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WINTER 2022

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Perils of COVID-19: Managing stress during pandemic Scalpel & Baton

THERE ARE A LOT OF SIMILARITIES BETWEEN CONDUCTING AN ORCHESTRA AND OPERATING AS A SURGEON

Rise of the Private Practice Courage, effort and capital just part of the framework

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10 Physician/Conductor: Similarities between conducting orchestra, operating as surgeon

EXECUTIVE COMMITTEE Stephen R. Permut, MD, JD PRESIDENT

Ricardo Morgenstern, MD

14 Ultrasound: Portable technology in hands of Temple medical students

PRESIDENT ELECT

Natalia Ortiz, MD, DFAPA, FACLP IMMEDIATE PAST PRESIDENT

John M.Vasudevan, MD

Perils of COVID-19: Managing stress during pandemic

17 A New, Affordable Model for Medical Practices

SECRETARY

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Starting out: Courage, effort and capital part of framework

21 Obesity, diabetes take toll on community: Addressing the challenges

24 Practitioner: Spirit of caring, compassion has infiltrated physician’s every interaction with patients

26 Strittmatter Award: Recipients create impact

Winnie Rao FIRST DISTRICT TRUSTEE Lynn Lucas Fehm, MD, JD PA Medical Society, President Michael A. DellaVecchia, MD, PhD, FACS EXECUTIVE DIRECTOR Mark C. Austerberry EDITOR Andy Andrews

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29 PAMED president was past president of PCMS

30 PAMED House of Delegates announces resolutions

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WINTER 2022

Contents

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Letter from the president

hile COVID-19 challenges and ever-new variants fill our newsfeeds, time taken for our own self-care — including a checkup of our mental well-being during these stressful times — remains important.

In this issue, writer David A. Kostival focuses on the work of two important groups, the Physician Support Line and the Physicians’ Health Program, in dealing with the ongoing pandemic.

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

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Physicians suffer the same stresses as any of us face; perhaps more in this health crisis. “Even physicians who are inherently resilient are at risk of neglecting their physical and mental health,” said Dr. Edwin Kim, medical director of the Physicians’ Health Program. PHP provides monitoring and advocacy for physicians who have substance use disorders, mental health issues or behavioral concerns that impact their ability to practice their profession safely. A mental health resource — a powerful one at that — is the Physician Support Line, the first of its kind because it provides physicians with a resource for counseling while remaining completely anonymous. Psychiatrist Dr. Mona Masood, with offices in Bryn Mawr and Ivyland, recognized the huge amounts of stress doctors face and became the founder and chief organizer of the Physician Support Line. The organization was started in March 2020, right at the beginning of the pandemic. And it really came from an “if-not-me-thenwho?” attitude, Masood said. She said an anonymous hotline was absolutely needed to give physicians an outlet for the stress they faced.

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

Philadelphia Medicine : Winter 2022

Love of music One outlet for stress could be a love of music. “I was always interested in music, and I wanted to be a conductor,” said Dr. Fawzi

Habboushe, in a story this issue by Michael C. Upton. “I understood that I had to be more involved and get into music in a proficient way.” At age 44, Habboushe began conducting, which led to the formation of the Philadelphia Doctors’ Chamber Orchestra. A lifetime with the orchestra fulfilled his desire to operate a baton when not using a scalpel. Habboushe’s love of music stems back to his childhood when he would admire his father, Petros, who served as an “amateur organist” at a church in his native Iraq. There are a lot of similarities between conducting an orchestra and operating as a surgeon. Of course, the subject matter is different, but a lot of the details, accuracy and intricacies can be similar, Habboushe said.

Exciting technologies These are exciting times to be in medical school with some surprising technologies making their way on campus. In another feature this issue by Kostival, point-of-care ultrasound technology began with emergency medicine out of a need in 24-hour emergency rooms, said Dr. Ryan Gibbons, associate professor of emergency medicine, director of the Emergency Ultrasound Fellowship and associate director of the Division of Emergency Ultrasound in the Department of Emergency Medicine, and director of Ultrasound in Medical Education at the Lewis Katz School of Medicine at Temple University. The technology in the hands of first- and second-year students is the Butterfly iQ+ point-of-care ultrasound. The probe is plugged into a mobile device, which then connects to the Butterfly iQ+ iOS or Android app. The device has access to six imaging modes, offering visualization of nearly every bodily structure. Temple University became the first school on the East Coast to give ultrasound devices to medical students: in this case, to every member of the class of 2025 in August and to the members of the class of 2024 in October.

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Starting practice

More features

In Upton’s story this issue about starting a private practice, several facts are apparent.

There are several additional features focusing on mental and physical health.

Physician-owned private practice is “one of the strongest career paths a doctor can pursue,” said Dr. Jaan Sidorov, former CEO of the PA Clinical Network, a subsidiary of the Pennsylvania Medical Society.

For one, Klaus Kroyer Madsen continues his two-part question-and-answer series with prominent diabetes and obesity experts this issue.

But there are challenges when it comes to determining office space and other issues that Upton outlines in the feature. Veronica Blum of MPN Realty, Philadelphia, believes it is helpful for practices to go into a space that was already a medical practice or similar facility. This will cut down any renovation costs needed to adapt the space to a new practice’s specific needs. Sites previously occupied by medical services move off the market quickly, Blum said.

Self-care — proper diet, exercise and other factors — is part of the dialog.

Surgery, president and CEO of the Faber Institute for Neuroscience, medical director of the Jefferson Neuroscience Network and senior vice president of Jefferson Enterprise Neuroscience. Also profiled: Dr. N. Scott Adzick, 2021 Strittmatter Award recipient, a pioneer in fetal surgery at Children’s Hospital of Philadelphia. I hope you enjoy this issue! •

We also feature an article by Susan L. Dr. Stephen Permut, president of the Peña on the many selfless contributions Philadelphia County Medical Society, works made by Dr. Wayne Bond Lau, winner of in the Temple University Hospital family the Philadelphia County Medical Society’s medicine department. 2021 Practitioner of the Year Award. Pena also profiles Dr. Robert H. Rosenwasser, 2020 Strittmatter Award recipient. Rosenwasser is the Jewell L. Osterholm MD Professor and Endowed Chairman in the Department of Neurological

YOUR CARE IS ORCHESTRATED BY A TEAM OF CARDIAC SPECIALISTS. When you have a heart network that is close to home, rest assured your heart is in good hands. We have a team of cardiologists in the Prime Pennsylvania Region. From risk assessments to diagnostic procedures, you can be confident that the most advanced cardiac care is always available nearby. Winter 2022 : Philadelphia Medicine

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FEATURE

‘COVID-19 HAS BLOWN THE LID OFF’ NEED FOR STRESS MANAGEMENT EXACERBATED BY PANDEMIC

By David A. Kostival, Contributing Writer

s the United States exceeds 800,000 COVID-19 deaths, it’s important to recognize the number reflects only deaths resulting directly from complications caused by COVID-19.

It does not account for deaths resulting from drug overdoses or suicides as an indirect result of the pandemic. And while we look to medical caregivers to help us safely navigate through the ongoing effects of the pandemic, physicians are not exempt from the stress. The American Hospital Association says about 400 physicians die each year from suicide, and that hundreds more have serious thoughts of suicide. WebMD states that about one doctor a day commits suicide in the United Sates every day, which translates to the highest suicide rate of any profession. The suicide rate in the general population is 12.3 per 100,000 people, while the number of doctor suicides is between 28 to 40 per 100,000.

Philadelphia Medicine : Winter 2022

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WebMD states that about one doctor a day commits suicide in the United Sates every day, which translates to the highest suicide rate of any profession.

Monitoring and advocacy The Foundation of the Pennsylvania Medical Society’s premier program is the Physicians’ Health Program (PHP). PHP provides monitoring and advocacy for physicians who have substance use disorders, mental health issues or behavioral concerns that impact their ability to practice their profession safely. Dr. Edwin Kim, MD, MRO, serves as the medical director for PHP. Kim said that prior to the pandemic, physician burnout had already become a growing concern. “This was certainly exacerbated over the last two years,” he said. “Even physicians who are inherently resilient are at risk of neglecting their physical and mental health.” Kim said some large health systems and academic centers have started programs to provide avenues for their physicians to seek additional support. “This included ways to engage mental health or counseling resources available to their employees,” Kim said.

Dr. Edwin Kim serves as the medical director for Physicians’ Health Program, an initiative of The Foundation of the Pennsylvania Medical Society.

But not all physicians work in a large group setting where structured support systems exist. For those situations, Kim said state and county medical societies or professional specialty associations have stepped up to create resources and toolkits for their constituencies, particularly independent practitioners and those in smaller group practices. “We have even seen grassroots, physician-led support groups arise early in the pandemic,” Kim said. “I think increasing awareness of these programs and tools is crucial.”

Stress doctors face Psychiatrist Dr. Mona Masood, with offices in Bryn Mawr and Ivyland, recognized the huge amounts of stress doctors face and became the founder and chief organizer of the Physician Support Line. The Physician Support Line is the first of its kind because it provides physicians with a resource for counseling while remaining completely anonymous.

Psychiatrist Dr. Mona Masood is founder and chief organizer of the Physician Support Line.

continued on next page

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cover story continued

‘Even physicians who are inherently resilient are at risk of neglecting their physical and mental health.’ – Dr. Edwin Kim

Masood explained when physicians attempt to seek care from their own health care systems, they do not feel secure and potentially put their practice or profession at risk. “We are penalized for seeking mental health,” Masood said.

“The Physician Support Line was started in March 2020, right at the beginning of the pandemic,” Masood said. “And it really came from an ‘if-not-me-then-who?’ attitude. “I saw the writing on the wall in regard to mental health,” she said. “We, too, were building the plane as we were flying it.” Being part of large physician social media groups, Masood said she began seeing posts about how poorly some were feeling in regard to mental health. Masood said an anonymous hotline was absolutely needed to give physicians an outlet for the stress they faced.

“Medical boards ask information to be disclosed on those seeking help for mental health,” she said. “Many doctors find they don’t get their licenses renewed or have to go through programs. There are a lot of systemic barriers, so no wonder that we have one of the highest suicide rates. COVID-19 has blown the lid off of it.” Masood explained that the Physician Support Line remained unaffiliated with any healthcare system on purpose in an effort to maintain integrity.

Loss of empathy As the COVID-19 pandemic progressed, Masood said one of the things physicians needed to watch out for as a warning sign was a loss of empathy for patients.

“That is something that really affects outcomes,” Masood said. “What has really been a red flag is a caller saying that they now do not “We started with 50, and have grown to having over several know why they ever went into medicine. When losing the essence hundred volunteers who run this nationwide,” Masood said. of why they went into medicine, they do not feel the same. They “When we looked into it, what we found is that there continues don’t recognize themselves. This is incredibly related to COVID-19.” to be a barrier to mental health care for physicians,” she said. “Mental Kim said doctors should be alert to a low mood that persists health resources affiliated with health care systems pose a problem. There is a systemic barrier for physicians seeking mental health care.” over time.

‘The Physician Support Line was started in March 2020, right at the beginning of the pandemic. And it really came from an ‘if-not-methen-who?’ attitude.’ – Dr. Mona Masood 8

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‘There are a lot of systemic barriers, so no wonder that we have one of the highest suicide rates. COVID-19 has blown the lid off of it.’ – Dr. Mona Masood

“Disruptions in sleep and appetite are clear signs that there is stress occurring, either physically or mentally,” Kim said. He advises physicians to conduct a daily or weekly personal check-in. “A physician may be facing burnout if one is finding it more difficult to recognize their passion for medicine, recognize increasing feelings of cynicism toward their profession, feelings of dread or unrelenting fixation on past difficult clinical situations or a sense of distrust toward coworkers or leadership,” Kim said. “The inability to cut down on alcohol, gambling or other uncontrolled behaviors can be warning signs of uncontrolled stress or strained mental health as well.” Masood said that what made COVID-19 illnesses incredibly unique, was that everyone was trying to find blame for what they were suffering. “There’s the people who will not mask, don’t believe in the science and will not vaccinate,” she said. “When you have that, you start feeling resentment. The human politicization and polarization have caused a lack of empathy.” When the pandemic started, Masood said calls focused on fears of becoming infected, but now calls are more focused on compassion fatigue, losing empathy and losing sight of what drew them to medicine in the first place.

Preventative measures Kim reminds physicians that preventative measures go a long way to help preserve physical and mental health. “Maintaining a healthy diet, exercise and sleep have never been more important to mitigate the effects of what can become chronic stressors,” he said. “Sometimes physicians put their own health last and have forgotten that they too can ask for help. Seeking professional help, asking your peer groups and leadership for more assistance or resources is key.”

“We are having hopeful discussions on the line, and perhaps this is an opportunity for change in health care,” Masood said. “It may change what we choose as acceptable behavior from health care administrators, including hours, hazard pay and knowing our own limits as human beings.” Masood wants to see a cultural shift in health care where physicians have to care for each other outside of patient care. “We can only talk about it with hope,” she said. “We’ve built a movement with hundreds of doctors behind systemic changes. Individual conversations become validating and normalizing.”

Expanded efforts As a direct result of her work, Masood said she has expanded her efforts on working on the stigma of mental health within medicine. She organizes ongoing seminars with medical students and is working with medical boards to try and change licensing questions. Kim said that the pandemic may have provided an opportunity for the Philadelphia-area hospitals and academic centers to create an inter-institutional solution. “The creation of a chief wellness officer, wellness group or taskforce can be a great first step in addressing the needs of their employees,” Kim said. More information on The Foundation of the Pennsylvania Medical Society can be found at www.foundationpamedsoc.org. In f o r m a t i o n o n t h e P h y s i cian Support Line can be found at www.physiciansupportline.com. The phone number for the anonymous hotline is 1-888-409-0141. • David A. Kostival is a contributing writer to Philadelphia Medicine.

Masood believes the pandemic has created a permanent change in health care. Winter 2022 : Philadelphia Medicine

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FEATURE

A lifetime with the orchestra fulfilled Dr. Fawzi Habboushe’s desire to operate a baton when not using a scalpel. 10 Philadelphia Medicine : Winter 2022

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Scalpel & Baton

‘THERE ARE A LOT OF SIMILARITIES BETWEEN CONDUCTING AN ORCHESTRA AND OPERATING AS A SURGEON’ By Michael C. Upton, Contributing Writer

olfing? Skiing? Fishing? So, what are the most popular pastimes for physicians?

Columbia General Hospital. Habboushe completed his residency at Philadelphia’s Graduate Hospital.

How about running? According to a survey by the American Medical Association, the highest-ranked activities doctors enjoy when not working are running or jogging. Bicycling, camping or hiking are also near the top of the list.

It was while he was in Philadelphia that he decided to rekindle his love for music, and entered Temple University’s music program.

Nowhere in the survey did conducting an orchestra rank among participating physicians’ favorite leisure activities.

‘Its own charm’

That is not the case with Dr. Fawzi Habboushe. At age 44, he began conducting, which led to the formation of the Philadelphia Doctors’ Chamber Orchestra. A lifetime with the orchestra fulfilled his desire to operate a baton when not using a scalpel.

“Music has its own charm, depending on what you are interested in,” Habboushe said. “Orchestra music can be any kind of music, as long as someone writes a piece and orchestrates it. I was always interested in music, and I wanted to be a conductor. I understood that I had to be more involved and get into music in a proficient way.”

Habboushe’s love of music stems back to his childhood when he would admire his father, Petros, who served as an “amateur organist” at a church in his native Iraq. “He played in a church, and we had an older organ we pumped with our feet,” recalled Fawzi, an 83-year-old retired thoracic surgeon. The young Habboushe played piano and violin. But following in his brothers’ footsteps, he went into medicine, temporarily leaving his passion for music behind. He graduated from the University of Baghdad College of Medicine in 1961 and moved to the United States to intern at the District of

In 1974, he began to study music at Temple under the auspices of the renowned Jonathan Sternberg, who conducted the university orchestra. He eventually became an assistant conductor to a group called The Doctor’s Orchestra, and the idea of creating a chamber orchestra developed. Orchestra music differentiates from chamber music because of the number of musicians. There is usually only one player per part in chamber music; a full orchestra doubles up sections to add volume. continued on next page

Dr. Fawzi Habboushe’s love of music stems back to his childhood when he would admire his father, who served as an “amateur organist” at a church in his native Iraq.

Winter 2022 : Philadelphia Medicine 11

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FEATURE continued At Temple, Habboushe studied musical scoring and gained the ability to imagine sound, a skill noted to be the conductor’s chief instrument. He studied every instrument of the orchestra. “Not so I could play them proficiently, but it helped me to understand the interaction with the musician playing the instrument,” Habboushe said. It was also around this time — while he was in his late 40s — when he co-founded the International Arts and Medical Association, an organization with a mission to combine arts and medicine. “There are a lot of similarities between conducting an orchestra and operating as a surgeon,” Habboushe said. “Of course, the subject matter is different, but a lot of the details, accuracy and intricacies can be similar.” Although both actions may seem to be a solo effort, they each rely on a strong team. Both surgeon and conductor rely on strong collaboration, constant communication and an innate intuition. Although the name implies the musicians in the ranks all practice medicine, the orchestra is open to anyone. Dr. Fawzi Habboushe encourages capable musicians from any profession to reach out.

‘There are a lot of similarities between conducting an orchestra and operating as a surgeon. Of course, the subject matter is different, but a lot of the details, accuracy and intricacies can be similar.’

– Dr. Fawzi Habboushe

Habboushe is retired, but he continues as a professor of medicine at Temple, where he teaches anatomy. “I love to teach and provide the application of anatomy to surgery,” Habboushe said.

Doctors’ orchestra As a nonprofit organization made up of approximately 40 volunteer musicians, the Philadelphia Doctors’ Chamber Orchestra has rehearsed and performed more than 300 scores since its inception more than 25 years ago. The mission is simple: Present and perpetuate symphonic music for the community. The Orchestra has taken its mission to many different venues over the years, sometimes playing in what Habboushe describes as “less than a true rectangle … only the space between the medical audience and the lecturer.” The group has played churches, hospitals, lecture halls and small to medium universities. Other venues, such as the Kimmel Center where the orchestra took part in a fundraising event for neurology research with Jefferson Sidney Kimmel Medical College at Thomas Jefferson University, stand out as highlights of his conducting curriculum vitae.

As a nonprofit organization made up of approximately 40 volunteer musicians, the Philadelphia Doctors’ Chamber Orchestra has rehearsed and performed more than 300 scores since its inception more than 25 years ago. The mission is simple: Present and perpetuate symphonic music for the community.

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“The best setting was at the Smithsonian Institute,” Habboushe said. The massive venue allowed for a 60-piece orchestra, which performed “Scheherazade, Op. 35,” a symphonic suite composed by Nikolai Rimsky-Korsakov. Notable pieces in the orchestra’s repertoire include “Jesu, Joy of Man’s Desiring” (Johann Sebastian Bach), “Symphonies 1 Through 9” (Ludwig van Beethoven) and “Symphonies 1 Through 4” (Johannes Brahms).

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For those who do not play an instrument, maybe attending an upcoming Philadelphia Doctors’ Chamber Orchestra concert can better the medical professional’s skill set. The International Journal of Surgery recently published a study citing that listening to Mozart and Bach can boost doctors’ performance by up to 11%.

Although the name implies the musicians in the ranks all practice medicine, the orchestra is open to anyone. Habboushe encourages capable musicians from any profession to reach out. Interested parties can join via the orchestra’s website: www. doctorsorchestra.com/join-us-1.

Players needed

“I am assuming it may take some time to get past this hurdle and make sure we are all safe from this virus,” Habboushe said.

Even though the orchestra had to cancel its 2020-2021 season because of the pandemic, the biggest hurdle facing the future of the orchestra is commitment.

He is still cautious about COVID-19 and gathering people together for rehearsal, let alone a performance. The plan is to have the orchestra return as soon as possible.

“There were not a lot of doctors interested in playing classical music,” Habboushe said. “There may be many more now, but doctors are busy. We are all busy. But to be able to accommodate practicing and rehearsing every week, and then performing it, becomes a difficult matter. That’s the limitation, but there are a lot of doctors who play an instrument.”

“I need to connect with the musicians,” Habboushe said. “My heart is still in it. The bottom line is I am looking forward to getting back to it.” •

As the orchestra moves into 2022, Habboushe hopes to find more of those doctor-musicians to fill the ranks of the Philadelphia Doctors’ Chamber Orchestra for a new season.

Michael C. Upton is a contributing writer to Philadelphia Medicine.

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Call us today for a consultation. 484.445.4145 • www.providencetreatment.com Winter 2022 : Philadelphia Medicine 13

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FEATURE

BUTTERFLY DEVICES

PORTABLE ULTRASOUND TECHNOLOGY IN HANDS OF TEMPLE MEDICAL STUDENTS By David A. Kostival, Contributing Writer

hen it comes to training students in the practice of medicine, keeping up with the latest technology often goes hand-in-hand with clinical skills.

Temple University recognized this earlier this year when it made a groundbreaking gift to all first- and second-year students in the Lewis Katz School of Medicine.

Because of what the university called a “generous donation” by Dr. Ronald Salvitti, MD, ’63, the Katz School gave handheld, portable Butterfly iQ+ ultrasound devices to every member of the class of 2025 in August and to the members of the class of 2024 in October. Temple became the first school on the East Coast to make such a gift. According to university officials, there are only two other medical schools, both on the West Coast, that gave its students the devices.

Six imaging modes The Butterfly iQ+ brings point-of-care ultrasound to the next level. The probe is plugged into a mobile device, which then connects to the Butterfly iQ+ iOS or Android app. The device has access to six imaging modes, offering visualization of nearly every bodily structure. In a press release, Jason Wingard, president of Temple University, said this was a path-breaking gift for medical students. “It allows us to introduce them to advanced medical imaging on the very first day that they begin their coursework, creating a solid foundation for them to become future leaders and innovators in the field of medicine,” Wingard said in a statement. Dr. Amy Goldberg, interim dean and professor of surgery at the Lewis Katz School of Medicine at Temple University, said the technology involved has been around for decades. But what is new is that the portable units can easily bring ultrasonography to a patient’s bedside. “This is cutting-edge with regard to education,” Goldberg said. “This is like a high-powered stethoscope. But where with a stethoscope you listen, the ultrasound sees. “If seeing a patient with abdominal pain, you will take this out of your pocket, plug it into your phone and take a look to see how the gall bladder looks,” she said. Goldberg said that is why it is so critically important to give a unit such as this to students.

The technology “is cutting-edge with regard to education,” said Dr. Amy Goldberg, interim dean and professor of surgery at the Lewis Katz School of Medicine at Temple University. “This is like a high-powered stethoscope. But where with a stethoscope you listen, the ultrasound sees.”

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First-year Temple medical students receive hand-held ultrasound units as part of the white coat ceremony in August. Courtesy of Ryan Brandenberg, Temple University

Point-of-care ultrasound technology began with emergency medicine out of a need in 24-hour emergency rooms, said Dr. Ryan Gibbons, associate professor of emergency medicine, director of the Emergency Ultrasound Fellowship and associate director of the Division of Emergency Ultrasound in the Department of Emergency Medicine, and director of Ultrasound in Medical Education at the Lewis Katz School of Medicine at Temple University. The Butterfly iQ+ is three-probes-in-one.

‘Train to use it’ “We have to learn how to adapt to new technology, but this enables the students to have it at a time while in medical school where they can train to use it,” Goldberg said. “Specifically, we’ve created ultrasound sessions to allow the students to become familiar with ultrasound and learn how to use it.” Goldberg said the students are ecstatic. “They understand this is an incredible resource that has been given to them, and they are proud that they are on the cutting edge of technology,” she said. “Clayton Christensen (an academic consultant who developed the theory of disruptive innovation) wrote about innovation years ago and how certain things, which are innovative, are disrupters,” Goldberg said. “Ultrasonography was one of those, and there are a host of different specialties in medicine that utilize ultrasound.” Quinn Harrigan, a second-year medical student, said she was surprised by the versatility of the device.

“Typically, ultrasounds have different probes for different types of examination, such as a curvilinear probe for the abdomen, phased-array probe for the heart and a linear probe for vascular assessment.” Harrigan said. “The Butterfly is three-probes-in-one. It lets us examine more than one organ system without carrying around multiple probes.” Harrigan said she and her fellow students are using the devices during workshops. “We are in a gastrointestinal block, and we used the devices to practice looking for the gall bladder and the portal triad during a practice session,” she said. “This type of work will enable us to be more comfortable assessing the gall bladder in future clinical settings. Being able to integrate clinical skills into our didactic-based first two years in this way facilitates an easier and more effective transition to the clinical third and fourth years.” continued on next page Winter 2022 : Philadelphia Medicine 15

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FEATURE continued

Second-year Temple medical students receive ultrasound devices. Courtesy of Joe Labolito, Temple University

Combine transducers

Beginning of careers

While handheld devices have been around a while, the Butterfly iQ has been able to combine all transducers into one unit, according to Dr. Ryan Gibbons.

William Mills Worrilow, another second-year medical student, said the opportunity will introduce students to relatively new technology at the beginning of their careers.

Gibbons is associate professor of emergency medicine, director of the Emergency Ultrasound Fellowship and associate director of the Division of Emergency Ultrasound in the Department of Emergency Medicine. He is also director of Ultrasound in Medical Education at the Lewis Katz School of Medicine at Temple University.

“Point-of-care ultrasound is being utilized at most academic centers in the emergency departments across the country as well as other departments,” Worrilow said. “Rather than starting our clinical rotations without any prior exposure to these devices, we will now have knowledge, familiarization and hands-on experience.”

“Typically, you need a cardiatric probe: something for the stomach and another for the vascular system,” Gibbons said. “What Butterfly has done is to put all of this into one probe and manage to put it in a handheld device. It is revolutionary: We are not seeing this from any other company.”

Worrilow said there are so many ways in which the devices can be used.

Gibbons said the advantage to students is that it can be used in any field of medicine. “By introducing it in the first year, they have something that they will grow with throughout their careers,” Gibbons said. “From a patient-care perspective, it doesn’t get any better.” Gibbons said point-of-care ultrasound technology began with emergency medicine out of a need in 24-hour emergency rooms. “This has been expanding into internal medicine,” he said. “This is something over the next couple of years that will be popping up throughout all fields of practice.” Gibbons said there are numerous medical schools that are teaching point-of-care ultrasound, but have not been able to give the students the hand-held devices to use routinely.

“We will be able to look at the heart real time to look for cardiac function and for the presence of a pericardial effusion,” he said. “We will be able to evaluate the lungs for fluid. We can look at the aorta for the presence of an aneurysm. We can look for the presence of fluid in the abdomen for our trauma patients. We would be able to look at the eye to assess for retinal detachments. We can look at the gall bladder to assess for cholecystitis and the kidney for stones.” Worrilow serves as one of the co-presidents of the Point of Care ultrasound interest group at the Lewis Katz School, and has helped to organize hands-on skill-based sessions for the first- and second-year students. “The fact that the device is portable and easy to use will be an incentive for me to use it more often,” Worrilow said. “I feel quite fortunate that the Katz School of Medicine has provided this amazing tool for our use.” •

David A. Kostival is a contributing writer “Along with the schools on the West Coast, we will be to Philadelphia Medicine. leading in this effort,” he said. “We have had other schools reaching out to us. This will be commonplace, eventually.”

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IN THE NEWS

A New, Affordable Model for Medical Practices

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

Rise of the Private Practice Courage, effort and capital just part of the framework By Michael C. Upton, Contributing Writer

hysician-owned private practice is very much an option for today’s professionals.

“It’s one of the strongest career paths a doctor can pursue,” said Dr. Jaan Sidorov, former CEO of the PA Clinical Network, a subsidiary of the Pennsylvania Medical Society. “It takes a lot of courage, effort, and capital.” Courage, effort and capital are just part of the framework for building a successful independent practice. While every practice and situation has its own needs, one of the universal first steps is acquiring a location and having a plan on what to do with that space.

Finding a location Veronica Blum of MPN Realty, Philadelphia, specializes in retail leasing and relies on her expertise as a landlord representative. She leads MPN’s retail leasing division. Her division has been busy this year placing medical practices in Center City locations. Doctors looking to start an independent practice need to take into account a number of items when considering a space, and those items all vary according to the type of practice; a dentist is going to need a lot more plumbing than a chiropractor, for example.

Veronica Blum of MPN Realty, Philadelphia, specializes in retail leasing and relies on her expertise as a landlord representative.

“There is a lot of infrastructure that is needed when starting a medical practice,” Blum said. She believes it is helpful for practices to go into a space that was already a medical practice or similar facility. This will cut down any renovation costs needed to adapt the space to a new practice’s specific needs. Sites previously occupied by medical services move off the market quickly, Blum said. Healthcare Facilities Today warns that even basic medical buildings use more electricity, heating, ventilation and cooling than a typical office building. When looking for a home for a new practice, doctors should consider the strength of the regional utilities and existing building facilities.

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Also, the need for medical imaging technology may dictate what spaces can be used as a practice. Local and state codes may require certain vibration-generating imaging equipment be isolated from other parts of the building. Architects note how the medical space is changing as large, lounge-like common areas are replacing tight waiting rooms. Pennsylvania ranks fifth in the nation for the number of active primary-care physicians. There are a lot of doctors in a lot of spaces. In Center City, Blum said new practices are moving into firstfloor spaces already adapted to meet Americans with Disabilities Act accessibility standards. “You have to consider zoning and accessibility,” Blum said. Outside of the city, real estate is much different. Suburban areas need parking, Blum said. Parking is one reason why strip malls are a popular choice among new suburban practices. Visibility is also a plus. Patient perspective When considering starting her own practice, Dr. Sue Kressly took the opportunity to innovate. In 2004 she started Kressly Pediatrics in Doylestown, a practice still flourishing today even as she enjoys retirement. Her vision was to focus on how health care works from the patient perspective.

When considering starting her own practice, Dr. Sue Kressly took the opportunity to innovate. In 2004 she started Kressly Pediatrics in Doylestown, a practice still flourishing today even as she enjoys retirement.

“The second half of my career was about starting, building, and growing a practice,” Kressly said. Kressly recommends private practice but, when looking back, she knows she would do a few things differently. She would plan more for the office’s future physical growth and spend more money on technology infrastructure. Whether in the city or the suburbs every expert stresses the importance of demographics and knowing where patients are coming from. The practice will fail if the patients cannot reach the location. Conversely, if there is a need for services the patients will come.

Revenue streaming David J. Zetter, a member of the National Society of Certified Healthcare Business Consultants, advises his clients to secure at least $100,000 to cover equipment and startup costs and a $100,000 line of credit to cover payroll and bills until revenue is streaming. Zetter recommends addressing these needs in the planning stage: electronic health record system, practice management system, medical billing service, medical transcription software, background check services, a credit card processor and an office manager. Kressly started by introducing technology as a more integral part of the patient experience. Her first task was to create a website where patients could access information without having to call into the office during working hours. This system may be rather commonplace today, but in 2004 a patient portal was almost nonexistent.

Dr. Sue Kressly started by introducing technology as a more integral part of the patient experience. Her first task was to create a website where patients could access information without having to call into the office during working hours. This system may be rather commonplace today, but in 2004 a patient portal was almost nonexistent.

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This forward thinking and deep planning is important for starting a successful independent practice. “The key to success is not replicating what is out there but thinking in innovative ways and starting from the lens of the patient and family,” Kressly said. According to Sidorov, successful practices develop an intensely loyal patient base. He recommends practices perfect customer service and employ a strong administrator who knows billing, office management, and all the intricacies of the health care system. Reputation advantage Sidorov understands the benefits of traditional advertising, but he knows simple reputation is a great advantage for independent practices. “Word of mouth among patients builds a practice,” Sidorov said. “It won’t happen overnight. The first few months to years are lean.” Establishing community partners is another key to success. Sidorov worked for one of those partners, the PA Clinical Network, which allows quality minded practices — 130 member-physicians in more than 65 practices — to collaborate to better approach payors for access to value-based care and quality recognition programs otherwise unavailable to practices with a smaller number of patients. Physician-owned private practice is “one of the strongest career paths a doctor can pursue,” said Dr. Jaan Sidorov, former CEO of the PA Clinical Network, a subsidiary of the Pennsylvania Medical Society.

“We help them report the quality, improve the quality and help them get paid more for quality by developing systems of care,” Sidorov said. “The doctors we talk to really treasure and enjoy the fact they are in control. By being in control, they can run the practice in innovative ways.” • Michael C. Upton is a contributing writer to Philadelphia Medicine.

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Obesity, diabetes take toll on community What’s available in terms of nutrition? What are the competing factors? What are the challenges? By Klaus Krøyer Madsen, MPH with Cities Changing Diabetes – Philadelphia

Editor’s note: The physical and mental cost to a community during the American crisis of diabetes and related comorbidities can be high. Part 1 in the fall 2021 issue of Philadelphia Medicine examined several community efforts to battle obesity and diabetes. Part 2 looks at specific ways to battle these comorbidities.

ince 2019, Philadelphia County Medical Society has been an active member of Cities Changing Diabetes – Philadelphia, a global program sponsored by Novo Nordisk that creates local private/public partnerships with communities to understand their unique obesity and diabetes challenges, identify areas and populations at greatest risk and design and implement targeted solutions. The program brings together medical and public health institutions, communities of faith, employers, insurers and nonprofit organizations. Philadelphia Medicine asked two of our members involved in Cities Changing Diabetes to share their perspectives about the challenges of obesity prevention: Ajay D. Rao, MD, MMSc, associate professor of medicine, Lewis Katz School of Medicine at Temple University Center for Metabolic Disease Research.

What the specific things that physicians can do in their practice to reduce obesity? Dr. Gadegbeku: First, just be available and develop a relationship. I sometimes talk to a few people who struggle with the conversation around weight and obesity. I know that people also feel challenged by the way we define obesity with the BMI. But I think the most important thing as a physician, that I see that I can do, is have a relationship with my patients where I can have that conversation, where they feel comfortable to talk to me about the challenges that they’re having with their weight. And most of them do, most of them disclose it on their own and start the conversation. But there are other times where I’m able to start that conversation in a comfortable way because I have established that relationship with that patient, and they know that I care and that I want to help. So, asking questions that not only are related to their lifestyle, diet, exercise, their other chronic conditions, medications, all of that, but also asking those questions that delve into the determinants of health. We know that medical care only accounts for 10% to 20% of the modifiable contributors to healthy outcomes. The other 80% is related to these other determinants of health, be it their physical environment, their economic status, their education and what’s available to them in terms of opportunities.

What’s available in terms of nutrition? What are the competing Annette Gadegbeku, MD, associate pro- factors? What are the challenges? Why are there challenges for fessor, Department of Family, Community them to make any kind of lifestyle changes? Do they know that & Preventative Medicine, assistant dean of lifestyle changes are not the end-all, be-all? They are definitely the community health, Drexel University College of first line to addressing this issue, but also as a physician I feel that Medicine; associate program director, DUCOM/ I’m obligated to explore all the options, including medication and Tower Health Family Medicine Residency surgical management, which we know are also effective and, maybe Program chief, division of community health. in some patients, even more effective, in addition of course to the changes in their lifestyle. continued on next page

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FEATURE continued record (EMR) systems can help us with various triggers that force us to think about how we can provide better care for each patient. Patients today have a gamut of treatment options for obesity. I think everybody can benefit from medical nutrition therapy with a registered dietitian, someone who really knows what contributes to overweight and obesity, and how to make behavior changes. There are many programs in the community as well that you can get involved with when it comes to keeping yourself active and learning how to cook healthier. These programs are really helpful for changing the way our patients behave. Finally, there is clear and emerging evidence that weight loss surgery is very effective in reducing the burden of this disease. And then of course, there are newer medications in this space that patients can finally get and can at least help them kick-start the process of achieving weight loss and establishing healthier lifestyles at the same time. Dr. Rao, how do you approach weight management overall for the overweight and obese patients you see as an endocrinologist? Dr. Rao: First and foremost, we get our nutritionists and dieticians involved. Small changes can go a long way. Weight loss in any fashion is the key. Weight loss surgery remains a valuable option for many patients. There have been some newer injectable agents that can be taken weekly that can really help with weight loss, also. When working with your internal medicine colleagues, how do you feel they are helping patients manage their weight before they even see an endocrinologist, Dr. Rao? Dr. Rao: They are trying their hardest, but there is so much they are managing. A lot of times a referral does not happen until diabetes is present.

Who are the patients that have insurances that are covering surgical There is a push for more obesity specialists, and this can be either management, bariatric surgery or medications? We know that a lot endocrinologists or internists with special interest in obesity medicine. of the approved medications for weight loss are not well covered by There are certification programs for this. insurance. But just trying to help with patients, and making sure patients have access to all the options that can support them in Having more providers who can focus on this problem is crucial. their challenges, their health and then their journey, are important. Dr. Gadegbeku, how would you like to see general practitioners Dr. Rao: First and foremost, one of our challenges is that we as and endocrinologists work better to address obesity? physicians do not yet fully recognize obesity as a disease. Electronic Dr. Gadegbeku: Oh, that’s a great question. I think utilizing health records are a critical tool in this effort, because they drive each other. I don’t know how many primary care physicians reach treatments in health systems and clinics. It is important to document out to endocrinologists to assist in managing their patients with obesity and properly code it in the medical record: That is essential obesity. Then I’m not sure how the reciprocal feedback or support for providing adequate care of a patient living with obesity. is with endocrinologists reaching back to primary care physicians

It is very clear that some of us are still sheepish about doing that because we worry that may be labeling the patient as obese. They walk out of our exam room with this paper now labeling them with being obese. But unless we do that, they don’t understand how serious this disease is. Proper coding may finally allow us to tap into appropriate treatment options. In addition, it prevents us from routinely forgetting about the condition. Patients who now have access to their medical records can finally understand the seriousness of obesity. The electronic medical 22 Philadelphia Medicine : Winter 2022

to support the management. So, I think even just partnering better, knowing each specialty and how they can support each other and what strength they both have in supporting and managing their patients together. Each specialist, myself as a primary care physician and another like Dr. Rao as an endocrinologist, can reinforce each other’s recommendations for management and goals for the patient. I think that would be most helpful, just recognizing our skills in each other and our strengths in each other, and working together to manage the patient together.

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‘I think the most important thing as a physician, that I see that I can do, is have a relationship with my patients where I can have that conversation, where they feel comfortable to talk to me about the challenges that they’re having with their weight.’ — Dr. Annette Gadegbeku

You mentioned the stigma of having obesity as a major barrier to treating the disease. How do you address that when providing care to your patients, Dr. Gadegbeku?

the block for a little bit and taking walks in the evening when it’s a little bit cooler out there. If you’re worried about going outside, even within your house, moving around can make a big difference. Somehow, we all have to stay away from being just stationary and having that bag of chips near you.

Dr. Gadegbeku: I think it’s hard to even address that without having a really good relationship with your patients or having really developed a relationship and trust in you, to even engage in a conMy wife and I have a young child and we’ve been trying to keep versation about that. Again, not only focusing on the negative, and him active, and it’s unusual for him the way things have been recently. the stigmatized language that we use, and conversation that we use And it’s unusual for a lot of us. around weight. But also focusing on the positivity and the esteem Sometimes we think that, oh, I need to get on the treadmill, I of that patient, uplifting them, supporting them, encouraging them need to go to the gym, and I need to do a big workout session. But and letting them know that they’re valued and that they’re loved, it can be just small victories, short walks and just short periods of that they are beautiful, they’re skilled, they’re educated, all of the more robust activity that can really make a big dent on this problem. things that you can know about a patient to encourage them and Dr. Gadegbeku: I try to stay healthy myself. I try to practice support them and to build self-esteem, and to let them know that what I preach. Again, it’s making lifestyle changes, not fads, not they can be successful. quick fixes in terms of how we eat, avoiding diet fads or overcome I think they feel so beat down. There’s even a lot of self-deprecating exercise challenges and all of that. But really trying to incorporate, language that they use toward themselves. And so just even calling when I can, healthier meals, healthier choices and trying to put the that out and helping to reverse some of that mindset. And it’s not an physical activity in some routine in my day. easy thing. It’s definitely easier said than done. But it’s important to I may not exercise every single day, but at least trying to establish let the patient know that they’re valued; encouraging them to achieve goals to get more physical activity in. And most importantly is attainable, achievable goals; celebrating their successes, no matter taking care of also my mental health. Again, I can see personally how minute it might seem to them; and really encouraging that where mental health can really impact my eating choices or activity this was a great accomplishment, whatever they did, whether they and sleep, so trying to get adequate sleep is essential. But trying to changed their way of eating, regardless of whether they saw results. do things that I enjoy, get an outlet and those will all eventually I mean, they are working toward being healthier inside as well, feed back into hopefully that healthier lifestyle for myself as well. • whether their numbers improved on their labs or they lost pounds or inches, whatever it is. And encouraging them to accomplish their other life goals, whether it’s a job or education. And I think those For more information about Cities are the areas where people do feel discriminated against, and they Changing Diabetes – Philadelphia, visit lose opportunities because they are not chosen for certain jobs or https://www.citieschangingdiabetes.com/ certain opportunities, even based on their weight. And so, having network/philadelphia.html. those conversations is really important, I think. Health is so personal for all of us. Do you mind sharing how you and your families stay healthy? Dr. Rao: I think first and foremost, this has been a very difficult time for all of us. In general, this is very hard to do, and then, especially in the last 20 months, I think it’s been even more difficult. Recently in our family, we’ve been just focusing on what we call small victories. Just getting up out of your chair, walking around

Klaus Krøyer Madsen, MPH with Cities Changing Diabetes – Philadelphia.

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‘HAVING KINDNESS IN YOUR HEART’ Spirit of caring, compassion has infiltrated physician’s every interaction with patients By Susan L. Peña, Contributing Writer

r. Wayne Bond Lau, winner of the Philadelphia County Medical Society’s 2021 Practitioner of the Year Award, is quick to credit his parents, HonKay and Meifong, for instilling in him a sense of obligation to care for others, long before he earned his credentials in emergency medicine. It was the reason he and his younger sister Bonnie, also an emergency physician, decided to pursue medicine.

And it also motivated both of them to volunteer at the Chinatown Clinic at Holy Redeemer Church every week.

‘Have to listen’ The key to gaining that trust, Lau said, is “you really have to listen. A lot of physicians talk at people rather than listening to what they’re saying. You have to recognize that at any given time, you could be in that person’s shoes. It gives you a humility and groundedness, and having kindness in your heart.” Lau remembers when he was 13 and his grandmother was in a terrible car accident, and he and his family rushed to be with her.

That spirit of caring and compassion has infiltrated Lau’s every interaction with patients in the Thomas Jefferson University Hospital’s emergency department.

“My memory is that the physicians never spent time with us to address our concerns and explain what was going on,” Lau said. He promised himself never to let a family go through such an ordeal.

Lau was inspired to go into emergency medicine because “when people come into the ED, they’re scared, and there’s so much happening,” he said. “You have 10 seconds to make people trust you. That’s a big challenge, to make a connection with someone and show them you can be trusted, that you care. The allure of that has never left me.”

Lau, who grew up in Lansdale, was accepted into an accelerated medical program at Penn State, allowing him to finish in two years and immediately enter medical school at Thomas Jefferson University, where he also completed his residency at Jefferson Hospital. His mentor/ residency director, Dr. Sharon Griswold, encouraged him to go into emergency medicine.

A spirit of caring and compassion has infiltrated Dr. Wayne Bond Lau’s every interaction with patients in the Thomas Jefferson University Hospital’s emergency department. He was inspired to go into emergency medicine because “when people come into the ED, they’re scared, and there’s so much happening,” he said.

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While still a resident, Bonnie, a medical student at nearby Drexel University, told him about the Chinatown Clinic, founded and directed by Dr. Vincent Zarro, where she had begun to volunteer. After Lau finished his residency, he began volunteering, and has spent every Wednesday night there from 5 to 8 ever since. Lau said the majority of the approximately 2,000 patients who come into the clinic each year are Asian: mostly Chinese-speaking, but also Vietnamese, Korean and Indonesian. More recently, the clinic is seeing a growing number of African-Americans, Spanish-speaking patients and Caucasians. Many are undocumented, and therefore uninsurable. Many suffer from diabetes and hypertension. “We don’t turn anybody away,” he said. “My parents came to this country to make a better life, and we’re seeing people that are also trying to make their lives better and achieve the American Dream for their children. It’s my privilege and my responsibility to take care of these people, who have nowhere else to go.”

Lau spends about a third of his working life in Jefferson’s emergency department as a physician, another third as a professor of emergency medicine in Jefferson’s Sidney Kimmel Medical College (where he is also assistant dean of student affairs) and the remaining third doing research on cardiac ischemia, “looking into what kind of proteins might help the heart during a heart attack,” he said. “It’s a hodgepodge of a life.” Fortunately, he finds respite at home, with his wife, Tingfang Chen, a child/adolescent psychiatrist at the Children’s Hospital of Philadelphia, and his daughters Audrey and Lois, ages 4 and 2. “I’m a blessed person,” he said. “I’m surrounded by love and care.”

Future of clinic Lau worries about the future of his beloved clinic, because the patients who use it are so vulnerable. To ensure it will continue after his own retirement, he puts a lot of effort into selecting the right students from the many applications to volunteer. “I try to cultivate a sense of belonging and family (among the volunteers),” he said. “My plan is to make sure to teach these students so they know how important it is to have a kind heart and care for people for the right reasons.” When asked what he would change about the health care system in this country, Lau told about the patient navigators who work at the clinic, translating for the patients, guiding them through the process and speaking up for them when necessary.

Forced to close In early 2020, when the COVID-19 pandemic arrived in the United States, the Chinatown Clinic was forced to close because the church felt uncomfortable having patients come in. Lau, who became the clinic’s medical director three years ago when Zarro retired, set up a hotline, so patients could have their prescriptions refilled; he and his volunteers stayed in touch with their patient community, giving them guidance on their medical issues and providing referrals. When the COVID-19 vaccines became available, they called their patients to let them know they were setting up vaccination events for the community. To their delight, they found that the majority had already been vaccinated.

“If every patient had a patient navigator in the ED, what a great sense of belonging and care they would have,” Lau said. “There would be less lawsuits, less miscommunication, less patient errors, and a greater feeling of being cared for.” Lau, predictably, comes down on the side of universal health care. “I think health care is not a privilege; it’s a right,” he said. “I will continue to do what I think is best, and inspire others to do the same. When you have more, you have a moral obligation to help those who have less. That was the most important lesson my father and mother taught me.” • Susan L. Peña is a contributing writer to Philadelphia Medicine.

“It was such a great experience to see people being receptive to the vaccine,” he said. “It was really tough to hang the sign on the door to say we were closed, and we didn’t know when we could open again.” The clinic reopened in July 2021.

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PCMS honorees

Award recipients spend years making impacts in their fields By Susan L. Peña, Contributing Writer

Editor’s note: The Philadelphia County Medical Society presented the 2020 and 2021 Strittmatter Awards on June 25, 2021 during the installation of its 160th president, Dr. Stephen R. Permut, MD, JD. We interviewed the winners, Dr. Robert H. Rosenwasser, MD, MBA, FACS, FAHA (2020), and Dr. N. Scott Adzick, MD, MMM, FACS, FAAP (2021), to find out why they chose their specialties and to explain their achievements in research and clinical practice.

Dr. Robert H. Rosenwasser When Rosenwasser was growing up in the 1960s in Shreveport, La., no one would have suspected that he would later become a neurological surgeon and researcher of note.

Dr. Robert H. Rosenwasser, 2020 Strittmatter Award recipient, with his wife, Dr. Deborah August.

Rosenwasser was already making his mark locally as a musician, having studied piano and violin as a child and playing guitar in rock bands. “I wanted to be a professional musician,” he said, chuckling. “Medicine was my fallback.” While attending Nicholls State University in Thibodaux, La., where he earned a bachelor’s degree in music and philosophy, Rosenwasser would study until 10 p.m. and then go out to paid gigs in New Orleans’ French Quarter. While he took courses in science, he was not a pre-med student, although many of his fraternity brothers were. As graduation approached, he began to consider what to do next, as the Vietnam War was winding down, but the draft was still active (his lottery number was 3).

Dr. N. Scott Adzick is surgeon-in-chief, founder (in 1995) and director of the Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment at the Children’s Hospital of Philadelphia. Adzick has not only become the pre-eminent pediatric general and thoracic surgeon of his generation, but for 30 years has led groundbreaking research on fetal surgery, a field that was in its infancy when he earned his medical degree. 26 Philadelphia Medicine : Winter 2022

When his friends suggested he go to medical school, he took the MCATS almost on a whim, and did well. Still undecided about his next step, he applied to the Louisiana State University medical school in his hometown, and was accepted.

Completed internship, residency Rosenwasser turned out to be a brilliant student; he completed his medical doctorate in 1979, and then completed his internship in general surgery at Temple University Hospital, where he also completed

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his residency in neurological surgery. “I started in cardiac surgery, and found it really boring,” he said. “I had liked neural anatomy in med school, so I started neurological surgery and liked it.”

“When I play with these talented musicians,” he said, “what’s nice is that I’m just one of the guys.” Rosenwasser resides in Villanova with his wife of 37 years, Deborah August, a neuroanesthesiologist.

His musical background actually helped him become a good surgeon, he said, “because if you’re a musician, your brain is connected to your hands. I’ve been training residents for years, and our best technical students have been those who played instruments.” By 1984, Rosenwasser had found his passion. That year he received a fellowship in open microsurgery with Dr. Charles Drake at the University of Western Ontario, “the epicenter of neurological surgery in the world.” He also completed a fellowship in endovascular surgery with Dr. Alex Berenstein, one of the founders of endovascular neurosurgery, at New York University in 1993. The following year, Rosenwasser was recruited by Thomas Jefferson University Hospital and became a professor of neurosurgery at the university’s medical school. He is the Jewell L. Osterholm MD Professor and Endowed Chairman in the Department of Neurological Surgery, president and CEO of the Faber Institute for Neuroscience, medical director of the Jefferson Neuroscience Network and senior vice president of Jefferson Enterprise Neuroscience. While Rosenwasser still practices non-emergency neurological surgery and continues to preside over the training of residents and fellowship recipients, he is most passionate about his research projects. “When you’re a good doctor, you help individuals, but when you do research and make a discovery, you can help millions of people,” he said. His earliest taste of that thrill came early in his career, when his lab helped define the role of the white blood cell in brain ischemia. Later, Rosenwasser co-authored a paper on the timing of interventions for vasospasms (secondary strokes) published in Neurosurgery, May 1999, that “changed the standard of care around the world.”

Stem cells For the past 18 years, Rosenwasser has been working on the use of stem cells in stroke recovery, and has received a $10 million grant to begin trials on humans. Additionally, he and other researchers at Jefferson are working on creating a brain/computer interface for paralysis in stroke victims, in which electrodes implanted in the brain can allow a patient to move a limb with an external skeleton in a natural way. These new treatments will be game-changers for stroke victims, who number about 750,000 each year, Rosenwasser said. Asked if he still plays music, he revealed that he is a member of the popular Buzzer Band, a country/rock band founded and led by drummer Vinnie Stix, that plays throughout the region. Rosenwasser enjoys playing rhythm guitar for the band on a part-time basis. They have even played at the Jefferson Gala, and at Villanova University, where he earned an MBA in 2017.

Dr. N. Scott Adzick, 2021 Strittmatter Award recipient, is a pioneer in fetal surgery at Children’s Hospital of Philadelphia.

Dr. N. Scott Adzick A few minutes into an interview with Adzick, a pioneer in fetal surgery at Children’s Hospital of Philadelphia (CHOP) since 1995, two things become obvious: He is a person with a huge heart, and he has an irrepressible zest for the history of this venerable, beloved hospital in his adopted city. Given the opportunity, Adzick will recite all the details about the visionaries who created the first 12-bed CHOP in 1855, and particularly about one of the founders, Dr. George Bacon Wood, whose descendants have been involved in funding the hospital — now one of the largest children’s hospitals in the world — and its research division to the present day. One of them, Richard D. Wood Jr. (chairman emeritus of Wawa), recently donated $25 million to the CHOP’s Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, of which Adzick is surgeon-in-chief, founder (in 1995) and director. Words like “amazing” and “incredible” are sprinkled through his narrative, and it’s this kind of enthusiasm and passion that have driven him to keep finding ways to treat genetic illnesses in the womb, and to encourage others to do so. He credits those who came before him, such as former U.S. Surgeon General C. Everett Koop, who preceded him as surgeon-in-chief at CHOP, for their vision and inspiration. (Adzick is the C. Everett Koop Professor of Pediatric Surgery at CHOP.)

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for outstanding science and technology programming. Since that time, he said, there have been exciting developments in CHOP’s research division, in spite of interruptions caused by the COVID-19 shutdowns. “Dr. Alan W. Flake (director of CHOP’s Center for Fetal Research) is close to doing the first in-utero bone marrow transplant to treat sickle-cell anemia at 12 to 14 weeks gestation (before the immune system kicks in),” he said. “We’re waiting for Food and Drug Administration approval, but we’re getting close.”

Richard D. Wood Jr. (chairman emeritus of Wawa) recently donated $25 million to the Children’s Hospital of Philadelphia Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, of which Dr. N. Scott Adzick is surgeon-in-chief, founder (in 1995) and director.

Mentors he remembers Adzick’s journey through long and arduous training at Harvard Medical School and beyond was full of mentors he remembers with admiration, including Dr. Judah Folkman, who was then surgeonin-chief at Boston Children’s Hospital; Dr. W. Hardy Hendren, chief of pediatric surgery at Massachusetts General Hospital; and Dr. Francis D. Moore, an iconic chief of surgery at then-Peter Brent Brigham Hospital. All of them instilled in Adzick a passion not only for pediatric surgery, but for continuing the work of research to help eliminate or treat genetic disorders. Adzick has not only become the pre-eminent pediatric general and thoracic surgeon of his generation, but for 30 years has led groundbreaking research on fetal surgery, a field that was in its infancy when he earned his medical degree. One of his successes in this field was developing a method for repairing myelomeningocele, the most serious form of spina bifida, in utero at 23 to 25 weeks’ gestation. Once the technique was developed, a large study found that, while it was not a “miracle cure,” the surgery would give the baby a “much better chance to have a more normal leg function, a chance to walk, and no hydrocephaly,” Adzick said. (Infants that have spina bifida of this type repaired after birth are usually paralyzed.) Now this surgery is the standard of care for spina bifida in many centers around the world, led by physicians trained at CHOP. Adzick has also presided over the development of techniques such as fetal surgery to correct twin transfusion syndrome, as well as corrective surgery in newborns for many congenital conditions.

Special delivery unit

He said CHOP’s big initiative on cellular and gene therapy is being led by Dr. William Peranteau (who holds the Adzick-McCausland Distinguished Chair in Fetal and Pediatric Surgery, endowed by Richard D. Wood Jr.). One of these projects is developing in-utero gene editing, using CRISPR technology, to treat “a whole list of single-gene disorders,” including cystic fibrosis. Animal trials have already shown promise.

Artificial womb Then there’s the artificial womb, a fluid-filled, temperature-controlled container supported by an external oxygenator to exchange oxygen and carbon dioxide, which Adzick said “may be a big breakthrough for our tiniest patients, at 23 to 25 months gestation. If you can have a bridge of four to five extra weeks for them to grow and develop, they may be able to survive. “Dr. Flake has worked on fetal sheep of similar size and found the artificial womb can support the fetus for four to five weeks, with normal development.” Under his leadership, CHOP has developed the Center for Birth Defect Outcomes, using data collected from about 28,000 referrals to create “an extremely powerful tool for counseling families and for the referring physicians to help us do things better and better,” Adzick said. Another new development is the Birth Defects Biorepository, a collection of genetic information on parents and baby, “so we can shed light on the genetic causes of defects, and extract strategies for prenatal treatment.” When he talks about such miraculous-sounding visions for the future, it’s clear Adzick is just as passionate about his chosen work as he was at the start of his career, and has no plans to stop anytime soon. “Dr. Koop always said that if you operate and save a child, you save a lifetime,” Adzick said. “That’s really true.” Adzick and his wife, Sandy, a former pediatric cardiac surgery nurse and world-class sailor, have a son, Mark, and daughter-in-law, Marguerite, and two grandchildren, Behr, 1, and Annie, 3 (who was born in CHOP’s Special Delivery Unit and is now “perfect”).

In 2008, Adzick led the creation of CHOP’s renowned Garbose “Grandchildren are the best things in Family Special Delivery Unit, the first birth facility specifically designed for healthy mothers carrying babies with known birth defects. the world,” Adzick said. • A three-part PBS documentary “Twice Born” (2015), directed by Susan L. Peña is a contributing writer to Monica Lange, was filmed during 15 months inside the unit, and Philadelphia Medicine. followed three families, from their decision-making process through the outcomes of their prenatal treatments. It won an Emmy Award 28 Philadelphia Medicine : Winter 2022

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IN THE NEWS

PAMED President Strategizes Medicine’s Future

‘It’s important to continue to educate physicians about what’s coming down the pike and how to adapt to it.’ By Myla Merkel, Pennsylvania Medical Society

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

Taking his oath of office in October 2020, DellaVecchia led PAMED through the toughest times of the pandemic, including transforming the 2021 annual House of Delegates meeting into a virtual event while focusing on the policy work that needed to be done. DellaVecchia said, “The pandemic challenged us and continues to challenge us. When push came to shove with this pandemic, we really rose to the challenge, all of us. It is a great example of what can be accomplished with our efforts.” COVID-19 continues to change health care on almost a daily basis, making DellaVecchia’s presidential initiative — advanced technologies in future medicine — timelier than ever. Technology in health care has been a long-standing passion for him.

Earned advanced degrees

the development of the COVID-19 vaccines. His lecture includes AI and the role it played with COVID-19 pandemic preparedness and response.

Preventative medicine DellaVecchia said that the practice of preventative medicine is where the advancements in technologies will play a vital role, using data collection and algorithms to continue to inform patients what they are at risk for. “What we like to do in medicine is heal people, but we also want to practice preventative medicine,” he said. “To do that, we start with collecting your data and figuring out what your risk factors are, while trying to bring down that risk according to certain mathematical algorithms and determining procedures that we can perform. “It’s important to continue to educate physicians about what’s coming down the pike and how to adapt to it, be a part of it, and most importantly, how to determine where it should be with patient care,” DellaVecchia said.

In addition to earning a medical degree from Temple University School of Medicine and completing residencies in anatomical and clinical pathology and ophthalmology, DellaVecchia earned advanced degrees in engineering and physics from Drexel University with a research emphasis in medical devices and photonics.

In addition to his role as the PAMED president, DellaVecchia has served on the board of directors for PAMED’s Political Action Committee (PAMPAC). He is a fellow at the College of Physicians of Philadelphia, where he also served on the board of trustees. He is a member of the Board of Governors of the American College The focus of his initiative is preparing physicians for the ad- of Surgeons. vancement of technologies such as artificial intelligence, robotics, DellaVecchia shows his commitment to advancing public health nanotechnologies, and biosensors that will forever change medical and preventive medicine through his community volunteer work education and the practice of medicine. and with veterans’ groups. “Nanotechnologies, biosensors, robotics and especially artificial “I speak on behalf of PAMED when I say that we are very grateful intelligence (AI) will saturate our profession and take over health for Dr. DellaVecchia’s leadership and commitment to PAMED,” said care in the not-too-distant future,” he said. “We must be at the table Martin Raniowski, PAMED’s CEO and executive vice president. and not on the menu to determine where these technologies fit into “His vision this past year was to look forward, see the possibilities and the profession and the proper care of patients.” determine how physicians can be part of that exciting future. We are The continuing education about the advancement of technologies delighted that his medicine and technology videos will remain a part was put together through a series of interviews and lectures with of PAMED’s CME library and will continue to benefit countless nationally recognized experts in the field. They included retired Col. members in the coming year.” •

Matthew Hepburn, MD, who was the vaccine development lead for Operation Warp Speed, founded in May 2020 to help accelerate

Myla Merkel is chief writer and media coordinator for the Pennsylvania Medical Society.

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In the news

PAMED House of Delegates meeting announces resolutions By Mark C. Austerberry, PCMS Executive Director

he 2021 Pennsylvania Medical Society (PAMED) annual business meeting was conducted virtually on Oct. 30.

The House of Delegates (HOD) is the society’s policymaking body. It is made up of more than 300 elected physician-members from around the Commonwealth of Pennsylvania. During this unique one-day virtual meeting, the physician-members were able to deliberate and act on issues related to health policy, managed care, public health, programming and PAMED administration. The Philadelphia County Medical Society (PCMS) delegation consisted of 57 voting delegates. Serving on the PCMS delegation carries with it the responsibility of representing the physicians of Philadelphia County, but it also provides an opportunity to influence the policies of organized medicine. This year, the PCMS delegates deliberated nearly 30 resolutions and elected trustees and officers in a single day. Below is an abridged list of 2021 resolutions that were adopted. For a complete listing of all the 2021 PAMED HOD resolutions, visit the PAMED website at www.pamed.org.

effectively, ethically, with independence of judgement, and for as long as they remain competent and wish to practice; and be it further RESOLVED, that PAMED will issue a report on these efforts, as well as any data obtained, no later than the 2023 meeting of the House of Delegates; and be it further RESOLVED, that PAMED Policy 160.975 (Resolution 303, H-2018, as subsequently presented as Board Report 18, H-2019) is repealed and shall be replaced with this PAMED Policy upon its approval by the House of Delegates. Resolution 21-303: Action Regarding Non-Medical Switching RESOLVED, that the PAMED oppose insurers policies that mandate non-medical switching, or give any direct financial inducement to a patient to require or incentivize switching off of a tolerated, effective therapeutic regimen, thereby circumventing the patient-physician relationship; and be it further RESOLVED, that PAMED advocate for state-level legislative action to disallow insurer policies that mandate non-medical switching off of a tolerated, effective therapeutic regimen, thereby circumventing the patient-physician relationship and be it further

Resolution 21-205: Syringe Service Programs in Pennsylvania

RESOLVED that PAMED affirm American Medical Association (AMA) Policy D185.976 Financial Incentives for Patients to Switch Treatments.

RESOLVED, that the PAMED will actively support advocacy for syringe services programs across the Commonwealth of Pennsylvania.

Resolution 21-404: Expanding Access to Buprenorphine for the Treatment of Opioid Use Disorder

RESOLVED, that PAMED shall support the legalization and public funding of syringe services programs and harm reduction programs in the Commonwealth of Pennsylvania, provided that funding for these programs does not detract from funding to cover treatment of substance use disorder.

RESOLVED, that the PAMED shall support eliminating the requirement for physicians to obtain a waiver while continuing training requirements to prescribe and administer buprenorphine for the purpose of initiating treatment of opioid use disorder; and be it further

Resolutions adopted

Resolution 21-301: Corporate Practice of Medicine RESOLVED, that PAMED will prioritize efforts to partner with the Department of Health to modify the physician survey conducted during the biannual license renewal for all Commonwealth physicians to help determine: 1) the current extent of corporate ownership of physician practices in the Commonwealth; 2) the nature of the corporate entities involved; 3) the pattern of such corporate ownership within the state as it relates to geography and / or physician specialty; 4) the effect of corporate ownership on the ability of physicians to practice medicine 30 Philadelphia Medicine : Winter 2022

RESOLVED, that PAMED support the elimination of the yearly patient cap on the number of patients one provider can prescribe buprenorphine to in the context of a short-term limited supply in the emergency room setting; and be it further RESOLVED, that PAMED support ACGME expanded residency training opportunities on evidence based medication-assisted treatment for opioid use disorder in the acute outpatient setting. Resolution 21-408: Ban on the Manufacturing of Menthol Tobacco Products by Tobacco Companies

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RESOLVED, that the PAMED shall support a ban on manufacturing, distribution, and sale of menthol tobacco products.

Resolution 21-209: Racial Equity as it Relates to the SarsCov2 Spike Protein

Resolution 21-407: Medical Use of Psilocybin in the Pennsylvania Commonwealth

Resolution 21-406: Increasing Minimum Staffing Requirements for Dementia Residents in Nursing Homes

RESOLVED, that the PAMED support the revaluation of psilocybin’s status as a federal Schedule I controlled substance; and be it further

May 2022 PAMED board meeting discussion

RESOLVED, that the PAMED support the National Institutes of Health (NIH) in implementing administrative procedures to facilitate grant applications and the conduct of clinical research into other medical utilities of psilocybin. Several resolutions were referred back to the PAMED’s Board of Trustees for decision or study. Physician-members can provide feedback, which will be considered official testimony on each item, and the information will be shared directly with the PAMED board members when they address the topic during the next scheduled meetings in February, May and August. Physicians with questions or comments should contact the PAMED Knowledge Center at 800-228-7823.

February 2022 PAMED board meeting discussion Resolution 21-202: Informing Physicians, Health Care Providers, and the Public that Cooking with a Gas Stove Increases Household Air Pollution and the Risk of Childhood Asthma

Resolution 21-206: WPSI (Women’s Preventative Services Initiative) Resolution 21-203: Support for Doulas Resolution 21-508: Option for Virtual Participation for Rural Delegates in Non-Pandemic Times

August 2022 PAMED board meeting discussion Resolution 21-402: PAMED advocate and legislate the pro-competition clause for MOC (Maintenance of Certification) and introduce it at the American Medical Association Lastly, and most importantly, special thanks to all the physician delegates that helped to guide PAMED policy for this coming year, especially during such an unprecedented time.

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Winter 2022 : Philadelphia Medicine 31

31 S T A N N U A L

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Philadelphia Medicine Winter 2022

Articles inside

Starting out: Courage, effort and capital part of framework

Strittmatter Award: Recipients create impact

PAMED president was past president of PCMS

Practitioner: Spirit of caring compassion has infiltrated physician’s every interaction with patients

Obesity, diabetes take toll on community: Addressing the challenges

Ultrasound: Portable technology in hands of Temple medical students

Perils of COVID-19: Managing stress during pandemic

A New, Affordable Model for Medical Practices