MCMS Physician | Spring 2016

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Your Community Resource for What’s Happening in Healthcare


Spring 2016

Impairment or Incompetence? It Can Be A Matter of Life or Death

Dispelling Myths About Superficial Venous Insufficiency

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Contents 2014-2016

Spring 2016

a Impairment or 8 Incompetence?

MCMS BOARD OF DIRECTORS Stanley Askin, MD Frederic Becker, MD Charles Cutler, MD

It Can Be A Matter of Life or Death

Madeline Danny, DO Immediate Past President

Sherry Blumenthal, MD



Joseph Grisafi, MD James A. Goodyear, MD George R. Green, MD Chairman, Membership Services & Benefits Committee

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

Jennifer Lorine, DO Robert M. McNamara, MD Rudolph J. Panaro, MD Mark F. Pyfer, MD Jay E. Rothkopf, MD President-Elect and Treasurer

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

James Thomas, MD President

Martin D. Trichtinger, MD Chairman, Political Committee

MCMS Staff Toyca Williams Executive Director

Editorial Board Jay E. Rothkopf, MD, Editor George Green, MD Mark F. Pyfer, MD Scott E. Shapiro, MD Toyca D. Williams, 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.

Disability and Long-term Care Insurance


Features 11 Diowave Laser Therapy Systems Presents High Dose Laser Therapy (HDLT) 13 Focus on Mental Health 14 Frontline Groups 15 Meet Your County Medical Society Leaders 16 Adventures in Non-opiod Pain Management 18 The ABCs of Payment Reform 20 Thinking Outside the Box 23 MCMS Awards Two Medical Student Scholarships 24 30 Stories for 30 Years 27 Professional Organizations A Worthwhile ROI 28 World Tuberculous Day 30 MCMS Happenings 31 Welcome New Members

Dispelling Myths About Superficial Venous Insufficiency


In Every Issue 4 Chairman’s Remarks 6 Editor’s Comments 31 News & Announcements

MCMS Physician is published by Hoffmann Publishing Group, Inc. I Reading, PA I 610.685.0914 I for advertising information: or

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Chairman’s Remarks

VALUE in Medicine Mark Lopatin, MD Chairman, MCMS Board of Directors


here has been a lot of discussion recently about value in medicine. As a catchphrase, the word may mean different things to different people, especially given the many stakeholders involved in providing medical care. So what is value? In simplest terms, value is defined as benefit divided by cost. Thus, we can increase value by either increasing benefits (i.e. improving outcomes) or by decreasing costs. However, there are many problems with this definition. What is a benefit? Who derives the benefit? Who defines it? How is it measured? Does the definition apply to an individual patient or to a population as a whole? For example, a drug that works for 90 percent of the population does not benefit a patient if he falls in the minority 10 percent. When we recognize that the benefit and cost to an individual may be very different from the benefit and cost to a third party payer the current definition becomes problematic.

Varying Perspectives

This is especially true given that different parties in health care, e.g. doctors, insurance companies, employers, and attorneys, have different agendas. The insurance company is focused on the larger population, and in general seeks to improve value primarily by reducing cost

for said population. The physician is focused on an individual patient and seeks to improve value primarily by increasing benefits to that patient. In addition, we must recognize that while cost can be objectively defined, benefits are inherently subjective. For example, how do we quantify the benefit of a grandmother being able to get down on her knees to play with her grandchildren? What is that worth? If I have an expensive drug that would enable her to do this, is it worth it? As a physician, my opinion may greatly differ from that of the insurance company. Ultimately, the decision of value in this case is determined by whoever is footing the bill. If it is determined that this benefit does not justify the cost, how do I explain to her that the benefit to her as an individual does not warrant the cost to society? How do I explain that to her grandkids?

A Balancing Act

These are some of the dilemmas that we face as we try to balance care for the individual patient against care for the population as a whole. We must remember that the needs of the individual patient are often in conflict with the needs of the group, and as physicians, other stakeholders may not see things the way we see them. Furthermore, we must recognize that the consumer of health care and the purchaser of health care are different entities and have different definitions of value. Last year, I had a patient who presented to me with 2 months of ankle pain. He had been


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seen by several other doctors and diagnosed first with gout, then cellulitis. Neither diagnosis seemed to fit the clinical picture. X-rays were negative. When I saw him, he had swelling of the ankle with local tenderness and pain with range of motion. It was not clear what was happening and my first step was to order an MRI to define the anatomy. This was denied by the insurance company.

Lack of Transparency Unfortunate

I eventually had to do a peer to peer and was informed that the patient needed to go to physical therapy (PT) before an MRI could be approved. I argued that we needed an MRI to define the structural integrity of the joint, but was rebuffed. When I asked what the rationale for PT was, I was told, “Because some patients get better with PT.” I specifically asked if this was a decision based on cost and was told no. When I informed the physician that this was malpractice, the reply was, “We don’t think so.” To make a long story short, my patient finally got his MRI done after failing one session of PT ( as we both knew he would) and the MRI showed a fracture of his distal fibula. Instead of trusting my judgement and experience, the insurance company insisted I follow a course of action that was purely formulaic based on their predetermined guidelines. The disturbing part of all of this is the lack of transparency. A cost decision by the insurance company was couched as a benefit decision, even though it was clinically incorrect. I would have accepted it more easily if I was told from the outset that this was a decision based strictly on cost, but decisions based on cost are felt to be an anathema even though they occur on a regular basis. So instead I was told that PT was what was best for my patient (by a nonrheumatologist who had never even seen the patient!). Eventually, physicians will ultimately be reimbursed based on the “value” we provide, but value to whom—the individual patient or the third party payer? I think you all know the answer to that. As physicians, we are being asked by each individual patient to increase benefits, i.e. to improve their health, while we are simultaneously being pressured by insurance companies to reduce cost for society as a whole. How should we proceed when we have two drugs that work for a patient with the more expensive drug providing greater cost to society but also greater benefit to that particular patient? Unfortunately, we are left in the middle, forced to pick and choose between two masters, with no way to serve both at the same time. That is where we find ourselves in this value debate, and until it is determined whether the needs of the individual patient or the needs of society should predominate, we will be faced with more and more difficult choices on how to provide the best care for our patients. And with the recent decisions re: MACRA and MIPS, it is only going to get worse. But more on that in a future column.

Oops... To Err is Human Details, details, ever so important in written communications. In the board member profile titled “Meet Your County Medical Society Leaders (Winter 2016), Walter Klein, MD, was not identified correctly in all references. Dr. Klein shrugged the error off; but, his young and highenergy namesakes demanded a correction. We agree.


Walter Klein, MD

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Editor’s Comments

Healthcare RX:

More Physicians Needed in Politics Hillary Clinton. Donald Trump. Ted Cruz. Feel the Bern!

Throughout my adult life, I’ve been told not to discuss religion and politics, especially at parties and family dinners. Today, I’m going to ignore that advice. Because I can. Because I have to. Because I have no choice. As we head into what promises to be a raucous election year, politics is at the forefront of my mind—and it should be in yours as well. But why? Why would I make such a bold claim? I have two reasons, both of which will take a little bit of explaining, so bear with me. You might not agree with what I have to say, but I promise not to bore you, or waste your time. Healthcare in the United States has become uncomfortably politicized. From women’s issues to the right to talk to our patients about guns, states (and in some cases, the federal government) have intruded further and faster into the physician-patient relationship than ever before. And in many cases, for no other reason than to garner votes. That offends me. And whether or not you’re a physician, it should offend you too.

Science is the Foundation of Medicine The practice of medicine, while both a science and an art, is first and foremost grounded in fact. Doctors and scientists do research, studies, clinical trials, meta-analyses, all to try and determine how to best treat our patients. From preventing illness to stamping out disease, the foundation of our profession is science. And it’s under assault. Big time. Now, I’m not going to launch into a treatise on climatechange, or even tackle the anti-vaccine movement (although when it comes to the latter, I probably should). Rather, I’d like to shed light on a deeper problem, one which lies at the root of many issues affecting not only American healthcare, but our politics, education system, and our standing in the world. It’s a simple thing, but it’s the great problem from which all others flow.

It’s the broadening acceptance of the idea that opinions are facts. Or that under some circumstances, opinions are more important than facts. I don’t know about you, but that scares me. And it should scare you, too.

Breakdown of Physician-Patient Relationship As physicians, we’ve all encountered patients and families who ignore our advice, but there’s a growing trend of competition, an almost adversarial streak in the physicianpatient relationship. Thanks to the internet, knowledge has greatly increased, and that’s a good thing. Patient empowerment is something to be desired, not feared—yet many doctors are more fearful than ever. Why? The answer is complex, but one issue for certain has been government merging of reimbursement and satisfaction. Patients who are unhappy with being told something they don’t want to hear can potentially affect a physician’s livelihood, leading to conflicts which are both intolerable and frightening. Especially when, in the eyes of the government, a Google search potentially carries more weight than a medical degree. A recently published study showed that physicians who acquiesce to patient wishes when it comes to ordering more tests and treatments—even when it flies in the face of the evidence—are less likely to be sued. We intuitively knew this, but now there’s data to support it. And our leaders ignore it, to the detriment of all. Fact: healthcare costs are out of control. Fact: the United States spends more per-capita on healthcare than any other nation in the developed world, yet continues to lag behind in many measures of both managing chronic disease and overall wellness. In fact, some of our states have the highest infant mortality rates in the Western world. Fact: the cost of medical education is staggering and shows no signs of easing up. Fact: physicians’ take-home pay accounts for about 10 percent of annual healthcare costs, yet almost every ‘solution’ our politicians propose to lower expenditures usually involves steep cuts to already-declining reimbursements, making it nearly impossible for many practices to keep their heads above water. Fact: defensive medicine, lack of emphasis on (and proper incentives for) preventative care, and the absence of accountability for poor lifestyle choices account for the lion’s


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share of the most expensive chronic health conditions in the US, yet our rose-colored glasses refuse to come off. So what to do? How do we begin to solve this problem? Here’s my answer: elect more physicians to office.

No Laughing Matter: Elect More Physicians to Office Now, before you burst out laughing or accuse me of being self-serving, hear me out. What I’m going to propose involves a ‘sea-change’ in how Americans approach their everyday lives. It won’t be fun. It won’t be easy. And yes, it’s political. But it’s also necessary. It starts with another fact: doctors, at our core, are objective problem solvers. We listen to our patients, gather data, map out scenarios, and present solutions. We are required in our professional lives to balance not only empirical evidence, but the ‘human touch’ as well. Throughout our careers, we’ve learned to listen, one patient at a time. And that’s what this country needs. Not slogans. Not sound bites. Not feel-good applause lines that get everyone riled up. Not a zeitgeist that glorifies the right to sue, the right to never be offended, the right to live our lives free from risk to the exclusion of everything else. Not a toxic culture based on the assignment of blame, where every undesired outcome must be somebody’s fault—and payment made accordingly.

No, we need solutions. For education. For healthcare. For strengthening our nation in a dangerous world. And above all, for the idea that as ordinary citizens, we cannot change our lives for the better. I don’t believe that, and neither should you. Do physicians have all the answers? Of course not. But our mentality, our “sit-down-and-listen, gather evidence, and weigh-the-facts” approach to treating our patients might just start to heal a broken political culture. At the very least, it will help facilitate substantive discussions over the deepening wounds that continue to ail us. No question, it’s an unsettling time, and when the going gets tough, it’s easier to choose heart over head, opinion over fact. And the medical profession has not been immune. One opinion that has been gathering steam is perhaps America no longer needs its doctors. It’s a whisper that has grown louder over time, and has even found its way into the laws of some states. As someone who tends to feel depressed after watching the news each day, I can only say not only is that way of thinking wrong, but quite the opposite is true. America still need its physicians, now more than ever. In the clinic, in the hospital, in the home. And if I had my way, especially in government. So step up, colleagues. Let’s work for change. For our patients. For our country. For our profession. We can do this.

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Impairment or Incompetence? It Can Be A Matter of Life or Death BY JAY ROTHKOPF, MD, EDITOR, MCMS PHYSICIAN

Case Scenario

Dr. M. has been a respected local physician and beloved member of the community for more than 40 years. As colleagues, you have maintained a robust professional relationship and continue to share multiple patients. But lately, something has changed. Over the past six months, you’ve begun to notice unusual patterns in his practice. At first, it was hard to define, but now it’s become impossible to ignore. A patient whom he sent to you for a workup was on outdated drugs for her diabetes and heart failure. Another, who came to your office a week before surgery, hadn’t been told to stop aspirin and plavix. A third had been prescribed antiviral medication for contact dermatitis, erroneously having been diagnosed with shingles despite not having evidence of such on physical exam. Alarmed, you pull him aside in the lounge of the hospital to relay your concerns. Upon being questioned, he is initially baffled at your critique of his care, but quickly becomes defensive and angry, promising to no longer send you referrals before storming out in front of a bewildered crowd. Upon further investigation, you discover that other problems have quietly arisen. He frequently shows up unprepared for meetings—when he bothers to show up. On rounds with the house staff, he doesn’t seem to know his patients. When asked if any formal concerns have been raised, the answer that everyone gives is, “But it’s Dr. M.” No one, it seems, wants to be the physician who questions his competency. Neither do you, but it’s now become clear patients may be at risk. In other words, it’s time to act. Where do you turn? What do you do?


his is one of the most challenging situations a physician may face. The prospect of confronting an impaired or incompetent colleague fills most doctors with a sense of dread. And for good reason. A medical career requires years of education and training, not to mention the potential accumulation of a substantial amount of debt. Once past residency and out into practice, a reputation takes even longer to build, yet can be shattered in an instant. No wonder this topic makes doctors uncomfortable. We’re all human, and at some point, have likely committed errors in judgement, either through ignorance or lack of skill. Most physicians will tell you that this is okay; as long as patients aren’t harmed or patterns emerge, the occasional error helps to serve as a reminder that we have to stay sharp. It’s like car accidents—a near miss might get the adrenalin flowing, but it doesn’t count. Or does it? Evidence exists that some physicians think otherwise. A survey conducted by the Mongan Institute for Health Policy at Massachusetts General Hospital and published in the July 2010 issue of JAMA revealed that more than one-third of U.S. physicians did not agree that they should always report incompetent or impaired physicians. This was a surprising finding given requirements from states and professional organizations that compel them to do so. Even in light of greater media scrutiny of this subject, the authors contended fewer physicians were being reported than one would expect. So what’s going on? Are physicians simply incapable of


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policing themselves, unable to step up when a colleague puts patients at risk? Is there an unspoken “white coat code” that prevents doctors from speaking up, similar to the much-maligned “blue wall” in law enforcement, or is there more to it than that? The answer, of course, has more than one layer.

Incompetent? Impaired? Is there a Difference? Let’s start with some definitions. Incompetence, simply put, is the inability to execute proper judgement using all available data when providing patient care. It can occur for many reasons, including (but not limited to) inadequate knowledge, not knowing one’s limits, and loss of confidence. Impairment, on the other hand, usually implies an organic cause such as physical and mental illness or substance abuse. While impaired physicians may or may not be fundamentally incompetent, it is reasonable to say that not all incompetent physicians are impaired. This is both a distinction and a difference, and an important one. Professionalism. It encompasses not only interactions with patients, but how we as physicians treat our colleagues. So what does some of the data say about professionalism and the “duty to report”? A survey sent out in 2009 attempted to address this very subject. Participants were asked to rate their responses to statements such as “physicians should report all instances of significantly impaired or incompetent colleagues.” They were also asked how prepared they felt to deal with such a situation and whether they’d had direct knowledge of an impaired colleague over the preceding three years. Those who answered “yes” were further queried on whether they’d reported the most recent witnessed incident, and what reasons were associated with failure to report. Thirty-five hundred surveys were sent out to physicians practicing internal medicine, family practice, pediatrics, cardiology, general surgery, psychiatry, and anesthesia. Of the 1,900 that were returned, only 64 percent of the respondents agreed that they should “always” report an impaired or incompetent colleague. About 70 percent felt they were prepared to deal with an impaired colleague, while 64 percent were comfortable confronting an incompetent one. Pediatricians were least likely to report feeling prepared, while anesthesiologists and psychiatrists felt most prepared. 17 percent of respondents had direct knowledge of an impaired or incompetent physician within the prior three years, but of those, only 67 percent filed a report.

Is There A White Coat Code of Silence? So what does this mean? Are physicians failing in a vital aspect of their duty? And if so, why? Intangible factors, such as the desire not to harm the career of a colleague or be seen as a snitch, certainly play a role. So does the idea that physician leadership will take care of the problem. In fact, 19 percent of respondents in the above study cited the expectation that “someone else” would report an impaired colleague as the primary reason for not doing so themselves. Another 15 percent felt that filing a complaint would do no good, and 12 percent actually feared retribution should they take such an action. Physicians in smaller practices, especially one- or twoperson groups, were also less likely to report, as were members of a minority or those who were foreign graduates. Both trends are disturbing, but a more thorough exploration of the reasons behind them is beyond the scope of this article. Then of course, there is the age-old debate of medicine being both a science and an art. Variations in practice, which for decades have been accepted via the adage “there’s more than Continued on next page

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one way to skin a cat,” have been supplanted by ‘big data’ and quality metrics. With the wholesale move towards population health, it becomes that much more difficult to prove cognitive incompetence. A physician who disagrees with a colleague’s treatment may find themselves accused of believing ‘their’ way is the only way, which is no more desirable than being labeled a snitch. At the very least, it is probably yet another reason for keeping a low profile, one which is likely underreported.

To Report or Not to Report Not reporting, however, can open individual physicians and entire groups to both direct and vicarious liability. For example, laws in some states assign equal responsibility to all members of a private practice. Fail to disclose an incompetent colleague, and should something happen, blame can be attached to every partner. While statutes vary across the nation, generally, the risks of not reporting generally tend to outweigh the benefits. Lawsuits, higher liability premiums, and loss of license can occur (New York state considers such failure professional misconduct). Clearly, despite significant discomfort with this subject, the very real consequences cannot be ignored.

individual and offer their help. If help is accepted, the program then works with the physician in question to develop an individual treatment plan, which also includes regular assessments and monitoring. In addition to providing treatment for physical, mental health, and substance-abuse disorders, the PHP also advocates for those who have successfully completed their requisite programs. Through testimony before the State Board of both Allopathic and Osteopathic medicine, as well as malpractice carriers, hospital credential committees, boards of trustees, the courts, and managed care organizations, PHP provides a vital resource for physicians looking to successfully re-enter clinical practice. Confronting a colleague who may be impaired is never easy, but the resources do exist to help. And by working together when problems arise, we demonstrate to the public that as physicians, we are committed to setting the highest standards of competence, practice, and trust—and to strongly policing ourselves.

Personal Update: Insurance Issue Unresolved

Resources Available for Physicians So how we do help an ailing colleague? Numerous avenues are readily available, but I’d like to focus on one in particular: the Foundation of the Pennsylvania Medical Society. For more than 60 years, the Foundation has not only been the philanthropic affiliate of PAMED, but has provided programs and services for individual physicians (and others) to help improve the well-being of all Pennsylvanians. More specifically, the Physicians’ Health Program is uniquely suited to help meet the needs of doctors in trouble. In fact, it has managed to grow from its initial inception in 1970 to one of the largest and most developed entities of its kind nationwide. With cooperative relationships across the state, it is well-positioned to help physicians who’ve fallen get back on their feet. Following an initial referral (which can be made anonymously), an investigation may potentially be launched. If a determination is made that a physician may be impaired or incompetent, the program will then reach out to that

Last issue, I wrote about my dismay after learning coverage for a medication I take, Humira, was about to change. After hours of phone calls to multiple entities, I finally learned that my co-pay assistance card would hopefully still cover all charges. So what happened next? Fair warning: it’s anti-climactic, like watching the end of an energizing action movie only to learn “it was only a dream.” Here goes. About a month after the initial set of calls, I received a second letter from my pharmacy vendor, this one offering an apology. That’s great, you may be thinking. They realized the error of their ways, and they wanted to make it right. Wrong. The apology was not for changing my coverage, but rather listing the wrong date. Instead of the new paradigm going into effect on January 1st, 2016, it actually won’t shift until the first of June. That’s it. Oh, and they’re sorry for any ‘confusion’ or ‘inconvenience’ this may have caused. And that’s all they wrote, literally and figuratively. So I’m still in the dark for several more months. But as soon as I know something, you will too. Believe it. And unlike them, I mean what I say.

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HIGH DOSE LASER THERAPY (HDLT) A Revolutionary Advancement in Private Pay Acute and Chronic Pain Management BY FRANK FAZIO, CMO TECHNOLOGICAL MEDICAL ADVANCEMENTS, LLC

How does HDLT work?

Results come from the laser’s ability to “bio-stimulate” tissue growth and repair. This results in accelerated wound healing with a dramatic decrease in pain, inflammation and scar tissue formation. Unlike all other treatment modalities, laser therapy actually “heals” tissue and is a powerful nonaddictive form of pain management.

What conditions are responsive to High Dose Laser Therapy?

Arthritis, neck and back pain, tendon, ligament and muscle injuries, foot and heel pain, neuropathy from diabetes, carpal tunnel syndrome, TMJ disease and non-healing wounds are just some of the numerous conditions responsive to this technology.

What does the treatment feel like and when can patients expect to see results?

Patients typically describe the feeling of warmth and profound relaxation. You can expect to begin to see results as shortly after administering one to two treatments. Treatment sessions can range from 10-15 minutes with the majority of pain conditions resolved within 8-12 sessions. The results are most often long term, however, chronic degenerative pathologies such as osteoarthritis and neuropathy require maintenance therapy.

Laser therapy has been around for more than 35 years so why Diowave now?

The effects of Laser light energy have been well documented over the last 35 years. Laser energy affects the body by accelerating the healing process of damaged tissues, noninvasively and without side effects. However, the problem over time has been that because of the limited power output of therapeutic lasers, the results on deeper seated pathologies like herniated discs, spinal stenosis, sciatica, back and neck pain, arthritis and neuropathy where marginal at best. The Diowave platforms of therapeutic lasers now offer clinicians the most

powerful and advanced healing technology available in medicine today. With that comes the ability to deliver significantly greater dosages of healing photonic energy along with penetration to depths never before seen in physical medicine. The key to better clinical outcomes according to Diowave’s Chief Medical Officer, Scott Davis, MD, MA, FASAM, is higher dosage and deeper penetration and Diowave delivers both.

Who is using Diowave Laser Technology?

Family and general practice, physical medicine and rehab, internal medicine, orthopedic and sports medicine, podiatry, VA System and the DOD, physical therapy, NFL, NBA, NHL, MLB and NCAA. Also large-scale health care systems and even small animal and equine veterinarians, to name a few. Cosmetic and plastic surgeons are now starting to embrace the technology.

Is your practice looking for a new private paycash profit center?

There is no better time than the present to discover how high dose laser therapy is increasing medical and financial outcomes in today’s world of declining insurance reimbursements. With our company’s technology and training, physicians can now begin the process of breaking away from the addiction to insurance-based medicine by offering their patients outcomes never before seen in traditional pain care. According to Dr. Davis, another great feature of HDLT is that a therapist or medical assistant can readily administer it. The physician’s time spent in case management is minimal and the income is passive.

To learn more about this revolutionary advancement in private pay pain management visit us at or call 866-862-6606.

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Disability and Long-term Care Insurance The Forgotten, Yet Equally Important, Insurances BY CARL H. MANSTEIN, MD, MBA, CPE


n the second part of this series, we will talk about disability insurance and long-term care insurance. All of us think we have an element of invincibility, but unfortunately that is not the case. That is why both of these policies are equally (and in many ways more important) than life insurance. For an otherwise healthy American citizen, the chances of becoming “disabled” is far greater than death before the age of 65. Therefore, disability insurance may be the first insurance policy you buy when you are starting out in practice, even before buying life insurance. Many of you are employed physicians, either as part of a large health system or university; and might say “My employer covers my disability insurance.” Look carefully at that policy. Most employers supply only a minimal disability payout. So what does it mean to be disabled? It varies from policy to policy. The best policies, and therefore the most expensive, state that the insured is unable to perform in his/her specific defined specialty. So if you are a cardiac surgeon and suffer a non-union fracture of the scaphoid, you can still function as a psychiatrist or radiologist and collect your disability payments. Most policies are not that generous, so it behooves you to check with your human resources department and see what the limits are for activity. Also, find out how long are you disabled before the payments kick-in. They can run anywhere from three to six months, so make sure there is money in the bank to take care of your family expenses while you are out of work. My overall advice is to buy as much disability insurance as the insurance company will sell you. This would be in addition to whatever policy you get from your employer. You are usually limited to how much payout you can get based upon your current salary. As your income rises, so should your disability

benefit; so regular discussions with a trusted insurance agent would be in order. Most policies stop both coverage and payments after age 65, so all of this must be factored into your overall financial planning. Long-term care insurance may be the most difficult of policies to understand. It is designed to take care of you should you be totally incapacitated and need to be in a nursing home. We all know how expensive, and sometimes inadequate, longterm care can be. This is truly one policy that you hope that you never need; but it can be a financial life-saver for your family. It does not take long to deplete a family’s savings if they have to pay for a long-term care facility. Usually, Medicaid will not kickin until all of the family’s resources are exhausted. Generally, most people do not need to consider these policies until age 50. Of course, the older you are, the more expensive they become. As I said, these policies can get quite complicated so it is important that you understand all of the nuances of terms and benefits. I would also recommend purchasing a policy for your spouse. Hopefully, this brief primer will be of value. It is important that every physician have three people as part of their financial partnerships: a certified financial planner, an accountant, and an attorney specializing in wills and trusts. Your attorney who has defended you in a malpractice case is not that guy. In my opinion, the three should be separate and not-overlap or be in the same business firm. It will help avoid conflicts of interests. Carl H. Manstein, MD, MBA, CPE, is a graduate of Abington High School, Amherst College, Temple University School of Medicine and LaSalle School of Business. He completed his plastic surgery residency at Duke University and is certified by the American Board of Plastic Surgery.

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Focus on Mental Health: Promoting Wellness through Integration and Intention BY VALERIE ARKOOSH, MD, MPH MONTGOMERY COUNTY COMMISSIONER


am pleased to have an opportunity to share information about mental health resources in Montgomery County. First, it is an opportunity to think more about mental wellness than mental illness. It is about promoting cognitive and emotional wellbeing; how we think, feel and relate to those around us. Like most facets of overall health, mental health is one that can benefit by incorporating intentional strategies that support wellness such as good sleep, physical activity and mindfulness. The nationwide focus on integrated healthcare is highlighting the benefits of regularly assessing and responding to patients’ mental health needs. Every conversation with a patient can be an opportunity for health promotion. Physicians are becoming increasingly skilled in the art of engaging individuals to become more participatory in their care and self-managing of their wellness. This is especially true in regard to mental health. Whether through services provided within a practice or through the creation of partnerships, patients are experiencing more warm hand-offs from physicians who identify the symptoms of a mental health diagnosis to practitioners who can help them address those symptoms. Often, people do not know where to begin to seek mental health treatment. Physicians and their staff can encourage those in need to call their insurance provider to identify practitioners in their network. Montgomery County provides a robust public mental health system that supports individuals and families in achieving greater mental health and wellness. It provides access for people who are uninsured, those covered

by Medicaid and Medicare as well as many private insurances. Montgomery County has six Community Based Mental Health Centers (CBHC). These centers are located in areas accessible by public transportation. The CBHCs provide not only treatment, but also services that assist in coordinating care for those with higher levels of need, including physical healthcare. Mobile supports such as recovery coaching case management, career services and peer support are available to help build skills in the community. At each CBHC, the county funds Administrative Case Management (ACM) services. ACM staff can support people seeking treatment in applying for benefits as well as determine other community resources for food and housing. Sometimes people do not recognize the need for support until they are facing significant issues. There are times too, when a person has not built the skills needed for self-management of mental health challenges. 24/7 Mobile Crisis services are available throughout all of Montgomery County. Anyone can reach out at any time (855) 6344673. More than anything, I encourage all physicians to offer hope. By providing hope and the belief that people can and do recover from significant mental health challenges, we offer our community the potential to gain or regain a coworker, parent, classmate, neighbor, or friend. For more information, I would be delighted to connect you with staff from our Department of Behavioral Health. I can be contacted at Additional information can also be found on Montgomery County’s website at http://

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To access the community mental health system in Montgomery County, call the local CBHC: Western Area- Creative Health Services (Children & Adults) 11 Robinson St, Pottstown, PA 19464, (610) 326-2767 Franconia/Salford Area Penn Foundation (Children & Adults) 807 Lawn Ave, Sellersville, PA 18960, (215) 257-6551 Lansdale Area - NHS Human Services (Children & Adults) 400 N. Broad St, Lansdale, PA 19446, (215) 368-2022 Abington Area - Central Behavioral Health (Adults) 2500 Maryland Rd, Willow Grove, (267) 818-2220 Abington Area - Child and Family Focus (Children) 2935 Byberry Road, Hatboro PA 19040, (215) 957-9771 Norristown Area - Central Behavioral Health (Children & Adults) 1100 Powell St, Norristown, PA 19401, (610) 277-9420 Lower Merion Area - Lower Merion Counseling Services (Children & Adults) 850 W Lancaster Ave, Bryn Mawr, PA 19010, (610) 520-1510 Montgomery County Adult Mobile Crisis Support 1-855-634-HOPE 1-855-634-4673 Montgomery County Children’s Crisis Support 1-888-HELP-414 1-888-435-7414

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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 (PAMED). 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. The Montgomery County Medical Society says thank you.

MCMS Frontline Groups as of March 31, 2016 Abington Medical Specialists Abington Memorial Hosp – Div of Cardiothoracic Surgery 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, For more information on how your practice can become a Frontline practice, e-mail 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 14 S P R I N G 2 0 1 6

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Meet Your County Medical Society Leaders PROFESSIONAL BACKGROUND Why I chose a career in medicine: I chose a career in medicine because I enjoy problem solving and helping people. It’s always an intellectual challenge. Being a doctor also requires that you keep up with new technology and techniques that demand constant learning.

Dr. Mark F. Pyfer is board certified in ophthalmic surgery by the American Board of Ophthalmology and a Fellow of the American Academy of Ophthalmology. He specializes in state-of-the-art refractive and cataract surgery. Dr. Pyfer serves on the teaching faculty of Wills Eye Hospital in Philadelphia, where he has performed over 15,000 vision correcting procedures since 1997. Dr. Pyfer received his medical degree from the University of Pennsylvania School of Medicine, graduating at the top of his class in 1995. After completing an internship in internal medicine, he went on to complete residency training in medical and surgical ophthalmology at Wills Eye Hospital in Philadelphia. While in residence at Wills, Dr. Pyfer coauthored the popular Wills Eye Manual, a reference book that has been translated into several languages, and is used by doctors around the world when treating eye disease. Name: Mark F. Pyfer, MD Specialty: Ophthalmology Currently Practices: Northern Ophthalmic Associates, Inc., Jenkintown Medical School: University of Pennsylvania School of Medicine Residency: Wills Eye Hospital Birthplace: Philadelphia Residence: Ft Washington, Pa

Describe your job: I’m always busy during office hours with exams and consultations and interpreting test results. As far as surgeries go, I do short but demanding microsurgical procedures such as cataract surgery and LASIK. Most rewarding elements of your career: It gives me great satisfaction to know that I’m helping people see better. People use their eyes every waking moment in life. Sight is precious. Blindness is feared as much as pain or death. More than anything, positive feedback from happy patients keeps me going.

OUTSIDE THE OFFICE Interesting childhood fact: My wife and I were both born in the same hospital in Philadelphia. My parents moved to the Pottstown area when I was quite young, and my wife grew up in Philadelphia. We did not meet until college in 1983. How did I end up practicing in Montgomery County: I have deep family roots in Montgomery County. I discovered my great uncle was Howard F. Pyfer, MD, an eye/ear/nose & throat specialist in Norristown during the early 1900s. He left an endowment in his will to MCMS to help young physicians meet expenses for CME that survives to this day as the Pyfer Fund. I did not know this until I joined MCMS. Dr. Howard Pyfer’s middle name is Franklin, and so is mine. The middle name of Franklin is traditional in my family— my grandfather and father are both named Benjamin Franklin Pyfer. What interests you outside of medicine: Biking, skiing, travel, Civil War history, technology If I could be anything other than a physician: Engineer (already was!), entrepreneur, inventor, pilot.

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My family: I have two children who are poised to take on medical careers. My son is in medical school and my daughter is pre-med in college. My wife is a pharmaceutical company executive. I greatly admire: I greatly admire Benjamin Franklin, Abraham Lincoln, and Elon Musk (Founder of Tesla and SpaceX ). I like the story in Ben Franklin’s biography by Doris Kearns Goodwin where she describes him as a “gentleman” in the language of the 1700s. This meant that through hard work in his printing business, he had become independently wealthy enough to not have to work every day to survive. This allowed Franklin to pursue his intellectual interests, invent, and support his fledgling country through philanthropic statesmanship. He was in my opinion a true “Renaissance Man”. Our society needs these folks even now to continue to prosper and grow.

WORTH NOTING You may not know: I started my career as an electrical engineer working at R&D at AT&T Bell Laboratories in the late 1980s. I was involved in high resolution digital sound and image coding, and worked on the precursers to digital audio CD, DVD, and HDTV formats. At that time, floppy discs and analog audio cassette tapes were standard. Optical disc drives had just been introduced, they were expensive and slow, used only for encyclopedias and reference books. Why I stay involved in organized medicine: Each doctor alone is relatively powerless in fostering change, but together our voice can be heard. Business interests in medicine are not always aligned with the best interests of patients and doctors must speak up for our patients and advocate on their behalf to provide good and cost-effective care. Advice to young physicians: Remain entrepreneurial if at all possible, control your own destiny. Be a professional, not an employee. Do what you love every day, if not change it.

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Adventures in Non-opioid Pain Management:

The Personal Story of One Lucky Hypermobile Patient BY APRIL FOX-REGAN, PRACTICE ADMINISTRATOR


was born with the genetic hypermobility disorder EhlersDanlos Syndrome (EDS). But, like many with this connective tissue disorder, I was not diagnosed until later in life. Although I sought medical attention from competent physicians, they failed to piece together the puzzle of seemingly disconnected symptoms until my early 40s. At age 42, I dislocated my clavicles while exercising. It was only after that overt sign of hypermobility that a physiatrist finally connected the dots. A lifetime of pain and neurological dysfunction had been, in actuality, all aspects of a single genetic disorder involving an excess of collagen in my tissues. (The Ehlers-Danlos National Foundation seeks to educate physicians on the signs, symptoms, and treatment of this rare – but not very rare – and painful disorder.) Sadly, my experiences were all too common for EDS sufferers, many of whom are misdiagnosed or undergo harmful orthopedic surgeries. Unfortunately, some are prescribed high doses of opiates by well-meaning physicians who know of no other way to treat complex, persistent musculoskeletal pain.

How I Managed the Pain My motivation in writing this article, however, was not to educate physicians about EDS, but rather to share my experience as a chronic pain sufferer in the hope that others might learn from my experience of successfully managing complex pain with the benefit of biomechanically-focused manual physical therapy.

I was lucky. At the time of my clavicular injury, I was already under the care of a world-class manual physical therapist for pelvic floor issues, and with her help, I learned to manage the pain of my clavicular condition – not by covering it with narcotics, but primarily through the manual correction of the actual joint subluxations, as well as the release of the myofascial spasm and nerve pain that they engendered. During my weekly appointments, my physical therapist carefully manipulated my joints back into alignment, often immediately alleviating acute pain. She also trained my husband on myofascial release techniques at home, and advised me on key stretching and strengthening exercises to help prevent dislocations. By the time I saw the geneticist in Baltimore who specialized in EDS to receive my official diagnosis, I was already being treated weekly by that same physical therapist. My long-awaited genetic consultation was affirming and enlightening. During my consultation, the adult EDS expert noticed I was more functional and used fewer pain medications than other patients suffering with similar EDS complications. When I described my care plan, the geneticist immediately asked for the name and number of my MTC (manual therapy certification) therapist. That was 10 years ago.

My Lifeline: Hands-On Physical Therapy Erica Fletcher, PT, MTC has been my lifeline to functionality for nearly 12 years. She practices in Narberth and received her post-graduate manual training from the University of St.

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Augustine for Health Sciences in St Augustine, Fla. The university offers a rigorous manual therapy certification program. “Manual” simply refers to hands-on physical therapy modalities. Just as great physicians are more than the sum of their post-graduate training, so too is Erica Fletcher who has pursued 30 years of continuing education and a treatment model centering on the “biotensegrity” model of care. This model of care focuses on the whole biological structure of the patient, the way in which muscles, fascia, ligaments and tendons interact in the support of the musculoskeletal system. My personal experiences with this rare therapeutic model have been amazing and I would encourage physicians treating patients with musculoskeletal pain to at least consider developing a relationship with a certified and experienced manual practitioner who treats patients on this “big picture” mechanical level. In my professional role as the practice administrator of a Montgomery County family practice for 27 years, I see a microcosm of my EDS story played out among our chronic pain patients. EDS patients are not alone in suffering subluxations and related complex myofascial and nerve pain, which can occur through deconditioning, overuse, or injury. I would, therefore, like to opine that the same lack of biomechanical knowledge that typically delays the diagnosis of EDS, may also be helping to drive the opioid crisis. I am very concerned that biomechanics expertise (or its absence) is not a part of the medical community’s dialog on this national public health crisis of opioid abuse.

What is EDS?

A Viable Alternative to Pain Management

unique features. It is highly improbable to have more than one

Often, real patient suffering is at the genesis of opioid use, which sadly can lead to abuse and addiction. But caring physicians, unaware of the truly life-transforming skills of a master MTC therapists, may feel they have no other tool to alleviate that suffering. In-depth, functional, biomechanical knowledge is rare among physicians. Additionally, physicians and conventional physical therapists are often unaware of the difference between conventional physical therapy and MTC certified practitioners. This is medicine’s blind spot, into which many pain patients are lost. I am sincerely curious about the number of addictions that could be stopped before they even start if more physicians would refer their pain patients to “whole body focused” manual therapists when appropriate. April Fox-Regan is a practice administrator with Marc Kress MD & Associates, Jenkintown, PA. For more information about EDS, visit,

Ehlers-Danlos Syndrome, often referred to as EDS, is a group of disorders that affect the connective tissues that support the skin, bones, blood vessels, and many other organs and tissues. Defects in connective tissues cause the signs and symptoms of Ehlers-Danlos syndrome, which vary from mildly loose joints to life-threatening complications. Although all types of EDS affect the joints and skin, additional features vary by type. An unusually large range of joint movement (hypermobility) occurs with most forms of Ehlers-Danlos syndrome, particularly the hypermobility type. Either directly or indirectly, Ehlers-Danlos Syndrome is known or thought to alter the biology of collagen in the body (the most abundant protein), which can lead to multi-systemic symptoms. Each type has certain physical traits and with notable exception to the most common form, the hypermobile type of EDS, most types have a known disease-causing gene. Each type is a distinct entity and may have very specific and type of Ehlers-Danlos syndrome, but as they have features and ‘biology’ in common, each type may appear to have variable features of other types. There are physical characteristics that are common to all types of EDS including hypermobile joints (joints that move in greater amounts than expected) and skin involvement. Although symptoms and physical features may vary greatly depending upon the specific form of EDS present, many affected individuals may have thin, fragile, hyperextensible skin that may bruise easily; abnormally loose joints that are prone to dislocation; and widespread tissue fragility with bleeding and poor healing of wounds.

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ow often in a day are you bombarded with acronyms describing what is happening in the area of payment reform? Everything from PQRS to MU that includes CQMs and the upcoming VBM…which takes us to MACRA…which did away with the SGR and includes MIPs, which is made up of APMs such as ACOs. Some days it feels like understanding payment reform is like digging through a bowl of alphabet soup! The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) made three important changes to how Medicare will pay for services given to Medicare beneficiaries in the future: 1. End the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services. 2. Make a new framework for rewarding healthcare providers for giving better care not just “more” care. 3. Combine existing quality reporting programs into one new system. Historically, Medicare payments have been allocated based on the fee-for-service model—providers are paid a “fee” for the service provided. Because of the rapid inflation of spending under the Medicare program, Congress “reformed” the system and implemented the SGR. This formula was geared to incentivize providers to reign in their prescribing and ordering and become more efficient, and

therefore benefiting from potential increases in fees. However, spending increased at a monumental rate and instead of increases in fees, this ended up becoming an annual debate, which led to a subsequent enactment of a “doc fix” to forgo the large decreases anticipated through the SGR. Through MACRA, we now see the end of SGR—and many providers breathe a sigh of relief. With the creation of the Physician Quality Reporting System (PQRS), providers began reporting their “quality” to Medicare. While this system originally incentivized providers based on “reporting” not necessarily on providing quality care, in recent years, this program has become one of the penalties that providers are seeing and the “quality” being reported is now playing into future payment reform. Another incentive program that Medicare created was the Electronic Health Record (EHR) Incentive Program, better known as Meaningful Use (MU). This program offered incentives over a number of years for implementing an electronic health record and meeting certain thresholds for reported measures. Included as part of MU was the reporting of Clinical Quality Measures (CQMs). These measures were not based on meeting thresholds, but were designed to assess how EHR systems were collecting and reporting data. CQMs are in essence a subset of PQRS measures that are pulled directly out of the EHR. Much confusion existed between the two programs as many providers thought that because they attested to MU and reported CQMs that they did not need to report PQRS. While there is some overlap and availability

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to report both together, they are still two separate programs and providers need to make sure they have covered both in their reporting efforts. This program has also moved from an incentive program to a penalty program for non-participation. While MU has been refined over the years, many providers still find it difficult to comply or simply are not interested in complying and choose to take the penalties. In 2013, we started hearing about a new program entitled “Value-Based Modifier” (VBM). The VBM measures the quality and cost of care provided to Medicare beneficiaries based on the provider’s performance on specific quality and cost measures. The program rewards quality performance and lower costs…and on the flip side can penalize you for lower quality and higher cost. PQRS measures are tied to VBM and here is where your “quality” reporting will begin to be scrutinized. If you are not participating in PQRS, you will automatically receive a downward adjustment for VBM. Following is the scheduled rollout for payment adjustments (+ and/or -) for VBM: 2015 - Groups of 100 or more Eligible Providers (EPs) started to see payment adjustments based on their performance in 2013; 2016 - Groups of ten or more EPs started to see payment adjustments based on their performance in 2014; 2017 - Groups of two or more EPs will start to see payment adjustments based on their performance in 2015; 2018 - ALL providers, including physician assistants (PA), nurse practitioners (NP), clinical nurse specialists (CNS) and certified registered nurse anesthetists (CRNA) who are solo practitioners or in groups of 2 or more EPs will begin seeing payment adjustments based on their performance in 2016.

APMs are another way to pay providers using methods such as: • Accountable Care Organizations (ACOs) • Bundled payment models (similar to DRGs or episode of care payment) • Patient Centered Medical Homes (PCMH) Later in 2016 we should start to see more definition as it relates to these new quality programs and how practices can prepare. But in the meantime, it is important to take a look at where you in regards to where we are going with payment reform. • Are you currently participating in PQRS or MU? • Do you know how to prepare for VBM and what your quality says about you? CMS has provided tools for practices to begin preparation. One of those tools is the Quality and Resource Use Report (QRUR). QRURs are confidential feedback reports offered under CMS’s Physician Feedback Program that provide information about the resources used (cost) and the quality of care provided by the physicians and group practices to Medicare Fee-for-Service (FFS) patients. Some of the data in this report is used to calculate VBM payment adjustments (+ and/or -). Using this report and honing your documentation or clinical practice can improve scores in future years. Utilizing your EHR to its fullest capabilities in managing your data and verifying the validity of reports generated can help you further improve your quality reporting. Make sure you keep informed and understand the ABCs of Payment Reform!

MACRA’s goal is to help us move quickly from paying for “volume” to paying for “value” and assist providers in successfully taking part in quality programs in the following streamlined ways: • Merit-Based Incentive Payment System (MIPS) • Alternative Payment Models (APMs) MIPS combines parts of PQRS, VBM and MU (or the EHR incentive program) into one single program based on: • Quality • Resource use • Clinical practice improvement • Meaningful use of certified EHR technology

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Thinking Outside the Box: Physician Innovators Say Patient Advocacy and Political Advocacy Linked BY TOYCA D. WILLIAMS, DEPUTY EDITOR, MCMS PHYSICIAN


hysicians John and Alieta Eck know all too well that patient advocacy happens inside, as well as, outside the exam room. For years, the New Jersey husband and wife have been at the forefront of physician and patient advocacy and believe better care is not wrapped in more government regulations. “Government can only meddle, restrict, coerce and underpay for services it promises to provide, all while taxing taxpayers beyond their ability to pay,” Dr. Alieta Eck has said on a number of occasions when given the opportunity to speak about health care reform. The Ecks shared how they handled their frustration with the inadequacy of New Jersey’s health insurance system during the June 7 Annual Membership Dinner of the Montgomery County Medical Society. Additionally, Jay E. Rothkopf, MD, was installed as the new president, and MCMS honored nine physicians who have practiced medicine for 50 years. Dr. Alieta Eck has been involved in health care reform since residency and believes that the government is a poor provider of medical care. She has testified before Congress on this issue and even ran for Congress in 2013 and 2014. 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. “We realized we would go under if we took Medicaid. With all the paperwork, we just couldn’t do it. So that is why we started this clinic apart from our practice and we care for people even if they can’t pay,” said Dr. Alieta Eck in a 2015 interview on a Fox Business Network talk show. To expand this model, the physicians have been working with New Jersey legislators on a bill that could potentially provide better care and access for thousands of New Jersey’s poor and uninsured and reduce the state budget. The legislation, Volunteer Medical Professional Health Care Act,

would allow physicians to donate their time caring for the poor and uninsured in non-government free clinics in exchange for the State providing medical malpractice protection within their private practices. Dr. Eck believes that such a law would relieve taxpayers of the Medicaid burden, improve patient access and reduce Medicaid utilization and expenditure. Medicaid expenditures in New Jersey exceed 10 billion a year. For more information about Zarephath Health Center, visit

Honoring the Physicians Who Have Nurtured in the Trenches for 50 Years Randall W. Bell, MD, 78, is a board certified ophthalmologist. The New York native graduated from Columbia University before attending medical school at Cornell University in New York. He attended the now Walter Reed Army Medical Center following medical school for his internship and residency. The eye surgeon was affiliated with several hospitals in southeastern PA including then Sacred Heart Hospital in Norristown, Wills Eye, Thomas Jefferson University and Bryn Mawr hospitals. A member of the Pennsylvania Medical Society for 40 years, he became a member of MCMS in 1986. Richard J. Carella, MD, is a board certified radiation oncologist at Bryn Mawr Hospital Radiation Oncology Center. Born in Boston, Mass., the 75-year-old graduated from Tufts University School of Medicine in 1966 and completed his internship and residency at St. Vincent Hospital in New York. He is a member of the American Society of Therapeutic Radiology & Oncology, American College of Radiology and Pennsylvania Radiological Society. He has been a member of the Pennsylvania Medical Society and MCMS for 31 years.

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Albert T. Derivan, MD, is a longtime pediatrician who specializes in child and adult psychiatry. The 76-year-old was affiliated with Thomas Jefferson University Hospital. He attended medical school at Rutgers New Jersey Medical School and graduated in 1966. Following medical school, he received the remainder of his medical training at John Hopkins School of Medicine, specializing in pediatrics. Anthony J. Fugaro, DO, is a recently retired board certified anesthesiologist. He retired as a staff anesthesiologist with Lankenau Hospital on Dec. 31. The Camden, N.J. native graduated from the Philadelphia College of Osteopathy in 1966. He completed two residencies – one in anesthesiology at Temple University Hospital and the other in internal medicine at Cooper Hospital in Camden. From 1968 to 1970, he served honorably in the U.S. Army Reserve and left as a major. Dr. Fugaro is a member of the American Board of Anesthesiology, American College of Anesthesiology, Pennsylvania Medical Society and Montgomery County Medical Society. The 76-year-old father of three sons is married to his wife Delia and lives in Media. Jack Lebeau, MD, FACC, is a practicing cardiologist with Abington Jefferson Health. The board certified internist obtained his medical degree from Case Western Reserve University, Cleveland, Ohio. Subsequent internship and residency programs were completed at Thomas Jefferson University Hospital. He completed two fellowships, both in cardiology, from Temple University Hospital and University of Pennsylvania Hospital. Between those two fellowships, he served in the U.S. Medical Corps in Ft. Meade, MD from 1970 to 1972. In addition to practicing, he is an adjunct professor at Arcadia University. He is a member of American Medical Association, American College of Cardiology, Pennsylvania Medical Society and MCMS. He is also planning to celebrate this professional milestone, 50 years in medicine, with medical school classmates later this year.

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Ronald Liebman, MD, is the founder and director of the Eating Disorders Program at The Children’s Hospital of Philadelphia (CHOP) Department of Child and Adolescent Psychiatry and Behavioral Sciences. He is also the senior attending staff psychiatrist in the Department. In 1966, he graduated from University of Pennsylvania School of Medicine and then went on to complete his medical training at Hospital of the University of Pennsylvania. Board certified in child and adult psychiatry, Dr. Liebman has devoted his career to the development and application of systems-based family therapy as an effective treatment modality for eating disorders, psychosomatic disorders, and substance use disorders. Dr. Liebman holds appointments as a clinical professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania, and has published many papers and textbook chapters on the treatment of eating disorders and psychosomatic disorders. He has been a member of Pennsylvania Medical and Montgomery County Medical societies for 23 years. Arthur B. Lintgen, MD, FACP, was a board certified internist who practiced with Internal Medicine Associates of Abington before retiring in 2013. Dr. Lintgen gladly followed in his father’s footsteps by becoming a physician. Born and raised in the Philadelphia area, he attended college at the University of Pennsylvania (1958-62) and medical school at the Thomas Jefferson University School of Medicine (1962-66). Dr. Lintgen continued his medical training at Abington Memorial Hospital. After two years in the U. S. Army, he established his internal medicine practice in 1972 at Abington Memorial Hospital, where he served on numerous committees and played a major role in Abington’s Internal Medicine residency teaching program. He was also on the staff at Holy Redeemer Hospital for several years. Dr. Lintgen initially had a solo practice, and then was joined by Paula A. Bononi, M.D., F.A.C.P. The practice merged with Jenkintown Internal Medicine and the late Theodore Skowronski, M.D., to form Internal Medicine Associates of Abington (IMAA) in 1994. IMAA was purchased by Abington Memorial Hospital in 1995. He is a Fellow of the American College of Physicians. He was Medical Director of Fort Washington Estates, Gwynedd Estates, Spring House Estates, Normandy Farms Estates, and Southampton Estates from the dates they opened until his retirement. His interests include music and sound, fishing, and meteorology. He continues to write classical music and film score reviews for The Absolute Sound and Fanfare magazines, and serves as a Director of the Avalon Fishing Club. He has been a member of his state and county medical societies for 43 years. Continued on next page

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Stephen Pripstein, MD, specializes in neuroradiology and orthopedic radiology. In 1966, he graduated from Temple University School of Medicine, followed by an internship at the University of Michigan in Ann Arbor. He completed both his residency in radiology and a fellowship in neuroradiology at Thomas Jefferson University Hospital. He practices in Bucks and Montgomery counties and has hospital affiliations with Abington Jefferson Health and Thomas Jefferson University Hospital. The avid horseman enjoys polo. He recalls performing an emergency embolization for uterine bleeding as one of the most gratifying moments in medicine. A year after the procedure, he saw the pregnant mother and her fetus during an ultrasound. Dr. Pripstein has been a member of his state and county medical societies for more than 20 years.

NOTEWORTHY PROFESSIONAL MILESTONES NAME Larry I. Barmat, MD Janet L. Beausoleil, MD Alicia A. Boellner-Kahn, MD Richard P. Borge Jr., MD Lynn A. Cook, MD Glennis R. Hall, MD Michael W. Milbourne, MD Marylee Mundell, DO Robert S. Nye, MD Dorothy A. Slavin, MD Maria A. Tucker, MD

Eli W. Zucker, MD, practiced family medicine in Hatboro until his retirement in 1998. In 1966, the Bronx, N.Y. native graduated from then Hahnemann Medical College, followed by an internship and residency at Abington Memorial Hospital. He proudly says he was the first family practice resident at Abington. He served in the United States Air Force from 1968-1970 and was honorably discharged as captain. He always knew the importance of organized medicine. While on active duty and anticipating the return to the area, he wrote MCMS about membership. Dr. Zucker, 75, recalls one of the most interesting moments in medicine happened while he was interning at Abington Memorial Hospital. A call girl, who was wearing only a mink coat, and her elderly client were brought into the ER. She claimed the client assaulted her. Dr. Zucker recalls that the response time of “every police officer in Abington, Cheltenham, Jenkintown and Lower Moreland� was just remarkable. He has been a member of the Pennsylvania Medical and Montgomery County Medical societies for 46 years.

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SPECIALTY Obstetrics & Gynecology Allergy & Immunology Pediatrics Cardiology Family Medicine Anesthesiology Cardiology Pediatrics Internal Medicines Infectious Disease Obstetrics & Gynecology

Marylee Mundell., DO

Richard P. Borge Jr., MD Michael W. Milbourne, MD

Larry I. Barmat, MD

Maria A. Tucker, MD

Alicia A. Boellner-Kahn, MD

Katherine S. Patil, DO

Anna Karasik, MD

Scott H. Fredd, MD

John S. Khoury, MD

Rowena McBeath, MD

Keith J. Mathers, MD

NAME Joseph S. Demidovich III, DO Scott H. Fredd, MD Anna Karasik, MD John S. Khoury, MD John M. Kowalksi, DO Bilal H. Lashari, MD Keith J. Mathers, MD Rowena McBeath, MD Katherine S. Patil, DO

Joseph S. Demidovich III, DO M C M S P H Y S I C I A N 22 S P R I N G 2 0 1 6

of SPECIALTY Medicine Internal Medicine Cardiology Pediatrics Neurology Emergency Medicine Internal Medicine Ophthalmology Hand Surgery Pulmonary Critical Care

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MCMS Awards Two Medical Student Scholarships Montgomery County Medical Society (MCMS) awarded two scholarships in the amount of $2,500 to local medical students

As an intern with the Uganda Prison Service, he saw this vividly in the countenances of HIV-positive inmates started on ARV treatments for the first time.

“Faces would start to glow again, CD4 counts would climb, and quality of life rapidly started to improve in immeasurable ways,” he recalls. “I am awed by the power of medicine and am motivated by the vast unknowns of human physiology.”

Quan ( Jack) Chen, son of Li Liu and Shunchao Chen, of Audubon, attends The Commonwealth Medical College, Scranton. Gregory T. Woods, son of David and Pamela Woods, of Lansdale, attends The University of Michigan Medical School, Ann Arbor. Chen, who plans to specialize in radiation oncology, shared in his application that he has been involved in oncological research for seven years and does not plan to stop. His research has gone from early detection of colon cancer through methylated markers at Drexel University to targeted drug therapy in melanoma at the Wistar Institute.

“My research has thoroughly taught me the importance of looking at cancer from many different viewpoints,” Chen said, who wants to expand his experiences by performing clinical oncological research, and then taking that knowledge to state of the art cancer center. “One day, I will be an oncologist who can change the meaning of the words ‘You have cancer’ for my patients into a phrase more meaningful than despair; a phrase for hope and expectation of the things to come.” Woods, who plans to specialize in pediatrics or obstetrics and gynecology, said he has always been fascinated by the effects that medicine and various therapies can have on the human body. The joy he finds in medicine will likely result in a “perpetual student.”

This award is possible, thanks to contributions from the Montgomery County Medical Society members and area physicians. “For many years, MCMS has invested in medical students’ education by providing financial assistance,” said James W. Thomas, MD, MCMS president. “These bright minds are our present and our future and should be applauded for desiring to serve others.” The MCMS mission is to represent and serve all physicians of Montgomery County and their patients in order to preserve the doctor-patient relationship; maintain safe, quality care; advance the practice of medicine; and enhance the role of medicine and health care within the community and across Montgomery County and Pennsylvania. The Foundation of the Pennsylvania Medical Society administers the fund for MCMS. The Foundation, a nonprofit affiliate of the Pennsylvania Medical Society, sustains the future of medicine in Pennsylvania by providing programs that support medical education, physician health, and excellence in practice. It has been helping to finance medical education for more than 60 years. For more information about this scholarship, call (717) 558-7854, or visit the Student Financial Services page at www. . Mission: The Foundation of the Pennsylvania Medical Society provides programs and services for individual physicians and others that improve the well-being of Pennsylvanians and sustain the future of medicine.

If you want to invest in the future of medicine, send tax-deductible contributions to The Foundation of the Pennsylvania Medical Society with MCMS Scholarship noted on memo line, 777 E. Park Drive, Harrisburg, PA 17105. For additional information, call MCMS, (610) 878-9530. M C M S P H Y S I C I A N 23 S P R I N G 2 0 1 6

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30 Stories for 30 Years The Foundation of the Pennsylvania Medical Society celebrates the 30th anniversary of the Physicians’ Health Program (PHP) by sharing 30 stories of how the program changed people’s lives. Here are some excerpts from a few of them: When my husband’s alcoholism came to light, he went into a rehab center and I went into a crisis. It felt like a handgrenade had gone off in my living room, and the pieces of my life were flying around me like shrapnel and debris. I honestly didn’t know what to hold onto, and what to let blow away. The counselor at the rehab center recommended that I get in touch with the PHP to learn about the voluntary monitoring program for physicians. Although I was reluctant to share our family secrets and to ask for the help that we needed, I found the phone number on the Internet and called the PHP while my husband was still in inpatient treatment. The reception I got from the PHP was warm and welcoming. I realized that I didn’t have to find my own way, because others had gone before me on this path. When I told the PHP counselor that my plan for my husband after his rehab discharge was to administer a breathalyzer test before he went to work, when he came home, before he drove with the kids, etc., I was quite wisely told that I couldn’t be a spouse and the sobriety police. What would I do if my husband kept drinking? How could I enforce these rules? What would happen with empty threats and ultimatums that might not work? I listened to the information about their program and started to have hope that I wouldn’t be alone to shoulder the burden of living with an alcoholic. Fast forward two years, and our family is doing well. I attend Al-anon meetings, and have found a whole group of people who understand this disease. I have learned that I am not responsible for anyone else’s drinking or sobriety. My husband has a strong AA program and attends 5-6 meetings per week. He has maintained his sobriety by using all the tools available, one of which is the PHP monitoring program. He has random blood and urine tests, and follows the program requirements of meetings and counseling. We don’t look at

these program requirements as an intrusion or a punishment. Instead, they are a welcome means of accountability. It is a way to reestablish trust and prove that he can “walk the walk” as well as “talk the talk.” Alcoholism can’t be cured, but it’s a disease that can be managed with the right strategy. I am grateful to the PHP for helping us live with alcoholism. — Tina Fell Oct. 12, 1988: DEA agents invaded my home in search of evidence regarding distribution of controlled substances. More than 70,000 doses were registered to me and not accounted for. That day was the first time I ever admitted (to the agents) that I was a drug addict. They had “other ideas.” This was the end of life as I knew it. My Pennsylvania medical license and DEA registration were suspended/revoked, as were my hospital privileges. Felony charges were issued three years later. I had to stop using narcotics, and that was not possible. On Oct. 14, two days later, knowing that my supply was frighteningly low, I did prepare for suicide. I prepared two syringes, one with Midazolam and one filled with Pavulon, and placed them in my top drawer. That same day, an old acquaintance of mine who had previously been in much trouble accepted my call. He gave me a phone number and said, “You do not have to feel this way anymore. Life can be beyond your wildest dreams.” The phone number was for the PHP. I spoke somewhat honestly for the first time about my addiction. They sent a gentleman to my home to escort me to Marworth, a rehabilitation facility. I have been involved with the PHP as a participant, monitor, and committee member for the past 27-plus years, with continuous sobriety since Day One. PHP provided the framework for my recovery, monitoring, and letters of support whenever needed. I owe them my life. I resumed practicing anesthesia in 1989 and have been professionally successful since that time. This is a direct result of PHP intervention. My story is a miracle. My path would not have been feasible without the support and guidance of PHP. — Dean Steinberg, MD

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As a medical student, my experience in the PHP has been quite interesting. Initially, I was hesitant, mainly because I had never imagined myself in a program like this. However, after almost a year in the PHP, I can honestly say that this program is the best thing that has ever happened to me. My family and closest friends constantly remind me how much better I am since joining the PHP. The staff is very kind, and it is clear that they care about you and your well-being. My most memorable patient experience that reminded me how great the program has been for me was on my psychiatric rotation. I was talking to one of my patients, and another patient happened to be sitting at the table with us. I had never met her before and I felt a very unique connection and understanding with her. She mentioned that she no longer drinks because no one likes being around her when she drinks. This patient went on describing her story, and I was able to relate on a very personal level. I understood her intimately, as my family and friends have been telling me how great I am to be around since I’ve stopped drinking. Through the PHP, I feel like I am finally in a place where I have always wanted to be. I feel happier than I ever have before. Mainly, I am grateful to PHP for making me a better person, and I know I will be a better doctor. — Anonymous

The Physicians’ Health Program (PHP), a program of The Foundation of the Pennsylvania Medical Society, the charitable arm of PAMED, provides support and advocacy to physicians struggling with addiction or physical or mental challenges. The program also offers information and support to the families of impaired physicians and encourages their involvement in the recovery process.

Providing You Peace of Mind... Is Our Pleasure!

Go to throughout the year to read new stories every month and donate online. Saving Lives and Careers For 30 years, the PHP has helped more than 3,000 physicians enjoy life without drugs or alcohol and continue to be successful physicians. To learn how you can make a difference by contributing to the PHP Endowment, contact Marjorie Lamberson, CFRE, at mlamberson@ or (717) 558-7846. Or, mail your gift to: The Foundation of the Pennsylvania Medical Society Physicians’ Health Program Endowment Campaign 777 East Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820

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610.645.8627 Publishing Group Publishing Group Experience the Difference, Call Today! M C M S P H Y S I C I A N 25 S P R I N G 2 0 1 6

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Dispelling Myths About Superficial Venous Insufficiency BY ROBERT L WORTHINGTON-KIRSCH, MD, FSIR, FCIRSE, FACPH, RVT, RPVI


n medical school, I learned two things about Superficial Venous Insufficiency (SVI): that varicose veins are a cosmetic problem with no significant health implications, and that treatment options are neither effective nor durable. Here is the reality today: Neither of these are true. Venous Insufficiency is caused by failure of the valves that control the direction of venous blood flow. Veins in the lower extremity dilate under normal physiologic load. In some people, normal physiologic stressors (e.g. dependent positioning of legs, pregnancy, aging) cause irreversible structural changes to the vein wall, ultimately leading to malfunction of the valves. This leads to pathologically high pressures in the veins of the lower extremity. The poor drainage of venous blood and higher-than-normal pressures in these veins cause symptoms associated with SVI (i.e. heaviness, aching, fatigue and swelling) as well as the sequelae of SVI which can include chronic edema, venous stasis dermatitis, lipodermatosclerosis (scarring and retraction of the subcutaneous tissues or the ‘brown leather collar’ appearance at the ankle) and venous ulcers. Additionally, the higher pressure within these veins can approach arterial pressures, so bleeding from a ruptured varicosity can be life-threatening. Untreated SVI also has been found to significantly increase a patient’s risk for DVT/PE. From a quality-of-life perspective, the discomfort, heaviness and aching associated with SVI can lead to decreased physical activity, thus contributing to a morbid lifestyle. And, people who suffer from chronic varicose veins are often deeply ashamed of the appearance of their legs. SVI is present in over 30 percent of adults, more than twice as many as have coronary artery disease. The quality-of-life impact of SVI is similar to that of congestive heart failure, chronic obstructive pulmonary disease or diabetes mellitus. Venous stasis ulcers account for at least 70 percent of ulcers seen in wound care centers. There are 2.8 million Americans with venous stasis ulcers, with 20,000 new ulcers annually. Care of venous stasis ulcers accounts for 2-3 percent of healthcare

expenditures ($1-1.5 billion/year). Each ulcer episode costs about $15,000 in wound care. Once a patient has developed an ulcer, coordinated care is essential to treat both the ulcer and the underlying venous hypertension. Ulcers will heal with appropriate treatment of the underlying SVI, but the damage to the skin and soft-tissue is often irreversible. Treating SVI before skin damage or ulcers develop is obviously ideal. Here’s the good news: the treatments for SVI developed in the last 10-20 years really work on 90 percent of all patients, with little or no down time. Minimally invasive techniques include thermal ablation of the saphenous trunks using either radio frequency or laser energy, followed by treatment of large branch varicosities with injection therapy using microfoams. These procedures have technical and clinical success rates exceeding 90 percent in the hands of experts, and extremely low complication rates. All are done under local anesthesia on a walk-in, walk-out basis. There is minimal disruption of patients’ busy lives. Emerging technologies hold the promise of even less imposition for the patient. After a treatment course and recovery period, which may take several weeks, approximately 90 percent of patients report that they are much improved or better. SVI is a chronic progressive disease. Because it is caused by a structural abnormality of the vein wall, we cannot cure this disease. But we can, and do, manage it very well. After treatment, long-term follow-up of patients is important to monitor for progression of disease and the need for further treatment. Our goal needs to be prevention of irreversible changes associated with SVI, decreased risk of VTE and improvement of quality of life in our SVI population. We can achieve these goals for our patients. Robert Worthington-Kirsch, MD, FSIR, FCIRSE, FACPh, RVT, RPVI, is an Interventional Radiologist who has been practicing in the greater Philadelphia area since finishing his Residency at Mercy Catholic Medical Center in 1990. He is Chairman of the CME Committee of the American College of Phlebology. Dr WorthingtonKirsch has been practicing at the Vein Clinics of America office in Wayne, PA since 2012, and is Director of Research for VCA.

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Professional Organizations – A Worthwhile ROI BY NICK HERNANDEZ

There are plenty of healthcare professional organizations, but are the yearly dues worth it to join? As budgets get squeezed, many physicians and practice managers have been cutting back on the number of professional associations they belong to. Although there is often a lack of perceived benefit, membership in professional associations yields a number of benefits. Taking an active role in professional associations can benefit physicians through networking opportunities, policy alerts, and continuing education.

1. Education Perhaps the most important benefit is education. (A plea here to physicians is to remember this applies to your practice managers. If you want a successful practice, run by a talented practice manager, you must be willing to support his or her professional continuing education.) Most associations provide an enormous amount of access to resource information such as case studies, articles, white papers and books written by experts in your field or area of interest. Providers and managers can keep up with the newest developments (clinical and operational) through their association membership benefits, including conferences. Take advantage of all the information your associations provide and remember that most of it is online and free.

2. Networking Another important benefit is networking. There is no better way to connect with peers and industry experts than through professional association membership. There is often a variety of networking venues to choose (e.g. listservs, membership connections and groups, national conferences, regional seminars, etc.), provided you are willing to get engaged with other members. Networking with professionals outside your place of employment can give you a broader perspective on the market and healthcare in general.

3. Industry standards Webinars are frequent these days as a means to deliver information on hot topics such as best practices, new statistics,

etc. No matter what your specialty is, staying on top of all of these issues is important.

4. Policy updates All healthcare workers know how much one piece of legislation can impact our profession. Professional associations not only update members about these types of changes but also often play an advocacy role on behalf of the membership. I have been involved in this with professional associations and it can often be a tiring effort to work with legislators at the state and national level. However, associations involved in advocacy are able to inform members how to prepare for any upcoming change.

5. Jobs Most people already know that they can search for jobs on association job boards as members. Keep in mind that your practice may want to utilize these job boards to post positions for your practice. Recruiters will often post on the job boards as well, so if you are working with a recruiter, be sure to let them know about your preferred associations.

6. Intrinsic value In addition to money, associations need support to survive. Associations are always in need of new blood to help organize their annual meetings, workshops, CME courses, and legislative committees. This means taking an active role in leadership positions or committees. Taking on these roles can not only help the association, but also benefit you personally (from leadership development to networking, to potential job searches). As the saying goes, “You get out of it what you put into it.” Undoubtedly the members who get the most out of an association are the ones who get involved and are more interactive. Nick Hernandez, MBA, FACHE, is the CEO and founder of ABISA, LLC, a consultancy specializing in solo and small group practice management ( He is a speaker, trainer and author who has over 20 years of leadership and operations experience.

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uberculosis is now the world’s leading infectious disease killer, claiming 1.5 million lives annually. More than 13 million people in the USA have TB infection. The theme of World TB Day 2016 was “Unite to End TB.” CDC and its domestic and international partners, including the National TB Controllers Association, Stop TB USA, and the global Stop TB Partnership are working together to eliminate this deadly disease. Anyone can get TB, and our current efforts to find and treat TB infection and TB disease are not sufficient. Misdiagnosis of TB still exists and health care professionals often do not “think TB.” Misdiagnosing tuberculosis as a lower respiratory tract infection (LRTI) and or community acquired pneumonia (CAP) can be a threat to controlling these two diseases in patients born/resided in TB endemic countries. Making an accurate diagnosis is critical in light of the increased use of quinolones to treat CAP. Patients with tuberculosis mistakenly diagnosed with LRTI/CAP and placed on quinolones treatment will show improvement, but not cured by this treatment alone. Repeated treatment with quinolones may lead to a quinolone-resistant TB isolate in the patient. Caution is advised. Drug resistant TB is a serious threat to the U.S. and the world. Treatment for tuberculosis should be treated in consultation with TB experts. Active TB is a reportable condition. Physicians should report any patient suspected or confirmed to have active TB to the Montgomery County Health Department (MCHD) within 24 hours. MCHD co-manages all confirmed TB cases. The responsibility for completion of treatment for TB disease is with the medical provider, not the patient. The intent in testing for TB is to diagnose persons who might have TB disease or tuberculosis infection in order to

reduce long-term disabilities/sequelae or death. A decision to test should be a decision to treat if the test is positive. Persons with a newly positive tuberculin skin test (TST) or interferon gamma release assays (IGRA) require a clinical evaluation and CXR to rule out possibility of tuberculosis disease. It is critical to rule out active tuberculosis disease. There is no rush to treat latent tuberculosis infection. Treatment with one or two drugs alone for a missed diagnosis of tuberculosis disease invites development of drug resistance. The usual drugs utilized for treatment of latent TB infection are isoniazid (INH) and/or rifampin (RIF). They are the cornerstone of treatment for TB disease as well. Treatment of latent tuberculosis infection substantially reduces the risk of developing TB disease in both the immediate and distant future. The lifetime risk of progression from infection to active and potentially infectious disease in a healthy adult is 5-10%. Children have a higher substantial lifetime risk of progression: • 40 percent in infants under 12 months of age • 25 percent in children one to two years of age • 10-15 percent in older children and adolescents. Primary school–aged children have a lower risk for progression. In summary, each case of tuberculosis has a significant impact on a person, a family, a workplace and a community. It will take full commitment of government and nongovernmental organization policy makers, the public health sector, medical institutions, medical practitioners, professional societies, scientific research organizations and communitybased organizations to “unite to end TB.” 3 4 Lobue P, Menzies D. Treatment of latent tuberculosis infection: an update. Respirology. 2010; 15:603-622 1 2

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Individuals Who should be Tested for TB Infection Risk for recent Tb infection

Risk for progression to Tb disease if infected ♦

• Close contact to infectious TB case. Retesting may be indicated 8-10 weeks after last contact 1. emigrated < 5yrs

- prisons and jails

- hospitals/health care facilities

- long-term care facilities - homeless shelters

- Mycobacteriology laboratory personnel

• Children exposed to adults at high risk for TB (e.g., HIV-infected adults)

1. Organ transplant ♦

2. Immunosuppressed patients (equivalent to > 15 mg/day prednisone for > 1 month) ♦ • Residents / Employees of:

• Persons with fibrotic changes on chest radiograph consistent with old-healed TB or history of inadequately treated TB (risk of reactivation 0.3% per year) ♦ • Persons with certain clinical conditions:

2. emigrated > 6-10 yr (co-morbid medical condition diagnosis) • Travel to high incidence countries

• TST convertors / Recently infected ♦ • Infants ♦ and children<5 yrs ♦ ‡

• Foreign born from high-incidence countries

• HIV-infected persons (10% per year to reactivate) ‡ ♦

3. Persons on tumor necrosis-alpha (TNF-a) antagonists [for example; Remicade, Enbrel, Humira, Cimizia, Simponi] and DMARDS ( Orencia, Arava) ♦

4. Silicosis ♦

6. Chronic renal failure ♦

5. Diabetes mellitus ♦

7. Certain hematologic disorders (leukemia/ lymphomas) - carcinomas of the head and neck and lung ♦

8. Underweight (> 10% under ideal body weight) ♦

10.Injection and non-injection drug users ♦

9. Gastrectomy / jejuno-ileal bypass ♦ 11. Excessive alcohol users ♦

12. Injection and non-injection drug users, Excessive alcohol users ♦ ‡ Indicates persons at increased risk for a poor outcome (e.g., meningitis, disseminated disease, or death) if active tuberculosis develops. ♦ Strong risk for reactivation ♦ Weak risk factor

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physicians and the community at large. You can find many resources including prescribing guidelines by visiting, opioidresources.

MCMS Speaks to County Commission About Opioid Crisis – Dr. Robert Dr. Robert McNamara, an emergency room physician at Temple University Hospital and MCMS board member, gave an update on county and state efforts to address the growing public health crisis of opioid abuse in Pennsylvania. He spoke during the April 21 Montgomery County Commission meeting. Dr. McNamara emphasized that the opioid crisis is partly the result of medical efforts to treat pain, which led to more prescriptions for opiate painkilling drugs. Patient satisfaction, he said, was part of a doctor’s overall evaluation. The increased awareness has led to prescription guidelines that benefit the medical community as well as patients’ understanding of why powerful painkillers aren’t as routinely being prescribed. Opioid prescriptions at Temple University Hospital, where McNamara serves as chair of emergency medicine, are down 40 percent.

MCMS Chairman Elected as PAMED 2nd District Trustee – Dr. Mark Lopatin was named 2nd District Trustee in February. A letter of support from MCMS President James W. Thomas, MD was sent to PAMED and Dr. Charles Cutler spoke eloquently on behalf of Dr. Lopatin during the PAMED board meeting. He is filling the remainder of the term vacated by former trustee Dr. John Pagan, who was elected in October to vice speaker of the PAMED House of Delegates. Dr. Lopatin will represent physicians in Delaware, Chester, Montgomery, Bucks, Lehigh and Northampton counties. Dr. Lopatin will also run for the same seat in October during the 2016 House of Delegates in Hershey, Oct. 21-23.

MCMS Leaders Take Opioid Message to the Hill – On May 17, MCMS leadership, along with Pennsylvania Medical Society and other county medical society leaders from around the state, visited with state legislators to discuss the state’s opioid crisis. Following the Capitol visits, PAMED convened an Opioid Awareness Symposium to address the various responses to the public health crisis. Physician General Dr. Rachel Levine discussed naloxone and alternative pain treatments. PAMED has been collaborating with more than 10 organizations to educate

Eighteen Physicians Received Reimbursements for CME – Thanks to the generosity of the late Howard F. Pyfer, M.D., the Montgomery County Medical Society offers reimbursement for Continuing Medical Education (CME) credits. Per the terms of Dr. Pyfer’s will, MCMS members under the age of 45 are eligible for a maximum reimbursement of five hundred ($500) dollars each year. Download an application from MCMS web site, Applications are taken throughout the year. The deadline to apply is Jan. 9.

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MCMS Hosts Its Annual Dinner with Legislators in Harrisburg – More than 30 physicians and Pennsylvania House legislators came together on May 23 to break bread and build relationships. The informal dinner is a valuable opportunity for physicians to meet with their state legislators and discuss personal and professional matters. Members are invited each year. If you are interested in participating in 2017, contact MCMS executive director, Toyca Williams, Call for Articles – MCMS Physician continues it hunt for great content. Many thanks to all those who have contributed to the magazine’s success. MCMS Physician provides comprehensive information on issues concerning quality health care in Montgomery County. The quarterly publication is distributed to all members, regional health care executives, legislators and general public. Articles should be health care related and human interest articles written by and/or about our members, medical issues that impact our physician and general communities, general hospital and health care news and society and member news. The deadline to submit articles for the summer issue is June 13, but again we can accept articles for subsequent issues. Submissions and inquiries should be sent to Toyca Williams, MCMS Physician Deputy Editor, Wanted: Part-time Medical Director –The Montgomery County Health Department is seeking a part-time medical director. To learn more about the position, visit the county’s web site, Physician Volunteers Needed at Local Medical Clinic — The Clinic in Phoenixville, a nonprofit medical clinic that provides primary and specialty care to the uninsured and underserved, needs primary care physicians to volunteer Monday afternoons and Tuesday and Thursday morning and afternoon shifts. The Clinic receives no government funding and operates solely on private donations and grants. The Clinic serves 34 townships/municipalities in

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News & Announcements Montgomery and Chester counties. For more information, email George Spyropoulos, DO at or call the volunteer coordinator at (610) 935-1134 ext. 33.

suggested topics to Toyca Williams, MCMS executive director, MCMS would like to continue to host live or virtual meetings to address challenges that negatively affect your practice’s health.

New Scholarship Opportunities for PAMED’s 2016-2017 Year-Round Leadership Academy – Have you taken on a leadership role or new responsibilities within your organization? The upcoming session of PAMED’s Year-Round Leadership Academy offers scholarship opportunities for early career physicians, emerging leaders in a hospital/health system, and office-based physicians who have taken on a new role to lead or facilitate changes to ensure practice sustainability.

Never a Bore: Looking for Latest Medical Mystery – No two days are alike in any medical practice. Each day brings new patient challenges, some fairly simple to resolve and others not so. The Philadelphia Inquirer readers want to know more about the medical mysteries that physicians encounter. If you have a medical mystery to share, contact Charlotte Sutton, Inquirer Health and Science Editor,

Join or Die, Says PAMPAC Leader – You may be familiar with Benjamin Franklin’s famous “join or die” political cartoon. In 2016 the choice for physicians is similarly stark, says John C. Wright, Jr. MD, chairman of PAMPAC. From burdensome legislation and regulation to mandates from insurance companies and health systems, threats to the physician-patient relationship are everywhere. PAMPAC is a grassroots coalition of physicians, residents and medical students who are committed to electing candidates for public office who will advocate for issues that are important to the medical community. This year, at the state level, an attorney general, 25 state senators and 203 state representatives will be elected. Every one of them can impact the way you practice medicine, Dr. Wright said. Learn more at advocate/pampac. Never Too Early to Plan For Next Meeting – MCMS welcomes and encourages members to attend the next Board of Directors meeting, Tuesday, Sept. 6, 6 p.m. The meetings are held at the MCMS office, 491 Allendale Road, Ste. 323, King of Prussia. If you are interested, contact Toyca Williams, MCMS executive director, or call (610) 878-9530. The MCMS Board of Directors represents you. For a list of board members, visit the MCMS web site, www. What Keeps You Up at Night? – MCMS wants to help you navigate the evolving health care environment. If there is a particular issue you are interested in knowing more about, let your county medical society staff know. Send

Share Your Passion Outside Medicine – The readers have missed hearing about your passions outside of medicine. We all have them, so open up and provide insight into your favorite pastime. You’ve read about our physician pilot who enjoys flying with his grandchildren, our ER doc who releases stress by coaching his dragon boat team in competitions all over the world or the determined young resident who scaled Mt. Everest and practiced medicine along the way. We want to hear more. MCMS Physician Editor Jay Rothkopf MD also encourages physicians to submit articles for the publication. For more information or to send articles or ideas, contact MCMS Executive Director Toyca Williams, at montmedsoc@ Like Us on Facebook – If social media is a favored hang out, then like MCMS on Facebook. Haven’t been on MCMS Facebook page lately, you’re missing out: • Top nine issues affecting physicians in 2016 • Nominations being accepted for PAMED Awards • Real-time updates on the naxolone standing order. • Decisions made on medical marijuana. • Updates on the CRNP Independent Practice Debate. • Varying opinions on maintenance of certification (MOC).

Welcome New Members MCMS is pleased to welcome the following individuals who joined the Society: December 2015 Dana Mincer, DO Ashesh Shah, MD Celia Tong, Medical Student Jillian Wawrzyniak, MD January 2016 Dona W. Chen, MD Bryan Ebert, MD Henry Liu, MD Amanda D. Miller, DO Pikai Oh, MD Daniel Ari Ringold, MD Debra Kay Null Vermette, MD Carolyn Joyce Van Why, MD February 2016 Catriona Mcdonald Harrop, MD Amy M. Smith, MD March 2016 Matthew A. Costa, Medical Student Marvin Goldstein, MD Rebecca Blank Horn, MD Jessica Whitney Jerrard, DO Katheryn Kirkwood, Practice Administrator Daniel O’Connell,MD Joseph Michael Ryan, MD Ntaliya Ternopolska, MD Carl M. Williams, MD Jeanie Yuh, MD April 2016 Anitha Bhat, MD Michale G. Choe, MD Colleen M. Dempsey, MD Joel I. Sorosky MD, FACS May 2016 Elena Mary Kazlo, DO To publish photos of new MCMS member physicians, please submit digital copies to

Necrology Report

MCMS regrets the loss of these society members since January 2016. Walter I. Hofman, MD Richard P. Whittaker, MD

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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.

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


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 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 Volume to Value Online Courses— Get the skills to succeed in value-based delivery with six online, on-demand courses.

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.