study in which one or more patients are prospectively assigned to one or more interventions (which may include a placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes. IMPORTANCE OF CLINICAL TRIALS Many hospitals and private practices in Lancaster County are involved annually in clinical trials to help with cancer research and other diseases. Lancaster Cancer Center typically conducts five to six trials per year with approximately 25-30 patients participating. The center is currently participating in five clinical trials. Clinical trials help find better treatments to fight cancer as well as improve therapies that help decrease the side effects of cancer treatment. Clinical research is the process by which new treatments are approved by the FDA (Food and Drug Administration) for use in the general public. Before a medication or procedure can be FDA approved, it must be tested to make sure it’s safe and effective. All cancer and supportive care drugs in use today were approved through the same process. Although clinical trials offer great hope for progress in the battle against cancer, less than five percent of adults with the disease join one, which slows down therapy advances. However, more than 60 percent of children with cancer get treatment through a clinical trial. Around three-quarters of children with cancer survive long term, compared with half of adults. Doctors

CLINICAL TRIALS ARE THE KEY TO MAKING PROGRESS IN THE FIGHT AGAINST CANCER. link the higher survival rate for children, in part, to their high enrollment in clinical cancer trials.

However, patients also have the right to be proactive and mention clinical trial participation, if they are interested, during their visit.

PARTICIPANTS IN CLINICAL TRIALS During scheduled visits, the doctor will discuss a patient’s diagnosis and treatment options. If there is a clinical trial currently being conducted for which a patient may be eligible, the doctor and/or research staff will discuss alternative treatment options.

OUTCOMES OF CLINICAL TRIALS Over the years, thousands of people have benefited from clinical trials. People are living longer lives because of successful cancer treatments that are the result of past clinical trials. Oftentimes people in studies get promising medical treatments that would not be available to them by any other means. However, there are risks and possible side effects to consider. For instance, it is not clear how a new treatment will work for each individual. In some cases, patients have negative reactions to a new type of treatment.

It’s up to the patient, his or her family, and the physician to decide if a patient should participate in a clinical trial. Patients who are interested in participating go through a detailed screening process to determine if they meet the necessary criteria. This helps define who is eligible to enroll in a trial. If you are eligible and your doctor thinks it’s in your best interest, you will be given the option of trial participation. Clinical trials can also be solely observational. The only difference is that observational trials involve no intervention, but are simply focused on quality of life, current treatment regimens, and the side effects of those strategies. The treatment trial is testing a new treatment, which may be a new drug or new drug combination. This trial poses a potential higher risk because the patient is undergoing a new therapy. It should be noted that a patient’s participation in a clinical trial is completely voluntary and can be revoked at any time. Patients are never placed in a clinical trial without their signed, informed consent.

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Clinical trials help doctors determine whether new treatments are safe and effective and work better than current treatments. Clinical trials also help us find new ways to prevent and detect cancer. They help improve the quality of life for people during and after treatment. Patients who participate in a clinical trial add to our knowledge about cancer and help improve cancer care for future patients. Clinical trials are the key to making progress in the fight against cancer. H. Peter DeGreen II, MD, has been supporting patients with participation in clinical trials for more than three decades. He serves as the principal investigator of multiple studies, which has influenced his current practice of medicine and benefited hundreds of patients throughout the years.


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

Passion Outside of Practice

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 Joseph Degenhard, MD, and his passion outside of practice.

Joseph Degenhard, M.D. WellSpan Family Medicine – Trout Run

plenty of outdoor experiences on hikes, and camping. I still have memories of Pinewood Derby races, candy sales, and long history trail walks around Baltimore. My son Owen, when in first grade, without any prompting from us, wanted to go to a Cub Scout meeting. My wife Leigh became a Den Leader for Owen and later for Quinn as they progressed through their Cub Scout years. I provided backup help with prep and organization of Den meetings. I spent many nights at summer camp making memories with my boys. We took Cub Scouts on many “go see it” outings, campouts, and hikes. The boys had great fun making and racing Pinewood Derby cars. Though I became a doctor, at one point I thought I’d grow up to be a park ranger, forester, or naturalist in a state or national park. I’d had plenty of positive experience interacting with these people on family vacations. I have always loved the woods. A turn in the road or trail that takes me into the deep forest gives me an inner release—as letting out a sigh can set free some of the tension of a long day at work.

3. Why is this pursuit special to you?

I like that the Scouts organization is accepting of all boys and reflects the best of our culture’s values. Every meeting opens with a recitation of the Scout oath and law—a litany of character ideals that can be referenced when evaluating positive or negative behaviors or experiences.

Passion Outside of Practice: Boy Scout Leader

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

I am an Assistant Scoutmaster in the Boy Scouts. My two sons have been involved in Scouting since they were young. I enjoyed their Cub Scout years and when they moved on to become Boy Scouts, I had gone on several camping trips as a parent in their first few years. I found it was enjoyable, and since I was going on the trips anyway, decided to formalize my involvement. The Scouts take an active role in leading their own activities. The boys run meetings, plan events, and organize outings. Elected boy leaders are involved in budgeting, buying food, and directing the loading/ unloading of supplies at Troop outing trips, as well as

organizing their patrols to ensure that every boy gets to participate. We parents act as helpful observers and ensurers of safety, allowing the boys to take as much responsibility as they are prudently able. The boys get practical experience in decision-making, guided by adult leaders.

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

My brothers and I were all Cub Scouts. My mother was a Den Leader—which meant that in addition to managing her own four kids, she had to corral the wild energy of a dozen other boys for a few hours each week at Den meetings. We were led through crafts and did lots of “go see it” trips to businesses, police stations, fire stations, and historical sites. Of course, there were

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Advancement in ranks helps the boys to take their own initiative to gain skills required at each level. There are boys who will ambitiously work through rank advancement and earn merit badges, while others are more interested in simply participating in the fun of the activities with their friends. Both approaches are valued. Beyond these structured benefits of the Scouting program, I am having fun. As a father, I value the opportunities it gives my sons to grow further, and as the grown-up kid who once wanted to be a park ranger, I get a big dose of outdoor adventure.

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

I like that Scouting offers opportunities to do hands-on adventures, outside, as an alternative to the increasingly electronically entertained world that today’s kids are living in. They learn through service to the community, planning and carrying out projects and events, and the boys have a lot of fun in the process.


Introducing the Lancaster General Health

Acute Low Back Pain Program LG Health has developed an Acute Low Back Pain Program designed to reduce the wait time for patients to see an appropriate provider for effective care, and to minimize the use of opioids, imaging tests, and invasive procedures as a first-line treatment. Our Acute Low Back Pain Program treats patients who are experiencing: • Acute pain • Pre and post-partum back pain • Degenerative disk disease • Sacroiliac joint dysfunction • Herniated or prolapsed disks • Sciatica • Lumbar/sacral (lower back) pain • Spinal stenosis

To refer a patient to LG Health’s Acute Low Back Pain Program, please call 717-544-3197.

Continued on page 28


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Patient Advocacy

warm HAND-OFF What is a

and why do I need to know? ROBIN L. ROTHERMEL

Senior Director, Physician Support, PAMED

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Warm Hand-Off

W

ith the implementation of the Prescription Drug Monitoring Program (PDMP) as well as the many other efforts underway to address the opiate epidemic, many physicians are coming face to face with the issue of patients who may be misusing or abusing opiates. Unfortunately, not all physicians are familiar with the issue, may not be experienced in how to have the sometimes-difficult conversation with a patient, and may not be aware of the resources available. There is wide agreement, however, that linking these patients to appropriate treatment is important. This process is referred to as a “warm hand-off” and provides patients with resources for dealing with their substance use and connects them to those resources. But how do you know if your patient may be misusing or abusing substances? There are many brief, validated screening tools that can be integrated into routine practice to identify unhealthy alcohol use, tobacco use, and drug use, including prescription medication misuse. These tools can be used in a variety of settings and do not have to be performed by a physician. It is not necessary, however, to use a screening tool. Depending

on your relationships with patients and the type of setting, you can have conversations about their use of substances. If you believe your patient may be misusing or abusing substances, how do you initiate the conversation? Talking with patients about substance use problems can be challenging. It would be ideal if every patient with a possible substance use disorder readily informed his or her physician of such and was amenable to receiving some type of intervention or treatment; but the day-to-day reality is very different. While some patients will openly discuss their situation, others will be selective with the information they share and deny or minimize their substance use. Others may admit that their substance use is negatively impacting their lives, but at the same time they will list a number of reasons why they are unable to participate in treatment at this time. And others may become angry and argumentative. Unfortunately, there is no one approach that works with every patient when broaching this sensitive subject. As with screening tools, there are different types of motivational interviewing techniques and brief interventions that can be used when talking with patients.

There is a continuum of treatment available for patients experiencing substance use disorders ranging from services provided on an office-based or outpatient basis to long-term residential services. Determining the appropriate level of care and type of services can be done by an addiction professional, and does not need to be the role of the physician. As with most types of health care, the type and location of services patients receive will be largely dictated by their insurance coverage. If you’d like to learn more about screening tools, talking with patients about substance use, and the warm hand-off to treatment, PAMED can help. PAMED has created a number of online CME programs to help physicians combat this growing crisis. For more information, visit www.pamedsoc.org.

Among PAMED’s online CME programs to help physicians address the issue of substance abuse by patients is a four-part series entitled: “Addressing PA’s Opioid Crisis: What the Health Care Team Needs to Know.” Session 3: Referral to Treatment provides information and resources to assist physicians in addressing substance use disorders, screening tools, intervention strategies, and referral for treatment services. This session contains four modules: Treatment of Substance Use Disorders; Warm Hand-offs; Dealing with Challenges; and The Role of the Physician. Each module provides information physicians should know when speaking with their patients. The information will assist physicians with identifying screening tools to assess patients’ substance use, conducting brief interventions, understanding the different types of treatment available, recognizing and removing barriers to patient compliance, and much more. The modules vary in length from approximately 5–30 minutes and do not need to all be completed at the same time. Participants can earn CMEs for each session that is completed. PAMED also has a 4-minute video demonstration of the warm hand-off “Helping Patients Pursue Treatment for Addiction."

See PAMED’s website at www.pamedsoc.org to access these resources. LANCASTER

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OPIOID

LEGISLATION What should physicians know? MICHAEL D. I. SIGET, JD, MPA Legislative & Regulatory Counsel, Pennsylvania Medical Society

O

n Nov. 2, 2016, Gov. Wolf signed a package of legislation designed to combat the state’s opioid abuse crisis into law.

“This issue is affecting far too many Pennsylvanians,” said Pennsylvania Medical Society (PAMED) President Charles Cutler, MD, MACP, shortly after the bills passed the Pennsylvania legislature. “PAMED and our physician members remain committed to the well-being of our patients and will continue working to stem this crisis.”

Over the course of several months, PAMED worked with physicians, legislators, and other stakeholders to help ensure that any legislation took a common sense, patient-centered approach. PAMED solicited physician feedback on the bills in order to share the Pennsylvania physician perspective with legislators. Here’s a look at four bills the governor signed that physicians and practices should be aware of:

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SENATE BILL 1202

(Sponsored by Sen. Gene Yaw, R-23rd District)

The law requires that: For each licensure renewal period, physicians and other prescribers complete at least two hours of education in pain management, identification of addiction, or the practices of prescribing or dispensing of opioids. For initial licenses, the requirement is four hours of education, with those hours being at least two hours of education in pain management


WINTER 2017

Opioid Legislation

or identification of addiction and at least two hours of education in the practices of prescribing or dispensing of opioids. This required training may be counted toward the 100 hours of the total CME required for biennial license renewal. Dispensers to query the PDMP system before dispensing an opioid drug product or a benzodiazepine prescribed to a patient under certain circumstances. Prescribers to query the PDMP system each time a patient is prescribed an opioid drug product or a benzodiazepine. WHEN DOES THE LAW—NOW KNOWN AS ACT 124 OF 2016—TAKE EFFECT? Jan. 1, 2017.

SENATE BILL 1367 (Sponsored by Sen. Yaw)

This law will limit opioid prescriptions for minors to a seven-day duration when consent is given by a minor’s parent or legal guardian, except in cases of medical emergency. There are also exceptions for cases involving chronic pain, cancer treatment, and for palliative care or hospice care. This law limits opioid prescriptions for minors to a 72-hour dose when an authorized adult, as opposed to a minor’s parent or legal guardian, is available to consent for the minor patient. Prescribers will be required to obtain written consent for the prescription from the minor’s parent or guardian or from an authorized adult. The form will then be maintained in the minor’s medical record with the prescriber. WHEN DOES THE LAW—NOW KNOWN AS ACT 125 OF 2016—TAKE EFFECT? The law now requires state licensing boards to create the consent form that prescribers will need in order to comply with the law. When the form is available, it will be published in the Pennsylvania Bulletin, at which point the mandates of this law will take full effect. PAMED will notify members via our website and the Dose weekly email newsletter once the form is published.

SENATE BILL 1368 (Sponsored by Sen. Tom Killion, R-9th District)

The law will establish a safe opioid prescribing and pain management curriculum in both medical colleges and other medical training facilities. SB 1368 will also allow a patient to sign a form prohibiting the prescribing or administering of a controlled substance containing an opioid to that patient. WHEN DOES THE LAW—NOW KNOWN AS ACT 126 OF 2016—TAKE EFFECT? Immediately.

HOUSE BILL 1699 (Sponsored by Rep. Rosemary Brown, R-189th District)

This legislation will limit the prescribing of an opioid drug product to an individual seeking treatment in certain settings (an emergency department (ED) or urgent care center, or an individual who is in observation status in a hospital), to no more than a quantity sufficient to treat that individual for up to seven days. An important exception included in HB 1699 allows a health care practitioner to prescribe more than a seven-day supply to treat a patient’s acute medical condition or if it is deemed necessary for the treatment of pain associated with a cancer diagnosis or for palliative care. WHEN DOES THE LAW—NOW KNOWN AS ACT 122 OF 2016—TAKE EFFECT? Jan. 1, 2017.

OTHER OPIOIDS LEGISLATION CONSIDERED BY THE PA LEGISLATURE Another bill, House Bill 1698 (Sponsored by Rep. Doyle Heffley, R-122nd District), did not win Senate approval. HB 1698 would have mandated health insurers to cover the cost of abuse deterrent opioid (ADO) analgesic drug products. While PAMED strongly supported the underlying purpose of the bill, serious concerns were expressed when a last-minute amendment was added to the legislation.

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The amendment, for which PAMED expressed concern, would have directed the Department of Health to create mandatory prescribing guidelines for ADOs and requires prescribers to distribute educational materials developed by the DOH to every patient they prescribe any opioid (not just ADOs) to. That amendment would have created unnecessary obstacles for physicians and other prescribers who believe their patients may benefit from ADOs. More importantly, the educational materials would have been a “one size fits all” approach and would not have taken into account the unique clinical needs of each patient. Pennsylvania physicians remain committed to combatting the opioid abuse crisis as well as providing care to patients who suffer from chronic pain. Physicians like James Goodyear, MD, FACS, have had the opportunity to speak with representatives from the administration and legislative staff in order to advocate on behalf of patients and physicians. Because of physician advocacy, PAMED was able to positively impact legislation for the betterment of patients. “Although it requires additional time and effort for physicians to input patient information and utilize the system in its current iteration, the Pennsylvania Prescription Drug Monitoring Program, and its online web site PMP AWARxE, exists as an extremely valuable resource for the health of the citizens of the Commonwealth,” said Dr. Goodyear. “Not only can it help physicians identify those patients who are at risk for opioid abuse and diversion, but when used in conjunction with a ‘warm hand-off’ (the process in which a person who overdoses and wants help is promptly referred by the doctor for appropriate treatment), it can actually save lives.” Learn more about PAMED’s “Opioids for Pain: Be Smart. Be Safe. Be Sure” advocacy initiative designed to reduce opioid abuse and overdoses at www.pamedsoc.org/opioidinfo. And, access additional resources in PAMED’s Quick Consult series at www.pamedsoc.org/ quickconsult.


From stroke to spine care, the neurology services your patients need are right here. You don’t have to go far to find an experienced neurologist. James Pacelli, M.D., is board-certified in neurology and has completed a fellowship in Stroke and Neurological Critical Care at the Hospital of the University of Pennsylvania, Philadelphia. Dr. Pacelli has an extensive background in stroke and stroke telemedicine. He offers quick consults and sees patients with a wide range of neurological issues, including dementia, stroke, migraine, epilepsy, Parkinson’s disease, multiple sclerosis and traumatic brain injuries. Call 717-839-6518 to make a referral.

James Pacelli, M.D. Board-Certified in Neurology

Regional Neurology & Pain Management Associates Member of the Medical Staff of Lancaster Regional Medical Center and Heart of Lancaster Regional Medical Center. These hospitals are owned in part by physicians.

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12/20/16 1:36 PM

Do you have patients who need cardiothoracic surgery? Count on Dr. Brown to see them quickly. A member of the American Board of Thoracic Surgery and the Lancaster Medical Society with 23 years of experience, Dr. Paul Brown knows how important it is to work closely with primary care doctors and other specialists in the timely and coordinated care and treatment of their patients. Count on him for quick initial consults and for a collaborative approach to patient care.

To make a referral, call 717-839-5719. Paul S. Brown Jr., M.D., FACS, FACC, FACCP Board-Certified by the American Board of Surgery, American Board of Thoracic Surgery, and ARDMS as a Registered Physician in Vascular Interpretation

233 College Ave., Suite 203 • Lancaster, PA 17603 LancasterCTVSurgery.com

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12/21/16 9:07 AM


WINTER 2017

Legislative & Regulatory Updates

Pennsylvania Medical Society Quarterly Legislative Update

TOP HEALTH CARE ISSUES Addressed During PA’s 2015-2016 Legislative Session

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he Pennsylvania General Assembly concluded its 199th regular session in November, passing more than 50 pieces of legislation in the final days of the 2015-2016 session. Of the 3,748 bills introduced by the legislature, only 291 bills were ultimately passed and signed into law. At last count, the Pennsylvania Medical Society (PAMED) was actively tracking 442 bills that had the potential to affect physicians and their patients. In a recent video, PAMED President Charles Cutler, MD, MACP, talked about PAMED’s advocacy efforts on these three issues:

Retroactive Denial – A law signed in November 2016 requires that an insurer cannot retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the initial payment. The law is a significant improvement over current retroactive review practices.

CRNP Independent Licensure – The PA House and Senate considered legislation that would allow CRNPs to practice independently. PAMED opposed the legislation, which was defeated this session thanks to the grassroots efforts of physicians who reached out to their legislators. PAMED will continue to support the preservation of physician-led, team-based care for all patients in Pennsylvania.

And, here’s a quick recap of several other significant health care issues considered by the legislature over the past two years:

Opioid Abuse – On Nov. 2, 2016, Gov. Wolf signed four pieces of opioids legislation into law, including legislation that updated the Prescription Drug Monitoring Program (PDMP) law and set certain prescribing practices for opioids and benzodiazepines. PAMED worked closely with legislative leaders and staff to ensure that what was signed into law took a patient-centered and common sense approach.

Credentialing, Insurance Reforms, and Telemedicine – We saw the successful introduction and advancement on several priority issues for PAMED, including legislation to streamline the prior authorization process, reform the insurance credentialing process, and promote the use of telemedicine in PA. While legislation on these issues did not become law, incremental progress was made. Continued on page 32

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Legislative & Regulatory Updates

Representing

Interstate Medical Licensure Compact Authorization – A law signed on Oct. 26, 2016, authorizes Pennsylvania to join the Interstate Medical Licensure Compact.

the Area’s

Finest

Biosimilar Substitution – Signed on July 21, 2016, a new law allows a pharmacist to substitute a prescribed biological product with a biosimilar, which has been determined by the U.S. FDA to be “interchangeable” with the biological product that was prescribed. The law requires a pharmacist who substitutes a biological drug to notify the prescriber of the specific product that was provided to the patient within 72 hours of dispensing it. Prescriber notification was a key provision that PAMED strongly supported. Hepatitis C Screening – The Hepatitis C Screening Act took effect on Sept. 18, 2016, and requires hepatitis C screening to be offered to certain patient populations. PAMED was successful in advocating that the final version of the bill contained no penalties on health care providers.

AnneLusk.com o 717.291.9101 | f 717.393.2336 | c 717.271.9339 100 Foxshire Drive | Lancaster, PA 17601

Medical Marijuana – Legislation establishing a Medical Marijuana Program in PA was signed into law on April 17, 2016.

Sotheby’s International Realty and the Sotheby’s International Realty logo are registered (or unregistered) service marks used with permission. Sotheby’s International Realty Affiliates LLC fully supports the principles of the Fair Housing Act and the Equal Opportunity Act. Each Office is Independently Owned and Operated.

Healer

Oral Chemotherapy Parity – In July of this year, Gov. Wolf signed legislation into law that requires fairness in cost-sharing between intravenous and orally administered cancer drugs. Naturopaths – The Naturopathic Doctor Registration Act requires doctors of naturopathic medicine to register with the State Board of Medicine. Naturopathic doctors may also be subject to disciplinary action by the Board for a number of reasons. PAMED worked to ensure that the final version of the bill was limited to board registration and did not expand a naturopath’s clinical scope of practice beyond naturopathy.

After decades of caring for others, Dr. Wert suddenly found himself on the receiving end of treatment. Stage four cancer had robbed his body of the strength he needed to continue helping impoverished countries receive proper medical care. Lancaster Cancer Center gave Dr. Wert his life back so he could return to helping those in need.

The 200th regular session of the General Assembly convened on the first Tuesday in January 2017. PAMED will continue working to ensure that Pennsylvania physicians have a seat at the table when important policy decisions affecting medical practice are discussed.

Proud to be the longest-running independent, community-based oncology/hematology practice in Lancaster County. To make a referral, call 291-1313.

Learn more about PAMED’s advocacy initiatives at

www.pamedsoc.org/advocacy.

Greenfield Corporate Center • 1858 Charter Lane, Suite 202 (717) 291-1313 • www.lancastercancercenter.com

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High-Quality Accredited CME/CEU Close to Home! Cardiovascular Institute of Philadelphia 2017 CME/CEU Programs

SUN 01.15.17

SUN 02.19.17

CVI’s 9th Annual Echocardiography Update

CVI’s 6th Annual EP/Arrhythmia Management Update

Loews Philadelphia

Hilton Penn’s Landing

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2017

NEW

CVI’s 24th Annual Cardiology Update:

CVI’s Interventional Cardiology Fellows Course

Clinical Management of Heart Disease

Loews Philadelphia

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SUN 03.05.17

CVI’s 13th Annual Update in Nuclear Cardiology

CVI’s 5th Annual Interventional Cardiovascular Medicine

Hilton Penn’s Landing

• Up to 40 CME/CEU Credits for All • ABIM MOC Points for Physicians • SDMS and VOICE Credits for Technologists • Pharmacology Credits for NPs in PA • FREE Cardiology Fellows Training/Certification Program • Impressive faculty of nationally recognized thought leaders and a diverse panel of regional experts • Up to $175 in Early-Bird Registration Discounts

Loews Philadelphia

• Up to 5 FREE Apple iPad Drawings • Discounted Parking • Delicious Meal Selections Included • SPECIAL FOR Philadelphia Medical Society Journal Readers! Each time you register use Special Code – PMSREADER to be entered in a free drawing for a FREE $250 VISA Gift Card for each program

To register and for more information, visit us online at www.cviphiladelphia.org or call 215.389.2300 CVI is a federally registered 501 (c)3 non-profit medical education foundation, not affiliated with any one academic medical center, health system or hospital, but an independent resource for all.

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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

FEEL THE BURN? Burnout is More Common Than You Might Think

HEATH B. MACKLEY MD, FACRO

I

don’t know any physician who doesn’t struggle with the work-life balance. We didn’t become physicians because we expected an easy job. And most of us understand that to be truly good at anything, it probably takes some talent, but it definitely requires a lot of work. There is no substitute for investing your time, from studying in medical school to working and studying in residency and fellowship to working while continuing the learning process as an attending physician. But it doesn’t stop there. To deliver quality health care to each individual, it requires time. Time to understand their stories, time to develop evidence-based plans for rarely seen diseases, time to talk to your colleagues to coordinate complex care. It also takes time to document each

encounter correctly. And it takes time to fulfill employer requirements if you’re employed or to administer the practice if you’re independent. Then there’s the time to supervise and train your team, plus time to educate learners if you work with them and patients no matter where you work. And we can’t forget the time for continued medical education (CME) and other professional development efforts. Medicine is undeniably a labor of love for most of us. But it is labor. The challenge is we all have lives outside of work. We have family and friends. We have hobbies, causes, religious activities, sports, artistic endeavors, and countless other things that make life full and meaningful. But we also need time to care for ourselves—to eat well, to sleep enough, and to see physicians for our own personal medical issues. The

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tension between being a good physician and these important aspects of life is relentless. And that is just one source of stress. Physicians see death, suffering, lawsuits, unfair insurance policies, and countless small offenses that can add to the pressure. It is no surprise that about 50 percent of physicians are suffering burnout. Burnout is a syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment (1). Burnout is not a sign of weakness; it is a consequence of chronic stress. As physicians, it is often easy to focus on our work instead of acknowledging the warning signs exhibited in ourselves or our colleagues. It is common for us to identify denial in our patients; however, it is less common for us to identify it in ourselves. This impacts all


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Feel the Burn?

of us in the house of medicine. Studies have shown burnout scores are associated with decreased work effort, an increase in major medical errors, and suicidal ideation. Even in less extreme situations, burnout’s association with lower job satisfaction has ripple effects on the morale of the entire clinic. With few exceptions, no physician is an island that burnout cannot reach. Pennsylvania Medical Society (PAMED) represents and advocates for physicians on many levels. As part of its educational programs offered to members, there are three programs (adding up to four hours of CME) that help physicians identify burnout, develop resilience strategies, and intervene on behalf of their colleagues (2). For most of us, this is not something we learned about in medical school. Just like other medical problems we learn about, there are evidence-based interventions that can be helpful, both on the individual level

(small group curricula, stress management and self-care training, communication skills training, mindfulness-based approaches) and the institutional level (modification of work processes, shortening of work shifts). The average benefit of these interventions reduces the relative risk of developing burnout by about 10 percent. Sometimes, we need more than CME to address a problem. The Foundation of PAMED, which has a long-standing commitment to helping physicians in need, recently led a successful “Resiliency Retreat” in November. Stay tuned for further retreats in the future. When one considers the potential impact of avoiding a “crash and burn” experience, all of us need to be more proactive with physician burnout. I would encourage everyone to learn more. And remember, PAMED is here to help!

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

WORKS CITED 1 West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81. 2 https://www.pamedsoc.org/learn-lead/ topics/physician-burnout

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THE WATERREVIEW: FRONT


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

Restaurant Review

Kyma Seafood Grill

reviewed by DAWN MENTZER Editor, Lancaster Physician & Freelance Writer

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ith the opportunity to take a turn at writing a restaurant review for Lancaster Physician, I immediately knew where I wanted to dine. My husband Shane and I had been to Kyma Seafood Grill for dinner several years ago, and I enjoyed cocktails there with a friend awhile back. I was far overdue for another visit, so I had made reservations for two at 6:30 p.m. on a Thursday evening. Upon arrival, we were promptly seated, even though the large parking lot was nearly packed. Located in the building that was once home to the Silk City Diner, Kyma Seafood Grill offers an ambiance of casual elegance. The décor includes nostalgic neon lighting around the ceiling and stylish pendant lighting fixtures at guests’ tables, which provide just the right amount of illumination. I appreciate that the dining room has a soft aura, yet doesn’t render you struggling to read your menu. Our server that evening, Ashley, was friendly, attentive, and knowledgeable about Kyma’s menu. Kyma’s drink menu includes a nice assortment of wine, plentiful domestic and imported beers, and a tempting list of martini choices. I selected a house merlot while Shane enjoyed bourbon on the rocks; both were generous pours.

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WINTER 2017

Restaurant Review

The selection of appetizers featured at the restaurant includes classics (like Jumbo Shrimp Cocktail and Steamed Clams), savory plates (such as Crab Lobster, Spinach and Artichoke Dip served with tortilla chips), and several Kyma specialties (like Mussels Kyma with Prince Edward Island mussels sautéed with onion, garlic, leeks, white, wine, and lemon). Shane and I shared an appetizer newly added to Kyma’s menu, Fried Greek Olives. Unsure of what to expect, we were pleasantly surprised at how much we loved them. The kalamata olives were fried to a golden brown and served over Greek yogurt with a side of warm pita wedges. The olives had a nice “kick,” which was nicely mellowed by the yogurt. The portion size was just right—it satisfied without making us too full to enjoy our meals. Kyma’s entrées include favorites from sea and land—from Fish and Chips to South African Lobster and Monterey Chicken to Filet Mignon. Shane selected Kyma’s Stuffed Flounder for his entrée with sides of french fries and sauteed mushrooms. His dish included two nicely sized filets, each stuffed with a respectable portion of

crab meat. The fish was cooked flawlessly, and Shane raved about the mushrooms (I “borrowed” one from his plate and understand why he was smitten with them). For my entrée, I chose the Colossal Crab Cake. This dish, a heaping half-pound of colossal king crab meat, lived up to my optimistic expectations. It had no filler whatsoever—just pure chunks of tender crab, exquisitely seasoned in a creamy mayo-based sauce with hints of mustard, Old Bay, and red wine. To accompany my entrée, I selected sides of tender asparagus with Hollandaise sauce and roasted garlic mashed potatoes. I could not have been more satisfied with my meal—truly, it was divine. Typically, Shane and I don’t order dessert when we dine out. But what restaurant reviewer worth anything would skip this essential phase of the assignment? When Ashley brought the dessert tray to our table, she explained that Kyma (and Johnny’s Bar and Steakhouse located in the lower level of the building) has an in-house bakery where they make their own confectionary creations. The dessert

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selection included a variety of cheesecakes, crème brulee, and key lime pie. Decisions, decisions! Ultimately, we agreed to share the key lime pie. I’m glad we did. It was rich yet refreshing—a perfect ending to a perfect meal. We thoroughly enjoyed our experience at Kyma Seafood Grill and encourage anyone who loves seafood to give it a try. Final notes: The restaurant’s location on Route 272 between Reading and Lancaster makes it easy to find and convenient to travel to. We advise calling in advance to make reservations. In warmer weather, you might want to check out Kyma’s outdoor patio bar “The Dock.”

Kyma Seafood Grill 1640 North Reading Road Stevens, PA 17578 (717) 335-3833

www.kymaseafoodgrill.com


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

PAMED Adopts

PHYSICIANS BILL OF RIGHTS Addressing Concerns of Employed Physicians

T

he Pennsylvania Medical Society’s (PAMED’s) Employed Physician Task Force recently developed a Physicians Bill of Rights designed to address the concerns of employed physicians working for hospitals, health systems, and other health care organizations in the commonwealth. On Oct. 21, 2016, PAMED’s Board of Trustees voted to approve the Physicians Bill of Rights. The Task Force—led by emergency physician Kristen Sandel, MD—sought to address member concerns about physicians’ clinical autonomy as well as the need for fairness concerning issues like employment contracts. “This is an exciting time for PAMED and employed physicians,” Dr. Sandel said. “I believe that we are the first statewide medical society to pass a Physicians Bill of Rights. My hope is that the Bill of Rights can be used as talking points between physicians and employers to continue to develop physician-friendly work sites focused on high quality, patient-centered care.”

THE BILL OF RIGHTS INCLUDES THESE 10 TENETS: Physicians should have autonomy in clinical decision-making. Physicians should have adequate staffing, equipment, and supplies to assist them in providing the best patient care. Physicians should not be required to agree to any unreasonable non-compete clauses. Physicians should be provided paid sick leave exclusive of personal or vacation days as provided to other employees.  Physicians should be provided with adequate, paid time to complete administrative tasks including, but not limited to, paperwork, charting, rounds, and calls that are required for the performance of their clinical duties. Physicians should not be required to, and their pay should not be dependent upon, the supervision of activities of mid-level practitioners in which they did not actively

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participate with on-site or at the time of the activity. A physician’s pay should be dependent on the physician’s ability and not on activities for which the physician does not control, such as patient scheduling, clinical ambience, and staff performance. Physicians should receive transparency in contract terms, including salary structure, benefits, and reimbursement for their clinical billing. Every physician’s contract for employment should specify a time limit and may not be terminated early without just cause. Physicians are entitled to academic freedom without censorship, including, but not limited to, clinical research, academic pursuits, and public expression. Reprinted with permission from the Pennsylvania Medical Society


WINTER 2017

Your MACRA Checklist: Are You Ready for Implementation on Jan . 1?

T

JENNIFER SWINNICH, CPP Director, Practice Support, PAMED

he Centers for Medicare and Medicaid Services’ (CMS’s) MACRA final rule will be implemented beginning Jan. 1, 2017. The rule calls for the creation of a Quality Payment Program consisting of two tracks: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

APM in 2017. Participating using the “Test the Quality Payment Program” option is simple; physicians and practices can avoid the four percent penalty by reporting at least one measure for one patient.

During the first year of MACRA implementation in 2017, most physicians are expected to participate in MIPS. Check out these steps physicians and practices can take to get ready for MIPS.

Quality – Replaces the Physician Quality Reporting System (PQRS); Scoring weight for 2017: 60 percent

Explore the MIPS measures. CMS offers tools you can use to select your MIPS measures:

Advancing Care Information – Replaces Meaningful Use; Scoring weight for 2017: 25 percent

Quality Measures – https://qpp.cms.gov/measures/quality

Find out whether you are required to participate. You participate in the Quality Payment Program if you bill Medicare Part B more than $30,000 in allowed charges per year, provide care for more than 100 Medicare patients per year, and are one of the following: physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified registered nurse anesthetist. You don’t need to report in 2017 if it is your first year participating in Medicare Part B, or if you significantly participate in an Advanced APM. Avoid a negative penalty in 2017 by choosing your participation option . These four participation options are available for 2017: a. Test the Quality Payment Program by submitting some data, b. Participate for part of the 2017 calendar year, c. Participate for the full 2017 calendar year, or d. Participate in an Advanced APM. Learn more at www. pamedsoc.org/MACRAFlexibility. Important Note: You will be subject to a negative four percent payment adjustment if you are eligible for participation but choose not to participate in MIPS or an Advanced

Learn more about MI PS and its performance categories:

Improvement Activities – A new category; Scoring weight for 2017: 15 percent Cost – Replaces Value-Based Payment Modifier; Scoring weight for 2017: not weighted CMS offers more details at https://qpp.cms.gov/measures/ performance. Decide if you’re participating in MIPS as an individual or as a group. The deadline for registering to report as a group is June 30, 2017. CMS “Get Prepared” page at https:// qpp.cms.gov/learn/getprepared has details. Make sure your EHR is certified by the Office of the National Coordinator for Health Information Technology. Use this tool to find out – https://chpl.healthit.gov/#/search. Use Your Quality Resource and Use Report (QRUR) to identify areas for improvement. The Pennsylvania Medical

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Society (PAMED) hosted a QRUR Workshop, and several resources highlighted during the workshop are available at www. pamedsoc.org/qrurworkshop. Consider participating in a qualified clinical data registry.

Advancing Care Information Measures – https://qpp.cms.gov/measures/aci Improvement Activities – https://qpp. cms.gov/measures/ia Review workflows to increase efficiency. Check out PAMED’s “Embracing the Benefits of Workflow Analysis” at www.pamedsoc.org/workflowanaylsis for details. More Resources PAMED will continue to update the MACRA webpage with news and updates. Members are encouraged to visit www. pamedsoc.org/macra frequently. Members with questions can also contact PAMED’s Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@ pamedsoc.org. Reprinted with permission from the Pennsylvania Medical Society.


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

LANDMARK INITIATIVE GETS THE GREEN LIGHT PHOTOS COURTESY OF PAMED

C

heers and applause broke out at the Hershey Lodge on Oct. 23, 2016, as Pennsylvania physicians voted overwhelmingly in favor of a landmark Practice Options Initiative to create clinically integrated networks (CINs) for physicians in the state. The message from physicians from across the state at the Pennsylvania Medical Society’s 2016 House of Delegates (PAMED-HOD) was resounding: Let’s assist in providing physicians with practice options, which would in turn ensure patient access to quality care in Pennsylvania. The Practice Options Initiative will create CINs as well as a Management Services Organization (MSO). It is a direct response to the evolving health care delivery system, which is moving rapidly toward value-based care. It will support all physicians by providing practice options and helping physicians maintain leadership and clinical autonomy. The initiative aims to help physicians succeed in MACRA and alternative payment models. A LOOK AT OTHER IMPORTANT HEALTH CARE ISSUES ADDRESSED AT PAMED’S 2016 HOD While the historic vote was one highlight of this year’s HOD, physicians addressed many other significant health care issues at the HOD. Here’s a look at just a few:

FROM PAMED’S HOUSE OF DELEGATES

Continue to Work to Ensure a Fairer, Less Burdensome Maintenance of Certification (MOC) Process Address Pennsylvania’s Opioid Abuse and Overdose Crisis  Advocate for More Consistent and Transparent Insurer Processes Explore Legislation that Would Help Protect Physicians and Patients and Ensure Physicians’ Clinical Autonomy Address Public Health Issues Affecting Patients in Pennsylvania Find more information about these ongoing PAMED advocacy efforts related to issues discussed at the HOD on Oct. 21-23: Maintenance of Certification – www.pamedsoc.org/MOC PAMED’s “Opioids for Pain: Be Smart. Be Safe. Be Sure.” Initiative – www.pamedsoc. org/OpioidInfo Credentialing and Insurance Reforms – www.pamedsoc.org/InsuranceReforms Article and photos reprinted with permission from the Pennsylvania Medical Society.

Thank you to the following dedicated members for serving as the delegates representing Lancaster City & County Medical Society: ROBERT K. AICHELE, JR., DO PAL South Family Medicine STACEY S. DENLINGER, DO Baron Family Practice LAURA H. FISHER, MD Lancaster Family Allergy JAMES M. KELLY, MD LGHP-Lincoln Family Medicine STEPHEN T. OLIN, MD LGH and SouthEast Lancaster Health Services REBECCA M. SHEPHERD, MD, MBA LGH Arthritis & Rheumatology DAVID J. SIMONS, DO, FAOCA Communty Anesthesia Associates THOMAS J. WEIDA, MD University of Alabama Health Sciences (alternate) KAREN A. RIZZO, MD Lancaster Ear, Nose & Throat, LLC (PAMED Past President)

Learn more about all of PAMED’s advocacy efforts at

www.pamedsoc.org/Advocacy. LANCASTER

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WINTER 2017

News & Announcements

LANCASTER CITY & COUNTY MEDICAL SOCIETY

PHOTOS COURTESY MORRIS MILLER

2016 Holiday Social and Foundation Benefit

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he 2016 Holiday Social and Foundation Benefit was held on Saturday, December 10 at Lancaster Country Club. With a record attendance, topping more than 130 members, sponsors, and guests, the evening festivities provided a wonderful opportunity to honor Lancaster City & County Medical Society members that were selected as 40 Under 40 awardees and the 2016 Foundation scholarship recipients. The event, designed to raise awareness and funds for the Lancaster Medical Society Foundation, also serves as the Society’s holiday event and offered a welcoming environment to network and catch up with fellow members.

Sponsors

Neurology & Stroke Associates, PC Lancaster NeuroScience & Spine Associates Medtronic Saxton & Stump Community Anesthesia Associates Conestoga Eye - Dr. David Silbert Richard A. Friedman, CLU, ChFC Insight Medical Partners Lusk & Associates, Sotheby’s International Realty Trout, Ebersole & Groff, LLP

More than $20,000 was raised for future scholarship awards. This year’s festivities included a silent auction of 17 themed baskets as well as a wine grab. Thanks to the generous contributions from our scholarship champions and a healthy competition among the bidders, more than $20,000 was raised for future scholarship awards. Founded in 1991, the Lancaster Medical Society Foundation is a 501(c) 3 nonprofit organization established to grant scholarships

to students from Lancaster County who are accepted or continuing a medical degree at an accredited allopathic or osteopathic medical school. Scholarship recipients exemplify good character, motivation, academic achievement, and financial need. Since its inception, more than $214,000 in scholarships has been given to deserving local students.

Scholarship Champions

(commitments received at time of printing)

Lancaster General Hospital Medical Staff Heart of Lancaster Regional Medical Center Medical Staff Lancaster Regional Medical Staff Marilyn Berger William & Anne Curtin Howell’s Glass Co., Inc. Orthopedic Associates of Lancaster, Ltd. Drs. Lora and Raymond Regan Kenneth G. Berkenstock, MD High Company, LLC LANCASTER

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Clarence H. Rutt, MD Stephen T. Olin, MD Stephen Brillhart, Realtor, Berkshire Hathaway Homesale Realty The Ciampaglia Family The Meyer LePrell Group Jeanette L. Hebel, MD Kelly Janke Dr. Paul H. Ripple


Unrivaled quality of care in an exceptional environment.

Your patient’s injury or illness may have been unplanned, But their recovery doesn’t have to be. Recommend a community with a reputation for innovative quality care. Willow Valley Communities offers short-term rehabilitation services as well as long-term skilled nursing care all in extraordinary comfort and style. With our in-house licensed therapy group and caring nursing team, not only will your patient receive the highest level of compassionate care, but also an average length of stay length of 25 days for short-term rehab and readmission rates far below the national average. Learn more today. Contact our Admissions Counselor at 717.940.4828. WillowValleyCommunities.org | Lancaster, PA


WINTER 2017

News & Announcements

Frontline Group Spotlight

LG Health Physicians Family Medicine New Holland

W

hat began as a somewhat risky financial endeavor has resulted in 40 years of consistent, comprehensive medical care for the eastern Lancaster County community. LG Health Physicians Family Medicine New Holland recognized the milestone in December 2016 with a luncheon and a look back on the people and the practice. Dr. Robert Johnson, one of the founding providers of the New Holland family medicine practice, is fond of telling people that it was the “smartest dumb” decision he ever made. When the offer was thrown out by one of their instructors, Johnson and a fellow residency classmate, James Albrecht, jumped at the chance to stay in the county to practice medicine. In 1976, plans for the construction of a family health center were underway, the impetus of which came from a local group of investors

and the willingness of Dr. Johnson and Dr. Albrecht to facilitate the practice. “The idea was good, but it was a risky one; we didn’t have patients,” Johnson remembers. Johnson needn’t have worried. In 40 years, the practice had historically undergone two small renovations and one major renovation in 2012, which added six exam rooms to house their growing practice. As of January 2017, the practice will have 27 employees and six providers, with an intention to add a physician assistant soon. Lois Zimmerman, employed 39 years with the practice, remarked, “I enjoy the people, and the doctors have always been nice to work with.” Zimmerman has seen many changes in her long-time employment in the field, citing working with insurance companies and the surge of urgent care facilities as two that have re-shaped the job.

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“With all the emergencies, work injuries, fractures, and lacerations, our job can never be boring,” remarked Zimmerman. Johnson saw the changes, too, and moved the practice in a direction to meet those changes by growing the practice and adapting to the use of computers. “It is vastly different than when we started, both inside and out. Medicine has become more complex, but the people are the same,” said Johnson. In reflection on his goals when he was just starting out with Dr. Albrecht, Johnson said, “New Holland is, and always has been, a wonderful place to be a family doctor. Forty years at this site and the accumulated series of events and experiences have culminated in a very satisfying practice.”


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

WINTER 2017 Frontline Practice Groups (with three or more physicians) have made a 100% membership commitment to LCCMS and PAMED. We thank them for their unified support of our efforts in advocating on your behalf and facilitating an environment for physicians to work collaboratively for the benefit of the profession and patients.

Allergy & Asthma Center

Lancaster Physicians For Women

Cardiac Consultants PC

Lancaster Radiology Associates Ltd

Community Anesthesia Associates

LGHP – Manheim Family Medicine

Community Services Group Dermatology Associates of Lancaster Ltd

LGHP – New Holland Family Medicine

Eastbrook Family Health Center

LGHP – Susquehanna Family Medicine

Eye Associates of Lancaster Ltd

Manning & Rommel Associates

The Heart Group of Lancaster General Health Hypertension and Kidney Specialists

OBGYN of Lancaster

Southeast Lancaster Health Services Inc Southeast Lancaster Health Services-Arch St Southeast Lancaster Health Services-Hershey Ave Surgical Specialists Of Lancaster Wellspan Family & Pediatric Medicine - Rothsville Wellspan Family Medicine Trout Run

Otolaryngology Physicians Of Lancaster

Hospice & Community Care

Patient First - Lancaster

Lancaster Cancer Center Ltd

Pediatrix @ Heart of Lancaster

Lancaster Neuroscience and Spine Assoc

Red Rose Cardiology

LCCMS EVENTS 2017 03.03.17 | Past President’s Breakfast

04.28.17 | Young Physician Social

5.11.17 | Spring Legislative Breakfast

Cork Factory Hotel, 7:30 a.m.

Bent Creek Country Club, 6 to 9 p.m.

Cork Factory Hotel, 7 to 8:15 a.m.

03.22.17 | Lancaster Women

May | Docs On Call

6.13.17 | Annual Dinner &

in Medicine Breakfast

in conjunction with PAMED

Business Meeting

Cork Factory Hotel, 7 a.m.

and WGAL

Lancaster Country Club, 6 to 9:30 p.m.

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WINTER 2017

News & Announcements

Welcome‌New Members Rima A. Bishar, MD Resident, Lancaster General Hospital Caitlin N. Colonna, DO Resident, Heart of Lancaster Regional Medical Center Christine M. Dang, MD Lancaster Regional Medical Center Cheryl A. Denick, MD Hospice & Community Care Dean M. Godfrey, DO Lancaster General Health Physical Medicine Daniel R. Grutter, DO Resident, Heart of Lancaster Regional Medical Center

Congratulations...Reinstated Members

Sara Marian Lucking, MD Dermatology Associates of Lancaster, Ltd.

Alyssa K. Anderson, MD Penn State Hershey Medical GroupElizabethtown

Jonathan D. Stewart, MD LGHP-Walter L. Aument Family Health Center

Melody Martin, MD Resident, Lancaster General Hospital

Jarod B. John, MD Brain Orthopedic Spine Specialists

Joan Brumbaugh Thode, MD Roseville Pediatrics

Vinitha Moopen, MD Wellspan Family & Pediatric MedicineRothsville

Glenn A. Kline, DO

Pamela A. Vnenchak, MD LGHP-Family & Maternity Medicine

Manda Null, DO Community Anesthesia Associates

Timothy J. Labosh, MD LGHP-East Petersburg Family Medicine

Margaret Phillips Administrator, Lancaster Ear, Nose and Throat

Oliver S. Wagner, MD LGHP-Susquehanna Family Medicine Jacqueline M.G. Wallace, MD

Robert M. Springer, III, MD

Thomas Showers, DO

Seth H. Gunderson,DO LRMC Anesthesia Consultants

Tracey M. Smith, DO Southeast Lancaster Health ServicesArch Street

Kristi L. Herbst, DO Retreat at Lancaster County

Karuna P. Spiegelman, MD Hospice & Community Care

Jason L. Higgs, DO Resident, Heart of Lancaster Regional Medical Center

Autumn Vogel Student, Penn State College of Medicine

Shawn M. Hines Student, Perelman School of Medicine, University of Pennsylvania

Kathleen A. Kreider, MD Eastbrook Family Health Center

In Remembrance...Deceased Members Henry W. Huffnagle, MD, FACS On October 7, 2016, Dr. Henry William Huffnagle died peacefully following a brief illness, surrounded by friends and loved ones. He was 83 years old. Dr. Huffnagle was a skilled and widely respected Lancaster physician, self-taught naturalist and botanist, community leader, and passionate advocate for land conservation and preservation issues in Lancaster County.Â

Charles A. Whitener, DO Resident, Heart of Lancaster Regional Medical Center

Dr. Huffnagle was born on September 24, 1933 in Quarryville, PA. He attended the Peddie School in Heightstown, NJ. He graduated from Franklin & Marshall College, and then completed his Doctor of Medicine degree and residency at University of Pennsylvania.

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

Follow us on Facebook at www.facebook.com/LCCMS LANCASTER

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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

Member Spotlight

Laura H. Fisher, MD Lancaster Family Allergy

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

Leader (survivor) and will be coaching Girls On the Run this year as well as volunteering as a room mother for each of their classes.

I practice allergy, asthma, and immunology at Lancaster Family Allergy, Lancaster, PA. I grew up in York County, was an undergraduate at Princeton, and went to medical school at Penn State Hershey where I met my husband. I did my residency training and allergy fellowship at Hershey, as well. I always wanted to settle in Central Pa, but my husband wisely did not want to live on the same street as all of my family members in York, so Lancaster was a good distance. We live on a small farm with multiple animals. I met my future great friend and current partner, Amanda Bittner, at a lecture on allergies to vaccines while I was still a fellow, and I connected with her and her group when I was ready to practice. We opened our own office four years ago to balance our similar practicing styles with motherhood.

What are your hobbies and interests when you’re not working? I am always working, like every other physician I know, with office work, CMEs, and volunteer commitments. However, I enjoy gardening, skiing (I am the slowest in my family now, though), and would like to get back into horseback riding (much harder to get myself on a horse now than when I was in my 20s). 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 was encouraged to join LCCMS by some other young physicians. Both that and my work with the state allergy board have shown me the importance of advocating for our profession and our patients. Although physicians are extremely busy with personal and work-related commitments, many decisions made in our state and our country are happening without us. Involvement is very important.

What do you like best about practicing medicine? I enjoy private practice in Lancaster because of all the interesting people that I meet. I can play with babies and get some mind-blowing stories from older patients. People are allergic to a lot of really weird stuff. I feel like I am constantly learning. Are you involved in any community, non-profit, or professional organizations? If so, please list he groups: Besides Lancaster City & County Medical Society, I sit on the Pennsylvania Allergy and Asthma Association Board. I like to be active with my daughters, Anna (8) and Lily (6). I am a recent Daisy Girl Scout

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WINTER 2017

News & Announcements Lancaster General Health Events

Lancaster Regional Medical Center and Heart of Lancaster Regional Medical Center Lancaster County Events

Wellness 101 Classes: Imagining Your Best Self

Learn how you can become healthier by setting goals that you can reach, making a plan to reach your goals, and finding your motivation to change. Free of charge. For dates, times, locations, and to register, visit https://forms.lghealth.org/ Classes/Group.aspx?groupID=WEL-BS

Free Weight-Loss Options Seminar

If diet and exercise aren’t enough to help you lose weight, BMI of Lancaster can help with surgical and non-surgical options. Learn more by attending one of our free seminars, held bi-monthly on the 4th Tuesday of each applicable month, from 6-7pm at

Share Your Wishes - Advance Care Planning Session

When: January 24, March 28, May 23, July 25, Sept 26, Nov 28. Where: Heart of Lancaster Regional Medical Center Time: 6-7p.m. RSVP: Register for an upcoming seminar by calling (717) 627-0398.

Advance Care Planning is thinking about, talking about, and planning what kind of medical treatment you would want if you were unable to make your own decisions. It is not always an easy topic to think about or talk about. This free class will help you understand more about advance care planning, why it is important, how to choose a healthcare agent, and above all, give you tools to continue the conversation with your loved ones. Where: Ann B. Barshinger Cancer Institute, 2102 Harrisburg Pike, Lancaster RSVP: For dates, times, and to register visit https://forms.lghealth.org/ Classes/Group.aspx?groupID=EVE-AP

Private consultations and an online seminar are also available. Visit LancasterWeightLoss.com for more information.

Childbirth Education And Support

The birth of a baby is an exciting and life-changing experience for your patients. Women’s Place at Heart of Lancaster Regional Medical Center, with an onsite Level III NICU, is committed to helping you during this special time through quality maternity care, breastfeeding support groups, and educational classes on childbirth, breastfeeding, infant massage, preparing siblings for a new baby and more. Register for classes by calling (717) 625-5420 and/or find the class schedule at LancasterHealthEducation.com.

Healthy Changes. Healthy You. Information Session

Healthy Changes. Healthy You. presents DIET FREE! Come and see what all of the buzz is about in this FREE information session. You will get to meet the class instructor, see a sneak peek of the class materials and learn more about this program that teaches you the 8 healthy habits that will change your life! Registration is required for this event. Where: Suburban Outpatient Pavilion, 2nd Floor Wellness Center, 2100 Harrisburg Pike, Lancaster RSVP: For more information and to register, visit https://forms.lghealth.org/ Classes/Group.aspx?groupID=HWM-HC

Stroke Support Group

“Putting The Pieces Back Together” Stroke Support Group at Lancaster Regional Medical Center offers stroke patients and caregivers the opportunity to openly and voluntarily discuss the goals, frustrations, experiences, and obstacles often faced with a stroke diagnosis. Our support group’s goal is to offer coping skills and non-judgmental empathy and understanding with the sharing of personal experiences, both positive and adverse. This group meets the first Wednesday of every month from 11 a.m. to noon. Light refreshments are provided. To RSVP, call Deana at 717-358-7208 or Robyn at 717-291-8015.

Freedom From Smoking

Are you ready to quit tobacco but need help getting started? Would you enjoy support from others who are also trying to quit? Then sign up for our free, Freedom from Smoking® class. Developed by the American Lung Association, this program helps to provide the support and tools necessary for adults who want to become tobacco-free.

RSVP: F or dates, times, locations, and to register visit https://forms.lghealth. org/Classes/Group.aspx?groupID=TOB-GP

WellSpan Health Lancaster County Events Plant The Seed Of Learning

Designed for families with children from newborns to age 2, this free, hands-on class offers helpful tips on how to educate children in a playful environment. It is sponsored in collaboration with WellSpan Ephrata Community Hospital, Cocalico School District, and Conestoga Valley School District.

When: Thursday, January 12 Where: WellSpan Ephrata Community Hospital Health Pavilion, 175 Martin Ave., Ephrata. Time: 6 - 7 p.m. RSVP: Registration is required, by calling 738-6667.

“I Can!” Challenge

This 12-week class is for people with diabetes or heart disease who want to improve their health. Topics include goal setting, healthy eating, stress management and exercise. Cost is $25.

When: Mondays, January 16 - March 20 Where: WellSpan Cocalico Health Center, 63 W. Church St., Stevens. Time: 6 - 7 p.m.  RSVP: To register, call 721-8790.

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Community Walk At Middle Creek Wildlife Management Area

Take a late winter walk and see some migrating birds during a community walk to be held from 3:30-5:30 p.m., at the Middle Creek Wildlife Management Area. The program starts with a state Game Commission program on waterfowl migrations at the Middle Creek Visitor’s Center, 100 Museum Road, Stevens. Then the group will travel to the Willow Point Trail, a paved, flat, mile-long trail that leads to an area where you can do bird watching. Participants should wear warm clothes and good walking shoes, and bring binoculars or cameras. The group will return to the Visitor’s Center for hot cocoa and other refreshments.

When: Saturday, March 11 Where: Middle Creek Wildlife Management Area. Time: 3:30-5:30 p.m. RSVP: Registration is required, by calling 270-7764.

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BRING IN THE NEW YEAR

WITH A NEW YOU! Tired, achy, painful legs? AVLC can help. Safely and effectively eliminate varicose veins without painful surgery. Treatments in the comfort of our facility. Walk in. Walk out.

Take the first step and call AVLC today! BEFORE

AFTER

Actual Patient Results

DAVID WINAND, MD, FACS 896A Plaza Blvd., Lancaster, PA 17601

717-295-VEIN (8346) S934929

Lancaster Physician Winter 2017  
Lancaster Physician Winter 2017