Philadelphia Medicine Winter 2016

The Official Magazine of the Philadelphia County Medical Society

WINTER 2016

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

Medicine

Dr. Paul Offit:

al r u g u a n I Issue

Philly’s Relentless Vaccine Detective

PENNSYLVANIA LAWMAKERS ARE WRITING THEIR OWN PRESCRIPTION FOR MEDICAL MARIJUANA

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

(215) 563-5343 www.philamedsoc.org

F e at u r e s Population & Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Dr. Paul Offit: Philly’s Relentless Vaccine Detective . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

EXECUTIVE COMMITTEE Michael DellaVecchia, MD, PhD, FACS PRESIDENT

Pennsylvania Medical Society’s 2015 House of Delegates Recap. . . . . . . . . . . . . . . . . . 16

Daniel Dempsey, MD PRESIDENT ELECT

PCMS Member, Dr. Theodore Christopher, Elected Vice President of the Pennsylvania Medical Society. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Anthony M. Padula, MD, FACS

Impact of Food Insecurity on Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Max E. Mercado, MD

Food & Nutrition Screening Algorithm for Primary Care Providers in Philadelphia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

IMMEDIATE PAST PRESIDENT

SECRETARY

J. Q. Michael Yu, MD, FRCPC TREASURER

BOARD OF DIRECTORS Angel S. Angelov, MD Martin Brown Richard J. Cohen, PhD, FCPP Donald M. Gleklen Enrique Hernandez, MD Cadence Kim, MD Harvey B. Lefton, MD Henry Lin, MD Curtis T. Miyamoto, MD Ricardo Morgenstern, MD Natalia Ortiz, MD, FAPA, FAPM Stephen R. Permut, MD, JD Dane Scantling, DO John Vasudevan, MD

Pennsylvania’s Physician General to Philadelphia: “Stopping the Flu Starts with You” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Pennsylvania Lawmakers Are Writing Their Own Prescription for Medical Marijuana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Antibiotic Resistance: The Med, Vet Connection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Car e e rs i n M e dici n e Patient Safety First: Physicians in Pharmacovigilance . . . . . . . . . . . . . . . . . . . . . . . . . . 22 The Expanding Role of the Physicians Assistant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 A Conversation with Dr. Paul D. Siegel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

FIRST DISTRICT TRUSTEE Lynn Lucas-Fehm, MD, JD

I n E ve ry I s s ue

EXECUTIVE DIRECTOR

Letter From the President. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Mark C. Austerberry

Health Awareness Calendar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 PAMED updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

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.

All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the publisher or editor.

Upcoming Events & Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 PCMS News. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

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Winter 2016

Contents

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Letter from the president

Michael DellaVecchia, MD, PhD, FACS President

Ushering in

the New Philadelphia elcome to Philadelphia Medicine, the official publication of the Philadelphia County Medical Society.

I wish to thank the Board of Directors for having the vision and courage to commit to such a high-profile, community-engaging project befitting Philadelphia’s status as a recognized world center for advancing health care through science, education and technology.

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, they must include your name, town, and phone number.

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Philadelphia is home to five of the nation’s premier medical schools, 15 prominent teaching hospitals, 27 acute care and specialty care hospitals, 12 accredited nursing schools, and 15 biotech, pharmaceutical, medical device and chemical companies, with nearly 100 more such institutions just beyond our city limits. Physicians are involved in every level of this health care delivery continuum, contributing to better patient outcomes. Through Philadelphia Medicine, the Philadelphia Medical Society aims to forge a stronger identity for the role Philadelphia physicians play in these efforts at home and around the world.

The Philadelphia Medical Society wants to expand and explore greater transparency between caregivers and care receivers. That’s why we’re publishing a magazine for Philadelphia physicians, medical practitioners and our community. We believe that we can improve upon our delivery of services by sharing our perspectives on population health issues, practice management strategies and legislative matters with the entire health care community and our patients.

Our editorial content will focus on the clinical, educational, and business issues affecting patient care and practice management, in the light of health care advancement through science, education and technology.

We plan to provide thought-provoking articles and relevant commentary concerning regional, national, international health and regulatory issues, practice management topics, and patient-centered outcomes that have an impact on the Delaware Valley.

Our goal is to actively promote growth, fellowship, and goodwill among all practicing physicians, health care educators,

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practitioners, science and technology innovators, and the general community. We aim to fill each issue with informative, educational, engaging content about Philadelphia medicine and health care.

We will put a human face on the practice of medicine with articles written by or about local physicians and other health care and social service professionals. In this, our inaugural issue, we hear from the renowned Paul Offit, M.D., on what is preventing a significant percentage of children in our area from getting vaccinated, and what impact that has on public health. That article spurred us on to explore Philadelphia’s population health issues with Jim Beuhler, M.D., the city’s director of Public Health. We also focus on the debate in the Pennsylvania legislature on medical marijuana, as a bill appears to be inching closer to passage.

And we hear from Pennsylvania Physician General Rachel Levine speaking about the timely topic of the flu at her Philadelphia press conference, hosted at the Philadelphia County Medical Society office.

We also identify some pressing practice management and care delivery items currently being addressed by the Pennsylvania Medical Society—issues that affect physicians, health care networks and patients. We hope you also find enlightening, the editorial perspectives on LBGT health issues and nurse practitioner independence, written by some of our area medical students. And, finally, we celebrate a number of our outstanding peers within the physician community, recognizing their service and achievements.

EDITORIAL BOARD Michael DellaVecchia, MD William S. Frankl, MD Corina Graziani, MD Alan Miceli, MA Stephen L. Schwartz, MD Paul D. Siegel, MD

We invite you to give us feedback about the stories you read in our magazine and about the magazine in general, and to also send us suggestions and story ideas for future issues.

Our email address is: Editor@philamedsoc. org. We also ask you to share this magazine with your peers and patients. It’s another opportunity to provide service to our professional and patient-centered communities.

Winter 2016 : Philadelphia Medicine

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FEATURE

POPULATION PUBLIC James W. Buehler, MD Health Commissioner, Department of Public Health

e live in an age of score cards.

We compare, add up and grade almost everything, including health care. The process in many ways is crucial to gaining an understanding of how well we are spending our health care dollars and how effectively we are treating the people in our care. But when it comes to health care, of course, we are not simply adding up runs in an inning.

One of the most difficult things to decipher is public health. For example, according to the County Health Rankings conducted by the Robert Wood Johnson Foundation, Philadelphia has the worst health ranking among Pennsylvania’s 67 counties. Did we gain that ranking because we have the worst doctors and hospitals in the state, or the worst health department?

Of course not. What we do have is the highest level of poverty among the state’s counties, and poverty is the strongest predictor of the health status of virtually any public health program. It’s an argument that can be substantiated with decades 6

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of research. In effect, we are all facing the health consequences of income inequality and the other social contributors to poverty.

That reality, of course, does not let us off the hook, or permit us to dismiss low health rankings. Rather, it means that we must take the conditions in our community into account if we want to improve health.

The health community in recent years has attached a new name to this process—“population health.” It has been used increasingly to describe the spectrum of activities that the federal government and others expect of physicians and health care institutions.

It reflects the aspirations of the health care quality improvement movement, embodied in the Centers for Medicare and Medicaid program, the Meaningful Use of Electronic Health Records (EHRs) and especially the Affordable Care Act (ACA).

From my vantage I hear the term “population health” used to reflect the shared aspirations of health care and public health

agencies in addressing disease prevention and health promotion.

The term, however, is frequently used in very different ways, with users often having something very different in mind. It often boils down to which population of interest it refers to. For a practice of the health care system, the population of interest is likely to be their patients. For an insurer, it is the people they cover. For a public health department, it is the people who reside within, or come into their country or state.

What unites these disparate interests? I believe the answer is twofold. First, measuring and monitoring the health of “populations” in a practice, health insurance plan, or political jurisdiction requires that the same questions be asked and answered, and, second, interventions that promote population health promise to strengthen kinships between the worlds of health care and public health.

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Population & Public Health

Here, I believe, are the questions these groups should ask themselves:  Who is in your population?  What do you know about the health and health risks of the people within the population you serve?

 How well are you doing your job in protecting or promoting the health of people within your population?

Understanding who is in the populations we serve is critical because it defines people’s needs for preventative health services, their likelihood of becoming sick, and their likelihood of having a good outcome as a result of our services.

At the population level, measuring how well we are doing requires the use of indicators or “performance measures.” This population-level approach can be discomforting to physicians because of differences in the degree of accuracy that is sufficient for population-level monitoring versus individual patient diagnosis and care.

It’s easy, in principle, to broadly define a desired performance measure, but it is not always easy to define such measure in operational terms. As a result, definitions are often imperfect. When summarized across a population, those imperfections are tolerable if they do not substantially skew your conclusions. For example, in measuring health care-associated infections, it is necessary to define criteria that distinguish

whether a particular infection is likely to have been acquired in the community or as the result of a health care exposure. That might be based on the timing of the onset of symptoms or diagnosis, the likely incubation period for a particular infection, or the types of procedures a patient underwent.

In aggregate, reviewing data from patients with infections so defined, especially when compared to others who did not have such infections, is likely to provide insights

into why some were at risk and how such infections could be prevented in the future.

Monitoring trends over time can provide insights into the impact of strategies to reduce their occurrence. This is true even if the data include a few patients whose infections were actually acquired outside healthcare or if a few patients who were in the “uninfected” comparison group actually had unrecognized infections.

Understanding the likelihood of such misclassifications affects the strengths or limitations of the conclusions we might draw from the aggregate data. For an individual patient, however, such misclassifications can be misdiagnoses, with attendant adverse consequences. Therein lies the rub that distinguishes population-level versus individual patient-level approaches.

The same is true in public health, where we apply “surveillance definitions” to monitor a spectrum of conditions of public health concern, using a variety of information sources.

These surveillance criteria are designed to

balance our competing interests in having complete estimates of the extent of different diseases while avoiding over counting. And, like health care performance measures and their possible imperfections, the data are useful in monitoring trends, identifying groups at greater or lesser risk of disease, and informing our programs.

For example, we use telephone surveys, such as the Community Health Survey conducted in the Philadelphia area by the

Public Health Management Corporation and the Behavioral Risk Factor Surveillance System sponsored by CDC and conducted statewide by the Pennsylvania Department of Health, to monitor obesity. This is based on self-reported answers to questions about height and weight. We know that some might fudge the answers to those questions and that people with telephones and those who are inclined to respond to surveys might not represent the population at large (statistical adjustments notwithstanding). While it would be better to actually measure height and weight, or even better to conduct tests that directly measures adiposity, the costs would be much greater or prohibitive. So, we settle for the telephone survey data, depend on occasional focused evaluations that assess validity, and, despite their imperfections, find them sufficient for monitoring trends in obesity in our community.

Turning to the second connection across different population perspectives, an important impetus for the Affordable Care Continued on page 8 Winter 2016 : Philadelphia Medicine

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feature continued‌

Act and the Meaningful Use EHR incentive program arises from the growing impact and cost of chronic diseases, missed opportunities for prevention or for minimizing the consequences of chronic conditions, and opportunities for assuring the continuity or integration of care, especially for people who receive care from multiple providers. This is manifest by the advent of Accountable Care Organizations, performance measures that track the use of preventive health care services, incentives that aim to reduce hospital readmissions, and the growing interest in community health workers to help assure that desired outcomes of health care are achieved once patients go home.

It is also manifest by the ACA-mandated Internal Revenue Service requirement that not-for-profit hospitals conduct community health needs, solicit health department input in developing those assessments, and, in turn, use those assessments to inform investments

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Population & Public Health

in community benefit programs. We all know that whether or not patients adhere to our recommendations depends on their resources and supports at home and within their families and communities.

This is true for taking medications, improving the consumption of healthy foods, quitting or not starting tobacco use, getting sufficient exercise, etc. Thinking along these lines takes us into territories that are familiar to public health departments, and it is where population-level approaches from health care and public health vantages begin to merge.

The work of health departments, such as ours, mixes services provided directly to individuals and community-level interventions. Some of this work is conducted directly by our staff, but much is conducted through partnerships and contracts with community-based organizations. As doctors and health care providers are drawn

increasingly to considering the interface between their offices, clinics, and hospitals (especially not-for-profit hospitals given the community benefit requirements) and the neighborhoods and communities where their patients live, public health departments can be a resource for information about services and organizations that might be useful for their patients.

The fact that health is shaped by the norms, values, opportunities, and barriers within communities, in addition to the health care services that are available to us, is nothing new. The worlds of health care and public health also have long-standing and fundamental connections. What is new is the mix of incentives, mandates, and opportunities embedded in the ACA and the Meaningful Use program that, under the mantle of promoting “population health,� will draw our worlds more closely together.

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Young physician insights

LGBT Health

Nurse Practitioner Independence

Co-authored by: Diana Huang, Temple Med ‘17 & Aleesha Shaik, Drexel Med ‘18

GBT issues have long been a focus in the public discourse, leading to the Supreme Court’s ruling to legalize same-sex marriage this June. That this topic is relevant and important to us as medical students is apparent by the number of LGBT interest groups now present in medical schools. Such platforms support LGBT students, but also allow us to advocate for better care for LGBT patients, and reduced health care disparities for this group that has historically faced discrimination. It is startling to realize that until 1973, the American Psychiatric Association classified homosexuality as a mental illness, and use of socalled “conversion therapy” was not uncommon. While use of conversion therapy is now considered unethical, more insidious inequities persist. Research suggests that LGBT individuals face health disparities because of societal stigma and discrimination, leading to higher rates of psychiatric disorders, substance abuse, and suicide. More research on this population is necessary to better understand the factors that contribute to health disparities for LGBT patients and find interventions that work.

From a training standpoint, medical students can benefit from increased exposure to LGBT patients and their health care needs, as they make up an estimated 4% of the population. Additionally, we can all advocate for this important problem on a broader scale. Medical student Graeme Williams, for example, brought a resolution to the Philadelphia County Medical Society calling for the Pennsylvania Medical Society to recognize and advocate for the reduction of LGBT health care disparities by supporting research into LGBT health issues and expanding access to care. At the Pennsylvania Medical Society House of Delegates meeting in October, all discussion of the resolution was positive, and it is now PAMED policy. Our goal as physicians and physicians-to-be is to provide equal care to anyone who needs it, irrespective of the patient’s characteristics, beliefs, or preferences, and it is time medical education and policies reflected that.

Diana Huang

or many years, nurse practitioner independence has been actively debated in the Pennsylvania state legislature.

Nationally, 21 states and the District of Columbia currently allow for NP independence. However, Pennsylvania state law currently requires that NPs work only under a collaborative agreement with a physician, the terms of which can vary. NPs fighting for independence say this rule unnecessarily prevents them from having their own businesses and expanding access to much-needed primary care in underserved areas.

Physician groups are nearly unanimous in their opposition to NP independence, saying it would endanger patient safety due to NPs’ lower level of training. They argue that the best patient care is provided by a care team, with doctors, NPs and other healthcare workers working together, allowing patients to benefit from the expertise of each and also improving access to care. The issue is a concern for medical students, possibly even deterring those looking to go into primary care, as nurse practitioner independence could lead to a two-tiered system of care where some patients are seen by a physician-led team, while others are just seen by nurse practitioners. Such a system could lead to fragmented care, and disrupt the goal of a patient-centered medical home.

While access to primary care is an important issue, we must be careful that the quality of care is not affected.

On October 22, 2015, the Pennsylvania House Professional Licensure Committee held a public hearing on HB 765, the current bill calling for NP independence. Many physician associations were represented, including the Pennsylvania Medical Society, American Academy of Pediatrics, Pennsylvania Academy of Family Physicians, and Pennsylvania Osteopathic Medical Association. They emphasized that NPs have less than 7 years of training, while physicians have more than 11 years before going into practice, and must pass numerous standardized exams to prove competency.

Additionally, experience with NP independence in other states has shown that it has little impact on health care access for the underserved, since most NPs choose not to practice in rural areas. The debate on NP independence is ongoing in the Pennsylvania state legislature.

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feature

Dr. Paul Offit:

Philly’s Relentless Vaccine Detective Alan Miceli

r. Paul Offit has spent much of his professional life battling the witch’s brew of ignorance being dished out, now often on the internet, about the risks of vaccines.

He is director of the Vaccine Education Center at Children’s Hospital of Philadelphia, professor of vaccinology at the Perelman School of Medicine at the University of Pennsylvania and co-inventor of the rotavirus vaccine, which saves hundreds of lives each day.

National news organizations often seek him out when someone takes a pot shot at children’s vaccines. Not surprisingly, reporters called him right after the September debate of the Republican presidential candidates. During the debate, Donald Trump unearthed the thoroughly disproven theory that vaccines can cause autism.

Trump told a national TV audience that he is in favor of vaccines, but in the very next breath, said he knows of a toddler who 10 Philadelphia Medicine : Winter 2016

got vaccinated then a week later became very ill and now has autism.

In 1998, British doctor Andrew Wakefield gave birth to the vaccine-autism myth by releasing a study that claimed he found a link between the two. A quick succession of other studies debunked Wakefield’s claim.

The British Medical Journal went so far as to call the Wakefield research “fraudulent,” and British medical authorities even stripped him of his license.

“The notion that vaccines cause autism,” Dr. Offit says, “has been refuted by a mountain of evidence. This is how he (Trump) thinks?

If that’s true then we’re in trouble.”

Dr. Offit says the two GOP physicians running for president had a chance to bury the issue during the debate, but only muddied the waters. Retired pediatric neurosurgeon Ben Carson did say that numerous studies have shown no link between vaccinations and autism, but then questioned whether all immunizations given

to children are necessary. Dr. Offit says, “He (Carson) takes the next step into darkness when he says that we should only give the vaccines that just prevent debilitating illness and death. They all do that.”

Then there’s Republican candidate Rand Paul, the ophthalmologist, who makes vaccinations an issue of personal freedom.

He said in the debate that parents should have the right to spread out the inoculations.

Dr. Offit says delaying the shots would increase the period of time when a child is susceptible to these diseases.

“Is it your freedom to do that, to put your child and other people’s children in harm’s way?” Dr. Offit asks. “That’s a freedom now?

Did these people go to medical school? Did they pay attention? They’re not appealing to most people. They’re certainly appealing to a loud, vocal, media-savvy, lawyer-backed minority of parents, but when they do that they put children at risk.”

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DR. paul offit

This vocal minority is well educated, Dr. Offit says. “They often have a job in which they exercise some level of control. They believe that they can know just as much about vaccines as anyone else who gives them advice.”

Dr. Offit thinks most parents are not at all like this group. “Most people in the Hispanic population in the city of Philadelphia, for example, just walk into the office and ask what vaccines they will be getting.

They believe that their doctor may know more than they do about vaccines. They believe that the public health community is probably making recommendations for their good. They aren’t as cynical as this other population.”

The vocal minority often use philosophical reasons to keep their children from getting immunized. In Pennsylvania, it’s the most common excuse parents use to opt out. Researchers have concluded that last

In order for something to be considered safe, its benefits have to clearly and definitively outweigh the risks. That’s true for every vaccine.

December’s Disneyland outbreak of measles was caused by a lot of those parents in that area who refused to get their children vaccinated. Studies indicate that the vaccination rate in that pocket of Southern California may have been as low as 50%.

Then there are the religious fundamentalists. Dr. Offit knows firsthand the

devastating effects that they can produce. He was working at CHOP in 1990-’91, when the beliefs of two fundamentalist churches in North Philadelphia were blamed for helping to cause a deadly measles outbreak.

The two churches rejected any form of modern medicine.

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Feature Continued…

DR. paul offit

Proposed Pa. Immunization Bills & Regulations: Two bills have been proposed this session that would make it tougher for parents to opt out of immunizations for their children. Senate Bill 696 and House Bill 883 would eliminate the philosophical exemption. The bills would not touch the religious exemption. Both bills are currently stuck in committee.

The Pennsylvania departments of Health and Education have announced proposed regulations that would eliminate a big loophole in current immunization regulations.

Right now, if a child enters school without the proper immunizations, parents have eight months to get the child vaccinated. The new regulation would require the vaccinations within five days. If for medical reasons, the doses cannot be administered that quickly, a parent would have to file a medical certificate indicating when the child would receive them. The proposed regulations would still allow parents to opt out of vaccinations for philosophical or religious reasons.

Supporters say the regulations would dramatically increase the percentage of children vaccinated, and that would significantly lower the chances for outbreaks of measles and other contagious illnesses.

A spokesperson for the Pennsylvania Department of Health says the regulatory review process could take from nine months to two years. You can find more detailed information on the proposed regulations, on page 35 of this issue’s “PAMED Updates.”

“This is not a religious issue,” Dr. Offit says. “’I can’t believe that the same God who “Most people, religious or not, understand that granted us sense, reason and intellect, also vaccines are important. The choice to put your intended us to forego their use.’” child in harm’s way violates the fundamental principles of every religion, which is to care The philosophical and religious exempabout your children, to care about your family, tions for vaccinations have caused areas to care about your community.” of the country to dip below the “herd immunity” level. Herd immunity happens The Philadelphia measles outbreak took when a very high percentage of people in place despite the fact that the measles an area are immunized, and as a result there vaccine had been available for almost is little chance for outbreaks of contagious three decades. More than 1,400 people diseases. Depending on the disease, however, got infected, hundreds ended up in the an area could need more than 95% of the hospital. Nine unvaccinated children died. population vaccinated, in order to gain The parents of six of them belonged to the herd immunity. two fundamentalist churches.

The epidemic did not end until a Philadelphia judge ordered very sick children to be hospitalized and healthy children to be inoculated. Dr. Offit said he asked the same question to every parent of the fundamentalist sect he met. “I asked why you didn’t treat your child. And their answer was always the same. ‘We were treating our children. We were praying.’ And you see, we allowed that. We were so slow to act in that setting, so slow to act, because we respected the parents’ right to raise their children as they saw fit, and practice their belief as they saw fit, and that really, really lived with me.”

Dr. Offit says a comment by Galileo more than 400 years ago is a cogent response to the fundamentalist belief about medicine:

The latest figures available for Philadelphia show that only 87% of kindergarten students Continued on page 14 Winter 2016 : Philadelphia Medicine 13

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Feature Continued…

received the MMR shots. Pennsylvania, by exemptions to vaccinations because they the way, has the second lowest vaccination don’t make sense.” rate in the country, at under 90%. Dr. Offit Dr. Offit says he understands why some says when too many people opt out, conpeople don’t want their children immunized. tagious diseases come back first, and other They’re asked to put their children through a frightening diseases can also get a foothold. regimen in the first years of life that require “Let immunization rates continue to 26 inoculations, as many as five in one day, decline and there’s no reason these other “to prevent diseases that most people don’t rare diseases, diphtheria, polio, can’t come see, using biological fluids that most people back. These diseases still occur in the world. don’t understand.”

International travel is common. Let your But he adds, there is very little risk to guard come down far enough and you’ll getting vaccines. “In order for something see polio come back.” to be considered safe, its benefits have to He believes Pennsylvania should do what clearly and definitively outweigh the risks.

California did, in the wake of the Disneyland That’s true for every vaccine.” measles outbreak. California created a law What drives Dr. Offit in part, to make sure that does not allow parents to opt out of vaccinations for their children for personal children get the protection they need early in or religious reasons. “Pennsylvania should life, is a childhood experience he had. When eliminate the philosophical and religious he was five years old he underwent extensive

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DR. paul offit

foot surgery that kept him in the hospital for a couple of months. He spent that time in a polio ward with 19 other children.

The young polio victims had a profound impact on the future doctor. “I had an image of those kids with polio. Many of them never had parents visit them. They were vulnerable and helpless and alone. I think that’s where the passion comes from.”

In 1953, just three years before Paul Offit entered that ward, there were 35,000 cases of polio in the United States. By 1961, after wide distribution of the polio vaccine, that number fell to 161. Now, the polio wards are empty—a testament to the men and women who have dedicated their lives to eradicating such horrible diseases—men and women like Dr. Offit.

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FEAture

PENNSYLVANIA MEDICAL SOCIETY’S

2015 House of Delegates Recap he Pennsylvania Medical Society (PAMED) Annual House of Delegates (HOD) meeting was held October 24 and 25, 2015, in Hershey, Pennsylvania. The HOD is the Society’s policymaking body and this year 220 physicians from across the state took action on many important issues. During the two-day meeting, the Philadelphia County Medical Society (PCMS) delegates deliberated and acted on issues related to health policy, managed care, public health, programming, and Society administration. The PCMS delegation consisted of 37 voting delegates and 16 alternate delegates, with a portion of the delegation composed of young physicians, residents and medical students. 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.

Here are some of the 2015 Resolutions highlights—those in red were proposed by the PCMS delegation.

LEGISLATION / REGULATION

Medical marijuana—Delegates voted that PAMED:

• Call for further adequate and well-controlled studies of marijuana and related cannabinoids in patients who have serious conditions for which preclinical, anecdotal, or controlled evidence suggests possible efficacy.

• Urge that marijuana’s status as a federal Schedule I controlled substance be reviewed with the goal of facilitating clinical research and development of cannabinoid-based medicines and alternative delivery systems

During the PAMED House of Delegates. Left to Right: Dr., Lynn Lucas Fehm, MD, JD First District Trustee; Michael DellaVecchia, MD, PhD, FACS, 154th President of PCMS

• Urge the National Institutes of Health to implement administrative procedures to facilitate grant applications and the conduct of well-designed clinical research into the utilization of marijuana • Support trials using cannabidiol oil to treat children with seizure disorders, funding for the trials, and a patient registry.

• After much debate in front of a standing-room only crowd during Saturday’s reference committee, delegates also voted to maintain PAMED’s position of opposing legalization of marijuana for medical use.

Protecting Pennsylvania physicians who wish to terminate futile medical care from civil and criminal prosecution—the delegates called on PAMED to conduct a thorough review of the existing law and newly enacted laws in other states to assure that Pennsylvania physicians are best equipped to handle difficult end of life treatment issues, and that appropriate protections are in place.

Source testing after health care worker blood-borne pathogen exposure—though existing PAMED policies already address this issue, delegates agreed that a renewed effort to assure prompt testing is timely.

EDUCATION / SCIENCE & PUBLIC HEALTH

Pictured are the Philadelphia County Medical Students at the close of the annual House of Delegates in Hershey on Sunday, October 24, 2015.

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Reducing health care disparities for LGBT patients—recognizing the unique health care needs of the LGBT community, delegates adopted policy calling on PAMED to advocate for expanded access and elimination of health care disparities for LGBT Pennsylvanians. PAMED was also directed to support further research efforts investigating LGBT health issues and to make information on these health issues available to Pennsylvania physicians.

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House of delegates recap

Recognizing National Board of Physicians and Surgeons (NBPAS) as an equal alternative to the American Board of Medical Specialties (ABMS) MOC and recertification process—delegates

The Education of Pennsylvania physicians, Fellows, Residents, and Students to the legislative processes of Pennsylvania and how to participate—delegates did not adopt this resolution, but agreed

did not adopt this resolution, agreeing that PAMED and its Board of Trustees has been fully engaged in efforts to improve the MOC process for Pennsylvania physicians. This includes conversations it has been leading at both the state and national level that have already led to positive changes announced by the American Board of Internal Medicine (ABIM) earlier this year.

to refer for study to the Board of Trustees.

Parity for International Medical Graduates (IMGs) with U.S. Medical Graduates (USMGs) in years of Graduate Medical Education (GME) required for licensure—PAMED was called on to support and aggressively pursue parity in the number of years of GME training required for IMGs and USMGs to obtain state medical licensure. The adopted resolution also calls on a progress report back to the HOD in two years.

Sleep facilities and safe transportation home for Pennsylvania residents—PAMED was directed to advocate for all physician residency programs in Pennsylvania to offer the option of safe transportation home, as well as sleep facilities in their institution, for residents who may be too fatigued to safely return home after an overnight shift. It also directs PAMED to request that all physician residency programs in Pennsylvania create and make publicly available a clearly articulated protocol for the use of these services.

Other noteworthy news included the election of the next PAMED Vice President and Board of Trustees Ted Christopher, MD, was elected as vice president of PAMED for the upcoming year. Dr. Christopher will serve one year as vice president.

Afterwards, he becomes president-elect for one year then in October 2017, he’ll take over as president of PAMED.

Also elected to the PAMED Board of Trustees from Philadelphia are the following physicians: Lynn M. Lucas-Fehm, MD, a radiologist at Abington, who will serve a four-year term as the society’s First District Trustee. As the First District Trustee, she’ll represent physicians from Philadelphia County.

William A. VanDecker, MD, a cardiovascular disease specialist from Temple, who will serve a four-year term as a Medical Specialties Trustee.

MANAGED CARE & OTHER THIRD PARTY REIMBURSEMENT

Improve delivery of peripheral arterial disease (PAD) care to Medicare patients at a lower cost to the state—delegates voted that

PAMED urge the Pennsylvania Department of Human Services to cover and reimburse in-office percutaneous PAD therapies.

Informing public of hospital revenue per inpatient day of care—the resolution as submitted called on PAMED to work with the Pennsylvania Department of Health and the Pennsylvania Health Care Cost Containment Council (PHC4) on this issue. Delegates referred this issue to the PAMED Board of Trustees for study, noting that, though there is strong support for transparency in health care costs, information must be clear and useful to both patients and physicians, and it would be irresponsible to embark on this path without first collaborating with other interested stakeholders.

Temple Medical Students surrounding Stephen Permut, MD, JD, Chair of the Department of Family and Community Medicine at Temple and Chair of the American Medical Association.

MEMBERSHIP/LEADERSHIP

Streamlining medical student membership—the delegates voted for PAMED to explore avenues of having Pennsylvania medical schools facilitate access to and build awareness of free membership for all current medical students.

The education of Pennsylvania physicians to the legalities of contracts—delegates voted in favor of PAMED creating a readily available presentation, educating physicians and physicians-in-training on the proper method of analyzing, questioning, and entering into contracts.

Regional local medical societies—in an effort to control cost and improve efficiencies, the delegates voted for PAMED to create a taskforce to examine the feasibility of forming larger regional medical societies.

Enrique Hernandez, MD, FACOG, FACS, is congratulated by PCMS Executive Director Mark Austerberry for his 8 years of services on the PAMED Board as the First District Trustee.

Drs. Cadence Kim and Dale Mandel following the close of the 2015 House of Delegates in Hershey, PA.

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Feature

PCMS Member,

Dr. Theodore Christopher, Elected Vice President of the Pennsylvania Medical Society

heodore Christopher, MD, an emergency medicine specialist from Philadelphia and past president of the Philadelphia County Medical Society, has been elected by his peers to serve as vice president of the Pennsylvania Medical Society (PAMED). He was elected during PAMED’s annual statewide meeting in October.

Dr. Christopher will serve one year as vice president, then one year as president-elect, before becoming president of the organization in October 2017. He has been a member of PAMED for 13 years, and has served on its board of trustees since 2011.

Dr. Christopher has been active in several medical organizations and has done volunteer work in his community. In addition to being a member of PAMED, he holds memberships in the American Medical Association (AMA), the American College of Emergency Physicians, the Society of Academic Emergency Medicine, and the Association of Academic Chairs of Emergency Medicine, serving as its president in 2010. At the state level, he is a member of the Pennsylvania Chapter of the American College of Emergency Physicians, serving as its president in 2003.

Board-certified in emergency medicine and internal medicine, Dr. Christopher practices at Thomas Jefferson University Hospitals in Philadelphia and is a faculty member of the Sidney Kimmel Medical College of Thomas Jefferson University, serving as professor and chair of the Department of Emergency Medicine. After graduating from Harvard College in 1977, he went on to earn his medical degree from the Icahn School of Medicine at Mount Sinai, in New York City.

Dr. Christopher lives outside of Philadelphia with his wife of 31 years, Claudia, a head trauma and spinal cord physical therapist. He has three daughters—Monica, a plastics and reconstructive surgery physician’s assistant at the Johns Hopkins Medical Center in Baltimore, and Vanessa and Adrienne, second- and third-year medical students at the Sidney Kimmel Medical College in Philadelphia.

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Feature

Impact of

Y IT R U SEC FOOD INon Health he maps contained in Philadelphia’s Community Health Assessment tell a story that is familiar to many of us. Map after map shows chronic health conditions and early mortality concentrated in our city’s poorest neighborhoods. Measurements of obesity, premature cardiovascular mortality and poverty all show the same neighborhoods in the shade of red designated for the worst health outcomes.

As physicians practicing in Philadelphia and seeing patients from these “red zones,” we are painfully familiar with these realities.

We see patients in their 40s with congestive heart failure brought on by years of uncontrolled diabetes and hypertension. We struggle to help our patients control chronic conditions made worse by unhealthy diets that contain far too much sugar, sodium, and saturated fat and by lack of exercise.

We prescribe medication after medication, often using them to substitute for the lifestyle changes our patients need but seem unable to make. And too often, these efforts are not enough, and we watch patients continue to experience early deaths from heart disease and stroke across the city.

Multiple studies have demonstrated the adverse impact of poverty and food insecurity on health. Food insecurity affects about one out of six city residents and is a particular risk to children and seniors. We know these factors affect our patients, but in the midst of our busy days and jam-packed schedules, often these problems may seem beyond the scope of what we can address in the course of a 15 or 20 minute visit.

Fortunately, Philadelphia now has a number of tools we can leverage to make it more feasible to address these issues by connecting (or having our staff connect) patients with the resources they need:

• THE COALITION AGAINST HUNGER (215-430-0556) will help patients complete applications for SNAP (food stamps) over the phone.

• PHILLYFOODFINDER.ORG is a guide to food assistance in Philadelphia and includes a searchable map of food pantries, soup kitchens, SHARE sites, senior meals and farmers’ markets.

• BENEPHILLY (844-848-4376) runs multiple sites throughout the city that help city residents to apply for all benefit programs for which they are eligible. All of these services are free.

• PHILLYPOWERED.ORG is a web site run through the Philadelphia Department of Public Health that includes a database of free and low cost exercise options throughout the city as well as inspiring stories of ordinary Philadelphians who have found ways to fit physical activity into their busy schedules and tight budgets.

These programs can help lift patients out of poverty, both directly through financial assistance, and indirectly, by helping to prevent health problems that can keep families mired in poverty. So how to begin?

Consider adding a validated two question food insecurity screen to your office practice:

1. Within the past year were

you worried about whether your food would run out before you had money to buy more?

2. Within the past year did

you run out of food, and did you not have money to get more?

Keep information about how to access food assistance programs in exam rooms and offer it to any patient who answers yes to either of the above questions. Once you start asking the questions, you may be surprised by what you learn about your patients.

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feature

FOOD

NUTRITION SCREENING ALGORITHM

For Primary Care Providers in Philadelphia

For Children

For Seniors

What providers need to be aware of: Environments that put children at high risk for hunger/food insecurity:

Seniors are more likely to be at risk of hunger or food insecurity if they are:

 Poverty

 Between the ages of 60 and 69

 Single parent household

 Living in poverty

 Parent or caregiver with depression and/or other mental health issues

 A high school dropout

 Social isolation

 Caring for a grandchild

 Child with special health needs  High heating and/or utility costs

 Divorced, widowed, or living alone  A renter  Frail (decreased physical functioning)

Food scarcit y can compound health problems

For All WHAT CAN PROViDERS DO: Ask the 2 questions to screen for food security

(See next page for screening questions)

Provide the SNAP Hotline number to all your patients: (215) 430-0556 At each following visit, check back about food access and food program enrollment (See next page for suggested language)

If there are concerns about hunger:

Risk factors or red flags for undernutrition:

Red flags for food insecurity and/or malnutrition:

 Make sure patients and their families are enrolled in all available food programs

 Underweight or stunted growth

 Low intake of nutrient-rich foods

 Overweight

 Vitamin and/or mineral

 Provide information on local food pantries

 Anemia  Problems with choking/swallowing  Vomiting/reflux/GERD  Child on a limited diet/extreme pickiness

 Dysfunctional child/caretaker feeding relationship

 Child is delayed in acceptance of foods/textures

 Chronic constipation/diarrhea  Significant dental caries  Child still using a bottle after age 2 years

20 Philadelphia Medicine : Winter 2016

deficiencies

 Skipping or splitting

medication dosages

Test, treat, and refer for health consequences as appropriate.

 Not taking medication with food as directed

 Altered effect of drugs

Originally Developed by Hunger Free Vermont

 Poor wound healing or

Adapted by:

immune dysfunction

 Frailty (indicators include:

unintentional weight loss; slowness; muscle weakness; exhaustion; low physical activity; decreased muscle strength)

 Depression; apathy; anxiety

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Food & Nutrition screening algorithm

HOW TO SUPPORT A FAMILY WITHOUT ADEQUATE FOOD RESOURCES

1. Never assume a family has adequate food resources—share information with all families:

Provide information on SNAP (Food Stamps) and share the Coalition SNAP Hotline Business Cards for assistance with finding food pantry referrals, summer meal sites, and applying for benefits.

2. Ask about food resources and assess food security:  A 2-question screen for food insecurity validated for use in the clinical setting:

“Please let us know if either of these statements is true for your family:”

 “Within the last 12 months we wor-

ried whether our food would run out before we got money to buy more.”

 “Within the past 12 months the food we bought just did not last and we did not have money to get more.”

 Or have a conversation about access to food and nutrition: • “Those healthier foods are very expensive; would you like information on additional food resources?”

• “Sometimes people have trouble making ends meet at the end of the month; would you like information on food resources?”

• “Medication and healthy foods can be expensive, but both are important; would you like information on resources that can help stretch your budget?”

3. Always use a family centered approach including addressing other risk factors for hunger such as accessing mental health services.

FOOD RESOURCES To find locations of food pantries, soup kitchens, low-cost groceries, farmers’ market sites, and more, visit the map at www.PhillyFoodFinder.org on a computer or smart-phone.

•

COALITION AGAINST HUNGER SNAP (FOOD STAMP) HOTLINE:

•

PHILADELPHIA CORPORATION FOR AGING: PCA is a private, non-profit

•

HOME DELIVERED MEALS & NON-PERISHABLES

MANNA: delivers free meals to people at nutritional risk due to cancer, diabetes, HIV/AIDS, and other chronic or life-threatening illness. (215) 496-2662

Aid for Friends: delivers free, home-cooked meals to isolated, homebound seniors.

(215) 464-2224

Jewish Relief Agency: delivers free boxes of kosher food, regardless of religious affiliation. (610) 660-9572

•

FREE AND DISCOUNTED FRESH PRODUCE

SHARE: offers $50 in groceries for $20 and community service. Accepts SNAP. (215) 223-2220

Philabundance: offers free produce once a week, year-round in NE and South Philly.

(215) 339-0900

Philly Food Bucks: for every $5 in SNAP purchases at a Food Trust farmers’ market, customers receive $2 to spend on fruits & vegetables. Visit PhillyFoodFinder.org

SNAP provides eligible families with extra money every month to help buy food.

Residents of Philadelphia, Bucks, and Chester counties can call the hotline to apply for SNAP over the phone, find food pantries near them, or learn more about other food programs. (215) 430-0556

organization serving as Philadelphia county’s Area Agency on Aging. It provides assistance on a wide range of programs and services, including food assistance, for people age 60 and older. PCA HelpLine: (215) 765-9040

to find a market near you.

•

FREE SCHOOL MEALS: In Philadelphia, all kids and teens attending public school in the School District of Philadelphia (or charter schools operated by the District) can now receive free breakfast and lunch without parents having to fill out additional paperwork. http://www.hungercoalition.org/ schools-newly-offering-free-meals

•

FREE SUMMER MEALS: When school is out, kids and teens age 18 and under and disabled persons over 18 who participate in school programs can get free meals in June, July, and August at over 1,000 sites in Philadelphia.

No income, ID, or registration is required. Call 1-855-252-MEAL or visit www.phillysummermeals.org to find your nearest site.

• WIC: Special Supplemental Nutrition Program for Women, Infants, and Children: WIC provides free supplemental foods, health screenings, nutrition education, and breastfeeding support to low-income pregnant, breastfeeding, and postpartum women, and to infants and children up to age five who are found to be at nutritional risk. Call 1-800-743-3300 for an appointment.

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Careers in medicine

PATIENT SAFETY FIRST: Physicians in Pharmacovigilance Yvonne Ukwu, MD, MBA

n today’s highly regulated global environment of the pharmaceutical industry, pharmacovigilance (PV) has become a core competency of any pharmaceutical company.

According to the WHO, pharmacovigilance is a culmination of the science and activities relating to the detection, assessment, monitoring, and prevention of long- and short-term adverse effects or any other drug-related safety outcome. PV is an integral part of product development and lifecycle optimization of therapeutic drugs 22 Philadelphia Medicine : Winter 2016

with the goal to improve patient lives and ensure their safety.

Evolution of Pharmacovigilance The sulfanilamide poisoning of over 100 Americans in 1937 and other similar events brought forward the enactment of the Federal Food, Drug, and Cosmetic Act of 1938, calling for an improved, superior system of drug control. The act required companies to perform animal testing and submit results to the FDA demonstrating

product safety prior to public distribution.

The act was further expanded with the Drug Amendments of 1962 in response to the devastating consequences of the thalidomide disaster that occurred in the late 1950s to early 1960s.

Thalidomide came to the European market in 1957 and was prescribed to pregnant women to alleviate early trimester morning sickness and nausea. Despite not having realized the benefit-risk profile, the drug was

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Physicians in pharmacovigilance

distributed and found to have teratogenic effects causing phocomelia, a congenital disorder characterized by limb abnormalities.

At the time, there lacked a clear system for reporting adverse events, which delayed concluding a causal link between such events and the thalidomide. From these events and more, regulatory bodies, worldwide, further enhanced their systems for market approval, drug surveillance, and safety reporting—pharmacovigilance.

Role of the Physician in Pharmacovigilance The main objective of PV activities is to identify new potential risks and facilitate development of an effective risk mitigation, minimization, and management plan for prevention of risks. This goal is achieved by collaboration of several players including: physicians, pharmacologic producers, public health officials, clinical research organizations (CROs), and manufacturers. Physicians in pharmacovigilance, often referred to as safety physicians, are a key component in successfully ensuring that diagnostic and therapeutic pharmacological solutions are safe and effective.

Safety physicians leverage their experiences to properly define benefit-risk profiles of products and to determine pragmatic solutions for complex drug safety problems in a timely manner. They are readily involved and highly influential in: medical review of reported adverse events in clinical trials and on the market; safety evaluation of the product label; development and review of critical reports submitted to the regulatory authorities; establishment of “best practices” by regulatory bodies; signal detection; risk minimization strategies; consulting and training; and mastery of technological tools used in monitoring cases. Their input and analysis can impact current and future therapeutic algorithms, including options for more advanced medical care for thousands of patients.

Signal detection and risk management are dynamic and evolving dimensions of pharmacovigilance. Early signal detection is used to identify risks associated with the

product and require ongoing refinement in order to increase drug applicability and value to public health. Evaluation of potential signals through critical data mining analysis and research are essential to generating submission documents and reports to the regulatory agencies. At the pre-market phase, results from signal detection analysis are a component of registration, product approval, and product label submission for market use.

The product label informs patients, providers, and payers of proper, safe product usability.

At the post-market phase, evaluating safety in a larger, more heterogeneous population allows for detection of events that might not be seen in smaller trial populations.

Increased product safety and efficacy has a direct relationship to the product value—the safer and more effective a marketed drug, the better the expected patient outcome.

Commercialization of a product is highly dependent on this expectation. Close monitoring, reporting, and mitigation by safety physicians and their drug safety teams at the pre-market stage are as crucial as such at the post-market period in the product lifecycle. They work to achieve maximum product longevity, helping companies retain their patents through surveillance, timely reporting, and product label amendments.

Thus, their analysis and recommendations are not only significant to the patient, provider, and payers, but to the company as well.

Physician Impact & Opportunities Physicians in pharmacovigilance, or safety physicians, are necessary to ensure accurate clinical interpretation and assessment of adverse events and safety signals.

Safety reporting is a global effort and has implications across all countries where a product is registered and marketed. Safety physicians are called to think globally while acting locally. As scientists, they are called to be innovative, critical, strategic thinkers for the betterment of aged products as well as creation of nouveaux therapeutic measures.

Their mastery of technologically advanced systems further enhances the development of improved clinical options for patient healthcare solutions.

To some, pharmacovigilance is a wellknown division of the pharmaceutical industry requiring physician support. Medical doctors at varying stages in their careers can participate and contribute to this dynamic discipline and influence the health care of thousands worldwide, including medical graduates who have completed or yet to secure residency positions. These areas of new opportunities provide an interesting alternative for graduated medical professionals to impact patient lives, and opt to still participate in clinical and/or academic medicine. No matter the arena of practice, physicians constantly strive to uphold patient safety first.

REFERENCES: Cobert, Barton L., and Barton L. Cobert.

Cobert’s Manual of Drug Safety and Pharmacovigilance. Sudbury, MA: Jones & Bartlett Learning, 2012. Print.

Junod, Suzanne White. “FDA and Clinical Drug Trials: A Short History.” FDA, U.S. Food and Drug Administration. N.p., 7 July 2014. Web. 14 Nov. 2015.

Fintel, Bara, Athena T. Samaras, and Edson Carias. “The Thalidomide Tragedy: Lessons for Drug Safety Regulation.”

Helix Magazine. Northwestern University, 28 July 2009. Web. 14 Nov. 2015.

“Pharmacovigilance.” Essential Medicines and Health Products. The WHO, n.d. Web. 14 Nov. 2015.

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The of the Physician Assistant Elana Gordon Attributed to: WHYY’s The Pulse (www.whyy.org/thepulse)

f you’ve ever gotten health care, for anything really, you’ve more than likely been helped at some point in a critical way by someone in this position.

No, it’s not the physician…but rather, the physician assistant.

“It’s not physician apostrophe ‘s’ [as in, physician’s assistant]. We’re not the possession of the physician,” explains Patrick Auth, director of the physician assistant program at Drexel University, of one of his biggest pet peeves. “It’s the physician assistant.”

Or ‘PA’ for short.

Whatever one might call it, the profession is booming right now, as the health system looks to it and other non-physician practitioners to help increase capacity and handle an anticipated influx in patients.

As a result, new training programs are popping up around Philadelphia and elsewhere. The number of PAs has more than doubled in the last decade, with about one PA out there for every 9 or 10 doctors.

Some patient surveys have found that people trust the doctor most, but the role of the PA itself has been changing, and even expanding.

24 Philadelphia Medicine : Winter 2016

So What Exactly is a Physician Assistant?

At first glance, one might think Jesse Coale is a doctor at State Road Medical Associates, a general medicine practice in Drexel Hill, Pennsylvania. He sees his own patients, diagnoses and treats them.

do. In Pennsylvania, the terms must also be approved by the state board of medicine.

Both he and the doctors are liable for his care.

“Somebody like Jesse, who’s been here a long time, I trust what he does,” explains Dr. Except he would never identify or intro- Namir Kosa, Coale’s supervising physician. duce himself that way.

“If this was somebody who’s starting now out of school, then I’d have to be with them, at “I can’t practice on my own,” he says. “I least in the beginning for a while until I’d be sure that they are doing the right thing and in have a supervising physician.” the way I want them to be doing it,” he says.

Coale, who also directs Philadelphia Kosa doesn’t even have to be in the office University’s physician assistant training prowhen Coale sees patients, but he does have gram, works under a negotiated agreement to be available by phone or electronically, with the physicians at State Road. That in case anything comes up. He also reviews agreement defines what he can and can’t

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The Expanding Role of the Physician Assistant

and signs off on all of Coale’s charts. Pennsylvania recently changed its rules to allow the option of less direct oversight.

A Little Bit of History & a Common Thread Coale recalls being hired on at the State Road practice about 25 years ago by a doctor who has since left.

“He needed help,” he says. “He couldn’t afford a full time partner, so he hired a physician assistant which happened to be me.”

John McGinnity, president of the American Academy of Physician Assistants, says the whole PA profession started as a response to primary care and rural access shortages in the late ’60s.

“So at that time, they decided, ‘let’s create a new profession, put them through an accelerated medical school type process like they did for doctors in World War II,” says McGinnity. “So we’re going to train them in the medical model, put them through an intense and accelerated program, and have them come out and improve access.”

PA training lasts two to three years, whereas training a doctor can take up to a decade. Nurse practitioners tend to have a Master’s or Doctoral degree after having practiced an average of 10 years.

He needed help.

He couldn’t afford a full time partner, so he hired a physician assistant.

Corporation, says PAs tend to fall into one of two roles: a substitute role, as is the case with Jesse, or a complimentary role, such as assisting in surgery. Physicians may also handle the more complex cases.

Policymakers are increasingly relying on PAs and nurse practitioners to address growing concerns about doctor shortages in the years to come. Their responsibilities are growing. A recent Institute of Medicine report also pointed to mid-level practitioners, working with doctors in a new team-based model of care, as key elements of increasing the health system’s capacity.

“Even without increasing the supply of physicians beyond what there currently is, even if the population grows and ages, there isn’t necessarily going to be a physician shortage because each physician can probably take care of more patients working with a team of nurse practitioners and physician assistants than a physician can working on his or her own,” says Friedberg.

In the last decade alone, the PA profession has more than doubled in size. There are approximately 100,000 certified PAs practicing across the U.S. Most states have either passed or updated laws pertaining to PAs, according to McGinnity. About a third of PAs are in primary care, a percentage which has actually declined since the profession’s early days. McGinnity says the rest have expanded across just about every specialty you can think of.

People may compare PAs to nurse practitioners, or NPs, which started around the same time. PAs and NPs may both serve as primary care providers, but the type and approach in training varies. In some states, NPs can practice totally independent of a physician.

“If you have a patient going for bypass surgery, the majority of vein grafts harvesting, that’s an area of expertise of PAs,” he says.

The PA field’s popularity, along with increasing health care needs, has fueled a major growth in PA training programs.

Dr. Mark Friedberg, a researcher specializing in workforce issues with the Rand

Thomas Jefferson University Hospital launched a program this spring.

More Training Programs But More Competition

Susan Dubendorfer, director of curriculum and evaluation at the new school, says students are in some highly coveted spots.

“We had almost 2,000 applications for 30 slots in our class that we’ve seated this year,” she says. Another 1,500 applied for next year’s class.

Some in the health industry become PAs as a second career, but 24-year-old Janel Jesberger, a Jefferson, PA student, says she was drawn to the profession after shadowing a PA, and seeing the kind of relationships in that practice that one could develop with patients. She’s interested in orthopedics but lightheartedly recalls first having to explain to her family what she was even getting a degree in.

“I come from a family of engineers, and they looked at me and were like, ‘What?

What is this? Just a nurse?’ So I had to explain that all over again,” she says.

PA school was a first choice for 27-yearold Samantha Melonas, adding that it may pay for itself in the first year or two after obtaining a license.

“The average salary coming straight out of school is around $80,000 or so, and then depending on the field you’re in, it’ll grow from there.”

The salary is about half of an average physician salary.

Nationwide, there are nearly 200 certified training programs, compared to about 50 in the early ’90s. There are currently 23 programs across New Jersey and Pennsylvania, including five new ones in the last two years, according to the National Commission on Certification of Physicians Assistants.

Philadelphia University plans to expand to Atlantic City soon. Temple is on track to open a program in two years. Three other schools—Mercyhurst, Slipperty Rock and Kean University—appear to have something in the works.

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Feature

Pennsylvania’s Physician General to Philadelphia:

“Stopping the Flu Starts with You” Alan Miceli

t has become an annual tradition with my sister-in-law each flu season. I ask her if she’s getting a flu shot and she invariably replies, “I don’t need one. I’m healthy and I’ve never had the flu.” This year, in an effort to get her to roll up that sleeve, I asked Pennsylvania Physician General Rachel Levine what she would tell my sister-in-law.

“Being healthy does put you in a lower risk category as opposed to people who have chronic illnesses, such as heart, lung, and kidney disease,” Dr. Levine said, then threw in the punchline, “but anyone can get the flu and get serious complications from it.”

She said the Centers for Disease Control recommends that everyone over the age of six months get vaccinated each flu season.

“It’s important because getting a flu shot helps contain the virus, helps keep it from spreading. So, the best way to protect yourself and your family and classmates or co-workers, is to get the flu vaccine.”

flu, anyone can get a super infection after the flu. So, it’s very important for everyone to get the vaccine.”

Dr. Levine has spread the word across the state that the best way to fight the flu is to get a flu shot. Her statewide effort included a news conference at the Philadelphia County Medical Society, where she drove home to reporters, the Pennsylvania Department of Health slogan, that “stopping the flu starts with you.”

“It’s important because getting a flu shot helps contain the virus, helps keep it from spreading.

So, the best way to t yourself and your family and classmates or co-workers, is to get the flu vaccine.”

even then the shot offered some protection, and probably helped vaccinated people who contracted the flu get by with milder symptoms. Dr. Levine said that the CDC is confident that this season’s flu shots are on the mark.

Along with getting the flu shot, Dr. Levine emphasized that people should wash their hands frequently and thoroughly. If you’re in a work environment, for example, where someone with the flu has opened a door, the virus can remain alive on the doorknob for 24 hours. It thrives on hard surfaces.

But you can remove it from your hands, by simply washing them. And Dr. Levine added that people with the flu should just stay home until they no longer have the worst symptoms.

To Dr. Levine, Philadelphia presents a special challenge during flu season. The virus can spread quickly in such densely populated areas. She said that’s all the more reason for the city’s residents to do what my sister-in-law should do—roll up their sleeves and get that shot.

Along with those who have chronic The Physician General added that we illnesses, Dr. Levine said pregnant women, should not be lured into thinking that our children under the age of two, and residents chances of getting the flu are diminished of nursing homes are at the top of the flu by the prospects of a mild winter. “The flu shot priority list. There’s a sobering fact season has nothing to do with the weather. behind the push for the flu vaccine. The The virus will arrive, regardless of whether CDC says that each year about 23,000 it’s warm and sunny or cold and snowy. A people in the U.S. are killed by the flu or lot of it depends on where the strains of the complications from it. virus are appearing throughout the world.”

“It’s safe to say that by far, more high risk people will die of the flu,” Dr. Levine pointed out, “but anyone can get a bad case of the 26 Philadelphia Medicine : Winter 2016

Last year, the flu vaccine was not a perfect match for the strains that ended up spreading across the country. But the CDC believes that

Anthony Padula, MD, immediate past president of PCMS, and Rachel Levine, MD, Physician General of Pennsylvania.

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Health Awareness Calendar JANUARY 1–31:

FEBRUARY 7–14:

MARCH 12:

• Cervical Health Awareness Month

• Congenital Heart Defect Awareness Week

• World Kidney Day

http://www.nccc-online.org/

http://www.heart.org/HEARTORG/

https://www.kidney.org/

• National Birth Defects Prevention Month http://www.nbdpn.org/

• National Glaucoma Awareness Month http://www.americanglaucomasociety.net/

FEBRUARY 23–MARCH 1:

MARCH 16-22:

• National Eating Disorders Awareness Week

• Brain Awareness Week

http://www.nationaleatingdisorders.org/

http://www.biausa.org/

• Thyroid Awareness Month http://www.thyroid.org/

JANUARY 6–12: • Folic Acid Awareness Week http://www.folicacidinfo.org/

JANUARY 26–FEBRUARY 1: • National Drug Facts Week http://www.drugabuse.gov/

MARCH 3–9:

MARCH 22:

• Endometriosis Awareness Week

• American Diabetes Alert Day

http://www.endometriosisassn.org/

• National MS Week http://www.nationalmssociety.org/

MARCH 9: • No Smoking Day http://www.cancer.gov/types/lung/patient/ lung-prevention-pdq

FEBRUARY 7: • Give Kids A Smile Day http://www.ada.org/en/

MARCH 10:

http://www.diabetes.org/

MARCH 23-29: • Arthritis Awareness Week http://www.arthritis.org/

MARCH 24-30: • Tick Bite Prevention Week http://www.cdc.gov/lyme/prev/

• National Women/ Girls HIV/ AIDS Awareness Day https://www.aids.gov/

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Careers in medicine

A Conversation with

Dr. Paul D. Siegel

r. Paul Siegel is one of the reasons that the Philadelphia County Medical Society is still a thriving institution, after more than 180 years.

Dr. Siegel has been a PCMS member for 54 years, and served as its 139th president. While practicing pulmonary medicine, he was also a clinical professor of medicine at Drexel University College of Medicine, and clinical associate professor of medicine at Thomas Jefferson University.

While practicing medicine and teaching, he also co-authored a textbook on acid base balance. Dr. Siegel is currently a member of the PCMS Editorial Review Committee.

You’ve been a doctor for more than 50 years.

What are the biggest changes you’ve seen in the medical profession?

Dr. Siegel:

Aside from the changes in technology, which are amazing, there is a change in the relationship between the practicing physician and the patient. It used to be a very personal relationship. Most family practitioners knew their patients over many years and developed a working relationship. Now, with all the health systems and the large groups of physicians, it’s more impersonal.

That sounds like a terrible change.

Dr. Siegel:

“Terrible” might be too strong a word. I valued the interpersonal relationships the most. That, unfortunately, has suffered in this age of specialization. The bigger the physician groups, the more they control physician-patient interaction, and the less time you have with your patient.

So what is the upside for the patient in this age of specialization?

Dr. Siegel:

The dramatic, life-saving advances in medical science. For example, when I first started practicing, stomach ulcers were a scourge among young men. By today’s standards, the 28 Philadelphia Medicine : Winter 2016

way we treated the disease back then would be considered primitive. Since ulcers were related to the production of acid by the stomach, treatment was directed toward decreasing or neutralizing stomach acid. The drugs available at that time were barely effective and the diets aimed at neutralizing acid were very rigorous. Also the drugs had many side effects—dry mouth, dilated pupils.

They interfered with urination.

A lot of these patients ended up in surgery. They would get a large portion of their stomach removed to decrease acid production. Today, most patients with the disease can get a 10day course of antibiotics and protein pump inhibitors, and 90–95% of them never get another ulcer.

Does specialization make greater demands of today’s doctors?

Dr. Siegel:

Yes. It’s amazing how science has improved the results in so many areas of medicine. But those changes have made the practice of medicine a much more complicated and sophisticated profession, that requires near constant study just to properly diagnose and treat patients or get them to the right specialists.

I was at a staff meeting a while ago, and one of my colleagues was complaining about the way modern medicine was heading. He said his experience of practicing medicine his way for 40 years was working just fine. A younger doctor looked at him and said, “Have you been practicing 40 years, or one year, 40 times?” If you sit still in this profession, it will race right past you.

What kind of advice would you give new medical students?

Dr. Siegel:

It’s different today than when I started. Today, you have to give up a certain amount of academic and practicing freedom to work in a large organization. That organization will make financial demands of you that we did not have when we started. But in return, you get more time off, fewer responsibilities and a more structured life.

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A Conversation with Dr. Paul D. Siegel

It’s a very rewarding profession. You often make life more enjoyable for your patients, and sometimes even save a life. If you want to do it, do it. You’ll never find anything else that will please you as much, and give you as much satisfaction, but be aware of what you’re getting into.

Do you see similarities between the newest crop of doctors and your class?

Dr. Siegel:

The main similarity is their desire to take care of people. They have that, or they wouldn’t be going into medicine. They all have that in different degrees.

But there are also differences. I think young people are much more interested in lifestyle than we were. We knew we were going to be working 60, 70, 80 hours a week, and have night and weekend calls. That was just part of the profession, you know. They don’t want any of that.

I don’t think the younger ones have the dedication to it the way we did.

Is that a concern to you?

Dr. Siegel:

In a way it is. It is. Not because they don’t care about the patient, but because the system sometimes makes it very difficult.

Why did you go into medicine?

Dr. Siegel:

Well, I was a mathematics major in college, but I knew I didn’t want to be a mathematician, and I took an aptitude test that indicated that I liked interacting with people. My teachers encouraged me to go into medicine. And that’s what I did, and I never regretted it.

When did you decide on pulmonology?

Dr. Siegel:

During my internship, the evening supervisor nurse was dating a young man who was in the pulmonary fellowship at Penn. He would wait in the emergency room for her to complete her shift. While he was there he showed me how to do simple pulmonary function tests. We would do these tests on patients with asthma before and after treatment. Being able to measure the results of the treatment with some precision appealed to my mathematical background.

I thought this is really good. I can measure what I’ve done— see the results. Then I started reading a bit about it. There

weren’t many fellowships then, and there wasn’t much you could do. You went into TB or ran a pulmonary function lab and in six months you learned everything you had to know.

All the other treatments, like ventilators, critical care, CT scans, fiberoptic bronchoscopy, came much later. When I first got into my specialty, the training was just how to do pulmonary function studies, how to understand pulmonary physiology, and taking care of TB, mostly TB. Lung cancer was relatively rare back then.

That’s surprising. Wasn’t there a lot of smoking back then?

Dr. Siegel:

It hadn’t been going on long enough. It takes 30 or 40 years for the cancer to develop.

You’re an avid reader of history. Do you have a favorite period of time?

Dr. Siegel:

The English and French period from Charlemagne and the Plantagenets. And I’m interested in Judaic history going back to some of the kings.

David and Solomon?

Dr. Siegel:

Yep, they were the beginning, just after Saul. They had a few things in common with modern day rulers. David generally was a very good king—did a lot of good things. But on his death bed, he’s handing over the power to Solomon, and he tells him to be wise, to be good, and by the way, you have to keep an eye on these guys. I promised I wouldn’t harm them, but I didn’t say you wouldn’t. Some of that history reminds me of The Godfather.

You also enjoy music.

Dr. Siegel:

Mainly classical music and jazz. Some opera. I’m not an opera buff, but I like it. They’re mostly these great tragedies, of course, in which everybody dies. …to beautiful music.

Dr. Siegel:

Yes. Just the other night we saw Otello, on an HD broadcast, and I have to say I enjoyed it. Everybody died, of course.

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Feature

Pennsylvania Lawmakers Are Writing Their Own Prescription for

Medical Marijuana Alan Miceli

urged lawmakers to not yet take this path.

PAMED wrote that “compassionate care is best done through research-based programs that involve significant oversight and safety.”

PAMED added that at some point medical marijuana may be proven to be beneficial and safe, but “we cannot in good faith recommend that cannabis be legalized at this time, given the known risks of harm and the lack of double-blinded peer-reviewed studies demonstrating benefit.”

PAMED urged the state and federal governments to fund research on cannabis products in the same rigid way other drugs are investigated. The state has responded to that call. The Pennsylvania Department of Health has announced that it’s launching a two million dollar research effort into cannabidiol oil, to see how well it works for children who suffer from medication-resistant seizures.

Senator Daylin Leach, Democrat from Montgomery County, who co-sponsored the medical marijuana bill that sailed through the Senate, dismisses the argument that more research is needed before medical marijuana should be allowed in Pennsylvania.

ennsylvania lawmakers appear to be inching closer to approving a medical marijuana bill, despite the concerns of many doctors in the state and the country, that medical marijuana has not yet been proven to be either safe or effective.

At the time this magazine was being published, a bill had been released from the House Rules Committee saddled with nearly 100 amendments.

In May, the Senate passed a medical marijuana bill by a 40-to-7 vote. Governor Wolf voiced support for the bill. There now appears to be enough votes in the House to approve a medical marijuana bill, but a House version could end up with amendments that would be deal breakers for the Senate and governor.

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Before the latest version was swamped with amendments, there was support in the House Rules Committee for a bill that would let patients get a “recommendation,” not a prescription, from a doctor for medical cannabis. The marijuana would be in pill, liquid, oil or spray form, but not leaf. The proposed bill would not allow smoking, and would not permit people to work or drive under the influence of cannabis.

Medical cannabis would be available to patients suffering from any one of more than a dozen diseases and other ailments.

If a medical marijuana bill becomes law in Pennsylvania, the state would join 23 other states with similar laws.

The Pennsylvania Medical Society’s (PAMED’s) House of Delegates in October

Leach claims there is only one reason PAMED opposes the bill. “The Pennsylvania Medical Society really has no interest in promoting patient safety or patient betterment. It exists for one purpose, and that’s to prevent doctors from being sued.”

Scot Chadwick, legislative counsel for PAMED, said it’s just “flat wrong” that the state organization is worried about doctors getting sued over medical marijuana. Chadwick said, in states where medical marijuana is legal, “I’m not aware of any cases where there has been a medical liability lawsuit against a physician who recommended marijuana.”

Chadwick said PAMED’s concerns center on one overwhelming fact—not enough research has been done on medical marijuana.

“Physicians would love to have another weapon in their arsenal to fight these serious diseases and conditions,” Chadwick

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Medical Marijuana

said. “And I think there is a lot of hope that eventually marijuana will be proven to be helpful. They’re (PAMED) just reluctant to utilize it until its safety and advocacy have been demonstrated.”

There is a great deal of support in the medical community for more research.

Articles published in June, in the Journal of the American Medical Association (JAMA), concluded that medical marijuana has not been proven to work for many illnesses.

The review evaluated 79 studies involving more than 6,000 patients. The studies indicate that medical marijuana works best for chronic pain and muscle stiffness for multiple sclerosis, but for other conditions the evidence is weak on its effectiveness.

The review went on to say that not enough study has been done to determine the longterm effects of medical marijuana use, and whether its use is justified in children whose developing brains may be more vulnerable to its effects.

and threw it into the sewer, and suggested she’d be more alert in class without it.

Philadelphia recently decriminalized possession of fewer than 30 grams of weed.

Since the regulation went into effect, police have cut the issuance of citations by about 75%. The city’s new mayor, Jim Kenney, who sponsored the decriminalization bill when he was a member of city council, says he is leaning against police issuing any citations for individuals caught using small amounts of weed.

Washington, Oregon, Colorado and the District of Columbia have legalized recreational marijuana. Ohio voters rejected recreational marijuana in November, but analysts believe Ohio nixed the bill because it would have allowed only a wealthy few to control the sale and distribution.

Many others who want recreational marijuana legalized believe that weed is basically harmless, yet researchers are struggling to find evidence that supports that belief.

An editorial in the same JAMA issue Scientists are fairly clear about the shortstated that approval in many states has been term effects for a significant number of users based on “low-quality scientific evidence, —memory impairment, loss of coordination, anecdotal reports, individual testimonials, paranoia and psychosis. But long-term effects legislative initiatives and public opinion. are less clear. A 2008 New Zealand study Imagine if other drugs were approved found that smoking pot can raise the risk of through a similar approach?” lung cancer, raising questions about other studies that have found little or no such link.

The editorial concluded that, “It’s unclear why the approval process should be different Another New Zealand study that followed from that used for other medications.”

1300 children born in 1977 found that those who used cannabis daily were 50% The push to legalize medical marijuana more likely to have psychotic symptoms, is taking place as pressure builds in some and were at greater risk than non-users of parts of the country to, at the very least, dropping out of school. relax recreational marijuana laws.

Yet another New Zealand study of a thouOne example of the shift in the approach sand people concluded that using cannabis to the increasingly difficult job of policing regularly from an early age correlated with a pot took place recently in New York City. steep decline in IQ that included memory The city’s police commissioner, William and reasoning problems. But there’s debate Bratton, was walking down Wall Street, over whether cannabis, alone, is to blame when he came upon a young woman—an for these study results, since adolescents apparent college student—with a school who smoke marijuana are also more likely backpack, smoking a joint. Instead of giving to drink excessively and engage in other her a citation, Bratton took the joint from her risky behaviors.

Many of these studies were completed before much stronger strains of cannabis entered the market. Cannabis grown in the U.S. today is about twice as strong as it was a couple of decades ago, while weed now smuggled into the country often packs three times the potency.

It’s not clear if legalizing recreational marijuana would dramatically increase use. In the Netherlands, where possessing a small amount of pot has been legal since 1976, heavy smoking takes place in tourist areas, but in the country as a whole, 7% of residents smoke. That compares to 5% in Germany and Norway.

But the National Institute on Alcohol Abuse and Alcoholism (NIAA) reported in the October online issue of JAMA Psychiatry, that marijuana use by U.S. adults has more than doubled, from 4.1% in 2001, to 9.5% in 2013.

The NIAA report added that about three out of every 10 people smoking weed manifested a marijuana use disorder. The report found that, “marijuana is associated with increased risk for many outcomes, including cognitive decline, psychosocial impairments, vehicle crashes, emergency department visits, psychiatric symptoms, poor quality of life, use of other drugs, a cannabis-withdrawal symptom and addiction risk.”

But the study went on to state that as with using alcohol, “many individuals can use marijuana without becoming addicted.”

Studies indicate that 9% of adult pot smokers become addicted.

DEA chief Chuck Rosenberg has rejected the notion that smoking marijuana is medicine, calling that conclusion a joke. On the day he issued the DEA’s “2015 National Drug Threat Assessment Summary,” he said that smoking marijuana “has never been shown to be safe or effective as a medicine.”

Right now, there does not appear to be any serious movement by Pennsylvania lawmakers to make recreational marijuana legal.

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feature

ANTIBIOTIC RESISTANCE: The Med, Vet Connection Stephen Graff

ntibiotic resistance is a pressing public health issue in America today.

Infections from so-called “superbugs” that can’t be beaten with our arsenal of drugs are responsible for more than 23,000 deaths a year and two million illnesses. And the cost to treat these infections? About $20 billion a year in excess health care costs, the CDC reports. So when new findings were published in early January 2015 in Nature showing a new potential antibiotic had been found, it was a bit of a feeding frenzy. Our saving grace was found in, of all places, the dirt, and the media ate it up.

But the promising news was met with an unfortunate truth. “The reality of the matter is that drug development takes time,” says Keith Hamilton, MD, director of the Antimicrobial Stewardship Program at the Hospital of the University of Pennsylvania.

“And any new drug will eventually become resistant. So we should now and in the future think critically when prescribing drugs. Overuse is a problem today in the health care system, but there are measures to help combat resistance while appropriately treating our patients.”

It’s a judicious approach that not only doctors at Penn Medicine support, but also veterinarians at the University of Pennsylvania’s School of Veterinary Medicine.

Vets?

The issue isn’t just in the health care setting. Antibiotics used in the agricultural setting play a role, as well. Farm animals, like chickens and cows, are treated with the drugs to help prevent infections from spreading among the herd or flock and 32 Philadelphia Medicine : Winter 2016

also used to promote growth, known as a sub-therapeutic use. But overuse is likely leading to resistant bacteria that cause infections in both animals and humans.

Whether it can spread resistance genes from animal bacteria to humans is still unknown.

The use of antibiotics has been going on for decades, but more recently a brighter spotlight has been cast on the farm industry, as the U.S. Food and Drug Administration (FDA) puts forth bolder guidance and recommendations.

“We, too, have to use the antibiotics diligently to help decrease antibiotic resistance,” says Sherrill Davison, VMD, MS, MBA, an associate professor of Avian Medicine and Pathology and director of the Avian Medicine and Pathology Laboratory at Penn Vet’s New Bolton Center. An expert in such poultry diseases as the avian flu and the commonly known salmonella, Davison has spent most of her 40-year career working with farmers and the FDA to make sure the food supply is safe and to help in the effort to treat animals fairly and keep them healthy. “We need those tools [antibiotics] in the future, so we have to be mindful about how often we use them now.”

The issue gained more steam last September when the White House called for an interagency task force to help guide antibiotic use in animal agriculture. The report specifically asks for the phase out of drugs used to promote growth and administration of drugs in “medically appropriate ways” only under the supervision of a veterinarian.

“Right now, we don’t know how antibiotics are being used in some cases, and that is why the task force is being assembled,” says

Davison, who says vets and the various animal industries are working closely with the FDA. “We need to have that vet oversight to see what antibiotics are being used—and how much.”

Today, there is a good amount of “antibiotic-free” food already on the shelves. Anything marked organic means the animals haven’t been treated with antibiotics for infections nor growth, while some labels indicate the animals were not treated with “antibiotic growth promotants.”

That same White House report proffered best practices for antibiotic use in humans, as well: quickly identify the microbe responsible for disease, ideally with inexpensive diagnostics; administer the most effective antibiotic at the appropriate dose, route, and time; and discontinue antibiotic therapy when it is no longer needed.

“Optimizing the use of our current antibiotics in human health care and animal agriculture will extend the longevity of these life-saving medicines and maximize their benefits,” the report stated.

Attitudes towards this judicious approach almost perfectly line up, as you can see from the experts’ comments. Yet, doctors and vets are often sitting at different tables. It’s a multidisciplinary problem that’s perhaps calling for a more multidisciplinary approach.

After all, there is inappropriate use happening on both sides.

“It’s an issue that people from all disciplines need to look at together: doctors, vets, federal agencies, and food producers,” says Davison.

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Antibiotic Resistance:

Hamilton agrees. Having more solidarity and national experts who represent large geographic regions discussing national strategies is important, he says.

“I think it’s vital to have a group that ‘cross advocates’ for the same goal, which is the judicious approach to antibiotics in humans and non-human animals. That definitely would be powerful,” says Hamilton.

“There are probably similar challenges in the vet and med world: communicating with patients—or in their case, farmers or animal owners—about the proper use of antibiotics.

The messaging is a big part of all this.”

Both sides of the campus are leading the way in the antibiotic space.

Penn Medicine has a successful antimicrobial stewardship program, which since its inception in 1993 has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce health care-related costs with its multifaceted approach. More recently, Hamilton started working with the Philadelphia public health department to help inform and guide the region’s hospitals about best practices in antibiotic use.

Faculty from Penn Vet often speak out about antibiotic resistance (check out this Q&A with Davison in the Philadelphia Inquirer).

“We know overuse in animals and humans both contribute to antibiotic resistance, but more collaborative research is needed to better quantify the relationships and better understand antibiotic resistance overall,” Davison says. “If we worked together, shared resources and research, best practices and concerns, it would only help tackle this more efficiently.”

The Yellow Fever Epidemic of 1793 in the city of Philadelphia is noted as one of the most severe in United States history. It was believed that refugees from SaintDomingue were carrying the yellow fever disease, so Philadelphia imposed a two-to-three week quarantine on immigrants as well as their goods. Because the epidemic had already reached its peak, it was unable to be enforced. Five thousand people were listed in the official register of deaths between August and November. Philadelphia, a population of 50,000, had 20,000 people flee the city by the end of September.

The responses of the government leaders in the city to the crisis varied. As the death toll in the city continued to rise, neighboring cities established quarantines for the refugees from Philadelphia.

Maryland tried very hard to prevent people from Philadelphia from crossing the Susquehanna River back over into their state. New York established a committee whose goal was to prevent the introduction and spreading of infectious diseases in the city. Springfield, New Jersey, Chester, Pennsylvania, and Elkton, Maryland were among the few towns that accepted and welcomed refugees.

The end of the Yellow Fever Epidemic did not end the controversies among the doctors of Philadelphia. Many of the city doctors heavily disagreed on what could cause such an outbreak, as well as treatment options.

The medical community did not know the natural history of yellow fever, and the limited resources and knowledge of that time didn’t help their case. The city of Philadelphia suffered yellow fever epidemics again in 1797, 1798 and 1799, keeping the origin and treatment controversies in existence.

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PAMED Updates

Proposed Immunization Changes Could Provide Greater Protections, Says PAMED President

he Pennsylvania Departments of Health and Education announced proposed changes to immunization requirements for schoolchildren on Nov. 5.

• Change to method of providing evidence of immunity for measles and for mumps from accepting a statement of history by parent or guardian to requiring a statement of history of disease by physician, nurse practitioner, or physician assistant

“Pennsylvania physicians through the Pennsylvania Medical Society have voiced growing concerns in recent years over immunization rates, vaccine exemptions, • Replacing the eight month provisional period with the following: and occasional outbreaks of diseases such as measles,” said Scott Shapiro, MD, FACC,  Requiring exclusion from school attendance FCPP, president of PAMED, in a statement. of a child who lacks a single dose of a single “Our long-standing policy has pushed to dose vaccine and/or the first dose of a establish a parental duty to immunize their multiple dose vaccine children in a complete and timely manner.

“The Pennsylvania Medical Society believes Health Secretary Karen Murphy and Education Secretary Pedro Rivera are correct in proposing changes to improve state-required immunization policy. This will help provide greater protection for Pennsylvanians.”

Specifically, the departments proposed the following changes to current regulations: • Definitions for new terms “full immunization” and “medical certificate” • Clarifications to existing vaccine requirements • Additional meningococcal dose before entry into the 12th grade

 Allowing a child that needs the next or final dose of a multiple dose vaccine five school days to obtain the next or final dose in the series before being excluded from school attendance; or  Allowing a child needing more than one dose of a multiple-dose vaccine series beyond the five days to attend school provisionally upon the submission of a medical certificate outlining the dates for additional vaccination

 Exempting from exclusion a child who is homeless  Exempting from exclusion for 30-days a child who is transferring from a school or country outside the commonwealth and cannot provide records  Providing limited waiver of vaccine requirements in the event of a disaster impacting the ability of children transferring into a school to provide records, or a nationally recognized vaccine shortage  Changing reporting times for schools to report kindergarten and 7th grade immunizations to allow schools more time to gather information and report  Requiring schools to report electronically to obtain more accurate reporting  The departments also said that they are not proposing any changes to the religious and medical exemptions in the regulations. Read more on the Department of Health’s website, including FAQs and its news release.

 Requiring school administrators to review the medical certificate and the child’s compliance at least every 30 days  Allowing school administrators to exclude a child who does not comply with the dates in the submitted medical certificate

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PAMED UPDATES

Combatting Pennsylvania’s

Opioid Crisis: TIPS FOR PATIENT CONTRACTS

urning the tide on Pennsylvania’s opioid crisis will take a team effort.

That includes constant communication and collaboration from various members of the health care team—from physicians to nurse practitioners to pharmacists.

Patients also have to be willing to do their part.

One way for physicians to hold their patients accountable is through narcotic contracts, said numerous prescribers who participated in the online educational series “Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know.”

You can learn more about this program at www.pamedsoc.org/opioidresources.

“This allows the patient to be equally as responsible,” said Cynthia Ferrari, PA-C, a physician assistant from outside Philadelphia.

“I think as doctors, PAs, nurse practitioners, we’re trying to make it better so patients have a better quality life and can take care of themselves and live independently. But we know now, especially looking at studies, that there’s a limit to where we find (opioids) beneficial and beyond that it’s not really benefiting the patient. If anything, we’re harming the patient.”

Unfortunately, most patients do not realize the risks and limitations. They need to be educated, and that’s another goal for any narcotic contract.

“It’s very important that you set limits with people and that you not make it easy for them to become addicted,” said John Goldman, MD, vice president of inpatient medicine at Pinnacle Health in Harrisburg.

“You need to make sure you’re the only one giving them meds, so you know how much they’re being given.”

What should be included in patient contracts? Dr. Goldman recommends adding the following items: 1. Patients should only receive opioid medications from their primary care prescriber. That means they are forbidden to seek refills from the emergency department or an urgent care center.

2. Patients agree to a regular but random urine drug screening. This ensures they take the proper doses of their medication, are not diverting or selling them, and aren’t taking other illegal substances.

3. Patients need to see their primary care provider on a regular basis in order to get refills. They should not simply call to order refills.

Tools For Prescribers

 The Pennsylvania Medical Society’s Opioid Prescription Guidelines checklist is a tool designed to help physicians and other prescribers discuss pain management with their patients and educate them how to comply.  The Pennsylvania Medical Society, in collaboration with the Pennsylvania Department of Health and other health care associations, is creating a multi-part online educational series for prescribers.

Part 1 of “Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know” teaches prescribers how to effectively use the new voluntary state opioid prescribing guidelines, and is now available at www. pamedsoc.org/opioidresources.

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PAMED Updates

IMPORTANT CHANGES

to Medicare Fee Schedule in 2016 he final rule detailing how Medicare will reimburse physicians in 2016 was issued by the Centers for Medicare and Medicaid Services (CMS) on Oct. 30, 2015.

With your practice and family responsibilities, we know you don’t have time to read and analyze the 1,358 pages to figure out how your reimbursement may be impacted next year. That’s another value of your Pennsylvania Medical Society (PAMED) membership. We have you covered with what you need to know.

The Pennsylvania Medical Society’s experts continue to analyze the final rule, but, at first glance, here are some of the items that may be of particular interest to physicians:

 Advance Care Planning – The rule finalizes a proposal for separate payment for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners. The Medicare statute currently provides coverage for advance care planning under the “Welcome to Medicare” visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment offers providers and beneficiaries greater flexibility in using these services.  Incident To – In an effort to clarify “incident to” requirements, CMS reiterates the supervising physician is the physician who bills for “incident to” services. In a conversation with CMS’ subject matter expert, PAMED was told the rule “is intended to clarify that the ordering physician or other practitioner and the supervising physician or other practitioner DO NOT need to be one and the same. Rather, the proposal is intended to clarify that the physician or other practitioner who bills for the “incident to” services must always be the supervising physician or other practitioner.”

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 Modifications to Physician Quality Reporting System (PQRS) – If an individual eligible professional (EP) or group practice does not satisfactorily report or satisfactorily participate in PQRS for 2016, a 2 percent negative payment adjustment will apply to covered professional services furnished by that individual EP or group practice during 2018. There will be 281 measures in the PQRS measure set and 18 measures in the GPRO Web Interface for 2016. Also, as recently authorized under the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA), CMS is adding a reporting option that will allow group practices to report quality measure data using a Qualified Clinical Data Registry (QCDR). The 2018 PQRS payment adjustment is the last adjustment that will be issued under the PQRS. Starting in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA.  Physician Value-Based Payment Modifier – In the final rule, CMS

finalized the following provisions related to the value modifier: • To apply the Value Modifier to non-physician EPs who are Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Certified Nurse Anesthetists (CRNAs).

• To use CY 2016 as the performance period for the CY 2018 Value Modifier and continue to apply the CY 2018 Value Modifier based on participation in the PQRS by groups and solo practitioners.

• For groups of ten or more EPs— Continue with maximum upward adjustment of +4.0 to be multiplied by an adjustment factor (to be determined at conclusion of the performance period) and a maximum downward adjustment of -4.0 in CY 2018.

• For groups of two to nine EPs and solo practitioners—Upward adjustment of +2.0 multiplied by an adjustment factor and a maximum downward adjustment of -2.0 in CY 2018.

 Physician Compare – The final rule continues the phased approach to public reporting on Physician Compare. CMS will continue to make all 2016 individual EP and group practice PQRS measures available for public reporting. All CAHPS for PQRS measures for groups of two or more EPs who meet the specified sample size requirements and collect data via a CMS-specified certified Consumer Assessment of Healthcare Providers and Systems (CAHPS) vendor are available for public reporting. In addition, all Accountable Care Organization (ACO) measures, including CAHPS for ACOs, are available for public reporting. CMS is also finalizing the following proposals:

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Important Changes To Medicare

• To include Certifying Board, and specifically add American Board of Optometry (ABO) Board Certification and American Osteopathic Association (AOA) Board Certification.

• To include an indicator on profile pages for individual EPs who satisfactorily report the new PQRS Cardiovascular Prevention measures group in support of the Million Hearts initiative.

• To continue making individuallevel QCDR measures available for public reporting, and, new to 2016, to publicly report grouplevel QCDR measures.

• To publicly report an item (or measure)-level benchmark derived using the Achievable Benchmark of Care (ABC™) methodology.

• To include in the downloadable database the Value Modifier tiers for cost and quality, noting if the group practice or EP is high, low, or neutral on cost and quality; a notation of the payment adjustment received based on the cost and quality tiers; and an indication if the individual EP or group practice was eligible to but did not report quality measures to CMS. • To publicly report in the downloadable database utilization data for individual EPs.

 CMS is not finalizing the proposal to include a visual indicator on profile pages for group practices and individual EPs who receive an upward adjustment for the Value Modifier.

CMS is, however, finalizing its proposal to publicly report an item-level

benchmark for group practice and individual EP PQRS measures using the ABC methodology. The benchmark will be stratified by reporting mechanism to ensure comparability and reduce the interpretation burden for consumers. The benchmark will be displayed as a five-star rating on Physician Compare. CMS will conduct analysis and stakeholder outreach around the star attribution methodology prior to public reporting in 2017.  PAMED will monitor any developments, and will continue to review the final rule and provide information on any changes that could impact your reimbursement.

Winter 2016 : Philadelphia Medicine 39

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pamed updates

Rep. Matt Baker Introduces

CREDENTIALING REFORM LEGISLATION iting a need to improve access to care and eliminate unnecessary costs in the health care system, Rep. Matt Baker (R-Tioga County) has introduced HB 1663, prompt credentialing legislation that has the Pennsylvania Medical Society’s strong support.

Rep. Baker’s bill specifically addresses the problem of unwarranted delays by health insurers in credentialing applicants for inclusion in their networks. Hospitals and physician practices routinely face the situation where a newly hired health care professional who is fully licensed and qualified to provide care is not reimbursed by insurers for months while the insurers work their way through an unnecessarily long and cumbersome credentialing process.

This costs hospitals and physician practices money, drives up the cost of health care, and limits access to care by keeping fully licensed and qualified providers on the sidelines until they are credentialed by insurers.

The ability to transmit data and process applications electronically long ago eliminated any justification for a lengthy insurer credentialing process, and Rep. Baker’s legislation will establish a standardized process and timeline for insurer action on credentialing applications. Key elements of HB 1663 include the following:

Uniform Application Form

Beginning on Jan. 1, 2016, all health insurers licensed to do business in Pennsylvania would be required to accept the Council for Affordable Quality Healthcare (CAQH) credentialing application when submitted by a health care practitioner for participation in the insurer’s provider panel.

Provisional Credentialing

If a health insurer fails to issue a credentialing determination within 30 days after receiving the completed CAQH credentialing application, the health care practitioner shall be deemed provisionally credentialed. A health care practitioner would

40 Philadelphia Medicine : Winter 2016

be eligible for provisional credentialing if (1) the health care practitioner has applied to participate in the insurer’s provider panel for the first time, or (2) the health care practitioner is a member of a provider group that is a participating provider.

Coverage & Reimbursement During Provisional Credentialing

A health insurer shall provide coverage and reimbursement for services rendered by an applicant granted provisional status under the same terms as are applicable to participating physicians in the applicant’s provider group.

The bill also contains enrollee protections during an applicant’s provisional credentialing status, and administrative penalties on health insurers for failure to comply with the bill’s provisions.

We believe these steps will go a long way toward eliminating unwarranted delays in processing credentialing applications, resulting in both cost savings and improved access to care, without in any way sacrificing patient safety.

PAMED thanks Rep. Baker for his leadership on this important issue, and urges physicians to join in this effort by contacting their local House member and asking him or her to support HB 1663.

We’ll be sure to keep you up to date on our efforts to enact the bill. In the meantime, you can reach our advocacy department with comments or questions at (717) 558-7823.

More Credentialing Advocacy

PAMED is also working closely with the Department of Human Services to ensure timely credentialing of physicians in the state’s Medicaid program. After discussions led by PAMED, DHS announced that, beginning in 2016, it will impose additional requirements on its Physical Health Managed Care Organizations (PH-MCOs) related to credentialing timeframes. Among them, PH-MCOs will be required to begin their credentialing process upon receipt of a provider’s application. If the application contains all of the required information, they must complete the credentialing process within 60 days.

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

pamed updates

Did You Receive Mail from Mcare?

It Could Impact Your Refund

n Nov. 16, 2015, Mcare mailed to physicians and medical practices notice letters with information about assessment refunds for their Mcare coverage.

The refunds are required by a settlement agreement for litigation in which the Pennsylvania Medical Society, The Hospital and Healthsystem Association of Pennsylvania, and the Pennsylvania Podiatric Medical Association challenged how Mcare calculated its annual assessments and diversion of Mcare funds by the Commonwealth.

If you paid an Mcare assessment (or an assessment was paid for you) for 2009, 2010, 2011, 2012, or 2014, refunds will be made for your coverage and you would have been mailed a notice letter. Medical practices also would have been mailed a notice letter if they paid an assessment for Mcare coverage in any of those years.

The notice letter was mailed in a #10 business envelope with double windows for the Mcare return address and your name and address. If your mail is handled by administrative staff, you should advise them to direct your notice letter to your immediate attention and to not open the envelope, as it contains confidential, time-sensitive information.

Be sure to retain your notice letter. You will need information in that letter to take next steps described below and to verify that any refunds for your coverage have 42 Philadelphia Medicine : Winter 2016

been correctly paid. You will also need this information if you have to contact Mcare about the refunds for your coverage.

Next Steps for Physicians

A notice letter enclosure provides an itemization of each refund for your coverage.

Any next steps that you must take to ensure proper payment of the refunds for your coverage depend upon the designation of your refund in the second column of your refund itemization.

Designation of Refund

Claimed

Assigned

Blank (no designation)

Payment of Refunds

If any refunds are payable to you, you can expect your check in the first quarter of 2016, unless you have one or more claimed refunds and you fail to make payment choices for all of your claimed refunds on the McareChoice website by Dec. 30, 2015.

Failure to make payment choices for all claimed refunds by that cut-off date will delay your payment until the second quarter of 2016 when Mcare makes the final round

Next Steps

Timeline for Action

Go to www.McareChoice.com to choose who Mcare should pay–you or the claimant; Mcare will honor your choice.

Endeavor to make your payment choices for claimed refunds by Dec. 30, 2015.

No further action is required; Mcare will pay the refund to the assignee.

Reach out to the listed assignee ASAP if you dispute a listed assignment; contact Mcare only if this does not resolve the dispute.

No further action is required; Mcare will automatically pay the refund to you unless you subsequently assign the refund.*

Endeavor to complete any assignments by Dec. 30, 2015.

*When a medical practice is owed a refund payment for the coverage of the practice entity, Mcare needs the practice’s Tax ID number before it can make any payment to the practice. The practice’s notice letter will include a form for the practice to provide its Tax ID number if Mcare does not already have this information. The requirement for a Tax ID number does not apply to physicians.

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THE PHILADELPHIA COUNTY MEDICAL SOCIETY

2016 Upcoming Events & Programs All program held at PCMS HQs unless noted

JANUARY 7 Child Abuse Training Program

6:00 PM – 8:30 PM

27 PCMS Executive Committee Meeting

5:00 PM – 6:00 PM

of payments. This payment delay will apply to all of your refunds, including those that will be automatically paid to you because they have been neither claimed nor assigned.

Your refund check will be mailed to the same address where your notice letter was successfully delivered unless you update your mailing address in the interim. However, Mcare will not mail a refund check to you if your refund notice is returned to Mcare as undeliverable.

Additional Information on Refund Process

PAMED’s website—www.McareRefund. org—includes further information on the Mcare settlement including the refund process. Resources available include: • Quick Consult on the Mcare Refund Notice Letter, which provides further details on next steps to ensure that refunds for your coverage are properly paid • Quick Consult on Legal Issues Impacting Mcare Refund Assignment and Claim Decisions, which provides information to help you determine whether it is in your best interest to agree to payment of a claimed refund to the claimant or to assign an unclaimed refund • Video on the McareChoice website, which walks you through the steps of making a payment choice on a claimed refund.

Watch for updates in PAMED’s Daily Dose email to members and at www.McareRefund.org.

Approved 2 hour courses for child abuse recognition and reporting training for physicians that is required for medical license renewal.

Meets once a month to plan PCMS meeting, agenda; conduct business between quarterly Board of Directors meetings.

FEBRUARY 16 Resident/ Fellow Contract Review Program

6:00 PM – 8:00 PM

17 Public Health Grand Rounds Program

5:00 PM – 6:30 PM

Program to address basic principles of the employment contract, negotiating tips, duties and obligations, representation and legal review, contract duties; restrictive covenant; malpractice insurance, dispute resolution.

“Working Together to increase Access to Long Acting Reversible Contraception (LARC) for Philadelphia Women” at the College of Physicians of Philadelphia Program will educate attendees about how to create changes in training, practice and funding approaches that will increase access to LARC for women in Philadelphia.

24 PCMS Executive Committee Meeting

Meets once a month to plan PCMS meeting, agenda; conduct business between quarterly Board of Directors meetings.

26 “Opportunities for Patient Care Coordination

8:00 AM – 10:30 AM

in Emergency Departments across the Greater Philadelphia Region”

5:00 PM – 6:00 PM

Regional programs to learn about HealthShare Exchange of Southeastern Pennsylvania, Inc. and the clinical activity use case in Emergency Departments.

MARCH

8

Med Student/Resident Panel Discussion on Residency Panel discussion with Residents/Fellows to address medical student residency questions.

6:00 PM – 8:00 PM

23 PCMS Executive Committee Meeting

5:00 PM – 6:00 PM

24 PCMS Board of Directors Meeting

5:00 PM – 6:30 PM

30 Doctors Day Social

6:00 PM – 7:30 PM

Meets once a month to plan PCMS meeting, agenda; conduct business between quarterly Board of Directors meetings.

Meets quarterly to make financial decisions on behalf of the Society

Winter 2016 : Philadelphia Medicine 43

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PCMS NEWS

Paul D. Siegel, MD

William S. Frankl, MD MS (Medicine)

r. Frankl has been a physician, administrator and educator in the field of cardiology for more than 38 years.

He has played a crucial role in organized medicine and academia for several medical schools in our area. During that time, Dr. Frankl has also served terms as president of the Philadelphia County Medical Society; district trustee from Philadelphia to the Pennsylvania Medical Society Board of Trustees; delegate to the PMS House of Delegates; president of the American Heart Association, Pennsylvania Affiliate; governor for Eastern Pennsylvania for the American College of Cardiology, and was twice elected to the Board of Regents of the American College of Clinical Pharmacology.

As a leader in the field of cardiology, Dr. Frankl has held numerous academic appointments including professor of medicine at Temple University School of Medicine; professor of medicine and chief of cardiology, The Medical College of Pennsylvania; Thomas J. Vischer Professor of Medicine and chair, Department of Medicine and director of the Likoff Cardiovascular Institute, Hahnemann University; and professor of medicine and director of regional cardiovascular programs, Allegheny University of the Health Sciences.

Dr. Frankl is also the author and co-author of more than 150 scientific articles and four textbooks of cardiology. Since retiring from the active practice of medicine in 2000, Dr. Frankl has undertaken a new career as a novelist and short story writer.

He has published two novels: Damaged Heart: A Medical Tale and The Merger; Two collections of short stories: Romance and the Vending Machine and Nightmare Worlds; and his recent novella, The Cyber Patient, an action thriller about terrorism, medicine and alternate universes. He has had more than twenty-five of his short stories published in a variety of literary magazines.

2015 CRISTOL AWARD RECIPIENT: The Cristol Award is presented to a PCMS physician member of The Philadelphia County Medical Society who has made a significant contribution to the Society, furthering and enhancing the educational, scientific and charitable goals, purposes and functions of organized medicine.

The award honors the memory of David S. Cristol, MD, an outstanding member of PCMS.

aul D. Siegel, MD, was the 139th President of The Philadelphia County Medical Society and has been a dedicated active member for over 54 years.

Dr. Siegel was born and raised in Philadelphia, Pa., and received his medical degree from Temple University School of Medicine. He completed his internship and residency at Albert Einstein Medical Center and Philadelphia General Hospital. Dr. Siegel is board certified in Internal Medicine and is currently retired from the practice of pulmonary medicine.

Dr. Siegel’s activities in organized medicine include: current member of the PCMS Editorial Review Committee; delegate to PAMED HOD since 1984; past member of numerous committees including: House & Staff; Board of Censors; Past Chair, HMSS/OMSS; Cancer Control Committee, Air Pollution Committee, Bylaws Committee, Nominating Committee; Budget and Finance; PCMS Board of Directors and PCMS Pfahler Board of Directors. Dr. Siegel is also past Chair of the Pennsylvania Medical Society Liability Insurance Company (now NORCAL) Claims Committee.

As past benefits chair of the Pennsylvania Medical Society’s Commission on Communications Technology, Dr. Siegel worked tirelessly to streamline the way in which doctors deal with insurers and was instrumental in expanding the Society’s web site as well as providing leadership for educational and informational resources for physicians and patients.

In addition, Dr. Siegel has held a variety of academic positions, notably, clinical associate professor of medicine at Thomas Jefferson University.

Dr. Siegel has published widely in his specialty, including articles and book chapters on tuberculosis, bronchitis, and emphysema. In addition he has also co-written a textbook on acid base balance which has been used in academic settings. He is an avid reader, especially of world history and Judaica; also a music buff. Dr. Siegel remains an enthusiastic tennis player and is also a former pilot.

We thank you, Dr. Siegel, for your years of unselfish dedication to The Philadelphia County Medical Society and Pennsylvania Medical Society, and to the thousands of grateful patients who you cared for.

Congratulations!

44 Philadelphia Medicine : Winter 2016

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Member Recognitions

Karem C. Mounzer PCMS Practitioner of the Year Recipient

r. Mounzer has received the prestigious annual award for his dedication to the medical profession in the areas of quality patient care and community service. The clinician, clinical researcher and educator is medical director of Philadelphia FIGHT and is a clinical associate professor of Medicine at the Perelman Medical School at the University of Pennsylvania.

Dr. Mounzer heads the Jonathan Lax Treatment Center, Philadelphia’s largest community-based HIV program. It is a comprehensive patient-centered community-based, federally qualified health service organization where state-of-the-art medical care is provided in a setting that includes case management, HIV education, mental health assessments, nutritional counseling, substance abuse referrals, advocacy, and behavioral-based adherence support interventions.

Dr. Mounzer’s clinical expertise is in HIV, HCV, sexually transmitted diseases and other general infectious diseases. He identified two major gaps in the care of patients with HIV infection—coinfection with hepatitis C virus and the complexity of multidrug-resistant HIV treatment. He established two subspecialty clinics to address these issues. The clinics serve as referral sites for HIV-1 infected patients in the tristate area.

Dr. Mounzer has participated as a principle clinical investigator in more than 60 pivotal trials evaluating the efficacy and safety of new HIV and HCV agents, HIV resistance, and treatment strategies to better contain the disease and its spread.

He has had a long term commitment to the HIV research team at the Wistar Institute. This partnership has enhanced understanding of the immune system’s role in controlling HIV and HCV, particularly the innate.

Dr. Mounzer continues to mentor pre-med, medical students, residents and fellows from colleges and medical schools who elect to spend their time serving in a community-based public health setting. He also continues to train staff, RNs, PA-Cs, and NPs to better understand and manage the complexities of HIV-infected patients.

Dr. Mounzer is a member of the Alpha Omega Alpha Honor Medical Society. He was approved for an O-1 Visa by Immigration and Naturalization Services dedicated to foreigners with “extraordinary ability” and has received the “Physician–PA Team Award” in Pennsylvania from the Pennsylvania Society of Physician Assistants in 2014.

Dr. Mounzer has published many peer- reviewed manuscripts and book chapters discussing HIV therapy and immunopathogenesis. He recently co-authored a paper in JAMA on HCV treatment in HCV/HIV co- infected patients and he serves as a reviewer to several prominent Medical Journals.

Dr. Mounzer completed his undergraduate and medical degrees (combined program) at Saint Joseph University, French Faculty of Medicine, in Lebanon. He graduated at the top of his class as a Doctor of Medicine in 1992. He completed his internship and residency in medicine at the Cooper Medical Center in Camden, New Jersey, for the University of Medicine and Dentistry of New Jersey (UMDNJ), Robert Wood Johnson Medical School. He then completed a fellowship in the

Infectious Diseases Division at UMDNJ Cooper Health Medical Center. He is board certified in Internal Medicine and Infectious Disease.

Dr. Mounzer was born and raised in the country of Lebanon. He is fluent in Arabic, French and English. He is married to Hala Eid, MD, the program director of the Rheumatology Fellowship at Cooper Medical Center. They have two children, Sarah and Marc, who play varsity tennis for Moorestown High School.

We congratulate Dr. Mounzer and thank him for his tireless efforts on behalf of the citizens of Philadelphia who have been touched by his compassionate care.

The award is supported by the Wiener Fund established by the late Jacob S. Wiener, MD, past member of PCMS.

Winter 2016 : Philadelphia Medicine 45

CONSIDER MEMBERSHIP in The Philadelphia County Medical Society

Membership in the Pennsylvania Medical Society and The Philadelphia County Medical Society go hand-in-hand, addressing the many issues facing the medical profession today and preserving the patient-physician relationship. PCMS Membership is available to all opathic (MD) and osteopathic (DO) physicians residing or practicing in Philadelphia County, who are in good moral and professional standing. Membership is also available to residents, fellows, medical students, and practice managers.

The PCMS physician leadership and staff are committed to addressing the issues confronting medicine today, and we are pleased to have you as part of that effort. By making the choice to be a part of organized medicine, you are choosing to have a voice in the way you practice medicine every day.

Member Benefits Understand Regulatory, Licensing, & Reimbursement Changes...

Community Health...

We’re here to answer your questions about health system reform, licensure requirements, scope-of-practice, and reimbursement issues. One call could pay for your dues many times over.

PCMS takes an active role in the health of our local community.

Our Block Captain Program provides education and access to primary care for residents who cannot afford healthcare. We also work with the Philadelphia Department of Public Health to develop and meet sound public policies.

Stay Current...

Discounted Rates...

Stay up-to-date on local, state, and national issues through our monthly member emails, quarterly magazine, legal and regulatory manuals, regular practice management meetings, and continuing medical education physician seminars.

Members get excellent rates on legal and business reviews of contracts through our legal referral program. We also provide group rates on liability, disability, long-term care, health, term life, and workers’ compensation insurances.

Advocacy...

Networking & Community Improvement Opportunities...

PCMS and PAMED have been committed to being your voice in state and national matters affecting the practice of medicine in our community.

PCMS provides opportunities throughout the year for physicians, residents, and medical students to meet, including a formal Awards Night. Join our speaker’s bureau, or participate in our “Docs on Call” live television program.

Apply Today Join the Philadelphia County Medical Society, and become more engaged in the decisions that impact your livelihood and the future of healthcare.

Member Application:

http://philamedsoc.org/index.php/members/ pcms-application/

Resident & Fellows Application:

http://philamedsoc.org/index.php/members/ resident-fellows-application/