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Your Community Resource for What’s Happening in Healthcare

FALL 2016

BERKS COUNTY MEDICAL SOCIETY

Growing Older –

Well

+Opiates or Medical Marijuana for the Treatment of Chronic Pain?

Student Sum mer Research Projects

Proud to Achieve Magnet Designation for the Highest Quality of Patient Care and Nursing Excellence Reading Hospital is honored to announce it has received Magnet designation for excellence in nursing from the American Nurses Credentialing Center Magnet Recognition Program®. This most coveted distinction recognizes healthcare organizations that demonstrate sustained superior patient care, patient safety, and innovation in professional nursing practice. We are proud of our 1,800 nurses and more than 4,000 interdisciplinary colleagues who worked tirelessly to achieve this level of care. This prestigious designation has been attained by only 7% of hospitals nationwide. We know both patients and nurses alike seek out hospitals with Magnet designation, because it is viewed as the “gold standard” for exceptional care. This achievement was completed with one goal in mind — to give our patients the highest level of care they have come to expect and so rightly deserve.

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Medical record

Contents

BERKS COUNTY MEDICAL SOCIETY

A Quarterly Publication

To provide news and opinion to support professional growth and personal connections within the Berks County Medical Society community.

Berks County Medical Society MEDICAL RECORD Lucy J. Cairns, MD

Editorial Board

D. Michael Baxter, MD Daniel B. Kimball, MD, FACP Betsy Ostermiller

FALL 2016

Features

Growing Older – 10

Well

+Opiates or Medical Marijuana for the Treatment of Chronic Pain?

Berks County Medical Society Officers Andrew R. Waxler, MD President Gregory T. Wilson, DO President Elect D. Michael Baxter, MD Chair, Executive Council Michael Haas, MD Treasurer & Chair, Finance Committee Anne Rohrbach, MD Secretary Lucy J. Cairns, MD Immediate Past President T. J. Huckleberry, MPA Executive Director Betsy Ostermiller Executive Assistant

Berks County Medical Society 875 Berkshire Boulevard, Suite 102B, Wyomissing, PA 19610 Phone: 610.375.6555 | Fax: 610.375.6535 Email: info@berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society. Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication. The Berks County Medical Record (ISSN #0736-7333) is published four times a year by the Berks County Medical Society, 875 Berkshire Boulevard, Suite 102B, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 875 Berkshire Boulevard, Suite 102B, Wyomissing, PA 19610.

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Physicians Questionnaire 2016-2017 Directory of Physicians Corrections Student Summer Research Project My Surgical Training and Early Practice Pay It Forward: The Joy of Mentoring Department of Labor - Are You Ready for the December 1, 2016 Changes? BCMS Fall Golf Outing Department of Family Medicine Lecture Series Fall 2016

Berks County Medical Society BECOME A MEMBER TODAY! Go to our website at www.berkscms.org and click on “Join Now”

In Every Issue

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Editor’s Comments President’s Message Compass Points Foundation Update Alliance Update

Content Submission: Medical Record magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Berks County Medical Society. Submissions can be photo(s), opinion piece or article. Typed manuscripts should be submitted as Word documents (8.5 x 11) and photos should be high resolution (300dpi at 100% size used in publication). Email your submission to info@berkscms.org for review by the Editorial Board. Thank YOU! Cover (Left to Right): Jack Lusch, MD; Dan Kimball, MD, FACP; Nicola Bitetto, MD; John C. Moser, MD

Medical Record magazine is published by Hoffmann Publishing Group, Inc. 2921 Windmill Road, Reading, PA 19608 | HoffmannPublishing.com | 610.685.0914 FOR ADVERTISING INFO CONTACT: Tracy Hoffmann, 610.685.0914 or Tracy@HoffPubs.com

Editorâ€™s Comments

Older and Lucy J. Cairns, MD Editor

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hortly after I turned 50 I came across a comment in something I was reading that permanently altered the way I felt about my future years. The writer observed that the first 40-50 or so years of life are a time of addition. We are in the process of adding to our abilities, accomplishments, and experiences. We are also adding to our family and to our circle of friends. At some point, the addition phase gives way to a time where subtraction becomes the dominant experience. Ouch. Of course this is a generalization and an oversimplification, but one that contains a large kernel of truth. Sooner or later, the aging process inevitably begins to subtract physical and, for too many, mental abilities. Loss of independence can follow. The longer we live, the more family members and friends are lost to death. Retirement often means the loss of an important part of our identity as a productive member of society, and a significant decrease in daily engagement with other people. For all but the wealthiest, the loss of income that accompanies retirement can cause a decreased sense of economic security. Older Americans in and out of the workforce are subjected to negative stereotyping and even outright discrimination based on age. The physician workforce in the U.S. (including Berks County) is aging right along with the general population. According to recent data presented in an Association of American Medical Colleges report1, as of 2014 11% of actively practicing physicians were between 65 and 75 years old, and close to 26% were between 55 and 64 years old. The report points out that this means up to one-third of currently practicing physicians in the country might retire within the coming decade. It goes on to project a range of significant physician shortages and makes recommendations to reduce these shortages. According to the AAMCâ€™s 2015 State Physician Workforce Data Book, the percentage of physicians in active practice in Pennsylvania in 2014 who were 60 or older was 29.9%. The aging of the physician workforce is likely to impact the ability of physicians and nonphysicians alike to access quality medical care, but aging has additional impacts on individual

Happier physicians who have reached the later years of practice or who have retired. As mentioned above, some of the changes at this time of one’s career and life are likely to be negative. But positive changes often occur as well, belying the stereotypes. In this edition of the Medical Record we decided to focus on facets of life that tend to improve in later years, thus ‘older and better.’ One big positive is that happiness and feelings of general wellbeing tend to increase in later life, according to the results of a number of academic studies and polls. Mid-life is the most stressful time, due to the number of demands placed on us relative to available time and energy. Once you get past mid-life, some of these demands (such as those related to child-rearing) ease off. But a change in attitude appears to be the major factor in finding greater happiness. “As we age, we have the opportunity to accept who we are, instead of focusing on who we feel we need to become,” said psychoanalyst Ken Eisold in Psychology Today2. “We relax into being ourselves. Our faces start to look like who we are. And the world settles into more and more familiar patterns. That acceptance brings diminished anxiety and a higher degree of enjoyment.” Of course, everyone’s experience is unique and it is dangerous to generalize, but acceptance of oneself and of the things that cannot be changed does sound like a recipe for happiness, or at least contentment. To sample the experiences of a group of Berks County physicians who are in or near retirement, we asked for a paragraph or two describing aspects of their current lives that are an improvement over their early-career lives, and for any advice they would like to give to the current younger generation of physicians. I hope you enjoy their contributions. For me personally, in the course of attaining ‘mature’ years I have lost my very dear parents and have had to adjust to becoming (perhaps) less important to and (definitely) less involved in the lives of my sons. Fortunately, so far I continue to enjoy the stimulation

and rewards of medical practice and retain a degree of health which allows me to get outside for the walks through the Wyomissing Park that I find so invigorating. To my great relief, my knees are tolerating another migration season of regular treks to the North Lookout at Hawk Mountain Sanctuary! My key sources of increased contentment at this stage of my life, however, are having lived long enough to see my sons ‘fully launched’ and to have accumulated a treasure trove of happy memories I can dive into at my leisure – feeling just as I imagine Scrooge McDuck felt diving into his swimming pool full of gold. I do also have a share of unhappy memories, but have learned not to dwell on those. For me, it is the increasing awareness of the limited time I have left that has triggered my keener appreciation of the good times I have had and still hope to have. Wishing you happiness and a long life. The 2016 Update: Complexities of Physician Supply and Demand: Projections from 2014 to 2025. Submitted by IHS. April 5, 2016.

https://www.psychologytoday.com/blog/hidden-motives/201006/happiness-and-age (accessed 9/11/2016)

“I wish we had known about hospice sooner.” Hospice care is so much more than what most people think. Many hospice patients have told us they wish they’d benefitted from the hope, compassion and comfort of our hospice care sooner. Any patient, family member or friend can contact us anytime, 24/7.

866.380.5874 heartlandhospice.com FALL 2016

President’s Message

O Andrew Waxler, MD, FACC President

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n September 13, I participated in the American College of Cardiology’s annual Legislative Conference in Washington, D.C. to advocate for patients and physicians. Striking while the iron was hot, with the assistance of long time PAMED Legislative consultant Larry Light, our Executive Director T.J. Huckleberry and I were also able to meet with the Legislative Aides representing our county’s Congressional districts, as well as Congressman Ryan Costello himself. It was a great day advocating for our patients as well as for our Berks County Medical Society(BCMS). As I was walking the Hill, I could not help but notice the monuments, buildings, and paintings created to honor the great leaders and statesmen that once served our country. Furthermore, as I sat in each Congressional office I could not help but wonder what Representative previously sat behind that desk.... Our Capitol and our country has an awesome and fascinating lineage of great men and women who helped shape our nation into what it is today. Returning back to Berks County, I did not have to go far to get the same sense of nostalgia. Stepping into our BCMS office we proudly display our portraits and plaques honoring all the great physicians who have led our society. Names like Keiser, Heister and Kurtz, the forefathers of our society, share the same wall space as our contemporaries, like Kimball, Truex, and (cough) Barbera. The strength of our lineage is only due to the strength of our leadership, and its influence on the next generation. Most recently, Gary Lattin, past president of the BCMS, retired after a long and brilliant career.

He founded the Berks Cardiologists group in 1972, and he has had a major influence here both in elevating the level of cardiac care as well as touching the lives of literally thousands of grateful patients. He remains a great role model and will be truly missed by all of us. He has left another set of great footsteps in Berks County that we can only attempt to follow. More recently, my buddy John Dethoff, a respected orthopedic surgeon, also retired. He and I have worked together in BCMS for more than a decade, particularly with our radio show Health Talk. While I suppose he’s entitled to retire, I am personally hoping that he will stay in the area for at least a few more years! I am truly honored to be holding the torch of the medical society this year, but as the portraits on our wall have reminded me…torches get passed. That is why it’s important not only for our society but for the advancement of medicine that new and younger physicians step up and into the leadership role. If you feel you are that physician or that you share our passion for patient care and physician advocacy, we at the medical society are eager to have you join us and perhaps be the next portrait on our wall.

Healthcare for Women. By Women.

Women’s Health is now available at Exeter Ridge Health Complex. Dawn M. Hasson, MD Karen J. Gurski, MD Lesley Sweeney, MD Christie L. Ganas, MD

Our Women’s Health team of gynecologists shares a unique perspective on Women’s Health — all women doctors dedicated to providing personalized care to women of all ages. Penn State Health St. Joseph is committed to treating each woman’s specific health needs and concerns with experienced, compassionate care. All from a woman’s unique perspective. Plus, because we’re part of Penn State Health, we have direct access to hundreds of our fellow Penn State Health specialists, 24/7/365.

And now, Women’s Health is even more accessible and convenient as we welcome Dr. Lesley Sweeney to our team and announce the expansion of Women’s Health to the Penn State Health Exeter Ridge Health Complex. It’s the care you want, the way you prefer it. Close to home or work. And woman to woman. Learn more at thefutureofhealthcare.org or call 610-378-2898 for an appointment at either location.

EXETER RIDGE HEALTH COMPLEX 3970 Perkiomen Ave., Exeter Township BERN CAMPUS Medical Office Building, 2494 Bernville Rd.

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C o m pa s s P o i n t s

So… Do I take a Drop? Timothy J. (T.J.) Huckleberry, MPA Executive Director

As many of you know, our fall outing was held on September 21, a day that was circled on my calendar all year in anticipation.

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Why, you ask? Is it because it’s the one day a year I get to drive a golf cart all day while wearing shorts and a hat and actually get PAID for it? Or is it because this event is actually a fundraiser and at the end of the day, I don’t have to pop a dozen antacids when I go over the bill? While both certainly help to make the day great for me, the real reason is because I have been working to improve my golf game. And by “improve” I mean a complete overhaul of every facet of my swing. Because while I am a scratch golfer while playing Wii golf with my five-year-old, I am in fact a horrible golfer off of my couch. So in the spring, I dropped a generous amount of cash on lessons. I also upgraded from the hand-me-down set of irons and clubs that was forged during the Eisenhower administration, bought a new Nike golf bag, Nike golf glove, two cases of Nike golf balls and a new pair of Nike golf shoes (I am debating if Nike dropped their golf line because of poor revenues or the fear that my golf game would only damage their reputation). And in an effort worthy of a Rocky montage, over the spring, my game did actually improve…at least on the driving range. But as the ever pragmatic Dr. Mike Haas warned me… “wait until you actually get out on the course.” Which was another matter. A few weeks ago, my good friend Kevin and I decided to go out and play a round. Obviously, I was extremely excited to go out and showcase my “improvements.” So with my brand new hybrid club in hand (for those who do not know what a hybrid is, it’s a cross between a two iron and a sledge hammer), I teed up on the first hole. Kevin looked on, equipped with his dry sense of humor and Dali Llama-like patience, as I took my practice swings, approached…and sent my Nike golf ball screaming down the fairway…. the other fairway…and into the forest where I can only assume it concussed some small woodland animal. So I turned to Kevin and asked, “so,…do I take a drop?” And the rest of the day went something like that. As Kevin pointed out somewhere around the 5th hole, “You certainly have a love/hate relationship with the trees…and the cart path, and retaining walls…and.” But as we all know, it only takes one swing to bring your

whole game around. Which leads me to the 8th hole. It started out much the same. I had a half decent drive, into the other fairway. But once I got to my ball, I thought I had a pretty reasonable shot to get it near the green. All I had to do was clear a row of trees. So I retrieved my trusty hybrid club, stood over my ball and went through the 32-point checklist of things I had to do to properly hit the ball (note: you can build an entire IKEA bedroom set with less instructions than hitting a #$%& golf ball correctly). And for once I accomplished a perfect swing! The air pinged with the sound of titanium striking its target, sending the ball airborne towards the green. I walked towards the green with the satisfaction only Arnold Palmer on Augusta’s 18th would ever have known. However, I could not find the ball. Was it in the hole? Did I Eagle on a par five? Did I finally justify the months of training? No. Scaling back my expectations, I searched the fairway in line with where that “perfect ball” was struck. Maybe with a good chip up to the green I could still get par or even birdie! But the ball could not be found. Exhausting my search on the ground, my last ditch effort forced me to look upward into the row of trees. And there, jammed between two branches about 8 feet off the ground, was my “perfect ball.” As I stared blankly at the efforts of my best swing of the day, ready to go on a tirade that would make Donald Duck and a longshoreman blush, I was met by Kevin, sitting in our golf cart, neck straining upwards towards the tree, and after a moment of hilarious silence he asked, “So, are you taking a drop?” The good news is that I did get slightly better as the day went on, and I became more consistent throughout the summer. Improving one club and iron at a time. I even got a par the other week. The important thing is that I am improving.

Which, if I can swing this back to our Medical Society for a moment, is exactly what we must continue to do here. Build off of our successes and continue to bring value. In October, we are going to take this approach to one of our most successful programs: Health Talk, our weekly radio show on WEEU. I am excited to announce the start of Health Talk TV. Thanks to the efforts of our current President, Dr. Andrew Waxler, we will be hosting a one hour TV show on BCTV every other month. Like Health Talk radio, we hope to educate our viewers on current health issues facing Berks County. I am excited about the opportunities this TV show will bring in expanding our Society’s message and providing our physicians another venue to reach out to the community. But we are not stopping there. In partnership with the Pennsylvania Medical Society, we are also starting our monthly webisode series: Healthtalk.net. These 2 to 3 minute videos are aimed at offering healthcare providers some critical expertise on subjects facing our community. The first series will be focused on the ongoing opioid epidemic and will feature members of our Substance Abuse Task Force, as well as other experts in our community. Healthtalk.net will be emailed out to all members each month and will also be available on our website: BerksCMS.org. I am absolutely positive that the “improvements” to Health Talk will be much better received than my golf game, but as I am sure Kevin would agree, both are definitely entertaining to watch!

FALL 2016

M e d i c a l R e c o r d F e at u r e

Growing Older –

Well by Michael Baxter, MD

he French author and philosopher Simone de Beauvoir once wrote about the perception of youth that “It is easier to imagine one’s self dead than it is to see yourself as an old person.” As I have become older I have come to better understand what she observed. Old age creeps up on one slowly at first like moss covering the base of a tree and then eventually expanding as it dominates all aspects of life. When I first came to Berks County 25 years ago I was a relatively young man focused on developing my career as a physician. I looked up to and learned from my senior colleagues, several of whom offer their recollections of medical practice and their views on aging in this issue of the Medical Record. For myself I have learned much from my own personal and professional experiences. This increased wisdom is certainly one of the benefits of aging. If only I could have had that same awareness 20 or 30 years ago. I frequently share with my residents that my advice and knowledge are not so much due to how smart I am but based on my many years of trial and error, of success and failure, with hopefully an emphasis on the former. Growing older can certainly be a challenge and indeed it seems to be a greater burden for some than for others. All physicians can reflect on those patients whose life fell apart during small challenges and those that somehow transcended the most difficult life experiences. Certainly growing older can be its own major challenge. As I reflect on this, I believe that there are three major factors which determine how well one handles the challenges of growing older and, for that matter, all of life’s challenges: health, financial security (with a qualifying comment) and the quality of meaningful relationships. One’s personal health status cannot be overstated as a contributing factor to how well one deals with aging. While I marvel at patients who wrestle with multiple health problems and yet maintain a positive attitude, it is far easier to approach our senior years if our physical and mental health is strong. Fortunately the tremendous biomedical advances and many environmental and social improvements of the past 50 years, not the least of which has been the implementation of Medicare, have contributed to a healthier population of older Americans who enjoy an active and productive life that surpasses that of previous generations. Our

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generation is also generally “wealthier” than our forebears. I would comment that my own perspective is that there is a big difference between a comfortable lifestyle and great wealth. I have seen many people with modest incomes who seem to be quite happy and some that are far wealthier who are not. That leads in my view to the most important factor for aging well, the quality of our most meaningful relationships. The actual “science of happiness” has demonstrated that the quality of our relationships and the ability to find true meaning in life are the most important factors in what we define as happiness. Those relationships of course depend on a lifetime of how we treat and interact with those around us. As physicians we have the advantage that we have spent our careers improving the quality of life of others while hopefully not neglecting our own wellness and the wellbeing of those closest to us. In spite of how often we look back at the good old days of medical practice, one advancement in our modern practice world has been the increasing emphasis on physician wellness, of the need to look after ourselves and those most dear to us. In my opinion many of our newer generation of physicians are responding positively to this message, a good thing for them, their families and yes, even their patients, who will benefit from a physician who is whole, with balance in their life. My experience is that older individuals who have reasonably good health, a comfortable income assuring a level of independence (one of the most important goals for every older person) and strong meaningful relationships in their lives, will face the challenges of old age with optimism and see it as a time for strengthening important relationships and exploring new opportunities. I also believe that physicians have an additional benefit as we age – a lifetime of the most meaningful and productive work that anyone can wish for – caring for our patients and sharing experiences with them that few other professions can even imagine. As I see my own career in medicine approach its final years, it is certainly my hope that I will be able to reflect not so much on my failures and what I have left undone, but on those many rich encounters with so many diverse individuals and families that have brought benefit to them and fullness to my life. Growing old well with those I care most about around me and reflecting on memories of a life well served – what more could one ask for.

BCMS Member Reflections As many of us retirees may have found, I did experience a sense of loss in the first year after my retirement in late 2013. I missed the daily intellectual challenges of medical practice along with the interactions with colleagues whom I had known for many years. However, retired life has brought new opportunities for service through my church and also the Western Berks Free Medical Clinic, along with the freedom to join the Wyomissing Band and volunteer at the Highlands. Spending more quality time with my family has also been an improvement, compared to the hectic demands of medical practice. If I were to offer any advice to those nearing or contemplating retirement, it would be to seek the involvement of a financial counselor to evaluate one’s overall situation. This service for me was very helpful in determining that I could really afford to retire based on our current financial picture, and served to help finalize my decision. I would also stress the value of continuing to be active in retirement, in areas that are of interest to you and are sustainable over the years.

EnGage in activities designed to keep you fit and healthy

J. M. Eager, M.D.

None of us are experts on retirement, no matter how much “retirement planning” we may have done. Each of us has to find our own path through it. I’ve seen two paths predominate among my friends and myself: There are those who were ready to cut the ties to their profession, devoting joyous time to pursuits that they’ve long waited to enjoy, such as music, golf, etc. Others need some continued connection to the field of medicine to and from which we gave and received so much. I’ve fallen into the latter group, and find satisfaction in part time advisory positions and CME. For me, seeing grandchildren grow to responsible, successful adults and being surprised to live long enough to greet great grandchildren have been wonderful. Social media make it possible to be in contact with the lives of family living 600 miles away on an almost-daily basis, renew old friendships, and to share time with friends around the world. Many of us have spouses who took over most of the maintenance of our lives while we spent so much time in medicine, and it’s been fun to assume some of those responsibilities. There is an opportunity, too, to actually come to know the person you’ve shared a life with on a much more complete level, and that is a joy. Each day, I find myself filled with gratitude that I was able to work in our profession, and be trained by wonderful teachers, and to work for many years with exceptional, dedicated medical professionals. One has to feel honored to have been a member of the club. Jack Lusch, MD

BCMS Member Reflections

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At The Highlands 610-775-2300 2000 Cambridge Ave. Wyomissing

TheHighlands.org A member of Reading Health System FALL 2016

BCMS Member Reflections “ S H O U L D I S TAY O R S H O U L D I G O ? ” REFLECTIONS ON WORK TRANSITION If you are practicing state of the art medicine and enjoying it you should stay. But maybe your state of health, life expectancy and personal goals other than medical practice prompt a consideration of closing your practice. For example, a few years of work in philanthropy, finance, or the arts may be very attractive after many years of intensive medical practice. The state of your finances will be paramount in your planning. If you need to provide medical insurance for yourself, spouse, or dependents, giving up a regular income may be impossible. If finances are satisfactory you can make a careful consideration of how you will spend your retired days, in consultation with your spouse and family. It is not likely you will have a lot of free time! The activities that filled my past 14 years of retirement include music (2-3 hours of piano study daily), moderately intense physical activity (swimming, etc.), world-wide travel, and work with nonprofit organizations. Two local organizations that have an intense need for volunteers are Adopt an Acre, Inc. (local farmland preservation) and the Berks Sinfonietta Chamber Orchestra. Physicians, retired or not, are welcome to contact me (ksmith3685@aol.com) if interested in helping, or with any questions regarding my retirement experience. — Barton Smith

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M Y T W E LV E Y E A R S O F R E T I R E M E N T 1I retired from my full-time position as Department Chair at the Reading Hospital in August 2004 and managed, like most in my position, to keep busy with numerous outside interests related to organized medicine and volunteer activities. As you might suspect, I did not miss the hassles, but I did miss the professional and personal relationships with colleagues and patients. I was surprised to be asked to accept a part-time position as a hospice medical director by my pastor. I had not intended to work after I retired but I found the rekindling of professional relationships as well as the personal relationships established with clients and families in the hospice program to be very professionally and personally rewarding. It gave me five years of experience in end-of-life care, which had been a professional area of interest for many years. I left that position in May 2010 and have been fully retired since then. Since my wife Eve continues her practice, I have become the chief cook at home, which I enjoy very much. Continued involvement in organized medicine at all levels and several local non-profit boards, as well as my church, have kept me busy enough not to be bored but has given me a flexible schedule that allows travel and engagement with adult children and five grandchildren during an exciting time in their lives. Having additional time to maintain relationships with my many friends has been one of the most positive changes I have experienced in retirement. My golf game has gotten much worse, but I still enjoy the time with friends who can tolerate my game. My billiards game has gotten much better, though. I highly recommend retirement as an enjoyable and rewarding time. — Dan Kimball, MD, FACP

A DV I C E TO E A R LY C A R E E R P H Y S I C I A N S . I am in my 14th year of retirement. I retired at age 72 from a General Practice of medicine that included an area of Industrial Medicine that allowed me to grow my solo practice. When I started to practice Office visits were $4.00 and House calls were $8.00, nine months Obstetric care and delivery was $125.00. We were afraid to raise our rates because the doctor down the street might charge less. That is called competition. Then in 1965-66 the Federal Government got involved and started Medicare, which helped to take responsibility for medical care from the hands of individuals and placed it in the hands of insurers and the Government. This removed competition between Medical practices. That change, and the regulations that government imposed, are responsible for the enormous surge in medical costs. It is now completely out of control. That, however, is the climate in which you will have to practice. Good luck!

The stresses of practice are great, but made worse by outside influences. These include Federal and State overregulation, hospital policies and politics, and third party insurers. Therefore I would recommend that doctors try to be self employed or employed in small groups that allow for the physician to control his work environment, hours, scheduling and vacation time. Time has shown that self employed physicians are more efficient and content with their lives. Salaried physicians never maintain as large a practice load nor work as many hours as “piece workers.” I recommend you work hard, keep learning, be available to your patients, fund your 401(k) plan, find time for your family and take time off as needed. I thoroughly enjoyed my years in practice and you can too. — John H. Gallen, M.D.

T H RO U G H T H E Y E A R S 1I have found that through the years physicians are becoming more dependent on studies and not utilizing history, physical examinations and use of the stethescope properly. These modalities, when used properly, can give one direction as to what studies to order. 1One should utilize all five senses when examining patients and one will become familiar with the phrase “I see, said the blind man.” 1Today’s young physicians must also pay attention to their financial status more so than those of prior years. As physicians we may feel we are too busy to assess stocks, bonds, ETF and mutual funds. Managing one’s own investments, however, is worth the time and effort. I have found that by letting an investment adviser manage your portfolio, they will charge you a percentage every year. If they charge you 2% for 30-40 years, this amounts to a substantial part of your portfolio. 1Reading several financial books taught me that mutual funds were best for me. I also read several magazines, such as Forbes, Bloomberg, and the Economist. I have learned about fundamental analysis vs. technical analysis in the evaluation of securities. On the Internet, one can assess brokerage houses, such as Fidelity and Vanguard. One can gain a lot of information at these sites. 1One should start saving and investing early so that one can take advantage of Compound Interest, which in mutual funds is given as shares. I found this to be very helpful in my retirement years. — Nicola Bitetto, M.D.

BCMS Member Reflections

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FALL 2016

BCMS Member Reflections Reflecting back on medicine, my exposure really goes back to the 1950s going on house-calls with my father. His office was right next to our house and we had a lot of contact with his patients. I went to medical school and eventually began practicing in the â€˜80s. Any causal observations renders obvious that much has changed in healthcare during that time. However, I think, the essence of medicine, which is dealing with the patient; communication, compassion, concern and desire to help the patient through whatever the problem, these are the essentials which have been present probably for the past 2000 years, since the time of Avicenna. The change that has the largest effect is the rise and dependence upon technology. Various forms of imaging, diagnostic interventions, various serological evaluations, surgical procedures, use of robotics and other technical devices really have become rampant. And, this is at the heart of the problem of medicine today. I think many of these procedures, devices and interventions are used rather indiscriminately. Many times, I believe their use is a hindrance to the communication with the patient. As you can imagine it is much easier to order an MRI on a patient who feels it is needed, then to explain why it isnâ€™t. Explaining why tests and procedures are not needed is time consuming and not always successful.

Nevertheless, I have found over the past several years that if the physician allows enough time to communicate with the patient, to establish a compassionate, reciprocal relationship allowing the patient autonomy, and sound information to make decisions regarding the healthcare, frequently renders it unnecessary to spend a lot of money on diagnostic procedures. In my opinion, the primary problem with medicine today is we spend too much money, and by this, I mean physicians spend too much money. I think this opinion which I have expressed through the years has got me into trouble here and there, but nevertheless, I feel it is valid and plan to stick to it. Although it is unpopular and I know I can be mordant. The rewards, gratitude and satisfaction Iâ€™ve received from my practice and patients for the past several years, simply by talking to them, have been most enjoyable. Some renowned physician in the past is alleged to have said that the secret to caring for patients is caring for patients. I think this is simply put, that it is as it is. Thank you, John C. Moser, MD

Age Distribution of Active Physicians, 2014

2016 Update The Complexities of Physician Supply and Demand: Projections from 2014 to 2025: Final Report Prepared for: Association of American Medical Colleges. Submitted by: HIS, Inc. April 5, 2016 14

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TO M Y D E A R F E L LOW P H Y S I C I A N S : I am glad to report my happy and good experiences in retirement. I had a challenging solo practice of general surgery from 1950 until 1986. I served as chairman of the department of surgery at Community General Hospital for thirty-seven years. I operated at Community General Hospital, at the old St. Joseph’s Hospital and at the Reading Hospital. Before 1965 there were only two American Board certified surgeons in Reading — Dr. Calvin Rentschler and Dr. Bob Impink, and there were no certified surgical specialists except for the ophthalmologists. There was no penicillin and no other antibiotics and no chemotherapy. In Reading the medical conditions were appalling. Many patients were in need of surgery, and there were not enough doctors to care for them. The hospitals were outdated. My mission in life was to care for as many patients as possible, and to rebuild Community General Hospital into a fully accredited hospital. Forty percent of my surgery during the 1950s and 1960s was charitable. I took few vacations. I operated day and night, and most of my life I worked over 100 hours a week. My dear wife raised our children. I spent more time in the operating room than I had with my dear family. We had great nurses, and we felt like a big family. 1I felt liberated and free in 1986 when I retired from surgery to take care of my sick wife. I discovered there are many available opportunities and benefits in retirement that beat working. I have really enjoyed having free time to enjoy tennis, golf, downhill skiing, traveling, reading, and writing. Now I have time to watch movies, and I dare to drink an occasional glass of wine. While I was operating I had few friends outside of my dear patients, my wonderful nurses and my fellow physicians. Now I live in the Heritage retirement village where I have many good friends. At 97 years of age I count my many blessings and I continue to enjoy life. My advice to all retirees is to keep physically fit and mentally alert. C. C. Jimerson, MD

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+Opiates or Medical Marijuana for the Treatment of Chronic Pain? by Emily Evans, BCMS President’s Intern for 2016 Advisors: Lucy J. Cairns, MD and Daniel B. Kimball, MD, FACP

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ain can be defined as an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. The two major types of pain are nociceptive pain and neuropathic pain. Neuropathic pain is the activation of nervous system lesions or dysfunction which often leads to chronic pain. This is the result of a pathological change or disturbance of function in a nerve. Nociceptive pain is the activation of nociceptors from non-neural tissue damage or potential damage. The term “nociceptive pain” is an intentional contrast with neuropathic pain, for nociceptive pain indicates a normally functioning somatosensory nervous system whereas neuropathic pain indicates abnormal function. Pain has many variations, but what duration of pain is considered chronic? Chronic pain is often defined as pain that perseveres for at least three months. The experience of pain has three components: the sensory component, the cognitive processing component, and the emotional component. The sensory component of pain includes the quality of pain and the duration of the sensation of pain. The planning to alleviate pain is the cognitive processing component of the sensory experience. The emotional component of pain involves the situation in which pain is experienced. For example, the pain of childbirth and the pain of cancer would elicit very different emotions. Two people with an identical painful sensation can have very different experiences based on their different emotional reactions and cognitive processing, which is why the study of pain and its treatment presents special challenges. When the body receives a painful stimulus, a signal travels up the spinal cord to the thalamus via the actions of neurotransmitters. Neurotransmitters are chemical signals within the body. These chemical signals bind to receptors on the postsynaptic surface of a neuron. This causes a signal to be sent down the axon of that neuron to the presynaptic surface of another neuron. This neuron then releases neurotransmitters onto the next neuron, and so on. This is how a signal is transmitted through neuronal pathways in the body. Negative emotions have been shown to increase the experience of pain because both sensations are linked to the same brain system. The connection between emotion and pain shows that experiencing pain is subjective. Genetics can influence our threshold to pain, how sensitive we are to pain, the likelihood of developing chronic pain, and our response to treatments. There are multiple genes related to pain, and variations/mutations in these genes contribute to an individual’s unique perception of pain. People may even report the experience of pain in the absence of any identifiable nociceptive stimulus or neuropathic lesion, usually for psychological reasons. If pain is subjective, then how can it be accurately and consistently measured? There is not yet an accurate and objective way to measure the intensity of a person’s pain. Studying the treatment of pain requires the use of tools like the 1-10 pain scale, as well as patient self-reporting on the severity of pain and how limiting it is when it comes to important life activities. There are diagnostic approaches to assess the cause of pain, such as a musculoskeletal examination. Assessment may also include laboratory tests, MRIs, and X-rays. These tests do not directly measure the pain a person is feeling, but are often useful in identifying abnormalities that may be the source of pain. While

such assessments may prove a person has reason to feel pain, there is no way to objectively measure how much pain a person experiences. In addition to intensity, pain is also generally categorized by its location, progression, onset, and the quality of the sensation. For example, a patient could describe his or her pain as sharp, throbbing, dull, burning, or aching. Opioids are a class of drugs that include both natural and synthetic substances that bind to one or more of the opioid receptors in the body. Endorphins are the neurotransmitters that bind to our opioid receptors; thus opioids mimic the action of endorphins. Opioids are one of the most common treatments for chronic, noncancer pain. An example of an opioid not produced in the body would be morphine. While morphine is not made naturally in the body, it is a natural product. Morphine can bind to opioid receptors and activate pain reduction in the same way endorphins can. It is used for the treatment of chronic pain, but has addictive qualities as well as adverse effects. Due to the addictive nature of opioids, medication obtained with a legitimate prescription may be stolen, used for non-medical purposes, or sold on the street. Medical marijuana has been approved in 25 states and the District of Columbia. Practically every one of these states has included chronic pain as a qualifying condition for the use of medical marijuana. There is some evidence that medical marijuana makes a significant difference in chronic pain treatment, and claims for it efficacy are easy to find. The National Organization for the Reform of Marijuana Laws (NORML) claims that marijuana should be “immediately made available by prescription to seriously ill patients.” This includes those experiencing chronic pain. Drug Enforcement Administration’s Chief Administrative Law Judge Francis Young claimed, “Marijuana, in its natural form, is one of the safest therapeutically active substances known to man...Marijuana has been accepted as capable of relieving distress of great numbers of very ill people, and doing so with safety under medical supervision.” The Americans for Safe Access (ASA) is a nonprofit organization whose goal is to legalize access to medical marijuana nationally, for both therapy and research. ASA claims that marijuana has legitimate medical value. To evaluate these claims, further studies are paramount to expanding our knowledge of medical marijuana to improve treatment, health care policies and legal protections. The mechanism of action for medical marijuana is not fully understood yet, but a group of related compounds found in the marijuana plant (referred to as cannabinoids) exert their effects by interacting with a system of cellular receptors called the endocannabinoid system. Included in the endocannabinoid system are the CB1 receptor, found in the central nervous system, and the CB2 receptor, found in the immune system. In the CNS, cannabinoid receptors are found most commonly in the hippocampus, cerebral cortex, basal ganglia, and the cerebellum. Of the cannabinoids found in marijuana, THC and CBD are the most studied and well understood. THC is responsible for the “high” experienced by smoking the plant. Dopamine is a neurotransmitter whose pathways in the brain are linked to the reward system, and dopamine pathways are stimulated by the action of cannabinoids. There are currently two synthetic cannabinoids (dronabinol and nabilone) approved by the FDA currently available in the U.S. Dronabinol (Marinol) is absorbed orally and has an onset action of around 30 minutes while nabilone (Cesamet) has a longer duration

of action of around 8-12 hours. Delivery systems such as inhalers, suppositories, and transdermal patches are still being evaluated. One must keep in mind that when the terms “medical marijuana” or “cannabinoids” are used, there is a myriad of varied products this could be referring to. There are drugs that contain direct chemical from the marijuana plant (Sativex), drugs that contain synthetically made chemicals identical to those from the marijuana plant (dronabinol, nabilone, dexanabinol, CT-3, cannabinor, HU 308, and HU 331), and drugs that do not work like marijuana but use the same brain pathways (rimonabant and taranabant). The variety of available and tested cannabinoids further complicates the analysis of the available data on the use of cannabinoids for the treatment of chronic pain. One of the most appealing aspects of medical marijuana is the hope of reducing a chronic pain patient’s dependence on opioids. If some form or forms of medical marijuana were proven to be effective pain-killers with little to no addictive properties, then it could potentially help address the current epidemic of opioid addiction and overdose. We would hope to see a reduction in opioid use in chronic pain patients also using cannabinoids. Unfortunately, there are many questions that remain to be answered before we can say with confidence continued on next page

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whether or not medical marijuana has a role to play in the treatment of chronic pain. What is needed is more basic research and more high-quality clinical trials. Marijuana consists of more than 400 compounds (most FDA-approved drugs have 1 or 2) with around 70 cannabinoids in addition to THC. Many of these compounds are not yet understood and could have potential medical benefits. However, it is difficult to get approval for research. A state may not authorize medical marijuana clinical trials without getting National Institute on Drug Abuse (NIDA) approval and receiving funding from the National Institutes of Health (NIH). Getting federal approval for research continues to be difficult because marijuana is legally classified as a schedule 1 drug. The Controlled Substances Act of 1970 classified marijuana as a schedule I drug alongside heroin. Schedule I drugs are labeled as having no known medical properties and a high risk for abuse. The difficulty of obtaining approval to conduct research is a major roadblock in the way for understanding the full potential of medical marijuana. In a systematic review and meta-analysis published in JAMA in June 2015, 28 studies (63 reports; 2454 participants) on the use of cannabinoids for the treatment of chronic pain were analyzed. All experiments were randomized controlled trials and used some sort of scale to measure a patient’s pain (numerical rating scale, neuropathic pain scale, global impression of change score). The conditions for chronic pain included neuropathic pain, cancer pain, diabetic peripheral neuropathy, fibromyalgia, HIV, MS, and rheumatoid arthritis. Seventeen of these studies were found to be at high risk for bias, while only two studies were at low risk of bias. The range of cannabinoids being evaluated included nabiximols (13), smoked THC (4), nabilone (5), THC oromucosal spray (3), dronabinol (2), vaporized cannabis (1), ajuvenic acid capsules (1), and oral THC (1). Patients who reported at least a 30% reduction of pain were more common with cannabinoids than placebo across these studies. It appeared that smoked THC provided the greatest pain reduction. These results suggest reduction of pain due to cannabinoids, but these often did not reach statistical significance in individual studies. In 3 trials there was no statistically significant difference in average quality-of-life scores between nabiximols and placebo, measured by the EQ-5D health status index. Another factor to consider when looking at results is the timeline of the experiments. These experiments did not evaluate medical marijuana for effectiveness for more than 3 or 4 months. Chronic pain can persist in a patient for a lifetime. It is pertinent to know the effects of medical marijuana in the long-term treatment of chronic pain. In a systematic review of randomized controlled trials published in the British Journal of Clinical Pharmacology in November 2011, 18 RTCs were analyzed in which cannabinoids were studied (including smoked cannabis, oromucosal extracts of cannabis-based medicine, nabilone, dronabinol, and a novel THC analogue) in chronic non-cancer pain patients. The conditions for chronic noncancer pain included neuropathic pain, fibromyalgia, rheumatoid arthritis, and mixed chronic pain. Fifteen of the eighteen studies demonstrated a significant analgesic effect of cannabinoid compared with the placebo. There were no reported serious adverse effects, and several reported significant improvements in sleep. The evidence supported the conclusion that cannabinoids are safe and modestly effective in neuropathic pain, with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis. A recent study surveyed 185 patrons of a medical cannabis 18

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dispensary. Around 67% of these patrons claimed to be using opioids before starting medical marijuana. After they started using medical cannabis only about 18% claimed to continue using opioids in addition to medical marijuana. Along with the reduction of opioid use, patrons reported a 45% improvement in quality of life as well as a significant decrease in adverse side effects affecting their daily function after starting cannabis. A 2014 study found that in states which legalized medical cannabis use, the mortality rate from opioid overdose declined about 25%. The evidence for the effectiveness of medical marijuana in pain treatment is strongest for neuropathic pain, demonstrating effectiveness in more than three dozen preclinical and clinical trials. It is noteworthy that cannabinoids have shown to be effective in providing neuropathic pain relief when opioids were not able to. In a trial of smoked cannabis which included 50 patients with HIVassociated daily neuropathic pain, an average reduction of pain by 30 percent was reported over the course of five days, even in those using low doses. Several trials testing Sativex, a whole-plant cannabis extract, showed that patients have a reduction in neuropathic pain. Opioids are often recommended as a treatment for neuropathic pain, but known risk factors include overdose and death. Medical marijuana has shown potential for reducing neuropathic pain without the adverse risks of overdose and death. Mark Colleen, from the Harm Reduction Journal, proposes that it is appropriate for physicians treating patients for neuropathic pain to evaluate their patients for cannabis and prescribe it prior to using opioids. This “harm reduction strategy” may lower the abuse and overdose rates associated with opioids. Lethal overdoses from cannabinoids do not occur, unlike opioids, because cannabinoid receptors are not located in the brainstem — the area which controls respiration. However, cannabinoid receptors are found throughout the body and can cause a variety of adverse effects such as hypotension, muscle relaxation, and decreased gastrointestinal motility. Cannabinoids are classified by the FDA as highly addictive, but their addictive qualities are in fact much lower than that of opioids. The withdrawal symptoms are mild in comparison to opiates. Withdrawal only lasts a few days and includes mild symptoms of insomnia with sleep electroencephalogram disturbance, restlessness, irritability, hot flashes, and occasional nausea and cramping. Withdrawal is milder than with opioids because cannabinoids are stored in adipose tissue, with a low rate of excretion and a half-life of 1-3 days. Therefore, the suspension of cannabinoid use does not cause the rapid declines in plasma concentrations that would cause intense withdrawal symptoms. There are many concerns about the harmful pulmonary effects of inhaled cannabis. A longitudinal study in a non-cancer population (5,115 men and women) with a known history of smoking was conducted over 20 years. Decreased pulmonary function was associated with tobacco exposure while occasional and low-cumulative cannabis use was not associated with these adverse effects. If, as many hope, medical marijuana proves to be a safe and effective pain treatment, it could be used to lower or replace a patient’s opioid prescription. With a reduction in the amount of opioids being prescribed, the addiction and overdose frequency should go down. Opioid overdose and abuse is a national epidemic in America, and prescription opioids are being used for some conditions in which the evidence for benefit is weak. A meta-

analysis of 20 randomized controlled trials on the effectiveness of opioids for treatment of back pain, the most common diagnosis in which long-term opioids are used, found only modest shortterm relief of pain. While there is reason to hope that use of medical marijuana might reduce the incidence of opioid addiction, marijuana itself can cause addiction in approximately 1 in 10 adult users. A small risk of psychotic disorder and a significant risk of symptom exacerbations and relapse in patients with an established psychotic disorder are also associated with marijuana. Evidence has been found of cross-tolerance between opioids and cannabinoids, which would affect the substitution of opioids with cannabinoids. The prospect of medical marijuana proving to be a legitimate, effective, and safe treatment for patients with non-terminal chronic pain may some day become a reality. However, with the current limited body of knowledge about cannabinoid usage in medicine, as well as the inconsistency of the cannabinoids used in currently available studies, it is unclear what the answer will be. The best course of action currently would be to reschedule marijuana as a drug with known medical benefits and thereby reduce the barriers to additional research.

Nicholson, Bruce. “Differential Diagnosis: Nociceptive and Neuropathic Pain.” AJMC, 01 June 2006. Web. “NORML Policy on Medical Use.” Medical Frequently Asked Questions. National Organization for the Reform of Marijuana Laws, 2016. Web. “Pain: Hope Through Research.” National Institute of Neurological Disorders and Stroke, 9 Mar. 2016. Web. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA.2015;313(24):2456-2473. Wilner, L. Scott, and Robert M. Arnold. “CANNABINOIDS IN THE TREATMENT OF SYMPTOMS IN CANCER AND AIDS.” Palliative Care Network of Wisconsin Fast Facts, 2015. Web. “Working to Reform Marijuana Laws.” Medical Frequently Asked Questions. National Organization for the Reform of Marijuana Laws, 2016. Web.

Literature Cited:

“10 Pharmaceutical Drugs Based on Cannabis - Medical Marijuana.” ProCon, 27 Nov. 2013. Web.

“About ASA.” Americans for Safe Access, 2016. Web.

Works Consulted:

Boehnke KF; Litinas E; Clauw DJ. Medical Cannabis Use is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J pain. 2016. 17(6):739-44.

Bachhuber, Marcus A.; Saloner, Brendan; Cunningham, Chinazo O.; Barry, Colleen L. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States. JAMA Intern Med. 2014. 174(10):1668-1673.

Cairns, Lucy J. “Medical Marijuana.” Berks County Medical Society, n.d. Web.

Fine P; Rosenfeld M. The Endocannabinoid System, Cannabinoids, and Pain. Rambam Maimonides Med J. 2013. 4(4):e0022.

D’Souza DC, Ranganathan M. Medical marijuana: is the cart before the horse? JAMA. 2015;313:2431-2432.

Gertsch J; Pertwee R; Di Marzo V. Phytocannabinoids beyond the Cannabis plant - do they exist? Br J Pharmacol. 2010. 160(3): 523529.

Gebhart, G. F. “Scientific Issues of Pain and Distress.” U.S. National Library of Medicine, 22 June 2000. Web. Harding, Anne. “MEDICAL CANNABIS HELPS CHRONIC PAIN PATIENTS CUT OPIOID USE: SURVEY.” J Pain, 29 Mar. 2016. Web. Hubbard, John R., Sharone E. Franco, and Emmanuel S. Onaivi. “Marijuana: Medical Implications.” American Family Physician, 1 Dec. 1999. Web. King, Steven A. “Medical Marijuana for Pain: What the Evidence Shows.” Psychiatric Times, 19 Aug. 2015. Web. Lynch, ME; Campbell, F. Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. Br J Clin Pharmacol. 2011. 72(5):735-44. Merskey, H., and N. Bogduk. “IASP Taxonomy.” International Association for the Study of Pain, 6 Oct. 2014. Web. National Cancer Institute: PDQ® Cannabis and Cannabinoids. Bethesda, MD: National Cancer Institute. Date last modified <05/27/2016>

Mack, Alison, and Janet E. Joy. “Marijuana and Pain.” Marijuana as Medicine?: The Science beyond the Controversy. Washington, D.C.: National Academy, 2001. N. pag. Print. Maldonado R; Baños JE; Cabañero D. The endocannabinoid system and neuropathic pain. Pain. 2016. 157:S23-S32. Petzke F, Enax-Krumova EK, Häuser W. Efficacy, tolerability and safety of cannabinoids for chronic neuropathic pain: A systematic review of randomized controlled studies. Schmerz. 2016. 30(1):62-88. Silverman, Jacob. “How Medical Marijuana Works: Making a Case for Legal Medical Marijuana.” HowStuffWorks, 11 Aug. 2008. Web. Stromberg, Joseph. “Marijuana Isn’t a Pain Killer - It’s a Pain Distracter.” Smithsonian, 20 Dec. 2012. Web. Emily Evans is currently in her third year as a Biology major at Gettysburg College. She plans to pursue a career in medicine. She is the daughter of BCMS member Steven M. Evans, D.O., who practices Emergency Medicine at Penn State Health St. Joseph and Pain Management with Reading Neck and Spine Center. FALL 2016

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PHYSICIANS QUESTIONNAIRE In conjunction with her research, Emily solicited the views of local physicians. Dr. David George and Dr. Steven Evans responded to her questionnaire: 1. In your practice, for what conditions do currently available chronic pain management options most often prove inadequate or problematic? I am a rheumatologist. In that role I see a large number of patients with osteoarthritis and also central pain hypersensitivity that we label “fibromyalgia.” Current therapies are inadequate for severe forms of these disorders. 2. How do you assess the severity of a patient’s pain? Its significance to their life? I assess the impact on quality of life and capacity to function. For example, we review the impact as it relates to relationships with others such as family members, ability to remain active and do daily tasks that he/she previously enjoyed doing, capacity to support oneself financially. 3. Are there non-pharmacologic pain treatments you feel should be more easily available? Cognitive Behavioral Therapy has been shown to benefit many people with chronic pain, but it is often not covered by insurance. Short-term physical therapy programs may be covered, but long-term activity support programs are not. Modalities such as acupuncture are not generally covered. 4. What is your current opinion regarding the potential role of medical marijuana in the treatment of your patients with chronic, non-cancer pain? There is very little research on the role of medical marijuana. At a national level, the drug is considered illegal and this has limited scientific investigation of its value. Most of the information available is of limited value to make important decisions about risk/benefit for the conditions mentioned above. 5. What would be your top priority for additional research into the use of medical marijuana for chronic pain? Large controlled trials comparing its use to standard therapy, addressing benefit and risk. Large databases/registries to monitor patients who begin to utilize medical marijuana so that the benefits and risks can be tracked. 6. If you plan to use medical marijuana for management of chronic pain, what factors would you consider in deciding whether to prescribe opioids vs. cannabinoids? I would not use medical marijuana for the conditions I treat without more research data. Respectfully, David George, MD Rheumatology 20

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1. In your practice, for what conditions do currently available chronic pain management options most often prove inadequate or problematic? Primarily chronic neck and back pain. I do have some patients with reflex sympathetic dystrophy and fibromyalgia. Also many patients with chronic hip, knee and shoulder pain. I use medications, physical therapy, surgery, steroid injections, exercise and lifestyle changes (such as weight loss). I also occasionally send patients for chiropractic, massage, and acupuncture. I encourage patients to explore yoga and meditation as viable modalities to control pain. 2. How do you assess the severity of a patient’s pain? Its significance to their life? They fill out a questionnaire. I also interview them. I also look for objective pain reflexes and evidence of symptom magnification during the exam and interview. 3. Are there non-pharmacologic pain treatments you feel should be more easily available? It would be nice if insurance companies paid for gym and pool memberships. Swimming is a wonderful modality for people with painful joints. Support groups and pain management-specific psychiatric counseling are also very helpful, but have poor availability. 4. What is your current opinion regarding the potential role of medical marijuana in the treatment of your patients with chronic, non-cancer pain? Marijuana is a viable adjunct. I will add it to my receptive chronic pain patients when available. 5. What would be your top priority for additional research into the use of medical marijuana for chronic pain? Good quality research on benefits and negative issues would be helpful. Randomly selected, double blinded studies related to medical marijuana would be very helpful to eliminate the cultural biases. 6. If you plan to use medical marijuana for management of chronic pain, what factors would you consider in deciding whether to prescribe opioids vs. cannabinoids? Age, pre-existing conditions, type of pain and patient acceptance. If medical marijuana use reduces patients’ reliance on opioids, that would be a significant benefit. Steven M. Evans, D.O. Reading Neck and Spine Center

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2016-2017 DIRECTORY OF PHYSICIANS: Please take note of the following change: Robert S. Jones, DO Reading Health Physician NetworkInfectious Diseases Sixth Avenue & Spruce Street Bldg. G2 West Reading, PA 19611 484-628-4630 Fax 610-374-8324

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Berks Medical Society and Caron Treatment Centers present A CME training

Here's to You!

Utilizing SBIRT for Patients of All Ages and Identifying Substance Abuse In the Senior Patient

Celebrating 10 years of helping our community hear better. Thank you from the staff of Berks Hearing Professionals.

November 5, 2016 7:30 a.m. – 10:00 a.m. Registration begins at 7:00 a.m. Breakfast: 7:30 a.m. Program: 8:00 a.m. – 10:00 a.m.

Location:

Highlands of Wyomissing Cultural Center 2000 Cambridge Ave, Wyomissing, PA 19610 Cost for attendees – Free (Includes 2 CME credits)

Presenters: • Joseph M. Garbely, D.O., FASAM, Vice President of Medical Services at Caron Treatment Centers. • Michael A. McCormick, D.O., Fellow in Addiction Medicine • William Santoro, MD, Chief of the Section of Substance Use Disorder, Reading Health System • Ming R. Wang, MD, Staff Physician overseeing the Seniors Program at Caron Treatment Centers

This training for health care professionals will provide: • The skills to utilize the comprehensive Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool to identify substance abuse in patients of any age.

Call today to schedule your complimentary hearing consultation!

The SBIRT can be performed in minutes, is reliable, verifiable and translatable to difference practices. Most importantly, SBIRT is effective in identifying substance-use risk and providing a process for intervention.

Birdsboro

Matthew Brooke Bldg 321 N Furnace St, Ste 90

• The information necessary to identify substance abuse in adults aged 65 and older. Substance abuse in adults 65 and older is the fastest growing health issue within this population. Addiction can often be difficult to detect among seniors because warning signs can mimic insomnia, forgetfulness, and other age-related concerns. This program will educate clinicians about the signs to look for and how to utilize the SBIRT as part of the intervention process.

610.404.8025 Wyomissing

1 Greenwood Mall

2 CMEs will be awarded upon successful completion of the program.

• Andy Waxler, MD, President of the Berks County Medical Society

To register please visit www.berkscms.org. For more information, call the Berks County Medical Society at 610-375-6555.

610.750.6107 Dr. Mindy K. Brudereck, Au.D. • Board-Certified Audiologist Dr. Bre Myers, Au.D. • Board-Certified Audiologist

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BCMS members are among the physicians who mentor students selected for the Reading Hospital’s Student Summer Training Program. Each summer, this program provides valuable clinical and research experience to motivated young people planning a medical career. The BCMS is proud of the mentoring our members provide, both within the hospital’s program and outside it in the form of allowing students to observe clinical practice. We are grateful to Reading Hospital for enabling the BCMS’s summer intern to attend the didactic sessions that are part of the hospital’s program, thereby enriching the experience. The research projects to which the Reading Hospital interns contributed are summarized in the following abstracts. —Lucy J. Cairns, MD

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Student Sum

Creation of a Diabetic Education Program For High Risk Patients Within the Family Healthcare Center by Taylor E. Olian, O.M.S. II, Dr. Mary Brigandi, D.O., Dr. Aseem Balhara, M.D., Dr. Louise Vlachos, D.O., Coleen Conrad, B.S.N., R.N. BACKGROUND: In the United States, it is estimated that over 8% of the population has Diabetes Mellitus. It is defined as a group of metabolic disorders that share the common feature of hyperglycemia. Diabetes Mellitus is the fifth leading cause of death worldwide and is associated with serious morbidity and mortality. Many patients’ diabetes remains uncontrolled due to their lack of even basic knowledge about their condition.

INTERVENTION: The study aims to provide 12 classes that will each focus on a different topic of diabetic education; among them are foot and eye care, diabetes long-term complications/symptoms, and medication information. The classes will include time for discussion and review of the previous session’s material, and most importantly support from the patient group. Patients will be encouraged to participate and share their ideas to the group. Group criteria are patients that have a hemoglobin A1C over 9 who have been recruited from the Family Healthcare Center at Reading Hospital. They will be given a survey before and after the completion of the classes to assess their knowledge of diabetes management. The program’s success will be assessed by a decrease in their hemoglobin A1C over a 6-month period. Levels will be measured before education, after 6 classes, and at completion. The study is supported by the findings of two prior international studies. One study conducted in Palestine showed that education classes lowered hemoglobin A1C values by 0.62%. Another study involving Type 1 diabetics in Spain showed that patients’ self-efficacy was increased and perceived barriers were decreased by the education classes conducted.

Taylor E. Olian is currently an O.M.S. II student at the Philadelphia College of Osteopathic Medicine.

mer Research Projects Utilizing Scribes to See More Patients: How Does it Affect Physician and Patient Satisfaction by Parth A. Javia, William J. Lovett, MD BACKGROUND: Current electronic health record (EHR) use poses many challenges to medical practice. It has been shown to decrease face-to-face interaction between physicians and patients, decrease physician productivity, and even to cause at least a temporary loss of income. One possible solution to these challenges is the implementation of medical scribes. Scribes have most commonly been used in the emergency room setting where they have been shown to generate 100% return on investment. However, research into the use of scribes in a primary care setting remains rather limited. This study hypothesizes that the “use of scribes in a family medicine residency practice will lead to improved provider and patient satisfaction, even when patient volume per session is increased.”

results available thus far from a sample of 325 patient surveys and 115 physician surveys, two conclusions are evident. First, patient and physician satisfaction with the scribe remain unchanged even when the physician sees a higher volume of patients. Second, patient satisfaction with the office visit was very high at baseline and remains unchanged with or without a scribe; however, it decreases when the physician sees a higher volume of patients.

Parth A. Javia is currently an M2 student at Lake Erie College of Osteopathic Medicine. continued on next page

METHODS AND PRELIMINARY RESULTS: This was a prospective interventional study focusing on assessing patient satisfaction across 3 domains and physician satisfaction across 2 domains. The 3 domains on the patient satisfaction side are office visits: on a standard schedule without a scribe, on a standard schedule with a scribe, and on an enhanced (busier) schedule with a scribe. The 2 domains on the physician satisfaction side are office visits: with a scribe and without a scribe. Data was collected via responses to Likert scale questionnaires assessing patient satisfaction with their office visit and the scribe and physician satisfaction with their patient load and the scribe. Analysis of the data is currently ongoing and includes chi squared tests to rule out bias within sample populations as well as t-tests and ANOVAs to compare questionnaire responses. Based on the

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Student Sum mer Research Projects Acute Uncomplicated Cystitis: an Evaluation of Prescribing Practices in the Reading Health System Emergency Department by Alyssa N. Floyd, Rebecca S. Cofsky, PharmD, and Robert S. Jones, DO, MS, FACP, FIDSA BACKGROUND:

RESULTS:

Acute uncomplicated cystitis (AUC) is one of the most common infections and indicators for antibiotic treatment in otherwise healthy women. A 2010 Update by the Infectious Diseases Society of America (IDSA) has identified clinical practice guidelines for the treatment of AUC to address the reported wide variation in prescribing practices. Nitrofurantoin and trimethoprim/ sulfamethoxazole (TMP/SXT) are the recommended first-line antibiotics. Fluroquinolones and beta-lactams are considered second-line antibiotics and should be reserved for when firstline agents cannot be used. A study was conducted to evaluate prescribing practices and adherence to IDSA guidelines in the treatment of patients diagnosed with AUC in the Reading Health System Emergency Department (RHS ED).

There were 312 eligible women diagnosed with AUC in the RHS ED during the study period. Patient age ranged from 16 to 96 years old, with an average age of 46 years. 296 (95%) patients received a prescription on discharge. The majority of patients with bacteria identified in culture were infected with E. coli (65%). E. coli was highly susceptible to nitrofurantoin (99%). In terms of patients who received a prescription on discharge, 46% received first-line antibiotics and 52% received second-line antibiotics. Of patients who received prescriptions for second-line antibiotics on discharge, only 2 (1%) had an allergy to both first-line agents. The most commonly prescribed antibiotics were ciprofloxacin (34%), TMP/ SXT (24%), nitrofurantoin (22%), and cephalexin (15%). Overall, 22% of first-line and second-line prescriptions on discharge were compliant with IDSA dosage guidelines. Only 12.6% of patients given a prescription on discharge received a first-line antibiotic with the recommended dose. The prescribed antibiotic was documented in the provider’s note 53.4% of the time.

METHODS: A retrospective chart review of non-pregnant women ≥ 16 years of age diagnosed with AUC in the RHS ED was conducted. A report generated via Safety Surveillor identified the above cohort by querying the Epic electronic medical record system. Patients’ charts were accessed electronically. Data collected included general demographics, pertinent antibiotic allergies, urinalysis and urine culture details, and antibiotic treatment.

CONCLUSIONS: E. coli accounted for the vast majority of infections causing AUC in women and was highly susceptible to nitrofurantoin and TMP/ SXT. Nitrofurantoin proved to be the most effective against E. coli based on susceptibility which supports its use as a first-line empiric treatment in the RHS ED. There was both extensive variation and a low rate of compliance in regards to standard dosages which reflects the need to standardize prescribing practices for ambulatory treatment of AUC in the RHS ED. We conclude that education on appropriate treatment per IDSA guidelines should be implemented.

Alyssa N. Floyd is currently a senior at Gettysburg College.

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Evaluation of an Electronic Clinical Decision Support Tool to Improve Compliance with Evaluation and Treatment of Hospitalized Patients with Thrombo-Embolic Events by J. Carvajal, A.A. Donato, MD BACKGROUND: Often patients receive inappropriate treatment and testing for thrombophilia when hospitalized for thrombo-embolic events, causing an overuse of resources and increase in cost. It was hypothesized that the use of the new order set would result in an increase in the appropriate use of low molecular weight heparin used and reduction in inappropriate testing.

INTERVENTION: A clinical decision support tool was created and embedded into an order set to direct the admitting physicians to choose low molecular weight heparin instead of heparin and to provide a basis on which tests were appropriate for the patient. Adult patients admitted to the hospital with Pulmonary embolism were selected based on the ICD coding (ICD-9: 415 and ICD:10: I26) from December 30, 2013 until April 24, 2016. Efficiency of the order set was based on two criteria: the fraction of patients using low molecular weight heparin versus heparin and the percent of patients who received inappropriate thrombophilia testing upon admission. Gene tests in unprovoked patients under 45 were considered appropriate,

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while all other testing was defined as inappropriate. Inappropriate testing was compared before and after the intervention.

RESULTS AND CONCLUSION: The results showed a decline in inappropriate testing with the use of the order set upon admission from 21% to 6.8%, but secondary physicians had a 16% use of inappropriate testing. With the addition of the order set, the use of low

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molecular weight heparin increased to 61% from 48%. The order set was considered successful for admitting physicians. To further improve this research, secondary physicians may be provided a support tool as well.

Juliana Carvajal is currently a senior at Albright College. continued on next page FALL 2016

Student Sum mer Research Projects Women’s Health Initiative Clinical Trials: The Interactive Effect of Calcium and Vitamin D Supplementation with Hormonal Therapy on Cardiovascular Events and Venous Thromboembolism by Xuezhi Jiang, John Robbins, Matthew Nudy, Kayler Gabbett, David O’Sullivan, Anita M. Kelsey, Aaron Aragaki, Erin S. LeBlanc, Lisa S. Martin, JoAnn E. Manson, James Shikany, Karen Johnson, Marcia Stefanick, Martha Payne, Jane Cauley, Barbara Howard, Peter F. Schnatz

OBJECTIVE: Evidence from limited data suggests that calcium and vitamin D (CaD) at moderate to high doses may reduce cardiovascular disease (CVD) risk. Using randomized trial data we analyzed if the effect of menopausal hormone therapy (HT) on various cardiovascular disease events is enhanced by calcium and vitamin D (CaD) supplementation.

DESIGN: A prospective, randomized, double-blind, placebo controlled trial was implemented among Women’s Health Initiative (WHI)

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postmenopausal women. A total of 27,347 women were randomized to the HT trials (0.625 mg/d of conjugated equine estrogens [CEE] alone for women without a uterus or 0.625 mg of CEE in addition to 2.5 mg of medroxyprogesterone acetate daily [CEE+MPA] for women with a uterus versus placebo). After 1 year, 16, 089 women in the HT trial were randomized to the CaD trial to receive either 1,000 mg of elemental calcium carbonate plus 400 IU of vitamin D3 daily or placebo. The mean (SD) duration of follow-up after CaD randomization were 6.2(1.3) and 4.6(1.1) years, respectively. CVD events analyzed in this subgroup analysis include coronary heart disease (CHD), stroke, pulmonary embolism, all-cause mortality, plus select secondary endpoints (total myocardial infarction, coronary revascularization, deep venous thrombosis, cardiovascular death, and all CVD events). The time-to-event methods were used and models were fit with a Cox proportional hazards regression model.

RESULTS: In the CEE trial, CaD did not significantly modify the effect of CEE on most CVD outcomes but did modify its effect on cardiovascular death (p-interaction = 0.03). In the CaD-placebo group, the effect of CEE on cardiovascular death was somewhat harmful (HR [95%CI] = 1.47[0.86, 2.53]); in the CaD-supplement group, the effect of CEE was somewhat beneficial (HR [95%CI] = 0.57[0.29, 1.10]). Similar results were found for CHD deaths, which account for the majority of the cardiovascular deaths (52 of 92; p-interaction=0.04). We did not observe significant CEE x CaD interactions for CHD, total CVD events, or any of the remaining endpoints. Contrary to the CEE trial, there was no evidence that the effect of CEE+MPA on cardiovascular death or other CVD endpoints was modified by the CaD supplementation (p-interaction = 0.24). Moreover, hazard ratios were in the opposite direction of those observed in the CEE trial.

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CONCLUSION: Calcium and vitamin D supplementation did not consistently modify the effect of CEE therapy on CVD events, but did appear to modify its effect on CVD death. The effect of CEE (active vs. placebo) on CVD death was favorable among women randomized to CaD supplement use but unfavorable among those randomized to CaDPlacebo. While CaD significantly modified the effect of CEE on cardiovascular death (p-interaction = 0.03), these differences were not individually significant. CaD did not significantly modify the effect of CEE+MPA on CVD death or any CVD events. Additional research on potential interactions between CaD and HT is warranted.

Kayler Gabbett is currently a senior at West Chester University.

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M e d i c a l R e c o r d F e at u r e Dr. Cedric C. Jimerson celebrated his 97th birthday this summer. Following a surgical internship in 1943-’44, he served for 2 ½ years as a Captain and surgeon with the U.S. Army Medical Corps before resuming his civilian training. The excerpts from his memoirs presented here describe these final years of training and his introduction to practice as Chief of Surgery at Community General Hospital in Reading. Surgeons training today in the U.S. have probably never encountered many of the disease states Dr. Jimerson treated routinely at the start of his career, and would certainly recoil in horror at the conditions which prevailed in local operating rooms in that era. Dr. Jimerson and his colleagues, with the help of dedicated nurses and other support staff, managed to provide excellent care under difficult conditions while putting in hours unheard of today. Contemplating the incredible changes that have occurred over the course of Dr. Jimerson’s lifespan makes me wonder how today’s ‘cutting edge’ practices will look when today’s young surgeons reach his time of life. —Lucy J. Cairns, MD

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My Surgical Training and Early Practice by Cedric C. Jimerson, M.D.

fter my discharge from the Army in May 1946, I resumed my surgical training and was accepted into the surgical residency at The New York Hospital. Before World War II this surgical residency at the relatively new 24-story New York Hospital included seven years of surgical training. After the war it was shortened to five years. There were huge public wards with several hundred of surgical patients. The surgical residency was a pyramidal system. The competition was severe, the work schedule was long and difficult, the rules were strict, and the salaries were ridiculous. As assistant resident I received $25.00 per month. However, the surgical training was superior.

Next, I completed a residency in thoracic surgery at the huge Bronx Veterans Administration Hospital in New York City. This was a large center for thoracic surgery. We had a huge number of young veterans in need of thoracic surgery for bronchiectasis, lung abscess¸ bronchial adenoma, Tuberculosis, and empyema. With the help of my assistant resident, Dr. Paul Kirschner, I performed one hundred pulmonary resections (pneumonectomies and lobectomies of the lung) with no operative mortalities during my one year as senior resident. They were subsequently reported by Dr. Kirshner, who later became professor at Mount Sinai Hospital in New York City.

In 1948 I served a residency in thoracic surgery in Pulmonary Tuberculosis at Sunmount Veterans Administration Hospital in Tupper Lake, New York. Tuberculosis is contagious, and most of the nurses, doctors, and employees in this sanitorium had recovered (?) from Tuberculosis. There was no effective medicine for Pulmonary Tuberculosis at that time. Sanatoriums providing bed rest and fresh air were popular. Thoracoplasties and lobectomies of the lung were the most common operations. Thoracoplasties involved resection of ribs in an effort to collapse portions of the lung, and to close the tuberculosis cavities. Many of the patients had advanced bilateral pulmonary tuberculosis, and they were inoperable. At the end of my residency in 1949 I was offered the position of Chairman of the Department of Surgery at the hospital at $10,000 per year. Because I had to live and eat with the patients frequently, my wife Julie and I feared I would get Tuberculosis, and spread it to our two babies. Although I was deep in debt, we decided to refuse the offer. Dr. Bliss Clark, a friend of mine from Bellevue, and chairman of the department of surgery at the New Britain General Hospital in New Britain, Connecticut, had developed a four year residency in general surgery. He offered me the fourth or senior year of that residency, which included thoracic surgery, urology, and gynecology, to begin 7/1/1949. I was glad to accept this amazing offer. After my completion of that excellent fourth year of the general surgical residency, I completed a sixmonth residency in pathology at the same hospital. In 1949 I searched from Massachusetts to North Carolina for a place to practice surgery. In Reading, Pennsylvania Dr. Calvin Rentchler, the chief of surgery at the Reading Hospital, told me there was no room for another surgeon in Reading. ( Actually, there were only two Board certified surgeons in Reading at that time.) There were no surgical specialists except for the ophthalmologists and one gynecologist. A few family physicians were doing surgery, after they had been trained as preceptors by older surgeons. Fortunately, Community General Hospital was looking for a chief of surgery. The president, Mr. Tomas Leinbach, welcomed me with open arms. He sent Dr. Simon Glick, the retiring surgeon, and Dr. Irvin Shaffer, the sole anesthesiologist, by train to New Britain, Connecticut to watch me remove a gallbladder to determine if I could operate. The Board of Trustees at Community General Hospital offered me the position of Chief of Surgery, and Chairman of the Department of Surgery. These seemed like hollow titles, because there was no trained surgeon on the medical staff of the hospital. I was shocked by the poor conditions of the hospital, but I decided to accept the position. In the 1950s there were relatively few hospital employed physicians. At Community General Hospital we had one anesthesiologist, Dr. Irvin Shaffer, one radiologist, Dr. John Stolz, and one pathologist, Dr. Hunter Cook. We referred to them as in-house physicians in contrast to the rest of us, the out-house physicians. There were no hospital employed emergency room physicians. The emergency department was the responsibility of the chiefs of medicine and surgery. Our medical staff at Community General Hospital was small. It consisted mostly of general physicians (family doctors). Our surgical service consisted of two surgeons and two general continued on next page

t s i p o r h t Philan Devoted Parent

Phys ician

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practitioners. Each of us was on call 24 hours a day 7 days a week every other month. Every member of the surgical staff had to take his turn of charitable care of all code 5 (indigent) surgical patients in the large wards. Also included was free medical care to patients in the large public surgical outpatient clinic. In 1960 my dear friend Dr. Carol Kring organized one of the first departments of emergency room physicians. The advent of formally trained and accredited emergency room physicians greatly improved the emergency medical care of patients in our local hospitals and elsewhere. Also, it relieved hospital medical staff physicians of considerable free work and responsibility. Hospital charges were ridiculously low. Since 1970 there have been tremendous increases in charges to patients for medical care in our hospitals. In 1950 our anesthesiologist charged $30.00 for general anesthesia. Initially we had no recovery room. The postoperative patients were taken directly from the operating room to their beds to recover. When the recovery rooms were built in 1951 there was a $35.00 charge to the patient. In the early 1950s at Community General Hospital we had a large 20 bed ward for male patients, and a 20 bed ward for female patients. In 1950 the patient was charged $5.00 for a ward bed. The two semi-private rooms cost $7.50 per day. The two private rooms cost $12.50 per day. During the 1970s and the 1980s the hospital charges were sky rocketing, and patient charges were soaring rapidly higher. It is not difficult to understand the reasons for this unparalleled rise in hospital costs and medical care. During the 1950s the wage scale of hospital employees was below the poverty level. Unemployed people on relief, or public welfare, and on government financial

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assistance were receiving more money each month than the average hospital employee could earn working. Nurses were overworked and under-paid. The nurses and the nurses-aides were working 12 hour shifts, 6 days a week. The operating nurses were on call several nights each week. Initially these nurses were not paid for being on call nights and weekends. In 1950 our nurses worked 60 hours per week, and they were paid one dollar per hour. Later the work-week was cut to 48 hours, the salaries were rapidly increased, they were paid for being on-call, they received paid vacations, and pension plans were started. Most of our wonderful nurses had been trained in diploma nursing schools. These diploma school nurses were well trained. They earned a good reputation for their excellent bedside care of patients in our local hospitals. I would like to emphasize that we had loyal, dedicated, hardworking employees at Community General Hospital. There was a prevailing feeling of caring and warmth in the hospital, and it seemed like a family working together for the good of our appreciative patients. In 1950 the medical condition of people in Reading was deplorable and appalling. There were many people in need of surgery, and there was a lack of trained surgeons to treat them. Reading was still recovering from the Great Depression. There was prevailing poverty. Most of the employers did not provide medical insurance for their employees. The majority of my patients were unemployed, and most of them did not have insurance. There was no Medicare or Medicaid. I performed many free operations on the poor patients without medical insurance. I extended courtesy to our physicians and their families, to our nurses in the hospital, and to members of the Board of Trustees. Consequently, forty percent of my surgery during the 1950s and early 1960s was free. There was no outpatient surgery. We did not have a central supply. Dedicated women volunteers in the Ladies Auxiliary rolled bandages, and made slings. During my early days at Community General Hospital we used rubber gloves in surgery. After these gloves were used they were washed, checked for leaks, patched if necessary, dried, powdered, placed into cloth envelopes, and autoclaved in order to be used again. Later cheaper and disposable synthetic gloves arrived. There was no air conditioning, and the air circulation was poor. Operating under the overhead surgical lights was beastly hot. During the summers there was danger of sweat dropping from the surgeon’s brow into the operative field. It was difficult to maintain sterility in the operating rooms. Sometimes there were holes in the window screens. When flies entered the operating room, surgery had to stop, and the sterile operative area had to be covered until the flies could be killed. I operated at St. Joseph’s Hospital, and at the Reading Hospital, and the conditions were similar. Unfortunately, the conditions were worse at Community General Hospital. There were no endotracheal tubes and respirators in the early years. Tracheotomies had to be performed frequently to maintain open airways. In the old operating rooms the surgical lights were inadequate. There were no instrument or sponge counts before I arrived. There were no radio-opaque markers on the surgical sponges. Cotton and silk on spools were bought at Woolworth’s, and they were cut into sutures and sterilized. Most of the surgical instruments were old and outdated. There was no electro-cautery. In spite of these seemingly primitive conditions, we were able to perform thousands of operations without an operative mortality, and with relatively few complications.

M e d i c a l R e c o r d F e at u r e

Pay It Forward:

The Joy of Mentoring by Heath Mackley, MD, FACRO

ndergoing the process of academic promotion in a university hospital is no small task, and in my case it includes distilling the last five years of work into a one to three page “personal statement.” A silver lining is that this forced reflection allowed me to put into words what I find the most valuable about my experience. In this process, I found myself writing recently, On a personal level, I have found mentoring to be one of the most rewarding aspects of my academic life at Penn State, and will continue to do that as much as I can. Mentoring is not something that is only found in the halls of academic medicine. All physicians are teachers. We teach our staff, we educate our patients individually, and we inform society about public health issues in community groups of all shapes and sizes and in the media. Organized medicine reflects this. One of the AMA’s founding principles was to set standards for medical education. The Pennsylvania Medical Society’s (PAMED) original and current mission statements include a commitment to advancing medical knowledge and promoting the public health. This is also found in my county’s mission statement (Dauphin), and I suspect this is found elsewhere thoughout the other county medical societies of Central Pennsylvania. Mentoring is a natural extension of this commitment to teaching. PAMED, the only voice that represents all physicians in the Commonwealth of Pennsylvania, has a program called Mentoring Matters. The website1 says, “This volunteer program is designed to match physician mentees and physician mentors within common regions, specialties, or practice settings, based on the mentee’s needs and interests and the mentor’s abilities and experiences.” Although on some level, this program is “new.” It’s really more of a reboot. When I told Dr. Parikh I thought it was a good idea that PAMED was doing this, he smiled and said, “I remember taking part in this in the 1980’s.” I’m sure our members with even longer institutional memories can describe past mentoring programs before that as well. Mentoring comes in more forms. Mentoring programs are a great start for people looking for advice, but I dare say a majority of mentoring takes place in informal relationships. Much of the best advice I received along my path have been in those settings, and I continue to seek out guidance during my “mid-career” as challenges and opportunities come and go. In some situations, I’m able to do something tangible for my mentor, but in most cases, I cannot.

But I can “pay if forward.” I’ve personally had the good fortune of mentoring local high school students, undergraduate students, medical students, residents, fellows, and early career attending physicians. All of those opportunities do not exist outside of university hospitals, but many of them do. But what’s in it for the mentor? We’re all patients. We all benefit from investing in the medical community. It’s rewarding to encourage bright high school and undergraduate students to choose medicine, but it’s equally valuable for a learner to shadow in a clinic before applying for medical school, because there is the occasional student that realizes after seeing clinical medicine that their best life decision is to go into something else that is often related, but that they will find more fulfilling. Likewise, medical students not only need to figure out which branch of medicine is best for them, but they also need specialty specific mentoring to help maximize their chance of matching into competitive programs. Residents, fellows, and early career physicians have struggles related to work-life balance, establishing a successful practice in a region they want to live, and for some to establish a niche that they can leverage into an academic career. Mid-career and later career physicians can struggle with work-life balance, the emotional impact of malpractice cases or physical illness, and developing leadership skills as some move up into management positions. End of career physicians have the challenge of navigating transition planning for their successful medical practice and the adjustment to the life change that comes with retirement. All students and physicians can benefit from mentoring, which means that all physicians of all ages could help by being a mentor. This means you! So, I encourage everyone, but especially PAMED physician members, to consider: if I have benefitted from mentoring in my medical career, how can I pay it forward? You’ll be glad you did!

Dr. Mackley, a Radiation Oncologist at the Penn State Cancer Institute, is the 5th District Trustee of the Pennsylvania Medical Society representing physicians of this county. https://www.pamedsoc.org/learn-lead/topics/work-life-balance/ MentoringMatters

FALL 2016

T h e F o u n d at i o n

of the

P e n n s y lva n i a M e d i c a l S o c i e t y

3 0 Ye a r s of C h a n g e T r a n s f or m i n g L i v e s

The Foundation of the Pennsylvania Medical Society, the charitable arm of 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 a couple of excepts: It was in February of 1989, and I appeared to be a very successful EM doc, but in my head, I knew my life was in crisis. But I didn’t know what to do or how to get out. I knew I was an alcoholic and was using scheduled drugs to get through work and the day. I was drinking and using drugs all day and night just to give the appearance that I was normal and successful. I had a DUI and was being investigated by the FBI, IRS, and DEA. No one else knew except my closest friend, who was also my attorney. On March 13, 1989, after having my home searched by the FBI, DEA, and IRS, I entered treatment for drug and alcohol abuse at the Mayo Clinic. When I got home, beside going to Alcoholics Anonymous meetings, I called the PHP, because I did not know how to deal with licensing issues, credentialing issues, malpractice issues, legal issues, and many other situations that eventually would come up. I can honestly say that over a 25-year period, PHP has helped and supported me with every issue. In the beginning, I did not believe any of the things I have now would ever be possible. Because of the help, guidance, and support of PHP, I have a great and respected medical career. I am also happy, serene, and drug-free. In short, I owe PHP my life and happiness. — MICHAEL S. ANTOON, DO, FAAEM

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Looking back, I wished I had done some things very differently in my professional and personal life. But if I could share one lesson I learned, it is never be afraid to ask for help — sooner rather than later. Asking for help is a sign of strength, being honest with oneself, and taking full advantage of what life has to offer. It spares the pain and consequences loved ones must endure by not seeking help sooner. Not everyone will give you a second chance. But those who do will give you the hope Emily Dickinson [wrote about in] a poem, which took me so many years to understand:

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“Hope” is the thing with feathers

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In the past 30 years, the PHP has had many success stories. There is one, however, that impacted me personally. As the person who collects fees from our participants, I, at times, find the task to be daunting — especially when requesting payment of past-due fees prior to the mailing of an advocacy letter. This leads to my story. There was a participant named Alice [name changed for anonymity] who was not the easiest person to talk with on the phone. Alice came into the PHP in the early stages of her recovery. She was usually combative, quick with a negative response, and resented being in the program. I was typically on edge when taking her phone calls, wondering if a simple question or request would be retaliated with a sharp rebuttal. As it happens, Alice’s career took her to another state, where she enrolled in a second monitoring program. Her PHP file was eventually closed due to noncompliance. However, several years later, she contacted the PHP in need of an advocacy letter. I was nervous about having to inform Alice of her past-due fees. All I could think of was our past exchanges and how negative they were. She immediately picked up on the hesitation in my voice and questioned it. I explained. Her response was remarkable: “Now that would not be good recovery.”

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Wow, she was a totally different person! It was gratifying to see such a dramatic change in her. Alice was considerate, respectful and clearly in good recovery. Her transformation was heartwarming, and will remain a constant reminder for me of the positive impact programs like ours have in changing lives. — WENDIE DUNKIN, PHP COMPLIANCE ASSISTANT

continued on page 35

FALL 2016

Physicians’ HEALTH Program The Foundation of the Pennsylvania Medical Society

30 Years of Change – Transforming Lives

“ONE IN TEN

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

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

•

WHY SHOULD I SUPPORT THE PHP?

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

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

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

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

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

The official registration and financial information of the Foundation may be obtained from the Pennsylvania Department of State, Bureau of Charitable Organizations, by calling toll-free within Pennsylvania, (800) 732-0999. Registration | w w w . bdoes e r knot s c imply m s . oendorsement. rg

777 East Park Drive • Harrisburg, PA 17105-8820

For more than 25 years, I have had the privilege of representing physicians, dentists, and other health professionals. One of the most challenging and rewarding aspects of my practice has been the representation of health professionals who have or may have a physical or mental impairment. For my clients who have connected with the Physicians Health Program for help, the PHP has been a reliable, constant, compassionate, and knowledgeable resource at every step in the process — helping to obtain an evaluation, supporting and monitoring recovery, and advocating for the retention or reinstatement of professional licenses. Many things have changed in 25 years — the faces at the PHP, the laws and regulations governing professional practice, and certainly the nature of the practice of medicine and dentistry. The stresses inherent in the practice of medicine and dentistry have always been considerable — never more than today. Through it all, the PHP has been there. The PHP has saved lives and has helped many health professionals achieve a stable recovery and continue working. For that, I express my gratitude and look forward to working together in the years to come for the benefit of health professionals in Pennsylvania. —JULIA E. GABIS, ESQ.

Go to www.foundationpamedsoc.org throughout the year to read new stories every month and donate online.

Challenging Cases? We Can Help... Do You Have Patients with: 1 Chronic Headaches Tinnitus Jaw Pain Insomnia Ear Pain without Signs of Infection

If so, they may be suffering from TMJ Dysfunction and/or Sleep Disordered Breathing, such as snoring and obstructive sleep apnea. We offer comprehensive diagnosis and treatment. Our many years of experience have resulted in a high rate of successful outcomes. Our philosophy involves a conservative, non-surgical, non-pharmaceutical approach to management with an emphasis on multidisciplinary care. Tammy Balatgek, DDS, MS

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SAVING LIVES AND CAREERS For 30 years, the PHP has helped more than 4,300 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@pamedsoc.org or (717) 558-7846. Or mail your gift to: THE FOUNDATION OF THE PENNSYLVANIA MEDICAL SOCIETY PHYSICIANS HEALTH PROGRAM ENDOWMENT CAMPAIGN

A Holistic Approach to Employee Benefits Power Kunkle delivers localized, high-touch services: Dedicated Client Relations Manager • Administration Support Services ACA Compliance Support • Benefits Compliance Review

Human Resource Solutions: Talent Recruitment • HR Compliance Audit • Employee Handbook Review Compensation Analysis • Training • General Human Resource Support

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Wellness & Health Promotion: Surveys and Assessments • Biometric Screenings • Education Program Development & Incentive Tracking • Wellness Policy Review Worker’s Compensation & Safety Integration www.PKBenefits.com • 1-866-685-1790 • contactus@pkbenefits.com FALL 2016

Berks County Medical Society Alliance

2016 fall

BCMSA President’s Report The Berks County Medical Society Alliance will be hosting the 5th District Luncheon on Tuesday, November 15th at 11:30am. We will be honoring Kathleen Hall as the new president of the Pennsylvania Medical Society Alliance. Please continue to watch your email and Facebook for upcoming details!

he Alliance has many exciting events planned this fall. We start off with our new member coffee on September 23rd. We are looking forward to reconnecting with old friends while welcoming new members to our organization. On October 13th we will hold our annual fall luncheon. Two of our members, Jill Haas and Kelly O’Shea, recently started Wanderlust Travel Consultants. We are fortunate that they will be presenting “Active Family Travel” at our luncheon. Donations will be accepted for the Animal Rescue League. On November 10th, we will hold our fall general meeting. TJ Huckleberry, Executive Direction of BCMS, will be updating us on the current interests of the medical society. I will also be sharing information from the Pennsylvania Medical Society Alliance’s fall meeting at Hershey. In December, we will hold our Holiday Brunch. As always, we would love to see new members at our events. If you are new and interested in attending any of our events, please contact kathyjrog@gmail.com for complete details on times and locations. We would love to welcome you to our group. Current members, please check out our current “salmon” yearbooks that were recently mailed for the complete slate of activities this upcoming year. All my best, Allison Wilson BCMSA President

Photograph from the Past President’s Luncheon held during late spring at Viva in West Reading

www.berkscms.org

M e d i c a l R e c o r d F e at u r e

DEPARTMENT OF LABOR

Are You Ready for the December 1, 2016 deadline?

he Department of Labor issued recent changes that could substantially impact your business. Are you ready? The Final Rule becomes effective December 1, 2016 and it includes increasing the current $455 weekly minimum salary required for employees to qualify for “white collar” exemptions to the minimum wage and overtime requirements under the Fair Labor Standards Act (FLSA). The new salary basis will be $913 weekly. As we know, the FLSA requires that covered employees be paid minimum wage for all worked hours and an overtime rate of not less than one and one-half times their regular pay rate for all hours worked in excess of 40 hours in a single workweek. To qualify for exemption from the FLSA’s minimum wage and overtime requirements, an employee must meet certain criteria.

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Nondiscretionary Bonuses, Incentive Payments, and Commissions in the Salary Level Requirement. Along with the changes, employers will be allowed to use nondiscretionary bonuses and incentive pay to satisfy up to 10 percent of the DOL’s new salary standard, provided such bonuses/incentives are paid on at least a quarterly basis.

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Duties Tests. The DOL’s Final Rule makes no changes to the standard duties tests required for the executive, administrative and professional exemptions.

A few helpful hints:

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Audit Job Classifications: Now is the time for employers to review and audit each job description to make sure all jobs are properly classified as Exempt or Non-exempt. According to reports, the Department of Labor has added 350+ investigators to their staff recently so they can increase the number of audits they perform.

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Review Salary Minimums: Employers may choose to increase the salaries of exempt employees who fall below the DOL’s new $913 weekly minimum, or reclassify employees as non-exempt and take steps to ensure employees are paid a minimum wage and overtime premium in accordance with FLSA standards.

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Provide Education and Training to Key Employees: Employers should consider having their HR staff educate and train front-line managers tasked with implementing new exemption standards. Employers should also consider development of a communication strategy and action plan for reclassification of affected employees.

Significant changes under the DOL’s Final Rule include the following changes for Exempt status:

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Increase in the Salary Basis Requirement. The Final Rule increases from $455 to $913 (or $47,476 annually) the minimum weekly salary level necessary for employees to qualify for a white collar exemption under the FLSA. This minimum weekly salary will adjust automatically every three years per the DOL. Increase in the Salary Requirement for the Highly Compensated Employee (HCE) Exemption. The Final Rule increases the minimum total annual compensation necessary for a “highly compensated employee” from $100,000 to $134,004 to qualify for exemption under the FLSA. This minimum annual compensation will also adjust automatically every three years.

FALL 2016

M e d i c a l R e c o r d F e at u r e s

Berks County Medical Society

Fall Golf Outing The Berks County Medical Society would like to thank the following businesses for their generous support of the Fall Outing: Alan Ross & Company Berks Visiting Nurse Association BMW of Reading Tompkins Vist Bank Weik Investment Services West Reading Radiology Associates The following golfers were the lucky winners: BEST OVERALL Greg Oswik Rich Oswik Ankit Shah

LONGEST DRIVE-MEN Rich Oswik SECOND OVERALL Bob Jones Gene Shaffer Bob Brigham John Casey CLOSEST TO THE PIN-WOMEN Patty Brown CLOSEST TO THE PIN-MEN Luke DeJohn

www.berkscms.org

OCTOBER 28 - No Conference (Residency In-training Exam) ___________________________________________________________ November 4 Friday’s Child Lecture Series – Newborn Screening 7208 Patricia Gordon, MD Penn State Hershey Medical Center, Penn State Children’s Hospital ___________________________________________________________ NOVEMBER 11 Zika Virus: The Latest ID Challenge 7294 Debra Powell, MD Chief, Section of Infectious Disease Reading Health System ___________________________________________________________ NOVEMBER 18 Is There a Role for Hypnosis in Patient Care? 7295 Nicholas Colasanti, CHT Certified Hypnotherapist Pennsylvania Center for Hypnosis ___________________________________________________________ NOVEMBER 25 – No Conference ___________________________________________________________

DECEMBER 2 Friday’s Child Lecture Series – Traumatic Brain Injury in Children – Practical Advice for Primary Care 7209 Harry Bramley, DO Penn State Hershey Medical Center, Penn State Children’s Hospital ___________________________________________________________ DECEMBER 9 The Infant with Fever: Is It Sepsis? 7296 Olubunmi Ojikutu, MD Children’s Health Center Christopher Valente, MD Emergency Department Reading Health System ___________________________________________________________ DECEMBER 16 *special time: 7:30 – 8:30 a.m. A Matter of Life and Death: Act 169 and Health Care Decisions for the Intellectually Disabled 7297 Kim Overby, MD, MBE Department of Bioethics, University of Pennsylvania Stacey Meadows, Esq. Saxton & Stump LLC John Graham Facility Director, Hamburg State Center ___________________________________________________________ > CME and AAFP credits have been applied for. Approval is pending. > Presentations may meet PSRM criteria as outlined by ACT 13 for Patient Safety Credit for CME as approved by the Pennsylvania Medical Society. All PSRM credit is recorded and self-reported by the physician.

LONGEST DRIVE-WOMEN Patty Brown

SIXTH OVERALL Michael Romeo Luke DeJohn Darryl Mueller Shawn White

Department of Family Medicine Lecture Series FALL 2016

All lectures will be held in the Reading Hospital Conference Center, Rooms 1 and 2 at 8:00 a.m. unless otherwise noted.

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