MCMS Physician | Fall 2016

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Your Community Resource for What’s Happening in Healthcare

MCMS

Fall 2016

Ethical Dilemmas in Medicine

Addressing the Elephant in the Room:

Your Colleague

Fighting Opioid Abuse in Pennsylvania

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Physicians’ HEALTH Program The Foundation of the Pennsylvania Medical Society

30 Years of Change – Transforming Lives

“ONE IN TEN

people suffer from addiction. At any time, there could be as many as 3,000 doctors in the state whom we could be helping.” Raymond Truex Jr., MD, FAANS, FACS

“Physicians, like the rest of the population, are vulnerable to chemical dependency, physical disability or breakdowns in mental health. Your support of the 30 Years of Change Campaign will make sure the Physicians’ Health Program will always be available to our fellow health care providers.” Raymond Truex Jr., MD, FAANS, FACS, Honorary Chair of 2016 PHP 30 Years of Change Campaign

•

WHY SHOULD I SUPPORT THE PHP?

For 30 years the PHP has provided confidential support, monitoring and advocacy to those who may be struggling with addiction or physical or mental challenge. • The PHP relies on contributions from physicians, hospitals and others so that the cost to the participant can be kept as low as possible during challenging times. • Your gift TODAY is an investment in an established endowment ensuring that the PHP will have funding support in perpetuity. • Your gift provides a transformational opportunity for your fellow health care providers who deserve a chance to live life in recovery and good health.

HOW CAN I HELP? PHP is a program of The Foundation of the Pennsylvania Medical Society – the charitable arm of PAMED. The program assists all physicians, physician assistants, medical students, dentists, dental hygienists, and expanded function dental assistants.

Please consider a gift to the PHP in honor of this anniversary to ensure that physicians will always have a place to go to when help is needed. Let’s make the most of it! In celebration of this milestone, the campaign has received a $30,000 challenge grant from an anonymous physician – by making your gift TODAY you will help us to take full advantage of this generous matching fund opportunity! Go to www.foundationpamedsoc.org to see true stories of transformation and recovery.

Contact the PHP at (717) 558-7819 or php-foundation@pamedsoc.org.

If you want to learn more about how to make a contribution to the PHP Endowment, visit www.foundationpamedsoc.org. You can also contact Director of Philanthropy Margie Lamberson, CFRE, at mlamberson@pamedsoc.org or 717-558-7846.

The official registration and financial information of the Foundation may be obtained from the Pennsylvania Department of State, Bureau of Charitable Organizations, by calling toll-free within Pennsylvania, (800) 732-0999. Registration does not imply endorsement.

777 East Park Drive • Harrisburg, PA 17105-8820

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Contents

Fall 2016

8 Ethical Dilemmas

2014-2016 MCMS BOARD OF DIRECTORS

in Medicine

Kathie M. Allen Practice Manager

Stanley Askin, MD

a

Addressing the Elephant a in the Room: Your Colleague

Frederic Becker, MD Sherry Blumenthal, MD

a

Charles Cutler, MD Madeline Danny, DO James A. Goodyear, MD

12

George R. Green, MD Chairman, Membership Services & Benefits Committee

Joseph Grisafi, MD Vice President

Walter Klein, MD President-Elect

William W. Lander, MD Mark Lopatin, MD Chairman, Board of Directors

Jennifer Lorine, DO Secretary

Cheri L. Matthews Practice Manager

Robert M. McNamara, MD Mark F. Pyfer, MD Jay E. Rothkopf, MD President and Treasurer

Scott E. Shapiro, MD Immediate Past Chairman, Board of Directors

Steven A. Shapiro, DO James W. Thomas, MD Immediate Past President

Martin D. Trichtinger, MD Chairman, Political Committee

MCMS Staff Toyca D. Williams, CAE Executive Director

montmedsoc@verizon.net

Editorial Board Jay E. Rothkopf, MD, Editor George Green, MD Mark F. Pyfer, MD Scott E. Shapiro, MD Toyca D. Williams, CAE, Deputy Editor 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 healthcare within the community, Montgomery County and Pennsylvania.

An Ounce of Prevention is a Pound of Cure A Zika Recap

Features

14 Meet Your County Medical Society Leaders 15 Why don’t hospitals want physicians and nurses to collaborate? 16 MCMS Honors Longtime Practicing Physicians and Installs Its 167th President 17 Grandpa Inspired Journey to Become a Physician 19 MCMS Annual Membership Dinner 20 The Philadelphia Soda Tax, Obesity and Public Health 21 Welcome New Members 24 Fighting Opioid Abuse in Pennsylvania 26 Helping Finance Physician Education 27 Meet Your Montgomery County Health Department Administrator Irshad Ali Shaikh, MD, MPH, Ph.D. 28 Legislative Update 31 Three Ways Medical Practices Can Budget Smart in the Coming Year

Surgery and Opioids: Changing the perioperative patient experience and expectation

22

In Every Issue 4 6 21 28

Chairman’s Remarks Editor’s Comments News & Announcements Legislative Update

MCMS Physician is published by Hoffmann Publishing Group, Inc. I Reading, PA HoffmannPublishing.com I 610.685.0914 I for advertising information: audrey@hoffpubs.com or karen@hoffpubs.com

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Chairman’s Remarks

A Necessary Conversation: Eliminating Systems That Erode the Patient-Physician Relationship Mark Lopatin, MD Chairman, MCMS Board of Directors

Do our patients know? You have heard a lot in these columns and elsewhere about the problems we face in medicine, i.e. how policy affects the care that we provide to our patients and threatens the patient-physician relationship. By the way, I call it the patient-physician relationship rather than the physician-patient relationship because I think it is important to put the patient first. Our current system does not do that. So what do we do about it? We complain to each other, but watercooler politics does not accomplish much. Many of us are not even aware of the changes in store. If we are not, certainly our patients are not. As we strive for greater understanding, we will host a Healthcare Town Hall on Oct. 6, 6 p.m. at the Health and Wellness Center, 847 Easton Road, in Warrington. (Please Note: The Philadelphia County Medical Society is holding a Healthcare Town Hall on Oct. 19, 7 p.m. at PCMS, 2100 Spring Garden St., Philadelphia.) The goal of this is to start a dialogue between patients and physicians as to how healthcare for patients is being affected by

current and changing policies from third parties. We have also invited legislators.

Perception, Not Always Reality All that our patients know is that their doctor has his or her face buried in a computer rather than focused on them. Do patients have any idea of how much data I must enter just to satisfy third party payers? Do they realize the complexities of using the right ICD-10 code? Do my long standing rheumatoid arthritis patients know that in order to code their visit, I have to state whether their rheumatoid factor is + or -. That means that I may have to look through many years’ worth of notes and labs to find a lab test that was ordered when I first saw the patient many years ago that no longer has any value. Do they realize that in some cases, I have to order the test now, even though it provides no benefit to them, just so I can code their diagnosis to satisfy their third party payer? Are they aware of the boxes I must click during their visit to satisfy their third party payer? For example, I need to define the severity of their pain. But when I ask for a number from 0 -10 that defines the severity of their pain, they typically respond with, “It depends. Do you mean the pain in my knees or my hands, the pain level now or last week, pain at its worst or at its best, pain on a good day, or on a bad day, etc.?” Likewise when I ask if their pain is better or worse,

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how do I document it when they say it is better than it was last week, worse than it was two weeks ago and about the same as it was at their last visit? I now joke with my patients, that I am no longer an M.D. My degree is now a D.E.O. i.e. data entry operator.

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Patience, A Virtue. Documentation Is Too Do patients know when they wait for me that the delay may be because I am doing a peer to peer (with much of the time spent on hold) trying to get a medicine or a procedure approved for another patient? Are they aware of the time it takes to write a letter of medical necessity to their insurance company justifying the need for their medicine? Are they aware of how much time and energy we spend as physicians, justifying what we do? Documentation is important but not for documentation’s sake. In fact, I believe that the justification has become more important than the doing. The outcome is not what is important. Only the process. If my patient is improving on a medicine that is being used off label, that medicine may well be denied, because it is not “approved” for that condition. Never mind that the medicine is helping my patient and is well tolerated. That does not seem to matter. Are patients aware that physicians will in the future be reimbursed based on guidelines from the government? Our reimbursement will depend on whether the government thinks we are doing a good job, based on how well we document. Are they aware how this will influence the care they receive? Do patients want their care determined by their doctor or by a third party who is not even in the exam room, based on a predetermined cookbook strategy? In any case, I ask the question, do our patients know all of this? What would they do if they knew? What would we want them to do? This call to action is intended to create a forum, between patients and legislators and perhaps even insurers, with the goal of returning the patient-physician relationship to the center of model care. I urge you to come to the Healthcare Town Hall on Oct. 6 and invite your patients, with the goal of having people share how their healthcare is being affected. There is already a proposed bill to limit pre-authorizations. I personally would like to see some type of legislation that would dictate that third party payers are accountable for the medical decisions they make. As always, if you are happy with our healthcare system, you do not need to do anything. But the patient-physician relationship is being threatened. Are we going to accept that without even raising an objection? I hope to see as many of you as possible on Oct. 6.

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Editor’s Comments

Collaboration Needed in Team-Based Care Are doctors safe? Depends on who you ask. Are physicians still necessary, important? Depends on who you are. If it sounds like I’m a little unsettled, I am. Why? Well, something happened in healthcare recently, and based on your point of view, it was either good, bad, or neither: Senate Bill 717 moved out of committee. Originally cosponsored by State Sen. Pat Vance, the proposed legislation would grant independent practice authority to Certified Registered Nurse Practitioners (CRNPs), as well as “strongly encourage” hospitals to “consider” making them full voting members of their medical staffs, a decision that under current law remains the purview of each individual institution. Last year, I wrote an article challenging the claims of the Pennsylvania Coalition of Nurse Practitioners that CRNPs were equivalent to physicians and that fragmenting the healthcare team by removing the requirement for collaborative agreements would improve patient safety, access, outcomes and satisfaction. The committee disagreed, and by the time this article comes to press, the bill will likely have moved to the Senate floor for a full vote. (Update: On July 12, the Senate passed Senate Bill 717 – legislation which would allow CRNPs to practice independently and eliminate the requirement that they collaborate with physicians – by a vote of 41-9. The bill now goes to the House of Representatives for consideration, where it has been referred to the Professional Licensure Committee.)

Don’t Take it Personally: Hard Not To

So why am I bringing this back up? Two reasons—one, to demonstrate the potential consequences to physicians should this legislation pass, and two...well, you’ll just have to keep reading. Full disclosure: on May 31 of this year, after a half-decade as a hospitalist at a long-term acute-care facility in southeastern Pennsylvania, the administration made a decision to move away from an on-site physician model to one primarily featuring

community-based physicians, all of whom have their own outpatient practices and can only dedicate a limited number of hours per day to in-house coverage of the hospital’s medicallycomplex, chronically-critically ill patients. Their solution? A critical care nurse practitioner, who will take the place of a board-certified physician. Why was this done? The answer, of course, is obvious — money. And if Senate Bill 717 becomes law, it will only get worse for physicians, especially those in primary care. From urgent-care clinics to hospitals, physicians may very well find themselves displaced. Undoubtedly, some of you will read this and think “Hmm, this sounds personal” and you would be right. It’s disconcerting when a hospital CEO posts a memo stating that moving from dedicated in-house physicians to nurse practitioners will improve coverage, safety, quality, and outcomes. But there’s a bigger issue here, and that is “what will happen to the patients?” Technically, it’s now outside my purview, but I can’t help but worry. Now, I know what you might be thinking: “Nonsense! We’ll always need doctors. You’re being paranoid.” One would hope, but maybe not. Despite the urging of the Pennsylvania Medical Society (PAMED), the Hospital Association of Pennsylvania (HAP) came out in support of SB 717. Money? Yes, but perhaps something more. As I previously stated, a provision in the bill would allow hospitals to admit CRNPs to their medical staffs, a decision which may seem harmless on its face until you consider the fact that traditionally, while nurses are ubiquitous in administrative positions, they usually don’t serve in medical staff leadership. Given that akin to the trend amongst physicians, CRNPs in hospital settings are also likely to be employed, this gives hospitals the opportunity to further diminish the power and influence of doctors, the leaders of the healthcare team. And the PA Coalition of Nurse Practitioners is fully on board.

Is This Debate Now PC? So where does that leave us? Right now, the zeitgeist in America is one of disruption, of feeling unsettled, of willingness to embrace radical change—sometimes without thinking through the consequences of what that change will bring. As a general rule, the word ‘disruption’ conjures up feelings of uncertainty, even chaos. The opposite of stability, it

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often heralds the onset of a period of distress. And it’s aptly timed. As I sit here writing today ( June 24), Britain has just voted to leave the EU. This is without a doubt a momentous, once-in-a-lifetime event, one that will have global ramifications, but back here in Fort Washington, it got me thinking about issues that are closer to home. They’re not as large-scale, but still important nonetheless. And it leads to a less-talked about side of this discussion: political correctness. “PC,” or the idea that some topics are universally offensive and should always be “off-limits,” is under assault. While I will not comment on the ramifications of that here, it is worth mentioning that political correctness can be taken too far, and what happens when it runs amok has been well-demonstrated in the scope-of-practice debate. When on organization posts on its website that opposition to their favored legislation is based on nothing more than sexism and misogyny, it stifles discussion and puts patients at risk. In a time when the public is gravitating towards those who “tell it like it is,” such antagonistic assertions demand a response. And here is mine: Nurse practitioners are not doctors. Now, I have nothing but the highest respect for the nurses and advanced-practice practitioners with whom I have worked and continue to work. From my years as a medical student, through residency and becoming an attending, I have learned much from those in the field of nursing. They are, in my opinion, exceptional people who work exceptionally hard in a highly-demanding and often under-recognized profession. Yet sadly, their political leadership has engaged in a state-by-state campaign of obfuscation and a misguided appeal to “professionalism” in an attempt to muddy the waters on why nurses practitioners are the same as (or even better than) doctors. Both sets of professionals are highly motivated and trained, but our skills, while complimentary, are not equivalent. Insisting otherwise simply to make things more “equal” or “fair” is an appeal to elevating emotion over fact. As a general rule, that almost never ends well.

What’s Best for the Patient? Before I get accused of being close-minded, let me say that there are many, many things an RN, BSN, MSN, and CRNP can do that I can’t do. It neither diminishes me as a physician nor devalues my contribution as a leader of the healthcare team to make that claim. Team-based care is the future, and I fully support it. It’s what best for our patients, our respective professions, and our communities. But that team should be physician-led, both now and going forward. Severing collaborative agreements between doctors and nurse practitioners will fragment the team, rather than preserve it. And that’s not good for anybody. So what’s the answer? In my opinion: continued collaboration. The PA Coalition of Nurse Practitioners has raised legitimate concerns over current laws governing the

process of how CRNPs are supervised, which PAMED has worked to address. Unfortunately, politics continues to trump what’s best for our patients, and as of this writing, the proposed “solution” to SB 717 has been to delay independent CRNP practice until after a 3,600-hour supervised “apprenticeship” by a physician, akin to a “faux residency.” While it sounds good on paper, it still doesn’t address the underlying fact that fragmenting the healthcare team will lower access, raise costs, and potentially increase unnecessary utilization of resources. It also papers over the fact that nurse education is fundamentally different from physician education. No bill from Harrisburg or anywhere else will change that.

Physicians: Educate Your Patients

So please, if you’re a colleague, take a moment to sit down and talk with your patients. Let them know how things like SB 717 may affect their access to physician-led, team-based care. Tell them that they can in fact play a vital role in the legislative process, at all levels. The passing of laws does not simply take place in a vacuum located in some distant capital—it involves all of us. If we are truly to engage in “shared-decision making,” we need to educate our patients, and get them involved. They are our partners in healthcare, and it’s time we opened up to them about what’s been going on. I think they’ll listen.

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COVER STORY

Ethical Dilemmas in Medicine Addressing the Elephant in the Room:

Your Colleague BY JAY ROTHKOPF, MD, EDITOR/MCMS PRESIDENT

Case Scenario

Dr. L is a successful, highly-respected specialist at the hospital where you have recently joined the inpatient team. As the newest member of an employed-physician practice, he ‘took you under his wing,’ introducing you to leadership, staff, and ‘showed you the ropes.’ For the first several months, your professional relationship seemed strong, but over the past few weeks, you’ve noticed a change. Subtle at first, it has now become more pronounced. When admitting new patients, he frequently pressures you to consult his group. The times when you’ve felt it hasn’t been necessary, he’s become angry and demeaning, questioning your judgement as to whether or not ‘appropriate care’ is being provided — sometimes in public. While previously pledging to support your involvement in committees and other ‘citizenship activities,’ other colleagues have said he’s now disparaging you behind closed doors. Upon an attempt to address these concerns face-to-face, he waved his hand and laughed, telling you that ‘his word was gold’ and that you were ‘a nobody,’ even implying that he potentially had control over both your employment and staff privileges, should he ‘so choose.’ Upon further investigation, you quietly discover that this behavior is not new, and in fact has been occurring for years. However, as the owner of a lucrative practice which has provided substantial benefit to the hospital (in addition to numerous political connections), no one has tried to challenge him directly. Although unsure of how to proceed, you feel that his behavior is unacceptable and you are uncomfortable allowing this situation to continue. Where do you turn? What do you do?

T

his is, without a doubt, the most uncomfortable subject about which I’ve written to date. From the time I was a kid, I’d always been taught that physicians were bound to, and practiced by, an uncompromising code of ethics. It was that code, along with an unshakable commitment to providing the best patient care, which was the respected core of the medical profession. The public holds doctors to a high standard, and as such, physicians must hold themselves to an equally high standard. But things can go wrong. Doctors are human, and therefore fallible. Sometimes, they behave badly. And when that happens, not only patients, but the profession itself can be harmed.

What to Do When Doctors Behave Badly

What, exactly, are ‘ethics’? Simply stated, the term ‘ethical’ means ‘to do the right thing.’ When referring to the practice of medicine, however, things quickly become far more complex. As defined by various professional organizations, unethical conduct is generally considered to be behavior that fails to a) put patients first; b) show respect for not only colleagues but all members of the healthcare team; and/or c) any action or actions which are either dishonest or not consistent with providing the best possible patient care (for a more comprehensive definition, please see the American Medical Association “Principles of Ethics” statement, available on their website at http://www.ama-assn.org/ama/ pub/physician-resources/medical-ethics/code-medical-ethics/ principles-medical-ethics.page?). Taken together, these concepts provide a framework for how physicians should conduct themselves in their day-to-day practice.

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So where and how do things go wrong? Unethical behavior can take many different forms, and often springs from experiences learned while in training. While incomplete, some evidence exists to support that claim. One study in the British Medical Journal found that nearly half of medical students surveyed felt pressured to act unethically during training, and fully two-thirds witnessed a clinical teacher behaving unethically. Examples included withholding a diagnosis of lung cancer from a patient due to the team not knowing its histopathological subtype; another involved a student being left to close a surgical wound despite being unsure of the correct technique. Another study from the University of Toronto revealed similar numbers, with nearly half of early fourth-year students reporting having been placed in clinical situations where they had been pressured to act unethically. Sixty-one percent reported having witnessed a clinical instructor behave in an unethical manner. Being at the bottom of the proverbial “food-chain,” students universally felt uncomfortable raising concerns, with fear of retaliation being the most common reason given for not speaking up. Even in situations where inappropriate behavior was obvious, there still was a

reluctance to get involved. Other ramifications aside, it does beg the question “what else are our physicians-in-training exposed to, and how does it color the way that they practice?”

Unethical Practices: A Learned Behavior

In an American survey, 35 percent of first-year and 90 percent of fourth-year students reported having witnessed unethical behavior. Another (which looked at six Pennsylvania medical schools) revealed that 98 percent of third- and fourthyear students had heard physician mentors refer to patients in a derogatory way while 61 percent reported having witnessed unethical incidents. Examples included the performing of unnecessary forceps deliveries “just for practice,” encouraging of students by residents to refer to patients using derogatory language, and in one instance, a senior resident in psychiatry sedating a fully-awake patient who refused to take her meds, documenting the presence of ‘impaired judgement’ before forcibly pushing intravenous haldol. As abhorrent as wha you just read may be, they are merely the symptom of a much larger problem: the onset of cynicism. We’ve heard a great deal about physician ‘burnout’ and the factors that cause it, but the experiences of students has been Continued on next page

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largely overlooked. Known as “traumatic de-idealization,” it is the process by which compassion and indeed one’s own ethical standards may begin to erode. In fact, the Pennsylvania study showed that witnessing bad behavior was associated with a greater likelihood of mimicking it in the future. When 303 individual students were surveyed across all four years at a single medical school, roughly one-third felt that derogatory comments made by senior physicians were “sometimes” or “often” appropriate. The more advanced the student, the more likely they were to defend the behavior. Opinions vary as to the cause, but most feel that a combination of “learned response” and the relative helplessness students feel at the bottom of the healthcare hierarchy are likely contributors. Solutions proposed include rigorous ethical training beginning in the first year and greater involvement by students in the running of the team, fostering a stronger sense of responsibility and ethics. So what about attendings? Students, after all, graduate, become residents, sometimes fellows, and then head out into the world to practice. And once there, a potentially new set of challenges await. Unethical behavior can take many different forms such as mistreatment of patients, financial misconduct, and mistreatment of employees and colleagues.

Unethical Behavior: Crossing Subtle Boundaries

How exactly, does one mistreat a patient? That’s a loaded question, one fraught with subjectivity. While there are certain universal behaviors that clearly violate ethical boundaries, others are a bit more subtle. We’ve all heard stories about the doctor with an abrupt bedside manner, or the one who crosses personal boundaries. Like the surgeon who throws an instrument in the OR or the internist who publicly belittles his or her residents on rounds, they’ve become almost archetypical in nature. But what about the doctor who refuses to make a decision, either out of fear of making a mistake or lack of confidence in his or her clinical skills? Inability to recognize one’s own limitations, although inherently different from abusive behavior, is still unethical, as it potentially puts patients at risk. Another example can be lack of empathy when addressing a clinical problem, such as ‘shaming’ an overweight patient whose diabetes has proven difficult to control. Although harder to define, words matter, and despite the best of intentions, physicians may unknowingly violate ethical boundaries by straying ‘off-script’ during patient encounters. It is the duty of each and every physician to be both intellectually cognizant and emotionally aware of how they are being heard, and to ‘consider their audience’ during professional encounters. Financial misconduct is both a sensitive topic and one which takes many forms. It can be directed against patients, employees or colleagues. An example that has received significant media attention involves so-called ‘out-of-network’ physicians covering emergency departments. After providing care, they then bill for services performed well in excess of what is known as the “usual, customary and reasonable fee.” While less prevalent in big cities, this can be a problem in rural hospitals, where there are fewer physicians per

capita and potentially just one or two insurers covering an individual market. A more insidious form involves physicians unnecessarily enlisting the aid of highly-trained colleagues to assist in procedures. Afterwards, they then double-bill the patient, often resulting in exorbitant charges. Interestingly enough, such practices are considered legal if they are agreed to when the patient signs consent, but are often hidden in the fine print — and rarely pointed out beforehand.

Unethical Behavior: Violations of the Stark Law

Yet another set of circumstances involves self-referral, which violates the ‘Stark Law’, or federal anti-kickback statute. A physician who orders a test or procedure on a patient that will result in a direct financial benefit to their practice violates this law. Although sometimes hard to define, doctors must always be wary of even the appearance of impropriety. More nebulous examples include pressuring colleagues for consults (mentioned in the opening casescenario), ordering of unnecessary tests, and sharing in reimbursement from referring patients to specific providers. Known as “fee-splitting,” this is not only unethical, but illegal in many states as well. The line separating unethical conduct from criminal behavior isn’t always clear. While not all unethical conduct is criminal, all criminal conduct is, by definition, unethical. And that brings us to our final subject: mistreatment by physicians of employees and colleagues. This by far is the most challenging to write about, and ultimately, the hardest to prove. Like financial shenanigans, it also comes in many flavors, and often gets swept under the rug. Understandably, it is often difficult to speak ill of a colleague, but certain circumstances at times may warrant action. The use of inappropriate language towards staff, while certainly unethical, is not criminal, while sexual advances, physical threats, and intimidation all rise to a more serious level. So how does one go about dealing with such a physician?

Unethical Behavior: Fear of Retaliation, Finding Solutions

In the opening scenario, the hypothetical new doctor was clearly being bullied by a more senior and established colleague. Young physicians, especially those in employed positions, may feel especially intimidated when confronted with disquieting behavior. Fear of retaliation and ‘blacklisting’ may drive a decision not to speak up, but depending on the circumstance, keeping quiet may be considered unethical as well. While ‘duty to report’ is generally thought of more in terms of incompetence or impairment, any behavior which puts patients at risk requires a robust response. Witnessing of harassment, invitations to participate in corruption, or abuse of any kind are intolerable situations and must be dealt with. For our young doctor, the first place to start is physician leadership, either a department chair or medical staff president. Often, concerns can be addressed and solutions reached without the need for further escalation. However, if the desired outcome remains elusive, other resources are available. Most hospital staffs have processes in place for

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dealing with grievances, which are usually spelled out in their institutional by-laws. Either the medical executive or an ad-hoc committee may be granted the authority to address ethical issues. Given that rules often vary between individual entities, it is important for physicians to be familiar with their home institution’s policies and procedures. Taking the time to do so may alleviate a significant amount of stress should the need ever arise, and make it easier to document unfortunate occurrences should legal action one day be taken. Beyond internal structures, both the county and state medical societies can also serve as important resources. While lacking the legal authority to intervene in Pennsylvania, said organizations can help steer physicians seeking aid down the appropriate path, either by serving as mediators or, when necessary, involving the state licensing board. Additionally, the AMA may also provide support via both personal and online resources. The AMA statement “Principles of Ethics” is available on the organization’s website and contains numerous answers to various dilemmas. In fact, it was the world’s first national code of professional ethics in medicine, and, at nearly 170 years of age, remains the oldest. This past summer, the AMA’s House of Delegates voted to affirm the most comprehensive update to the Code of Ethics in the past 50 years. This will not only help bring it into the 21st century, but also serve as a continuing reminder to the public and lawmakers of the medical profession’s commitment to self-regulation. On the state level, the Pennsylvania Medical Society also has a statement of ethics, which is similarly available online at www.pamedsoc.org.

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Ethical Behavior: Doing the Right Thing

I’ve painted a somewhat grim picture here, one that exposes an ugly side of medicine. But as a physician, I strongly feel that this topic deserves our utmost attention. Like the controversy over resident work hours, ethical dilemmas can be a challenge to solve, and equally uncomfortable to talk about. The overwhelming majority of physicians are outstanding, hardworking, and moral people, but like any other person, doctors can stray. Understanding where the lines are — and where to turn when one feels they’re being crossed — is vital to the maintenance of transparency and trust. In an era when medical professionals are drowning in an almost endless sea of mandates and regulation, it is important to show we are keeping our eye on the ball. By unswervingly putting patients first, we not only demonstrate our integrity, but gain credibility in pushing back against calls for even more rules and oversight. I’ve spoken many times in these pages about the sacred nature of the patient-physician relationship, and the importance of reclaiming it from outside influence. To do that, we must not only engage our patients, but make sure they know we are always acting in their best interests. In other words, that we will ‘do the right thing’. Always.

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An Ounce of Prevention is a Pound of Cure A Zika Recap

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ika virus was first discovered in 1947 and is named after the Zika Forest in Uganda. In 1952, the first human cases of Zika were detected and since then, outbreaks of Zika have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. Zika outbreaks have probably occurred in many locations. Before 2007, at least 14 cases of Zika had been documented, although other cases were likely to have occurred and were not reported. Because the symptoms of Zika are similar to those of many other diseases, many cases may not have been recognized. In December 2015, the Commonwealth of Puerto Rico, a United States territory, reported its first confirmed locally transmitted Zika virus case. Cases of local transmission have also been confirmed in two other US territories, the United States Virgin Islands, and American Samoa. Local mosquitoborne Zika virus transmission has been reported in two areas of Miami, Fla. (http://www.cdc.gov/zika/intheus/florida-update. html). There is no vaccine to prevent Zika.

Five Things You Need to Know About Zika Zika primarily spreads through infected mosquitoes. You can also get Zika through sex. Many areas in the United States have the type of mosquitoes that can spread Zika virus. These mosquitoes are aggressive daytime biters and can also bite at night. Also, Zika can be passed through sex from a person who has Zika to his or her sex partners. The best way to prevent Zika is to prevent mosquito bites. • Use EPA-registered insect repellent. It works! • Wear long-sleeved shirts and long pants.

• Stay in places with air conditioning or window and door screens. • Remove standing water around your home. Zika is linked to birth defects. Zika infection during pregnancy can cause a serious birth defect called microcephaly that is a sign of incomplete brain

development. Doctors have also found other problems in pregnancies and among fetuses and infants infected with Zika virus before birth. If you are pregnant and have a partner who lives in or has traveled to an area with Zika, do not have sex, or use condoms the right way, every time, during your pregnancy. Pregnant women should not travel to areas with Zika. If you must travel to one of these areas, talk to your healthcare provider first and strictly follow steps to prevent mosquito bites during your trip. Returning travelers infected with Zika can spread the virus through mosquito bites. During the first week of infection, Zika virus can be found in a person’s blood and can pass from an infected person to a mosquito through mosquito bites. An infected mosquito can then spread the virus to other people. Couples with a partner who lives in or has traveled to an area with Zika should take steps to protect during sex. For More Information

• Interim Guidance for Healthcare Providers Caring for Pregnant Women: MMWR: http://www.cdc.gov/mmwr/ volumes/65/wr/mm6529e1.htm?s_cid=mm6529e1_w • Summary: http://www.cdc.gov/zika/hc-providers/ pregnant-woman.html

• Fact Sheet with Testing Algorithms: http://www.cdc.gov/ zika/pdfs/testing_algorithm.pdf • Interim Guidance for Prevention of Sexual Transmission of Zika Virus: http://www.cdc.gov/mmwr/volumes/65/wr/ mm6529e2.htm?s_cid=mm6529e2_w

• Updated information on active transmission of Zika virus from the Florida Department of Health: http://www. floridahealth.gov/newsroom/index.html Reprinted with permission from the Centers for Disease Control and Prevention, www.cdc.gov.

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Mosquito Bite Prevention (United States) Not all mosquitoes are the same. Different mosquitoes spread different viruses and bite at different times of the day. Type of Mosquito

Viruses spread

Biting habits

Aedes aegypti, Aedes albopictus

Chikungunya, Dengue, Zika

Primarily daytime, but can also bite at night

Culex species

West Nile

Evening to morning

Protect yourself and your family from mosquito bites Use insect repellent Use an Environmental Protection Agency (EPA)-registered insect repellent with one of the following active ingredients. When used as directed, EPA-registered insect repellents are proven safe and effective, even for pregnant and breastfeeding women.

Active ingredient

Some brand name examples*

Higher percentages of active ingredient provide longer protection DEET

Off!, Cutter, Sawyer, Ultrathon

Picaridin, also known as KBR 3023, Bayrepel, and icaridin

Cutter Advanced, Skin So Soft Bug Guard Plus, Autan (outside the United States)

Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)

Repel

IR3535

Skin So Soft Bug Guard Plus Expedition, SkinSmart * Insect repellent brand names are provided for your information only. The Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services cannot recommend or endorse any name brand products. CS258143A

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February 17, 2016

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Meet Your County Medical Society Leaders PROFESSIONAL BACKGROUND

Dr. George Green graduated from the University of Pennsylvania Medical Center. He is board certified in internal medicine as well as allergy and immunology and works at Abington Medical Specialists in Abington. He is also a senior aviation medical examiner. Dr. Green is a member of the Montgomery County Medical Society (MCMS) Board of Directors and is also active in the Pennsylvania Allergy & Asthma Association. He has served on the MCMS Board of Directors for 28 years and works diligently on the Membership Services and Benefits and Finance committees. Name: George Green, MD Specialty: Internal Medicine, Allergy & Immunology Currently Practices: Abington, Pa. Montgomery County Medical School: University of Pennsylvania Medical Center Residency: Mayo Clinic Fellowship: University of Pennsylvania Medical Center Birthplace: Philadelphia, PA Residence: Huntingdon Valley, PA

Why I chose a career in medicine: I initially had registered to go to MIT for engineering, but a neighbor who was an internist got me interested in medicine. I ending up embarking on a medical career at St. Joseph’s in Philadelphia and continued on to medical school at the University of Pennsylvania Medical Center (HUP). I did a rotating internship at HUP followed by a medical residency at the Mayo Clinic, and then an allergy and immunology fellowship back at HUP. I was then asked to stay on as faculty and take over the practice of my chief who left HUP that year. Describe your job: I am in a group practice (Abington Medical Specialists) where I now work part time mostly seeing patients with allergic or immunologic diseases. I am also a senior aviation medical examiner and sees pilots for their periodic flight physicals. Most rewarding elements of your career: Patient care. To be the recipient of the training to diagnose and treat such varied illnesses and have such grateful patients is such a gift. Most interesting day in medicine: When Dr. Francis Wood, chief of medicine at HUP, told me that he could not take me as a medical resident since Dr. I. S. Ravdin, chief of surgery, had already selected me to be one of his residents. In the end, Dr. Wood arranged for me to be accepted to the medical residency at the Mayo Clinic. Interesting childhood fact: I was the eighth of 10 children born during the great depression. I grew up during WWII while my two older brothers fought across Europe with General Patton. After the war, we moved to a farm in the far northeast Philadelphia area. How did you end up practicing in Montgomery County: I was recruited to work part-time with a cardiologist and pulmonologist at Abington which gradually became my main practice. I was able to maintain my academic rank as clinical professor at HUP through part-time practice, clinic and research.

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What interests me outside medicine: Other interests include flying (I still own a Piper Saratoga) and hunting and fishing. I am a member of Bright Creek Park Association. If I could be anything other than a physician: I would be an airline pilot. As a long-time aviation medical examiner, I see many pilots and am impressed with their professionalism. My family: Trudy and I have four wonderful children and eight grandchildren. The children are happy in their chosen professions. George Jr. and his wife Karen are architects in northern New York; Trudy is a high school art teacher in Lower Moreland, and her husband, J. Smith is a coastal engineer with the U.S. Corps of Engineers; Matthew is the chief financial officer for a Geneva-based Pharmaceutical Company in Singapore, and his wife, Julie is a high school math teacher at the Singapore American School; and David is an internist working as a hospitalist for the Intermountain Medical Group and is chief of medicine at the Latter Day Saints Hospital in Salt Lake City, Utah. I greatly admire: My mentors at Penn and Mayo. Most interesting moment in medicine: Presenting my first research paper to the general session at the American College of Physicians annual meeting You may not know: I am a senior aviation medical examiner and avid pilot with current IFR qualifications and over 3,000 hours experience flying. I received the “Distinguished Service Award” from the American Academy of Allergy, Asthma and Immunology in February 2016. Why I stay involved in organized medicine: I love being a physician and feel that we need the AMA and the state, county and specialty societies to advocate and preserve our ability to practice. Advice to young physicians: Young physicians should look forward to the challenge of caring for their patients as a gift that you owe to yourself.

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IN C ASE YOU MISSED IT

Why don’t hospitals want physicians and nurses to collaborate? The following is a statement from Scott Shapiro, MD, president of the Pennsylvania Medical Society and a practicing physician in Montgomery County. Dr. Shapiro reacts to the Hospital & Healthsystem Association of Pennsylvania deciding collaborative agreements between physicians and nurse practitioners are not important.

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t a time when hospitals are being criticized for nurse staffing shortages, the Hospital & Healthsystem Association of Pennsylvania (HAP) has decided to fracture healthcare teams by supporting legislation that would remove important patient safeguards. The Pennsylvania Medical Society (PAMED) believes HAP should be working to bolster physician and nurse collaboration and supporting legislation that would help to insure that hospitals and health systems across the commonwealth have the appropriate number of nurses on staff. Many Pennsylvanians have personal experience of being in a hospital, needing a nurse, but having none available to help them. Moreover, family members of patients should not have to roam the halls looking for a nurse when their mother, father, or child needs help. This concerns physicians greatly, and it should concern HAP. PAMED believes patients deserve better. With the complexity of patients increasing, and the need to promote team-based care between healthcare professionals, now is not the time for hospitals to make things worse by further risking the safety of their patients by lobbying to eliminate physician-nurse practitioner collaboration. Instead, HAP should be promoting team care that is best for patients and providers. Studies have consistently shown that when healthcare professionals work together in a coordinated, efficient manner, care improves. So, why don’t hospitals want physicians and nurses to collaborate? It all comes down to cost. Hospital administrators think that the costs associated with physician and nurse practitioner collaboration are eating into system profits. Apparently, they see the elimination of these agreements as a way to save money. Just as hiring more nurses costs more money, so too does the cost of making sure that physicians and nurse practitioners collaborate. But isn’t patient safety worth that investment? Physicians and

nurses working together should be driving patient care, not hospital administrators. Mike Young, a HAP Board member and CEO of PinnacleHealth in Harrisburg, summed up the perspective of many in hospital leadership when he said “I, as CEO of PinnacleHealth, lead the healthcare team” at a House of Representatives hearing in Harrisburg last October. PAMED and Pennsylvania patients could not disagree more. Physicians should lead healthcare teams, making the best decisions for a patient’s care based on medical practice and science, not hospital costs and profits. Every day, PAMED physician members and their patients rely on the nursing profession to extend care whether it is on a hospital floor or in a physician office. The likelihood of a medical error happening increases as patient safety nets are removed. Today, hospital patients are more acutely ill than ever before with medical complexities and co-morbidities that require a high degree of attention from both the nursing and medical professions. Rather than supporting efforts to throw out collaborative agreements, HAP and nurse practitioners should be looking to advance House Bill 476 and other initiatives to safeguard the provision of quality healthcare. PAMED urges HAP to keep the team together and work to support physician and nurse practitioner collaboration, not eliminate it. Pennsylvania patients deserve better. Update on Issue: On the evening of July 12, the Senate passed Senate Bill 717 – legislation which would allow CRNPs to practice independently and eliminate the requirement that they collaborate with physicians – by a vote of 41-9. The bill now goes to the House of Representatives for consideration, where it has been referred to the Professional Licensure Committee. See additional details in the quarterly legislative report found on page 28. The Pennsylvania Medical Society was founded in 1848. To learn more about PAMED, visit its web site at www.pamedsoc.org or follow on Twitter @PAMEDSociety.

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MCMS Honors Longtime Practicing Physicians and Installs Its 167th President

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early 100 physicians and their guests enjoyed fellowship with colleagues, family and friends during the Montgomery County Medical Society (MCMS) of Pennsylvania annual membership dinner on June 7. MCMS installed Jay E. Rothkopf, MD, as its president and recognized nine physicians who have practiced medicine for 50 years — Randall W. Bell, MD, FACS; Richard J. Carella, MD; Albert T. Derivan, MD; Anthony J. Fugaro, DO; Jack Lebeau, MD; Ronald Liebman, MD; Arthur B. Lintgen, MD; Stephen Pripstein, MD; Eli W. Zucker, MD. “I cannot understate the role he [his father] played in cementing my decision to become a doctor,” said Dr. Rothkopf at the dinner as he recalled witnessing and being inspired by the medical careers of his father and grandfather as a youth. “Henry [his grandfather] laid the foundation of my interest, but it was Dad who brought me into this field. It was from him I learned the depth of commitment, the meaning of the relationship between physician and patient, a bond that sometimes had to take precedence over family.” Today, the Temple University School of Medicine graduate carries forward his family’s legacy of being a compassionate physician and servant leader. The avid writer shared vivid details of childhood memories that illustrated how his grandfather and father would navigate the challenges and rewards of taking care of their patients. As MCMS president, Dr. Rothkopf plans to help physicians navigate the changing landscape of medicine by focusing on strengthening patient–physician relationships. Patient engagement is key to changing the healthcare paradigm by restoring its primacy and freedom from unwelcome influence and unreasonable demands. ”I envision a future where our patients are our partners, not only in maintaining their health, but in advocacy, shaping policy, and helping to remake the practice landscape,” said Dr.

Rothkopf, a hospitalist with OnCall Hospitalist Staffing. “Our patients are a resource, one which we can not only teach, but from whom we can learn. We must help them to understand the issues, and show them where their power lies: the vote.” As a physician, husband to Debbie and father to Michael and Matthew, the Ft. Washington resident understands firsthand the frustrations of his patients and his colleagues. He, too, is a patient who lives daily with managing an incurable medical condition -- Crohn’s Disease. “If the foundation of any lasting relationship is trust, then it’s time to entrust (patients) with helping us reclaim the bond that is at the center of our profession. Our patients trust us with the most precious thing they have — their health. They trust us with their secrets, their hopes, their fears. Isn’t it time we trust them too?” he asked. The dinner’s keynote speakers shared similar sentiments. For years, New Jersey physicians Dr. John Eck and Dr. Alieta Eck have been at the forefront of physician and patient advocacy and believe better care is not wrapped in more government regulations. They shared how they handled their frustration with the inadequacy of New Jersey’s health insurance system. In 2003, the Ecks founded Zarephath Health Center, a free clinic for the poor and uninsured that is described as faith in action. The clinic cares for more than 300 patients per month by utilizing the donated services of volunteer physicians and nurses. The center gives physicians an opportunity to revert back to the old model of donating time each month to care for the poor and uninsured. The physicians and staff believe that being uninsured does not have to be a cause for despair but can be an opportunity for others to reach out and help people who have fallen into hard times.

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Grandpa Inspired Journey to Become a Physician

Newly Installed President Takes a Trip Down Memory Lane ( Dr. Jay E. Rothkopf, MD, was sworn in as the 167th president of the Montgomery County Medical Society. The following are excerpts from his installation speech. You can find the full speech at www.montmedsoc.com.) Wyncote, PA, 1983. A modest house on Bach Road, not far from Cheltenham High School. It’s 8:30 at night, early June. Outside, the air is warm and muggy, filled with the chittering chorus of hunting bugs. There’s still enough light to make out the trees, but not for long. Overhead, the evening’s first stars are beginning to glitter like a dust of diamonds. A voice echoes down the street. It’s the sound of teenagers at play, giddy with the freedom only summer can bring. But inside, it’s a different world. A little boy, newly turned six, scampers up the stairs to his pop-pop’s study. The door is open, and he wanders inside. There’s a lamp on the desk, one of those heavy-duty ones with a 100watt bulb. It casts long shadows across the piles of clutter, but the boy doesn’t notice. A man is sitting there, glasses on, elbows resting on the faded wood, forehead creased as he peruses a report. He hasn’t noticed the boy yet. On tiptoe, the boy creeps inside, silent as a mouse on the thin green carpet. Closer, closer, and...BAM! He jumps into the older man’s lap, searching for a hug. His concentration broken, but in a good way, the statelylooking man — still dressed in his work shirt, but minus the tie — lays down the piece of paper and gives him a squeeze. His desire fulfilled, the boy wiggles free and slides down to the floor. “Would you like a story?” the man asks. “Yes please.” The man points towards the bed, a smile on his face. “Hop up.” The boys obeys, snuggling into the pillows like a week-old puppy. Once settled, the man begins to talk. “The year was 1942,” he begins, “and I had just landed on a base in Burma...” I don’t remember all the details of that night, but the disease we discussed is still fresh in my mind—lichen planus. I’m sure I learned a lot about it, but 34 years later, all I can remember is the name, and the sense of wonder at hearing his stories. My grandfather, Henry Rothkopf, passed away in 1996. By the age of 82, he’d seen many places and been many things. But if you asked him, he’d always say he was a physician first. From his days as a flight surgeon in that distant war to his decades practicing in North Philadelphia, medicine was his first love —

followed closely by tennis. Even two bypass surgeries couldn’t keep him down, and he continued to see patients until three months before his death from multiple myeloma. Even when not feeling well, he still went to work until the chemo made him too weak to drive. The bedtime stories soon gave way to readings from a special text—the 1967 Merck Manual. I wished I could’ve brought it here tonight, but sadly, it’s long gone. Most of you would find it quaint, a miniature tome from which HIV and the five flavors of hepatitis are conspicuously absent. It had rabies though, and for many years that was my favorite disease. I mean, think about it—a virus that transforms a human being into a wild animal. For a kid, there was nothing cooler. Or more scary. I see the world a lot differently now. As the years slowly passed, I began to spend more time with my father, himself a cardiologist who practiced with Pop-pop. Although he passed away back in 2009, I cannot understate the role he played in cementing my decision to become a doctor. Henry laid the foundation of my interest, but it was Dad who brought me into this field. It was from him I learned the depth of commitment, the meaning of the relationship between physician and patient, a bond that sometimes had to take precedence over family. It was through him that I was first exposed to death. 1987. Albert Einstein Medical Center, East Tower. Her name was Elsa Freed, a shriveled little woman who’d been admitted with congestive heart failure, and she wasn’t doing well. She was 102, and the image of her wrinkled face turning up to gaze at mine will be forever burned into my brain. Why, you might ask? Simple — It was during that encounter that Mrs. Freed died. One moment, she was stroking my cheek, her eyes filled with the longing and even faint hint of jealously the very old sometimes feel when exposed to the very young — and then her hand fell back, her eyes dimming like the last sparks of a summer campfire, and she was gone. Dad sprang into action, shouting out her name and digging his fist into her chest with what years later I would learn was called a sternal rub. Within seconds, the room was packed, and I was gently shooed into a corner before the curtain was pulled, obscuring my view. I remember a lot of loud voices and funny

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sounds — the swish of the ambu-bag, the loud clicks from the defibrillator. And then it got quiet. The curtain retreated, and the team shuffled out. Hidden beneath the sheet, I couldn’t see the body...but I wanted to. I felt an odd mixture of fascination and fear, like turning on a movie you’re not supposed to see. I wasn’t quite sure what had happened, but I knew it wasn’t good...and I wanted to know more. But before I could ask any questions, Dad shooed me out, and the orderlies came in. It wouldn’t be the last time I watched somebody die. So where am I going with this? What’s the point of all the nostalgia? For one thing, it’s given me perspective on the state of medicine today. Since becoming an attending seven years ago, I’ve heard many lament the death of “ownership,” the idea that our patients must always come first, no matter what time it is or what other obligations we may have. A whisper has grown that doctors are becoming shift workers, more concerned with lifestyle and going home at five o’clock than staying late to do that one extra admission, or meet with the anxious family who couldn’t get in until late in the day. With all the pressures physicians now face, the erosion of autonomy has taken center stage. When referring to what’s happened, I’ve heard some people — usually other doctors — say “they don’t make ‘em like they used to.” Depending on your generation, you might agree...but I don’t. As doctors, we often look back, even wallow in a “Golden Age” where our respect was never questioned, our decisions went unchallenged, and the patientphysician relationship was sacrosanct, free from the interference of insurance companies and non-clinical hospital administrators. A lot of that is gone now, but it is not forgotten. Nor is it beyond our reach. To be fair, I never practiced in that time, but I’d like to think that at least on some level, I understand the mindset, the emotion behind wanting to hold on, to preserve. Behind the fear that somehow, something special is slipping away, and that if we don’t act soon, all will be lost. With all the hats physicians now must wear, with all the battles we’ve been forced to fight, we’ve been hesitant to enlist the one resource that can help us turn the tide: our patients. It sounds different, I know, but hear me out. (Want to read more of Dr. Rothkopf ’s riveting installation speech,visit www.montmedsoc.com .)

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The Philadelphia Soda Tax, Obesity and Public Health BY SHERRY L. BLUMENTHAL MD, MSED, FACOG

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ayor Jim Kenney of Philadelphia proposed a 3-cent per ounce tax on sugar-sweetened beverages as a mechanism to fund pre-K education and other city health and education programs. In June, the Philadelphia City Council agreed and approved a 1.5-cent-per-ounce tax on sugarsweetened and diet beverages, the first such tax imposed in a major U.S. city. While Mayor Kenney and his supporters are not touting this tax as a way to improve public health, there may be huge benefits (pun intended) and most municipalities and countries that have successfully levied this tax have done so to improve the health of the populace. The city plans to start collecting the tax Jan. 1. Philadelphia’s tax will be levied on distributors. Only time will tell how much the tax will affect consumers.

L ink Be twe e n Su gar an d O b e s ity? I have noted a slow increase in the weight of my gynecologic patients at each of their yearly visits. I asked one obese patient to describe her diet and she responded “I do not eat that much.” In fact, her food consumption was not excessive. Then I asked what she drank, and discovered that she downed two liters of Coca-Cola a day! There are studies linking consumption of sugar and sugary beverages, soda in particular, to a growing public health crisis — obesity. Philadelphia has the distinction of being one of the fattest cities in the U.S., and our country is one of the fattest in the world. Obesity in children and adults has sky-rocketed. This has led to a substantial increase in type II diabetes, coronary

artery disease, stroke, obstetric complications that may impact offspring of obese women, and numerous orthopedic problems. As Mark Bitman writes in the May 25 New York Times article, “There are those — including (one) presidential candidate — who oppose soda taxes as a regressive tax on the poor. But it is poor people who are disproportionately targeted in the marketing of sugary foods, and poor people who most suffer the health consequences of consuming them. Furthermore, as Philadelphia’s plan demonstrates, this tax will benefit low-income residents in two ways: It will increase their services and decrease their likelihood of developing chronic disease. Nothing regressive about that.” I agree with his comment. Studies have shown that urban poor communities have less access to fresh fruits and vegetables. Additionally, humans, who are drawn to sugar and simple carbohydrates, tend to purchase foods in convenience stores that provide minimal nutrition but maximum calories. Increasing funds for education also increases the opportunity to educate children about nutrition and encourage consumption of healthier options. According to the Centers for Disease Control (CDC), the 2015 obesity rate in young adults increased to 26.5 percent. The rate is 34.6 percent in adults between ages 40 and 59, and 30.1 percdent in adults 60 and over.

O b e s i t y L i n ks to O t h e r D i s e a s e s There are more obese women than men. In obstetrics, the risks of pregnancy in the obese are well known. There is an increase in gestational diabetes, large-for-gestational age fetuses, hypertension and pre-eclampsia, congenital anomalies, intrauterine fetal demise and neonatal death, spontaneous abortion and recurrent miscarriage. Maternal obesity causes epigenetic changes in the fetus, predisposing him or her to obesity,

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News & Announcements metabolic syndrome, and earlier adult death than fetuses of normal-weight women. Obese pregnant women have a higher risk of delivering by cesarean section and also a higher risk of surgical complications such as infection and thrombotic episodes. Cancer risk is higher in obese women. There is a significant increase in breast, ovarian, and endometrial cancers. In both sexes, there is increased risk of kidney, pancreatic, stomach, and esophagus cancers and higher rates of prostate cancer in men. Cancer treatments are more difficult and may be less effective in the obese since radiation treatment areas may be harder to localize and higher doses may be needed. Chemotherapy doses required may be higher also, and more toxic to the patient. Survival in some cancers, such as cervix in women, are lower in the obese. The cost of the morbidity in the obese, such as more need for joint replacement and higher complication rate of surgery, is significant. Equipment needs to be modified for obese patients and hospitals are purchasing larger wheelchairs, seats, operating tables, and surgical equipment. It appears that weight loss is very difficult to sustain, especially in the extremely morbid obese category. Therefore our best strategy is prevention, which begins in childhood. “Soda producers and distributors, as well as the Teamsters members who deliver the product, argue that the tax is a job killer, and may spend as much as $10 million to make that case. There’s zero evidence to substantiate that claim; people who don’t buy soda will most likely buy other beverages, in most cases produced by the same companies.” Many cities, notably Berkeley, CA, have levied “Soda taxes” as a ballot initiative, but a notable “laboratory” for change has been Mexico, “which established a national tax on soda and junk food in January 2014. In that country of 120 million people, sales of sugary beverages have indeed declined, while those of bottled water have increased,” according to Bitman. The Food and Drug Administration has changed food labeling to include “added sugars.” Ingredient labels are highly deceptive — they may list sugar in many different ways, i.e. “evaporated cane juice,” brown rice syrup, and corn syrup. There may be four different names for sugar in one product, misleading the public as to how much they are consuming.

Sug ar i s N ot th e O n l y Cu l pr it Sugar in our diets is not the only culprit — large portions, processed foods, and high fat foods also contribute to the obesity epidemic. Sugar, however, is a large contributor, and there are multiple benefits to the public health by taxing consumption of sweetened beverages to reduce consumption and raise money for needed services. Shame on the beverage industry to misrepresent this tax as a “grocery tax”! I hope that soon this tax can be on the ballot for approval in Montgomery County and the rest of Pennsylvania. It appears to be a winwin situation. Sherry L Blumenthal, MD,MS Ed, FACOG, is a retired Obstetrician/Gynecologist previously on staff at Abington Memorial Hospital. She is past chair of the PA Section of The American Congress of OB/GYN, on the Board of MCMS, and the Obstetric Trustee to the PAMed Board of Trustees. She lectures and writes on Obesity in OB/Gyn. M C M S P H Y S I C I A N 21 FA L L 2 0 1 6

Welcome New Members MCMS is pleased to welcome the following individuals who joined the Society: April 2016 Anitha Bhat, MD Michael Choe, MD Colleen Dempsey, MD Joel Sorosky, MD, FACS May 2016 Elena Kazlo, DO June 2016 Kathleen Faccio, DO Nancy Finnigan, DO Marina Goldman, MD Barani Mayilvaganan, MD Margarita McDonald, MD Rupal Patel, MD Firas Saidi, MD Amruta Unawane, MD, MBBS July 2016 Darwin Deen, MD Kirstin Sanborn, DO August 2016 Zain Ali, MD Odunayo Banjoko, MD Robert Gerring, MD Ida Micaily, MD Aditya Munshi, MD Harrison Winters, Medical Student To publish photos of new MCMS member physicians, please submit digital copies to montmedsoc@verizon.net

Necrology Report

MCMS regrets the loss of these society members since April 2016. Stanley M. Nowacki, MD Fred D. Raymond, Jr., MD

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SURGERY AND OPIOIDS: Changing the perioperative patient experience and expectation

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hould patients expect their doctor to write an opioid prescription when recovering from surgery? In recent years, they have. Studies show that not only are patients going home with a prescription for drugs like oxycodone, but they’re also filling those prescriptions at a high rate. A report published in the Journal of the American Medical Association ( JAMA) in March 2016 found that out of 14 million patients studied who underwent certain operations considered low-risk, 80 percent filled a prescription within seven days for any opioid. The overwhelming majority – 86 percent – of these prescriptions were for hydrocodone/ acetaminophen or oxycodone/acetaminophen. Another study also published in JAMA during March 2016 involved more than 2.7 million Medicaid subscribers who had a tooth removed. That study found 42 percent filled a prescription for an opioid within seven days. “Pretty clearly, opioids after surgery have become a routine of postoperative pain management,” said Scott Shapiro, MD, president of the Pennsylvania Medical Society (PAMED). “However, with worries rising about the addictive nature of certain pain relievers and pressure building to address an overreliance on such medications, the days of this type of prescribing are numbered.” Dr. Shapiro said as prescribing practices change, patient expectations and thus patient satisfaction when recovering from surgery will need to be nurtured as other options are tried.

OPIOIDS EXPLODE ONTO THE SCENE Although Americans make up only 4.6 percent of the world population, they consume 80 percent of global opioid supply. That figure increases to 99 percent when looking at hydrocodone.

From 1997 to 2007, retail sales of commonly used opioid medications jumped from 50.7 million grams to 126.5 million grams. With such increase, it should come as no surprise that the number of people who admitted to abusing painkillers also increased. One study suggests that between 1992 and 2003, there was a 90 percent surge in abuse. “Emergency departments often see the end-result of opioid abuse,” said Merle Carter, MD, FACEP, president of the Pennsylvania College of Emergency Physicians who practices medicine in Philadelphia. “Certainly over my career, I’ve seen too many individuals end up in my emergency rooms who have overdosed.” In mid-February 2016, Modern Healthcare took a closer look at the root of the country’s opioid abuse problem and traced it back to 1996 when Purdue Pharma began promoting a new drug to fight pain – OxyContin. Early on, the medication was billed as being safe because it would slowly release narcotic ingredients, making it unlikely to become addictive. “We were told that this new drug would be the answer to many issues related to pain, particularly since a year earlier pain became the fifth vital sign and the American Pain Society recommended it be added to the indicators that assess overall health,” said Bradley Levin, MD, FACC, FACS, FASAM, DABAM, CMRO, of York County Medical Society who is also a member of the York County Heroin Task Force. According to Dr. Levin, there was even a time when physicians would be penalized for not prescribing opioids. Nearly 10 years later in 2007, Purdue would plead guilty in federal court to criminal charges that they misled regulators, doctors, and patients about the drug’s risk of addiction as well as its potential to be abused. “We know better today, but the beast was unleashed and as addictions grew so did doctor shopping and other illegal activities,” said Dr. Levin. “Those seeking pills got really good at finding what they wanted and in some cases pushed the drug out onto the street.”

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Post-surgery: If Not Opioids, Then What? While opioids have been the primary treatment for pain while recovering from surgery, side effects and adverse reactions are possible, and they’re being addressed by both physicians and patients. “Opioids can cause nausea, confusion, vomiting, constipation, and respiratory depression as well as the risk of abuse,” said Patrick Smith, MD, vice president of the Pennsylvania Orthopaedic Society (POS). “Orthopaedic surgeons are implementing multimodal protocols in the presurgery period as a means to reduce patient pain, shorten the recovery period and avoid opioid use.” According to Dr. Smith, who is chair of the POS Opioid Task Force, orthopaedic surgeons begin postoperative pain reduction modalities at least one week prior to surgery. Total knee replacement is a prime example. In the past, this procedure required hospitalization for almost a week in addition to several weeks of post-surgery opioid pain medication.Today’s multimodal approach allows patients to take fewer narcotics and spend only a day or two in a facility. The Enhanced Recovery After Surgery (ERAS) protocol begins at least one week prior to surgery with a diet rich in carbohydrates and protein as well as hydration with sports drinks. On surgery day, a patient receives oral medications designed to reduce pain by working in several different ways: an anti-inflammatory medication reduces swelling; a neuromodulating medication blocks pain receptors; and a long acting narcotic reduces actual pain. In addition, an adductor canal catheter is inserted preoperatively and connected to a pump for up to 48 hours of post-operative pain control. The ERAS protocol further enhances pain management by intraoperative injection of the knee capsule with a mixture of bupivacaine with epinephrine and ketorolac. Postoperatively, the anti-inflammatory, neuro-modulating and narcotic medications are continued. Using this multimodal technique, post-operative pain is controlled well enough to allow the patient to ambulate in physical therapy within a few hours of surgery and to leave the hospital setting within a day or two. The patient may still require oral narcotic analgesics in the early postop period, but narcotics are quickly weaned and the patient is transferred to non-narcotic medications typically by six weeks post-op. “Orthopaedic surgeons across the country regularly perform procedures that make a difference in a person’s life, but comes with some degree of pain while recovering,” he said. “With the ERAS, we are partnering with our patients to reduce post-operative pain and to quickly return them to their active lives.” Mackenzie Moran of Carlisle, Pa., is a lacrosse player at Baldwin Wallace University in Ohio, who early in the 2016 season tore both her ACL and meniscus. She’s also a patient whose doctors used a combination of therapies – before, during, and after surgery – to address pain. Hours after her surgery she was home resting, and within days back in classes at Baldwin Wallace.

“Recovery isn’t fun, and some pain was part of my experience,” she said. “Between my team doctor from the Cleveland Clinic, athletic trainers at Baldwin Wallace, my surgeon at Penn State, and a physical therapist in my hometown, I had a plan that included a variety of ways to ease my pain ranging from a nerve block to ice. I really only used Percocet for a short time and everyone encouraged me to minimalize using it.”

‘Be Smart. Be Safe. Be Sure.’ Launches Back at the Pennsylvania Medical Society, Dr. Shapiro sees a need for greater patient empowerment as part of the solution to the country’s opioid crisis. “It’s as much a part of the answer as physician education, prescribing guidelines, and opioid tracking,” he said. “Patients will see prescribing patterns change and alternative options tried to reduce opioid use. That’s going to be the new expectation instead of relying so heavily on opioids.” As such, Dr. Shapiro’s organization launched a patient empowerment advocacy program in May titled “Opioids for Pain: Be Smart. Be Safe. Be Sure.” According to Dr. Shapiro, the initiative will educate the public through physician offices and state politicians who offer health and senior fairs. Social media will also be tapped. “Patients in pain deserve care and compassion,” Dr. Shapiro said. “Treating pain is among the most difficult – and most common – reasons patients come to us. “As physicians, we are often under pressure to ‘satisfy a patient’s pain’ and sometimes this requires prescribing an opioid,” he said. “But caring also means sometimes saying no and recommending an alternative course of treatment – no matter how difficult that may be.” Dr. Shapiro said the initiative will encourage patients to ask their doctors several important questions when a prescription is written. Questions include 1. Is this prescription an opioid? 2. At what level of pain should I take this prescription? 3. Do I have to take every pill in the prescription? 4. Where can I safely dispose of remaining pills? 5. What can I do to avoid addiction? 6. What are possible warning signs of dependence or addiction? 7. What can I do if I believe that I might have developed a dependence on this drug? “Ultimately, when it comes to opioid use, patients and their doctors need to be smart; they need to be safe; and they need to be sure,” Dr. Shapiro said. “That’s our key message.” For more information about the Opioids for Pain: Be Smart. Be Safe. Be Sure initiative, visit www.pamedsoc.org/opioidinfo. Reprinted with permission from the Pennsylvania Medical Society (PAMED). Information brought to you by the Pennsylvania Health News Service Project, consisting of 21 Pennsylvania-based medical and specialty associations and societies. Inquiries about PHNS can be directed to Chuck Moran via the Pennsylvania Medical Society at (717) 558-7820, cmoran@ pamedsoc.org, or via Twitter @ChuckMoran7.

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Fighting Opioid Abuse in Pennsylvania INTRODUCING PAMED’S INNOVATIVE EDUCATIONAL SERIES AND OTHER RESOURCES HEALTHCARE TEAMS CAN USE TO ADDRESS THE OPIOID CRISIS The problem: Opioid abuse, misuse, and overdoses are increasing, both in Pennsylvania and nationally. While some requests for pain medication are legitimate, others are likely to be from pill scammers who have become addicted to opioids. The solution: A multi-pronged approach that includes physicians, patients, and healthcare organizations like the Pennsylvania Medical Society (PAMED) working collaboratively to address this growing epidemic.

PAMED, in collaboration with the Pennsylvania Department of Health and 11 other healthcare associations, is creating a comprehensive online educational resource to help prescribers combat this problem. “Addressing Pennsylvania’s Opioid Crisis: What Healthcare Teams Need to Know” is a multi-part course that examines all the tools prescribers can use to identify patients with addiction issues and get them help. The first session of the course addresses how prescribers can use the statewide voluntary opioid prescribing guidelines, and the second session takes a closer look at the state’s naloxone law. Both are available at www.pamedsoc.org/ opioidscme. Additional sessions are forthcoming. This educational series features: • Videos and interviews with physicians, other prescribers, and state officials working on the front lines of the crisis • The latest statistics and data • Details on how to use opioid prescribing guidelines for physicians, emergency departments, and other providers • Scenario-based learning to help implement the lessons into daily practice

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This crisis spans nearly every state in the U.S., but has hit Pennsylvania particularly hard. Nearly 2,500 deaths were reported in Pennsylvania as a result of drug overdoses in 2014, and more people die from drug overdoses than in car accidents. No one disputes the magnitude of the prescription drug abuse crisis in Pennsylvania and the nation at large. The question is, how do we combat the problem? “I think that we have to understand this is a public health crisis and we all have a role to play in terms of solving this,” said PAMED member and Pennsylvania Physician General Rachel Levine, MD.

THREE WAYS TO INCREASE YOUR CONFIDENCE IN MANAGING OPIOID THERAPY 1. Familiarize yourself with these state-endorsed, voluntary guidelines for opioid prescribers in Pennsylvania: • Chronic Non-Cancer Pain • Emergency Department Pain • Geriatric Pain • Obstetrics and Gynecology Pain • Pain in Dental Offices 2. Get involved with grassroots advocacy and initiatives by having a discussion with the physicians in your county or region. Call PAMED’s Speakers Bureau at (800) 228-7823, ext. 2620 for details. 3. Have a conversation with your chronic pain patients using PAMED’s Opioid Prescription Checklist to help facilitate the pain-management discussion. Visit www.pamedsoc.org/opioidresources to access these resources and more.

“We need to get past the idea that these are somehow just drug abusers that are miscreants and throwaway members of our society,” said Dr. Levine. “This crisis hits everyone — our mothers, fathers, brothers, sisters, sons, daughters, rural, urban, suburban,” she said. “We have to get past the idea that this is someone else’s problem. We have to get people into treatment and recovery. Addiction is a disease; we have to erase the stigma.” PAMED’s education seeks to address the many layers and complexities of this crisis. Learn more and get CME credit by visiting www.pamedsoc.org/opioidscme. Access additional resources such as prescribing guidelines in PAMED’s Opioid Abuse Resource Center at www. pamedsoc.org/opioidresources. “Opioid CME is not currently mandated by the state, but one way to ensure it stays that way is for Pennsylvania physicians to use the voluntary opioid guidelines and take this voluntary CME,” said Dr. Levine.

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Helping Finance Physician Education

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he Foundation of the Pennsylvania Medical Society, a nonprofit affiliate of PAMED, sustains the future of medicine in Pennsylvania by providing programs that support medical education, physician health, and excellence in practice. It has been helping finance physician education for more than 60 years. “We recognize that medical students play a vital role in the future of medicine in Pennsylvania, so we proudly administer scholarships to deserving students across the commonwealth,” said Heather Wilson, the Foundation’s executive director. Applications for several scholarships will be accepted July 1– Sept. 30, 2016.

Myrtle Siegfried, MD, and Michael Vigilante, MD, Scholarship. Students residing in Lehigh, Berks, and Northampton counties and entering their first year at a U.S. medical school may apply for the $1,000 award.

Allegheny County Medical Society Medical Student Scholarship. Residents of Allegheny County can apply for a $4,000 award. Applicants must be enrolled full-time at a Pennsylvania medical school as third- or fourth-year students.

Scott A. Gunder, MD, DCMS Presidential Scholarship. Secondyear students at Penn State University College of Medicine who are Pennsylvania residents may apply for this $1,500 award. Postmark deadline: April 15.

Blair County Medical Society Medical Student Scholarship. Blair County residents attending a United States medical school may apply for the $1,000 award. Applicants must also be enrolled full-time as second-, third-, or fourth-year students.

To find out more about scholarships, call the Foundation at 717-558-7852, or visit the Student Financial Services page at www.foundationpamedsoc.org. Since 1948, more than $19.6 million in loans and scholarships has been awarded to nearly 4,500 students. Thank you to the generous contributors who have made these scholarships possible! If you would like to donate to the future of medical education through any of these designated funds, make your check payable to The Foundation of the Pennsylvania Medical Society, and indicate which scholarship you would like to support in the memo line. Mail your gift to the Foundation of the Pennsylvania Medical Society, 777 E. Park Drive, Harrisburg, PA, 17105. If you have questions regarding support of student scholarships, please feel free to contact Marjorie Lamberson, CFRE, via email at mlamberson@ “ONE IN TEN pamedsoc.org or by phone at ” 717-558-7846. SUPWHY SHO

Endowment for South Asian Students of Indian Descent Scholarship. Pennsylvania residents of South Asian Indian heritage may apply for this $2,000 award. Additionally, applicants must be enrolled full-time as second-, third-, or fourth-year students at a Pennsylvania medical school. Lehigh County Medical Auxiliary’s Scholarship and Education Fund Scholarship. Lehigh County residents attending a U.S. medical school full-time may apply for this $2,500 award. Lycoming County Medical Society Scholarship. Lycoming County residents attending a U.S. medical school full-time may apply for a $3,000 award. Two recipients will be selected. Montgomery County Medical Society Scholarship. Montgomery County residents attending a U.S. medical school as first-year students may apply for this $1,000 award.

Additional scholarships are available each year with alternate deadlines: Alliance Medical Education Scholarship. Pennsylvania residents attending a Pennsylvania medical school as second- or third-year students may apply for a $2,500 award. Multiple recipients will be selected. Postmark deadline: Feb. 28.

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Meet Your Montgomery County Health Department Administrator Irshad Ali Shaikh, MD, MPH, Ph.D. BY VALERIE ARKOOSH, MD, MPH MONTGOMERY COUNTY COMMISSIONER

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am pleased to introduce Dr. Irshad Shaikh, recently appointed Health Administrator of the Montgomery County Health Department (MCHD). A medical epidemiologist and a health manager by training, Dr. Shaikh brings more than 18 years of experience in public health practice at global, federal, state and local levels. He has held staff positions at leadership levels within the United Nations/ World Health Organization (WHO), U.S. Centers for Disease Control and Prevention, Departments of Health in the District of Columbia and Pennsylvania, and Chester City, Pa. In more than 25 countries spread over four continents, Dr. Shaikh has worked in areas of health policy and planning, services delivery, global health security, health emergency preparedness and response, disease surveillance and outbreak investigation, HIV/AIDS, Maternal Child Health, lead poisoning, applied epidemiology, health research, and monitoring and evaluation. Dr. Shaikh holds a medical degree, a master’s degree in public health, and a doctorate in epidemiology from the Johns Hopkins Bloomberg School of Public Health where he also maintains a faculty appointment. He has taught at graduate level since 2000, advised doctoral level students, published over 20 articles in top-tier, peer-reviewed health journals and has contributed writing as a subject matter expert in books by the American Public Health Association (APHA). Before joining MCHD, Dr. Shaikh was working for the WHO and responsible for global health security and related capacity building for the Eastern Mediterranean Region (EMR). His work included leading disease surveillance and outbreak response from emerging and re-emerging pathogens, namely Ebola, SARS, MERS-CoV, and ZIKV. Additionally, his work involved the implementation of international health regulations (IHR 2005) in 22 countries in the EMR stretching from Sudan and Somalia in East Africa to Morocco and Tunisia in Maghreb in Africa to Greater Middle East to Pakistan to Iran and Afghanistan in South Asia.

At the United Nations, Dr. Shaikh strived at the global level to bring the public health and the clinical practice communities together to capitalize upon the opportunities afforded by the interconnected world of today with the goal of reducing health disparities and addressing emerging and re-emerging threats to health. He strongly believes that the experience acquired globally serves very well to address the same two issues here in Montgomery County, i.e. health security and heath disparities. Dr. Shaikh brings a unique blend of global and local experience to this position, having served for over a decade as Health Commissioner in Chester City, addressing health disparities, especially the complex issues of infant mortality and childhood lead poisoning. Dr. Shaikh and I share the belief that the lines between clinical and public health practice are blurring with success in either area increasingly dependent upon the other. Patient health and safety is a harbinger of community health, and a healthy community in turn provides ‘herd’ protection to everyone in that community. Working in tandem, clinical and public health enable both our healthcare systems and our communities to thrive. Strong linkages between clinicians and our public health professionals will ensure comprehensive health emergency preparedness and response, disease surveillance and monitoring, health promotion, protection, hygiene and healthy living. Our vision for the MCHD and our residents is a health secure community with reduced health disparities and an integrated health system optimally realizing synergies between public health and clinical practice. Improving health equity, maternal child health outcomes, reducing infant mortality, childhood lead poisoning, adolescent/teenage suicides, opioid abuse and deaths from overdose are among our top priorities. MCMS is strategically poised to lead the process of realization of this vision as an equal and essential partner with the MCHD and we look forward to working with MCMS and other stakeholders who share this vision. Dr. Arkoosh can be reached at val@montcopa.org. Dr. Shaikh can be reached at IShaikh@montcopa.org.

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Legislative Update BY HANNAH L. WALSH, ASSOCIATE DIRECTOR, LEGISLATIVE AFFAIRS, PAMED

With passage of the 2016-2017 state budget in early July, the General Assembly recessed for the remainder of the summer, not to convene again for regular business until September. When they do return, it will be for a limited number of session days before the two-year legislative session concludes at the end of November. The House of Representatives has 12 scheduled session days remaining this year while the Senate has nine. The short schedule this fall is due to the fact that it’s an election year in Pennsylvania. When voters go to the polls to cast their vote for the next president of the United States in November, they’ll also have an opportunity to vote for their local representative in the state House and possibly their state senator. All 203 House seats and half of the Senate’s 50 seats are up for re-election in 2016. It’s in the weeks following the November election that legislators are considered to be least accountable to voters. Votes on legislation during this time are made by either legislators who have retired or been defeated for re-election, or who don’t have to face voters for another two to four years. Commonly referred to as a “lame-duck” session, the General Assembly stopped the practice of meeting to vote on bills after the election several years ago amidst sharp criticism and calls for reform. While the General Assembly’s schedule this fall limits the amount of legislation action that can take place, there are a number of current issues that still have potential to move. Any bill that isn’t signed into law when the two-year legislative session concludes at the end of November will have to be reintroduced in the 2016-2017 session to begin the legislative process all over again.

Opioid-related Legislation The state’s opioid abuse epidemic has continued to intensify, with significantly higher rates for drug-poisoning deaths in Pennsylvania than the U.S. average. A report released in July 2016 by the DEA indicates that 3,383 Pennsylvanians died of a drug-related overdose last year – up 23.4 percent from 2014. In an effort to stem the crisis, many states, including Pennsylvania, have enacted mandates on use of a PDMP (Prescription Drug Monitoring Program), mandates on prescriber and dispenser education, increased access for naloxone, and measures to expand treatment for substance use disorders. Some states – such as Massachusetts, Maine and New York – have taken a more radical policy approach by restricting the amount of opioids a clinician can prescribe to just a few days’ supply, with specific exceptions. The Pennsylvania legislature is equally eager to take further action to address the proliferation of misuse and abuse of opioid prescriptions in our state. Until measurable reductions are seen in the number of opioid-related harms occurring across the Commonwealth, the number of legislative solutions proposed to this problem and the pressure to enact them will continue to grow. At the time of this writing, over fifty bills

have been introduced to address what has become the leading cause of accidental death in Pennsylvania, killing more people each year than motor vehicle accidents. On Sept. 16, Gov. Wolf called for a joint session of the House and Senate to focus on the opioid epidemic. Gov. Wolf also identified several policy priorities that he is encouraging legislative leaders to accomplish during the remainder of the 2015-16 session. The proposals include requiring prescribers to check the PDMP every time they prescribe; increasing education about opioid and pain management for current and future medical professionals; limiting the quantities of opioids that can be prescribed in emergency departments; requiring health insurance plans to provide coverage for abusedeterrent opioids; adding opioid misuse to existing public school curriculum on drug and alcohol abuse; and establishing a voluntary non-opioid directive form for patients who don’t wish to receive opioids in their medical care. The Pennsylvania Medical Society (PAMED) is in the process of reviewing legislation introduced related to the opioid crisis, including the proposals mentioned, and is seeking feedback from physicians so that their interests are best represented.

Prescription Drug Monitoring Program (PDMP) On Aug. 25, Pennsylvania’s new statewide prescription drug monitoring program (PDMP) went live, enabling prescribers to view the prescribing history of their patients. Prescribers are required to query the program for each patient the first time a patient is prescribed a controlled substance by the prescriber for the purposes of establishing a baseline and a thorough medical record, and if they believe or has reason to believe, using sound clinical judgement, that a patient may be abusing or diverting drugs. In the weeks since the PDMP went live, PAMED has received numerous questions from physicians regarding various aspects of the law and what it specifically requires of them, as well as issues they have encountered with the PDMP system itself. PAMED has shared these questions and concerns with the Department of Health (DOH) and has requested official clarification from the Department. DOH is charged with administering the program under the law. Among the questions and comments received, physicians have asked whether the administration of a controlled substance, as opposed to the prescription, necessitates a physician to query the PDMP; whether it is permissible for prescribers and dispensers to talk to each other about a patient’s prescription history if the prescriber or dispenser suspects abuse or diversion of controlled substances by the patient; if changes in dosage orders for the same controlled substance is considered a first-time prescription requiring a new query; are prescribers allowed to prescribe if the PDMP is down or undergoing maintenance and, if so, if there is anything they must do for record-keeping purposes; and more.

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In addition to questions, reports of technical issues and suggestions for system improvements have also been communicated to DOH. PAMED will share with physicians any responses it receives from DOH regarding these matters and others.

Workers’ Compensation Reform On Sept. 13, the House Labor and Industry Committee held an informational hearing on House Bill 1141, legislation that would institute a number of important reforms to Pennsylvania’s workers’ compensation system. Rep. Stan Saylor (R-York) introduced the bill this session. HB 1141 addresses several issues with information access and reimbursement that often plague physicians who treat injured workers. The bill would ensure that providers have access to information about the injured worker’s claim, including the claim number and the description of the specific work-related injury for which the insurer has accepted liability. Workers’ compensation employers, insurers and their agents would be required to accept bills electronically, enabling reimbursements to be processed faster and with more accuracy. HB 1141 would prohibit a practice commonly referred to as “silent discounting,” where a health insurer or its “affiliates” pays providers at a discounted rate – in other words, below the mandated workers’ compensation fee schedule – without their knowledge, approval or contractual agreement. It would also prohibit insurers from using coercive tactics to compel a provider to accept discounted reimbursements. Finally, the legislation would increase penalties on payors who fail to timely implement updated fee schedules each year; define “healthcare provider” to clarify that the term does not include an entity that does not have a National Provider Identifier; and define “case management” according to national standards to include a variety of case management, care coordination, evaluation and management services. During the hearing, the Labor and Industry Committee heard testimony from a panel of individuals representing organizations which strongly support HB 1141—PAMED and the Pennsylvania Orthopaedic Society (POS)—followed by individuals testifying in opposition. Members of the insurance industry and the Department of Labor and Industry opposed legislation, stating that the bill would increase costs within the workers’ compensation system without necessarily improving care. As the meeting was informational, the Committee did not hold a vote on HB 1141.

CRNP Independent Licensure On the evening of July 12, the Senate passed Senate Bill 717 – legislation which would allow CRNPs to practice independently and eliminate the requirement that they collaborate with physicians – by a vote of 41-9. The bill now goes to the House of Representatives for consideration, where it has been referred to the Professional Licensure Committee. Prior to Senate passage, SB 717 was amended to require CRNPs to have a minimum of three years and 3,600 hours of experience before they can practice independently. While well-intentioned, PAMED believes the logic of this amendment was flawed. Requiring a minimum number of years or hours of work experience in an unstructured setting with highly variable

experiential learning does not replace the expertise and support that comes with physician oversight, and is no match for a physician’s education and training. PAMED has continued to express strong opposition to the legislation, which is being supported by the Pennsylvania Coalition of Nurse Practitioners (PCNP), the Hospital and Healthsystem Association of Pennsylvania (HAP), and AARP Pennsylvania, among others. On Sept. 16, PAMED sent a “Call to Action” to all physicians, asking that they call or email their state representative and urge his or her opposition to SB 717. If SB 717 fails to become law by the time the 2015-16 session concludes in November, the legislation will have to be reintroduced next session, which begins in January. The prime sponsor of SB 717, Sen. Pat Vance (R-Cumberland), is not seeking re-election this year. A registered nurse by training, Sen. Vance has for years been a strong proponent of advancing the scope of practice and role of the nursing profession in Pennsylvania during her tenure. At this time, it is unclear who will take up the cause and reintroduce the bill next year in the Senate. Similar legislation was also introduced this session in the House of Representatives by Rep. Jesse Topper (R-Bedford) as House Bill 765.

Hepatitis-C Screening HB 59, which was signed into law on July 20, requires all individuals born between 1945 and 1965 to be offered a Hepatitis-C screening test when receiving health services as an inpatient in a hospital or when receiving primary care services in an outpatient department of a hospital, healthcare facility or physician’s office. The bill provides for some exceptions to this requirement, such as if an individual is being treated for an emergency, has previously been offered or been the subject of a screening test, or lacks capacity to consent to a screening test. If an individual accepts the offer of a Hepatitis-C screening test and the result is reactive, the law ensures that a healthcare provider offer or refer the individual for follow-up healthcare, which must include a Hepatitis-C diagnostic test. There’s no doubt that HB 59—now Act 87 of 2016—is well-intentioned and that increased Hepatitis-C testing of this at-risk population would be beneficial. However, PAMED has consistently opposed legislation that mandates aspects of the physician-patient relationship. PAMED was successful in advocating that the final version of the HB 59 contained no penalties on healthcare providers. Since the law’s passage, PAMED has received a number of questions from physicians regarding its implementation. PAMED sent a letter to DOH on Aug. 31 requesting clarification on the requirements of the Act, which is set to take effect Sept. 18, but at the time of this writing has not yet received a response. A Quick Consult has also been made available to PAMED members to provide guidance on some of the most frequently asked questions. Hannah Walsh is the Pennsylvania Medical Society’s Associate Director of Legislative Affairs. Email her at hwalsh@pamedsoc. org.

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Frontline Groups Join an elite group of practices that are 100 percent committed to the Montgomery County Medical Society and the Pennsylvania Medical Society. Frontline Practice Groups — three or more physicians in a group — stand on the front line of the medical profession by making a commitment to 100 percent membership to the Montgomery County Medical Society and the Pennsylvania Medical Society. Your support helps MCMS and PAMED to advocate on your behalf and provide a forum for physicians to work collectively for the profession, patients and practice.

MCMS Frontline Groups as of August 31, 2016 Abington Medical Specialists Abington Neurological Associates Ltd. Abington Perinatal Associates PC Abington Reproductive Medicine Annesley Flanagan Stefanyszyn & Penne Armstrong Colt George Ophthalmology Berger/Henry ENT Specialty Group Blue Bell Family Practice Cardiology Consultants of Phila-Blue Bell Cardiology Consultants of Phila-Einstein Cardiology Consultants of Phila-Lansdale East Norriton Women’s Health Care PC Endocrine Metabolic Associates PC ENT & Facial Plastic Assoc. of Montgomery County Gastrointestinal Specialists Inc. Green & Seidner Family Practice Hatboro Med Associates Healthcare for Women Only Division King of Prussia Medicine LMG Family Practice PC Lower Merion Rehab

Main Line Gastroenterology Associates-Lankenau Marc Kress MD & Associates Marvin H. Greenbaum MD PC Neurological Group of Bucks/Montgomery County North Penn Surgical Associates North Willow Grove Family Medicine Otolaryngology Associates Patient First - East Norriton Patient First – Montgomeryville Patient First - Pottstown Pediatric Associates of Plymouth Inc. Performance Spine and Sports Physicians PC Rheumatic Disease Associates Rheumatology Associates Ltd. Surgical Care Specialists Inc. The Philadelphia Hand Center PC Thorp Bailey Weber Eye Associates Inc. Total Woman Health & Wellness Ob/Gyn TriValley Primary Care/Lower Salford Office TriValley Primary Care/Upper Perkiomen William J. Lewis MD PC

Through your membership, MCMS Frontline members and practices receive special recognition and benefits that include: • A 5 percent discount on your county and state dues. • A certificate of recognition to hang in your office. • Regional meetings covering topics like 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. • Quarterly recognition in MCMS Physician magazine. • Continual recognition on the MCMS web site, www.montmedsoc.com. For more information on how your practice can become a Frontline practice, e-mail montmedsoc@verizon.net or call (610) 878-9530 or PAMED, (800) 228-7823 or (717) 558-7750. M C M S P H Y S I C I A N 30 FA L L 2 0 1 6

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Three Ways Medical Practices Can Budget Smart in the Coming Year BY NICK HERNANDEZ

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t is once again the time of year when medical practices should be working to finalize their operating budget for the next calendar year. Unfortunately, too few practices actually take the time to create a meaningful budget, instead seeing the endeavor as a complex, timeconsuming process that likely will not be used. Creating and following a budget involves self-discipline and sacrifice, but will help you develop wise spending habits to better manage your practice’s finances now and into the future. If you’re continually seeing failure at budgeting, the best place to look is usually at the fundamentals. It only takes a fundamental misstep or two to transform a well-planned and well-formed budget into a complete disaster. Budgets should be realistic, flexible, and consistent with practice goals and objectives. Here are three keys to consider that will point you on the right track toward success as you build your budget: 1. Know why you are budgeting. If you’re developing a budget just because someone says it’s a good idea, it probably won’t help very much. Similarly, if you’re just following the steps in a practice finance workbook because it suggests this is a great way to move towards financial success, budgeting won’t help much at all. The reason for budgeting is to help you spend less than you earn. It shows you where your spending weaknesses are and provides the structure for you to get stronger in those areas. If you’re in the dark about how much your practice spends and where you spend it, changing habits will be difficult. And even if you’re financially comfortable, a budget can help you identify unnecessary expenditures and deduce ways to redirect funds towards your priorities. 2. Be realistic. It’s not going to work if you make huge, unrealistic assumptions right off the bat. Small steps work; big steps result in failure. Operating a medical practice can be unpredictable at times, and things happen that are out of your control. Consequently, look at where money can be moved around within a budget. For example, practices often use budgets to plan for future business growth and expansion. Capital saved on regular business expenditures may be

placed into a special reserve account designated for selecting new business opportunities. Budgeting for future growth opportunities ensures that practices have capital on hand when needing to make quick decisions for expanding business operations. This capital may also be used during slow economic times as a safety net for paying regular business expenses. 3. Be flexible. There will usually be moments when you’re learning to budget when you discover that some element of your budget is just not right. Take time to readjust figures. It’s not realistic because you forgot about some key piece of information while making your plans, and that means the budget you developed doesn’t really work. Don’t panic. Don’t abandon your plans. Just go back to your plans, make the needed adjustments, and start over again. This is normal, it happens to everyone. It does not mean your budget was a failure at all, it just means it needed to evolve a little bit. Regularly revisiting your practice’s budget will help you better control financial decisions because you will know exactly what you can afford to spend versus how much the practice is projecting to make. An accurate, useful budget can be a valuable decision-making tool to analyze potential business threats and opportunities and help physician owners and practice administrators make sound, strategic, and disciplined choices. Having a business budget in place enables you to plan ahead, prioritize your allocation of funds and gauge whether your financial predictions are being met. It will also enable you to make educated decisions to enhance your business operations with added clarity and efficiency. When properly executed, a practice budget will quickly become one of the most valuable resources in a practice’s decision-making toolbox. A proactive, comprehensive budget gives a practice the ability to properly track results, identify areas of concern, and quickly intervene when issues arise. And don’t be afraid to seek out the professional advice of a healthcare consultant or CPA. They have worked with many practices and can help identify budgetary items which you may be inclined to overlook.

Nick Hernandez, MBA, FACHE, is the CEO and founder of ABISA, LLC, a consultancy specializing in solo and small group practice management (www.abisallc.com). He is a speaker, trainer and author who has over 20 years of leadership and operations experience.

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Physicians

Play a Key Role in

Fighting Opioid Abuse PAMED Tools and Resources Child Abuse Reporting Laws—Suite of resources to help you understand and comply with the state’s child abuse reporting laws. www.pamedsoc.org/childabuselaws

ba t b u s e i a m Co ioid a ylvan o p e n n s f r om i n P h h el p w it

D E M A P

PAMED’s Opioid Education and CME “Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know”— Multimedia education with video interviews, statistics, prescribing guidelines, scenariobased learning, and more • CME credits available • Free for PAMED members

Long-acting and extended-release opioids online courses—Learn about prescribing, monitoring, assessment, and documentation • CME credits available • Free for all prescribers in Pennsylvania

ICD-10 and coding resources—Access specialty-specific crosswalks that map commonly-used ICD-9 codes to ICD-10, get physician documentation training, and find other coding resources www.pamedsoc.org/icd10 CME Consult—Get the latest PAMED patient safety and risk management activities in this CME compendium available both online and in print. CME credits available. Free for members; $249 for nonmembers www.pamedsoc.org/cme Volume to Value Online Courses— Get the skills to succeed in value-based delivery with six online, on-demand courses. www.pamedsoc.org/valuebasedcare

Opioid Prescription Checklist Use this checklist to start the conversation about pain management with your patients. Includes a list of things to consider when taking pain medication and is printed in the form of a prescription notepad. $4.95 for members; $19.95 for nonmembers

Visit PAMED’s opioids resource center for the latest news, education, and tools.

www.pamedsoc.org/opioidresources