BCMS Script Newsletter, June 2022

BCMSScript.

Newsletter of the Bucks County Medical Society

Summer 2022

President’s Message OUR MISSION The Bucks County Medical Society strives to advance the professional and personal development of its physician members by providing educational and practice related resources as well as legislative advocacy.

Moreover, the Bucks County Medical Society seeks to promote optimal outcomes for our patients as well as the public health of the Bucks County community.

Hello and welcome! I hope you enjoy reading this newly revised and re-formatted semi-annual membership newsletter. I am a colorectal surgeon working in Bucks County and I am the president of the Bucks County Medical Society. I greatly value this society and appreciate you being a member of this society as well.

The Bucks County Medical Society strives to advance

the professional and personal development of its

physician members by providing educational and practice-related resources as well as legislative advocacy. In addition, the Bucks County Medical Society seeks to promote optimal outcomes for our patients as well as the public health of the Bucks County community.

Now more than ever, being part of a local medical community is important.

It gives us the opportunity to focus on our specific needs. The Covid pandemic has highlighted that different medical communities go through different crises, problems, and triumphs at different times and in different manners.

This society endeavors to actively support the Bucks County physicians in addressing these particular issues.

In addition, the demographics of this society continue to change. New physicians are starting practice in an increasingly complex medical world and older physicians continue to need to adapt to changing legislation. Providing resources to ease the burden on physicians is an active goal of the society.

Given these and other changes affecting Bucks County physicians, we have been collecting information from the members of the society both privately and through an online survey. Preliminary interpretation of these results suggests that programs supporting advocacy for our medical profession and educational resources are of top importance to our members. In addition, the desire for more member engagement and the resumption of in-person activities has been expressed. While ongoing changes in the Covid pandemic still impose challenges to scheduling in-person events at this time, we will continue to pursue this option with continued risk-assessment. Regardless, whether in-person or virtual, the society will seek to initiate new programming.

In addition, I welcome every member to reach out to me or to any members of the board with specific concerns, topics or interest pertinent to this group.

Again, I thank everyone for their commitment to this society. I eagerly invite active participation in this group. Thank you!

—Dan Latta

Eosinophils Christopher Drumm MD

Not everyone has a favorite type of white blood cell, but I sure do.

Eosinophils have always been my favorite.

If I see them elevated on the differential, I am usually less worried than when there are other elevations in different types of white blood cells. Neutrophils worry me about a significant infection and lymphocytes are even worse.

Eosinophils help in many ways from trapping substances, killing cells, bactericidal activity and even anti-parasitic activity. But usually, it just means that you are a highly allergic person.

Often these patients have 1 or all of the allergic triad.

The allergic triad consists of allergic rhinitis, asthma and atopic dermatitis.

that lead to this food impaction and gastrointestinal symptoms. These classic symptoms along with more than 15 eosinophils per high power field is how the diagnosis is made.

Now that I have thought about all the issues that are associated with eosinophils, I am going to rethink my favorite type of white blood cells. Maybe it is time for me to move my love to monocytes. But if not for eosinophils and the reaction I had to cats maybe I would not have met my wife. Which lead to me having my children. This is a thank you to my eosinophils.

If they were not as responsive in my life who knows where I would be in life. Thank you, Eosinophils.

“ CO R N E R

QUOTE

Asthma is a common respiratory condition that can be associated with eosinophils. Asthma causes inflammation and bronchoconstriction in airways.

There are some new medicines that specifically treat allergic asthma. These patients often have to get their IgE levels checked. This is a way of checking your immunoglobulin levels associated with eosinophils.

Attacking the eosinophils has lead to big changes for some patients with asthma.

“ The aim of medicine is to prevent disease and prolong

Ivermectin has become an infamous medication over the past few months. But it has been used in the past to treat certain parasites. Both strongyloidiasis and river blindness are treated with ivermectin. Why is this relevant? Because parasites cause eosinophils to rise.

But now we are seeing more eosinophilic esophagitis.

This is a condition that was first diagnosed in the 1980s. This causes esophageal impaction, abdominal pain and even food refusal at times. This has been diagnosed more and more over the past few years.

Patients with this condition often have food allergies

BCMSScript.

“

I have had allergies for years and so I realize that my bone marrow is working hard right now making eosinophils. Runny noses, sneezing, scratchy throat, itching eyes and post-nasal drip are all symptoms that may be coming from these eosinophils. I cannot even spend time with someone that has cats due to my allergies. They set my eosinophils on fire. I once had to end a relationship with a girlfriend (that had a cat) over allergy issues.

life, the ideal of medicine is to eliminate the need of a physician.”

—William J. Mayo

2

Doggie Dementia Christopher Drumm MD Residency was a difficult time for most young physicians. But it was also a time that my family grew. We got a dog named Murray. He is a Shih Tzu that is 10 pounds with a Mo-Hawk. He was named after a character from a television show on HBO called Flight of the Concords.

I have treated many patients with dementia but never an animal. He did not get an MRI of his brain. I did not do a Doggie Mini-Mental Status Exam. He has not been prescribed Aricept or Namenda. But I know his memory is leaving his cute little body. Just earlier today he got lost in the house he has lived for many years.

In between long days of seeing patients Murray was always there to greet me at the door upon arrival home. He never complained how much I worked and was always ready to cuddle. We took long walks which were part of my attempt at preventing burnout.

Since I have completed residency and I have now been an attending for over 12 years. Murray has been here with me for many years. I have learned about many medical conditions and illnesses. Day after day treating humans does not always prepare one for the illnesses that may also happen to your animals.

Doggie Dementia is a real disease but it is actually called Canine Cognitive Disorder.

Canine Cognitive Disorder, also known as Doggie Dementia presents with anxiety, failure to remember routines, decreased desire to play, confusion and dogs wandering aimlessly. Murry has CCD. Vets do tests to rule out other conditions and at times, do MRIs of dog’s brains.

Some dogs are treated with Anipryl (generic selegiline) which in the human world we use to treat Parkinson’s.

But not for Murray. I will carry him outside. I will retrieve him from the corner and put him back in his bed if he gets lost. I will continue to talk to him hoping that he recognizes my voice. Murray is not the same dog that he was when he was a puppy, but he is still loved. He may not have his memory, but he still has his Mo-Hawk.

Murray is 14 years old now. His hearing and sight have diminished but the hardest part is seeing his spark dim.

He has been getting lost in our house. He has forgotten how to get in and out of our home. He does not even want to go for walks anymore. I think he recognizes my smell and voice, but I am not sure. He appears confused and I think he has dementia.

3

BCMSScript.

Will There Be a Role for the Physician in the New World of Augmented Intelligence?

by Marilyn Heine, MD In November 2019, I presented to medical students at the Drexel University College of Medicine on the topic, “Will There Be a Role for the Physician in the New World of Augmented Intelligence?”

Have you asked Siri or Alexa a question? That involves Natural Language Processing (NLP) where your voice is changed into a form understood by a computer that generates a response. NLP can help physicians as it automatically reads, prioritizes, and digests journal articles into readily accessible personalized daily doses of the most relevant findings.

Have you searched for something on Google? Google increasingly uses Deep Learning where layers of algorithms have been designed in networks to simulate pathways in the human brain.

AI: Artificial or Augmented Intelligence?

The question is increasingly pertinent. Augmented intelligence, also called artificial intelligence or AI, continues to advance. The volume of medical knowledge is growing faster than we can assimilate it.

Meanwhile graduating medical students who invest in their education and training – more than ten thousand hours over at least seven years with greater than $200,000 in average total student loan debt – deserve reassurance that they will have a meaningful future.

“Augmented” Intelligence has become the preferred term among key technology companies, other innovators, and physician AI experts. The American Medical Association (AMA) House of Delegates adopted policy on AI using the term “Augmented Intelligence” to emphasize that AI’s role should be to enhance – not replace – human intelligence. This policy guides the AMA’s AI-related advocacy to promote that practicing physicians should shape healthcare AI to safely and effectively improve patient care. AMA resources on healthcare AI are found at an AMA microsite: www.amaassn.org/amaone/augmented-intelligence-ai

About a decade ago, medical educator and author Peter Densen, MD observed that medical knowledge doubled in a few years. He predicted that for medical students who were graduated in 2020, the volume of medical knowledge would double within 73 days.

How can we keep up?

Clinical Cases and Concerns AI can help inform prognosis, therapy, screening, or diagnosis. Data can be derived from online sites, electronic health records, wearables, apps, and other tools. Machines can scan vast quantities of data and pinpoint subtle signs and symptoms that physicians might otherwise miss. If AI is embedded within the workflow, it could enhance patient care in real-time.

What if we utilize technology to help us to benefit our patients? Nearly 70 years ago, the computer scientist Alan Turing asked, “Can machines think?”

He anticipated human-like intelligent machines that we call AI. The dramatic growth of healthcare AI is driven, in part, by faster and bigger computers, the rise of Big Data, and use of the “cloud.” AI has the potential to streamline the opportunities for us to efficiently absorb information.

AI has the potential to decrease morbidity and mortality. Here are vignettes of patients given fictitious names.

• Darlene has diabetes and is at risk for blindness.

She needs to be screened for diabetic retinopathy but is unable to readily access an ophthalmologist.

What if Darlene’s primary care physician can screen her for diabetic retinopathy using AI?

Daily Dose of AI AI is based on algorithms, or decision trees, where computers complete tasks in a manner typically associated with a rational human being. AI is something we already often use in our daily lives.

BCMSScript.

• John has an irregularity on imaging that is too early to identify as cancer. What if his early cancer can be found using AI?

4

• George presents to the emergency department with evidence of a urinary tract infection, but appears to be stable. What if his emerging sepsis could be detected early to help improve his chance of survival by using AI?

Informatics expert John Mattison, MD wrote about the need to incorporate “highly variable and contextual human considerations into the treatment plan [that] really requires thoughtful and empathic discussion between doctor and patient.”

• Gloria’s breast cancer treatment is based on pathology studies and generally done tests.

What if her breast cancer treatment could be tailored more specifically using AI?

What human elements does the physician bring to the physician-patient relationship?

• Compassion: The ability of the physician to provide comfort and reassurance is central to the patientphysician relationship.

However, let’s highlight some concerns:

•E mpathy: The physician’s role to assure that support is conveyed and assess that patients understand.

• Bias: We must ensure equity. Whose data forms the basis of the AI algorithms? Are unconscious biases baked in without the developers being aware? Can AI risk-stratify and personalize care, or will it entrench existing biases and exacerbate disparities? How can we optimize population health?

• Social determinants of health: An appreciation for the patient’s unique context.

• An open mind: The ability to adapt, demonstrate cultural competence, and understand the patient’s level of health literacy. A human can recognize and address a variance, but AI is based on pattern recognition and might overlook conflicting clinical information.

• Privacy: How is patients’ protected health information (PHI) being used? Is patient consent obtained prior to sharing sensitive data? Is PHI being monetized? Are patients informed that even if PHI is de-identified, the data may later be re-identified? Our online interactions generate an abundance of potentially trackable data.

Informatics expert Russ Altman, MD, PhD said, “[It] is very difficult to imagine [the human element] being replaced by computers.”

• Black box: Who is influencing the algorithms? Are the algorithms adequately tested? Do the algorithms stay constant or do they change? What is the level of transparency?

The education and training of physicians is especially valuable in the era of AI, where clinical acumen is paramount to determine when an AI-guided recommendation is valid for the patient you are seeing.

• Liability: Who is responsible for using or not using AI? Who is held accountable if AI provides misinformation?

When we ask, “Will there be a role for the physician in the new world of Augmented Intelligence?” be assured that the answer is yes. Patients never care how much you know until they know how much you care.

Physician involvement early in the development process is essential to help shape the algorithms, identify biases, ensure equity, and build confidence. AI can be transformative only if physicians are instrumental to its design, validation, and implementation.

Augmented intelligence, if applied correctly, with physician leadership, gives us an opportunity to maximize time to do what we love most: meaningful and rewarding care of patients.

Role of the Physician with AI

Marilyn Heine, MD, MJH, MD, FACEP, FACP, FCPP is Clinical Assistant Professor of Medicine at Drexel University College of Medicine. She is in active clinical practice in southeast Pennsylvania.

Some question whether AI has the potential to replace the physician’s role.

5

BCMSScript.

Inside Out Alisha Maity M.D.

I re-watched the movie Inside Out on my post-call day and wow did it hit me hard.

Inside Out for those who don’t know is a Pixar animated film about a young girl who learns to deal with her emotions.

The day passed, the evening passed, and the next morning began. The ICU never stops humming with activity, and I had forgotten about my patient, his wife, their two kids who would never get to see their dad again. Then at 7 am sharp, another man’s heart stopped - this one’s not from COVID but from a mysterious illness that we hadn’t even had time to diagnose. I was responsible for calling the patient’s wife as we began to initiate chest compressions and shocks. Throughout the code, she pleaded with me to do everything. I told her we would and hung up. Then finally, I called her back – “I am so sorry to tell you this but at 7:24 am, your husband died.” I didn’t hear anything on the other end.

This was a movie that I adored the first time I saw and then never had the time to revisit. It’s a movie that ultimately tells us that sadness is essential to life.

It’s a simple enough message but one that is easy to overlook – we live in a world that is constantly trying to spin us on the positives, to sell us the American Dream, to deny that as much of life is about suffering as it is about joy. Deepening the emotions that we hold is a part of growing up, not just during puberty, but a constant lifelong, snowball effect of recognizing how complicated our feelings can be.

Like a grotesque reflection of the events of the previous day, she came in with two daughters, all were in tears.

Again, I wordlessly entered the room. I have never had such a feeling of mis-belonging than when I’m in these rooms. The wife was holding her husband’s hand. The two grown daughters were weeping. We stood there for some time, feeling the silence.

Pushing away grief is something that you are required to do in medicine. Grief lingers everywhere – there are disheveled, elderly patients with no family in sight, young kids addicted to opioids, and most recently, people of all ages whose families have been touched by Covid.

Sometimes as a doctor, you feel like a wind-up monkey, stuck repeating words of hope and reassurance – “we did everything we could” “I’m so sorry” without really feeling anything. In that moment though, I couldn’t help myself. I turned to the daughters as we watched their mom holding her husband’s hand “It was so hard to talk to your mother this morning. You seem like such a close family”. “We were. We are,” they said, smiling. I bit my lip under my mask. Tears were visibly welling up behind my glasses, and it was hard to keep from completely losing it. His wife told me about their 50 years of marriage, how they had met when she was 15 and he was 17 and how he had promised on a weekly basis to quit smoking but how he had a mind of his own.

In the ICU just a few months ago, it was routine to watch people and see their O2 requirements go up and up until they were intubated. Every day we would throw steroids and remdesivir at them but still nationwide around 80% of those who were intubated, would die. Every day as interns, we were responsible for calling these peoples’ families – putting on our best new doctor voices and trying to balance providing a little hope while maintaining expectations so that there were no surprises when their loved one finally reached the end.

I started my 28-hr shift with a death – a 55-year old man who had rapidly deteriorated from COVID. I called the family as his BP and O2 continued dropping. I had met them in person the day before and his wife had said to me rather sharply – “why is this happening, I had a walking-talking, loving husband 1 week ago.” On this morning, I called her and told her to come in as soon as possible. Five minutes after that call, I called to tell her that he had died. She and their two daughters came in while we were rounding – we were all alerted to their presence by the wails that echoed down the ICU hallways. I made my way over to them and stood there while they wept in front of me. There was nothing I could say.

BCMSScript.

I felt myself releasing.

I felt the events of the last 24 hours wash over me.

I felt pure, pure sadness.

And I lived in that sadness for several minutes until it was time for me to finish my notes, pack up my things, and turn off my hospital brain. I went to sleep, woke up, and watched Inside Out.

6

Legislative Corner

WELCOME

The PAMED advocacy team and physician leaders carefully review all legislation to determine whether its passage could impact the practice of medicine.

Top current issues include prior authorization, the venue rule, and scope of practice.

New Members: New Join

Carlos Sanchez, MD

New Join

Betsy Benjamin, MD

New Join

Joshua Samuel Brikman, DO

New Join

Richard Chang, MD, FACS

New Join

Sarah Syed

New Join

Madeeha Subhan Waleed, MD

New Join

Yasmin Yokigal Lachir, MD

New Join

Avi Iontel Davis, MD

New Join

Abhishek Dutta, MD

Hot Topics and Action Items: • Venue Rule: PAMED and a coalition vehemently oppose the Pa. Supreme Court’s proposed venue rule change that would allow medical liability lawsuits to take place outside of the county where the alleged malpractice occurred and could return our state to the medical liability crisis of the early 2000s, decreasing access to care for patients and driving up health care costs.

Please ask your legislators to co-sponsor Rep. Kauffman’s resolution to amend Pennsylvania’s constitution to protect the venue rule.

• Prior Authorization Reform: Senate Bill 225 would reform the onerous prior authorization and step therapy (“fail first”) processes that delay appropriate patient care and increasingly undermine longstanding decisions made between physicians and their patients.

Reinstated Members: Reinstatement

Natasha Dionne Meadows, MD

Reinstatement

Neil Vadhar, MD

Please ask your legislator to support Prior Authorization Reform (SB 225).

Take Action Here:

BucksCMS.org/join

7

BCMSScript.

400 Winding Creek Blvd.

Mechanicsburg, PA 17050-1885

Upcoming Events!

Bucks CMS Board Meetings:

Legislative Breakfast

7/13/22—6:30 PM Zoom, pending

TBD October 8:00 AM Zoom, pending

9/14/22—6:30 PM Zoom, pending 11/2/22—6:30 PM Zoom, pending

PAMED House of Delegates and Annual Business Meeting 10/21/22—10/22/22 Hershey and Virtual

THANK YOU FOR BEING A BCMS MEMBER! BUCKSCMS.ORG