Philadelphia Medicine Spring 2022

SPRING 2022

A Recognized World Center for Advancing Health Care through Science, Education & Technology

CRC SCREENING: GUIDING OUR PATIENTS THROUGH THE OPTIONS

CLINICIANS:

You can help end the HIV epidemic Riding the Waves of Burnout

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CRC Screening: Guiding our patients through the options

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PCMS Calendar 2022

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Clinicians: You can Help End the HIV Epidemic in Philadelphia

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Riding the Waves of Burnout

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Recharge Rooms

Philadelphia County Medical Society 2100 Spring Garden Street, Philadelphia, PA 19130

(215) 563-5343 www.philamedsoc.org

EXECUTIVE COMMITTEE Stephen R. Permut, MD, JD PRESIDENT

Ricardo Morgenstern, MD PRESIDENT ELECT

Natalia Ortiz, MD, DFAPA, FACLP IMMEDIATE PAST PRESIDENT

20 Helping Your Organization Meet the Upcoming Challenges of the Tobacco Epidemic

John M.Vasudevan, MD SECRETARY

Anthony Rosa, MD TREASURER

BOARD OF DIRECTORS Oneida Arosarena, MD, FACS Dom Bucci, MD James L. Cristol, MD Cadence A. Kim, MD, FACS Harvey B. Lefton, MD Dale Mandel, MD Max E. Mercado, MD, FACS Curtis T. Miyamoto, MD Anthony M. Padula, MD, FACS Andrew Roberts, MD David A. Sass, MD, FACP J. Q. Michael Yu, MD, FRCPC Graeme R. Williams, MD, MBA

22 Senate Candidates 23 Government vs. Medicine: It Could Be a Slippery Slope

24 “Alexa, I want to talk to a doctor.”

25 PM Resident/Med Student Spotlight: Winnie Rao

26 2022 NRMP Delivers a Strong Match to Thousands

28 Protect Your Practice from Cyber Attacks

Winnie Rao FIRST DISTRICT TRUSTEE Lynn Lucas Fehm, MD, JD EXECUTIVE DIRECTOR Mark C. Austerberry Editor Tracy Hoffmann

30 Introducing My Benefit Advisor 31

11th Annual Clinical Update in Gastroenterology

In Every Issue Letter From the President. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Philadelphia County Medical Society.

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Philadelphia Medicine is published by Hoffmann Publishing Group, Inc., Reading, PA HoffmannPublishing.com | (610) 685.0914 FOR ADVERTISING INFO CONTACT:

Tracy Hoffmann • Tracy@Hoffpubs.com • 610-685-0914 x201

SPRING 2022

Contents

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An ambitious undertaking known as Ending the HIV Epidemic Initiative (EHE) contains key strategies that include early diagnosis, rapid treatment, transmission prevention, and quick outbreak response time.

Pennsylvania’s status as a swing state makes the coming elections crucial for both political parties as they vie for control, and we urge voters to make informed decisions as they cast their ballots.

Local clinicians will be asked to participate by learning more about HIV epidemiology, testing, treatment, and prevention options in Philadelphia, informing sexually active patients about prevention, discussing HIV in a destigmatizing manner, reducing barriers to prevention and care, and supporting health equity.

Physician Burnout

Colorectal Cancer Screening

An ongoing concern for medical professionals under the last years of stress during the COVID-19 pandemic are the lingering effects of stress which may result in both physician burnout and related psychiatric concerns.

Ana Maria Lopez, MD, MPH, and Ashithkumar Beloor-Suresh, MBBS, provide our readers with detailed information on colorectal cancer (CRC), a cancer that can be detected early in the carcinogenesis process making it an excellent candidate for cancer screening.

Letter from the president

ealth, technology, but also political news take the forefront for our readers as we look ahead to the upcoming election season in Pennsylvania where control of the senate and choosing a new governor are on the horizon.

Stephen R. Permut, MD, JD, and President, PCMS

We Welcome Your Comments!

They should be sent to our email address at editor@philamedsoc.org.

If you would like your comments considered for publication, please include your name, town, and phone number.

EDITORIAL BOARD Andy Andrews, Editor Daniel Dempsey, MD Corina Graziani, MD Susan Robbins, MD, MPH, FAAP

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In this issue, writer Karen Chandler talks with Philadelphia’s SaraKay Smullens, author of Burnout and Self-Care in Social Work, a newly revised edition of Smullens’ research on the root causes, symptoms, and helpful strategies surrounding the potentially fatal condition known as burnout.

Updated CRC guidelines from the U.S. Preventative Task Force are described in this issue, providing guidance on which age groups best benefit from these cancer screenings and an overview of screening types.

Cybersecurity

Smullens says, “it is essential that We switch gears to another concern burnout warning signs are clearly marked that affects all of us. Cybersecurity and and communicated before lives are destroyed!” cyberattacks are words we hear every day, Further discussion on this topic can be but not many people are aware that there found in the article on Recharge Rooms by were over 18 billion records exposed by data Bethany Marshall, an enlightening description breaches in the U.S., last year alone. on the increasing interest and need in hospitals Eric Roebuck, CEO/CISO of Valander to provide relief and self-care options for Cybersecurity, expresses the need for every medical and associated professionals who company to provide multiple layers of security experience high levels of stress in their lives. against both data breaches and ransomware attacks, with leaders understanding the Ending Philadelphia’s HIV challenges and costs of keeping data safe as Epidemic opposed to a crisis caused by a breach.

The Philadelphia Department of Public The installation of a Chief Information Health’s initiative to end the spread of HIV is of great interest to area physicians and this Security Officer into a larger company or a contract with information security issue will help spread the word.

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professionals for smaller organizations are both potential ways Roebuck describes to lessen the threat of a cyberattack.

But Roebuck expresses caution in this informative article. “You must push a culture of leadership through a framework and be as committed to protecting your organization as the bad guys are to attacking you.”

“Alexa, I want to talk to a doctor.”

More technology than ever is available to both medical professionals and their patients, and new on the horizon is the availability to reach out for a conversation with a physician by simply asking Alexa.

While some note that Alexa’s new feature will help break down the barriers to health care, others express concern that underserved communities will not have the technology or ability to use the service and that it might cost additional lost profits for physicians and medical facilities already struggling through the effects of the pandemic.

We hope you enjoy the wide range of topics we cover in this issue! • Dr. Stephen Permut, president of the Philadelphia County Medical Society, works in the Temple University Hospital family medicine department.

Writer Karen Chandler discusses some opposing views on the newly released feature that is a collaboration between Amazon and Teladoc Health, rated #1 among direct-to-consumer telehealth providers in the J.D. Power 2021 U.S. Telehealth Satisfaction Study.

DEDICATED TO

ALWAYS READY TO PUT YOU FIRST

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FEATURE

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CRC SCREENING: GUIDING OUR PATIENTS THROUGH THE OPTIONS

By Ashithkumar Beloor-Suresh Ana Maria Lopez

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olorectal cancer (CRC) is a common cancer that can be detected early in the carcinogenesis process making it an ideal target for cancer screening. Thought to be due to multiple carcinogenic “hits,” CRC precursors in the form of polyps may be identified prior to frank malignancy. Approaches to CRC screening include direct visual techniques and stool-based techniques. The former has the advantage of being diagno-peutic or both diagnostic and therapeutic. The lesion or polyp may be identified through direct visualization and removed for diagnostic evaluation.

This action also serves to arrest the carcinogenic process at that anatomical location. Direct visualization requires an appropriate bowel prep with full evacuation. For people who may have difficulty with this process, stool-based studies may be more acceptable. This article is intended to be of help as background for our conversations with our patients about CRC screening. These conversations can help guide patients through the data and help them make sense of the options and identify the study that will be most acceptable to them.

Epidemiology: CRC is the third most common cancer worldwide, excluding non-melanoma skin cancer. CRC appears to peak in incidence between 65-74 years of age; however, the incidence of CRC in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016. [1] It is estimated that 10.5% of new CRC diagnoses occur in persons younger than 50 years. [2] The incidence of CRC is also reported to be higher in Black/African, American Indian, and Alaskan Native adults, persons with a family history of CRC or inherited genetic syndromes such as Lynch syndrome or familial adenomatous polyposis, men, and persons with other risk factors such as obesity, diabetes, long-term smoking, and unhealthy alcohol use. The reason for higher incidence may be

related to multiple factors including access to care, underlying co-morbidities, and molecular or genetic factors. These factors remain under active investigation. [3] CRC screening that identifies pre-malignant or early malignant lesions can play a vital role in decreasing both CRC incidence and mortality.

Updated US Preventive Services Task Force (USPSTF) Recommendations on CRC Screening: The USPSTF updated its CRC screening guidelines earlier this year to recommend CRC screening in people aged 50-75 years with substantial net benefit and those between 45-49 years of age with moderate net benefit. In people aged 76-85 years, CRC screening has a small net benefit, and people who have never been screened for CRC in this age group are more likely to benefit.

This recommendation applies to asymptomatic adults 45 years or older who are at average risk of CRC (no prior diagnosis of CRC, adenomatous polyps, or inflammatory bowel disease; no personal diagnosis or family history of known genetic disorders that predispose them to a high lifetime risk of CRC—such as Lynch syndrome or familial adenomatous polyposis). Those with a history of these conditions would not be at average risk for CRC and would be considered for high-risk care.

CRC Screening Tests: The various recommended tests are based either on stool-based examinations or visualization of the gut through endoscopic or imaging techniques. The options differ based on their effectiveness, convenience, cost, availability, safety, and patient acceptance. The recommendations for screening for continued on next page

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COVER STORY continued

the specially designed kit to the lab with a single stool sample within 72 hours. It is recommended every 1- 3 years.

All positive stool-based testing require colonoscopy for further management. [4] Stool-based tests have the advantage of being done at home, at the time of the patient’s choosing, and in a non-invasive manner. They do not require bowel preparation, unlike direct visualization tests. With more frequent screening intervals, a long-term commitment to screening activity helps achieve its benefit.

2) Visualization: Visualization may take place directly through endoscopy or indirectly through imaging.

CRC discussed in this review do not include serum tests, urine tests, stool-based tests requiring multiple tests, or capsule endoscopy for CRC due to limited evidence and/or lack of efficacy in comparison to the studies presented.

According to the USPSTF, there is no particular best test. The best test is the one the patient is most likely to complete.

1) Stool-Based Tests: Stool-based tests include the Fecal Immunochemical Test (FIT) and the Multitarget stool DNA tests with fecal immunochemical testing (sDNA- FIT).

Fecal Immunochemical Test (FIT): tests for the presence of hemoglobin in the stool sample using antibodies. This increases the accuracy of detection over the traditional guaiac fecal occult blood test. The patient collects and returns the stool sample in a specially designed FIT kit within 24 hours from collection to prevent false negatives due to hemoglobin degradation. FIT is recommended annually starting at 45 years of age.

Multitarget stool DNA tests with fecal immunochemical testing (sDNA-FIT): It tests for specific DNA biomarkers present in the cells shed from the colon and rectum along with the FIT component, and only the combination of these two tests is currently approved by the FDA. The patient returns

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Endoscopy: The primary approach for direct visualization of the colon for cancer screening is colonoscopy. Although flexible sigmoidoscopy allows for direct visualization, its view of the colon is limited and incomplete. Direct visualization approaches allow for diagnostic biopsies which may result in therapeutic interventions if the lesion can be fully excised at the time of diagnosis. If normal, subsequent colonoscopy in average risk individuals is recommended every ten years.

Imaging: Computed Tomography (CT) Colonography, or virtual colonoscopy, utilizes CT imaging techniques to construct 2D/3D images of the colon to facilitate visualization of abnormalities on the surface of the colon. These changes may correspond to premalignant or malignant changes and would need follow-up with direct visualization, colonoscopy. Unlike colonoscopy, if normal, subsequent virtual colonoscopy in average risk individuals is recommended every five years.

These visualization studies provide the advantage of longer intervals between screenings; however, the studies cannot be performed at home and require bowel preparation and the expertise of a medical professional. These studies also carry the risk of complications from sedation and instrumentation like bleeding or perforation.

When to stop CRC screening: The current recommendations are to continue screening in average-risk individuals until 75 years of age. Considerations of life-limiting co-morbidities are always necessary. As our population ages healthfully, there will be more persons 76-85 years of age whose individualized risk for cancer, life expectancy, and comorbidities will demonstrate a benefit for screening. Generally, screening in persons over 85, is not recommended.

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PCMS CALENDAR 2022 Recommendations from other professional organizations:

April 9 8th Annual Jefferson Virtual Liver Disease Symposium 8 AM – 3 PM Register at https://cme.jefferson.edu/login?destination= node/34361

Various professional organizations (The American Academy of Family Physicians (AAFP), American College of Physicians (ACP), American Cancer Society (ACS), and the US Multi-Society Task Force on CRC) weigh on CRC screening. At the time of this writing, ACS and the US Multi-Society Task Force on CRC have guidelines that align with the USPSTF recommendation to initiate screening at age 45 for average risk individuals. Similarly, there is general consensus to consider screening cessation after 75 years of age, to individualize screening in persons 76-85 years of age and to stop screening after 85 years of age. [6]

April 28

Conclusions:

PCMS 11th Annual Clinical Update in Gastroenterology – CME Program via Zoom 8:00 AM - 12:45 PM Register at www.philamedsoc.org

Screening is largely attributed to saving lives from cancer. CRC has a well-defined carcinogenic process that is well-suited for early detection. With the multiple approaches that are currently available for early detection and risk reduction from colorectal cancer, most patients are likely to find one acceptable to them. Direct visualization of the colon with colonoscopy has the distinct advantage of (potentially) being both a diagnostic and a therapeutic study.

With our thoughtful patient engagement in CRC screening, it is our hope that all late CRC diagnoses will be relegated to historical interest only. •

Executive Committee Meeting 6:30 PM

April 30

May 26 Executive Committee Meeting 6:30 PM

June 2 Practicing Mindfulness 7:00 PM

References:

June 9

1. Contributions of adenocarcinoma and carcinoid tumors to early-onset CRC incidence rates in the United States. Ann Intern Med. 2021; 174 (2):157-166. doi:10.7326/M20-0068

June 17

2. Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017; 67 (3):177-193. doi:10.3322/ caac.21395

Installation & Awards Night Philadelphia Country Club 6:00 PM – 10:30 PM

3. Cancer stat facts: CRC. National Cancer Institute. Accessed March 30, 2021. https://seer.cancer.gov/statfacts/html/colorect.html

Additional Summer/Fall Programming (Date & Time TBA)

4. Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR. Screening for CRC: updatedevidence report and systematic review for the US Preventive Services Task Force. JAMA. Published May18, 2021. doi:10.1001/jama.2021.4417 5. Knudsen AB, Rutter CM, Peterse EFP, et al.CRC screening: a collaborative modeling study for the US Preventive Services Task Force.

JAMA. Published May 18, 2021. doi:10.1001/jama.2021.5746 6. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/ colorectal-cancer-screening

Board Meeting 6:30 PM

Include: • Cardiology Update Sudden Cardiac Arrest • HOD Committee Preparation • Block Captain Community Update • SCAN Child Abuse Program for license renewal

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FEATURE

CLINICIANS: YOU CAN HELP END THE HIV EPIDEMIC IN PHILADELPHIA

BY Philadelphia Department of Public Health, AIDS Activities Coordinating Office (AACO), Ending the HIV Epidemic Team members:

Kathleen A. Brady, MD

Brian Hernandez

Afrah Howlader

Olivia Kirby, MPH

Drexel Shaw, MPH

Mars Potros, MPH

Evan Thornburg

Tanner Nassau, MPH

Anna ThomasFerraioli, MPH

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s part of a national effort to reduce new infections of human immunodeficiency virus (HIV), the Philadelphia Department of Public Health (PDPH) has established an ambitious ‘Ending the HIV Epidemic (EHE) Initiative’ to achieve the following goals: reduce new HIV infections by 75% to less than 118 new infections per year by 2025 and by 90% to less than 47 new infections by 2030. At the start of the initiative in 2017, there were an estimated 470 new infections in Philadelphia.

To achieve these goals, the EHE initiative has created four main strategies: 1. Diagnose all people with HIV as early as possible.

2. Treat people with HIV rapidly and effectively to reach sustained viral suppression.

3. Prevent new HIV transmissions by using proven interventions, including pre-exposure prophylaxis (PrEP), non-occupational post-exposure prophylaxis (PEP) and syringe services programs (SSPs).

4. Respond quickly to potential HIV outbreaks to get needed prevention and treatment services to people who need them.

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Local clinicians, regardless of their specialty, can contribute to Ending the HIV Epidemic...

These four strategies work together to reduce the incidence of HIV over time. Medical advancements in HIV care and prevention, such as anti-retroviral therapy (ART) and PrEP, are critical parts of these strategies. With input from the community, Philadelphia has developed its own EHE Community Plan, which is available in English and Spanish at ehe.hivphilly.org.

Local clinicians, regardless of their specialty, can contribute to Ending the HIV Epidemic by: 1. Learning more about HIV epidemiology, testing, treatment, and prevention options available in Philadelphia.

2. Informing all sexually active adults and adolescents that PrEP can protect them from getting HIV. 3. Normalizing and destigmatizing HIV and sexual behavior by discussing these topics in an open-ended, non-judgmental manner.

4. Prescribing PEP to patients for whom it is clinically indicated.

5. Learning about strategies to reduce barriers to HIV prevention and care.

6. Being a champion for health equity.

HIV in Philadelphia In 2019, 446 Philadelphians were newly diagnosed with HIV. As in previous years, there were significant disparities in the rate of HIV diagnoses by sex at birth, race/ethnicity, and transmission routes. Non-Hispanic Black and Hispanic Philadelphians carry a disproportionate burden of HIV, with rates of new diagnosis that were 3.4 and 3.2 times greater than the rate among white Philadelphians, respectively. Men who have sex with men (MSM) had rates that were 26.5 times greater than those who acquired HIV through heterosexual contact and people who inject drugs (PWID) had rates 10.1 times greater than among heterosexuals.

There were 18,621 people living with diagnosed HIV (PLWDH) in Philadelphia in 2020. The plurality of Philadelphians living with HIV were assigned male sex at birth (72.1%), non-Hispanic Black (63.7%), age 50 or older (54.8%), and MSM (38.9%). There remain significant needs for improvement in receipt of medical care and HIV outcomes. Among PLWDH with evidence of care in the past 5 years, 78.2% received care in 2020 and 67% were virally suppressed.

EHE Activities and How Philadelphia Clinicians Can Help Improve Access to PrEP Philadelphia’s EHE Community Plan outlines a goal for 50% of people with a PrEP indication to be prescribed PrEP by 2025. One strategy PDPH is employing to achieve this goal is to increase access to PrEP for priority populations. PDPH’s activities to implement this strategy include expanding PrEP clinical-community partnerships (like low-threshold sexual health centers) and expanding PrEP access through the offer of same-day PrEP. The Centers for Disease Control and Prevention’s most recent clinical practice guidelines for pre-exposure prophylaxis (PrEP) focus on increasing PrEP use by people who could benefit from it. There are two new recommendations: (1) prescribe injectable cabotegravir as PrEP for sexually active adults (approved by the FDA in 2021) and (2) inform all sexually active adults and adolescents that PrEP can protect them from getting HIV. In addition to these new recommendations, providers are encouraged to offer PrEP to anyone who asks for it, regardless of self-report of behaviors that are considered risk factors for HIV acquisition. All medical disciplines and specialties are encouraged to prescribe PrEP, including primary care providers. Providers can help end the HIV epidemic in Philadelphia by discussing sexual behavior with patients in a non-judgmental and open-ended manner, and by informing sexually active adults about PrEP. continued on next page

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To assist providers who want to learn more, PDPH has a PrEP technical assistance (TA) team, which provides content-based assistance through educational materials, evaluation of provider services, quarterly PrEP provider meetings, and a monthly “PrEP Update for Providers.” This newsletter provides the latest PrEP news and features policy updates, new PrEP resources, and information on upcoming conferences/webinars. Sign up to receive the newsletter by emailing PreventHIV@philly.gov.

Provide PEP HIV post-exposure prophylaxis (PEP) is anti-retroviral medication given to an HIV-negative person who may have been exposed to HIV within 72 hours of the exposure to prevent transmission of HIV. PEP is indicated if, within the prior 72 hours, a person had condomless sex or shared syringes or other injection equipment with a person known to have HIV or whose HIV status is unknown.

Despite the effectiveness and strong recommendation for usage of HIV PEP from the Centers for Disease Control and Prevention, many Philadelphians are not aware of PEP, who it’s recommended for, and where to access PEP in the city.

PDPH has released an RFP for the development of a Philadelphia PEP Center of Excellence (PEP COE), where any Philadelphian can access this vital medication when necessary. Expected to be fully operational by summer 2022, the program will include a 24-hour call line and a brick-and-mortar PEP COE. The call line will allow Philadelphians to speak to a health care provider to assess eligibility for PEP and arrange for after-hours access to a starter dose if needed.

The COE will provide comprehensive PEP services according to the national guidelines for prescribing PEP, as well as navigation services to assistance with paying for PEP.

PDPH has released an RFP for the development of a Philadelphia PEP Center of Excellence (PEP COE), where any Philadelphian can access this vital medication when necessary.

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Clinicians, thank you for all you do to care for vulnerable Philadelphians every day. Let’s act now to end the HIV epidemic in Philadelphia.

A licensed medical provider with prescribing privileges in good standing can prescribe PEP to anyone meeting the exposure criteria.

For the most updated PEP prescribing guidelines for clinicians please refer to National Guidelines to Prescribing PEP at: https://www.cdc. gov/hiv/clinicians/prevention/pep.html

stigmatized and marginalized communities. Through the work of the PDPH’s HIV Health Equity Special Advisor, the agency has implemented policies, practices, and program requirements that aim to rework inequitable systems that stand in the way of successful HIV prevention and care.

Reduce barriers to HIV prevention and care services

Because systems change begins at home, PDPH established its own HIV Health Equity Policy, which are explicit internal guidelines Patients experience many individual and structural barriers when to support health equity practices throughout the system of HIV trying to engage in HIV prevention and care services. Patients cite prevention and care. Funded programs undergo a Health Equity barriers that include limited resources to pay for services, lack of Assessment, with assessment results used to design health equity appointment availability at times or locations that are accessible to action plans. The action plans and associated program performance them, lack of access to transportation, insecure and unsafe housing, reporting are being used to evaluate processes and outcomes, and to and lack of adequate behavioral health services. continuously improve systems.

To reduce barriers, PDPH has funded several clinics and health centers across the city to provide low-barrier HIV prevention and care services for Philadelphians. Strategies used to reduce barriers include offering flexible appointment times or walk-in capacity, leveraging multiple funding sources to ensure access to services regardless of insurance status, and revising policies to ensure flexibility amid the COVID-19 pandemic. Telemedicine appointments continue to be an essential point of care for many. Providers are also participating in health equity initiatives with PDPH, with the goal of ensuring more equitable access to HIV prevention and care service (regardless of their race, gender identity, sexual identity, and drug use), quickly linking patients to care, and offering immediate Anti-Retroviral Therapy (iART), which is defined as starting HIV treatment within 96 hours of the initial diagnosis.

PDPH supports programming to improve HIV outcomes through the Philadelphia Regional Ending the HIV Epidemic (EHE) Collaborative. The Collaborative is currently working to help providers expedite HIV treatment availability through the iART Working Group.

Enhancing Equity Practices and Working to address HIV Stigma Historically, marginalized communities have been neglected and mistreated when seeking HIV prevention and care. This mistreatment allows HIV diagnoses to remain consistent and pervasive in

PDPH is also tackling low health literacy in HIV prevention and care programs by requiring low literacy assessments, providing low literacy/low color perception resources, reimagining how we depend on and require consumers to use technology, and preemptively making language and ASL translation quick and easy to access, as well as implement.

Philadelphia clinicians can contribute by becoming champions for health equity and equitable access to services in their own organizations. They can do this by participating actively in their own organizations’ health equity efforts or by advocating for new or expanded equity efforts in their organizations. Clinicians can learn more about advancing health equity by exploring the American Medical Association’s Center for Health Equity resources. Also, providers can advocate for and be mindful of literacy, technology use, and language access needs that may be less discussed but still widespread barriers to equitable health care access. Multiple resources are available through the CDC, HRSA, and the National Library of Medicine.

Clinicians, thank you for all you do to care for vulnerable Philadelphians every day. Let’s act now to end the HIV epidemic in Philadelphia. •

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Waves of Burnout

By Karen L. Chandler

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s the COVID-19 epidemic ebbs and flows, burnout among medical professionals is on the rise.

conflicts in family or other close relationships and can even affect those interactions that are more distant.

In the second edition of her book, Burnout and Self-Care in Social Work, author SaraKay Smullens, a certified family life educator, group psychotherapist, and social worker basing her private and pro-bono clinical practice in Philadelphia, updates the text’s content with a further enhanced exploration and understanding of burnout.

Physical burnout is based in the body’s physiological response to stress and can be evidenced in a multitude of illnesses that may range from sleep disturbances to the common cold, to cardiovascular disease, however, Smullens confirms that no physical symptom should be assumed caused by burnout without the indicated medical evaluations.

The wife of Dr. Stanton Smullens, a retired surgeon and New to the second edition of her book is Smullens’ fifth former chair of the Pennsylvania Patient Safety Authority, dimension of concern, societal burnout, a state she describes Smullens realizes the effects stressors have on physicians, as being “overwhelmed, overburdened, and overloaded by a especially during the onslaught of COVID-19, and ac- ‘perfect storm’ of grave, threatening, and unaddressed societal knowledges how any discussion of burnout in doctors has problems,” much like the crisis realized by many physicians been mainly limited to their professional lives. working through the COVID-19 pandemic.

“It is essential that burnout warning signs are clearly marked Smullens notes that the Medscape Physical Burnout and communicated before lives are destroyed! Wherever and Depression Report in 2022: Stress, Anxiety, and burnout originates – personally, professionally, relationally, Anger showed a five-percentage point increase in overall physically, or societally (or a combination) – it impacts physician burnout, from 42 percent in 2020 to 47 percent interactively bringing grave danger. When overwhelmed, in 2021, and an increase in emergency room physician overloaded, and overburdened by external pressures, when burnout from 43 to 60 percent last year. The report added anxiety and exhaustion seem everywhere, the destruction that most doctors felt that burnout intruded upon most of self-confidence, self-respect, and an inability to connect aspects of their lives, with 54 percent feeling its effects to with others are in the wings.” (Burnout and Self-Care in be strong to severe, including in their relationships. The Social Work, 2nd edition) Maslach Burnout Inventory is a source recommended by While professional burnout remains a topic of concern, Smullens for anyone looking for help in evaluating their Smullens discusses the other aspects of burnout that impact own experience with burnout.

each other and should be examined and recognized: “personal (our inner world capacity to deal with stress); relational (unresolved conflicts in families and in close relationships), societal (the impact of unresolved conflicts played out 24/7 through technology), and physical (our bodies speak to us, offering clues.)”

Smullens describes personal burnout as an upheaval in the cognitive, intellectual, psychological, emotional, or spiritual life, or a lacking in one’s inner world to deal with stress, while relational burnout is based in unresolved

Gathering over thirty years of clinical experience, Smullens sides with other experts who believe that burnout is a condition separate from depression and while there can be an overlap between the two diagnoses, Smullens explains that many people who believe they are suffering from depression are actually burned out. The World Health Organization officially describes burnout as a syndrome, rather than a psychiatric illness, such as depression, that could carry a stigma. Burnout is evidenced by a combination of reduced personal accomplishment, emotional

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FEATURE continued exhaustion, and depersonalization, and can all be brought on by chronic occupational stress.

recognize fulfilling options before our very eyes in love, friendship, and work.” – SaraKay Smullens

“Depression caused by loss, rejection, betrayal, connivance can be experienced as a fierce body punch. One may feel blindsided and bewildered as if slats in the floor of an emotional home have disappeared. With burnout the body speaks to us differently: ‘My shoulders, my arms, my being can no longer carry what is asked and expected. My brain feels fried’”. (Burnout and Self-Care in Social Work, 2nd edition)

Self-care in a multi-pronged approach is the way health care professionals can fight back from the grasp of burnout, a condition that has claimed lives as evidenced by rising suicide rates in physicians.

Smullens writes that researchers have used four attendant syndromes or “wake-up calls” to better explore the tumultuous waters of burnout, and while the complex faces of burnout may overlap, each of the attendant syndromes provides valuable insights into the experience of burnout.

Compassion fatigue is the attendant syndrome that results when medical professionals give until they have nothing left and it highlights the emotional and physical fatigue that many caregivers experience.

Compassion fatigue always plays a factor in the other syndromes and indicates a need to take a break for self-care.

Personal, physical, relational, and societal self-care can work together to create better quality of life for physicians. Smullens confirms the importance of finding a program of strategies and attitudes that speak to each person in a way that is both enjoyable and can become an integral part of daily life, whether it is journaling, learning a new skill, or making a date night with a partner.

Smullens believes that doctors may often forget the power of their own creativity and encourages a renewed focus on making time to devote to a dream, and when one dream does not become fulfilling to seek another.

On the professional front, Smullens notes that some health care institutions are putting together wellness programs for staff to use including such features as recharge rooms and counseling services, and she hopes medical schools will follow suit and teach self-care strategies for students to reduce the risk of burnout.

Originally defined by Freud, the second attendant syndrome, countertransference, results as a patient’s influence gives rise to a “All health care leaders in organizations, institutions, and governpractitioner’s positive or negative subconscious feelings about a sig- ment and industry must prioritize major improvements in settings… nificant person from his or her own previous experiences. Smullens Recharge Rooms are a wonderful example. A culture of trust is advises physicians encountering this syndrome to continually face essential in all healthy settings — someone to go to and process with how they feel about each patient and be aware of how patients trigger if overwhelmed. My research shows that anxiety is alleviated when past or current emotions. one can speak honestly to one reported to — a sign of a healthy Vicarious trauma and secondary trauma, considered the third functional setting. In dysfunctional settings, anxiety is imposed attendant syndrome, results from a medical professional’s direct and from the top, as a control mechanism. People are pitted against frequent exposure to victims of trauma. Smullens notes that caring each other; one does not know whom to trust.” – SaraKay Smullens for patients who became ill or died after a COVID-19 infection may In her book, Smullens tells of echo a physician’s own personal trauma of watching a loved one in the tragic suicide of 49-year-old a similar situation, and that processing the resulting emotions with Lorna Breen, MD, a Manhattan a colleague or other professional can be helpful. emergency room physician superThe fourth attendant syndrome is considered by Smullens to be moral distress and injury, an experience felt by medical professionals unable to provide the highest quality of care and healing, a factor in burnout exacerbated by the COVID-19 crisis.

visor at a hospital devoted, but ill-supplied, to serve the underprivileged during the COVID-19 pandemic. Breen’s father, Dr. Philip C. Breen, said after his Smullens explains that a key to smoothing the turbulence of daughter’s death, “she tried to do burnout is for physicians to move from compassion fatigue to comher job and it killed her.” passion satisfaction, an effort that lessens the grasp of the attendant syndromes and is further helped by employing self-care strategies.

Smullens’ personal message to health care professionals is both “The goal is to go from compassion fatigue to compassion satisencouraging and cautionary. faction. Key to this is the ability to have boundaries with patients,

Yes, physicians care — but empathy is the goal. Empathy connotes She said, “evidence-based self-care strategies, behaviors, and boundaries, while sympathy connotes union. Energy and inner attitudes, if integrated into your life, will prevent, address, and resources must be protected for personal lives. Also, those in the alleviate burnout. Your body and what I think of as an “InnerSelf medical profession often see themselves as SuperMen and Women, Voice” that each of us has, but often ignore, as we push ourselves, and often extend themselves beyond reason. It is important to will signal when burnout is a threat. Listen!” • be able to protect oneself, to say No and to understand that if we cannot say No, we cannot say Yes, and further, we will be unable to

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IN THE NEWS

A New, Affordable Model for Medical Practices

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pace sharing, also called coworking, has become a popular option for general office work over the last decade but, until recently, has not been available in health care. MedCoShare, as the name implies, has recently opened one coworking facility in Philadelphia, and is about to open another in Marlton, N.J. The company offers doctors and other health care providers flexible space and support services that help independent providers practice on their own terms at a fraction of the cost of setting up a traditional office.

Ronak Vyas, an experienced real-estate agent and broker, founded the company in 2019. Along with partners who include other real-estate experts and health care providers, he created MedCoShare to fill what he saw as a major gap in the traditional office leasing model.

“There are many doctors whose needs just are not met by the typical office lease,” Vyas said, “so I see this as an exciting innovation in the health care office market.” There are many obstacles to starting a practice, including initial expenses, operational challenges and a significant degree of risk, which are neither practical nor affordable for an individual or small partnership. Part-time and short-term

medical office space is not part of the traditional leasing model. Health care-space landlords typically require tenants to sign leases ranging from 5 to 10 years, which often include personal guarantees.

These spaces then require long and costly fit-outs before a provider can start seeing patients. Setting up an office also requires establishing long-term commitments for cleaning, medical waste removal, support staff and more.

of the Hahnemann hospital system. They started operations in the summer of 2020. In spite of the pandemic, MedCoShare has attracted a variety of health care providers, including specialists in cardiology, dermatology and men’s health, and other types of ancillary providers such as estheticians, massage therapists and more. “Being a new small business owner in the midst of a pandemic, MedCoShare has been a blessing,” said Marybell Rodriguez, a nurse practitioner who performs skin care procedures. “Where else could I start a business, build clients and have a flexible membership with no long-term commitments for peace of mind during the uncertainty?”

According to one of Vyas’ partners, Gregory Goldmacher, MD, “Many doctors are increasingly unhappy with the lack of autonomy in working for hospitals or large groups, and are considering private practice again, or for the first time, or going part-time as they move toward retirement In less than a year, the company has filled or shifting family obligations,” Goldmacher said. its first space and is poised to grow. The location “Coworking space could provide an ideal option.” in Marlton is scheduled to open at the end of Having an affordable coworking space/part-time January, and Vyas and his partners are evaluating office to split telehealth and in-person visits would more locations in King of Prussia. “Our goal is to be an effective hybrid practice model, or could give build locations in the region, develop our support a provider options to see patients in more than one service offerings and then go national,” Vyas said. location, one or two days a week in several offices. “We think this will become a popular new practice Vyas and his partners opened their first location model across the country, similar to the way urgent in an outpatient clinic in the Fishtown neighborhood care has grown over the last decade.” • of Philadelphia, an office left vacant by the closure

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FEATURE

Recharge Rooms I

n late March 2020, Mirelle Phillips knew a seismic earthquake had erupted globally for healthcare workers and it would only be a matter of time until the tsunami hit. In this case, the tidal wave would be the long-term mental health implications of battling COVID-19.

Physician burnout, defined as a work-related syndrome involving emotional exhaustion, de-personalization, and a sense of reduced personal accomplishment, had already reached global epidemic levels. The 2018 Survey of America’s Physicians Practice Patterns and Perspectives reported that 78% of physicians had burnout, an increase of 4% since 2016.

Phillips’ design and technology firm, Studio Elsewhere, was focused on developing mixed-reality environments in collaboration with neuroscientists in hospitals that supported the evaluation and treatment of brain health issues, working with a range of patients who suffered from stroke to severe depression and anxiety. Through her work, she discovered that one of the ways of improving the overall patient experience was to first focus on the provider.

By Bethany Marshall

“We would hear so many stories unfold inside the rooms during that time about the trauma workers were facing in their units. They were also isolated from the rest of their communities, so it became quite a profound experience for them to sit around a virtual campfire and talk about what they were going through and know they weren’t alone,” Phillips shared.

For Dr. Dahlia Rizk, the Head of Hospital Medicine at Mount Sinai Beth Israel, the intervention couldn’t have come at a better time. “Each day we were faced with stress and uncertainty as there was still so much unknown about the disease. I had to be separated from my family and young children so that I wasn’t putting them in danger everyday coming home from the hospital. Then I heard about Mirelle’s work from David and knew what a gift it could be for our staff. I quickly brought it to our President so that her team could install it in the hospital.”

When Phillips was shown the site, she noticed an emergency triage tent that had previously been used for patients and now was vacant. When she walked in, she immediately could envision it transformed into a sanctuary for workers.

“When she told me what she was thinking, it was hard at first to imagine,” Nicole Porto, the Director of Patient Experience for She worked with Dr. David Putrino, Mount Mount Sinai Downtown, remembered. “The tent was cold, sterile, Sinai’s Director of Innovation of Rehabili- with fluorescent lights. It was hard to imagine it becoming a space tation and Human Performance, to design anyone would want to go to during their break. But I had full and develop a Recharge Room – an enriched confidence and trust in Mirelle’s vision and knew she and her team mixed-reality environment specifically tailored could make something special.” to the psychosocial needs of physicians and Over a weekend, the Studio Elsewhere team transformed the triage staff at a hospital to address burnout. They planned a pilot of the tent into a multi-sensory oasis, filled with silk trees and experiences Recharge Room for high-needs ICU and ER workers. staff could choose through voice-activation. “It was a fairly intuitive Then, almost overnight, a huge number of physicians and nurses became ICU workers once New York City became the global epicenter of the first surge. Dr. Putrino and Phillips quickly worked together to transform his 3,000-square-foot laboratory into a relief hub for staff with three Recharge Rooms. Word of mouth quickly spread through the hospitals about a space in the basement where workers could leave their units for a few minutes and be transported to a beach at sunset or rainforest. During surge, the center was receiving on average, over 300 visits from staff per day.

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concept, the tent actually already had a cocoon shape, so we were able to create the feeling of being in a welcoming, comfortable space with the experiences, lighting and aroma.”

The space was an instant hit not just for physicians and nurses, but all staff, including EMS members and security personnel.

“I love seeing the diversity of roles when you walk into any of our Recharge Rooms. It’s designed to be a space without hierarchy, particularly because these issues impacting mental health extend

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across all workers in a hospital.” Phillips noted that support services like environmental service workers were the unsung heros, often left out of the ‘frontline hero’ vocabulary, but at-risk on a normal basis in their jobs.

lighting and aroma. The team creates the content themselves by shooting in various nature-based landscapes and collaborating with the acclaimed composer and violinist, Tim Fain, on custom scores for each experience.

Over at the VA Hampton hospital, Chaplain Carol DuFresne had been researching ways to bring something specifically to the environment services team at the hospital, many who were former veterans. “When Chaplain Carol called me out about bringing the Recharge Room to that specific population, it was like getting the phone call I had hoped for. Our goal is to partner with incredible people like her who see an application in their own community that could really benefit from this intervention,” said Phillips, who comes from a veteran family and grew up near MacDill Air Force base in Tampa, Florida.

“The work has a fascinating balance of translating cutting-edge research we have with our neuroscience and clinical partners with the artistry of the experience itself,” Phillips said. “It’s a symbiotic relationship. Something coming up a lot right now for healthcare workers is a struggle with purpose and tapping into it as a north star when they’re facing competing issues on a daily basis that prevent them from doing what ultimately fulfills them. We know their day is full of withdrawals for their brain-body budget, so we design for a deposit.”

Phillips recognizes that our societal view of physician burnout also can be misleading. “Most physicians enter medicine as a calling, rather than a simple career choice. They are service-oriented and their primary focus is ensuring the best care for their patients. They’re

Dr. Mar Cortes, a neuroscientist overseeing a clinical study of the Recharge Room at Mount Sinai, is working to better understand the neural underpinnings of the intervention. “We’re using a battery of different neurophysiological measurements including EEGs to understand the why, how, and when of what we’re seeing from the pre and post surveys.’’ In November 2020, she and Dr. Putrino authored a study of the impacts of the rooms on workers demonstrating a 60% reduction in short term stress after a 15-minute session.

“I can see the applications of this work in every part of the hospital, not only to help manage stress, anxiety, and depression but to transform the entire experience of what care can feel like,” said Dr. Cortes.

Since 2021, an alarming trend has been the staff shortages with thousands of nurses and other staff leaving for traveling nurse positions or the career all together. Phillips was asked a lot about how much the Recharge Rooms would be needed outside of the COVID-19 crisis.

“I think we’re actually just seeing the tip of the iceberg right now.

None of these problems will be going away anytime soon and will require a robust federal response. I’m very happy to see the progress organizations like the Lorna Breen Heroes Foundation have made with Congress to pass the Dr. Lorna Breen Health Care Provider Protection Act.” Phillips said. The Act’s central focus is to reduce and prevent suicide, burnout and mental and beahvioral health conditions among health care professionals, and is named in honor of New York City ER doctor Lorna Breen, who died by suicide on April 26, 2020.

already a highly resourceful and resilient community by nature. I think what we are also seeing is symptomatic of the moral injury they’ve sustained, which the pandemic became a tipping point.”

This year Studio Elsewhere plans to expand the Recharge Rooms to more hospitals across the US and internationally, while also focusing on innovation projects to benefit patients and their caregivers living with brain health issues like dementia and traumatic brain injury, and also early childhood and youth interventions for anxiety and depression.

“What I’ve come to realize is that there are only two categories of Americans right now – those who are dealing with a mental health Since the first surge, Phillips and her team at Studio Elsewhere issue directly or within their inner circle, and those who have yet to. have partnered with over 40 hospitals across the nation and worked It will require tremendous collective effort and ingenuity to overcome,” with hundreds of hospital leaders from teams like Nursing, Spiritual Phillips reflects. “At the same time, there is a joy in that collective Care, Patient Experience and Well-Being and Resilience, to evolve and collaborative work with others. It’s tangible and long-term. It and deepen the resource. Her colleagues at Studio Elsewhere are a certainly has given me a deeper purpose in showing up every day to talented interdisciplinary team of engineers, creative technologists, my community and knowing we can make a meaningful difference designers, and artists who develop the technology and custom together.” • multi-sensory experiences that include immersive visuals, music, Spring 2022 : Philadelphia Medicine 19

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FEATURE

Helping Your Organization Meet the Upcoming Challenges of the Tobacco Epidemic

By Jody Nicoloso, BS, and Frank T. Leone, MD, MS

Introduction There are approximately 34 million people who currently smoke cigarettes in the United States.(1) One-third to one-half of those people will eventually die of a preventable tobacco-related disease, typically 10 years earlier than people who do not smoke cigarettes.(2) The toll of death and disability related to tobacco use is enormous, accounting for a staggering number of excess hospital days, millions of potential life-years lost and over $50 billion in attributable healthcare costs annually.(3)

published treatment guidelines incorporating tobacco dependence into workflow, and have identified the billing and documentation requirements necessary to sustaining their efforts.(7,8) The evidence base has established effective, multi-disciplinary care of tobacco dependence as an important provider benchmark, with systematic approaches to incorporating tobacco dependence treatment into care pathways as an important step toward ensuring best possible outcomes.

The Philadelphia County Medical Society (PCMS) has taken on a leadership role in promoting the evolution of tobacco care in Generally, when we think about the preventable consequences of our region by partnering with a variety of other tobacco dependence on our patients, our minds focus on the steps healthcare entities to guide the development our patients might take to prevent these outcomes. Alternatively, and implementation of the new regional STAR it’s fair to ask which American institution, if not healthcare, is in Accreditation (Smoking Treatment Accreditathe best position to take on the responsibility of doing more to tion and Recognition). Along with other partners like the Greater prevent more of those preventable deaths? Relative to the emphasis Philadelphia Business Coalition on Health, Aetna Better Health of placed on population-based controls, efforts to increase the ability Pennsylvania, Health Partners Plans and Community Care Behavof healthcare systems to provide effective case treatment have been ioral Health, PCMS has joined Health Promotion Council (HPC) comparatively weak, and have traditionally been placed low on and the University of Pennsylvania to identify systematic methods experts’ lists of tobacco control priorities.(4,5) by which healthcare organizations might improve the continuity But if not us, then who? of care between providers and increase the rate at which patients receive evidence-based pharmacotherapies for tobacco dependence.

Getting ahead of the tobacco epidemic involves seeing the problem PCMS members will have the opportunity to provider leadership as not just a behavioral antecedent to downstream illness, but rather at home, helping to guide their organizations toward achieving this as a complex current illness resulting from pathologic distortions in important quality distinction. brain biology induced by exposure to nicotine.(6) Organizations that can successfully incorporate the treatment of tobacco dependence into their day-to-day routines of providing high-quality care Why a tobacco treatment accreditation? transcend the traditional boundaries of disease-focused interventions Accreditation is a visible signal of the organization’s professionalism and address the root threat to their patients’ long-term well-being. and commitment to the highest standards of community-based, Professional societies from across the spectrum of medicine have comprehensive care. The HPC STAR Accreditation recognizes the

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wide variety of tobacco-related activities that can happen within a healthcare organization, aimed at improving the lives of the community members they serve. IMPACT Accreditation does not require adherence to any pre-defined method or mechanism of tobacco treatment integration. Applicant organizations are expected to be unique in their makeup and consequently unique in their approach to integration.

• Cancer centers, cardiovascular or pulmonary disease centers, recovery care organizations or other similar centers of excellence • Inpatient behavioral or physical health facilities • Entire health systems

How does STAR Accreditation add value to the There are five care domains that are used to identify those orga- organization?

nizations that offer truly superior care to their constituents. General STAR Accreditation improves the quality of care by promoting Operations relate to the processes put in place by the organization focused attention on tobacco dependence. Tobacco dependence aimed at accurately identifying and documenting tobacco dependence interventions improve survival, reduce readmissions, shorten hospital among the patients served. Given that details of tobacco use history stays, prevent exacerbations, improve patient satisfaction, lower overall may be essential to developing and implementing an integrated costs of care and improve quality of life. Accreditation creates a level treatment plan, organizations are asked to describe their policies of distinction that adds brand-value, easily recognized by payors and regarding current use patterns, past abstinence attempts, and severity purchasers, provides a vehicle for patient-facing promotion and raises of tobacco dependence. Organizations are also asked to describe the the organization’s stature as a concerned, proactive member of the process used for implementing comprehensive tobacco dependence surrounding community.

Treatment Planning, including the evidence-based guideline used Upon achieving STAR Accreditation, organizations can to guide pharmacotherapy decision-making, and the manner in show off their proactive stance. Partnering with HPC, the which treatment planning is integrated into the care pathways organization becomes the subject of press releases, web-based of other illnesses or conditions. Accredited organizations are promotion, high-visibility banners and signage advertising expected to utilize Professional Personnel with qualifications their community credentials, and a variety of leave-behind commensurate with their assigned tasks, including access to hard copy materials that raise the visibility of the organization supervisory personnel and ongoing training and professional within the health promotion space. development. Given that effective multi-disciplinary care relies on Communication, the methods used for inter-staff How PCMS members can make a difference communication across departments and locations are critical PCMS members have always been recognized as leaders to delivering services to high-prevalence communities. Because in their local medical community. The STAR Accredited organizations each have value of membership is intrinsic to our their own unique character, each applicant members’ ability to share ideas and organization has the opportunity to identify promote growth in patient care. Our their own particular Focused Expertise or members make up a variety of “organifacility that they believe exemplifies the zations” that would qualify for STAR organization’s pursuit of a fully-integrated model of care. For example, organizations may choose to highlight Accreditation. Finding ways to help your organization achieve this their efforts to refine marketing or patient messaging, their systematic important distinction would add significant value to the organizamethods for facilitating physician involvement, their unique approach tion’s community outreach, and help to elevate the organization as to tobacco-related clinical training or continuing medical education, a recognized leader in providing comprehensive care to community or their use of complex health information algorithms to identify, members. PCMS members strive to deliver top-notch care to their patients, and STAR Accreditation is a mechanism by which organitrack and treat tobacco dependent patients. zations can get free technical assistance to achieve their tobacco goals.

What qualifies as a STAR-eligible healthcare organization?

Healthcare organizations eligible for STAR Accreditation can be variously described. The fundamental characteristics of an eligible organization include: • Responsible for the care of persons with diagnosed conditions / disorders.

• Reimbursed for care through third-party payer.

• Accountable to the public for outcomes of care.

• Utilizes multi-disciplinary teams to provide care.

• Prescriptive authority within Pennsylvania.

Examples of STAR-eligible organizations include, but are not limited to:

Understanding smoking as an addiction can fundamentally change the frame within which we treat our patients. Enriching our interventions has the potential to increase our confidence when dealing with a seemingly intractable problem and minimizes the potential for frustrating smoking conversations. Confidence is equally important for patients; PCMS members assist their organizations by increasing the confidence that patients feel when dealing with this sensitive problem. Finally, when Accredited organizations become the norm, arguments can be made to support improved reimbursement for these efforts.

To learn more about tobacco dependence, or to discuss how you might help your organization become STAR Accredited, please contact the Comprehensive Smoking Treatment Program at the University of Pennsylvania by calling 1-888-PENN-STOP or email to: pennstop@uphs.upenn.edu. •

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FEATURE

Senate Candidates

By Larry Light

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r. Michael DellaVecchia is concluding his tenure as the 171st president of the Pennsylvania Medical Society (PAMED).

You will make a serious mistake if you underestimate the importance of the 2022 US Senate primary and general elections in Pennsylvania. Voters in those elections will seek to fill the seat being vacated by Senator Pat Toomey (R). Political strategists for both parties are certainly not falling into that trap. By all accounts the race to win the open seat in Pennsylvania has been identified as ground zero in this election cycle. In both parties, the goal must be to choose the most electable candidate for the statewide general election while navigating the difficult waters of party politics in the primary.

The most obvious reason for the high-profile status is that functional and political control of the US Senate is at stake. With the Senate currently split 50-50 and the majority dependent on the fact that Vice President Kamala Harris (D) is constitutionally the presiding officer, the 2022 election cycle looms as both contentious and pivotal.

is making heavy television ad buys and holding voter engagement sessions designed like a talk show. His strategy is to build respect in the polls by taking advantage of his widespread name recognition.

Just weeks before the election, though, the highest polling Republican candidate is David McCormick, a hedge fund executive who is rebuilding his roots in the state. Meanwhile Fetterman, the state’s Lt. Governor but an acknowledged party outsider, has continued to campaign in his non-traditional work clothes while aggressively meeting with voters in what he says are “forgotten” areas and attacking GOP candidates as he leads the Democratic polling. He points to Super PACs supporting the wealthy GOP candidates who are also investing significant personal funds to back their campaigns.

There are a few unique situations that will factor into the primary cycle. Lt. Gov. Fetterman and Congressman Conor Lamb on the Democratic ballot are both from Allegheny County. The other viable candidate is State Representative Malcolm Kenyatta from Philadelphia.

The unknown is whether one of the two western PA candidates can The contest in Pennsylvania, one of only a handful of Senate earn enough votes to defeat both the other western PA candidate races nationwide viewed as competitive, garners even more notoriety and the eastern PA candidate. Republicans Dr. Oz and David Mcbecause Pennsylvania is correctly regarded as a swing state. A Dem- Cormick are both transplants from out of state who have migrated ocratic winner will “swing” the seat from the Republican column to the southeastern part of the state. Also on the Republican ballot to Democratic column and a Republican victory may very well will be Carla Sands, a former ambassador to Denmark, activist and “swing” control of the Senate in favor of that party. This in a state commentator Kathy Barnett and businessman Jeff Bartos. Political where Democrat Joe Biden in the 2020 President election reversed pundits are not surprised that even with millions spent on advertising the win by Republican Donald Trump in 2016. So the high profile before the start of 2022, the early leader in polling was “undecided.” status is well deserved.

Voters would be well advised to not just show up on May 17th Both parties have competitive primaries with several candidates without making some attempt to review candidate backgrounds and vying for a landmark win. Legal challenges and court rulings will policy positions before deciding on their candidate of choice. In the have a telling effect on the congressional and state legislative races modern era they can do that by wading through websites, media on voters’ ballots because of reapportionment, but those are not coverage, texts and emails. an issue in a US Senate race. Consequently, the Senate contest will The usual script in a primary election campaign places most stand above the fray in 2022 Pennsylvania politics candidates in accord with their own party primary opponents on Since neither statewide party decided to make an endorsement the major policy issues, setting the stage for the partisan-oriented in their Senate primary, the multiple candidates crisscrossing the November mid-term elections. Topics like fracking, abortion, voting Commonwealth have been aggressively raising money, making rights, Senate filibusters, trade with China, border security, Covid 19 high- priced media buys and attacking not only their primary treatments, inflation, gas prices, health care and gun control provide opponents but leading candidates in the other party. It is truly a a wealth of contentious issues for future debates. turbulent campaign, and it has been challenging for the candidates One aspect of this election cycle and their campaign operatives to raise funds, spread their message, is that there remains the possibility demonstrate their strength in polls and collect commitments of that Pennsylvania voters will elect a support prior to the May 17th primary.

US Senator who is African American With so much at stake the individual candidates are often the (Kenyatta), or a woman (Clark) or subject of intense interest, especially in the media. Surprisingly, in a physician (Oz). Any one of those a party specific primary election one leading candidate, Republican would be a historic first. • Dr. Mehmet Oz, is also attracting attenttion from the early leader in Larry Light retired from PAMED as the other party race, Democrat John Fetterman. Dr. Oz, a physician the Senior Vice President for Physician who morphed his surgical career into a daytime television personality, and Political Advocacy.

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FEATURE

Government vs. Medicine It Could Be a Slippery Slope

By Karen L. Chandler

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ecent political moves will have governments weighing in on what treatments physicians can choose for their patients.

identifying how the boards are impacted by and dealing with health care professionals who spread false or misleading details about COVID-19.

And while there are legislators who are licensed physicians, the majority are not.

The survey revealed 67% of boards experi- The Tennessean also reports that Dr. Stephen enced an increase in complaints about licensed Loyd of the Board of Medical Examiners physicians disseminating false or misleading reviewed Todd’s bill and expressed that as information. 26% have provided statements written it would not have a great impact regarding the dissemination of the misin- on the board whose goal is only to fight the formation, while 21% have actually taken spread of provably false information. disciplinary action against a licensee who But Loyd did agree that the bill may create actually spread COVID-19 misinformation. a path for physicians to argue that their false The Tennessean reports that Dr. Melanie Blake, claims were actually opinions and thereby Tennessee Medical Board president, spoke protected by the new law. out about the legislation in September 2021. In Pennsylvania, a similar bill that would

To counteract misinformation believed to be spread by some physicians and exacerbated by the media, the Tennessee State Board of Medical Examiners adopted a policy to penalize physicians who speak out with false information about COVID-19 vaccines and treatments. These doctors could face a potential loss of their licenses to practice.

Despite the support of the policy by the American Board of Internal Medicine, the Federation of State Medical Boards, and others, the state of Tennessee took a different stance.

of COVID-19 just like any other illnesses they treat on a regular basis. We’ve never seen restrictions on physicians like we have in the last 18 months.”

She said, “You don’t get to use your Tennessee allow physicians to veer from the guidelines state medical license in order to promote a was put in place by the Centers for Disease platform just spewing medical misinforma- Control and Prevention for their COVID-19 Only months after the September 2021 tion to your patients. I think we have an treatments. policy to tighten the reins on physicians ethical obligation to investigate it and stop State Representative Dawn Keefer (R-York), was put in place, Tennessee legislators voted it and I think the citizens of our state expect the bill’s author and secretary of the House to stop the licensing board from punishing nothing less.”

Health Committee, said, “I am advocating licensed physicians in regard to their choices Called the “Tennessee COVID-19 Treatment for treatment, period, for patients’ right to of COVID-19 treatments and required the Freedom Act,” the bill prevents the Tennessee try, these patients who are being told in the policy to be removed.

Board of Medical Examiners from disciplining hospital there’s nothing else we can do for Following Tennessee’s lead, North Dakota doctors for anything “solely related to the them. Why not a Hail Mary?” passed a similar law and 24 more states on physician’s prescription, recommendation, Further complicating an already complex both sides of the aisle are considering the use, or opinion relative to a treatment for situation was revealed in Politico with an same path. And Pennsylvania is included COVID-19,” to include treatments that explanation by Chaudry. have not been approved by the state’s health in the mix.

“Legal structures developed for the 20th department or the FDA. Dr. Humayun Chaudhry, CEO of the century are, in many states, not suited to disFederation of State Medical Boards (FSMB), The bill’s author, State Representative Chris cipline doctors who broadcast misinformation called the decisions and considerations an Todd, defends his position to MedPage on social media because the physicians are Today by saying “doctors in this state have not directly treating patients,” Chaudry said. “unwelcome trend.” been handed an unconstitutional ultimatum He added, “at the end of the day, if a physician from a board that has repeatedly exceeded “So, some boards – and other regulators that who is licensed engages in activity that causes its legal authority. As representatives of the license providers and the non-profits that harm, the state medical boards are the ones people, we must do everything in our power certify physicians for their expertise – feel that historically have been set up to look into to rein in this abuse and restore the liberties uncertain about disciplining such doctors, the situation and make a judgement about and freedoms our physicians are guaranteed even though they might be contributing to lagging vaccination rates.” what happened or didn’t happen.” under our constitution.”

In December 2021, the FSMB reported Todd added, “my bill does that, but it also Chaudry remains concerned by legislators’ findings from its 2021 annual survey of guarantees the ability for doctors to practice attempts to halt oversight of medical prostate medical boards, with the survey’s focus as they are licensed and trained for treatment fessionals. “And if you start to chip away at that, it becomes a slippery slope.” • Spring 2022 : Philadelphia Medicine 23

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FEATURE

“Alexa, I want to talk to a doctor.”

By Karen L. Chandler

P

atients across the United States will now be able to summon the help of a medical professional, almost as easily as they request a song or a recipe.

Teladoc Health, rated #1 among direct-to-consumer telehealth providers in the J.D. Power 2021 U.S. Telehealth Satisfaction Study, announced their new virtual care technology in February.

Certain Echo devices such as Echo, Echo Dot, and Echo Show will support Amazon Alexa’s voice-activated general medical virtual care and allow customers to connect via audio with a Teladoc provider 24/7. And Teladoc reports that video visits are on their way.

To initiate a visit, customers can say, “Alexa, I want to talk to a doctor,” to any supported Echo device and be connected to the Teladoc call center which will then gather insurance information and inform the patient what, if any, portion of the standard $75 fee will be covered. An available physician will call the patient to continue the visit but wait times could vary.

Amazon will not be able to access, record, or store the content of patient calls.

Edison Research reports that about a third of Americans aged twelve and older own a smart speaker and about a quarter of those speaker owners have an Amazon Alexa device.

also help with access.

But others worry that older patients, those who may need the convenience most, may never have the ability or technology to engage in a virtual visit.

Despite more people using virtual doctor visits during the pandemic, the number of those patients has slightly decreased. It is reported that many appreciate the option of telemedicine for its convenience but not as a replacement for their care.

The Teladoc rollout with Alexa coincides with Walmart, CVS, and Walgreens adding their own virtual programs and care clinics that will compete with the standard U.S. health care system.

The New Yorker reported in June 2020 that many rural hospitals and country clinics were already suffering with staffing shortages and the lost income due to procedures delayed during the pandemic and fear the financial hit that may come along with an increase in telemedicine.

Fewer in-person visits causing economic losses could force smaller medical facilities into bankruptcy, a trend starting prior to the pandemic, and it has been estimated that as many as 60,000 family medicine physicians may lose their practices post-pandemic.

“Teladoc Health’s collaboration with Amazon is yet another step in breaking down barriers to healthcare access,” said Donna Boyer, a chief product officer at Teladoc Health, in a recent press release.

It seems that doctors may not all be sold on telehealth as stated in a 2019 AMA survey saying only one in three specialists had full confidence that virtual visits would be beneficial to their practices and only two in five primary doctors agreed telehealth would be of help.

Virtual Alexa Teladoc visits are intended for non-emergency health concerns, such as a patient’s experience with common symptoms of flu, a cold, or allergies.

Some doctors believe that offering virtual care to a patient they know is quite a different story from talking through symptoms during an initial tele-visit.

Debra Chrapaty, vice-president and chief operating officer of Amazon Alexa, added that patients who are caring for a sick child during the night or suffering allergy symptoms during the workday may appreciate the convenience of talking to a health care provider from their home or office.

And a tele-doctor carries the same liability as a physician seeing a patient in person; virtual doctors will hopefully tell patients with symptoms that could evidence an underlying condition to make a trip for an in-person evaluation and testing.

While some patients may appreciate the convenience of telemedicine, they do need an internet connection and the equipment to participate. The bi-partisan infrastructure bill held a $65 billion budget allotted to expanding access in rural areas and helping families to pay an internet bill and some pandemic policies put in place will 24 Philadelphia Medicine : Spring 2022

“And, in spite of the time-and-money-saving advantages of telehealth, a lot of people clearly want to be in the physical presence of their physician, undergoing the familiar rituals of a checkup—the doctor’s scrubbed hands emerging from the crisp cuffs of a white lab jacket—that no screen can yet provide,” said The New Yorker. •

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FEATURE

PM Resident/Med Student Spotlight

Winnie Rao

MD Candidate 2023 Drexel University College of Medicine Chair, PCMS Medical Student Section As Chair of the PCMS MSS and a Medical Student Section leader, Member of the PCMS Board of Directors, Delegate to the House of Delegates, member of the AMA, etc., how has organized medicine impacted your career in medicine?

What are your hobbies and interests?

Being involved in organized medicine within different roles, I have learned how to become a better advocate and a better leader for my colleagues and my patients. I have learned how to communicate effectively to support policy. These experiences allow me to continue to my involvement in organized medicine as a physician.

For what reason(s) did you become a member of the Philadelphia County Medical Society and what do you value most about your membership?

I recently received a certification in free diving allowing me to always test my limits underwater. I also love going outdoors either running or hiking. And also spending time with my dog.

What drew you to Philadelphia ?

I was born and raised in Philadelphia.

As I left the city for college, I realized how much I loved Philadelphia and how much the city offers especially the residents and the delicious food.

What do you like most about medical school?

I currently go to Drexel University College of Medicine and what I love most about this school is their commitment to its community.

In the first year of medical school we’re required to do service around Philadelphia.

I love that I am able to understand the needs of local residents and how their needs affect their health. They also have Health Outreach Project (HOP), a student run clinic that allowed me to work as a patient advocate at

the Streetside Clinic at Prevention Point in the Kensington neighborhood. One of the reasons that led me to medicine was the ability to give back to the community from which I came, and I valued that the medical school’s curriculum provided that. I also appreciate the support from my medical school peers and faculty. I would not be where I am today without them.

Are you involved in any community, or non-profit organizations? If so, please list the groups: N/A ):

I believe there is more to treating a patient than within the four walls of a medical office.

I believe as a physician, it is important to be involved in policy as it plays a huge part in addressing the health inequities seen in our patients. What drew me to Philadelphia County Medical Society was their commitment in advocating for their patients, colleagues, and the voices of medical students. I value the ability to network with local physicians and medical students throughout the city with the help of this society. Joining this society was the first step for me as a student to get involved with local and state policy as well as learning how to write and submit resolutions into the state. Compared to other counties throughout the state, I believe PCMS has been the most supportive medical society of medical student voices. I also appreciate that this county offers a free membership for medical students because this allows me to get involved with policy without the worry of annual fees. • Spring 2022 : Philadelphia Medicine 25

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feature

2022 NRMP DELIVERS A STRONG MATCH TO THOUSANDS T

his year’s Main Residency Match included 47,675 registered applicants and a record 39,205 certified positions. All categories of applicants saw improvements over 2021. Growth in the number of PGY-1 positions was most visible in Emergency Medicine (n=81), Family Medicine (n=93), Psychiatry (n=140), and Internal Medicine categorical positions (n=356). As a percentage of positions filled based on positions offered, Family Medicine saw a 2.7 percentage point decrease this year compared to last, and Internal Medicine saw a 0.7 percentage point decrease. Psychiatry saw a 0.6 percentage point decline.

The number of unfilled positions, driven in part by the decreased number of ranks submitted by U.S. MD and DO seniors for Emergency Medicine, could reflect changing applicant interests or projections about workforce opportunities post residency. Emergency Medicine has grown considerably over time, having added 643 positions since 2018, an increase of 28.2 percent.

The 2022 Main Match also saw record gains in the PGY-1 match rates for U.S. MD and DO graduates. The percent of U.S. MD graduates matched to PGY-1 positions increased from 48.2 to 50.5 while the percent of U.S. DO graduates matched to PGY-1 positions increased from 44.3 to 53.6. These are the highest percentages on record for both applicant types. This year, 2,262 positions were unfilled after the matching algorithm was processed, 335 more than last year. Of those, 2,202 (97.2%) were first-year positions.

There were 370 more positions available during Match Week this year for unmatched and partially matched applicants, an increase of 19.6 percent. • Learn more at https://www.nrmp.org/match-data-analytics/residency-data-reports/ 26 Philadelphia Medicine : Spring 2022

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2121 K Street NW, Suite 1000, Washington, DC 20037 www.nrmp.org Email: support@nrmp.org Toll Free: (866) 653-NRMP Phone: (202) 400-2233

2022 Main Residency Match® By the Numbers*

Complete data here: https://www.nrmp.org/match-data-analytics/residency-data-reports/ See Definitions on p.1 of Advance Data Tables for explanation of terms

Positions

Total Positions** Total PGY-1 Positions** Total Positions Filled** Total PGY-1 Positions Filled** Unfilled Positions Unfilled Positions Offered in SOAP Percent of All Positions Filled*** Percent of PGY-1 Positions Filled***

U.S. MD Seniors

U.S. MD Seniors Submitting Program Choices** U.S. MD Seniors Matched to PGY-1 Positions** Percent of U.S. MD Seniors Matched to PGY-1 Positions*** Percent of PGY-1 Positions Filled by U.S. MD Seniors***

U.S. DO Seniors

U.S. DO Seniors Submitting Program Choices** U.S. DO Seniors Matched to PGY-1 Positions** Percent of U.S. DO Seniors Matched to PGY-1 Positions** *** Percent of PGY-1 Positions Filled by U.S. DO Seniors***

All Applicants

Total Registered Applicants Applicants Certifying Rank Order Lists** Applicants Matched to PGY-1 Positions** Percent of Active Applicants Matched to PGY-1 Positions***

Couples

Couples Submitting Program Choices Couples Match Rate***

CHANGE FROM 2021 39,205 36,277 36,943 34,075 2,262 2,262

↑ ↑ ↑ ↑ ↑ ↑

1,099 1,083 764 722 335 370

2.9% 3.1% 2.1% 2.2% 17.4% 19.6%

94.2 ↓ 0.7% 93.9 ↓ 0.9% 19,902 18,486 92.9 51.0

↑ 36 ↑ 51 ↑ 0.1% ↓ 1.4%

7,303 6,666 91.3 18.4

↑ 202 ↑ 339 ↑ 2.2% ↑ 0.4%

2.8% 5.4%

47,675 42,549 34,075

↓ 1,025 ↑ 41 ↑ 722

2.1% 0.1% 2.2%

0.2% 0.3%

80.1 ↑ 1.6% 1,222 93.7

↓2 ↑ 0.3%

*Numbers do not include the Match Week Supplemental Offer and Acceptance Program® **Highest on record ***Increases or declines reflect absolute percent changes since 2021 Spring 2022 : Philadelphia Medicine 27

p h i l a m e d s o c .org

FEATURE

PROTECT YOUR PRACTICE FROM CYBER ATTACKS

28 Philadelphia Medicine : Spring 2022

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“The most pressing issue in cybersecurity today is that criminals are far more committed to stealing data than leadership is to protecting it.”

— Eric Roebuck, CEO CISO, Valander Cybersecurity

T

he Cybersecurity world is a mess. According to Security magazine, there were 1,767 publicly reported data breaches exposing 18.8 billion records in 2021. This is a decrease from 2020’s pace. Although this may seem like progress, let me assure you it is certainly not. Data breaches have decreased because a more profitable attack has taken its place; Ransomware. Ransomware and data breaches, however, are the symptoms, and not the disease.

development are aimed at breaking into systems and making money on data theft and encryption. Because most organizations have a lack of understanding about cybersecurity issues at the highest level, the commitment to protection is nowhere near the commitment of invasion, handing the bad guys an enormous advantage.

dedicated to stealing data than we are prepared to protect it. Again, it’s their ONE and ONLY job!

As Sun Tzu wrote in the Art of War, “If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle.” •

So how do we minimize the risk of cyberattacks? The only way to counteract this is with written policies, procedures and guidelines There will always be cyberattacks with the data-rich environments that are understood and followed by everyone. We begin by reviewing created by our high-tech world. The issue, therefore, is not that there our current organizational vulnerabilities which are probably stagare attacks, but how do we create a culture to deter them from attacking gering and quite invisible to the average employee. We then develop our organizations. The only way to start gaining ground is to instill understandable, and enforceable, written documentation, while a culture of security at every level within our organizations. It starts creating a culture of detailed processes and protocols that identify with command emphasis from the top. Leaders must understand the infrastructure and employee cyber hygiene. A framework like the challenges and costs associated with keeping data safe as compared Nist 800-53 or the ISO 27001 must be implemented and taught. to the crippling costs and effects of data breaches.

The Nist 800-53 can be implemented with less pain by using a SAAS First, it’s important to understand who is attacking your company, program like Compliancepro.info to help leadership go step-by-step and why. When we close our eyes and imagine who the hackers are, through the process. And we must continually remind our team we envision an overweight, dirty, and socially awkward person in that any misstep can be immediately detected by cyber criminals. their parents’ basement, pounding on their keyboards at three am.

The process to mitigating disaster is a massive undertaking for all This is not the case. There are entire companies staffed with cyber team members, but most importantly for leadership. Other responhackers dedicated to stealing your data to sell it or make you pay a sibilities compete for our time and attention. Hence, this problem ransom for the privilege to exist. It’s their job, 24/7, and it’s about can only be solved by understanding, then delegating the task. A making money or inflicting pain! competent Chief Information Security Officer could be a first step Next, in the cyber battle, it’s important to note that when one for larger companies. Smaller organizations may wish to contract type of attack is controlled, another is on the way. There are coun- information security professionals to secure their IT environment. tries with cyber armies in the tens of thousands that can see your Ultimately, however, the responsibility to keep data safe still falls on vulnerabilities at the speed of light from half a world away. Even you. You must push a culture of leadership through a framework beginners have enough free tools and training at their disposal to and be as committed to protecting your organization as the bad become a threat in a matter of weeks. Each of these enemies is more guys are to attacking you.

As leaders we underestimate our adversary. The bad guys are far more committed to stealing organizations’ data and encrypting their systems than leaders are to protecting them. This is not an issue of competence, but one of time and culture. Cyber criminals have the luxury to being singularly focused on attacking. All their research and

Spring 2022 : Philadelphia Medicine 29

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FEATURE

Introducing My Benefit Advisor We Focus on Your Benefits.

You Focus on Your Practice.

M

any Docs and Firm Administrators struggle with understanding and getting the most out of their employee benefits and may not be aware of the different services available to enhance their employee benefits offerings. As a solution for its members, Philadelphia County Medical Society is proud to offer members access to the My Benefit Advisor (MBA) program.

MBA is designed to guide members through the complexity of planning, communicating, and managing an employee benefits program that meets the needs of their employees and is in-line with financial objectives. Our experts have an in-depth understanding of the marketplace, compliance regulations, and strategies for long-term cost containment.

MBA provides numerous resources, tools, and products to benefit medical practices, strengthening their employee benefits program and setting their business up for success.

Resources for MBA Clients: • Consulting: Our experts have a wealth of experience to help you understand your options to make an informed decision and guide you through the implementation process • Discounted Insurance Resources: Exclusive savings and programs through the Med Society to help save money 30 Philadelphia Medicine : Spring 2022

• Unique Programs: Solutions for student loan debt repayment, Payroll, HRAs, and more • Online Enrollment & Communication: Effectively communicate your benefits program, improving tracking and collection of enrollment data, and enable employees to update personal information, make benefit elections, and view side-by-side plan comparisons and summaries • Human Resources Support: Complimentary access to comprehensive HR solutions including live phone support, training courses, and an online library to assist practices large & small • Medicare: We guide you through the processes to help you find and enroll in the coverage that fits your needs • First-Class Service: Our service team and resources ensure employers have continuous assistance with the ongoing administration of their benefits program and employees have answers to everyday benefit questions • Compliance Education: Simplifying complex health care reform topics and highlighting employer responsibilities There are many more advantages to the MBA program. We advise clients from individuals and families to small & mid-size practices. For more information about My Benefit Advisor, visit this website: pcms.mybenefitadvisor.com or contact Jim Pitts at (610) 684-6930. •

A Continuing Medical Education Program Saturday, April 30, 2022 8:00AM-12:30PM Program Director, Harvey B. Lefton, MD, FACP, FACG, AGAF, FASGE, past President, PCMS

Gary D. Wu, MD

Henry P. Parkman, MD

David A. Sass, MD

Raina Shivashankar, MD

No fee to attend. Program will be held as a Zoom video conference.

Registration is required. RSVP at:

https://philamedsoc.org/events-and-news/pcms-events/ You can also RSVP or learn more by calling (215) 563-5343 Topics to be discussed: Update on the Gut Microbiome for Clinicians

Gary D. Wu, MD Ferdinand G. Weisbrod Professor in Gastroenterology, Director, Penn Center for Nutritional Science and Medicine, Co-Director, Penn CHOP Microbiome Program; Co-Director Center for Molecular Studies in Digestive and Liver Diseases, Perelman School of Medicine, University of Pennsylvania

Approach to the Patient with Esophageal Disease Henry P. Parkman, MD Stanley H. Lorber Research Endowment Fund Chair in Gastroenterology, Professor of Medicine, Lewis Katz School of Medicine at Temple University, Director, Gastroenterology Motility Laboratory, Temple University Hospital

Trends in Liver Disease

David A. Sass, MD, FACP, FACG, AGAF, FAASLD Professor of Medicine; Medical Director, Liver Transplantation; Sidney Kimmel Medical College at Thomas Jefferson University

Updates in the Medical Management of Inflammatory Bowel Disease

Raina Shivashankar, MD Assistant Professor of Medicine, Division of Gastroenterology, Associate Director, IBD Center and Program Director, Inflammatory Bowel Disease, Fellowship, Division of Gastroenterology & Hepatology, Sidney Kimmel Medical College at Thomas Jefferson University

ACCREDITATION This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Pennsylvania Medical Society and The Philadelphia County Medical Society. The Pennsylvania Medical Society is accredited by the ACCME to provide continuing medical education for physicians.

The Pennsylvania Medical Society designates this live activity for a maximum of 4.5 AMA PRA Category 1 Credits™ Physicians should only claim the credit commensurate with the extent of their participation in the activity.

Philadelphia County Medical Society | stat@philamedsoc.org 215-563-5343 | http://philamedsoc.org

31 S T A N N U A L

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