Medical record Berks County Medical Society

Best Wishes in Retirement

Tenured Society Executive Director Retires The

Conversation Project

Discussing End of Life Wishes

Physician Perspectives on Medical Marijuana

SUMMER 2014

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Medical record 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.

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THE BERKS COUNTY MEDICAL RECORD Lucy J. Cairns, MD, Editor

EDITORIAL BOARD D. Michael Baxter, MD John Moser, MD Betsy Ostermiller

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RetractionSpring 2014 Issue

The Berks County Medical Society would like to sincerely apologize to Dr. Nicola Bitetto for mislabeling a photograph taken at the Installation Brunch. Pictured was Dr. Nicola Bitetto, not Dr. Hector Ceda receiving his 50 Year Award from Dr. Michael Baxter. Dr. Ceda also received his 50 Year Award at that time, but was not present for a photograph.

Kristen Sandel, MD, President Lucy J. Cairns, MD, President-Elect D. Michael Baxter, MD, Chair, Executive Council Michael Haas, MD, Treasurer Andrew Waxler, MD, Secretary Pamela Q. Taffera, DO, Immediate Past President COVER PHOTO: SUSAN ANGSTADT, READING EAGLE

Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, 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. All manuscripts and letters should be typed double-spaced on standard 8 1/2"x11" stationery.

The Berks County Medical Record (ISSN #0736-7333) is published four times a year in March, June, September, and December by the Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, 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, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610.

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Table of Contents SUMMER 2014

FEATURES

Big Name Hunting Collecting Medical Autographs

Medical Perspectives on Medical Marijuana 14 The Conversation Project 18 Do I Really Want to 24 Work for these People? Bruce Weidman with Dr. Barton Smith

DEPARTMENTS Editor’s Comments

Foundation Update President’s Note

9 8

Office Management Update

Members in the News

Alliance Update

Legislative and Regulatory Updates BCMSA Events Calendar

ALLIANCE Past President’s Luncheon- Back Row: Emily Bundy, Kaaren Orquiza, Lynnie Gregor, Dee Dee Burke, Jill Haas, Carol Perlmutter, Toni Calata, Diana Kleiner, Laurie Waxler Front Row: Kathy Rogers, Carole Lusch, Lisa Geyer, Debra LaManna

22 26 30

Editor’s Comments

The Cannabis Conundrum

“

n the arena of ‘medical’ marijuana, the evidence available to physicians regarding the safety and effectiveness of cannabis-derived products for treating specific diseases and symptoms is, in general, not of the same caliber as the evidence for drugs which have undergone the process required for approval by the FDA. Research on use of marijuana for medical purposes in the U.S. has been largely stymied by federal policy classifying it as a Schedule I Controlled Substance—in the same class as heroin and other drugs deemed to be highly addictive and having no recognized medical use. Efforts to have this classification reconsidered by the federal government, using an evidence-based analysis, have gone nowhere.

This head-in-the-sand posture ignores current scientific knowledge about how chemical components of marijuana affect various body systems—knowledge that underpins a strong argument for enabling rather than obstructing more research on potential medical uses for these components, referred to as cannabinoids. There are 66 different cannabinoids unique to the cannabis plant. One of this large group, 9-THC, is the one primarily responsible for the ‘high’ associated with smoking marijuana, and several others are psychoactive to a lesser degree. Still other cannabinoids are not psychoactive, and in fact the most abundant of these (CBD) appears to decrease the ‘high’ produced by THC.

“

In a previous editorial I wrote at some length about the importance of trust in the doctor-patient relationship. Trust that the physician will consider the patient’s best interests above all else is the necessary foundation for the therapeutic nature of the relationship. Equally important in maintaining this trust is the perception that the physician is making decisions and recommendations based on expert knowledge. After all, the patient is placing their health, and often their very life, in the doctor’s hands. Those hands better know what they are doing!

Obviously, writing a ‘prescription’ for marijuana is an act far removed from prescribing any FDA-approved medication.

Lucy J. Cairns, MD, Editor 6 | MEDICAL RECORD

In the body, cannabinoid effects are mediated by cellular receptors, of which four subtypes have been identified. The CB1 receptor system is present at high levels in the brain, and at lower levels in the peripheral nervous system and non-nervous tissues. Activation of the CB1 receptors tends to affect mood, memory, cognition, psychomotor performance, appetite, and perception of pain. The CB2 receptor system is found primarily in the immune system. The concentrations of individual cannabinoids present in marijuana vary according to the strain of the plant, growing conditions, and storage conditions. The mix of cannabinoids and other marijuana components actually delivered into a person’s body varies with the method of consumption—via smoking dried leaves, flowers, and seeds or ingesting a food or candy containing marijuana or vaping extracted marijuana oils. Currently, when a Pennsylvania physician prescribes a medication, he or she knows the patient will receive an exact dose of a purified product that has met a standard for safety and effectiveness. While the medical marijuana legislation that has

been introduced in the PA legislature restricts the marijuana available to patients to products to be produced in state-licensed and state-regulated commercial cannabis farms, significant uncertainty will remain as to dosing, safety, and effectiveness. And there is no doubt that when patients are harmed, or perceive they have been harmed, by use of ‘medical’ marijuana, the legal system will be used to try to hold the prescribing physician accountable. Thus, Pennsylvania physicians will face a conundrum if marijuana becomes legal for medical use in the state. On the one hand they will risk federal penalties and real but difficult-to-quantify potential for causing harm to some patients if they prescribe marijuana. On the other hand they will face some patients in their offices who are suffering unrelentingly despite use of currently available treatment, and for whom a marijuana product might well spell relief. The question in my mind is, how can physicians in this situation, with the limitations of current knowledge, honor the trust their patients place in them? The answer, I believe, is to be honest about what is known and not known about marijuana’s place in medicine, and write prescriptions only for those who indicate an understanding of the ‘unknowns’ and a willingness to accept more risk than is generally the case when a physician hands over a prescription.

For more information about the medical conditions that would be approved for treatment with marijuana under the bill currently being considered in Pennsylvania, and for some perspective from other members of the Berks County Medical Society, see my article in this issue.

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President’s Message Kristen Sandel, MD

“It ain’t over ‘til it’s over” – Yogi Berra

ell, we have reached the dog days of summer. Historically, the phrase has been attributed to the Romans, as they associated this time of year with Sirius, the Dog Star, which is the brightest star in Canis Major. In baseball, the dog days refer to the dates between July 3rd and August 11th, the 40 day stretch when both the temperature and humidity are at their peak. It is during this time of the year when things seem to slow down as the newness of spring and early summer turns into the sticky, hot mid-summer that sometimes seems to drag on forever, especially for those who play on the diamond day in and day out.

In the past, the summer months have exhibited limited activity at the Berks County Medical Society. Normally, our Executive Council takes a break from its monthly meetings, as vacations and other obligations take center stage. This year, the game has changed.

with a proclamation from the Pennsylvania Senate honoring his dedication to the BCMS. Obviously, the society will miss Bruce and all of the experience and energy he has brought to his role over the past 27 years. We thank him for his service. Due to Bruce’s retirement, the society has been more active than usual over these dog days of summer. The Personnel Committee has appointed a Search Committee to identify and hire a new Executive Director who will be able to guide us through these difficult and rapidly changing times in medicine. The Search Committee has been actively meeting and we hope to have a director in place by the end of the calendar year. We thank Betsy Ostermiller for all of her efforts as our interim director during this period. A period of transition is always a very difficult and vulnerable time for any organization, but we are hoping to make this one as smooth as possible for everyone, especially our members. While we, as a county society, are in a state of flux, the changes in the landscape of medicine both at a local and national level are vast and ongoing. We have seen ICD-10 delayed, once again, this time until 2015, and the SGR has not been fully resolved, but patched for yet another year. We continue to be challenged with scope of practice issues, and we have just begun to see the impact of the Affordable Care Act on our practices and on our patients. Our leaders at the county and state level continue to work diligently with legislators and hospital officials on multiple levels to improve the practice environments in Berks County for our physicians, and improve the quality of care for our patients.

Dr. Michael Baxter, Bruce Weidman and Crystal Weidman On June 5th, the society held a celebration for Bruce Weidman, our Executive Director, who retired after 27 years of service to BCMS. There were many guests from both the county and state society present to honor Bruce and wish him well as he enters into retirement and is able to spend more time with his family. Senator Judy Schwank was also on hand to present him 8 | MEDICAL RECORD

There are so many moving parts to the practice of medicine at this time that it would be difficult to call these the dog days of summer, at least when speaking about health care. We will not give up on any of these fronts in order to ensure we are sufficiently advocating for the physicians and patients of Berks County. I would be hard pressed to use multiple quotes from baseball over this past year without quoting the great Yogi Berra…”It ain’t over ‘til it’s over!”

Foundation Update From my viewpoint:

Medical Marijuana

By Jon Shapiro, MD, Physicians Health Programs Medical Director

recent trip to the Federation of State Physician Health Programs Annual Conference, in Denver, highlighted some of the controversy surrounding the legalization of marijuana. It has raised several complex issues. I endorse the American Society of Addiction Medicine policy on medical marijuana. Marijuana is not a standardized product. It has not been adequately studied as a treatment for the many indications for which it is recommended. Also smoking is an unhealthy delivery system. In states with medical marijuana physicians do not prescribe it in a specific fashion but rather give the patients a certificate which allows them to use any dose they choose.

There is some consensus in the medical field that marijuana is not good for growing brains. Studies have suggested stunted intellect and emotional growth in young people who use large amounts of marijuana on a regular basis. The use of cannabis similar to the use of alcohol should be restricted to adults. The safe operation of motor vehicles is extremely important. Mothers Against Drunk Driving has been an exceptionally influential and informative group-no doubt saving countless lives on our highways. The correlation between blood THC level (the active chemical fraction of marijuana) and performance is quite complex. It is difficult to set a safe level of THC for driving or other critical functions.

In the addiction field we frequently refer to the common final chemical nature pathway of a variety of substances in the brain. People in recovery are advised to avoid all mood altering substances including marijuana to avoid triggering urges and relapse. Never forget the law of unintended consequences. Colorado is reporting an increase in THC poisoning. The new marijuana is much stronger than the classic weed of the 19 70s so adults are showing up in emergency rooms with anxiety and other symptoms of overdose. There is also concern that candy and pastries laced with THC could be eaten accidentally by children. Research with airline pilots has demonstrated that marijuana can reduce performance. Importantly test pilots were unaware of their own temporary impairment. Until safe levels of marijuana usage are determined its use must be prohibited in people in critical positions. A zero tolerance policy should be advocated for transportation workers and health care workers. What is at issue for us here is not the public policy of legalization of marijuana but rather maintenance of public safety. Marijuana use should be disallowed for young people, for recovering addicts and for those in whom we entrust our lives.

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SUMMER

2014

Big Name Hunting

Collecting Medical Autographs By Barton Smith, MD

he greatest reward of a career in medicine is undoubtedly the privilege of caring for patients, and often being able to help them. But from the time we enter med school we are exposed to great mentors, and we learn about the giants of practice and medical research who built the fund of medical knowledge that allows us to help patients. Some, like Freud or Roentgen are known to most, others such as Laennec or Virchow mostly to those of us in the profession. If we “stand on the shoulders of the giants who teach us”, we can also hold examples of their handwritten documents in our hands. Collecting memorabilia of those you admire is not so difficult or expensive if they are alive and communicating, but more difficult and expensive if they “are no longer signing”, as is said in the autograph world about the dead.

The spring 2014 issue of The Historical Review of Berks County, the periodical of the Berks History Center, contains my article on collecting historical autographs, in which I give an overview of the collecting process. This Medical Record article will be mainly an exercise in “dropping names”, perhaps stirring your interest in getting close to medical history. I was 15 years out of medical school when I became seriously interested in this hobby. When I began collecting, I reflected on the number of famous medical personalities I had missed, such as the great cytologist George Papanicolaou who still had a lab at Cornell when I began school. It would be interesting to have a signed reprint of one of his articles on the “Pap Test”, but I’ve never seen anything by him on the market, and no one at Cornell Medical College can find an example of his hand writing for me. For now, I will settle on the unsigned Greek currency note with his image, even that having been replaced in Greece by the impersonal Euro.

10 | MEDICAL RECORD

The Biochemistry Professor at Cornell was Vincent DuVigneaud, Nobel Laureate in 1955 for his work synthesizing the poly peptide hormone oxytocin. Years later I lamented not having his autograph until finding in my files 2 applications for summer grants to work in his department, documents now with an honored spot in my collection. I did miss getting the Nobel winners Dickenson Richards and Andre Cournand, awarded the Prize in 1956 along with the German physician Werner Forssmann for work on cardiac catheterization; Richards and Cournand were still at Bellevue Hospital when I was a medical resident there.

In person autographs are gratifying to the collector because they usually don’t cost anything and they are surely authentic. If you can anticipate being in a position to get one, it’s good to have an article or photo to get signed, then hope you get a legible, complete, ink signature. It’s not particularly desirable to have it personalized, unless, of course, you can get a pithy statement written with it. An ‘in person” example from my collection is illustrated at the top of this article. I am holding a program from a medical conference at Mt. Sinai Hospital in Manhattan celebrating the 50th anniversary of the description of Crohn’s disease. In the last minutes of the conference Burrill Crohn appeared at the back of the auditorium, 98 years old and alert, but in a wheel chair. Seated nearby, I approached him as the conference ended, shook hands, and had him sign the program. (His signature is more legible than most younger MDs.) I saw one other attendee get his program signed by Crohn. The Crohns-Colitis foundation was going to publish a Crohn signed book on the disease as a fund raiser, but Crohn died at age 99 before it was ready.

It’s especially gratifying to obtain an autograph before the signer achieves wide-spread fame. Being a gastroenterologist, I was well aware of the importance of the discovery of Helicobacter pylori, so when I attended a conference in Philadelphia where Dr. Barry Marshall was a participant, I was able to get him to sign his article about the bacterium a few years before Marshall won the Nobel Prize. In recent years physicians seem more active on the political scene, a recent example being the cardiac surgeon William Frist, a leader of the US Senate a few years ago. Currently 3 MDs are Senators, Rand Paul, Thomas Coburn, and Richard Burr. They are surely more approachable now than if one of them should become President, for example; if you chance to get their autograph try to get one for me too. Other physicians have become famous for reasons other than their medical

Barton Smith, MD holding a program for the Symposium celebrating the 50th anniversary of the description of Crohn’s Disease. Crohn died at age 99 less than a year after signing. Photo Credit: Bill Uhrich of the Reading Eagle

ABOVE: Sigmund Freud - A printed card of thanks sent to an unknown person who had sent Freud greetings on his 80th birthday. Many of these cards are known, but not with Freud’s written comment “don’t wish me too many more”, which might be considered a death wish. LEFT: Rene Laennec - A document of completion of a course of study signed by the inventor of the stethoscope, an exceptional clinician.

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career, and make nice additions to a medical collection. Some examples would be the Russian composer Borodin (also a great advocate for women’s rights, founder of the St.Petersburg Woman’s Medical College), pediatrician and poet William Carlos Williams, and Roger Bannister the first man to run the mile in less than 4 minutes and later a prominent neurologist.(Bottom Right Opposite Page)

TOP: Rudolf Virchow - An autograph letter written and signed by the great pathologist, founder of cellular pathology, the first to recognize leukemia and the describer of the phenomenon of pulmonary embolism. BOTTOM: Wilhelm Roentgen - A social letter written and signed by the discoverer of x-rays, who received a Nobel Prize for his work in 1901, the first years the awards were given.

Famous patients are fair game also, best if you are tactful and have a personal relationship with them. During my time on the staff of The Reading Hospital the boxers Kid Gavilan and Muhammad Ali passed through, the late great band leader Stan Kenton spent some weeks on Dr. Herbert Johnson’s service after Kenton’s mugging in the garage of the Hotel Abraham Lincoln. I did shake hands with Kid Gavilan and told him I admired his famous “Bolo Punch”, I never saw Ali, and although I often said “Hi” to Kenton when he was being walked in the hallway of A4, no autographs resulted, but in fact Kenton didn’t know his name for most of his stay after the concussion.

On the other hand, as a medical resident I did help care for Alfred Sloan, Jr. one of the founders of General Motors, and great benefactor of the Memorial Sloan Kettering Medical Center where he was hospitalized. He was admitted for a relatively minor infection, and then had a prolonged stay because his house keeper decided while he wasn’t in the way his condo needed redecorating. Seeing him daily, I had time to chat a bit, and dropped some broad hints about my desire to read Sloan’s book My Years With General Motors. The hints fell on deaf ears, literally and figuratively, so when his discharge appeared imminent, I bought a paper back edition and got a very nice signature. In about 5 years the cheap paper of that edition was very fragile, so I sold it to an autograph dealer for $25. If I had splurged for the hard cover edition it might be worth $100 today. In my article for the Berks History Center magazine I mention some of the perils of buying autograph material. Briefly, I suggest joining The Manuscript Society (www.manuscriptsociety.org) and buying from dealers who belong to the Professional Autograph Dealers Association (www.PADA.org). If you do buy the expensive “big names” you should also know how to care for the documents, protecting them from light, water, and temperature extremes.

I have found collecting autographs and manuscripts a stimulating hobby, one which gives a great appreciation for history, and one leading to encounters not only with the famous, but with other collectors, dealers, historians, and archivists who have often become intellectually stimulating friends. In the final analysis, the manuscript itself, although treasured, takes second place to the knowledge gained and friends made.

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Medical Perspectives on Medical Marijuana By Lucy J. Cairns, MD

Several factors have recently converged to make passage of a medical marijuana law in Pennsylvania a distinct possibility. First, public opinion in the state is now overwhelmingly in favor of legalizing marijuana (cannabis sativa) for medical use. Results of a Franklin and Marshall College poll in February 2013 indicated that 82% of Pennsylvanians favored allowing adults to use marijuana for medical purposes if recommended by a doctor. On March 3, 2014 a Quinnipiac University poll showed support in Pennsylvania at 85%. When analyzed by age, gender, and political orientation groups, a minimum of 78% in each group supported medical marijuana. Editorials urging the passage of a medical marijuana law recently appeared in major news outlets in Harrisburg’s PennLive/Patriot News (April 11) and Pottstown’s The Mercury (May 13).

he second key factor is development of bipartisan support for such a law in the state legislature. Senator Mike Folmer (R-Lebanon) is a prime sponsor of SB 1182, titled the Governor Raymond Shafer Compassionate Use of Medical Cannabis Act. The other sponsors at the time of this writing include one other Republican senator and nine Democrats (among whom is Senator Judy Schwank). In the House, Rep. Jim Cox (R-Berks) will shortly be introducing HB 2182, which will be similar to the Senate bill but with updated language based on discussions with the Senate. Sen. Folmer and Rep. Cox are both motivated by a desire to alleviate suffering on the part of patients with symptoms that cannot be relieved with currently available treatments. In response to a request for comments for this article, Sen. Folmer provided a statement which included the following: “While the Pennsylvania Medical Society would like to wait for federal approval, there are Pennsylvania patients suffering and leaving Pennsylvania to seek medical treatment. … Senate Bill 1182 will provide safe access to patients in a medical environment.” Rep. Cox explained his involvement in this effort by saying, in part, “I feel that it is our responsibility to 14 | MEDICAL RECORD

address this as a means to help patients who are suffering with ailments whose symptoms cannot be relieved with conventional medications. I feel that it is imperative that we move forward with the input and expertise of the medical community.” (private communication). The third factor making a medical marijuana law more likely in Pennsylvania’s near future is Governor Corbett’s low approval rating. Governor Corbett does not support access to medical marijuana beyond a very limited program proposed to benefit a small number of children with a severe seizure disorder. If he is replaced by Democratic challenger Tom Wolf after this year’s election, Pennsylvania will have a Governor who has come out in support of a much broader medical marijuana law. Thus, a high percentage of Pennsylvanians would trust their doctors to prescribe marijuana for medical conditions, and momentum is building to pass legislation which would allow such prescriptions to be written. How does this issue look from the other side of the prescription pad—to the physicians who would be faced with implementing such a law? By an act of Congress-- the Controlled Substances Act of 1970--marijuana

was placed in the same category of drugs (Schedule I) as heroin: drugs with very high potential for abuse and addiction and no currently accepted medical use. In contrast, cocaine and methamphetamine were placed in Schedule II, considered to have less potential for abuse and dependency than Schedule I drugs and known to have accepted medical use. As long as this classification remains in effect, any physician who writes a prescription for marijuana risks federal prosecution and puts their career in jeopardy. In addition, this classification has been an almost insurmountable hurdle to performing research on the potential medical benefits of products derived from cannabis. Therefore, the evidence available to physicians on the safety and efficacy of medical marijuana products does not in most cases rise to the level of that available for drugs which have been approved by the FDA based on clinical trials. Nevertheless, many physicians and other healthcare providers in states with medical marijuana laws do write prescriptions. The reasons likely include the limitations of conventional medical treatments in alleviating suffering and treating certain diseases, the availability of some evidence for a beneficial effect from use of cannabis in certain conditions, and the perception that cannabis is a relatively safe drug compared to many FDA-approved medications. In the interest of increasing public awareness of physician perspectives on this issue, and of stimulating involvement of the medical community in the shaping of public policy, a number of Berks County physicians were presented with the following summary of some of the most salient provisions of SB 1182 (as of mid-June) and asked for their comments:

Provisions of Senate Bill 1182

Would legalize prescription of medical marijuana products for a “debilitating medical condition” to include any of the following: 1. Cancer or the treatment of cancer 2. Glaucoma or the treatment of glaucoma 3. Post-traumatic stress disorder or the treatment of post-traumatic stress disorder 4. Positive status for human immunodeficiency virus, AIDS, or the treatment of either HIV or AIDS 5. A chronic attenuating disease or medical condition or its treatment that produces one or more of the following: cachexia or wasting syndrome; severe or chronic pain; severe nausea; seizures, including seizures characteristic of epilepsy; severe and persistent muscle spasms, including spasms characteristic of multiple sclerosis or Crohn’s disease; intractable pain; any other medical condition or its treatment that is recognized by licensed medical authorities attending to a patient as being treatable with cannabis in a manner that is superior to its treatment without cannabis.

The marijuana products that would be licensed for production: cannabis flower (i.e. dried leaves, flowers, and seeds) and cannabis concentrate (i.e. extracted oil). Patients with a valid ‘medical cannabis identification card’ could legally possess up to one ounce of cannabis flower or up to 3 ounces of cannabis concentrate. The ID cards would be issued by a Medical Cannabis Board upon review of specified documentation from the patient and the prescribing medical professional. “Medical Professionals” include: a physician, registered nurse practitioner, dentist, physician assistant, nurse midwife, psychiatrist, or other professional who is licensed under the laws of this Commonwealth and is permitted to prescribe Schedule III medication under the Controlled Substance, Drug Device, and Cosmetic Act.

The following comments were submitted by Berks County doctors:

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

It is well known among pain management physicians that there are few good options to treat nerve dysfunction (neuropathic) pain. We often end up empirically trying opioids for lack of a better option, which poses significant risk to patients. Add in the prescription drug abuse epidemic that this country faces and anyone can easily understand why pain management physicians are so eager to explore non-opioid alternatives when treating patients suffering with neuropathic pain. The relevant literature suggests that cannabis can prove more effective in treating neuropathic pain than using higher dose opioids - all while incrementally decreasing the risk posed to patients. Therefore, I am cautiously optimistic that cannibinoid products may help a certain subset of appropriately selected chronic pain patients.

The fact that the federal drug enforcement agency (DEA) still lists cannabis as a schedule I substance (i.e. no accepted medical use / high abuse potential) troubles me though. Assuming Pennsylvania Senate Bill 1182 passes, I plan to educate myself more on the subject, focus on best practice consensus guidelines and be guided by the anesthesiology adage... start low and go slow... in my practice and for each patient that may receive a cannabis prescription with my DEA number on it.

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‘There are probably as many physician opinions on this subject as there are physicians in Berks County, but all share the core principles which guide the decision-making of ethical physicians.’

Elliot B. Werner, M.D. (Eye Consultants of Pennsylvania, Glaucoma Specialist)

In response to your questions: 1. How likely to prescribe medical marijuana? Moderately likely for selected patients. I would get legal advice before prescribing. I would also need to know details about dosage and consistency, delivery systems and manufacture and quality control. 2. In favor of expanded research? Yes. We need good randomized clinical trials. 3. How might availability of medical marijuana affect the care I provide? I would need to watch carefully for side effects, particularly on older patients who constitute the bulk of any glaucoma practice.

Diane T. Bonaccorsi, M.D. (Green Hills Family Medicine Associates)

1) If marijuana remained Schedule I, I would be unable to prescribe it because schedule 1 drugs can only be used for research with a dedicated license. As you are aware, Schedule I drugs are thought to have no current accepted medical use. That being said, I believe this is an unjustified and antiquated designation. Marijuana is currently being studied for multiple medicinal uses, from multiple sclerosis , glaucoma, ALS, fibromyalgia and depression to cancer, seizure disorders and many more. It has been a help to patients with chronic pain. I would prescribe it to appropriate patients if it were Schedule II or less. 2) I would absolutely support more research regarding the medical use of marijuana. 3) I would have no problem with a specialist prescribing medical marijuana to one of my patients for appropriate reasons- say an oncologist or pain management physician for pain or an ophthalmologist for glaucoma. It is pretty well known that marijuana is less addictive than heroin, cocaine, caffeine, alcohol and tobacco. So why isn’t tobacco a schedule I drug? It fits the criteria of no accepted medical use has a high abuse potential with risk of severe psychological and physical dependence. I believe marijuana is unjustly labeled and should be decriminalized for medicinal use by qualified, licensed medical providers. It is known that 80% of Americans support the use of medical marijuana.

16 | MEDICAL RECORD

Daniel A. Forman, D.O. (RHPN-Hematology/Oncology)

To be honest, I feel that medical practitioners are being used by those with social and economic agendas to help legalize this substance. Also, if marijuana is legalized for “Medical Purposes,” it sends the incorrect message that this drug actually has medicinal value, and may be “good for you.” From a medical perspective, legalizing marijuana prior to having the drug proven to be safe and effective for the indications for which it is being promoted is working backwards compared to the usual regulatory process. Marijuana should undergo the same scrutiny that other drugs go through prior to being allowed to be sold to consumers. Last year I reviewed some articles on medical marijuana for a Palliative Care journal club. What struck me regarding the evidence reviewed in those articles is that marijuana, and oral cannabinoids, seem to be only modestly beneficial compared to placebo, and not really “better” than some of the older drugs, when used for nausea and vomiting. The majority of patients who received oral cannabinoids in these studies suffered from significant side effects, particularly sedation. Fatigue is a common disabling side effect of cancer treatments, and a concern to our patients, so we generally try to avoid medications that cause such. Our goal as oncologists is to allow our patients to be active and productive, and we like their downtime to be minimal. Prescribing a medication that causes fatigue, difficulty concentrating, and severe dry mouth is working contrary to these goals. It is unusual for one to suffer from nausea or vomiting associated with chemotherapy in 2014, given the potency and efficacy of our modern anti-emetics. As an oncologist, I can see a very narrow niche for this agent in the rare patient who has neuropathic pain or anorexia not aided with currently available medications. The patient would have to accept the significant side effects known to this class of drugs, alluded to above. Whether marijuana for social use should be legal or not is the real discourse that we should be having. Taxation, safety while driving, the potential for addiction, and the possibility of it being a “gateway drug” are the some of the issues that I am sure will never be agreed upon. As a physician, I am concerned that patients with chronic pain, many of whom are already drug-dependent, will begin to use another class of potentially addicting drugs with overlapping side effects.

I am also concerned about the fact that smoked marijuana has risks similar to those of inhaled tobacco, namely premature heart disease and cancer of the upper aero-digestive tract. As a parent, I am concerned that the increased availability and permissiveness of this addicting substance will encourage use among teenagers and young adults, who are at increased risk for abuse and addiction as compared to older adults. There are probably as many physician opinions on this subject as there are physicians in Berks County, but all share the core principles which guide the decision-making of ethical physicians. The maxim to “first, do no harm” is inculcated into every medical student, and no drug prescription is written without a calculation of the risk of an adverse reaction relative to the risk of alternative treatments or no treatment for the problem at hand. This is difficult enough when evidence from well-designed long-term clinical trials is available. For at least some of the symptoms or disorders listed in SB 1182, the quality of available evidence is so poor that this calculation would better be characterized as a guess. Further uncertainty is injected into this calculation by the fact that cannabis contains more than 400 chemicals from 18 chemical families, and that more than 2000 chemical compounds are released when it is smoked. When you throw in the availability of different strains of cannabis, each with a different chemical profile, the reluctance of many physicians to prescribe “marijuana” without more research seems the only responsible position.

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However, another core principle of medical practice is to use one’s knowledge and skills to alleviate suffering. Indeed, the desire to relieve suffering is one of the most common motivations for pursuing a medical career. Unfortunately, almost all physicians have the experience of caring for patients with debilitating conditions which cannot be effectively treated with currently available medication (or other treatment modalities). If a medical marijuana law is enacted in Pennsylvania, physicians will have another treatment option which is likely to benefit some of these patients, with risks that seem to be no higher, and in some cases lower, than risks posed by a number of commonlyprescribed drugs. For further reading:

Marijuana and Medicine: Assessing the Science Base (Institute of Medicine Report released 04/07/2003)

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Smoke Signals: A Social History of Marijuana—Medical, Recreational and Scientific. Martin A. Lee (c. 2012) Marijuana Policy Project at www.mpp.org

www.pamedsoc.org/medmarijuana to read testimony provided by PAMED at the Jan. 28, 2014 hearing on SB 1182 held by the Senate Law and Justice Committee, and to hear a media call-in hosted by PAMED the same day featuring several PA physicians. Note: Thanks for Sara Braun Radaoui (Communications major at Penn State U.) for help researching for this article.

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2014

Conversation Project By Dan Kimball, M.D.

f you are among those who have not yet started ‘the conversation’ about your end of life wishes with your loved ones, you have lots of company—namely, over 70% of your fellow Americans. The Conversation Project (TCP) is a national grassroots education program designed to facilitate this conversation. It was founded in 2010 by Ms. Ellen Goodman, and came under the auspices of the Institute for Healthcare Improvement in 2011. TCP is a source of tools individuals can use, and I recommend that physicians consider using these tools themselves and in their work caring for patients. Advance care planning is appropriate for all adults, not just those who have attained a certain age, since a medical crisis requiring important decisions about our health care can occur at any time. Therefore, now is the time to clarify and communicate the kind of care we want, and don’t want—how we want to live at the end of our lives. The issues involved are many, and our feelings are likely to change over time, so we are really talking about a series of conversations rather than a single one.

There are many potential barriers to having these important conversations. It is scary to have these conversations -- they are personally uncomfortable and may cause certain strong emotions. These conversations may identify family conflicts that are difficult to resolve. We don’t get to practice these conversations. As physicians, we all can recognize that it is difficult to make decisions about when to stop current treatments or to change treatment decisions. These conversations are difficult to initiate. Having these conversations takes time and patience, commodities which are scarce in modern medical practice. While surveys of the public indicate a great interest and willingness on the part of individuals to have these conversations with their physicians, and to document end-of-life wishes, very few have actually done so. 18 | MEDICAL RECORD

TCP provides tools for use by you and your patients in reflecting on and making explicit the personal values that drive end-of-life care decisions. All of us need to think about whether we value quality of life over quantity of life; how much involvement we want to have in the health care decisions affecting us individually, how much involvement we want our families to have, and who would be best to serve as a substitute decision -maker in situations where we are not capable of making decisions for ourselves. These decisions, to a large extent, represent value judgments, with no “right” or “wrong” answers. Having assessed one’s own values, then one is prepared to decide which values are most important, and which potential decisions these value judgments inform. One may then be able to complete a statement like “The three most important values for me which might impact end-of-life decision making for me are ___________, ___________, and _________. Examples for me are (1) Quality over quantity of life, (2) comfort and (3) I don’t want to be alone.

Having done this type of values self-assessment, the next important question might be, with whom do I want to have this conversation? For many of us it might be our spouse or partner, or a son, daughter, parent, principal spiritual leader, or our physician. Your thought process might be: with whom is it safe to have this scary conversation? Potentially, who do I think might be a good person to be a substitute decision- maker for me if I were incapacitated? Many of us might automatically think of a spouse or partner, but that individual may or may not be the best choice. That individual might not want to have to make those types of difficult decisions. Better to find that out now rather than in the middle of a medical crisis. If one turns to children to make those decisions, is one child better positioned to make those tough decisions than another child? Are there family issues related to sibling decision- making that need to be considered?

Having decided with whom to have an initial conversation, consider when is the best time to have the conversation and where should it be held. The timing of the conversation might be driven by a changing medical condition, or at the time of a holiday or planned family gathering, or just before the kids go off to college. Ideally, it will be a time when there will be no interruptions or distractions, and when you will not be pressured by a time limit. Ellen Goodman talks about a “virtual kitchen table” as the place to have the conversation. That might indeed be at the time of a relaxed meal, or it might be on a nice long walk or drive in the car, sitting at a favorite place in the park, or at a favorite restaurant. Your family may have a tradition for the best place to have such difficult conversations. So, having decided on these important elements, how do you want to introduce this tough conversation, and what exactly do you want to say? The TCP gives several suggestions for initiating the conversation, but it is important for you to convey that this is an important issue for you, that you want to share your thoughts and hear the reaction of the listener to your ideas. Perhaps they have given the same issues some thought and would be willing to share those thoughts with you. Perhaps you can remember a death in the family that you would characterize as being a “good death” or a “bad death,” and can share that you wish your death to be like that experience or not like that experience, and invite your listener’s thoughts on that judgment. This might be the time to mention the three most important values that you identified after your values self-assessment process. This might be the time to share any specific health concerns that you have for yourself, any thoughts you have about the selection of a surrogate decision maker or healthcare agent, or any family tensions or disagreements that may come to play in such decision making. Are there circumstances that you would consider to be worse than death? Are there important milestones that you wish to meet, if possible? Where would you prefer to receive care: at home or elsewhere? What type of intensive treatment would you want to receive or not receive? When would it be important to you that the focus of care would shift from a curative attempt to a goal of comfort? What affairs do you need to get in order or discuss with family members or significant others? These are not the only issues that need to be discussed, but they represent a reasonable beginning. TCP provides some helpful tips about this conversation. Be patient! Not everything will necessarily be decided in one conversation; this may be the first of many conversations. Don’t judge! A good death does not mean the same thing to everyone. Don’t steer the conversation, just let it happen. Nothing is set in stone! You and your loved ones can change these decisions as circumstances change. Every attempt at conversation is valuable.

TCP notes, “Each conversation will empower you and your loved ones. You are getting ready to help each other live and die in way that you choose!” Take some time after the initial conversation to reflect on the experience. Was there anything said in that conversation that needs further discussion or clarification? Where there people not in attendance who need to attend the next conversation, like siblings who never agree on anything? What do you want to cover in the next conversation that was not covered in the prior conversation?

Please go to the Convers ation Project www. theco website at nversationp roject.org an the very info d read some o rmative stori f es about peo had the conve p le who never rsation, as w ell as about have had the those who conversatio n . Another pote resource is at ntial useful the “My Gift of Grace” web mygiftofgrace si te at www. .com which offers additio useful questi n al tools with ons for discu ssion on thes e types of is sues.

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SUMMER

2014

Office Management Update

Job Descriptions could be your “weak link” in the hiring process! By Jessica Dean, Employee Benefit Consultant, Power Kunkle Benefits Consulting

recent article on SHRM.org indicates that job descriptions can be so out-of-date or poorly written (or even nonexistent!) that they fail to attract top talent, curb employee development, and even reduce retention of high-potential employees. Not all employers have recognized the importance or need for a well-crafted job description. A job description not only is exclusive to the need for the job vacancy posting, it is a communication tool that clearly defines what you need to hire and also to retain those top employees at point of hire and beyond. They play an important role in onboarding, compensation, skills development, career planning and performance management.

Having an accurate job description creates a concrete set of expectations for the employer to communicate to the employee. The employee is aware of his/her responsibilities as outlined in the job description, so there is less confusion as to job expectations. It can also serve as an evaluation tool for employers to measure job performance based on pre-defined job duties.

Perhaps most importantly, accurate and up-to-date job descriptions will limit company liability. Poorly written job descriptions have been successfully used by employees against former employers in recent litigation. Job descriptions that have been carefully and thoughtfully prepared will also help employers when dealing with worker’s compensation cases and return-to-work scenarios. Medical providers have a better understanding of what employees are required to do so that they can manage the employee’s return-to-work in a more productive and efficient way. 20 | MEDICAL RECORD

reparing good job descriptions often start with a job analysis of the position. The manager may be interviewed as well as current incumbents. A job analysis includes: • Job responsibilities of current employees • Analysis of duties, tasks and responsibilities that need to be accomplished by whomever fills the position • Research of other companies who have similar jobs Once enough information has been obtained, write a thorough, detailed job description. Components of a job description are: • Succinct and accurate job title • Overall position description or summary (include three most important responsibilities) • Essential functions or responsibilities (no more than seven) • Required knowledge, skills and abilities • Required education and experience • Description of the physical demands • Description of the work environment Common mistakes when writing or updating job descriptions: • Poorly crafted job title (It shouldn’t read like an obituary) • Not making obvious what the position entails • Too much text (Is it clear? Is it specific? Is it appealing?) • Too many tasks (should be saved for a procedural manual) • Failure to focus on core competencies (different than skills or qualifications) • Failure or fear to update (job descriptions should be reviewed for accuracy once per year) • Failure to be accurate for physical demands of position

Think of your job description as your next job ad! You want to be able to show candidates your commitment to the culture of your organization and the importance of this recruitment tool. If it is an applicant’s first contact with you, you want it to be favorable. It should be clear, concise and searchable given the upswing in the use of hand-held devices by job seekers.

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Alliance Update Welcome to our 2014-2015 Executive Board

Our Installation Luncheon was held at the Berkshire Country Club on May 8, 2014. We were honored to have Cindy Richards, Pennsylvania Medical Society Alliance President and Kathleen Hall, Pennsylvania Medical Society Alliance South Central Region Director join us and perform the installation of our officers. The 20142015 Officers that were installed at this time were Lindsay Romeo, President; Amy Impellizeri, Vice-President of Health Project; Allison Wilson, Vice-President of Membership; Kara DeJohn, Treasurer; Amanda Abboud, Assistant Treasurer; Meghan White, Recording Secretary; Jacquie Fernandez, Corresponding Secretary; Emily Bundy and Kathy Rogers, Directors. Finally, on behalf of the BCMSA, we would like to say “Congratulations” to Bruce Weidman, Executive Director of the Berks County Medical Society, on his retirement this past June. Bruce has not only been a friendly face at the BCMS office, but he has also been a wonderful supporter of the Alliance and our endeavors. We wish him a fantastic and relaxing retirement, and thank him for his years of service and support!

Scholarships and Philanthropy

Thank you members of the BCMS and BCMSA for your generous donations to our Holiday Card fundraiser this year! We raised $12, 945 this year which has allowed us to provide six $1000 scholarships to individuals studying a health-related field in Berks County. Additionally, we were able to provide donations to the following organizations in our community: Breast Cancer Support Services, The Children’s Home of Reading, Aaron’s Acres, Girls on the Run, Berks Women in Crisis Camp Peaceworks, IMABLE Foundation, Mifflin County Library, and the Western Berks Free Medical Clinic. These organizations do so much for our community that we are pleased to be able to help support their efforts.

Spring General Meeting

Thank you to our speaker, Dr. Lucy Cairns, who shared the history of Hawk Mountain Sanctuary. Her presentation was an interesting account of the life and work of conservation activist Rosalie Edge, including her purchase of the land for Hawk Mountain Sanctuary in 1934. This purchase provided protection for the hawks and eagles that had previously been slaughtered along this portion of the Appalachian Mountains. Today the Sanctuary is a beautiful place to observe the wonders of these magnificent birds in the wild. As President-Elect of the Berks County Medical Society Alliance, Dr. Cairns is organizing a joint-outing for members of the BCMS and BCMSA and their families. Look for more information about this outing to Hawk Mountain Sanctuary in September! Thank you to Lisa Banco for hosting our Spring meeting, and to our members who donated items to the Nurse-Family Partnership. Back Row: Pam Charendoff, Lindsay Romeo, Amy Impellizzeri, Jacquie Fernandez, Kathleen Hall, Lisa Banco, Diana Kleiner, Allison Wilson, Kathy Rogers, Jill Haas, Jody Menon, Gretchen Platt. Front Row: Amanda Abboud, Cindy Richards, Kalpa Solanki, Sue Russo, Emily Bundy, Carol Perlmutter, Lisa Geyer.

22 | MEDICAL RECORD

TOP PHOTO: Incoming Officers 2014-2015: Lindsay Romeo, Kathy Rogers, Meghan White, Amanda Abboud, Allison Wilson, Amy Impellizzeri, Jacquie Fernandez, Emily Bundy

Annual Health Project

The BCMSA presented “Cyberbullying and Social Media: Implications in School and Your Community” on April 10, 2014. It was attended by approximately fifty people including nurses and educators who were able to receive continuing education credits for attending the program. Speakers included Robert Heiden and Heather Calabria, Detectives with the Berks County District Attorney’s Office, and Josh Ditsky, M. Ed, Director of College Counseling at Berks Catholic High School. The speakers provided an overview of social media sites, the dangers that are associated with today’s media sites and the internet, and fantastic tips on how to carefully use these media sites and potentially avoid possible problems. It was sobering to hear how easily predators can gather information and that there have been local cases involving on-line predators, as well as cases of cyberbullying that had tragic effects. This program was a fantastic way to provide important safety information about a serious issue to our community. Thank you Kalpa Solanki and the Health Project team for another excellent program!

Physicians Honored at Doctor’s Grove Ceremony

The Doctor’s Grove Ceremony and luncheon was held on Friday, April 25, 2014 at the Berks County Heritage Center. Here are the names of those who were honored this year: • Armin B. A. Rhauda, M.D., given in loving memory by his wife Patricia Rhauda, M.D. • John M. Penta, M.D., given in honor of by Ruth E. Penta • Ross L. Wademan, M.D., given in honor of by Marilyn A. Wademan and Family • Larry A. Rotenberg, M.D., given in honor of by his loving family- Alison, David, Jonathan, and Leah Beth • Robert R. Schweizer, M.D., given in loving memory by his wife Kathryn M. Schweizer Again there was a nice turnout this year of Alliance members and families who wished to honor or remember physicians in our community. Thank you to the Berks County Medical Society for providing the catering for this event!

SUMMER

2014

Do I Really Want To Work For These People ? By Bruce Weidman

suppose that twenty-seven years in the same job is a long time to most people, but as we get older and reflect back on a life well spent, "time goes by in the blink of an eye". When I accepted the position as Executive Director of the Berks County Medical Society, I never expected it to me by life's career. I took one day at a time, enjoying what I was doing, and never gave a thought to leaving. Therefore, I feel blessed in so very many ways, not only for the job which has always been both interesting, challenging, and different every day, but for the blessing of meeting, working with, and knowing on a personal level wonderful people. I've worked for twenty-eight presidents with twenty-eight different personalities. That in itself has made the job both interesting and challenging. I am grateful to have worked for very bright physicians. I love their self-assured confidence and courage in taking care of people when they are ill. I've always said that the practice of medicine is the world's second oldest profession. It is second only to the world's oldest profession where folks were having health problems and needed doctors to make them better. I would like to take you back briefly to 1987 when your county medical society was an entirely different "kettle of fish". I will never forget that fateful Thursday night in April 1987 when I was called to interview for the position of executive director. I arrived promptly before the appointed time, as I am always early for everything...just ask my wife. The interview was held at Medical Hall on Walnut Street in downtown Reading. When I walked in, the search committee members had arranged their chairs in the shape of a U, and there was a single chair inside the center of that U. Dr. Stolz, BCMS president at that time and chair of the search committee told me to be seated in that single chair which he referred to as the "Hot Seat". The committee then proceeded to ask me a series of questions which I felt comfortable answering. I later learned there were fifty applicants for the position and ten of those applicants were invited to be interviewed. I was pleased to make the final cut, and was offered the position. My only reservation was, did I really want to work for people who put applicants in the "hot seat"? Talk about being intimidated! I had to ask myself again, "Do I really want to work for these people; I mean really"?

The second nostalgic memory is how the society was functioning back in 1987. The word to describe it was dysfunctional. BCMS was offering CME programs the first three Wednesdays of every month, but the topics were driven by the pharmaceutical companies, and most of the audience was retired physicians. I remember one physician who attended every Wednesday who smoked cigarettes at the back of the auditorium throughout the 24 | MEDICAL RECORD

entire program, and thus, we referred to him as "The Smoker". We had another physician who paced constantly at the back of the auditorium during the program, and he was known as "The Pacer". Then there was a third physician who was not a member, so she always sat on the sofa in the lobby and listened to the lectures form there. I guess since she was a non-member, she thought she was not entitled to sit in the auditorium. I also might mention that this woman had a special affinity for cats, so each week she wore a different sweatshirt with a photo of a cat on the front. Thus, she became known as "The Cat Doctor".

There is one other aspect of these early CME programs that stands out vividly in my mind: the food. You see, possibly as a cost-cutting measure, the caterer provided food that was left over from wedding receptions from the previous Saturdays. Jumbo shrimp cocktail and cheese cake was typical fare for those Wednesday CME's. After several months of those experiences, I once again said to myself, "Do I really want to work for these people?" So what changed? Well, fast forward a couple of years to the time when the Society went through some major changes. Dr. Jonathan Stolz and Dr. Richard Bell, my first two presidents, attended a PAMED Leadership Conference in the spring of 1987. They both went to a lecture at the conference entitled, "What Makes a Successful County Medical Society?". Roger Mecum, then Executive Director of the Wayne County Medical Society, was the speaker for that seminar. Doctors Stolz and Bell came back from that conference fired up to reinvent the BCMS, and the first part of that reinvention was hiring me. You can see they were risk takers!

Over the past twenty-five years BCMS has gone through many dynamic changes thanks to conscientious efforts of physician leaders who were not afraid of change and who had a vision of the role BCMS could play in supporting and assisting physicians in their practice of medicine. The first major change was selling Medical Hall and moving to the professional office building across from Albright College. This move also facilitated dropping those Wednesday CME programs because we knew our members

were getting CME's at their hospitals as well as from their professional societies. We quickly learned that our educational forte was providing practice administrators and office managers with seminars that focused on the "business side of medicine".

In addition to the guidance of forward-thinking physicians and PAMED, we added Residents' Day and The Memorial Lecture, Legislative Breakfast, Residents and Young Physicians' Socials, a state of the art membership journal (The Medical Record), an effective Grievance and Satisfaction Committee, a weekly radio talk show (Health Talk), a fall outing (Golf Tournament), Practice Management Seminars, and recently, a Summer Intern Program. Consequently, I know with the addition of a new executive director, BCMS will continue to evolve into an even more dynamic organization to serve physician members and their patients. In closing, it has been both a privilege and honor to have served as your executive director for the past twenty-seven years. I have learned much, and it has been a positive life-changing experience. I owe a great debt of gratitude to the many physician mentors who have helped me along the way. Most of all, thank you so very much for taking a chance on this Pennsylvania German boy!

Best Wishes on Your Retirement! A celebration in honor of the retirement of Bruce Weidman, Executive Director of the Berks County Medic al Society for the past 27 years, took place on June 5, 2014 at Green Valley Country Club.

Bruce posing with his friends from the Pennsylvania Medical Society from left to right: Kay Barrett, Denise Zimmerman, Bruce Weidman, Scot Chadwick, Michele Gaiski

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SUMMER

2014

Legislative Update Lyme Disease Bill Nears Finish Line By Scot Chadwick

id you know that Lyme disease is the most commonly reported vector-borne illness in the United States? According to the Centers for Disease Control and prevention (CDC), in 2012it was also the country’s seventh most common nationally notifiable disease, despite the fact that 95 percent of the cases are reported from just 1 3 states. Pennsylvania sits at the top of that unfortunate baker’s dozen, joined only by Massachusetts as states with more than 5,000 confirmed or likely cases in 201 2. The good news is that Lyme disease is treatable, and patients usually do very well when the disease is diagnosed early enough. However, patients who are not quickly diagnosed and treated can experience a wide range of nasty symptoms, and some go on to face Post-Treatment Lyme Disease syndrome (PRLDS), with lingering symptoms of fatigue, pain, or joint and muscle aches while Pennsylvania physicians do a great job treating Lyme disease patients, it is important for the general public to be aware of the disease’s prevalence and symptoms, as well as the measures that can be taken to reduce the risk of tick bites. And that’s where state government can help. Senate Bill 177, introduced by Sen. Stewart Greenleaf (R-Montgomery County), would establish a task force in the Department of Health to make recommendations to the department regarding a wide range of surveillance, prevention, information collecting, and education measures;. The Department of Health would be charged with the task of developing a program of general public and health care professional information and education regarding Lyme disease, along with an active tick collection, testing, surveillance and communication program.

The department would also be directed to cooperate with the Pennsylvania Game Commission, the Department of Conservation and Natural Resources, and the Department of Education to ensure that the information is widely disseminated to the general public, as well as to school administrators, school nurses, faculty and staff, parents, guardians and students. The bill passed the Senate 50-0 on April 29, 2013, and the House passed an amended version of the legislation 195-2 on June 11, 2014. All that remains is for the Senate to approve the House amendments, which I hope and expect will happen this month, before the bill lands on Gov. Corbett’s desk. 26 | MEDICAL RECORD

The Pennsylvania Medical Society has long supported legislation calling for the state to take a more active role in information gathering and public education regarding Lyme Disease. Unfortunately, earlier versions of the legislation also contained problematic language statutorily endorsing long-term antibiotic therapy, a controversial treatment protocol rejected by the CDC, which ultimately doomed those bills to failure. However, Senate Bill 177 does not contain that highly contentious provision, and we’re pleased that the bill seems poised for enactment. We’ll let you know when that happens. As always, you can reach me with comments or questions at 717-558-7814 or schadwick@pamedsoc.org.

Tort Reform - Progress, But the Work Goes On By Scot Chadwick

ne of the things l’ve learned from talking to physicians is that they often aren’t aware of all of the good work the Pennsylvania Medical Society (PAMED) does on their behalf. A perfect example is tort reform.

Most Pennsylvania physicians report that they continue to engage in defensive medicine as a result of the state’s hostile medical liability environment, which is another way of saying that there are still too many non-meritorious lawsuits filed against health care providers, That being the case, it’s perfectly understandable that physicians who aren’t familiar with our efforts assume that PAMED isn’t doing much to address the problem.

The fact is that PAMED has made a lot of progress on tort reform, and our list of accomplishments is pretty long. And the proof, as they say, is in the pudding. For example, did you know that annual medical liability lawsuit filings are down 45 percent from what they were a little more than a decade ago? That’s right, medical liability lawsuits against physicians and hospitals have been cut nearly in half thanks to our hard work.

Before l get into some of the specific achievements that delivered those results, let me state emphatically that we aren’t resting on any laurels. On the contrary, we strongly believe that we still have a long way to go in our efforts to create a fair and balanced medical liability environment in Pennsylvania.

PAMED has a robust, ongoing tort reform agenda that includes caps on pain and suffering awards, limits on plaintiffs’ attorney fees, increased liability protection for physicians who provide emergency care, strengthening the Certificate of Merit court rule, and closing the loophole in the expert witness requirements. We’ll know we’ve succeeded when young physicians start saying they want to practice in Pennsylvania due to our medical liability climate, rather than saying they’re leaving because of it. Still, coming back to the point I made at the start of this post, we probably need to do a better job of making physicians aware of PAMED’s achievements that led to the big drop in lawsuit filings, so here goes. Punitive damages - Punitive damages are allowed only if a health care provider engaged in willful or wanton conduct or in reckless disregard to rights of others, and punitive damages are capped at 200 percent of compensatory damages except in case of intentional misconduct.

Affidavit of non-involvement - Defendants can obtain quick dismissal by filing an affidavit stating that they were not involved with the plaintiffs care individually or through agents and employees and had no obligation to provide care to plaintiff individually or through agents or employees. Collateral source rule - Limits double recoveries for past “losses,” covered by collateral sources such as private health and disability insurance. Periodic payment - Mandates periodic payment of future medical damages with automatic cut-off at death.

Reduction to present worth - Mandates reduction to present worth of future work loss damages.

Remittitur - Requires the court to consider the adverse impact of a verdict on availability or access to health care in the community when ruling on a motion to reduce verdict.

Venue - Medical liability actions may be filed only in the county where the cause of action arose, or if multiple defendants, only in a county where action against one of the individual defendants could be brought. Joint and several liability – Modifies joint and several liability rules so that defendants less than 60 percent liable will only be responsible for their proportionate share of award. Apology - Physician apologies and other benevolent gestures (except admissions of fault or negligence) to a patient after a poor outcome are inadmissible to prove liability in a medical liability action.

Certificate of Merit - Requires attorneys who file a professional liability action to file a certificate of merit stating that he/she has in hand a supporting report from a qualified expert within 60 days of filing claim. I have to confess that to non-lawyers (confession: l’m a lawyer) a lot of this may sound like legal mumbo-jumbo. However, collectively these victories are the reason lawsuit filings are down 45 percent. so, if you hear a physician say PAMED needs to do something about tort reform, please do three things:

• • •

Show that physician this list of accomplishments Point out that lawsuit filings are down 45 percent as a result, but most importantly Tell him or her that PAMED is hard at work on the next wave of reforms.

As always, you can reach me with questions or comments at 717-558-7814 or schadwick@pa medsoc.org.

Statute of repose - Seven-year absolute time limit on filing of claims except in the case of an injured minor or foreign object left in the body. Preserves the existing two-year absolute limit on filing of wrongful death or survival claims except in case of fraud or wrongful concealment of cause of death. Expert witness qualifications - Establishes expert witness qualifications, including active practice or teaching and either same or similar specialty or board certification in same or similar specialty when defendant physician is board certified.

SUMMER

2014

Making lt Easier for Physicians to practice in Multiple States By Angela Boateng, Regulatory Counsel

he bar exam is a rite of passage for many law school graduates. After at least three years of law school, approximately two months of preparation, and anywhere from 16 to 21 hours of test time, the capstone for a fortunate applicant is admission to the illustrious state bar. Once completed, the mantra is usually “never again!,, However, if the attorney decides to move and wants to practice law in another state, she will have to do it all ... over ... again. lt’s enough to compel any practicing attorney to stay put, or at least consider very, very, very hard if the new (fill in the here) is worth it. A uniform bar exam has been created to streamline the bar examination process and allow applicants to sit for one exam for multiple states. So far, a handful of states are on board. lf you or your loved one is interested in moving to any of these states, you,re in luck. lf not, I feel for you. But I digress (... sort of).

Physicians face a similar predicament Currently, physicians must apply for a license to practice medicine in every state where they wish to practice. Although each application is not accompanied by an exam (for some physicians, MOC may take care of that), the licensure process is arduous - with a significant amount of cost, paperwork and time associated with each state,s application.

But alas, there may be some relief in sight! Earlier this year, the Federation of State Medical Boards drafted the Interstate Medical Licensure Compact. This compact would streamline the process for physicians to obtain licenses in multiple states. The interstate compact creates a new license category for participating states – the expedited license. The proposed eligibility requirement for this newly proposed license is raised; in addition to holding an unrestricted license to practice in a member state, a physician seeking an expedited license will be required to hold specialty certification recognized by the American Board of Medical Specialties or the American Osteopathic Association’s Bureau of Osteopathic Specialists. However, receipt of an expedited license will not authorize practice in all participating states. Applicants must identify and 28 | MEDICAL RECORD

pay the requisite application fees for each state where she wishes to practice medicine. In addition, physicians would be required to fulfill all continuing education requirements in participating states where renewal is desired. An interstate commission would be established to serve as the regulatory body for the compact. The commission would oversee all of the administrative functions of the Compact and would interpret and enforce all of the rules of the interstate agreement. States that opt to participate would be responsible for enacting the compact under the state law. The compact, however, would not override the state’s existing authority to regulate the practice of medicine within its respective state. State medical boards would maintain what is considered the hallmark of their existence - regulating the practice of medicine and protecting the health and safety of patients in the state.

The compact addresses one of the barriers to the practice of telemedicine. As previously noted in a PAMED update, many in the medical community agree that expanding telemedicine in Pennsylvania could ease concerns over escalating health care costs and access to care issues.

Twelve United States senators have signaled support for the compact. Currently, Pennsylvania is not one of them; however, since the state has already indicated its support for telemedicine, maybe support for the interstate compact will follow suit. Stay tuned.

Suicide Prevention Bill Reaches Governor’s Desk By Scot Chadwick

ast week I reviewed Senate Bill 177, an important public health initiative aimed at reducing the incidence of Lyme disease, and predicted that the bill would soon reach Governor Corbett’s desk. Happily, I was proven right, and we’re just a signature away from establishing an education and monitoring program for Lyme disease in the Department of Health.

Today I want to talk about another public health measure that awaits the governor’s signature, this one dealing with youth suicide prevention and child exploitation. When signed, House Biil 1559 will require school entities to adopt an age-appropriate youth suicide awareness and prevention policy, inform school employees, parents, or legal guardians of the policy, and post the policy on the school’s internet website. School entities would be required to provide four hours of training in youth suicide

place for the 2015-2016 school year, while the child exploitation awareness program (optional, remember) would be required to be in place at the same time for school entities that choose to implement it. We’ll let you know if and when Gov. Corbett signs both the Lyme disease and suicide prevention/child exploitation bills into law.

awareness and prevention every five years for educators in school buildings serving students in grades six through twelve. In turn, the Department of Education would be responsible for developing a model youth suicide awareness and prevention curriculum and making that curriculum available to all school entities including, upon request, nonpublic schools.

Be sure to check in with us frequently, as this happening. We could see action next week on legislation relating to biosimilars, Hepatitis C, pharmacist scope of practice, workers ‘compensation, and other issues of importance to Pennsylvania physicians, so stay tuned.

While the bill would make the suicide awareness and prevention program mandatory, it also includes language authorizing school entities to voluntarily develop an age appropriate child exploitation awareness education program and incorporate the program into the school entity’s existing curriculum for students in kindergarten through grade eight. A school entity would be permitted to make child exploitation awareness training available for employees, and as with the suicide prevention program, the Department of Education would be required to develop a model child exploitation awareness curriculum, and make that curriculum available to all school entities including, upon request, nonpublic schools.

As always, you can reach me with questions or comments at 717-558-7814 or schadwick@pa medsoc.org.

The Berks County Medical Society and The Pennsylvania Medical Society Invite you to attend our “Welcome to Berks” event for Residents, Young Physicians’ Section and New Physicians “Say Cheese” Restaurant Thursday, July 31, 2014 from 6-9PM 600 Penn Avenue, West Reading Drinks and hors d’oeuvres A casual evening to meet and mingle Call 610-375-6555 to RSVP or email info@berkscms.org

The bill, introduced by Representative Frank Farina (DLackawanna county), went back and forth several times between the House and senate, but ultimately was approved unanimously by both chambers. lf signed by Gov. Corbett, the suicide awareness and prevention program would be required to be in

SAVE THE DATE!

Groundbreaking Medical and Dental Organiza<on Collabora<ve Gathering!

For Berks County Den/sts and Dental Hygienists Physicians, Nurse Prac//oners, and Physician Assistants Con/nuing Educa/on Credits will be available

First in a series on

RETURNING THE TEETH TO THE BODY

“Into the Mouths of Babes: Providing Preven7ve Oral Health Care for Infants and Young Children”

September 17, 2014 from 5:30 to 8:30 pm.

at the Reading Country Club

Sponsored by: BCDS, BCMS, Berks County Community Founda/on, The Wyomissing Founda/on, and United Way of Berks County

SUMMER

2014

Members in the News Robert S. Jones, DO recently was re-elected to serve on

the board of trustees of the Pennsylvania Osteopathic Medical Association, a statewide organization for osteopathic physicians. Dr. Jones is director of infectious diseases at RPS Infectious Diseases in West Reading, and Chief of the Infectious Disease Section and Director of Osteopathic Medical Education at Reading Health System, West Reading. Dr. Jones is also Chief of Infectious Diseases Section and Director of Infectious Control at St. Joseph Medical Center, Bern Township.

Kelley C. Crozier, MD has been named Chair of the Department of Physician Medicine and Rehabilitation. This 12th clinical department at Reading Health system encompasses inpatient, outpatient, and ambulatory services in the fields of physiatry, brain injury rehabilitation, physical therapy, occupational therapy, speech therapy, and audiology. These services had formerly been organized as the Section of Physical Medicine and Rehabilitation within the Department of Medicine. Dr. Crozier has served as chief of this section since March of 2002 and provided clinical and administrative leadership during the creation of a separate inpatient facility for acute rehabilitation, sub-acute transitional care, and brain

Calendar of Events

injury rehabilitation. The growing volume of services as well as their increasing importance in population health management across the continuum of care resulted in the determination that a separate department was needed.

In addition to coordinating multi-disciplinary services provided by physicians, allied health providers, and other clinical professionals, Dr. Crozier remains medical director of Reading Health Rehabilitation Hospital.

The new Section of Addictions Medicine has been established within the Department of Psychiatry. The chief of this new section is William Santoro, MD, a member of the Medical Staff since 1985 and medical director of Reading Hospital’s Drug and Alcohol Center since 1989.

Dr. Santoro is board certified in both Family Medicine and Addiction Medicine and is a diplomate of the American Board of Addiction Medicine. He will continue to practice addiction medicine and family medicine through his practice with Reading Health Physician Network-Family Medicine in Laureldale, as well as provide ambulatory and inpatient consultations for patients with addiction issues.

BERKS COUNTY MEDICAL SOCIETY CALENDAR

Friday, July 25 7AM Administrative Committee Thursday, July 31 6-9 PM YPS / Resident’s Social-”Say Cheese” Friday, August 22 7AM Administrative Committee Thursday, September 4 6PM Executive Council Monday, September 8 Noon Retired Physicians Luncheon Wednesday, September 24 Golf Outing-Golden Oaks Friday, September 26 7AM Administrative Committee Saturday, September 27 Noon-4PM Hawk Mountain Family Outing Thursday, October 2 6PM Executive Council Tuesday, October 14 8-Noon CPR Recertification Saturday & Sunday October 18 & 19 PAMED House of Delegates-Hershey Friday, October 31 7AM Administrative Committee Thursday, November 6 6PM Executive Council Friday, November 21 7AM Administrative Committee Thursday, December 4 Noon Retired Physicians Luncheon Thursday, December 4 6PM Executive Council Friday, December 19 7AM Administrative Committee 30 | MEDICAL RECORD

READING HOSPITAL PEDIATRIC AND FAMILY MEDICINE CME CALENDAR All lectures are held from 8-9AM in the Reading Hospital 5th Avenue Conference Center, Rooms 1 and 2.

September 5 Friday’s Child lecture-pediatric topic September 12 Update on Skin Cancers Jonathan Zieff, DO, Reading Hospital Dermatologist September 19 - No lecture September 26- Topic and speaker TBD October 3 - A Day in Pediatrics October 10 ICD 10 Update- Thomas Weida, MD

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s u p p o R t

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Hoffmann Publishing Group

Published on Jul 21, 2014

The Berks County Medical Society Medical Record Summer 2014

Published on Jul 21, 2014

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