Your Health Affects Patient Outcomes
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Contents FALL 2014
2014-2016 MCMS BOARD OF DIRECTORS
Burnout 6 Physician Your Health Affects
Stanley Askin MD Frederic (Rocky) Becker MD Charles Cutler MD Madeline Danny DO
Immediate Past President
Tita de la Cruz President, MCMS Alliance
Walter I. Hofman MD Secretary
James A. Goodyear MD George R. Green MD Chairman, Membership Services & Benefits Committee
Dennis Jerdan MD Walter Klein MD William W. Lander MD Mark A. Lopatin MD
Reaching the Summit in Life and Passion
Robert M. McNamara MD Rudolph J. Panaro MD Mark F. Pyfer MD Chairman, Public Relations Committee
Jay Rothkopf MD President-Elect and Treasurer
Carl F. Schultheis Jr. MD Scott E. Shapiro MD Immediate Past Chairman
James Thomas MD President
Martin D. Trichtinger MD Chairman, Political Committee
Patricia Turner Practice Manager
MCMS Staff Toyca Williams Executive Director
Editorial Board Jay E. Rothkopf MD, editor George Green MD Mark F. Pyfer MD Scott E. Shapiro MD Toyca D. Williams MCMS Physician is a publication of the Montgomery County Medical Society of Pennsylvania (MCMS). The Montgomery County Medical Society’s mission has evolved to represent and serve all physicians of Montgomery County and their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance the role of medicine and health care within the community, Montgomery County and Pennsylvania.
22 Get the Facts
Features 8 10 11 12 16 17 18 20 25 26 28 31 32 34
Learn to Navigate the Stormy Sea of Physician Burnout Frontline Groups 100% Committed to MCMS Meet Your County Medical Society Leaders Comprehensive Breast Care What Should Happen to Medical Records when Physicians Leave Practice? 4 Chairman’s Remarks Restrictions on Medical Records 5 Editor’s Comments Copying Charges for 2014 35 Membership News & Announcements Dining with Diabetes Program
In Every Issue
Legislative and Regulatory Update Licensure Renewal Deadline Fast Approaching The Critical Impact of Health Care Providers on Influenza Vaccinations Conflict in Team-Based Care Fall Fun Ideas Collection Strategies Can Help Physician-Patient Relationship MCMS Happenings
MCMS Physician is published by Hoffmann Publishing Group, Inc. I Reading, PA HoffmannPublishing.com I 610.685.0914 I for advertising information: email@example.com or firstname.lastname@example.org
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MCMS Needs You . . . We Are Stronger Together
llow me to introduce myself. My name is Mark Lopatin and I am the new chairman of the Montgomery County Medical Society. I am a rheumatologist in private practice and have served on the Board of Directors since 2004, as a past president, chairman of the medical legal committee, chairman of the Montgomery County Mediation Task Force, and I currently serve on the PAMPAC board. In other words, I have been involved. One of the most frequent questions I get asked is, “Why? Why be involved?” People tell me the medical society has no power to effect change. The medical legal committee does not do anything. In sum, it is an exercise in futility. I disagree.
Shaping Medical Policy From a global perspective, the medical society has helped to shape policy such as the apology bill that recently passed. It also helped in terms of making certificates of merit mandatory for lawsuits. The medical legal committee has done three programs in the last six years on teaching physicians how to avoid lawsuits, and what to do if you get sued. We are currently working on a program that would educate physicians on legal issues involving disability. You know—all those forms that ask when the patient will go back to work, and how much time they will miss in the future. I never know how to fill them out. Do you?
You Are Needed to Effect Change With all the issues facing us today, the changing environments in health care, the new requirements for maintenance of certification, the continued need for tort reform, insurance issues and others, we cannot solve these challenges as individuals. We need a unified voice to help us take better care of our patients in an environment that seems more and more hostile to patient needs. So if this all sounds like a glorious advertisement, it is. My life has been very enriched by my involvement in the medical society, as can yours. I urge you to go to our website www.montmedsoc.com. Find out about what is happening politically that affects the way you practice. Get CME credits. Join the speaker’s bureau. I encourage you to come to a MCMS board of directors meeting and find out more firsthand. Our next board meeting is Nov. 4. I look forward to the challenge that awaits me. I hope you will join me. I cannot do it alone. I have a soapbox that I carry with me at all times, and I am not afraid to use it, but my voice will be louder if yours is alongside it.
The Benefits of Membership If nothing else, I have gained tremendously by being involved. I have made new contacts, and new friends. I have a number of resources I would not have had otherwise. If I have a routine medical legal question, I have lawyers I can talk to (at no charge) whom I trust because I have gotten to know them individually. I have contacts in Harrisburg who can help me with insurance, medical legal and other practice issues. If I have a political issue, there are a number of legislators whom I am on a first-name basis with and can call. Being active in the medical society has afforded me speaking engagements with which to attract new patients. It has given me the opportunity for free CME credits, including patient safety credits. But mostly, it has given me a much greater understanding of how medicine works (and fails to work) and has helped me to realize that the problems I face in taking care of my patients are not unique. The collaborations I have had with other doctors have been invaluable.
Mark Lopatin MD Chairman, MCMS Board of Directors
I would love to hear from you. If you have suggestions, general comments or ideas for future issues, please email Mark A. Lopatin MD or the MCMS Executive Director Toyca Williams, email@example.com.
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Fall Brings Crunchy Leaves, Back to School and More Stress to Manage
t’s back to school time. As I watch my two young sons run around the house, I’m finding it hard to believe that they’re seven and five. It seemed like a heartbeat ago they were babies, and now the siren-calls of second grade and kindergarten beckon. Wow. I try not to dwell on it, to look forward, but like the song says, “It’s so hard to say goodbye to yesterday.” The past is precious, and often bittersweet, but the future always holds more promise. Or so a college professor of mine once said, in a boring but informative class about Shakespeare. Philosophy aside, the fall is now upon us, with all its rituals and holidays, changes and errands. As the year heads into its closing quarter, as usual, there’s a lot for us to talk about. First off, I invite you to join me in welcoming a new chairman of the Montgomery County Medical Society Board of Directors, Mark A. Lopatin, MD. A practicing rheumatologist in Abington, Dr. Lopatin brings many years of leadership and experience to MCMS, and we look forward to benefitting from his insight and ideas. Be sure to check out our Chairman’s profile, where he reveals his passion for effective communication and how it may help move the society forward. Then, we take a look at a difficult yet growing problem: physician burnout. It’s an ugly word, one that generates feelings of discomfort, and even fear. Increasing and pervasive throughout the profession, its symptoms are many, as are the number of those affected. Achieving a healthy work-life balance is more important than ever; yet, finding it has become even more elusive. In an article by psychiatrist Dr. Steve Cartun, we explore this difficult issue, how to recognize it, and ways to help those affected. It’s a read you don’t want to miss. Next, we turn to the subject of conflict in the workplace. With the movement towards physician employment, a new series of challenges have come to light. Chief among these challenges are the dynamics of team-based care, as well as learning to adapt to an unfamiliar culture. In an original article, I detail my experiences working as a hospitalist, along with examples of dealing with strife, and the strategies that may be used to help navigate the potential minefield of complex relationships.
Dr. Erin Lally shares one of her Passions Outside Medicine in mountain climbing. A resident at Wills Eye Hospital, her commitment to challenges both mental and physical has led her from the wards to the summit of Mount Everest. It is a rare look at a dangerous sport, one that most of us will never attempt. October isn’t just the time for crunchy leaves and Halloween, it’s also Breast Cancer Awareness month. In this issue, Dr. Beth DuPree, surgeon and medical director for Integrative Medicine with Holy Redeemer Health System, discusses the use of integrative medicine in the care of the cancer patients, as well as breaking down the high-tech approaches to breast cancer surgery. Hot on its heels, November is American Diabetes Month, and we take a closer look at a unique diabetes education program right in our backyard. As Thanksgiving approaches, programs such as Penn State Extension’s Dining with Diabetes can help patients be more proactive in the selection of food and its healthy preparation. In light of the continuing epidemic of Ebola, we feature a short question-and-answer piece about the virus, which we hope will help educate both physicians and patients. In our efforts to also educate the community, we remind everyone—physicians included—to get a flu shot, the only proven method for reducing the incidence and severity of seasonal influenza. Other features include a political update, strategies on improving collections, the PAMED Annual Business Meeting and Education Conference, Oct. 17-18, Hershey, as well as information on license renewal. 2014 is a license renewal year for physicians, and PAMED has many online CME resources to help meet the mandatory requirements. Lastly, with the coming of autumn, we feature a list of local festivals across the county. We hope you and your family will be able to enjoy them. It’s hard to believe how quickly time flies, but this issue marks a year since our initial debut. On behalf of our publisher, the Montgomery County Medical Society, our physicians and staff, and especially our readers, I would like to say thanks. It’s been an amazing ride, and none of this would be possible without you. With that in mind, I would like to again invite physicians across the county to share your voices with us. If there’s something you’d like to see us discuss, or an issue you’d like to have addressed, please let us know. We’ve started out strong, but it’s up to us to keep the momentum going. Together, I know we can do it. Or to say it another way . . . the best is yet to come. Warm regards, Jay Rothkopf MD Editor
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Physician Burnout Your Health Affects Patient Outcomes By Steve CarTun MD
s it any wonder that 400 physicians commit suicide each year? It is a proven dynamic in social psychology that frustration leads to aggression. Perhaps the majority of physicians expiate this aggression into leaving the field, reducing their hours, or turning it against themselves and their lives. The stakes are high. More and more physicians are being forced to decrease patient face time, increase the practice of defensive medicine and emphasize their collective focus on electronically typing a note, instead of the patient who is the focus of that documentation. On a childhood playground, such bullying and intimidation would lead to the principal’s office. In the field of medicine, the same deplorable behavior leads to bonuses and profits for the landlords. Should this behavior be labeled as racist? There certainly appears to be a war against physicians simply because that is who they are. Or perhaps, it meets the threshold for discrimination. Case in point . . . a few years back I decided to start a practice that integrated primary care with behavioral health. I contacted a respected expert in this field. I told him about my wanting to work with
the insurance industry. He agreed with me that this was the future of health care. After all, primary care doctors acknowledge that the majority of the medical symptoms they treat bear a psychiatric cause
or morbidity. However, after each reasonable idea that I shared, he responded that the insurance companies “will think that you are just trying to sell them something.” It took me a few minutes to understand that this premonitory refrain was not intended to sharpen my pitch, but instead to undermine it. A subsequent email truly revealed his ire. One of his kinder colleagues advised me to ask him to introduce to me the medical director of one of the insurance companies. She encouraged me that he would be delighted to comply. I sent him a follow-up email and he responded
by writing that “I don’t want to destroy my relationship with him by introducing you.” The reply baffled me. Where had I gone wrong? Medical Degree Equals Respect, Oh Really . . .
After some reflection, I realized that I had gone wrong by acknowledging that I had a medical degree. For some reason, this degree inflames some—from patients who feel marginalized, administrators who seek to reduce physician wages, insurance companies who seek to boost profits and doctors who, after being gutted by all of these forces, pay large sums to attend conferences that teach them how to leave clinical medicine. Such aberrant attacks against medical doctors would be labeled as unconstitutional against any other group in our society. When an individual sacrifices 10 years or more of their youth, surviving a militarily equivalent boot camp that is relentless in punishing its soldiers, and then releases them into a battleground that Sun Tzu would have called unjustified, can there be any positive that surfaces? Of course not! Aristotelianism logic is clear about one matter: if a system seeks
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to promote and secure private interests that view doctors and their patients as a problem, then these groups will be manipulated and forced into a silo that suffocates them. As one physician noted in a survey of the profession, this viewpoint embodies the wish that patients and physicians should just go away. Medicine, according to another physician, “has turned from a noble profession into a business where physicians are traded.” Another stated that “the system is broken because we failed.” We turned against each other instead of uniting together. Redefining the Battlefield
What then to do? It is obvious that the role of doctors and their autonomy will continue to be eroded if we don’t redefine the battle rules. Physicians are well educated and have an above average intellect. However, 82 percent of physicians surveyed believe that they have absolutely no impact on the current health care system. This is equivalent to pilots being commanded to navigate the entire flight using the automatic switch. This works well in clear weather until it is time to land in a storm with great turbulence. This is now a crucial time for physicians to disable the auto pilot and seize control of the throttle. At any given time, 50 percent of physicians have at least one of three burnout symptoms. When a physician is exhausted and unable to replenish his or her energy after a weekend, or a longer vacation, this is one of three symptoms required for the diagnosis of burnout. Dissociation, and its attendant view of patients as objects or potential lawsuits, is another prong for the surface expression of burnout. Finally, the unfortunate belief by physicians that actions have no positive impact on their patients completes the third prong required to meet the diagnosis.
health care institution. In his book Blink, author Malcolm Gladwell notes that physicians who are more frequently sued spend less time with their patients. While time is an immobile variable in our current health care climate, the quality of that time is not. Merely telling a patient that you are going to listen to their breathing or their heartbeat creates a connection that is missing when doctors are burned out. Restoring Resilience . . . Never Too Late
Value alignment is a key factor in preventing burnout. Most physicians enter medical school because they want to take care of patients. This motivation leads physicians to value their relationships with patients above everything else. When that relationship is severed by managed care and financial loss, physicians need to see more patients per hour just to make ends meet. This destroys the doctor-patient bond, and removes the very motivation that propelled the physician to make all the sacrifices demanded through the arduous training process. There are many ways to restore value alignment. Restoration of our values and hopes, and our ability Continued on page 8
Providing You Peace of Mind... Is Our Pleasure!
Poor Physician Health, Poor Patient Outcomes
Unfortunately, many physicians have been inculcated to believe that their own health comes last. It is always about patient care. It is never about them. Yet studies demonstrate that physicians who take care of themselves are also helping their patients. Research has demonstrated that the diabetic marker, Hemoglobin A1C, is less well controlled when the treating physician is unhappy. Patient adherence is very dependent upon physician satisfaction. By not taking care of themselves, physicians are actually harming their patients. Any competent physician must know and be able to implement sound clinical acumen. By not taking care of themselves, physicians are in practice ignoring an important driver of patient outcomes. Poor outcomes potentially lead to increased malpractice liability, by both the physician and the MCMS
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Learn to Navigate the Stormy Sea of Physician Burnout
to overcome these obstacles, can potentially create resilience. Instead of being diminished, we can become stronger, and use our strengths to make a positive impact on the health care crisis. Resilience can be learned and developed at any age. It is not related to native intelligence or genetic determinants; it is a skill, a way of thinking and being. Think Outside the Box
By Cliff H. Lyons, Medical Director, Pennsylvania Medical Society Physicians’ Health Programs
One way to develop resilience is to bring entrepreneurship back to the dream. For years, many physicians gained pride and satisfaction by running their own practices. Although doing so now is probably handicapped by regulations and restrictions, physicians can create value in other ways by not limiting their imagination. One can start a health care company that integrates technology with treatment, build a restaurant chain that incorporates diabetic focused menus, develop a practice funded by a grant or venture capital that is strictly based on translational research, write a book that will help patients navigate the complexity of the evolving health care system, teach pre-med students clinical skills that will help them enhance their applications to medical school, become involved in health care politics, integrate computer science into neuroscience models being developed by the NIH, and the list goes on.
A 2012 archive internal medicine study concluded that 46
percent of all U.S. physicians had at least one symptom of burnout, and that physicians at the front line (primary care, ER) were most significantly affected. My first thought upon hearing this was, “no kidding.” My next thought was, “I am surprised the rate is not higher!” One simple definition of burnout is “physical or mental collapse caused by overwork or stress.” Medicine is a very demanding field with lots of stressors. Early on, we are able to rebound from the stress and recharge our batteries. However, with long-term stress, we can become cynical and exhausted. As a family physician, as well as medical director of the Physicians’ Health Programs, I have seen and experienced the devastating effects of burnout. The external sources of stress are many. Some are systemic – e.g. medico-legal issues, insurance and governmental demands and complexities. Others relate directly to patient care – dealing with difficult patients, delivering bad news, etc. Add in the stress of running a medical practice and almost anyone will struggle to maintain serenity. There are no easy answers. Fortunately, the Pennsylvania Medical Society does have information and support available for its members. Our internal response to stressors is another major contributor to burnout, and that is where the PHP can really help. Maladaptive escape—via drugs, alcohol, gambling, sex —can culminate in a full-blown addiction, and the PHP can provide confidential assistance. My own journey of recovery enabled me to learn new and better ways to cope with stress. One great gift has been the realization that if I don’t take care of myself, I can’t be there for anyone else. Seems simple, but I was not taught this in medical school or residency! Another gift has been participation in a physician recovery group, where I am able to share my struggles, difficulties and successes, receive support and learn from the experiences of other doctors. You can start your own wellness group. The website, www.theheartofmedicine.org has some great ideas. The PHP is happy to help as well. Call (717) 558-7819. Don’t be afraid to ask for help. We are all in the same boat, and medicine today can be quite a stormy sea! MCMS
continued from page 7
Burnout Coping Skills
Additionally, humor is an integral part of resilience and survival. George Burns in the movie “Oh God,” states that God is a comedian playing to an audience that is afraid to laugh. Humor can heal. Studies at the University of Maryland have demonstrated that patients who have humor are more likely to be protected from the consequences of a heart attack. Tense moments in a number of life circumstances can potentially trigger a humorous response. This may be an innate defense mechanism to help us to cope with stressors that would otherwise incapacitate us. Learning mindfulness, which involves practicing to focus on the present, provides a window into what is happening in the moment. The past and future recede while you focus all of your attention on your breathing, your experiences, and simply being. The value that this adds to being in the moment is not relegated to just our professional activities, but to our individual moments in all aspects of our lives as well. There are many avenues to learning mindfulness, and there are many courses in most communities that offer opportunities to practice this tool. Cognitive biases, such as deeply held beliefs, can undermine our effectiveness to be effective practitioners 8
Physician Burnout and lead us to misinterpret environmental cues. For example, let’s visit the examination room and evaluate the following scenario. A new patient appears to be angry and uncooperative. The patient had to find another physician due to her prior physician retiring. It might lead us to tell this new patient that they can leave and find another doctor. Managed care, falling reimbursements, and an overall decrease in patient respect for their physicians, all contribute to raw emotions, which often dwell not far from the surface. However, if we could learn, through empathy, to put ourselves into the heart of this patient, we would understand how fear and grief hide behind the defensive structure of this superficially angry and irritated human being. Our insight into this person’s defensiveness might lead us, instead, to empathize. We might tell her that we understand her fear and reticence to meeting a new physician who just doesn’t know her as well. Instead of fracturing an already tenuous connection, we could help her feel comforted and understood. We would feel much better about meeting her, and she would feel soothed and cared for. The deeply held beliefs about how we have coped with being provoked can be rewired through the neuroplasticity of growth. All of these tools can enhance our ability to respond to a changing health care environment that induces a sense of uncertainty and anxiety within all of us. The American Medical Association recently awarded $11 million in grants to 11 medical schools. The focus of these grants is to reform medical education, not only in how medical education is taught, but in educating the next generation of doctors how to make changes within the system itself. As physicians, we will inhabit the same space that these medical students will fill as they become residents, then attendings. We owe to them, and to future generations of patients, a much better health care system than the one that ensconces us today. Let us all join together and increase our resilience. Let us all work together, not in individual silos, but in an overarching and collaborative manner. Let us now create a more equitable and patient-centric profession. We cannot wait for the next generation of physicians. We must act now.
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Steve Cartun MD is a board-certified psychiatrist who is developing a private practice in Haverford. He is working with the Pennsylvania Medical Society to develop programs to prevent burnout in medical professionals. Trained at Yale and served as chief resident, Dr. Cartun has been a consultant for student health centers at Yale, Westminster Choir College, Rider University, and the University of Pittsburgh. He completed a yearlong elective program in the Yale Law and Psychiatry Division, and served as a MOOT court consultant at Yale Law School. MCMS
Jennifer Sandner Vice President, Business Development
firstname.lastname@example.org Office 484-442-6533 Cell 610-608-8706 Member FDIC 9
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Frontline Groups 100% Committed to MCMS Is your practice among an elite group that is 100 percent committed to the Montgomery County Medical Society? You can be. . . Frontline practices – three or more physicians in a group – stand on the front line of the medical profession by making a commitment to 100 percent membership in the Montgomery County Medical Society and the Pennsylvania Medical Society (PAMED). MCMS continues to provide a forum for physicians to work collectively for the profession, patients and practice. The Montgomery County Medical Society says thank you.
MCMS Frontline Groups as of September 2014: Abington Medical Specialists Abington Memorial Hosp-Div of Cardiothoracic Surgery Abington Perinatal Associates PC Academic Urology-Pottstown Advocare Main Line Pediatrics Cardiology Consultants of Philadelphia-Blue Bell Cardiology Consultants of Philadelphia-Lansdale Cardiology Consultants of Philadelphia-Norristown Endocrine Specialists PC ENT & Facial Plastic Assoc. of Montgomery County Family Practice Associates of King of Prussia Gastrointestinal Specialists Inc. Green & Seidner Family Practice Hatboro Medical Associates Healthcare for Women Only Division King of Prussia Medicine LMG Family Practice PC Lower Merion Rehab Main Line Gastroenterology Associates-Lankenau Marlowe Zwillenberg & Ghaderi LLC Marvin H Greenbaum MD PC Neurological Group of Bucks/Montgomery County
Northern Ophthalmic Associates Inc. North Penn Surgical Associates North Willow Grove Family Medicine Otolaryngology Associates Patient First - Montgomeryville Pediatric Associates of Plymouth Inc. Pediatric Medical Associates Performance Spine and Sports Physicians PC Respiratory Associates Ltd Rheumatology Associates Ltd Rheumatic Disease Associates Ltd Rittenhouse Hematology Surgical Care Specialists Inc. The Philadelphia Hand Center PC Thorp Bailey Weber Eye Associates Inc. Tri County Pediatrics Inc. TriValley Primary Care/Franconia Office TriValley Primary Care/Lower Salford Office TriValley Primary Care/Upper Perkiomen William J. Lewis MD PC
Through your membership, the Montgomery Frontline members and practices receive special recognition and benefits including: • A 5 percent discount on your county and state dues. • A certificate of recognition to hang in your office. • Regional meetings covering topics such as risk management, employment law and payer and regulatory matters. These meetings are designed exclusively for member practice managers and office staff, free of charge. • Additional discounts and services from county and state endorsed vendors. For more information on how your practice can become a Frontline practice, e-mail email@example.com or call (610) 878-9530 or PAMED group relations at (800) 228-7823 or (717) 558-7750, ext. 1337.
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Meet Your County Medical Society Leaders
Mark A. Lopatin, MD, the recently inducted chairman of the Montgomery County Medical Society (MCMS), has strong interests in physician communication challenges, tort reform and issues related to the way the malpractice system affects the practice of medicine and compromises patient care. Dr. Lopatin has served as a member of the 21-member MCMS Board of Directors since 2004, including a term as president in 2009â€“2010. Name: Mark A. Lopatin, MD Specialty: Rheumatology Currently Practices: Rheumatic Disease Associates in Willow Grove Medical School: Medical College of Pennsylvania Residency: Medical College of Pennsylvania Fellowship: Thomas Jefferson University Hospital Hometown: Havertown Residence: Jamison, Bucks County
PROFESSIONAL BACKGROUND Why I chose a career in medicine: I knew that I would go into medicine at an early age due to a strong interest in science, especially biology.
Why rheumatology? I chose rheumatology
because I liked the subject matter, but in retrospect, it was an unconscious decision that fits with my personality. I love solving puzzles. Rheumatology is all about solving puzzles, figuring out which one of multiple possibilities is the right answer for each patient. I also am the kind of person who needs time to process data and sort through it. I am not good with quick decisions and snap judgments. I would never have made it as an emergency physician. Rheumatology allows me the time I need to make good decisions. I also like the fact that I get to know patients over time, i.e. to share their lives. I can think of one patient in particular whose chart over a 20-year period documents that she had a new boyfriend who then became her fiancĂŠ and husband, as well as the arrival of their three children. Lastly, rheumatology has offered me a lifestyle that enables me to be home for my kidsâ€™ soccer games and performances.
Most rewarding elements of my career:
The most rewarding aspects of my career are the relationships I have with my patients. It is
an incredible high and a humbling experience when a patient thanks you for making a difference in their life. I can think of a story involving a patient whom I first saw in 2005 with a very complicated and serious illness that I was able to guide him through. He survived and regained his health and would often come in for follow-up visits over the years. I got to know him and his wife over time. I would sometimes see him at the gym. About a year ago, before he moved to Florida, he and his wife came in for his last visit. As we concluded the visit, she tearfully thanked me and told me that if I ever felt down about medicine, or if I ever felt that things were too tough in medicine, I should think about her husband and remember that not only did I positively impact his life, but that I also touched the lives of all of his family members who love him very much and still have him around. My eyes still well up a little with tears when I recall that visit.
An achievement most proud of: I was asked to chair the Montgomery County Mediation Task Force, consisting of lawyers and mediation experts, far more knowledgeable than me in these matters, with the goal of putting forth a pilot program at a local hospital looking at mediation as an alternate means of dispute resolution in medical malpractice cases. We had to first create a program and then sell the idea to a local hospital. Working together over a threeyear period, we were able to build the program and install it at Abington Memorial Hospital. OUTSIDE THE OFFICE Interesting childhood fact: I took karate as
a teenager and earned my 2nd degree brown belt and was an instructor in the karate studio at age 16. I fought as the #1 seed for the University of Pennsylvania karate team my freshman year in college.
How did I end up practicing in Montgomery County? I wound up in
Montgomery County serendipitously. When I finished my rheumatology fellowship, I wanted to stay in the Philadelphia area, but could not find a rheumatology position. I accepted a primary care position with the opportunity to do some rheumatology, but I wanted a full-time rheumatology position. One evening while attending a rheumatology lecture, I overheard a doctor whom I did not know, telling a colleague that he was looking for another rheumatologist for his practice at Abington. I immediately approached him about the available position, was interviewed and was fortunate to be offered the position. I moved to Willow Grove from Philly two years later, and now reside in Bucks County.
What interests me outside medicine:
Fantasy baseball, professional football, skiing, golf, travel, and almost any kind of strategy game, e.g. Scrabble, Othello, backgammon, and chess. MCMS
My family: I have been married for almost
23 years to Suzan, who is a retired elementary education teacher. I have two daughters in college, Dana, who is in her senior year at Dickinson College, majoring in political science, although she would love a career in theatre or as a singer. My younger daughter, Melanie, just started her freshman year at Franklin and Marshall College and plans to major in biochemistry. And then there are Max, Molly, and Harry Potter, our standard poodles.
If I could be anything other than a physician: Theater performer, if only I could sing or dance.
I greatly admire: Jackie Robinson. I greatly admire people with the courage to stand up to the masses, and I cannot think of anyone more courageous than Jackie Robinson. WORTH NOTING Most interesting moment in medicine:
I had a patient once who had a true multiple personality disorder. She sometimes would allow some of the other personalities to come out and when she did, it was clear to me that I was truly dealing with a different person. One day she came in with wrist tenderness and asked me to inject her wrist. While I was preparing the syringe, one of her other personalities came out, and this personality not only was not having any wrist pain, but actually had a completely different exam. Then a third personality came out who had an even different exam from the first two. I faced the dilemma of whether or not to inject the wrist. I ended up holding off. Talk about managing the whole patient.
You may not know: I have a strong interest
in the need for tort reform and the way that our current malpractice system affects the way we practice medicine and compromises the care that our patients receive. I also have an equally strong interest in physician communication and difficulties we face in this area. I believe that our inabilities in communicating with our patients, other doctors, insurance companies etc., are by far the biggest problem we face in medicine today. I have lectured on the subject of better communication both to patients and to physicians.
Why I stay involved in organized medicine: The personal enrichments I have
received from being involved in organized medicine in terms of new contacts, friends, personal resources and self growth are immeasurable. Furthermore, organized medicine has allowed me a microphone to talk about the issues that I feel passionate about such as tort reform, defensive medicine, and communication.
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Comprehensive Breast Care From Screening to Thrivership
By Beth Baughman DuPree, MD, FACS, ABIHM
hat exactly is comprehensive breast care? Is it enough in 2014 to call a program comprehensive if you provide state-ofthe-art technology? When I graduated from medical school in 1987, the standard treatment for breast cancer was a modified radical mastectomy. During my surgical residency, the options for women expanded to include breast conservation and reconstruction if a mastectomy was necessary. Our systemic treatment changed drastically as we began to give chemotherapy based on the biology of the tumor, not simply the size and nodal status of the tumor. Fast-forward as we now offer skin-sparing mastectomies and nipple-sparing mastectomies. Sentinel lymph node biopsy has become the standard of care. We have evolved rapidly technologically, but have we focused enough attention on the woman or man and how their diagnosis affects every aspect of their lives?
My definition of comprehensive breast care is complete care of a patient from screening through diagnosis and treatment into survivorship and eventually what we call ‘thrivership.’ Breast cancer is a diagnosis that creates momentary fear in women as they obtain their screening mammograms or perform a breast self-exam in the shower. For women that find a mass or have an abnormality on their breast imaging, the fear is paralyzing and they struggle to function until they know that they do not have cancer. For women and men who undergo a biopsy and are diagnosed with breast cancer, their journey is just the beginning. Advanced clinical care, convenient for patients In order to create a true ‘comprehensive’ breast care program, we knew that our state-of-the-art imaging center needed to be in the same location as our breast surgeons. Currently 3D Tomosynthesis is available and, just recently, automated
whole breast ultrasound became available for high-tech breast screening at Holy Redeemer Women’s HealthCare, 45 Second Street Pike, Southampton, PA. When a patient comes for a ‘real-time read’ mammogram, she has her screening film (3D if ordered by her doctor) and if she requires additional imaging, it is done at that time. She leaves the appointment after the radiologist completes the assessment and she knows that she has no image evidence of breast disease. If, on the other hand, an abnormality is identified, she meets our nurse navigator and she is referred to a breast surgeon of her ordering physician’s choice. If she is referred to Comprehensive BreastCare Surgeons of Holy Redeemer, she has an appointment within 48 hours—often times the same day or next morning. Minimally invasive breast biopsies are the standard of care and are performed at our facility both in our office and in the adjacent radiology breast-imaging suite. Diagnostic vacuum assisted biopsies, both ultrasound and stereotactically guided, can be done by both our breast imager radiologists and our breast surgeons. If an MRI biopsy is required, it is performed on the hospital campus, just a few miles away. If breast cancer is diagnosed, a comprehensive detailed consultation is carried out with the patient, her family and her chosen breast surgeon. The treatment options are given to the patient and a detailed plan to treat the cancer is created. Our staff and nurse navigator help every step along the way from genetic counseling and testing to getting the precertification for an MRI. All this is carried out in a timely manner because the treatment of the cancer is just the beginning.
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Comprehensive Breast Care
Beyond clinical care: emotional and spiritual support A breast cancer diagnosis changes everything— emotionally, spiritually, and physically. There are many programs that provide excellent care for the physical manifestations of cancer, but few provide the emotional and spiritual support that we provide at Holy Redeemer. Our 12-week-to-wellness program began in September. It has been designed to help cancer survivors balance their lives with nutritional guidance, an individualized physical fitness program, and meditation.
Surviving Cancer in Style
Creating Thrivers A cancer diagnosis is a scream from the universe to wake up and be present in your life. In partnership with The Healing Consciousness Foundation, our patients receive five one-hour personal healing therapies from guided imagery (to prepare for surgery), to massage, yoga, and personal life coaching to name just a few of the services. Healing is unique to each individual, and we understand that the support we provide must allow every woman or man to find healing in whatever way they need. Our profession allows us to be physicians and healers as we provide the opportunity for healing to occur as we remain clinically focused on curing the physical cancer. We have support groups for our newly diagnosed, our young survivors, our genetic risk group ‘Living in My Genes’, our ‘Meta-friends’ (for those living with Stage IV breast cancer), and our ever-growing monthly Bucks County Breast Friends. We know that we have given our patients the tools that they need on their journey; they return to our office not simply surviving the physical manifestations of their breast cancer, but thriving in their lives that are richer and fuller after cancer. We pride ourselves on creating thrivers out of survivors. Yes, it’s possible to provide the best that Western medicine has to offer while providing guidance and support for staying well. As more and more evidence shows, it is the totality of an individual’s life that affects wellness, and the treatment our patients receive on the phone, in the office, in the operating room, during rehabilitation and beyond empowers breast cancer survivors to become life thrivers.
“At the most difficult time in my life Jude and Therese were there to give my life some normalcy. I didn’t know the first thing about hair or wigs when I met Therese. She was a wealth of knowledge. She helped me find the wig and hairpieces that fit my lifestyle: something for work, something for the pool, something for when I exercised. It gave my husband and me peace of mind. He says, ‘You look just as beautiful; it’s like you never lost your hair!’ I am so thankful for Jude Plum Salon—a bright spot at a dark time in my life.” Alicia D., Cancer Survivor Shown wearing her wig
Dr. Beth DuPree is chair of surgery and the medical director of Integrative Medicine at Holy Redeemer Health System. For more information about the programs and services provided at Holy Redeemer Health System, visit its web site, www.holyredeemer.com or call, (800) 818-4747.
Call for your free consultation
610.527.1770 821 W. Lancaster Avenue Bryn Mawr, PA 19010
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Passion Outside of Medicine
Reaching the Summit in Life and Passion By Erin Lally, MD
started climbing in 1992 when my family began spending time in the mountains of Colorado. As an aspiring gymnast, I had an early awareness of balance and strength, and naturally found myself drawn to the idea of combining my mental and physical strength. I was intrigued by the challenge of how to propel my body up the sheer granite faces, up thousands of feet, through all kinds of weather and thin air, to finally arrive on top of a Rocky Mountain peak. Throughout the 1990s and early 2000s, I scaled many of the 14,000-feet peaks in Colorado. In the summer of 2006, I traveled to the French and Swiss Alps and scaled Mont Blanc, the Matterhorn, and several other technical mountains. I was enamored with mountaineering. I fervidly read books on famed Himalayan peaks and heroic tales of man versus mountain. Careful planning throughout my undergraduate years enabled me to graduate from Georgetown University a semester early to participate in my first Himalayan expedition. On this trip, I succeeded in reaching my goal of Camp II (approximately 22,000 feet) on Mount Everest. Sitting at Camp II, overlooking the vast Khumbu Icefalls, I promised myself that I would one day reach the summit Everest. Shortly after returning to the states, I traveled to the Bolivian
Andes on yet another climbing expedition. In Bolivia, I summited six peaks ranging from 18,000-20,000 feet in a 10-day period. I was able to hone my ice-climbing skills and learn more about high-altitude mountaineering, such as crevasse-rescue, avalanche awareness, and winter camping. A Dream Becomes Reality In medical school, my passion for the mountains succumbed to long hours in the library and/or cadaver lab. During my senior year of medical school, I had some flexibility in my schedule and took advantage of it. I reestablished myself as an athlete and physically conditioned my body. By stacking my vacation and elective blocks at the end of the year, I was able to carve out a three-month period to make my dream a reality. This was my opportunity to summit Everest.
In March 2011, I set off for a nineweek journey that, ultimately, led me to the “roof of the world.” I was part of a small, international expedition, led by famed Argentinian Himalayan climbers. My group consisted of the two guides, climbing Sherpas, one Argentinian man and a Palestinian woman from Dubai (the first Palestinian to ever summit Everest who is now a well-recognized celebrity in the Middle East). After two months of steadfast training and acclimatization up and down the lower flanks of the mountain, we were ready for our summit push. Precariously perched at Camp IV on the South Col, a vicious storm nearly ended our expedition. The South Col is an inhospitable, exposed ridgeline between Nepal and China that looms at 26,000 feet. Fraught with hurricane-strength winds, negative 40-50 degree temperatures and extreme hypoxic conditions, many fellow climbers and teams were turned around. After enduring what would be one of the most treacherous nights of my life, the weather improved in the predawn hours. I climbed through the night under a clear, moonlit sky, saw the sunrise over the Earth’s curved horizon, climbed Hillary’s Step, and reached the top of the world. I was standing at 29,029 feet, with all digits and limbs accounted for.
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Reaching the Summit in Life and Passion
correspondence with emergency room physicians at Base Camp, I managed to thaw bottles of saline, set up IVs and administer steroids, heparin and oxygen to climbers suffering from cerebral edema, pulmonary edema, severe frostbite and hypoxia. My day of joy and excitement rapidly gave way to a life-threatening emergent situation. I helped stabilize the patients overnight until we could arrange for helicopter rescue, which later became one of the highest helicopter-rescue-missions in history, and transported the climbers/ patients to Kathmandu. Several of the “missing” climbers were later pronounced dead. We later learned a few others had survived and made it to Camp II the following day. ac I was back in the U.S., enjoying Within a week of this ordeal, the comforts of running water, fresh food and a bed. Days later, I accepted my medical degree from Thomas Jefferson University, an accomplishment that I cherish as much as my Everest success. While my current challenges aren’t athletic endeavors, I am constantly striving to better myself, and the care I provide for if patients. I plan on returning to Nepal and other countries in, need t to provide ophthalmic care and cataract surgery for the indigenous populations. My summiting Everest has taught me that there is no feat that is insurmountable or dream that is unattainable. By simply putting one foot in front of the other, the world has no limits.
A View Like No Other—Almost 30,000 Feet Up It was a moment of jubilation for my team and me. I felt like I could touch heaven. I was standing in a cloudless sky of brilliant blue, yet my feet were on solid ground. Looking down on the rest of the world, I felt invincible yet was reminded of my mortality by my heavy, labored breathing and numb fingertips and toes. Never before have I felt so alive. I was proud and emotional, realizing this dream had come true. I was able to use a satellite phone to call my family in the states to share the news of my summit. They were my lifeline back to reality, even though they were a world away. After about 20 minutes on the summit, I began the long descent back to base camp. Shortly after arriving back at Camp IV after 20-plus hours of climbing, we were informed that 15 Spanish climbers were unaccounted for after their summit bid. Our team’s two Argentinian guides and a group of Sherpas set out on a rescue mission to find the missing climbers. After hours of a painstaking search for the climbers on the upper echelons of the mountain, four of the missing climbers were located and found to be in critical condition.
Dr. Erin Lally is currently a senior resident in ophthalmology at Wills Eye Hospital. She received rher undergraduate degree in French and Theology from Georgetown University in 2007 and completed her medical school training at Thomas Jefferson Medical College in 2011. She did an internship in internal medicine at Albert Einstein Medical Center in Philadelphia in 2012 and is due to complete her residency training at Wills Eye Hospital in the Spring of 2015. She is inspired by both mountaineering and ophthalmology and hopes to one day combine her passions by providing eye care to indigenous people of remote Himalayan villages. After completion of residency, she said there are several 8,000-meter peaks in Nepal and Pakistan that she hopes to climb in the near future. The next big climb will be the highest mountain peak in North America, Denali (Mount McKinley) in Alaska, where she hopes to make a ski-descent.
Tragedy on the Summit The guides carried and dragged the victims all the way to Camp II, roughly 3,000 vertical feet from where they were found, to a make-shift triage tent that we had fashioned. Here, ill-prepared and exhausted from the prior day’s efforts, I learned that I was the only “medical personnel” (i.e., fourth-year medical student) to help. Under close radio
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pamedsoc.org to learn more
What Should Happen to Medical Records When Physicians Leave Practice?
s we reluctantly are pulled through the summer months, we are forced to recognize a very important annual event: BACK TO SCHOOL! Most parents are feeling elated! Reflecting on my own childhood, I would imagine that most kids, however, do not share in their parent’s joy. Despite the differing opinions about the celebratory nature of the occasion, all are getting prepared. In preparation for this occasion, some parents and custodians will need to make sure that their child’s immunizations meet state requirements for school attendance and will need access to medical records to do so. As a result, a handful will discover that their child’s physician has passed away, retired, or is no longer practicing in the state. Throughout the year, we regularly get calls from former patients and distraught parents in search of their medical records. Here’s a brief overview of what we’ve shared with former patients in search of their medical records. Who has ownership of the medical records?
The hospital, solo or group practice has ownership of patient medical records. The rights of a physician departing a practice will depend on the arrangements. Patients do not own their medical records; however,
copies of the medical records should be provided upon a patient’s request. How long are physicians required to keep the medical records?
State Board of Medicine regulations say this is at least seven years from the last date of service for adults, and at least seven years from the last date of service and one year after the patient turns 18, whichever is longer, for minors. Regulations for osteopathic physicians are almost identical, except that the extended period of time for minors is two years after the patient turns 18. When a physician retires or is no longer with a practice, what happens to his or her patients’ medical records?
Patients should be notified when a physician is leaving a practice, is retiring, or has passed away. Generally, it is good practice for the physician to send a letter to his or her patients to notify them of his or her impending departure. If the physician has passed away, his or her estate may also consider placing a notice in the newspaper to inform patients how they can access their medical records. If the physician was part of a group practice, the group may retain the records. Upon the patient’s request, the group should provide the patient with a copy or transfer a MCMS
copy to the patient’s new physician. Medical records that are not forwarded to a new physician should be retained by the group practice. • If the physician was a solo practitioner, arrangements may have been made for another practice to take over the care of the patients. Preparations may also have been made for a local hospital to store the medical records. Patients of solo practitioners no longer in practice are often encouraged to inquire with area practices and hospitals when in search of lost medical records. PAMED has lots of resources available on this topic and others related to medical records. Visit www.pamedsoc. org for details. Reprinted with permission from the Pennsylvania Medical Society (PAMED). The author, Angela Boateng, is PAMED’s regulatory counsel who writes a monthly blog on regulatory matters, www.pamedsoc.org.
Restrictions on Medical Records Copying Charges for 2014 Physicians generally may charge for providing copies of patient medical records. However, the Pennsylvania Judicial Code and federal law limit the allowable charge and in some cases prohibit any charge. The lesser of the Judicial Code and federal limits applies when both are applicable. Health care providers are not required to charge for providing copies. Physicians often waive any charge that otherwise would be allowed, especially when providing a copy to the patient or another physician or health care provider for treatment purposes. The following charts show the maximum charges allowed by the Judicial Code for 2014. The Judicial Code limits do not apply to X-ray film or any other portion of a medical record that cannot be reproduced photostatically. Unless otherwise noted in the chart, for paper copies provided to a patient or the patientâ€™s personal representative HIPAA only permits a reasonable cost-based fee for copying and postage. For electronic protected health information (PHI), upon request of a patient, federal law requires health care providers to provide an electronic copy to the patient and to transmit an electronic copy to a third party. The fee may not exceed the labor cost to copy and transmit the record. *The chart does not address patient confidentiality considerations, including whether a HIPAA patient authorization is required. General Rules Source of request
Postage, shipping, and delivery
Prohibited by HIPAA privacy rule
Copying (per page)
Paper Pages 1-20
Personal representative, such as parent of minor
Same as limits for patients
Prohibited by HIPAA privacy rule
Designee of patient, such as attorney with authorization
Same as limits for patients
Special Purpose Requests To support
Postage, shipping, and delivery
Social Security claim or appeal
$27.02 flat fee
No additional charge permitted
Federal or state needs-based benefit program
$27.02 flat fee
No additional charge permitted
The physician may require the requester to provide documentation of the purpose of the request, such as an appointment of representative form (SSA-1696-U4) when the patientâ€™s attorney makes the request for a Social Security claim or appeal.
Third party requests Source of request Subpoena (except as below) Subpoena from district attorney Commonwealth agency (executive or independent), such as licensing board
Postage, shipping, and delivery
Same as limits for patients
No additional charge permitted
No additional charge permitted
No additional charge permitted
Not permitted as general rule Allowed only if required by law or authorized by agency guidelines, statements of policy, or notice in Pennsylvania Bulletin
This document may not be reproduced in whole or in part without the express written permission of the Pennsylvania Medical Society. MCMS
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Dining with Diabetes Program Focuses on Improving Health and Diabetes Outcomes By Mandel Smith, Educator Penn State Extension – Montgomery County
e all seem to know someone that has diabetes—a coworker, a friend or even a family member. This is not surprising. The U.S. Centers for Disease Control reports that 29.1 million people, or 9.3 percent of the U.S. population, have diabetes. In Pennsylvania, approximately 8.7 percent of the population has been diagnosed with diabetes. The cost of diabetes and pre-diabetes in the U.S. hovers around $218 billion. What is Diabetes? Diabetes is a group of diseases characterized by high levels of glucose or sugar in the blood. Blood glucose is the body’s primary source of energy and comes from food. It can also be made in the body by the liver and muscles. Blood carries glucose to all the cells in the body to be used for energy. Insulin, a hormone that is produced in the pancreas, helps the blood provide glucose to cells. High levels of blood glucose can occur because there is a problem with either how insulin is produced or how it works. Over time, having too much glucose in the blood can cause health problems and diabetes can develop. There are three main types of diabetes: type 1, type 2 and gestational diabetes. With type 1 diabetes, the body no longer makes insulin. Approximately 5 to 10 percent of people
with diabetes have type 1 diabetes. Those that have been diagnosed with type 1 diabetes have to take insulin by injection or by pump. Without insulin, this type of diabetes can be life threatening. Type 1 diabetes develops most often in young people, but it can also develop in adults. Type 2 diabetes occurs most often in people older than 45. Overweight individuals that do not get enough exercise are at greater risk for developing type 2 diabetes. Type 2 diabetes can begin with insulin resistance. This is a condition that happens when fat, muscle and liver cells do not efficiently use insulin to carry glucose into the body’s cells. This can cause the body to require more insulin to help glucose
enter the cells. The pancreas can keep up with this extra demand for insulin for a while, but over time, the pancreas will not be able to meet this increased demand. For example, the pancreas may not be able to produce enough insulin when blood sugar levels rise, such as after meals. Gestational diabetes can develop when a woman is pregnant, and it affects 3 to 8 percent of pregnancies. Gestational diabetes usually goes away once the baby is born. However, 40 to 60 percent of women that develop gestational diabetes are more likely to develop type 2 diabetes later in life or within 5 to 10 years. Diabetes Causes Health Complications Diabetes can lead to serious health problems which can affect nerves, kidneys, mouth, eyes, and feet. Adults with diabetes are also at high risk for cardiovascular disease. In fact, people with diabetes are more than twice as likely as people without diabetes to suffer from heart disease or stroke. To prevent health problems, a person with diabetes needs to keep blood glucose levels as close to normal as possible, manage blood pressure and also manage cholesterol levels. Lower Your Risk There are also things that a person can do to lower the risk of developing type 2 diabetes or if you are pre-diabetic. Losing weight and increasing
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Dining with Diabetes Program Focuses on ImprovingManaging Health andanDiabetes Outcomes Incurable Disease physical activity can reduce the risk of developing diabetes by as much as 58 percent. Even losing 5 to 10 percent of body weight can make a difference. Exercise helps the body use insulin. Thirty minutes a day of moderate exercise, such as walking, can reduce the risk of developing diabetes. For those already diagnosed with diabetes, reducing blood pressure and cholesterol will decrease the risk of cardiovascular complications as well as kidney disease. Recent studies have shown that with proper diet and exercise, type 2 diabetes can be delayed, controlled, or even prevented. Montgomery County Penn State Extension offers an education program for adults with diabetes. The Dining with Diabetes program is to empower people with diabetes to be more confident in managing their diabetes. The program includes a series of interactive presentations, exercise segments and recipe demonstrations and tastings. Participants increase their knowledge of healthy food choices and learn how to prepare healthy versions of their favorite foods. Penn State Extension Educators and health education partners demonstrate healthy cooking techniques, raise awareness of the importance of essential medical tests associated with diabetes management and promote physical activity as a component of diabetes control. The program consists of four weekly classes that last about 2 hours each. A follow-up class is held three months from the first class. In addition to the educational component of the program, participants with diabetes also have the opportunity to have their A1c and blood pressure measured. To learn more about this Penn State Extension program in Montgomery County, contact Mandel Smith at (610) 489-4315. Visit the Dining with Diabetes website, http://extension.psu.edu/health/diabetes for more information about the program across Pennsylvania. Sources: Your Guide to Diabetes: Type 1 and Type 2, National Institute of Diabetes and Digestive and Kidney Diseases, National Diabetes Information Clearinghouse, http://diabetes.niddk.nih. gov/dm/pubs/type1and2/ Diabetes Overview, National Diabetes Information Clearinghouse, U.S. Department of Health and Human Services, National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, http://diabetes.niddk.nih.gov/ dm/pubs/overview/
Buttermilk Chocolate Cake Yield: 18 Servings
Ingredients 1 ¾ cups all-purpose flour 1 ½ cup plus 2 Tbs. Splenda Brown Sugar Blend ¾ cup cocoa powder 1 ½ tsp. baking soda 1 ½ tsp. baking powder 2 tsp. cinnamon ¼ tsp. salt 1 ¼ cups 1% buttermilk 2 large eggs ¼ cup tub margarine (not light), melted 1 ½ tsp. vanilla extract 1 cup boiling water Nonstick spray Powdered sugar for garnish (optional) Method 1. Preheat oven to 350 degrees. Coat a 9”x13” baking dish with nonstick spray. 2. In a large bowl, combine flour, Splenda Brown Sugar Blend, cocoa, baking soda, baking powder, cinnamon, and salt. Set aside. 3. In a large mixing bowl, combine buttermilk, eggs, melted margarine, and vanilla. Mix on low speed until well blended. Gradually beat in boiling water. Gradually add flour mixture and mix on low speed until just blended. 4. Pour batter into prepared pan and bake 25 minutes or until a toothpick inserted in center comes out clean. Cool cake on a wire rack. Dust with powdered sugar if desired. Serving size 1 piece (63g), calories 130, total fat 4 g, sodium 240mg, total carbohydrate 19g, and dietary fiber 1g
35 Things Everyone Should Know about Diabetes, Diabetes and You Get the Facts, 2011, written by; Mardi Richmond, Journeyworks Publishing, Santa Cruz, CA National Diabetes Statistics Report, 2014, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, Centers for Disease Control and Prevention, http://www.cdc.gov//diabetes/pubs/statsreport14. htm MCMS
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Legislative and Regulatory Update
ore than 350 health care related bills are awaiting action at the state Capitol. Traditionally, few controversial issues are addressed in the fall of the second year of a two-year term, as most House and Senate members are focused on their reelection efforts and the Nov. 4 general election. The House and Senate, which scheduled five session days in September and another five in October, will try to take care of as much unfinished business as possible before the two-year term ends on Nov. 30. Following are highlights of recent legislative and regulatory actions. Medical Liability Lawsuit Filings Remain Below Pre-Reform Levels Despite a slight uptick in the number of 2013 medical malpractice filings, lawsuit abuse reforms that were adopted in 2002 appear to be having a positive impact to weed out meritless lawsuits. According to the Administrative Office of Pennsylvania Courts (AOPC), the latest filings show a 43.4 percent decline from the “base years” of 2000 to 2002. Specifically, the AOPC credits the elimination of venue shopping and requiring a certificate of merit. The Pennsylvania Medical Society (PAMED) led the fight for these changes, and our prediction that they would cause a significant reduction in unnecessary lawsuits has been proven accurate. However, more remains to be done. The AOPC points out that 77 percent of jury verdicts in 2013 went to the defense. In other words, personal injury lawyers are
still taking too many cases to trial that do not involve physician negligence. The Pennsylvania Medical Society has a robust, ongoing tort reform agenda that includes caps on pain and suffering awards, limits on plaintiffs’ attorney fees, increased liability protection for physicians who provide emergency care, strengthening the Certificate of Merit court rule, and closing the loophole in the expert witness requirements. Controlled Substance Database Senate Bill 1180, which would establish a statewide controlled substance database, is close to enactment, though its fate is by no means assured. Earlier this session the House passed a House bill (HB 1694) by a vote of 1917, and subsequently the Senate passed a Senate bill (SB 1180) 47-2. Progress subsequently stalled, as House members advocated for their bill while Senators pushed for their version. However, on Sept. 24, there was a breakthrough when the House Health Committee amended and approved the Senate bill. At this writing, time is growing short, as the House and Senate are each scheduled to be in session doing substantive business for only five more days – Oct. 6, 7, 8, 14 and 15 – before the two-year term ends on Nov. 30. Still, five days is enough if the commitment exists to get it done. Under its rules, the House could consider the bill on final passage as soon as Oct. 7, leaving the Senate at least three days to schedule a yes/no vote on MCMS
the amendments added by the House. A yes vote would send the bill to Gov. Corbett’s desk. The major remaining hurdle appears to be the disagreement that remains over the degree of access law enforcement personnel should have to the patient records in the database. Civil libertarians and patient advocates (including PAMED) argue that patients have constitutionally protected privacy rights when it comes to their sensitive medical records, and that law enforcement personnel should be required to obtain a court order based on probable cause to view them. Meanwhile, law enforcement agencies believe they need more liberal access to the database to aid them in their efforts to apprehend lawbreakers. PAMED is working to resolve the issue and get the bill before Gov. Corbett for his signature. Naloxone Bill on Governor Corbett’s Desk As expected, on Sept. 24, the state Senate approved House amendments to an important drug abuse initiative, sending Senate Bill 1164 to Gov. Corbett, who is expected to sign it into law in early October. As originally introduced and passed by the Senate, Senate Bill 1164 provided Good Samaritan immunity to individuals who seek to obtain aid for someone experiencing a drug overdose. The reason this matters is that individuals in the company of someone experiencing an overdose may have been engaged in illegal activity at the time (i.e. using or selling drugs), and may be reluctant to seek help for fear of getting themselves in trouble with the law. The bill removes that obstacle, prohibiting law enforcement personnel from prosecuting an individual if they only became aware of the criminal activity because the individual was aiding a person experiencing a drug overdose. The House of Representatives added an equally significant amendment to the bill, allowing naloxone, a lifesaving opioid antagonist, to be prescribed to first responders like firemen and police officers, as well as to friends and family members of persons identified as being at risk of experiencing a drug overdose. Importantly for prescribers, the House amendment also provides liability protection to prescribers and the aforementioned individuals if they administer naloxone in good faith to someone who they believe is experiencing a drug overdose.
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Political Update The only portion of the bill that was somewhat controversial was the section granting health care providers authority to prescribe or dispense naloxone to a friend or family member of an individual at risk of experiencing an opioid-related overdose. The concern was that giving naloxone to the friends of an at-risk individual might give them a false sense of security and actually encourage risky behavior. However, naloxone is known to precipitate withdrawal in individuals receiving opioids, making them extremely miserable. Pharmacist Administering Flu Shots to Children Under current law, pharmacists may administer injectable immunizations, biologicals and other medications to individuals over the age of 18. In the 2011-2012 session of the General Assembly, Rep. Seth Grove (R-York) introduced legislation that would have eliminated any minimum age restriction from the existing law. PAMED opposed the bill on patient safety grounds, as did all of the primary care physician specialties, and the bill died without any legislative action. In the current session, Senate Bill 819, introduced by Sen. Ted Erickson (R-Delaware), would permit pharmacists to administer flu shots only to children ages seven and older. PAMED now supports Senate Bill 819. In its original form, the bill would have authorized pharmacists to administer all childhood immunizations, a proposal that again faced strong opposition from PAMED and physician specialty societies. However, limiting the bill’s scope to flu shots has eased those concerns to some degree, and there’s a chance that the bill will be enacted this fall.
acupuncturist would continue, as before, to be required to obtain a medical diagnosis before continuing treatment beyond 60 days. The requirement of a medical diagnosis after 60 days when a patient is being treated for a condition is essential for patient safety. For example, lower back pain could be caused by any number of serious conditions, including cancer. The 60-day diagnosis requirement provides assurance that serious underlying conditions are discovered sooner rather than later. The language of the new law is consistent with current law, while clarifying the provision that wellness patients who present no symptoms of a condition may be seen beyond 60 days without a referral for a medical diagnosis. Act 134 also adds a provision requiring acupuncturists to carry liability insurance coverage. Non-Compete Clauses in Physician Employment Contracts Another pro-patient initiative is House Bill 2342, which would prohibit employers from including non-compete clauses in physician employment contracts. Such clauses prohibit physicians who leave an employer from practicing nearby for several years, forcing patients to seek a new physician and potentially disrupting their treatment. Law firms are ethically prohibited from using non-compete clauses in employment contracts, and physician employers should be too. (Updates compiled by MCMS staff from Pennsylvania Medical Society sources. For updates on legislative and regulatory matters, visit the PAMED web site, www.pamedsoc.org and read the Weekly Capital Update.)
Physician Dispensing in Workers Compensation A bill that stands a decent chance of being signed into law this year is House Bill 1846, which would place restrictions on reimbursements for physician dispensing in workers compensation. Introduced by Rep. Marguerite Quinn (R-Bucks), the bill has been amended in both the House and the Senate, where it currently resides, and could well be amended again before it reaches Gov. Corbett’s desk. However, as of this writing physician reimbursements for drugs dispensed to workers compensation patients would be capped at 110 percent of the original manufacturer’s average wholesale price, and reimbursement for most drugs would be limited to 20 days. Tighter restrictions would be placed on reimbursements for Schedule II and III controlled substances, with seven-day limits for both unless surgery is required, which would trigger an additional 15 days of reimbursement for Schedule II drugs. The legislation is intended to address the soaring costs of dispensing in workers compensation. Acupuncture Bill Signed Into Law Senate Bill 990, which amends the Acupuncture Licensure Act, was signed into law by Gov. Corbett on Sept. 24. Now known as Act 134, Senate Bill 990 clarifies the existing provision of the Act that permits acupuncturists to administer to those who visit them beyond 60 days without obtaining a medical diagnosis from a physician, dentist or podiatrist, as long as the person is not being treated for a condition. Under the law, if a person presents any symptoms of a condition, the MCMS
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Get the Facts
he 2014 Ebola outbreak is the largest Ebola outbreak in history and
the first in West Africa. The current outbreak is affecting multiple countries in West Africa but does not pose a significant risk to the United States. A small number of cases in Nigeria have been associated with a man from Liberia who traveled to Lagos and died from Ebola, but the virus does not appear to have been widely spread. The Centers for Disease Control and Prevention (CDC) is working with other U.S. government agencies, the World Health Organization, and other domestic and international partners and has activated its Emergency Operations Center to help coordinate technical assistance and control activities with partners. CDC has also deployed teams of public health experts to West Africa and continues to send public health experts to the affected countries.
What is Ebola? Ebola, also known as Ebola virus disease, is a rare and deadly disease caused by infection with one of the Ebola virus strains (Zaire, Sudan, Bundibugyo, or Tai Forest virus). Ebola viruses are found in several African countries. Ebola was discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Since then, outbreaks have appeared sporadically in several African countries. What are the signs and symptoms of Ebola? Signs and symptoms of Ebola include fever (greater than 38.6°C or 101.5°F) and severe headache, muscle pain, vomiting, diarrhea, stomach pain, or unexplained bleeding or bruising. Signs and symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, although 8 to 10 days is most common. How is Ebola spread? The virus is spread through direct contact (through broken skin or mucous membranes) with blood and body fluids (urine, feces, saliva, vomit, and semen) of a person who is sick with Ebola, or with objects (like needles) that have been contaminated with the virus. Ebola is not spread through the air or by water or, in general, by food; however, in Africa, Ebola may be spread as a result of handling bush meat (wild animals hunted for food) and contact with infected bats. Can I get Ebola from a person who is infected but doesn’t have fever or any symptoms? No. A person infected with Ebola is not contagious until symptoms appear. If someone survives Ebola, can he or she still spread the virus? Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been found in MCMS
semen for up to 3 months. People who recover from Ebola are advised to abstain from sex or use condoms for 3 months... How is Ebola treated? No specific vaccine or medicine has been proven to cure Ebola. Signs and symptoms of Ebola are treated as they appear. The following basic interventions, when used early, can increase the chances of survival—providing fluids and electrolytes, maintaining oxygen status and blood pressure and treating other infections if they occur. Early recognition of Ebola is important for providing appropriate patient care and preventing the spread of infection. Health care providers should be alert for and evaluate any patients suspected of having Ebola. Who is most at risk of getting Ebola? Health care providers caring for Ebola patients and family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in direct contact with the blood or body fluids of sick patients. In some places affected by the current outbreak, care may be provided in clinics with limited resources (for example, no running water, no climate control, no floors, inadequate medical supplies), and workers could be in those areas for several hours with a number of Ebola infected patients. Additionally, certain job responsibilities and tasks, such as attending to dead bodies, may also require different PPE than what is used when providing care for infected patients in a hospital. How can health care providers protect themselves? Health care providers can take several infection control measures to protect themselves when dealing with Ebola patients.
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Get the Facts • • •
Anyone entering the patient’s room should wear at least gloves, a gown, eye protection (goggles or a face shield), and a facemask. Additional personal protective equipment (PPE) might be needed in certain situations (for example, when there is a lot of blood, vomit, feces, or other body fluids). Health care providers should frequently perform hand hygiene before and after patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves.
Can hospitals in the United States care for an Ebola patient? Any U.S. hospital that is following CDC’s infection control recommendations and can isolate a patient in their own room with a private bathroom is capable of safely managing a patient with Ebola. These patients need intensive supportive care; any hospital that has this capability can safely manage these patients. Standard, contact, and droplet precautions are recommended.
and spread in the United States. CDC has staff working 24/7 at 20 Border Health field offices located in international airports and land borders. CDC staff is ready 24/7 to investigate cases of ill travelers on planes and ships entering the United States. Although someone could become infected with Ebola in Guinea, Liberia, Nigeria, or Sierra Leone and then fly to the United States, it is unlikely that they would spread the disease to fellow passengers. A person infected with Ebola is not contagious until symptoms appear. Nevertheless, CDC and health care providers in the United States need to be prepared for the remote possibility that a traveler could get Ebola and return to the United States while sick. What do I do if I’m returning to the U.S. from the area where the outbreak is occurring? After you return, pay attention to your health. • Monitor your health for 21 days if you were in an area with an Ebola outbreak, especially if you were in contact with blood or body fluids, items that have come in contact with blood or body fluids, animals or raw meat, or hospitals where Ebola patients are being treated or participated in burial rituals. • Seek medical care immediately if you develop fever (temperature of 101.5oF/ 38.6oC) and any of the following symptoms: headache, muscle pain, diarrhea, vomiting, stomach pain, or unexplained bruising or bleeding. Continued on page 24
What is being done to prevent ill travelers in West Africa from getting on a plane? CDC works with partners at ports of entry into the United States to help prevent infectious diseases from being introduced
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215-487-1300 | www. cathedralvillage.com
SHORT-TERM REHABILITATION & WELLNESS MCMS
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Get the Facts
Get the Facts •
continued from page 23
Tell your doctor about your recent travel and your symptoms before you go to the office or emergency room. Advance notice will help your doctor care for you and protect other people who may be in the office.
What do I do if I am traveling to an area where the outbreak is occurring? If you are traveling to an area where the Ebola outbreak is occurring, protect yourself by doing the following: • Wash your hands frequently. • Avoid contact with blood and body fluids of any person, particularly someone who is sick. • Do not handle items that may have come in contact with an infected person’s blood or body fluids. • Do not touch the body of someone who has died from Ebola. • Do not touch bats and nonhuman primates or their blood and fluids and do not touch or eat raw meat prepared from these animals. • Avoid hospitals where Ebola patients are being treated. The U.S. Embassy or consulate is often able to provide advice on facilities. • Seek medical care immediately if you develop fever (temperature of 101.5oF/ 38.6oC) and any of the other following symptoms: headache, muscle pain, diarrhea, vomiting, stomach pain, or unexplained bruising or bleeding. • Limit your contact with other people until and when you go to the doctor. Do not travel anywhere else besides a health care facility. Should people traveling to Africa be worried about the outbreak? Currently, Ebola has only been reported in Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. A small number of cases in Nigeria have been associated with a man from Liberia who traveled to Lagos and died from Ebola, but the virus does not appear to have been widely spread. CDC has issued a Warning, Level 3 travel notice for United States citizens to avoid all nonessential travel to Guinea, Liberia, and Sierra Leone. CDC has also issued an Alert, Level 2 travel notice for travelers to Nigeria urging them to protect themselves by avoiding contact with the blood and body fluids of people who are sick with Ebola. You can find more information on these travel notices at http://wwwnc.cdc.gov/travel/notices. CDC currently does not recommend that travelers avoid visiting other African countries. Although spread to other countries is possible, CDC is working with the governments of affected countries to control the outbreak. Ebola is a very low risk for most travelers – it is spread through direct contact with the blood or other body fluids of a sick person, so travelers can protect themselves by avoiding sick people and hospitals where patients with Ebola are being treated.
Why were the ill Americans with Ebola brought to the U.S. for treatment? How is CDC protecting the American public? A U.S. citizen has the right to return to the United States. Although CDC can use several measures to prevent disease from being introduced in the United States, CDC must balance the public health risk to others with the rights of the individual. In this situation, the patients who came back to the United States for care were transported with appropriate infection control procedures in place to prevent the disease from being transmitted to others. Ebola poses no substantial risk to the U.S. general population. CDC recognizes that Ebola causes a lot of public worry and concern, but CDC’s mission is to protect the health of all Americans, including those who may become ill while overseas. Ebola patients can be transported and managed safely when appropriate precautions are used.
Are there any cases of people contracting Ebola in the U.S.? CDC confirmed on Sept. 30 the first travel-associated case of Ebola to be diagnosed in the United States. The Liberian national traveled from West Africa to Dallas, Texas, and later sought medical care at Texas Health Presbyterian Hospital of Dallas after developing symptoms consistent with Ebola. The medical facility isolated the patient. Based on the person’s travel history and symptoms, CDC recommended testing for Ebola. On Oct. 8, the Liberian national died at the Dallas hospital. CDC recognizes that even a single case of Ebola diagnosed in the United States raises concerns. Knowing the possibility exists, medical and public health professionals across the country have been preparing to respond. CDC and public health officials in Texas are taking precautions to identify people who have had close personal contact with the ill person and health care professionals have been reminded to use meticulous infection control at all times. What is CDC doing in the U.S.? CDC has activated its Emergency Operations Center (EOC) to help coordinate technical assistance and control activities with partners. CDC has deployed several teams of public health experts to the West Africa region and plans to send additional public health experts to the affected countries to expand current response activities. On the remote possibility that an ill traveler arrives in the U.S., CDC has protocols in place to protect against further spread of disease. These protocols include having airline crew notify CDC of ill travelers on a plane before arrival, evaluation of ill travelers, and isolation and transport to a medical facility if needed. CDC, along with Customs & Border Patrol, has also provided guidance to airlines for managing ill passengers and crew and for disinfecting aircraft. CDC has issued a Health Alert Notice reminding U.S. health care workers about the importance of taking steps to prevent the spread of this virus, how to test and isolate patients with suspected cases, and how to protect themselves from infection.
Reprinted with permission from the Centers for Disease Control and Prevention, www.cdc.gov MCMS
Licensure Renewal Deadline is Near: What You Need to Know
he deadline for license renewal is fast approaching! Physicians licensed by the Board of Osteopathic Medicine must renew their license no later than Oct. 31. Physicians licensed by the Board of Medicine must renew their license no later than Dec. 31. All physicians must meet continuing medical education (CME) requirements as a condition of license renewal. If you do not have the required number of CME credits to renew your license, the Pennsylvania Medical Society (PAMED) has the solution: the CME and Educational Catalog offers 50 plus credits of free or discounted online CME activities, all designed to meet patient safety and risk management requirements and based on topics and needs identified by physicians. Just a reminder that under the new child abuse reporting laws all physicians seeking to renew their license on or after Jan. 1 will need to complete two hours of approved CME on child abuse as a condition of licensure. However, if you renew your license before Dec. 31, you will have until 2016 (when licenses are scheduled to be renewed again) to meet the new training requirement.
The Department of State’s Boards of Medicine and Osteopathic Medicine also recently announced the availability of online applications for new licensees. Initial license applications for the following license types are now available online: physician and surgeon, physician assistant, respiratory therapist, athletic trainers, acupuncturists, and genetic counselor. Individuals seeking an institutional license under the Board of Medicine also may submit an initial application online. Physicians and other professionals seeking to renew existing licenses may submit paper applications or submit applications online. Paper applications may be downloaded from the Board of Medicine and the Board of Osteopathic Medicine websites. Online applications may be accessed through a separate website for current license renewals, www.mylicense.state.pa.us. For additional information and to access the online applications, visit the web sites for the Board of Medicine,, ifand yo t the Board of Osteopathic Medicine, www.dos.state.pa.us. The Pennsylvania Medical Society will provide updates through our Daily Dose email as soon as online applications for all licensees are available on the Department of State’s website. y
Schedule Your F i n a n c i a l Check-Up With
215.665.6658 • 800.526.6397 LeiseWMG@Janney.com www.LeiseWMG.com
Janney Montgomery Scott LLC 1717 Arch Street Philadelphia, PA 19103 www.janney.com | Member: NYSE, FINRA, SIPC
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The Critical Impact of Health Care Providers on Influenza Vaccinations
The Critical Impact of Health Care Providers on Influenza Vaccinations By Ruth Cole, Director of Clinical Services, Montgomery County Health Department
It is estimated that 20 percent of Americans get the flu every year, resulting in between 3,000 and 49,000 preventable deaths each year in the nation from flu-related illnesses. Though influenza is a vaccine preventable disease, it continues to be a significant source of morbidity and mortality for Montgomery County residents. Over the last influenza season (2013-14), there were 1,132 laboratory positive cases of the flu in Montgomery County, with 181 hospitalizations and five deaths attributed to the virus. The year before was a more severe season, with influenza disease resulting in 256 hospitalizations and 11 deaths in the county. Six Months and Older Should Be Vaccinated
Despite the harm caused by the virus, and the accessibility of the vaccine, vaccination rates remain low, with only 44 percent of Pennsylvanians aged 6 months and older in 2011-12 being vaccinated. However, to achieve community immunity for influenza infection, thereby protecting the most vulnerable groups, 80 percent of healthy persons and 90 percent of high risk persons would need to be vaccinated. Historically, manufacturers produced a limited supply of the vaccine, since consumer demand was low. Yet the supply of vaccine has increased since the 2010-11 flu season, when the CDC first issued the universal recommendation, that all people ages 6 months and older be vaccinated against influenza. This
season, there will be a projected 154160 million doses of vaccine available in the United States, with 78 million of those doses comprised of the quadrivalent flu vaccine. As influenza vaccine presentations continue to be developed, studies are conducted to monitor which formulation is preferable for patients based on age and medical history. For instance, after reviewing efficacy data, this year the CDC is recommending the nasal spray (LAIV) as the preferred vaccine for healthy children 2 through 8 years of age, since it may work better than the shot in this age group. Studies confirm the important role of health care providers in impacting vaccination rates, revealing that a strong recommendation from a patient’s health care provider is the primary reason that they receive a flu vaccination. The vaccination status of health care workers themselves is an important consideration in decreasing the spread of infection. Nationally, during the 2013-14 season, only 63 percent of health care workers received their flu vaccine. Do No Harm—Physicians Need Vaccination, Too
Proponents of mandatory vaccination of health care workers appeal to professional codes of ethics, including principles of professional obligation, such as “Do No Harm” that compel providers to take all prudent measures to protect the safety of their patients. Since workers are contagious, spreading the influenza virus even before symptoms appear, they argue
that being vaccinated is the necessary action of a health care provider who is acting to put “Patients First.” The vaccination rate among providers whose employers required vaccination was 89 percent, while the rate was 70 percent of providers whose employers recommended vaccination, compared to a rate of 44 percent of workers whose employers did not have a policy regarding flu vaccination. In light of this, health care providers in many sectors have already implemented policies, or are considering requiring the staff in their practices to be vaccinated against influenza as a condition of employment, in order to protect their patients’ safety in the face of this preventable infectious disease. Montgomery County Residents No Excuses
Beyond the health care provider office, there are many points of access for patients to receive flu vaccination, including pharmacies, work sites and schools, among others. The Montgomery County Health Department (MCHD) is conducting a Community Influenza Campaign, which is open to all Montgomery County residents, in several locations throughout the county. A list of flu sites can be found at MCHD’s website, www.health.montcopa.org . For the latest updates this flu season, visit the CDC’s website, www.cdc. gov. For more information about MCHD’s Immunization Program, contact registered nurse Kalyn Roberts, (610) 278-5117, ext. 6822 or email, firstname.lastname@example.org.
2014-2015 MONTGOMERY COUNTY HEALTH DEPARTMENT
Free Walk-In Influenza Immunizations Montgomery County Residents Only
Medicare Beneficiaries and Clients with Health Insurance: Please bring insurance cards DATE
9/30/14 - Tuesday
10 AM – 1 PM
Norristown Public Library 1001 Powell Street, Norristown
10/3/14 - Friday
10 AM – 1 PM
Sunnybrook Ballroom 50 Sunnybrook Road, Pottstown Upper Merion Township Building 175 West Valley Forge Road, King of Prussia
10/7/14 - Tuesday
3:30 PM – 6:30 PM
10/10/14 - Friday
10 AM – 1 PM
Congregation Beth Or 239 Welsh Road, Maple Glen
10/18/14 - Saturday
10 AM – 1 PM
Montgomery County Community College 340 DeKalb Pike, Blue Bell (Physical Education Center)
10/25/14 - Saturday
10 AM – 1 PM
10/30/14 - Thursday
3:30 PM – 6:30 PM
11/1/14 - Saturday
10 AM – 1 PM
Abington Junior High School 2056 Susquehanna Road, Abington Arcadia University 450 South Easton Road, Glenside
(Commons Bldg. Great Room, Enter through Kuch Center) (Parking Lot #: 9 & 10)
Upper Perkiomen High School 2 Walt Road, Pennsburg
The above planned sites are dependent upon vaccine availability. Influenza vaccine is recommended for all individuals age 6 months and older. For more information, visit www.health.montcopa.org
Montgomery County Health Department Norristown 610-278-5117
Willow Grove 215-784-5415
Accommodations for Persons with Disabilities will be available
Josh Shapiro, Chair Leslie S. Richards, Vice Chair Bruce L. Castor, Jr., Commissioner 8/4/2014
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conflict By Jay E. Rothkopf MD
onflict. It’s a word that conjures images of negative emotions, raised voices, and flushed faces. Indeed, it’s another way of saying ‘fight,’ something we never want to see in the workplace. And yet, we’ve all been there: the three a.m. call from a resident or nurse who doesn’t know their patient or what to do next. The hospital administrator who asks for a change, yet fails to understand why it’s bad for patient care. Physicians, as leaders of the team, are often expected to solve disagreements, yet many of us lack formal training in the resolution of conflict. For decades, this was considered a ‘soft skill’, learned ‘on-the-fly’ in the day-to-day grind. But not anymore. In a world increasingly defined by patient satisfaction and team—based care, the ability to maintain cohesion across trans-disciplinary providers— as well as interact with non-clinical administrators--has become an expectation. Physicians have to adapt, or risk being left behind. So where to begin? As problems go, few are more complex than team dynamics. As a hospitalist, I am frequently exposed to multiple viewpoints, and expected to balance both opinions and egos. I haven’t always been successful, but I’d like to share some of the things I’ve learned. 1) Always keep calm - few things are more important than maintaining an
air of compassion and professionalism. People tend to judge others based on how they react to adversity, and the workplace is no exception. Physicians, trained to function independently, may perceive a threat to autonomy when a non-colleague challenges the plan of care, or even take such actions personally. This is generally counter-productive. It is important to remember that we’re all here for the patient, and the nurse’s role is to foster communication. If a physician expresses exasperation or anger, a perception of unapproachability may develop, which may be difficult to undo. It is also worth pointing out in any conflict, whomever loses their temper first usually shoulders the blame for escalation. Also, a grievance between parties may be legitimate, but the minute someone chooses to get angry, the behavior, rather than the issue, becomes the focus of attention. An anecdote from my own experience involved a nurse who lacked comfort in her ability to draw labs from the arms of edematous patients. Rather than admit her deficiency, she would often insist on a PICC line, despite a hospital policy discouraging their use for this reason. When I pointed this out to her, she became very defensive. I was then faced with a choice: get angry myself, or try to drill down to heart of the matter. At one time, my inexperience would have led me down the first path, but in refusing to get
visibly upset, I was able to show her she could open up to me. In other words, I “made it okay” to admit her failing. The end result--more training for the nurse— was a win for everyone, including the patient. It’s an important lesson, and one I haven’t forgotten. 2) Know your team (and their limits)- with the broader advent of clinical teams comes an increased need for delegation in both the office and hospital settings. States continue to pass laws allowing allied health providers more autonomy, and in today’s complex environment, team members such as pharmacists may be making independent decisions. As such, it is vital for physicians to know the strengths and weaknesses of each member of their clinical team. The cornerstone of this is communication, which is best accomplished through multi-disciplinary rounds. Such gatherings need not be long, but allowing a 10-minute period to run through the patients can help align the plan-of-care for the day. It also allows different members of the team to better understand one another’s perspectives, which can also help avoid miscommunication. Last year, I had a patient on my service with chronic hypotension. While able to tolerate hemodialysis, he had difficulty participating in physical therapy. Multiple physicians were involved in his care, yet were unable to fully solve what had been a long-standing
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Conflict During my residency, an intern on my ICU team was perceived as abrasive by the nursing staff, yet was generally congenial to other physicians. When direct feedback from several of the nurses failed to elicit a change in behavior, the nurse manager and I met to discuss the situation. I vividly remember his calm and “can-do” attitude that immediately fostered an air of problem solving, and as a team, we were able to intervene and help produce the desired result. Unfortunately, sometimes conflicts arise between the physician and nursing leadership, or the head of other clinical departments, which can lead to unnecessary tension and affect morale. Having been in both situations, the best solution often is to sit down with the other party and allow for a mutual airing of grievances. In most circumstances, this may be enough to produce a “reset,” and lead to a solution without one party feeling as if they have been professionally compromised. It is generally advisable to have an observer present for any such meeting, both as a potential mediator and for mutual protection. If the conflict is unable to be resolved, documentation of the inciting incident is vital, as well as any attempts at resolution. Such documentation should be purely objective, and as detailed as possible.
problem. The patient, who wished to work on improving his strength, was understandably frustrated at the slow pace of his progress, as were the members of the clinical team. After three weeks in the hospital, a conflict emerged between the patient’s nurse and the therapy department regarding the timing of medication designed to increase the patient’s blood pressure. The nephrologist wanted the medication given just prior to dialysis, the therapists wished it given just prior to therapy, and the nurse, who thought that the dose was inadequate, felt caught in the middle, as well as unsure of which physician could best address her concerns. As the attending, I was more easily accessible (and in charge of his care), but she did not wish to run afoul of the nephrologist, who had been following the patient in the office for many years. Unfortunately, by the time I was made aware of the conflict, the situation had escalated and egos were bruised. The result—a discussion on the appropriate chain of communication—has helped prevent similar issues. 3) Establish a working relationship with clinical leaders - nursing managers and supervisors can be a valuable resource in mediating conflict, and it’s important to build an early rapport. Often individuals in these positions have good “people skills,” allowing for early intervention when problems arise. Nurse managers also serve as a bridge between the clinical floors and the administration and can help to smooth out differences in perspective.
Continued on page 30
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Conflict 5) Maintain strong ties with physician leadership - as the liaison between administration and the medical staff, the chief medical officer/medical director should be the ‘go-to’ person for resolving major issues. Physicians chosen for leadership roles generally come from diverse clinical backgrounds, and may or may not have had formal training to prepare them for a more expansive role. Nevertheless, the CMO can often be your best advocate in a conflict situation, especially if the disagreement is between a physician and administration. We’ve all heard the term “disruptive physician,” but how does one face a “disruptive administrator”? The answer is: very carefully, and with help. Two years ago, I had a fairly tumultuous relationship with the administrators of my hospital. From my perspective, their concerns seemed petty, and were often presented in an intimidating matter. At one point, I even considered leaving my position due to the stress of this ongoing conflict. Despite multiple efforts by my physician employers to remedy the situation, little changed in our day-to-day interactions. I felt increasingly frustrated, especially since our disagreements came not from any clinical issue, but rather, differences in personalities. It wasn’t until the medical director became involved that the concerning behavior began to change. While things were never ‘perfect,’ had he not been available as a ‘bootson-the-ground’ resource, I would likely have felt compelled to leave. Many physicians tend to be critical of colleagues who take on administrative roles, but without their voice, it would be a lot harder to address our concerns. They are our backup, the pipeline to administration. While diplomacy is, by necessity, part of their role, it is always better to have an advocate than “go it alone,” especially in today’s complex world. A lot of what I’ve written may seem like common sense, but as a younger physician, I wish I’d had more of a template to help me navigate these issues when first starting out. Medical education still emphasizes “hard skills,” like history taking and the physical exam, over human resource training and dealing with non-clinical stakeholders. Fortunately, that is starting to change, as programs across the nation embrace formal coursework on communication and the building of teams. As American health care continues to evolve, hopefully, more physicians will acquire leadership roles, and help steer the changes which will continue to come.
continued from page 29
4) Schedule regular meetings with administration - as those responsible for running the hospital, administrators represent the ultimate authority on the non-clinical side of patient care. For years, physicians and administrators tended to view each other with a degree of suspicion, but contrary to popular belief, the lines between clinical medicine and its business side have begun to blur. For physicians in private practice, that statement is nothing new, but for those who have entered the world of employment, it often comes as a surprise. While nursing has long been established in hospital administration, physicians are now starting to catch up. Organizations such as the American College of Physician Executives are bridging the gap between the C-suite and the bedside, making cultivating relationships with administrators even more important. Interactions don’t necessarily have to be grandiose, or even formal. While scheduled meetings should occur (especially in the context of aligning goals), simply dropping by once in a while to say ‘hello’ can go a long way towards putting administration at ease, and even help you be seen as a leader. And if conflicts occur on the clinical floor, the C-suite often may have to get involved. Either way, open lines of communication between physicians and administrators are mutually beneficial to both parties.
HIGH-QUALITY, AWARD-WINNING MEDICINE?
BECAUSE YOU DESERVE MORE.
Everyone expects a hospital to offer expertise, technology and quality care, but what about genuine caring for your physical and emotional well-being? At Mercy Suburban Hospital, you can have it all. DeserveMore.org/Suburban
Mercy Suburban Hospital is voted Best Hospital in Montgomery County in The Times Herald’s 2014 Best of Montco Readers’ Choice Awards.
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Fall Fun Ideas
Fall Fun Ideas
October – November Saturdays Collegeville Farmers’ Market, 217 East Main St. - 9 AM to 1 PM
November 4, 2014 General Election at a Voting Station near you, 7:00 AM - 8:00 PM
October 25, 2014 “The Plantation Whereon I Live”: A Hands-On Experience of Everyday Life at Pottsgrove Manor, Pottstown, 610-326-4014 - 11 AM - 3 PM, montcopa.org/pottsgrovemanor
November 15-16, 2014 The Kennel Club of Philadelphia’s National Dog Show, Greater Philadelphia Expo Center, Phoenixville...8 am to 6 pm (Sat), 8 AM to 5 PM (Sun), nds.nationaldogshow.com/
November 1, 2014 Flu Clinic, Upper Perkiomen High School, Pennsburg, 10:00 AM - 1:00 PM
November 29, 2014 Waterfowl Watch, Green Lane Park, Green Lane, 215-234-4528 1:00 PM - 3:30 PM
November 2, 2014 The Underground Railroad in Quilts, Historical Society of Montgomery County, 1654 Dekalb St., Norristown, 610-272-0297 2:30 to 3:30 pm, www.hsmcpa.org
December 6, 2014 JINGLE FEST to benefit families battling CANCER, Greater Philadelphia Expo Center, Phoenixville 10 AM – 3 PM, www.horsepowerforlife.org
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The Business of Medicine
pamedsoc.org to learn more
Collection Strategies Can Help Physician-Patient Relationship: Protect Bottom Line By Carol Bishop, Associate Director of Practice Economics and Payer Relations, Pennsylvania Medical Society
ollecting money from patients is one of those necessary things that few physicians or their staffs are comfortable doing. But, practices must have a good process in place to collect deductibles, co-payments, and co-insurances if they want to continue to offer quality health care. When communicated clearly and respectfully to patients, these processes may also help avoid negative impacts on the physician-patient relationship and damage to the practice and/ or physician’s reputation. Practices should take a step back and examine their current procedures — from how patients check in, to patient billing and collections. Clearly Communicating Policies and Procedures With Patients
The first steps in creating this process should include finding a reliable system for checking eligibility, accurately estimating the patient’s financial obligation, and reviewing the estimate with the patient prior to their appointment or when they check in. When a patient knows upfront what their financial obligation may be, they are more likely to pay all or some of what they owe at the time of service. To ensure accuracy, it is absolutely vital that staff collects and enter demographic and insurance information correctly at time of check in. The best practice is to verify coverage and the applicable cost share amounts (i.e., co-payment, deductible, and co-insurance). The Practice’s Bottom Line: Collection Strategies
The bottom line: health care costs money. With payments from patient services poised to make up a larger and far more critical percentage of providers’ total revenue, bad debt can no longer be viewed as simply the cost of doing business. It now has the potential to damage your practice. Practices need to ensure that the policies and procedures are effectively used to prevent balances from becoming delinquent such as: • •
Practices should also:
Implement a solid financial and billing policy that details expectations for charging, billing, and collection of accounts receivable. Educate patients, especially new patients, on their financial responsibilities and billing policies and procedures. This will encourage them to comply. Some examples are office brochures, welcome letters, and websites. The information should include the insurance companies the practice participates with, policies for collecting co-payments, deductibles, co-insurances, as well as payments for non-covered services. Information should also include the practice’s process for filing claims, credit cards that are accepted, the process and timing for sending out patient statements, when payment is due, and the policy for turning balances over to a collection agency. • Review financial policies annually, especially due to the ever-changing rules of private and public health insurance carriers. • Ensure that the office staff is fully knowledgeable of the policies and procedures, as well of any changes which may be made to the financial policy. • Train the front office staff to double-check for past due balances on the patient account and consider reminding the patients of such balance. • Consider payment plans; patients may be more inclined to make a payment or pay the balance if this option is available to them.
Hard to Collect Balances
For those hard to collect balances, practices should stick to their protocols listed in their financial policy and procedure manual, such as phone calls, late payment notices, and the process for placing patients on payment plans. The practice’s physicians should also be fully aware of the financial policies and procedures because many times physicians want to know who may be sent to a collection agency.
Collecting payment (e.g., co-payment, co-insurance, deductible) prior to services being provided Increasing the pace of collections to include reducing the number of days between when a bill is sent and when payment is due
There is no better time to collect than when the patient is at the office. This will help to avoid wasting more time and money for billing patients later. Even if a patient is not able to pay in full, the opportunity for patients to pay a portion of their bill or set up a payment arrangement with automatic withdrawals is one that is becoming more prevalent.
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Collection Strategies Can Help Physician-Patient Relationship: Protect Bottom Line
Some practices find it very difficult to pursue patients who owe the practice money or who fail to pay their co-payments, deductibles, co-insurances, or past due balances at time of service. However, it is important to keep in mind that the physician has provided important services to the patient and deserves to be paid for such services. When the patient claims he or she cannot pay a balance, the practice should do their due diligence to work out a payment arrangement that is comfortable for both parties. For those patients who simply refuse to pay their balance, this should be handled in accordance to the practice’s financial policy. All patients should understand that health care costs money. If the patient is truly in difficult circumstances, the practice’s willingness to work with the patient will show patient loyalty and goodwill. Find more tools, valuable information, and suggested strategies from the Pennsylvania Medical Society (PAMED) at www.pamedsoc.org/collections.
Higher Copayments and Deductibles Delay Medical Care, A Common Problem for Americans, Managed Care www. managedcaremag.com/archives/1001/1001.downstream.html Changing Your Thinking on Patient Collections, Medical Practice Insider www.medicalpracticeinsider.com/best-practices/changing-yourthinking-patient-collections How to Clearly Communicate Patients’ Financial Obligations, Medical Practice Insider www.medicalpracticeinsider.com/best-practices/how-clearlycommunicate-patients-financial-obligations Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services, Kaiser Family Foundation http://kff.org/medicare/issue-brief/paying-a-visit-to-the-doctorcurrent-financial-protections-for-medicare-patients-whenreceiving-physician-services/
Collection Protocols for the Medical Practice, PAMED, www.pamedsoc.org/collectionprotocols Patient Liquidity at Time of Service Big New Problem for Providers, Insurers, Managed Care
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– Maintenance of Certification (MOC) is one of several topics to be discussed as part of the 2014 PAMED Annual Education Conference and House of Delegates (HOD), Oct. 17-19 in Hershey. At the request of the Montgomery County Medical Society Board of Directors, the session on MOC was added to an impressive agenda of educational opportunities that address the practice, business and life of medicine. Other topics include ICD-10, patient-centered medical homes, long-acting opioid analgesics, physician burnout, physician-executive partnerships and so much more. You need CME credits? Register and view a full agenda, www.pamedsoc/hod. In addition to the CME offerings, all attendees have an opportunity during the reference committees to discuss a number of resolutions that address the practice and business of medicine.
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Welcome New Members... MCMS is pleased to welcome the following individuals who joined the Society in 2014:
January 2014 Kyle Solomon, MD Stuart Z. Dershaw, MD Sandeep Dhand, MD
April 2014 Lee P. Adler, MD Mark Anderson, MD Marcus E. Carr, MD Rotem Friede, MD Ravi J. Kumar, MD Mark L. Sobczak, MD Annie N. Kotto, MD Hasan S. Khawaja, MD Steven M. Domsky, MD
February 2014 Luciano Lorenzana, MD Sonia Mehta, MD Allen Chiang, MD LaMar Christian, Medical Student March 2014 Jerilyn Custer, Practice Administrator Annie Wang, DO
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July 2014 Michael D. Esrick, MD Benjamin Noh, MD Nancy D. Sarvet-Haber, MD Karen P. Zimmer, MD August 2014 David H. Duong, MD Taylor T. Givnish, Medical Student Alexis J. Lukach. Medical Student Pravin A. Taneja, MD
MCMS regrets the loss of these society members in 2014: A. Anthony Arce, MD B. David Grant, MD, FACS William W. Wilson, MD
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June 2014 Regina H. Kurrasch, MD Ramona F. Swaby, MD
May 2014 Amy J. Aronsky, DO Joan M. Addley, DO Tulin Budak-Alpdogan, MD Antonio D. Marrero, Medical Student Michael Rachshtut, MD Gerald F. Tremblay, MD
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