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Medical record Your Community Resource for What’s Happening in Healthcare

WINTER 2017

BERKS COUNTY MEDICAL SOCIETY

Pennsylvania’s New Opioid Restrictions

Opioid Poorly-Responsive Cancer Pain Feel the Burn: Burnout is More Common Than You Might Think


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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

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.

WINTER 2017

Features

Pennsylvania’s New Opioid Restrictions 10 Opioid Poorly-Responsive Cancer Pain

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18 A Resident’s View of the House of Delegates 19 Where do you turn when you know a doctor is not appropriately prescribing controlled substances? 22 Feel the Burn: Burnout is More Common Than You Might Think 24 Welcome New Members 26 Members in the News 27 Reading Physician Retiring as Board Chair 29 Tips on Handling Holiday Stress

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! 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


Editor’s Comments

we are most effective

when we act together D

Lucy J. Cairns, MD Editor

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espite all efforts to date, the rate at which people are becoming addicted to and dying from abuse of opioids in Berks County and beyond continues to climb at an alarming rate. According to the CDC, the number one risk factor for heroin addiction is addiction to prescription opioids, and 45% of those addicted to heroin are also addicted to prescription opioids. Almost half of all deaths from opioids involve a prescription opioid.1 Therefore, the CDC concludes that opioid prescribing “continues to fuel the epidemic.” In response to this data, both federal and state governments have taken actions designed to reduce the prescribing of this class of medication. Action has come in a variety of forms. One very strong action was taken by the federal government in 2014, when the rules for prescribing drugs combining oxycodone with another medication (such as aspirin) were changed. Since that time, such prescriptions cannot be called in to a pharmacy and no refills are allowed unless the patient returns to the physician and obtains a new prescription. Other actions include the development, by both governmental and professional bodies, of guidelines for pain management and opioid prescribing, and the passing of legislation designed to limit opioid prescribing. In Pennsylvania, several such bills were signed into law by Governor Wolf in November, and all practitioners who prescribe opioids must now follow new rules or risk their professional licensure. A brief summary of these bills appears in this edition of the Record, followed by comments from some of our BCMS members. Governor Wolf has signaled a willingness to consider changes to the new requirements next year, so it is vital that physicians and other prescribers communicate with the Governor and their state legislators regarding any changes they would like to see. Unintended consequences that place unreasonable burdens on physicians and patients must be minimized. One year ago, the leadership of the BCMS decided to make addressing the opioid crisis a top priority for the organization and reached out to other community stakeholders to form the Substance Abuse Task Force. In the spring, we held the well-attended Opioid Abuse


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CME Forum and organized a very successful drug take-back event. In the summer, with assistance from PAMED, we initiated a webinar series (HealthTalk.net) featuring brief presentations by local experts aimed at providing our members with information useful in daily practice to improve the care of people in need of help with substance use/abuse. The BCMS weekly talk radio show Health Talk (on WEEU) devoted two shows to this subject in 2016, and numerous articles published in the Medical Record have provided insight and information on a wide range of topics related to the opioid crisis. Any physician (or lay person) who would like to review the Medical Record articles, listen to the Health Talk shows, or access HealthTalk.net will find them on the Berks County Medical Society website, berkscms.org. The number of opioid prescriptions dispensed in the U.S. declined each year from 2013 to 2015, but the number of overdose deaths from prescription and illegal opioids combined has continued to rise. In my opinion, this fact sends a strong signal that more attention must be paid—and more resources devoted to—the other root causes of the opioid crisis. Physicians must continue to be part of the solution, and we are most effective when we act together. If you are not a member of the BCMS and PAMED, consider adding your strength to ours. If you are a member, Thank You!

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President’s Message

F Andrew Waxler, MD, FACC President

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or some reason, death around the holidays always seems to be more heartbreaking and newsworthy whether it be a celebrity or a friend. Perhaps the most curious of recent celebrity deaths was the passing of Debbie Reynolds who died suddenly, just a day or two after the devastating loss of her daughter Carrie Fisher. While I have no “inside information,” it is fairly obvious to me and many other physicians that Ms. Reynolds died of takotsubo cardiomyopathy, which is more colloquially known as “broken heart syndrome.” First described in the 1990s, this condition predominately affects elderly women who develop an acute cardiomyopathy shortly after experiencing severe emotional/psychological trauma. This phenomenon may actually be more common than we realize. As a child, I witnessed the results of broken heart syndrome firsthand — before it was considered “a condition.” My grandfather, a first generation turn-of-the-century Russian immigrant who taught himself English, put himself through medical school, and had a several-decade career as a general practitioner physician, suffered a small myocardial infarction in 1975. Ironically, he recovered but my grandmother passed away, at home, in her sleep, while he was still hospitalized. Years later, when the syndrome was described officially, I instantly recognized this as what caused the sudden death of my heart-broken grandmother; her body’s reaction to the fear of losing my grandfather.

These stories remind me — and should remind all of us — that life is precious and fragile. We all know it and we say it every day, but are we really taking the steps necessary to enjoy the life we have? Have we said “in just a minute” too many times to our kids so that they don’t ask for us anymore? Have we put our spouses off with statements such as “Sorry, I just need to catch up on some paperwork.” The holiday season is a time for family and friends, and the New Year allows us all the opportunity to reflect on the past year what’s been good, and maybe what’s been not so good. With that reflection, we think about a new start, a “clean slate” — we talk about “New Year’s resolutions,” but we rarely follow through. Let this be the year to make it happen! Follow through on some of those promises we’ve made to ourselves. Cheers to having your best year yet! As physicians we owe it to ourselves and our patients to be at our best, but with the ongoing demands on us — professionally and privately — it is hard to find that crucial “balance” for ourselves. In the upcoming year, and as part of one of my last acts as President, BMCS is in the process of piloting a Physician Wellness Program to help our members take better care of themselves both mentally and physically. Please keep an eye out for some new member benefits coming your way in 2017. I wish all of you a truly happy, healthy, and successful new year!


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

Timothy J. (T.J.) Huckleberry, MPA Executive Director

8 Things I Said to Wilson to Con H Two-Year Presiden A

s I have written in many of my previous articles, 2016 has certainly been a year of change at the Berks County Medical Society. The latest change is an important and fundamental alteration to our leadership structure that I am sure will benefit the future of our Society in many ways – an additional year of service as President. It’s genius! ...the only thing I needed to do was make sure our President-Elect, Dr. Greg Wilson, would be OK with it before I brought it to our Executive Committee. Here are the top selling points I gave to Dr. Wilson… 8.) By the end of 2019, you will be the longest serving President in the Berks County Medical Society’s storied 193-year history (until Dr. Mike Haas takes over, but Dr. Wilson doesn’t need to know that). 7.) It gives you more time to accomplish your goals and objectives for your term. In our nation’s political structure, the school of thought is that the President’s first 100 days in office is the only window of time to successfully push the Commander-in-Chief ’s agenda…and he doesn’t have EMRs and the new PDMP to contend with everyday! An extra year will give our Society’s president a better block of time to achieve his or her objectives.

President-Elect, Dr. Greg Wilson

6.) It gives us a chance to actually dust off and look at our by-laws. Believe it or not, this change demanded an amendment to by-laws. Which called for an annual executive council meeting and a majority vote. It was a heavily attended meeting for this reason…or perhaps because of the taco bar we provided. 5.) If you don’t do it, Dr. Waxler said he will extend his term for the next 10 years. 4.) We have a real and sincere need to foster and acquire young leadership. Simply put – there are not enough members on our current committee to sustain our current leadership structure. A one-year presidency is like lighting a spark to the wind…and we are running out of matches.

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o Dr. Greg Him into a ntial Term

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3.) It significantly lowers our annual budget. Seriously. The annual expense on letterhead changes alone makes the move worth it, but the real savings is in our Installation Brunch. We spare no expense at the brunch, and I don’t want to skimp or scrape on any part of it. The brunch is part of our identity. However, by making the presidency a twoyear term, we will make the brunch a bi-annual event – significantly saving the Society money without downgrading one of our key events.

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2.) Speaking of the brunch…how about we move it closer to the spring? The last two years have been a disaster in terms of weather and dangerous travel conditions. If we move it to March, the chance of inclement weather will be lower. Incidentally, this year’s Installation Brunch will be held on Sunday, March 12, 2017. 1.) It will be a very quiet two years. I promise. I mean, I am sure after the presidential election, there won’t be any fundamental changes to healthcare or anything, right? Well, hopefully Dr. Wilson hasn’t picked up the paper since November, but all joking aside, the two biggest hurdles facing ANY society is attracting young members and achieving financial stability. While I am sure that a two-year term for our Society’s President does not look like a big deal on paper, I can assure you that this measure significantly helps address the hurdles we are facing. I want to thank Dr. Wilson and Dr. Haas (our upcoming President-Elect) for seeing the opportunities in the two-year term and agreeing to take it on.

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

Pennsylvania’s New T

he epidemic of opioid abuse and the overdoses and deaths accompanying this public health scourge claimed even more victims in Berks County and beyond in 2016 than in 2015. On November 2, Governor Tom Wolf signed into law a package of bills requiring

changes in the way health care practitioners prescribe opioid medications and putting the licensure of any practitioner who does not comply at risk. The new requirements include checking the PDMP system before writing every prescription for an opioid (or benzodiazepine), with some exceptions, and quantity limits on such prescriptions under certain circumstances. A premise behind some of the new requirements is that one factor stoking the opioid epidemic has been careless prescribing habits by physicians and others, which need to be reined in. While there is some truth to this scenario, it is a gross over-simplification of the wider problem. Prescribing habits are just one small piece of a much larger puzzle. Raising barriers to the dispensing of prescriptions for opioids is likely to make it more difficult for some pain sufferers to obtain relief and will do little to put the brakes on the opioid epidemic unless more action is taken to address the other pieces of the puzzle, which include barriers to the access of alternative pain management treatments, lack of access to addiction treatment, and the easy availability of inexpensive heroin. A brief summary of the bills which affect opioid prescribing appears next, followed by comments from Berks County Medical Society members. — Lucy J. Cairns, M.D., Editor

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Opioid Restrictions Summary of Recent Pennsylvania Opioid Legislation Provided by Hannah Walsh, PAMED Associate Director for Legislative Affairs

Health care practitioners who violate the provisions of this bill are subject to licensure sanctions by the appropriate state board, although practitioners who comply with the provisions of this bill are presumed to be acting in good faith and will have immunity from civil liability.

SB 1202 – Revisions to the PDMP law SB 1202, sponsored by Senator Gene Yaw, will amend the Achieving Better Care by Monitoring All Prescriptions Program (ABC-MAP) law, better known as the PDMP law. SB 1202 contains several major revisions to the PDMP law, including:

HB 1699 – Opioid limits in emergency departments

• Requiring dispensers to query the PDMP system before dispensing an opioid drug product or a benzodiazepine prescribed to a patient under certain circumstances.

HB 1699, sponsored by Representative Rosemary M. Brown, will limit the prescribing of an opioid drug product to an individual seeking treatment in certain settings (an emergency department (ED) or urgent care center, or an individual who is in observation status in a hospital), to no more than a quantity sufficient to treat that individual for up to seven days. HB 1699 does contain an exception that allows a health care practitioner to prescribe more than a seven-day supply to treat a patient’s acute medical condition or if it is deemed necessary for the treatment of pain associated with a cancer diagnosis or for palliative care. In order to go beyond the seven-day limit, a health care practitioner must document in the individual’s medical record that a non-opioid alternative was not appropriate to treat the medical condition. Regardless of the amount prescribed, a health care practitioner under these settings is prohibited from writing a prescription that allows for a refill for an opioid drug product. Other parts of the bill require:

• Requiring prescribers to query the PDMP system each time a patient is prescribed an opioid drug product or a benzodiazepine. However, querying is not required if a patient has been admitted to a licensed health care facility or is in observation status in a licensed health care facility after the initial query as long as the patient remains admitted to the licensed health care facility or remains in observation status in a licensed health care facility.

• A health care practitioner under these settings to refer an individual for treatment if the individual is believed to be at risk for substance abuse while seeking treatment. • A health care practitioner under these settings to query the Prescription Drug Monitoring Program (PDMP) system to determine whether a patient may be under treatment with an opioid drug product by another health care practitioner. This requirement does not apply to any medication provided to a patient in the course of treatment while undergoing care in an ED.

• Requiring an individual applying for an initial license or certification issued by a licensing board to be a dispenser or prescriber, to complete, within the first 12 months after obtaining the initial license or certification, four hours of education, with those hours being at least two hours of education in pain management or identification of addiction and at least two hours of education in the practices of prescribing or dispensing of opioids. • Requiring dispensers or prescribers applying for the renewal of a license or certification to complete at least two hours of continuing education in pain management, identification of addiction or the practices of prescribing or dispensing of opioids. The education indicated above is not in addition to the 100hour CME requirement for physicians but rather is part of the 100-hour CME requirement. In addition, prescribers who don’t have their own DEA number and who do not use the registration number of another person or entity as permitted by law to prescribe controlled substances are exempt from this CME requirement. continued on next page WINTER 2017

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Summary of Recent Pennsylvania Opioid Legislation continued from page 11

SB 1367 – Opioid prescribing for minors SB 1367, sponsored by Senator Gene Yaw, will limit the amount of opioids that may be prescribed to a minor to no more than a seven-day supply unless a prescriber determines that more than a seven-day supply is needed to stabilize the minor’s acute medical condition. For the exception to apply, the prescriber is required to document the acute medical condition in the minor’s record with the prescriber; indicate the reasons why a non-opioid alternative is not appropriate to address the minor’s acute medical condition; and that the prescription is for management of pain associated with cancer, for use in palliative or hospice care, or for management of chronic pain not associated with cancer. Before prescribing an opioid for the first time to a minor, a prescriber is required to do the following: • Assess whether the minor has taken or is currently taking prescription drugs for treatment of a substance use disorder. • Discuss with the minor and the minor’s parent, guardian, or with an authorized adult certain specified risks and dangers. SB 1367 will require the Department of State’s Bureau of Professional and Occupational Affairs, in consultation with the licensing boards, to create a standardized form for prescribers to use to obtain written consent from a minor’s parent, guardian, or authorized adult, in order to prescribe an opioid to that minor. Violations of this bill may subject a prescriber to administrative sanctions by the appropriate licensing board.

SB 1368 – Opioid Education and voluntary non-opioid directive SB 1368, sponsored by Senator Thomas H. Killion, will require the licensing boards to implement curriculum regarding safe prescribing practices for controlled substances containing opioids. This curriculum may be offered by medical schools, medical training facilities, dental schools, and other providers. This education will not be mandated as a graduation requirement but will instead be left up to each educational institution to determine whether it will be required for graduation. SB 1368 will also allow a patient to sign a form prohibiting the prescribing or administering of a controlled substance containing an opioid to that patient. Guidelines for the implementation of this form will be drafted by the Department of Health. Practitioner who recklessly or negligently fail to comply with a patient’s voluntary non-opioid directive may be subject to a licensure sanction by the applicable state board.

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Kristen Sandel, M.D. Associate Director, Department of Emergency Medicine, Reading Hospital Comments regarding HB 1699: Opioid Limits in Emergency Departments

The heroin and opioid epidemic is sweeping the nation and unfortunately Pennsylvania and Berks County have not been immune to this terrible problem. While I applaud our state legislators’ efforts to curb this epidemic, passing legislation limiting the ability of Emergency Medicine physicians to prescribe pain medication creates a slippery slope with respect to the practice of medicine. Although it is unusual for an Emergency Medicine physician to prescribe more than seven days of medication, there are circumstances that would necessitate longer prescriptions. Emergency Physicians are very conscious of this issue and in 2014 the Pennsylvania College of Emergency Physicians passed a guideline for the treatment of pain in the Emergency Department. Until exceptions are clearly defined, HB 1699 has the potential to place physicians and patients in a difficult situation both medically and legally. Some areas of the Commonwealth continue to struggle with access to care issues and there are times that patients have significant, acute pain and are not able to schedule an appointment with a specialist or their primary care physician within a reasonable period of time. In these circumstances, the Emergency Department remains the safety net for this population of patients. I am encouraged by the efforts of our State Representatives to eradicate this epidemic of opioid abuse and hopeful that the Pennsylvania Medical Society can work hand in hand with the legislature to amend this legislation to ensure that appropriate patient care pain needs are addressed.

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Jason T. Bundy, M.D. Center for Pain Control

I read the summarized bills with great interest. My response is perhaps like that of many physicians: “Oh great, more legislative mandates, more red tape, more liability and less physician autonomy.” Certainly the PDMP and better education / awareness about the prescription opioid abuse epidemic are all steps in the right direction. However, it seems excessive to hold Pennsylvania physicians medico-legally liable for not accessing (or paying a proxy to access) the PDMP every single time a legitimate, low-risk chronic pain patient with consistent drug screens receives a controlled substance prescription. In addition, the state legislature seems to have fallen into a pattern of withholding medical licensure over very specific medical training issues like child abuse recognition and now opioid prescribing. Shouldn’t physician training programs be teaching this material from day one? If they aren’t, maybe their federal funding should be withheld instead of piling on more unfunded physician mandates.


Anyway, I predict that if Governor Wolf signs this legislation into law, it will indeed make it harder for all patients in the state to remain on controlled substance pain medications. That is probably a good thing for patients struggling with addiction issues, but definitely a bad thing for chronic pain patients that are earnestly struggling with severe pain and have few other options. These chronic pain patients may not be able to find a physician willing to prescribe controlled substance pain medications because the liability and / or hassle of prescribing them have simply grown too burdensome. (I am already seeing that trend here in Berks County due to the recently released CDC opioid prescribing guidelines for primary care physicians.) I predict that this type of legislation will only accelerate this problematic trend because there simply aren’t enough chronic pain management physicians available in this state to care for all the patients who have a legitimate need for ongoing opioid treatment.

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SB 1367 provides a new awareness for both prescribers and patients about the dangers of opioid medications especially for minors. It is good for patients and their parents to be educated about the addiction potential. These conversations might take a little more time for prescribers but the prevention of addiction and the hardship it causes for many families in our society will make it more than worth it! Many families are unaware that the longer opioid medications are taken the more potential there is for addiction. Some patients also don’t try a lesser pain medication because “the strong one is working.” They may be afraid that they will not have adequate treatment of their pain. The seven-day limit will at least require a patient to take a non-opioid at that point and see if it is sufficient in controlling their pain. In many instances it will be. If it is not, then more conversations and reevaluations can occur, allowing a plan to be devised to make sure the medications are not overused. The law allows for exceptions such as pain from cancer, use in palliative care and for the management of chronic pain not caused by cancer. These exceptions must be well documented. The law also asks that prescribers assess whether a minor has been treated for a substance abuse disorder and is taking or has taken medications to treat a substance abuse disorder. This is protective for both patients and prescribers. The consents take a little more time to explain and require more paperwork, but given the epidemic of addiction in our society, these conversations are crucial and necessary to make sure everyone involved understands the risks and dangers of opioid medications.

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Anne P. Ambarian, M.D. Family Medicine Patient First Urgent Care

As with most requirements and regulations in our profession, they are usually a direct result of things gone awry. The opioid prescribing laws are no different. Briefly, providers are now required to do CME on opioid prescribing, query the Prescription Drug Monitoring Program (PDMP) every time an opioid or benzodiazepine is written, and be aware of consent and quantity limits for minors. In addition, Emergency Departments and Urgent Care Centers are restricted to a quantity of treating for no more than 7 days. The PDMP is fairly user friendly but obviously is one more step and takes more time. The biggest complaints were the initial annoyance of the PDMP program being easily accessible on all computers and remembering yet another password that changes. The other rules are basically common sense. A minor should have consent to get these medications, and now we will have the added step of being required to obtain written consent. Most emergency departments and urgent care centers are not giving out 7 days of these substances even without the law, so in essence, no change for us. There certainly are positives, including objective data about patients’ prescriptions including date prescribed and quantity given, deterring duplicate and over-prescribing (we in Urgent Care hope for an “antibiotic” PDMP). It has opened up communication about the addictive and harmful effects of misuse and overuse. I have personally seen several patients who have been weaned off chronic narcotics and feel much better. All of which is great news! Overall, the program is more positive than negative.

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Lee Radosh, MD Director, Family Medicine Residency Reading Hospital

Finally, the “opioid crisis” is getting attention. This affects (kills!) so many more people than so many other illnesses/infections to which we devote much greater resources. We have routinely asked patients about trips to Africa, and spend exorbitant time and money preparing for potential infectious epidemics. Yet people die in mass numbers – daily – right in front of us, and we do virtually nothing. Until now. While I loathe laws and government interventions dictating how I practice medicine, I can understand the rationale for political intervention. This is a public health crisis. It drains our state and federal finances, and well-intentioned leaders want to do something. It is reasonable to expect practitioners to check databases, and exercise due diligence when prescribing these potentially dangerous therapeutics. However, until there are automated pathways, unfunded government mandates may be counterproductive. Some reflections based on my experiences: • Unforeseen consequences . . . With so much pressure to avoid these medications, and heavy burdens for those who do prescribe, more and more clinicians are simply saying no, they won’t manage these medications. This means the few providers left will be overwhelmed, patients will be even more viewed as pariahs as they move in desperation among clinicians, and many will turn to the cheaper, more accessible heroin. The term “opioid refugee” is becoming more commonplace describing this situation. • Much has been written regarding the perfect storm of factors that got us where we are. But this is also a symptom of global issues such as lack of access to – and affordability of – mental health treatment, addiction services, and pain management. No legislation to limit opioids will achieve its goals without addressing these barriers. • Those of us in primary care must admit sad truths, through no fault of our own. It is quicker and easier to prescribe a month of opiates than dig deep into root causes of a patient’s complaint. Why waste time referring to physical therapy when many patients – even with insurance – can’t afford co-pays, certainly can’t afford the time off to go? The most complex patients often do not follow-up with referrals to psychiatry and other specialists. The wait times can themselves be prohibitive, and sometimes the patient then gets kicked out of that practice. They invariably land back in the PCP’s lap, to send to the overburdened emergency department, or dismiss from the practice to become someone else’s problem. But we often continue to sub-optimally manage, as the limited alternatives available to patients may be worse, and we want to help. And imagine what the effect will be when more PCP compensation is tied to patient satisfaction! The bottom line: until we fundamentally change how primary care is compensated, these

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patients wander and suffer. Society cannot expect great care of these patients in a 15 minute office visit, and the current reimbursement structure for primary care makes (the necessary) longer office visits financially nonviable. • We are fortunate to have some excellent pain management experts locally who truly provide comprehensive care. Unfortunately, many others provide injections but then send the patient back to the PCP when the injection wears off. And the cycle continues. • Many guidelines for pain management have been established, most of which are perfect for “la-la land.” You, a reader of this journal, are an affluent member of society. Yet even you might recoil from the costs (financial, and especially time off from work and other responsibilities) for recommended therapies usually not covered by insurance: massage therapy, acupuncture, yoga, and other non-pharmacologic interventions. Now, imagine you are a blue-collar worker already struggling to make ends meet. Helpful guidelines? For many patients, I think not.

• For those addicted, in addition to counseling and many other traditional treatments, there are now effective, proven medications to assist with abstinence. Embarrassingly, most physicians are probably more comfortable diagnosing lupus and writing for hydroxychloroquine, than diagnosing opiate-use disorder and writing for medication-assisted treatment such as a naltrexone formulation (such as long-acting Vivitrol). These are some of the barriers in combatting this epidemic. There are innovative signs of progress; the warm hand-off program in the Reading Hospital Emergency Department is one example. But in early December, the Philadelphia news reported 35 heroin overdoses in a 5-day span. Imagine if the headline read “35 deaths in 5 days from new virus X.” People would wear masks on the subway in fear, and there would be emergency legislative sessions! We must let our policies and medical practice be dictated by the data of what really affects patients. But without addressing the previously described issues, wellintentioned recent laws will probably only scratch the surface.

• There is of course overlap among patients with chronic pain, those on chronic opioids, those addicted, and those suffering from co-morbid mental health conditions. However, we must remember that too often these terms and categories are used interchangeably. Each patient is different. Each issue deserves its own attention for reform.

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

Opioid Poorly-Responsive Cancer Pain by Tamara Sacks, MD, David E Weissman, MD, and Robert Arnold, MD

BACKGROUND Relief of cancer pain from opioids is rarely all or nothing; most patients experience some degree of analgesia alongside opioid toxicities. When the balance of analgesia versus toxicity tips away from analgesia, the term ‘opioid poorly-responsive pain’ is invoked. While opioid poorly-responsive pain is not a discreet syndrome, it is a commonly encountered clinical scenario. This Fast Fact reviews key points in its assessment and management.

DIFFERENTIAL DIAGNOSIS OF OPIOID POORLY-RESPONSIVE PAIN 1. Cancer-related pain a. Cancer progression (new fracture at site of known bone metastases). b. Causes of pain (eg. neuropathic pain, skin ulceration, rectal tenesmus, muscle pain) that are known to be less responsive to systemic opioids or opioid monotherapy. c. Psychological/spiritual pain related to the cancer experience (existential pain of impending death). 2. Opioid pharmacology/technical problems a. Opioid tolerance (rapid dose escalation with no analgesic effect).

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a. Worsening of a known non-cancer pain syndrome (diabetic neuropathy). b. New non-cancer pain syndrome (dental abscess). 4. Other psychological problems a. Depression, anxiety, somatization, hypochondria, factitious disorders. b. Dementia and delirium both can affect a patient’s report of and experience of pain. c. Opioid substance use disorders or opioid diversion.

MANAGEMENT STRATEGY 1. Initial Steps a. Complete a thorough pain assessment including questions exploring psychological and spiritual concerns. If substance abuse or diversion is suspected, complete a substance abuse history (see Fast Facts #68, 69). b. Complete a physical examination and order diagnostic studies as indicated. c. Escalate a single opioid until acceptable analgesia or unacceptable toxicity develop, or it is clear that additional analgesic benefit is not being derived from dose escalation. If this fails, consider:

b. Dose-limiting opioid toxicity (sedation, delirium, hyperalgesia, nausea – see Fast Facts #25, 142).

i. Rotating to a different opioid (e.g. morphine to methadone).

c. Poor oral absorption (for PO meds) or skin absorption (e.g. transdermal patch adhesive failure).

ii. Changing the route of administration (e.g. oral to subcutaneous).

d. Pump, needle, or catheter problems (IV, subcutaneous, or spinal opioids).

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3. Non-cancer pain

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d. Treat opioid toxicities aggressively. e. Use (start or up-titrate) adjuvant analgesics, especially for neuropathic pain syndromes.


f. Integrate non-pharmacological treatments such as behavioral therapies, physical modalities like heat and cold, and music and other relaxation-based therapies – see Fast Fact #211. 2. Additional steps – Pain refractory to the initial steps requires multi-disciplinary input and care coordination. a. Hospice/Palliative Medicine consultation to optimize pain assessment, drug management, and assessment of overall care goals. b. Mental health consultation for help in diagnosis and management of suspected psychological factors contributing to pain. c. Chaplain/Clergy assistance for suspected spiritual factors contributing to pain. d. Interventional Pain and/or Radiation Oncology consultation. e. Rehabilitation consultations (Physiatry, Physical and Occupational Therapy) to maximize physical analgesic modalities. f. Pharmacist assistance with drug/route information.

REFERENCES

(PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts. Copyright: All Fast Facts and Concepts are published under a Creative Commons Attribution-NonCommercial 4.0 International Copyright (http://creativecommons.org/licenses/by-nc/4.0/). Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know! Disclaimer: Fast Facts and Concepts provide educational information for health care professionals. This information is not medical advice. Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Health care providers should always exercise their own independent clinical judgment and consult other relevant and up-to-date experts and resources. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

1. Mercadante F, Portenoy RK. Opiate Poorly Responsive Cancer Pain Parts 1-3. J Pain Symptom Management. 2001; 21(2):144150, 21(3):255-264, 24(4):338-354. 2. Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002; 20(19):4040-9. 3. Fallon M. When morphine does not work. Support Care Cancer. 2008; 16(7):771-5. 4. Quigley C. Opioid switching to improve pain relief and drug tolerability. Cochrane Database of Systematic Reviews. 2004, Issue 3. Art. No.: CD004847. DOI: 10.1002/14651858.CD004847. 5. Hanks GW. Opioid-responsive and opioid-non-responsive pain in cancer. Br Med Bull. 1991; 47(3):718-31. 6. Hanks G, Forbes K. Opioid responsiveness. Acta Anaesthesiologica Scand.1997; 41:154-158. Author Affiliations: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (TS, RA), and Medical College of Wisconsin, Milwaukee, Wisconsin (DEW). Version History: Originally published May 2009; copy-edited August 2015. Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made is available online by the Palliative Care Network of Wisconsin

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A Resident’s View of the House of Delegates by Rachel Sachs, D.O., Family Medicine Resident, Penn State Health St. Joseph, Resident Representative to the BCMS Executive Council

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n October, I was invited to be the resident delegate for Berks County Medical Society at the Pennsylvania Medical Society House of Delegates in Hershey, Pa. As a first-time attendee of the House of Delegates, which is the legislative and policymaking body of PAMED, I was excited to have the opportunity to learn about the process of setting policy for PAMED. The first day I met with the other residents and students as a caucus to discuss the proposed issues, which are in the form of resolutions submitted by PAMED member physicians. I learned that the resolutions are debated in front of Reference Committees, and any member may participate in the debates. Members of assigned committees are then tasked with deciding whether to recommend that the House of Delegates reject the resolution, accept the resolution as submitted, or accept a version amended by the committee based on the debates. After the work of the Reference Committees is completed, all the delegates meet as a body to further debate and vote on each resolution and conduct other PAMED business. One of the major outcomes of the 2016 House of Delegates was the adoption of a resolution approving the concept of and funding for development of the Practice Options initiative. This initiative will create Clinically Integrated Networks and a Management Services Organization for PAMED members to help them succeed in the rapidly evolving health care delivery environment. One of the proposals that the Residents and Students Caucus discussed in detail was “Addressing Pennsylvania’s Opioid Abuse and

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Overdose Crisis.” This resolution proposed that PAMED support removing existing barriers for PA residents who seek addiction treatment and increasing the availability of Naloxone in schools. Although our caucus included residents/students from all different fields of medicine, each person had a story of a patient he or she worked with who was addicted to opioid medications. We all agreed on the importance of regulation of opioid usage both nationally and in Pennsylvania. We talked about the benefits of having Naloxone more widely available in schools. We also thought that the policies creating barriers for patients in accessing certain addition treatment facilities were outdated and needed to be updated to improve treatment options. The proposal was supported by the full PAMED delegation. As a resident physician, I always find it challenging deciding which patients need narcotic medications for their pain and which can be treated with non-narcotic alternatives. In addition, some patients may have been on narcotic medications for years and are addicted or unable to wean themselves from the medications. This proposal supports expanding the referral options available when a physician encounters a patient who needs help. Although a lot more work and changes are needed in this area of addiction medicine, it was exciting to be a part of the legal process. I look forward to returning to the House of Delegates next year and learning more about how to improve the lives of Pennsylvanians by being an active member of the largest physician organization in the state.


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

Where do you turn when you know a doctor is not appropriately prescribing controlled substances?

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very state is facing the opioid crisis. “We all want our doctors to prescribe appropriately and prevent abuse. The difficulty for physicians is that they are the ones who are responsible for treating patients but also the ones who can help alleviate the fallout of addiction. Some doctors need help understanding the guidelines and others need remediation when they are inappropriately prescribing,” said Marcia Lammando, RN, BSN, MHSA, program director of LifeGuard.® That’s why LifeGuard, in collaboration with the University of Pennsylvania’s Pain Management Institute, introduced an interactive assessment and education program for physicians experiencing difficulties with controlled substance and opioid prescribing. Core competencies will be highlighted as well as in-depth controlled substances education with a focus on opioid prescribing. LifeGuard, a nationally recognized clinical assessment program for physicians, operates under The Foundation of the Pennsylvania Medical Society. “You will be able to deploy what you learn in this course in your practice,” said Philadelphia Physician Michael Ashburn, MD, MPH, Professor of Anesthesiology and Critical Care Director, Pain Medicine, Penn Pain Medicine Center. “This course is intended to provide practicing clinicians with rich information regarding best practices related to the use of opioids to treat chronic non-cancer pain. Our goal is that physicians will clearly understand when and how to use opioids, such that they have the knowledge and skills to properly care for this patient population.” Course material will include best practices as defined by both the CDC clinical practice guidelines as well as the relevant Pennsylvania state clinical practice guidelines. Dr Ashburn said the program will also cover state-specific education related to controlled substance and opioid prescribing guidelines and registries. “The use of standardized patients will allow students to practice their skills related to patient education and management, especially with regard to the management of complex patients and situations.” The course is co-directed by Dr. Martin Cheatle, a pain psychologist with extensive experience in the evaluation and treatment of addiction. “We plan on working hard to make sure students understand how to screen patients for substance use disorder. In addition, students will be able to improve their skills on best practices with regard to patient referral for substance use disorder treatment,” Dr. Ashburn said. continued on next page

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Through the use of interactive methods, the program will assess the physician’s knowledge gained by participation in the program. This program differentiates itself from other didactic prescribing programs through targeted instruction focused on the physician’s prescribing habits. Ongoing monitoring of a physician’s prescribing practices can be offered by LifeGuard for a specified period of time in an effort to measure compliance with guidelines and evaluate educational outcomes, when applicable or requested. This program will offer 25.5 AMA PRA Category 1 Credits™* and courses for the remainder of this year are offered in Philadelphia. Dates are available by request. Dr. Ashburn noted that LifeGuard is on the cusp of introducing two new programs to not only assess physicians’ medical knowledge and practice patterns, but also to provide significant education addressing these identified deficiencies and gaps. If you would like to learn more details, please contact Marcia Lammando, RN, BSN, MHSA, Program Director of LifeGuard®, at mlammando@lifeguardprogram.com or 717-909-2590. Please visit www.LifeGuardProgram.com for even more information. *Accreditation Statement:

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Pennsylvania Medical Society and The Foundation. The Pennsylvania Medical Society is accredited by the ACCME to provide continuing medical education for physicians. *Designation Statements: Live Presentation: Controlled Substance and Opioid Prescribing Educational Program — The Pennsylvania Medical Society designates this live activity for a maximum of 16.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. *Pre-course Enduring Materials: The Pennsylvania Medical Society designates these enduring materials for a maximum of 9.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activities.


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

Feel the Burn: Burnout is More Common Than You Might Think by Heath Mackley, MD, FACRO

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don’t know any physician that doesn’t struggle with the worklife balance. We didn’t become physicians because we expected an easy job. And most of us understand that to be truly good at anything, it probably takes some talent, but it definitely requires a lot of work. There is no substitute for investing your time, from studying in medical school, working and studying in residency and fellowship, and working while continuing the learning process as an attending physician. But it doesn’t stop there. To deliver quality health care to each individual takes time. Time to understand their stories, time to develop evidence based plans for rarely seen diseases, time to talk to your colleagues to coordinate complex care. And it takes time to document each encounter correctly. And it takes time to fulfill employer requirements if you’re employed, or it takes time to administer the practice if you’re independent. And it takes time to supervise and train your team. And it takes time to educate learners if you work with them, and patients no matter where you work. And it takes time for continued medical education (CME). And it takes time to work on your professional development. Medicine is undeniably a labor of love for most of us. But it is labor.

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But we all have a life outside of work. We have family and friends. We have hobbies, causes, religious activities, sports, artistic endeavors, and countless other things that make life full and meaningful. But we also need time to care for ourselves, to eat well, to sleep enough, and to see physicians for our own personal medical issues. The tension between being a good physician and these important aspects of life is relentless. And that is just one source of stress. Physicians see death, suffering, lawsuits, unfair insurance policies, and countless small offenses that can add up. It is no surprise that about 50% of physicians are suffering burnout. Burnout is a syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment . Burnout is not a sign of weakness, it is a consequence of chronic stress. As physicians, it is often easy to focus on our work instead of acknowledging the warning signs exhibited in ourselves or our colleagues. It is common for us to identify denial in our patients; it is less common for us to identify it in ourselves. This impacts all of us in the house of medicine. Studies have shown burnout scores are associated with decreased work effort, an increase in major medical errors, and suicidal ideation. Even in less extreme situations, burnout’s association with lower job satisfaction has ripple effects on the morale of the entire clinic. With few exceptions, no physician is an island that burnout cannot reach. Pennsylvania Medical Society (PAMED) represents and advocates for physicians on many levels. As part of its educational programs offered to members, there are three programs, adding up to four hours of CME, that help physicians identify burnout, develop resilience strategies, and intervene on behalf of their colleagues. For most of us, this is not something we learned about in medical school. Just like other medical problems we learn about, there are evidence-based interventions that can be helpful, both on the individual level (small group curricula, stress management and self-care training, communication skills training, mindfulness-based approaches), and the institutional level (modification of work processes, shortening of work shifts). The average benefit of these interventions reduces the relative risk of developing burnout by about 10%. Sometimes, we need more than CME to address a problem. The Foundation of PAMED, which has a long-standing commitment to helping physicians in need, recently led a successful “Resiliency Retreat” in November. Stayed tuned for further retreats in the future.

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When one considers the potential impact of avoiding a “crash and burn” experience, all of us need to be more proactive with physician burnout. I would encourage everyone to learn more. And remember, PAMED is here to help! Dr. Mackley is a Radiation Oncologist at the Penn State Cancer Institute and 5th District Trustee for PAMED, representing physicians of this county.

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

Welcome New Members

Why did you decide to practice medicine in Berks County? There is a great diversity of patients in this region. What do you like best about practicing medicine? I enjoy the day to day interactions with patients and their families.

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he Berks County Medical Society is pleased to welcome Dr. Colin T. Murphy, Radiation Oncology specialist with Berks Radiation Oncology Associates. Dr. Murphy earned a B.A. in Economics and English from Columbia University and subsequently completed a Post-B.A. Pre-Health program at the University of Pennsylvania. He graduated from Temple University School of Medicine in 2011 and completed a Transitional Internship at the Reading Hospital and Medical Center prior to undertaking training in Radiation Oncology at the Fox Chase Cancer Center. He served as Chief Resident there in 2014-2015. To get to know Dr. Murphy a little better, we asked him to respond to the following questions: Describe the focus of your practice and any areas of special interest/expertise. My practice includes the radiotherapeutic treatment of most adult patients with solid tumors, with special interest in breast, gynecologic, urologic, thoracic, and head and neck cancers.

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If you could change one thing about the current practice environment, what would it be? I wish that the pace of innovative changes in treating difficult cancers was faster. Are you involved in any nonprofit/ community groups at this time? Not yet, but I look forward to doing so in the near future. Please tell us a little about your family and the activities you enjoy outside of work. I enjoy spending time with my wife and two sons, and I always make time to watch the Eagles, win or lose. Name one thing about your practice / field of medicine that you think all your patients should know. Berks Radiation Oncology Associates at the McGlinn Cancer Institute offers state of the art therapies, rivaling most (and in some cases surpassing) large academic institutions.

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he Berks County Medical Society is delighted to welcome Adam J. T. Smith, Radiation Oncology specialist with Berks Radiation Oncology Associates. Dr. Smith graduated from Emory University with a major in Chemistry and a minor in Philosophy. He attended UCLA School of Medicine in the Medical Scientist in Training program, earning his Ph.D. in 2008 and his M.D. in 2010. After an internship in Internal Medicine at the University Medical Center of the University of Nevada, he trained in Radiation Oncology at the University of Kentucky. He served as Chief Resident there in 2014-2015. To get to know Dr. Smith a little better, we asked him to respond to the following questions: Describe the focus of your practice and any areas of special interest/expertise. Ours is a general radiation oncology practice, providing curative and palliative treatments to all adult cancers.


BCMS_Directory_2017_FINAL.qxp_Layout 1 12/13/16 10:02 AM Page 1

Need an eye consult or referral? Why did you decide to practice medicine in Berks County? For me and my family it was the perfect blend of a close-knit feeling of a small town with easy access to anything you could want from a major city. What do you like best about practicing medicine? It is a unique combination of doing highly satisfying work that is at the same time extremely humbling. If you could change one thing about the current practice environment, what would it be? Billing requirements that encourage encyclopedia-length clinic notes with a haiku-worth of salient information. Are you involved in any nonprofit/ community groups at this time? Not at this time but I look forward to future endeavors. Please tell us a little about your family and the activities you enjoy outside of work. My wife, Sara, teaches yoga at Body Zone and Just Breathe as well as performing the Herculean labors required to keep the household running. My daughter, Chloe, is in kindergarten and takes ballet/tap. She loves movies, pretending, and drama of any kind. My son, Leo, is at Montessori Country Day preschool in Gouglersville and only eats peanut butter and jelly sandwiches. In my spare time I like to read and go running.

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

Members in the News “The American Academy of Pediatrics Section on Oral Health presents the 2016 Oral Health Service Award to C. Eve Jensen Kimball, MD, FAAP, for working to advance children’s oral health through education, medical/ dental collaboration, and advocacy.” It was presented at the AAP National Conference & Exhibition Meeting in San Francisco, CA on 23 October 2016. This award is given to a member of the Section on Oral Health that has contributed significantly to the mission of the Section to improve children’s oral health and medical/dental collaboration. It was recently announced that Dr. Aparna Mele is being honored by the Girl Scouts of Eastern Pennsylvania at their annual Take the Lead banquet being held on March 30, 2017. The honorees are positive role models for the girls of today, providing them with the courage, confidence and character necessary to make an impact on our community. Dr. Mele was selected for the impact the educational event she founded, “Guts and Glory,” has on our community. Anyone interested in attending the Take the Lead banquet, please call the BCMS office.

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Penn State Health St. Joseph elevates Chris Newman, MD, to Chief Medical Officer Christopher Newman, MD, has been named the Chief Medical Officer of Penn State Health St. Joseph following the retirement of Gary Lattin, MD. In his role, Dr. Newman has primary accountability for clinical leadership and clinical quality and medical staff relations. He serves as the key administrative liaison to the employed and independent medical staffs. He also oversees physician governance and has a significant strategic responsibility for developing clinical integration strategies. Dr. Newman joined Penn State Health St. Joseph as Associate Chief Medical Officer 18 months ago from Lehigh Valley Health Network’s Physician Group. Prior to joining Lehigh Valley, Dr. Newman was the President and a managing partner for Lehigh Area Medical Associates, a large, private internal medicine practice in Lehigh County. Dr. Newman is a graduate of the University of Scranton, where he earned his bachelor’s degree in biology. He completed medical school at Georgetown University School of Medicine, Washington, DC, and his residency at Georgetown University Medical Center. In the spring of 2016, he received an MBA from the prestigious University of Virginia’s Darden School of Business.


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

Reading Physician Retiring as Board Chair D

Dr. Raymond C. Truex Jr., MD

r. Raymond C. Truex Jr., MD, led the Foundation of the Pennsylvania Medical Society Board of Trustees for more than a decade. He will remain on the board as immediate past president as he transitions the role to Virginia E. Hall, MD. The Foundation has grown under Dr. Truex’s steady guidance. “Dr. Truex is one the most authentic leaders I have ever encountered. Each day during his leadership, the singular focus was to improve the human condition of a physician. He was brutally aware of the significance of our work and how lives hang in the balance. He humbly and steadfastly reached out to many individuals to say, ‘Life in sobriety is possible. The Foundation can help. Let me guide you on your way to a life of wellness with help from the PHP,’” said Foundation Executive Director Heather A. Wilson, MSW, CFRE. She continued, “His heartshare was boundless as he personally picked up the phone to speak with a loan recipient family to tell them that we had forgiven the debt after an unexpected illness tragically took a young physician’s life. He participated in LifeGuard’s ground-breaking late career physician symposium to truly understand the importance of a fair and non-biased assessment. He not only talked the talk, he walked the walk. His generosity of time, talent and treasure was ceaseless and the Foundation is better because of his vision, relentless passion and influence,” said Wilson. Previous Foundation Executive Director Virginia Henning agrees. She said, “Dr. Truex has been an exemplary leader of the Foundation. During our time together, he seized every opportunity to be a strong advocate, and he always said thank you to those who supported our mission. He often remarked that it was from gratitude that he served and that he gained so much more than he gave. Dr.

Truex has expressed his passion for our programs so naturally and with such grace that his influence will be felt for many years to come. I thank him for his inspirational guidance, his unending patience, his deep humility, and his infectious spontaneous laugh.” Former Board Chair Gerald Pifer, MD, said, “Dr. Truex was a great board member and side kick as vice chair when I served as chair. He is soft spoken, a man of few, but very important words, a dry sense of humor and a man I would share a foxhole with any day!”

The Foundation, a nonprofit affiliate of the Pennsylvania Medical Society, sustains the future of medicine in Pennsylvania by providing programs supporting medical education, physician health, and excellence in practice. It has been helping to finance medical education for nearly 60 years. The Foundation offers scholarships and low-interest loans for medical students. Its Physicians’ Health Program provides support and advocacy to physicians struggling with addiction or physical or mental challenges. The program also offers information and support to families of impaired physicians and encourages their involvement in the physician recovery process. LifeGuard assists physicians when clinical practice is called into question. The Foundation is funded by grants and contributions from physicians, hospitals, and others interested in physician health issues. Would you like to make your yearend gift to the Foundation in honor of Dr. Truex’s time on the board? Call the Philanthropy Department at 717-5587846. Dr. Truex will be notified of your generosity. WINTER 2017

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Berks County Medical Society Alliance

T Members Kelly O’Shea and Jill Haas presented “Active Family Travel”

The Alliance has had a very busy fall season. We started off the year with a new member coffee to meet new medical spouses and invite them to our group. In October we held our annual Fall luncheon at the home of Kathryn Marr. Two of our own members, Jill Haas and Kelly O’Shea of Wanderlust Travel, shared a presentation on “Active Family Travel.” Collections of dog and cat food and supplies were taken for delivery at the Animal Rescue League. Also in October, President Allison Wilson traveled to Hershey to attend the Pennsylvania State Alliance Annual Meeting. She was proud to bring home the “2015-2016 Health Project of the Year” award from the PMSA. Congratulations to Chair Lisa Banco and her committee: Lisa Geyer, Jody Menon, Kalpa Solanki, Sue Russo, Amy Impellizzeri, Lynnie Gregor, Dee Dee Burke, Emily Bundy, Diana Kleiner and Kathryn Marr. This award came with a threehundred-dollar stipend which we will place in our Community Service Fund. Our November general meeting was hosted by Michelle Trayer. We were joined by BCMS Executive Director TJ Huckleberry who updated us on the medical society and legislature from the PA House of Delegates. In November we were also proud to host newlyinstalled PMSA President Kathleen Hall at the Annual 5th District Luncheon. In December, we gathered at the home of Amanda Abboud to celebrate the holidays. Donations were collected for “Toys for Tots.” We would like to thank all BCMS/BCMSA members who donated generously to our Annual Holiday Card fundraiser.

Members of Pennsylvania Medical Society 5th District gathered at Berkshire Country Club in November.

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MMe de idci acla lRRe ce oc ro dr dFFe aetaut ru er e

Tips on Handling

Holiday Stress

W

ell, it’s that time of year again!! The shopping and crowds. The back-to-back diet busting parties. The long chats with the in-laws. When you think of all of this, we understand how easy it is to feel not so wonderful at this most wonderful time of the year!! Here are some basic tips on How to Handle & Minimize Holiday Stress: u Get Organized and Plan Ahead: • Make lists or use an appointment book to keep track of all your holiday events and all the tasks you need to do. Set aside specific days for shopping, baking, visiting friends and other activities. Plan your menus then make a shopping list – that will help with last-minute scrambling to buy items you forgot. • Don’t over-schedule yourself! Allow enough time to relax and recover after visiting with friends and family. u Be Realistic and Forget Perfection: • Don’t sweat the small stuff and your holiday will be more enjoyable. The holidays don’t have to be perfect or the same as last year. As your family grows or changes, traditions and rituals often do as well. Pick a few that you want to hold onto and be open to creating new ones too. Don’t expect miracles and learn how to say “NO.” u Fit in Exercise and Take a Breather: • It is the last thing on your mind when you are stressed out about the holidays but studies show that exercising will relieve some of that stress and boost your mood for up to 12 hours. It will also give you some “me” time, which is much deserved. • Make time for yourself – spending just 15 minutes alone without any distractions may refresh you enough to handle all that you need to do. u Holiday Shopping tips: • Ask people what they want instead of searching endlessly for that “perfect gift.” If you can, shop early when you will find more of a selection. Set up a gift budget and stick to it – it will prevent the buyers’ remorse later. u Share the Tasks: • You do not have to accomplish EVERYTHING yourself. Once you make your “to-do list,” ask your family or friends to help you. u Pick your Battles: • You will be in close quarters with your family members at some point over the holidays so set aside your differences and agree to disagree. Don’t let the actions of others ruin your joy. u Be Grateful: • You have a lot to be thankful for in your life and this is the season to celebrate all of it – family, friends, your health, your job, etc. Just enjoy life and all it has to offer!

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

Berks County Medical Society’s Upcoming Event READING ROYALS

PINK IN THE RINK NIGHT SATURDAY, FEBRUARY 18TH @ 7PM READING ROYALS vs. ELMIRA JACKALS  Pink Hat Giveaway  Diamond Level Seating  Pink-themed Specialty Jersey to be worn by the team to benefit local efforts to treat and eradicate breast cancer.

If you have any questions or would like any more information feel free to contact Jake Friedman at 610-898-7277 or via email at jfriedman@royalshockey.com

For more information or purchase your ticket, please go to w w w.berkscms.org.

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Berks County Medical Society Medical Record Winter 2017  

The official publication of the Berks County Medical Society. www.berkscms.org. Medical Record is published by Hoffmann Publishing Group, In...

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