ACMS Bulletin August 2023

Dispelling a Common Myth: Most Melanomas Do Not Arise from Moles

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Editorial....................................5

• Lost in Barbieland

Deval (Reshma) Paranjpe, MD, MBA, FACS

Editorial ..................................8

• Socratic Method / Creative Failure

Richard H. Daffner, MD, FACR

ACMS Photo Contest ............11

Perspective............................12

• Dispelling a common myth: Most melanomas do not arise from moles

Nicole Velez, MD, FAAD, FACMS

John Miedler, MD

Perspective ............................14

• Regulation of Delta-8 THC Should Be a Public Health Priority

J W Bookwalter III, MD, MBA

FAANS, FABNS, FACS

Society News..........................20

• Pittsburgh Ophthalmology Society: September 14 and October 5 Meeting Details AMA

• Vutrisiran (Amvuttra®)

Madison Abbs, PharmD

Arianna Sprando, PharmD, BCPS Legal

• Contracting Essentials for All Physicians, Especially Residents and Fellows

Adam J. Appleberry and Michael A. Cassidy

2023

Executive Committee and Board of Directors

President

Matthew B. Straka, MD

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Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com)

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Lost in Barbieland

Deval (Reshma) PaRanjPe, mD, mBa, FaCs

Early one Saturday morning a few weeks ago, I realized I actually had a few hours free. What did I do? I bought a ticket on Fandango and raced to the movie theater before the practical side of me could change my mind. I had really wanted to see Barbieheimer, that unholysounding double-feature of Barbie and Oppenheimer, but I only had two hours, and Oppenheimer was three all by itself. Barbie it had to be that day.

I had read the reviews, of course, and was incredibly curious. Could director Greta Gerwig actually pull off an intelligent, many-layered take on a childhood doll and her fantasy world which remained true to the memories of many American generations and avoided being annoying? Could it skirt the polarization of the American populace today and skewer it at the same time? Could it make you laugh and provide some much needed escape?

The answer is yes, on all counts.

Barbie is not woke; it skewers “wokeness”. Barbie is not ultraconservative; it roasts the “manosphere”. The message of this movie is that common sense and equilibrium need to return to the world

where gender relations are concerned. Furthermore, both men and women take refuge in fantasy worlds to help themselves deal with the problems of an incredibly confusing real world, and that this approach, while understandable, isn’t particularly mature or helpful after a point.

Spoiler alert.

Barbie wakes up in Barbieland every morning looking perfect, pretends to eat a plastic waffle and pours herself pretend milk. She wafts down from her Barbie Dream House and straight into her high-heeled shoes, and drives her pink convertible to the beach, where Ken can be found. In fact, all the Kens can be found there. All women in Barbieland are called Barbie; they come in every color. Barbies are distinguished either by profession (President Barbie, Doctor Barbie, Lawyer Barbie, Journalist Barbie, Physicist Barbie etc etc) or by attribute (Stereotypical Barbie, Weird Barbie etc). Except of course for Skipper, and pregnant Midge, who was discontinued (ironically, because reallife conservative parents disapproved of a pregnant doll and not, as some men’s rights activists claim, because the premise of Barbie makes no room for motherhood). All men are called

Ken (except for Allan, Ken’s same size friend) and their only profession is Beach. Not lifeguard, not surfer, not ecologist. Just Beach. There are only two genders in the film, in keeping with the Mattel universe, which must have frustrated both progressives and “antiwoke” persons spoiling for a fight.

Ken’s only purpose in life is to be with Barbie. He is allowed no other aspirations in Barbieland—every position other than Beach (one of many double entendres) is held exclusively by women. Ken’s natural competitive instincts are both stimulated and stymied by the very nature of Barbieland. To add insult to injury, he is continually heartbroken because Barbie won’t give him any alone time, preferring either to throw elaborate dance parties or have girls’ night…every night. Barbie has no self-awareness and treats Ken like a child incapable of making his own adult decisions. Naturally, this makes Ken sad and angry and frustrated, although by his own admission he has no idea what he’d do with Barbie alone anyway since they’re anatomically incorrect. This applies to all Kens in Barbieland—they feel like superfluous accessories.

Continued on Page 6

From Page 5

All of this changes one day when Barbie wakes up and has a Very Bad Day (wakes up looking terrible, has burnt toast and spoiled milk, and develops flat feet and thoughts of death). Sent to see the mystic Weird Barbie (the one whose hair was cut off and dyed with magic marker), she is offered a Matrix-like choice of red or blue pill and instantly chooses her old life again, only to discover that choice is an illusion and that she must go to the real world to find and fix the psychological crisis of the little girl who is playing with her. Ken stows away for the ride and together they discover that the real world is the opposite of Barbieland in terms of gender and power, much to Barbie’s chagrin and Ken’s delight. Barbie finds the two female humans who are responsible for her plight, and Ken evangelizes Barbieland with the Patriarchy. Absolute chaos ensues in both worlds.

I won’t spoil what happens next, but the ghost of Ruth Handler, Barbie’s American creator played by a kindly no-nonsense Rhea Perlman, intervenes like a watchmaker God. She makes sense of both worlds for us and liberates Barbie (and Ken, and by extension all of us) to make her own choices and not feel bound by what society or prevailing trends want us to do or be.

Ironically, the first Barbie doll design was directly stolen from that of a post-WW2 German doll called Lilli who worked in the oldest profession. Handler had decidedly different career choices in mind for her Barbie doll.

For some girls in my generation and the ones before, Barbie and all her various respectable professions were indeed a license to dream big. If Barbie could be a doctor, then so could any little girl. Representation is critically important, especially when you are told by adults and children alike that “girls aren’t doctors, only men can be doctors!”. I wonder how many women in medicine today who grew up without female physician role models were inspired or reassured by Doctor Barbie, and it makes me happy.

My personal relationship with Barbie was decidedly different. My parents are both physicians, so I had role models-and I was told in no uncertain terms by both of them at the age of 3 that I was also expected to be a physician when I grew up. I could be anything else—the sky was the limit—lawyer, marine biologist, private detective, FBI agent, novelist, ballerina—but only after I graduated from medical school.

Furthermore, my mother, a pediatrician, didn’t approve of girls playing with Barbie dolls before a certain age due to concerns about causing unrealistic body image issues and eating disorders. So when four-year old me asked for a Barbie in first grade, the answer was no (and looking back, I think my mother was absolutely right). This caused rejection from the little girls in my peer group, whose position was “you can’t play with us if you don’t have a Barbie, and no, we won’t share or take turns. Besides, you don’t look like Barbie.” They were all blonde; I was me. I had just one kind girl friend who would play astronaut with me at lunch time—we’d sit in adjacent cubbies and go through an entire meticulous pre-launch and blast-off sequence and

describe the stars and the planets and universe to each other while eating PB+J sandwiches. I’m grateful to her even now for taking some time off from Barbie each day to play with me.

But all of this left me a social pariah, with no choice but to approach The Boys for friendship. The Boys were not concerned with thoughts of homemaking or even career. They were only concerned with two games: Cars and War. In fact, they were not concerned with me or my gender; they were just glad to have an extra soldier on their team. None cared except for one of them with an attitude (rumors swirled that his father hit him for not being macho enough) who insisted that I couldn’t play War because I was a girl, and that I couldn’t play Cars because I didn’t own a Matchbox Car. Two nice boys who considered me their kid sister firmly stuck up for me, insisted I would be a good lookout during wargames, and kindly shared the “less cool” Matchbox Cars from their private collections with me during playtime. The boy with the attitude had no choice but to shut up. My sponsors’ team also won the wargames when they happily learned I could craft them an entire GI Joe Navy out of reinforced paper boats. (My grandmother had taught me origami.)

In her own way, Barbie taught me some powerful lessons through my exile. She taught me that there are kind and reasonable people to be found among both men and women. She taught me that men make great friends and allies, should be appreciated for their character and actions, and were not to be looked primarily as a necessary component to getting married and having a family—a lesson some of

those other girls may never have had the chance to learn in person. I hope they did get that chance—I am fortunate I did. I hope the kind boys who spoke up against their peers and loaned me their racecars also grew up knowing that girls make great friends and allies and should similarly be appreciated for who they are as people--not viewed as mysterious creatures or sex objects. I hope they continued their kindness and inclusivity towards women as adults.

I learned that women can sometimes fence themselves in, and that courage and imagination is needed to break the mold and blast off into space. I learned that sexism among men can be born of pain and insecurity, and that it just takes a few good men who act as mentors and allies to speak up and level the playing field for women on grown-up societal battlefields. I hope that we are all better adults for those experiences. I certainly have a lot of men friends today that I treasure--and a close group of

female friends chosen for their similarity to that little girl who broke away and played astronaut--because of Barbie.

My mother felt bad and unexpectedly bought me a Barbie doll in high school. I was touched and grateful for the gift, but also confused because I thought the time for playing with Barbies was long past. I knew I was going into medicine and was excited about it by then. And then I remembered—Barbie was not just a career doll—she was a fashion plate! I had discovered fashion magazines by high school, made her great costumes

and gorgeous gowns for fun and dreamt of wearing them in real life one day— a great distraction while studying for the SATs.

Like Ruth Handler said, both Barbie and the Patriarchy are both just crutches for humans to deal with a confusing and often painful world. Ultimately, you have to break free of both to find yourself, relate to each other with kindness and respect, and make the choices that feel right to you without self-judgment or worrying what others think.

Maybe I can still be a private detective. I have the fedora, after all.

“Talented, Seasoned, “On Top of the Details”

PENDING

Socratic Method/Creative Failure

RiChaRD h. DaFFneR, mD, FaCR

Ihave spent the major portion of my life as a teacher training medical students, residents and fellows in my chosen specialty (Diagnostic Radiology, with special interest in musculoskeletal abnormalities and spine injuries) as well as Boy Scouts, aged 11 to 18-years old. I was fortunate to have encountered many excellent teachers along my journey. These men (considering the era in which I trained) exposed me to the Socratic Method and one of its branches that I call Creative Failure. As a result, having adopted those principles, I am most likely to answer a question from a student with another question.

Socrates of Athens (470 – 399 BCE), an early Greek philosopher/ teacher, engaged in the disciplined practice of thoughtful questioning, allowing his students to examine ideas logically and to determine (challenge) the validity of those ideas. The Socratic Method is a form of cooperative argumentative dialogue between individuals, based on asking and answering questions to stimulate critical thinking and to draw out ideas and underlying presuppositions. The student asks a question, the teacher often replies with a different question, and the process continues until the student arrives at the answer to his/

her original question. Socrates based his method of teaching on the premise that the student already had the answer within himself. The disciplined, thoughtful dialogue was steered by the teacher to elicit the answer from the student.

The classic Socratic Method uses six philosophical “tools” designed to: 1) Clarify concepts, 2) Probe the student’s assumptions, 3) Probe rationale, reasons, and evidence, 4) Question different viewpoints and perspectives, 5) Probe implications and possible consequences, and 6) Question the question itself.

My first encounter with a teacher who used the Socratic Method was in my freshman year at Albany College of Pharmacy. I was having difficulty understanding the principles of calculus (math was never my forte) and gingerly approached the professor, the late Dr. Joseph Lapetina. And, after several hours of personal tutoring, I figured it out. His mantra was, “Get the data, plug it in and turn the crank, and out will come your answer”. (Joe became a life-long friend and we served together on the College’s Board of Trustees until his death at age 95 in 2019.)

My next exposure to the Socratic Method occurred during my first clinical rotation during my junior year of medical school. The late Dr. Casimir

Pietraszek was a pulmonologist assigned to my floor at the E. J. Meyer Memorial Hospital (now Erie County Medical Center) in Buffalo, NY. One day on morning rounds, I asked him if there was any way of balancing admission diagnoses of new patients so we could see a variety of diseases. At the time two-thirds of our patients had COPD. He looked at me and replied, “Are you an expert in managing COPD?” I was not; the lesson was learned. More importantly, the seeds were planted for the method I would use when I became a teacher. Three of my radiology mentors, Drs. William Barry, George Baylin, and Lawrence Davis also used the Socratic Method. All were also philosophers who taught me the ins and outs of academia (and curmudgeonry1).

My mentors added a seventh philosophical “tool”, Creative Failure Creative Failure is the practice of allowing a student to make mistakes (provided those mistakes pose no danger to self or others) in the hope that the learner will realize his/her error(s) and, more importantly, the reasons why they occurred. I used this concept with my medical students and my residents and continue to use it with my Scouts. Two examples follow:

Prior to installing PACS (Picture Archiving and Communication System), I would not allow first-year

residents to pre-dictate their reports. Instead, they would review the studies, write their impressions on a pad, and when they were finished with a batch of films, they would review them with me or another attending radiologist. If I approved their interpretations, they would dictate them and then wait for the dictations to be returned, where they signed the reports. I would review the reports, comparing them with the images to insure accuracy, and make any necessary corrections before cosigning. Once we began using PACS, I allowed the first-year residents to predictate. They would often ask, “What if I make a mistake?” I told them I didn’t care if they made mistakes. We would correct them when we reviewed the images because at the review session I had the images, I had the resident, and I had his/her report. If there were any errors in interpretation or in the text of the report, we made the appropriate changes using the voice recognition tool of the PACS after discussing the reasons for the errors. Once we agreed on the revised report, I pushed the “Send” button, and the report “was in the system and available to the clinician(s).

The Scouting program provides many opportunities for the leaders to practice Creative Failure. Several years ago, I participated on a ten-day backpacking trek through Philmont Scout Reservation in New Mexico. Our backpacks typically weighed between fifty and sixty pounds, and I was determined not to have to take any extra steps if possible. The trip had two purposes. The first was to enjoy the beautiful scenery in a wilderness setting and partake in the many activities Philmont provided. The second was to teach the boys the

fundamentals of wilderness camping, including navigating by using map and compass (orienteering) and wilderness ecology and etiquette. Our crew of ten consisted of seven youths and three adults. Our daily protocol included forming our “line of march”, which was the single file order of each participant. One boy had the lead (called the “pathfinder”), setting the pace of the trek. We rotated this position each day, as we did with the rest of the duty roster (cook, cleanup, wood gatherer, etc.). Immediately behind the pathfinder was another boy who carried one of the maps of the reservation. I was next, behind the “map man”. A second adult was in the middle of the column and the third adult was the “sweeper” at the end of our column to make sure none of the crew straggled. We also had a rule that at no time would we be spread out so that the “sweeper” could not see the “pathfinder.” Any member of the crew could call a halt at any time and for any reason.

Each of the adults had a map of the reservation on which we had marked our intended hiking route. The “map man” also caried a marked map. Every day the adults would review the map and look for any prominent landmarks or points of interest along our trek. Periodically, when we passed such a site, I would call a halt to our hike to ask the Scouts where they thought we were. The usual answer was that we were on a particular trail. That became a teaching moment when I told him to get the map out, look at the surrounding landscape and see if there was anything they could correlate with the map.

Many of the trails intersected along our route. In most instances, when

encountering an intersection, we had only two choices to make to continue our trek. At each intersection, I would ask, “Mr. Pathfinder, which way do we go?” When he answered, I would then ask, “Are you sure?” If he answered affirmatively, and if I knew he was right, I’d say, “Lead on.” If I knew he was wrong, I’d ask, “Are you really sure?” That would prompt him to get out a map and use his compass to determine the correct direction in which we should proceed. This technique proved valuable near the end of our trek when we encountered a convergence of five trails. A trail marker had been placed in a stone cairn indicating each of the five trails. However, boys being boys had rotated the staff on which the markers were attached. By that time, the lesson had been learned and the “pathfinder” immediately used the map and his compass to find the correct trail.

Several years later I was attending a district camporee in Beaver County where the main activity was orienteering. Each patrol was accompanied by an adult from a different troop. Each patrol was given a map as well as a series of compass directions and approximate distances. The adults with each patrol had a marked map to assure that the group would not get lost. At one point, the road we were hiking on ended at a T- shaped intersection. The patrol leader read his compass and directed us to start hiking exactly 180° (we went left instead of right) from the direction we were supposed to take. Since we were only carrying our canteens, and in some cases just a day pack, I didn’t mind taking a few extra steps. After we had traveled about 100 yards, and it was obvious the patrol leader had Continued on Page 10

From Page 9

not recognized his error, I stopped the group and I asked, “Mr. Patrol Leader, where are we?” He proudly pointed to the map and indicated where he thought we were.

“What’s that blue squiggle on the map?” I asked.

“It’s the creek, sir,” he replied. Then he pointed to the creek, on our left, that ran alongside the road.

adjacent lumbar vertebra, explaining her pain. My resident, from Georgia, upon seeing the findings said, in his deep southern drawl, “Fellahs, there’s a lesson here. Crocks daah (die), too.” Unfortunately for the patient, CT scanning and ultrasound exams had not been developed. The important lesson is that for most patients with a diagnosis of psychosomatic illness, the symptoms are real, and in fact a small number of these patients indeed have real abnormalities accounting for their symptoms.

“But if we’re where you said we are, the creek should be on our right. How do you explain that?” I asked.

Without hesitation, he replied, “The map is wrong.”

“Is there another explanation?” I asked.

Sigmund Freud’s view of humor was that it was a conscious expression of thoughts that society usually suppressed or was forbidden.2 As long as the humor, in this case name-

calling, is meant in a benign fashion, it is considered harmless.

Then it dawned on him that we had gone the wrong way!

And that is how creative failure works. I allowed the patrol leader to make a mistake. The error did not imperil our safety and was easily correctable. And, more importantly, the boys learned to check their directions at each intersection. Interestingly, the result was different for another patrol who had made the same mistake. The adult with them did not realize the error and the patrol ended up several miles inside Ohio. The “Lost Patrol” was returned to camp by two Ohio State Highway Patrol cars after they stopped at a farmhouse to ask directions.

However, in today’s politically divisive atmosphere, it is best to use humor only when you truly know your audience. As a good example, I remember the not so “good old days,” when it was expected that a speaker at a conference or a refresher course would tell jokes. Many of the “old timers” were very colorful characters. Today, fortunately, speakers are business-like and jokes are tacitly forbidden, since they are bound to offend someone. Finally, we should always remember that no matter how unpleasant some of our patients are to us, they are still our fellow human beings.

I have found the Socratic Method and Creative Failure to be useful tools for teaching at multiple levels, whether the learners were adults or youth.

Reference:

Dr. Daffner, associate editor of the ACMS Bulletin, is a retired radiologist who practiced at Allegheny General Hospital for more than 30 years. He is emeritus clinical professor of Radiology at Temple University School of Medicine and is the author of nine textbooks. He can be reached at bulletin@acms.org.

1. Daffner RH. Curmudgeons. ACMS Bulletin, September 2020, pp 271 – 274.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

References

1. Shem S. The House of God. Richard Marek Publishers 1978.

Dr.Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine.

2. Freud S, (Strachey J, Trans.). Jokes and their relation to the unconscious New York: W. W. Norton, 1960 (Original work published 1905).

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2024 ACMS Bulletin Photo Contest

Please note instructions below for participating in the 2024 ACMS Bulletin Photo Contest:

1 Email your VERTICAL jpg photos with a resolution of 300 dpi or higher to ACMSBulletin@acms.org. Photos should be 8”W x 10”H. No more than three photos may be submitted.

2 You must be an ACMS member physician to submit photos.

3 Include the name of the photo (please keep file names short) as well as your name, specialty, address and phone number in the email.

4 You will receive verification that your photo has been received and is eligible to be entered in the contest.

a) Horizontal photos will not be considered.

b) Photos with low resolution will not be considered.

c) Panoramic shots or photos featuring specifically identifiable individuals relatives will not be considered.

d) Be aware top third of image will be obstructed by Masthead.

5 5 The deadline for submission is Monday, October 3rd, 2023. After this date, a group of individuals selected by the ACMS Board of Directors and ACMS Editorial Board will vote on the top 12 photos.

6 Winners will be announced on the ACMS website, in the Bulletin and via email. The 1st-place winner’s photo will appear on the January 2024 cover; the remaining winning photos will appear on Bulletin covers throughout the year.

7 Please continue to check the ACMS website and future issues of the Bulletin for further updates and reminders.

8 If you have any questions, please contact Contact Cindy Warren at ACMSBulletin@acms.org.

Dispelling A Common Myth: Most Melanomas Do Not Arise from Moles

niCole velez, mD, FaaD, FaCms

It is not uncommon to hear patients and occasionally physicians describe moles (nevi) as “precancerous.” At time of skin exam, some may report they had “precancerous moles” removed in the past and may request that other nevi be excised in the hopes of “preventing melanoma.” In fact, prophylactic excision of nevi has not been shown to reduce melanoma risk. The confusion is understandable as even among dermatologists the description and management of nevi is a topic that has been under much scrutiny.

Nevi, benign melanocytic proliferations, are found on most patients. Here are a few important points that may be helpful to all physicians, regardless of specialty:

The majority of melanomas do not arise from pre-existing moles. Studies show that over 70% of melanomas arise “de novo” and have no associated nevus. In other words, most melanomas appear as a new growth that did not arise from a prior nevus. The lifetime risk of a nevus transforming into a melanoma is 0.03% for men and 0.009% for women.1

Dysplastic nevi can look clinically similar to melanoma, but do not have a higher chance of becoming melanoma as compared to benign nevi. Dysplastic (or atypical) nevi are

defined clinically as moles with 2 of the 3 following characteristics: variable pigmentation, irregular asymmetric outline and indistinct borders. These are features that can also be seen in melanoma and distinguishing a dysplastic nevus (DN) from a melanoma can be challenging clinically.2 Therefore, if a lesion is suspicious, biopsy is warranted to exclude melanoma.

Histopathologically, all melanocytic lesions are evaluated at low magnification for breadth (overall size) and the presence or absence of symmetry and circumscription. This is why it is recommended that the entire lesion be submitted for histologic evaluation. Benign melanocytic nevi are typically smaller in size, and they are relatively symmetric and well circumscribed. DNs also demonstrate architectural disorder and cytologic atypia that is graded mild, moderate, or severe. Architectural disorder refers to features such as bridging of adjacent nests of melanocytes along the dermoepidermal junction, extension of the junctional component beyond the dermal component at the periphery of the lesion (shoulder sign), and lentiginous melanocytic hyperplasia along the dermoepidermal junction. Cytologic atypia is characterized by variable nuclear enlargement and nucleoli. There is also associated

lamellar and concentric fibroplasia within the dermis, and there is often an associated inflammatory cell infiltrate.

In most cases, the diagnosis can be reached following review of the routine hematoxylin and eosin stain slide. However, in some cases DNs can display overlapping features with malignant melanoma. For example, DNs that have been previously excoriated or partially sampled can display architectural disorder that resembles changes that are also seen in malignant melanoma (i.e. contiguous growth of melanoctyes along the dermoepidermal junction and upward spread of melanocytes into the epidermis). These histologic changes are referred to as recurrent nevus phenomenon.

When a definitive diagnosis cannot be reached following review of the routine hematoxylin and eosin stain slide, additional studies can be performed to further evaluate the lesion. Immunohistochemical stains (i.e. Melan A, SOX10, HMB-45, PRAME, Ki67) are routinely employed in these circumstances, and other studies can also be utilized when findings are still equivocal following the review of the immunohistochemical stains (i.e. gene expression profiling, SNP array, next generation sequencing).

john mieDleR, mD

Patients with higher numbers of nevi and/or atypical nevi are at higher risk of melanoma. As overall number of nevi (benign or dysplastic) increases, so does melanoma risk. Patients with 41-60 nevi have a 2.2X increased risk of melanoma, and patients with 101-120 nevi have an almost 7-fold increased risk. For most of these patients, if they develop a melanoma, it will be a “de novo” lesion (not associated with one of their moles). However, the number and atypia of their nevi can be phenotypic markers of melanoma risk.3 If you have patients with numerous nevi and/or large (>5 mm), multicolored, asymmetric nevi, they should be seen by dermatology for an annual exam. A retrospective, cross-sectional study at the University of Pittsburgh showed that patients who had an established dermatologist were more likely to have a diagnosis of in situ melanoma or thinner invasive melanoma than patients without an established dermatologist. They hypothesize that the education received during dermatology exam and the ability to obtain an appointment more easily, may allow for earlier diagnosis.4

Nevus associated melanoma does not occur more frequently with dysplastic nevi. When a melanoma does arise from a prior mole (nevus associated melanoma), it is more often in an acquired vs. congenital nevus (nevus that appears within the first year of life). Among the acquired nevi, dysplastic nevi do not have a higher risk of turning into melanoma than benign nevi.3

Guidelines state that only dysplastic nevi with severe atypia need to be fully excised. Grading of dysplastic nevi is a nuanced skill with some inherent subjectivity that requires an overall assessment of the degree

of cytologic atypia and architectural disorder within a given lesion. If you are performing skin biopsies in your office, be certain that (1) you sample the entire lesion (do not perform a partial biopsy of a pigmented lesion) and (2) that you send the biopsy to a laboratory with an experienced dermatopathologist to review the case. Good data supports that mildly and moderately atypical DNs do not need to be re-excised, even if biopsy margins are positive. According to findings from a multicenter retrospective study performed by the Pigmented Lesion Subcommittee, moderately atypical DNs did not evolve into melanoma. However, 20% of patients who had a moderately atypical DN went on to develop a melanoma at another site during the study – supporting the recommendation that these higher risk patients be followed by regular skin exams.5 Severely atypical DNs are likely not precursor lesions either. However, because severely atypical DNs and melanoma can display overlapping histopathologic findings, it is recommended that these lesions be fully excised to prevent misdiagnosis.6 Importantly, negative margins on punch or shave biopsies do not confirm complete lesion removal. Studies show 30% of punch excised melanocytic lesions with negative margins in the initial sections, had positive margins when additional sections were reviewed.6

BRAFV600E mutation is the most common mutation in melanoma. Eighty percent of benign nevi also harbor this mutation. Genetic studies suggest that secondary and tertiary proliferation mutations (mainly TERT and CDKN2A) are needed to produce melanoma. Despite some genetic similarities, most nevi, even most atypical nevi, do not progress to melanoma. Patients and

clinicians should not consider nevi “precancerous.” Instead, they should understand that patients with a higher number of nevi and clinically atypical nevi are at overall higher lifetime risk of developing melanoma and require dermatologic monitoring. In addition, UV exposure is the main cause of genetic mutations leading to melanoma. Encouraging sun protection can help reduce melanoma risk.

References

1. Tsao H, Bevona C, Goggins W, Quinn T. The transformation rate of moles (melanocytic nevi) into cutaneous melanoma: a population-based estimate. Arch Dermatol 2003; 139: 282–288.

2. Drozdowski R, Spaccarelli N, Peters, MS, et al. Dysplastic nevus part I: Historical perspective, classification and epidemiology. J Am Acad Dermatol 2023 Jan;8(1):1-10.

3. Dessinioti C, Geller AC, Stratigos AJ. A review of nevusassociated melanoma: What is the evidence? J Eur Acad Dermatol Venereol 2022 Nov;36(11):1927-1936.

4. Cheng MY, Moreau JF, McGuire ST, Ho, J, Ferris LK. Melanoma depth in patients with an established dermatologist. J Am Acad Dermatol. 2014 May; 70(5):841-6.

5. Kim CC, Berry EG, Marchetti MA, et al. Risk of subsequent cutaneous melanoma in moderately dysplastic nevi excionally biopsied but with positive histologic margins. JAMA Dermatol. 2018:154(12):1401-1408.

6. Spaccarelli N, Drozdowski R, Peters MS, et al. Dysplastic nevus part II: Molecular/genetic profiles and management. J Am Acad Dermatol 2023 Jan;8(1):1-10.

Dr. Nicole F. Vélez is a board certified dermatologist and Mohs surgeon at Pittsburgh Skin: Dermatology & Mohs Surgery, with offices in Shadyside and Cranberry, PA. She can be reached at nvelez@pittsburghskin.com

Dr. John Miedler is a board certified dermatopathologist at Dermpath Diagnostics in Pittsburgh, where he has practiced for the last 11 years. He can be reached at jmiedler2@ dermpathdiagnostics.com.

Regulation of Delta-8 THC Should Be a Public Health Priority

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“Like making methamphetamine from cold medicine, just because the starting materials are legal does not make the resulting product legal (or safe).”

Christopher Hudalla, president, and chief scientific officer, ProVerde Laboratories2

Delta-8 tetrahydrocannabinol (THC) is found in the cannabis plant. Both marijuana and hemp plants are separate genera of this species. Delta-9 THC is the best-known psychotropic in the marijuana plant. Delta-9 naturally occurs in relatively high concentrations in the marijuana flower.1 If someone purchases a Delta-9 product it is likely extracted directly from the marijuana plant. Though Delta-8 THC is also produced naturally by the cannabis plant, it is not found in significant amounts within the plant. The Hemp Bill doesn’t mention Delta-8 anywhere. Hemp advocates and others who sell it have used this loophole to legally market Delta-8 products, usually with no age restrictions.5

The marketing of Delta-8 began when an oversupply of CBD extracted from USgrown hemp caused the price of CBD to plummet. Producers looked for avenues to convert that to something profitable.2 Simple chemistry from the 1960s allowed the conversion of CBD into Delta-8. The

reaction produces a high percentage of Delta-8 and reaction by-products. Christopher Hudalla of ProVerde Laboratories has tested thousands of products labeled Delta-8. “There’s some Delta-8 in there, but there’s very frequently up to 30 [chromatographic] peaks that I can’t identify.” A lot of people are doing a poor job of cleaning up their reaction products, he adds, which results in “quite a soup” of by-products and other unwanted compounds.2 It is possible to separate Delta-8-THC from unwanted reaction leftovers or by-products, but “most people are not actually taking the time to distill it or use chromatography” to do so, says Kyle Boyar, a staff research associate at the University of California San Diego’s Center for Medicinal Cannabis Research.

Concentrated amounts of Delta-8 THC are manufactured through a conversion from hemp-derived cannabidiol (CBD). The synthetic process involves refluxing CBD in an organic solvent such as toluene or heptane with an acid that serves as a catalyst. Currently, no one is measuring the pH of Delta-8 products or testing for strong acids and residual metals left behind.2 Delta-8 binds to the endocannabinoid system in a slightly different fashion than Delta-9 because of the location of its double bond. This is what is thought to make Delta-8 much less potent than regular THC.1 People report effects that are about half or twothirds of those of Delta-9.3

Since the natural amount of Delta-8 THC in hemp is very low, additional chemicals are needed to convert other cannabinoids in hemp, like CBD, into Delta-8 THC (i.e., synthetic conversion). Concerns with this process, according to the CDC, include:

• Some manufacturers may use potentially unsafe household chemicals to make Delta-8 THC through this chemical synthesis process. Additional chemicals may be used to change the color of the final product. The final Delta-8 THC product may have potentially harmful by-products (contaminants) due to the chemicals used in the process, and there is uncertainty with respect to other potential contaminants that may be present or produced depending on the composition of the starting raw material. If consumed or inhaled, these chemicals, including some used to make (synthesize) Delta-8 THC and the by-products created during synthesis, can be harmful.

• Manufacturing of Delta-8 THC products may occur in uncontrolled or unsanitary settings, which may lead to the presence of unsafe contaminants or other potentially harmful substances.4

National poison control centers received 2,362 exposure cases of Delta-8 THC products between January 1, 2021 (i.e. date that Delta-8 THC product code was added to database), and February 28, 2022. Of the 2,362 exposure cases:

• 58% involved adults, 41% involved pediatric patients less than 18 years of age, and 1% did not report age.

• 40% involved unintentional exposure to Delta-8 THC and 82% of these unintentional exposures affected pediatric patients.

• 70% required healthcare facility evaluation, of which 8% resulted in admission to a critical care unit; 45% of patients requiring healthcare facility evaluation were pediatric patients.

• One pediatric case was coded with a medical outcome of death.4

One concern not noted by the National Poison Control Centers is the lacing of putative Delta-8 products with other agents like fentanyl. The illicit market in THC vape cartridges was responsible for the now well-known crisis of severe pulmonary disease as a result of using Vitamin E oil in the cartridge. There are rumors of poisonings in Philadelphia occurring with fentanyl-laced Delta-8 cartridges causing death.

There is also particular concern about another cannabinoid called THCO-acetate, the acetate ester of THC, popping up in gummies and vapes. It is basically acetylated THC, which does not occur naturally in cannabis plants. Heroin was created by acetylating morphine over 100 years ago, resulting in a drug that is much more potent than morphine because of pharmacokinetics. If regulators simply ban Delta-8-THC as they did with Delta-9-THC to outlaw cannabis federally, the market will make Delta-10-THC or other types of ring isomers or alkyl chain analogs such as tetrahydrocannabivarin. Some of these analogs could be toxic or wildly psychoactive. The regulatory language needs to be broad, or we will be stuck in a multiyear cycle of legislative fixes.2 This contrasts with the 2018 farm bill, which limited the amount of delta-9-THC, only, in hemp and hemp-derived products, such as CBD.

By law in Pennsylvania dispensaries are required to have available on-site a Health Care Provider (HCP), either a pharmacist, nurse practitioner, or physician assistant to counsel patients about what cannabis preparations are appropriate for their diagnosis. There is a significant variety of cannabis medications in varying forms. The

interplay of Delta-9 THC, CBD, other lesser-known cannabinoids, and terpenes, as well as the type of delivery mechanism, can have a significant impact on producing the desired therapeutic response depending on the diagnosis and the patient’s response to treatment. The general public does not know this and may assume that Delta-8 and Delta-9 are interchangeable and may inappropriately dose themselves with no benefit, aggravate their underlying condition, or delay appropriate medical treatment. The DOH requirements for maintaining not only the appropriate HCP but the rigorous security, testing, and product labeling are costly. Those selling Delta-8 and CBD products are not required to do any of that. With the headwinds the cannabis industry is experiencing today, this imposes significant financial hardship and is likely to stress the medical cannabis industry resulting in closures and/or reduction in service.

There are some efforts to regulate Delta-8. The federal Drug Enforcement Administration has a proposed rule that is not yet final—indirectly classifying Delta-8 as a Schedule 1 controlled substance, which would make it federally illegal. The state of Michigan recently passed legislation that classified Delta-8 as marijuana and therefore the production, testing, distribution, and sale of Delta-8 will now be regulated by the state’s Marijuana Regulatory Agency (MRA).1,6 Effective October 11, 2021, it is illegal for businesses to sell Delta-8 without proper licensing from the MRA.

The focus of regulation should be that all cannabinoid-based products be subjected to rigorous testing to ensure that the consuming public knows what compounds and dosages they are consuming and that the products are

free from contaminants and impurities, especially fentanyl. Additionally, this should be extended to the import of these products from other states and countries. The internet-based trade cannot be quantitated at this writing but is likely quite significant given the quasi-legal status of these cannabinoids. This is no different from what the alcohol industry is currently required to do not only in our state but nationally.

References:

1.https://www.michigan.gov/cra/consumer-connection/Delta-8information#:~:text=Delta%2D8%20Information,michigan.gov.

2. Erickson, B. E. (2021). Delta-8-THC craze concerns chemists. Chemical & Engineering News; American Chemical Society. https://cen.acs.org/biological-chemistry/ natural-products/Delta-8-THC-craze-concerns/99/i31

3. Wikipedia Contributors. (2023, April 7). Delta-8Tetrahydrocannabinol. Wikipedia; Wikimedia Foundation. https://en.wikipedia.org/wiki/Delta-8-Tetrahydrocannabinol

4. “5 Things to Know about Delta-8 Tetrahydrocannabinol –Delta-8 THC.” U.S. Food and Drug Administration, 2023, www.fda.gov/consumers/consumer-updates/5-things-knowabout-Delta-8-tetrahydrocannabinol-Delta-8-thc. Accessed 12 Apr. 2023.

5. https://www.webmd.com/mental-health/addiction/what-isDelta-8

6. Goggins, P. (2021, March 31). What is Delta-8? Leafly; Leafly. https://www.leafly.com/news/science-tech/what-isdelta8-thc

Introduction

Vutrisiran (Amvuttra®) is an injectable medication that received FDA approval in June of 2022 for the management of polyneuropathy associated with hereditary transthyretin amyloidosis (haTTR)1. Transthyretin amyloidosis is a rare, genetic disorder, affecting approximately 1 in 1,000,000 people, caused by a mutation in the transthyretin gene, which leads to the misfolding of the transthyretin (TTR) protein. The mutated TTR proteins aggregate into amyloid plaques that accumulate in organs and tissues. The accumulation of TTR proteins can cause debilitating complications and, in severe cases, mortality. A common complication seen in haTTR is polyneuropathy, which often presents numbness, tingling, distal weakness, and gait abnormalities. This can result in altered ambulation, reduced dexterity, and decreased overall quality of life. Polyneuropathy occurs in approximately 60% of haTTR patients and has been shown to progress ten times faster than that of diabetic neuropathy2. Vutrisiran is a chemically modified, small interfering ribonucleic acid (siRNA) agent that decreases the synthesis of TTR proteins in the liver by silencing the TTR gene. By decreasing the synthesis of misfolded TTR proteins, less aggregation into amyloid plaques occurs, thus decreasing the deposition of these plaques into organs and tissue. This mechanism has been shown to decrease the severity of polyneuropathy3. Vutrisiran has been clinically proven to provide a sustained decrease in TTR protein synthesis, decrease incidence of polyneuropathy, and improve overall quality of life1

Vutrisiran (Amvuttra®)

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Safety

There are currently no known contraindications to vutrisiran. The phase I trial showed no severe reactions, drug-related discontinuations, or treatment-related death3. There were no clinically significant changes in laboratory measures, vital signs, or physical examination. In the phase III HELIOS-A trial comparing patisiran and vutrisiran, injection site reactions including symptoms of pain, redness, or burning were reported in 6.7% of patients receiving vutrisiran and were all mild in severity 4. Authors note that patisiran had significantly more infusion-related reactions in comparison to vutrisiran. There are no dose adjustments recommended by the manufacturer for patients with altered renal or hepatic function3

Tolerability

Vutrisiran is well tolerated by patients. The most common adverse effects observed with vutrisiran use included arthralgias and dyspnea, both of which are common complications of the disease state itself. In the HELIOS-A trial, 11% of patients experienced arthralgia symptoms and 7% experienced dyspnea compared to placebo4. In some cases, vutrisiran has been shown to decrease serum vitamin A levels (occurred in approximately 7% of patients studied), which could result in ocular complications such as night blindness. The manufacturer recommends patients consume the daily recommended amount of vitamin A via diet or supplementation3

Effectiveness

During the phase I clinical trial conducted in healthy patients, a single 25 mg dose of vutrisiran resulted in a maximum TTR protein reduction of 94% and an average TTR protein reduction of 80%, which was sustained for approximately 90 days3. During the 18-month phase III clinical trial of vutrisiran (HELIOS-A), a single subcutaneous dose demonstrated an 87% decrease in serum levels of TTR protein, which was sustained over 18 months. In addition, serum TTR decreased significantly within three weeks of treatment. Results showed that 48% of patients experienced a reversal of neuropathy symptoms using the modified neuropathy impairment score (mNIS+7) from baseline compared to only 4% in the placebo group. In addition, 57% of patients experienced improvement in quality of life from baseline compared to only 10% in the placebo group4. Compared to patisiran (Onpattro®), a medication approved in 2018 with the same mechanism of action, vutrisiran has been shown to be just as effective with less adverse effects and easier administration.

Price

Vutrisiran is priced per subcutaneous dose (25 mg/0.5 mL) which is given once every three months. One injection of vutrisiran (0.5 mL) is priced at $139,050.00, which would make the total annual cost of the medication $556,200.00. However, through the Alnylam Pharmaceuticals manufacturer site, patients can find an assistance program that helps uninsured patients to receive the medication at no cost and patients with commercial insurance to receive each dose at decreased cost5 Patisiran costs approximately $7,000 per dose for a patient weighing greater than or equal to

Materia Medica

one hundred kilograms. Since this medication is given once every three weeks, the total annual cost is approximately $121,333.33. Although the cost is lower, the time of administration is significantly longer than that of vutrisiran, which could result in more indirect and intangible health care costs, such as the patient’s time spent in the office, increased stress, or discomfort of a prolonged infusion6.

Simplicity

Vutrisiran is 25 mg/0.5 mL subcutaneous injection which is administered by a healthcare provider in the office once every three months5 This medication can be injected into the subcutaneous tissue around abdomen, upper thigh, or upper arm and is relatively painless. In comparison, patisiran is an intravenous infusion given every three weeks that takes approximately eighty minutes to infuse. There is no premedication or lab monitoring required for vutrisiran and no observation period required post-injection, as there is with patisiran5,6. Due

to the known decrease in vitamin A levels, it is recommended that all patients take a vitamin A supplement as needed to maintain the daily recommended dose3.

Bottom Line

Hereditary transthyretin amyloidosis presents with many debilitating complications, including polyneuropathy, a result of mutated TTR proteins2. Vutrisiran is a small interfering RNA therapeutic that targets the synthesis of the transthyretin protein by silencing the TTR gene in the liver. Vutrisiran showed a clinically significant decrease in serum levels of TTR protein, which was sustained for 90 days. The overall decrease in serum TTR proteins has been proven to improve symptoms of polyneuropathy and overall quality of life3. Vutrisiran can be prescribed in patients with varying degrees of polyneuropathy in haTTR and is given once every three months with no premedication or lab monitoring required. Due to the debilitating nature of the disease, the

Strategic Planning

opportunity for patients to conveniently receive an injection that can significantly improve their life quality is unmatched. The improvement in polyneuropathy symptoms allows for patients to maintain independence in ambulation and other activities of daily living. Although the retail cost of vutrisiran is high, the manufacturer provides several patient assistance programs that allow patients to obtain the medication at a lower cost5. Overall, vutrisiran should be considered as a safe, effective, and tolerable option for the treatment of polyneuropathy in patients with hATTR.

At the time of authorship, Dr. Madison Abbs is a PGY-1 Pharmacy resident at UPMC St. Margaret and can be reached at abbsmc@ upmc.edu. Dr. Arianna Sprando is a PGY-2 Ambulatory Care/Family Medicine resident at UPMC St. Margaret. Dr. Heather Sakely, PharmD, BCPS, BCGP, provided editing and mentoring for this article and can be reached at sakelyh@upmc.edu.

References

1. Keam S. J. (2022). Vutrisiran: First Approval. Drugs, 82(13), 1419–1425. https://doi.org/10.1007/s40265-022-01765-5

2. Hereditary ATTR Amyloidosis. Cambridge, MA: Alnylam Pharmaceuticals, Inc. hATTR Amyloidosis—A Rapidly Progressive, Multisystem Disease

3. Habtemariam BA, Karsten V, Attarwala H, et al. Single-Dose Pharmacokinetics and Pharmacodynamics of Transthyretin Targeting N-acetylgalactosamine-Small Interfering Ribonucleic Acid Conjugate, Vutrisiran, in Healthy Subjects. Clin Pharmacol Ther. 2021;109(2):372-382. doi:10.1002/ cpt.1974

4. Adams, D., Tournev, I. L., Taylor, M. S., Coelho, T., PlantéBordeneuve, V., Berk, J. L., González-Duarte, A., Gillmore, J. D., Low, S. C., Sekijima, Y., Obici, L., Chen, C., Badri, P., Arum, S. M., Vest, J., Polydefkis, M., & HELIOS-A Collaborators (2022). Efficacy and safety of vutrisiran for patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy: a randomized clinical trial. Amyloid: the international journal of experimental and clinical investigation: the official journal of the International Society of Amyloidosis, 1–9. Advance online publication.

5. AMVUTTRA Prescribing Information. Cambridge, MA: Alnylam Pharmaceuticals, Inc.

6. Onpattro (patisiran) [prescribing information]. Cambridge, MA: Alnylam Pharmaceuticals Inc; May 2021.

Contracting Essentials for All Physicians, Especially Residents and Fellows

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• Malpractice Coverage

• Plan for Worst-Case Scenario

Restrictive Covenants (Non-Compete Agreements)

situation; a 50-mile restriction may be considered reasonable in an extremely rural area but would likely be unreasonable in a more densely populated area.

As many residents and fellows enter their final year of training, the recruiting period for physicians is on the horizon and these soonto-be attending physicians will begin exploring their options. After nearly a decade or more of medical training, these physicians will finally have an opportunity to take control of their careers and choose their next opportunity.

More often than one might expect, we see new physicians become hesitant to fully review and negotiate their first contracts. Perhaps, after reaching their final goal, they don’t want to seem too aggressive and fear having an offer rescinded. To help facilitate this process, we’ve put together this brief guide to help physicians navigate contract negotiations.

Although the full contract should always be read and understood in its entirety, there are some sections that play a key factor in negotiations that every physician should understand.

• Non-Compete Agreements (Restrictive Covenants)

• Contract Term & Termination

• Compensation

Restrictive Covenants, often referred to as non-compete agreements, are contractual clauses that put temporary limitations on your employment once your current agreement ends. Although there are some states in which restrictive covenants are unenforceable by law, this is uncommon; restrictive covenants are routinely enforced in many states. In January 2023, the FTC proposed a rule that would prohibit companies from entering into noncompete agreements with their employees. As of right now, this is simply a proposal, and the agency is still soliciting public comments before the rule becomes finalized. Once finalized, litigation to challenge the rule is inevitable. Regardless, Pennsylvania already heavily scrutinizes physician non-compete agreements to protect the overall interests of the public.

Generally speaking, restrictive covenants must be designed to reasonably protect the employer without unreasonably restraining the physician. This is often achieved by prohibiting a physician from practicing in the current employer’s immediate area for a reasonable period. For example, if you were a pediatrician, the restrictive covenant might prevent you from practicing as a pediatrician in any facility within 25 miles of your current employer for a period of one year once your current employment ends. The reasonableness of the time and geographic restrictions are dependent upon the facts surrounding your current employment

Standard restrictive covenants are usually applicable regardless of the reason for termination. In situations where both the employer and the physician could terminate the agreement without cause with only 60- or 90days’ notice, you are taking on a considerable risk that could force you to relocate, at least temporarily, once this agreement terminates. You should attempt to protect yourself against termination without cause or termination initiated due to a breach of the employment contract by the practice. You could also hope to negotiate a longer-guaranteed employment period or a longer notice period for termination without cause. Understanding the restrictive covenant of your contract is critical as you begin your career.

Contract Term & Termination

Contracts can either be for a specific term (i.e., length of time) or can be evergreen, continuing indefinitely until terminated for some reason. Many contracts have a provision allowing both the employer and the physician to terminate the contract without cause upon 30-, 60-, or 90-days’ notice. For a physician fresh out of residency or fellowship, you would hope for an initial term of at least 2-3 years; it will take time for you to transition and fully understand the expectations of becoming an attending physician. Whether it’s a matter of understanding how many office hours are typically expected, how many hospitals will be covered, your average call coverage

responsibilities, or even fully understanding the achievability of your wRVU targets, your first year as an attending physician will be full of new experiences and lessons. Having a longer initial contract term will give you a level of comfort during this transition. Also, because you are likely subject to a restrictive covenant, a longer term should provide additional assurances against you having to relocate so soon.

Malpractice Coverage

One significant change as you transition from residency or fellowship to practicing as an attending physician is your exposure to being sued for malpractice. This makes it critical that you fully understand the protection your employer provides you, such as malpractice insurance. Malpractice insurance coverage is usually available in two forms, occurrence and claims made.

• Occurrence coverage will often cover events that occur during the term of the insurance policy, regardless of when the claim is made; this type of coverage is preferred.

• Claims made insurance usually covers events only if they occur during the term of the policy and relate to a claim that is made during the term of the policy; this type of coverage is usually less expensive but also provides less protection. You will need to know the type of malpractice insurance that is provided by your new employer and take that into consideration as you negotiate the terms of your new employment and explore employment options.

Compensation

Although compensation is likely one of the top considerations as physicians explore their new opportunities, it should be one of the final items you agree upon. If possible, you

should defer the compensation decision until any other issues are resolved. Compensation provisions typically consist of a base salary with productivity expectations and may even come with a signing bonus or relocation bonus. To fully understand compensation, you should evaluate the employment opportunity as a whole. For example, if the compensation is high but the benefits are poor and you are expected to shoulder a disproportionate amount of call time, maybe the high compensation is not worth the expectations compared to another opportunity with lower compensation but better benefits and less call time requirements.

Be prepared to ask questions about the practice’s specific expectations of you. For example, the practice should be able to provide data on the historical performance of physicians in the practice so that you can better understand the achievability of your wRVU targets. Throughout this process, keep in mind that the hospital or practice is going to try and hire you for as low of compensation as you are willing to accept; do not be hesitant to ask for a larger compensation if you feel the initial offer is lacking. Be prepared to bring data to the conversation and know your worth. Once the negotiations are complete and the contract is signed, you will not have this opportunity to advocate for yourself until the contract is up for renewal, or you transition to a new employer. Use whatever leverage available to you (i.e., restrictive covenant or term length) and negotiate to be adequately compensated for your services.

Plan for the Worst-Case Scenario

Most likely, your relationship with your new employer will be great, you will flourish in this new environment, and you will never need to revisit your contract again. Although that is the scenario we all hope for, that is not the scenario you should plan for when negotiating your contract. If an issue arises, you need to fully understand your rights and responsibilities as well as make sure that you are protected when it comes to things such as severance pay and restrictive covenants. The language that is in the contract sets the stage for how any adverse situation might play out. While negotiating your contract, you have a chance to advocate for yourself by inputting protections in any unpleasant situation. No matter how unlikely an issue is to arise, you should still plan for the worst-case scenario and build in protections for yourself during the negotiating process.

Conclusion

As your medical training concludes and this new chapter of your career begins, you will face many new experiences, both rewarding and challenging. Do yourself a favor and take the time to make sure your contract with your new employer sets you up for success. You’ve worked so hard to get to this point - this is the time to reap the benefits of all your efforts.

Pittsburgh Ophthalmology Society: September 14 and October 5 Meeting Details

The Pittsburgh Ophthalmology Society will host their first meeting of the 2023-2024 monthly meeting series on September 14, 2023.

The meeting (and all future meetings) will take place at the new monthly meeting location, the PNC Champions Club at Acrisure Stadium (100 Art Rooney Ave, Pittsburgh, PA 15212). The venue is centrally located on the North Side with parking available in several lots that are within walking distance of the stadium. Please visit the POS website for additional details.

Registration begins at 4:00 pm with the first lecture beginning at 4:30 pm. Members will receive registration information, including the link to register by email. Please note, registration is required (no walk-ins, please) and will be managed on-line only. The Society would like to thank Mallinckrodt Pharmaceuticals, RxSight, and Sight Sciences for sponsoring the program.

After completing her cornea fellowship at Massachusetts Eye and Ear Infirmary, Harvard Medical School, Dr. Saeed stayed on as faculty for 5 years where she was program director of the cornea fellowship, director of the pediatric cornea service, and associate director of the ocular surface imaging center, before joining the University of Illinois last year.

Her lab conducts research on the characterization and management of Stevens Johnson syndrome, with a focus on genetic epidemiology and risk factors. She is an international expert on SJS/TEN and has standardized treatment for ocular disease in SJS/TEN. Dr. Saeed is also PI and a collaborator on several NIH-funded programs to study genetic risk factors in the development of SJS/TEN with and without ocular disease. Her clinical practice is focused on providing expert care for adult and pediatric patients with severe ocular surface disease. Her other clinical and research interests include pediatric corneal disease, including keratoconus, imaging of the ocular surface, public health, and eye banking in the developing world.

Dr. Shields completed her ophthalmology training at Wills Eye in 1987 and subsequently did fellowship training in ocular oncology, oculoplastic surgery, and ophthalmic pathology. She has authored or coauthored 12 textbooks, over 1400 articles in major journals, over 300 textbook chapters, given over 700 lectureships, and many awards. The 5 most prestigious honors include:

• The Donders Award (2003) given by the Netherlands Ophthalmological Society every 5 years to an ophthalmologist worldwide who has contributed to the field of ophthalmology. She was the first woman to receive this award.

• The American Academy of Ophthalmology Life Achievement Honor Award (2011) for contributions to the field of ophthalmology.

The Society gratefully acknowledges support of the program from the following:

CARR Healthcare Realty, First National Bank and Thea Pharma, Inc.

The September meeting features guest faculty Hajirah Saeed, MD, MPH, Associate Professor of Ophthalmology, Illinois Eye and Ear, University of Illinois Chicago, IL; Research Associate Professor, Loyola University Medical Center; Lecturer (part-time), Harvard Medical School, Boston, MA. Thank you to Srinivas Kondapalli, MD for inviting Dr. Saeed.

On October 5, 2023 the Society welcomes Carol L. Shields, MD - Chief Ocular Oncology Service, Wills Eye Hospital Professor of Ophthalmology, Thomas Jefferson University of Philadelphia. Thank you to Pamela Rath, MD, for inviting Dr. Shields.

There is no meeting in November as the American Academy of Ophthalmology’s national meeting will take place November 3-6, 2023.

Congressional Update: Action Needed to Fix Medicare

ContRiButoR: jim PaWelski | ama DiReCtoR, FeDeRation Relations

The need for Congress to act quickly and decisively to fix a broken Medicare payment system cannot be overstated. The fiscal stability of physician practices and the longterm viability of our nation’s entire health care system hang in the balance.

Medicare payment reform is the first pillar of the AMA Recovery Plan for America’s Physicians. Our needs include immediate relief from annual funding cuts and fundamental changes to Medicare reimbursement centered on simplicity, predictability, relevance and alignment, principles first outlined in reform principles issued last fall.

The current Medicare physician system reflects none of those principles, which needs to change. The government’s own Medicare Economic Index (MEI), which gauges the inflation in medical practice costs, will hit 4.5% in 2024, its highest level in two decades.

When combined with the 3.8% hike in the MEI recorded in 2023, that means medical practice costs increases will have exceeded 8 percent over just two years. Many individual and group physician practices have experienced cost increases well beyond this

level, while still seeking a full recovery from pandemic-related setbacks.

However, provisions in current law required the Centers for Medicare & Medicaid Services to implement a 2%, across-the-board reduction in Medicare physician payment rates this year, with another 3.36% cut to the conversion factor scheduled for 2024. In stark contrast to the annual payment increases tied to inflation given to hospitals, skilled nursing facilities and other entities that bill Medicare, physician practices have fought to reduce or delay payment cuts nearly every year.

Taking inflation into account, Medicare physician payment rates fell 26% from 2001 to 2023, while practice costs rose by 47% over the same period. We must place physician practices on sound financial ground through Congressional action to fix the Medicare physician payment system.

Legislative relief

The AMA is strongly supporting the Strengthening Medicare for Patients and Providers Act (H.R. 2474), a bipartisan measure now pending in the 118th Congress,

which would provide the crucial link between the Medicare physician payment schedule and the MEI, and finally put physicians on an equal fiscal footing with other entities drawing Medicare payment. Physicians can contact their representatives in Congress through this AMA portal to urge passage of H.R. 2474.

For those physicians who are meeting virtually or in person with their legislators and staff, a variety of resource material is available on a dedicated web site, FixMedicareNow. org, including plain language explanations of the need for: automatic, annual inflation-based payment updates, reforms to budget neutrality policies, and simplifying the Merit-Based Incentive Payment System (MIPS).

The AMA intends to fight tirelessly for a financially stable and wholly predictable Medicare physician reimbursement model that protects both physicians and the patients they serve. We urge you to join us in urging Congress to ensure that Medicare continues to fulfill its crucial role in safeguarding both the health and financial well-being of tens of millions of Americans.

ACMS Summer 2023 - We’ve Been Busy!

ACMS Night at the Pirates Game

On Saturday, July 15th, 125 ACMS members and their families gathered for the ACMS Night at the Pirates Game. The Pirates took on the San Francisco Giants, followed by a Zambelli Fireworks Night. There was a pre-game tailgate in the Blitzburgh Room at the Babb Insurance Building, with complimentary food from Steve and Benny’s Food Truck. The Pirates did not emerge victorious, and a little bit of rain put a (literal) damper on the walk to the stadium, but the night was a great success and we look forward to doing it again next year! Visit acms.org for more photos!

Women in Healthcare Committee Kick Off Event

On August 9th, the ACMS Celebrated National Women’ s Day with a sold-out Women in Healthcare Committee networking event at the Longue Vue Club. The Pink Patio was the perfect backdrop for our event. Attendees heard remarks from committee co-chairs Anu Anand, MD and Tiffany DuMont, DO, as well as a keynote address from Margaret Larkins-Pettigrew, MD, MEd, MPPM, FACOG.

Dr. Larkins-Pettigrew’s words about overcoming adversity and her tips on how to rise as a leader served as a great starting point for this new committee. The next event will be held in the late-fall with a date to-be-determined very soon.

and more!

….

The Return of “Put the Self-Care in Healthcare”

saRa hussey, mBa, Cae – aCms exeCutive DiReCtoR Duquesne univeRsity sChool oF PhaRmaCy

Last year, the ACMS launched our “Put the Self-care in Healthcare” campaign in honor of Physician Suicide Awareness Day on September 17. In addition to honoring that day of awareness, our team also created a campaign to provide resources, discounts, services, and support tools for our members. Last year, we were overwhelmed at the response from local businesses. We engaged with businesses around Allegheny County who offered exclusive discounts to healthcare workers and provided us with giveaways like gift cards, tickets, and more. We were spotlighted on the Rick Dayton radio show and the “Yinz are Good” podcast, and we even received a message from (now former) Gov. Wolf.

This year, as this campaign evolves, we’ll be adding in some personal touches. We’ll be sharing thoughts directly from ACMS members, and we’ll share some words of encouragement from the patients that our physicians care for on a daily basis. We are making a strong effort to secure more press coverage to raise awareness about physician suicide and promote mental health resources for healthcare professionals. Using our platform, we aim to further advance the conversation on this important issue while reserving space on September 17, Physician Suicide Awareness Day, to honor those who we have lost or who are struggling.

Through our efforts to raise awareness, we aim to reward and motivate physicians. Our partners in dining, entertainment, fitness, coffee, spas, and more will provide weekly discounts, and we will unveil a new prize package every week. Physicians can earn entries for these prizes throughout the month, and all prizes will be awarded at September’s end. Additionally, we will offer several smaller giveaways throughout the month to prioritize our members’ mental health.

We invite and encourage you to follow ACMS on our social media channels, including

Self Care in Healthcare

LinkedIn, Instagram, Facebook, and Twitter… or X…. or whatever Elon Musk is calling it by the time this article goes to print. Congratulations! You now have the opportunity for early entry to win one of our many prizes. We want to hear from you, our ACMS members, about how you do “selfcare”. Send us your pictures and stories of things that you do to decompress, get away from the workplace, or spend quality time with your friends, family, or pets! Email Mel Mayer (mmayer@acms.org) with your photos and stories. All submissions will receive a prize entry and will also be featured in a future edition of the ACMS Bulletin as we wrap up the campaign.

Duquesne’s College of Medicine Set to Launch Fall 2024

aRtiCle authoR: ken WalteRs Duquesne univeRsity

In one of the boldest moves of its 145-year history, Duquesne University is on schedule to launch its College of Medicine (COM) in fall 2024.

The COM is recruiting students now and will enroll 85 students in 2024 with the plan to grow annual enrollment to 170 students beginning in 2026. The medical college anticipates enrolling 680 students over all four years by the 2029-2030 school year. It will be the second medical school in Pittsburgh and the first Catholic medical school in Pennsylvania.

“This new college is the ultimate expression of our commitment to promoting healthcare equity in the region and beyond,” said Duquesne President Ken Gormley. “It’s our boldest initiative to date and builds on our legacy of making a positive social impact by working with people and communities, including in underserved areas, to help meet critical needs.”

The new college will arrive at an important time. The U.S. will experience a shortage of more than 120,000 physicians - especially primary care doctors - by 2032, according to the Association of American Medical Colleges. The shortage is expected to be felt most acutely in urban and rural communities, which often lack access to health services.

“Communities with stronger primary care services have better health outcomes, improved quality of care, lower costs and higher patient satisfaction,” said COM Dean Dr. John Kauffman. “Our doctors will be trained to very high standards of medical excellence and will understand and meet the healthcare needs of their patients, including those living in underserved regions.”

The Right Place, The Right Time

With its expertise in nursing, pharmacy, allied health care and the sciences, Duquesne is perfectly positioned to launch a medical college with a focus on integrative health.

“We envision a college of medicine that ties together interprofessional opportunities across all of our health programs,” said Duquesne Provost and Executive Vice President David Dausey, who is also an epidemiologist. “Integrative medicine considers the medical practitioner and the patient as partners not only in healing but also in prevention and general wellness. Integrative health values what often is termed ‘western’ scientific approaches to medicine just as much as conceptions of health, wellness and other cultural approaches to healing.”

In addition to training physicians, nurses and other healthcare practitioners, Duquesne’s program will include work in the ethics of integrative medicine as well as a focus on serving marginalized populations, aligning integrative health practice with Spiritan values of service that have been a hallmark of Duquesne for more than 140 years.

“The new college of medicine will focus on excellence in medical training at its core,” Dausey said. “To achieve our bigger goals for the region, such excellence is foundational to serving our communities and most importantly, the students we will attract.”

Through its Center for Integrative Health, Duquesne has provided thousands of health screenings, flu shots, COVID vaccines and asthma clinics for vulnerable populations in the region.

State-of-the-Art Education with Community Support

The COM building will feature state-of-theart medical equipment, including advanced simulation technologies, maker spaces and virtual anatomy, using HoloLens technology. The first class of entering students will also be supplied with portable handheld ultrasound devices, which are an important tool for examining patients. The devices can be easily transported to a patient’s location, making them ideal for residents in communities that lack access to care.

The college has developed partnerships with health centers throughout Pennsylvania, ensuring third- and fourth-year students gain a comprehensive education during their residencies. A variety of hospital and health care systems throughout the region will partner with the COM by offering clinical positions and other learning opportunities to its students.

Duquesne’s College of Medicine Under Construction.

While exploring the potential for the medical college, Duquesne officials conferred with representatives from regional universities, medical professionals and a variety of individuals in city and state government. The University’s plans were met with enthusiasm, with regional hospitals noting that even with existing medical schools in the area, their needs for residents and interns remained high.

In turn, the COM has received generous financial support, with significant contributions from government agencies, foundations and University donors. This support has been vital to building the COM -- construction is well underway and building completion is scheduled for spring 2024, where it will stand across the street from the UPMC Cooper Fieldhouse on Forbes Avenue.

This funding also aids COM programs, including contributions to support the college’s leadership; modern fertility awareness education; state-of-the-art medical education equipment; and programming focused on providing care to vulnerable populations.

Annual Fritzky Family Integrative Health Summit

September 21 - 22, 2023

Duquesne University, Pittsburgh, PA

Earn LIVE Hours of AMA/AOA/CPE CE credits

This multi-disciplinary summit connects healthcare practitioners and professionals who are dedicated to improving patient care and defining the future of integrative health.

Learn More & Register by September 8, 2023.

duq.edu/HealthSummit

Duquesne’s College of Medicine When Completed.

My Summer as an ACMS Intern

By: Isabella Lin, ACMS Intern

Interning at the Allegheny County Medical Society was an opportunity I’m extremely glad I took, and I have come to realize that this is because ACMS has roots in many fields. There is engagement in medicine, business, marketing, event planning, writing, and so much more. To work at ACMS is to work with numerous and varying professions, people, and places, that give you a little taste of everything.

For ten weeks, I worked hard, finished tasks, created ideas, and planned. I learned things as simple as writing a solid email to things as complex and logistical as hosting an event at a country club, writing a blog, and reaching out to businesses all around Pittsburgh. The role of ACMS is such that there is a lot of engagement with people and places all over the city; I was able to form connections with small businesses and begin creating a network.

Here’s the thing: people fail to understand doctors’ incredible role in their communities. Doctors carry such an amount of weight on just two shoulders and are usually lacking in recognition for their work. This summer, I was able to work every day knowing that I was helping physicians that deserved more from their communities. Through publications/press, event hosting, and educational courses/seminars, ACMS lends a hand to thousands of physicians city-wide; this is no small feat. Being a part of the planning was a testament to that.

The overarching goal of ACMS is one with which I can personally identify, given that I have two doctor parents. I have seen the stressful, angry, crazy, and desperate underbelly of medicine. And the answer to this problem lies within the pillars of advocacy, education, fellowship, and wellbeing.

You wouldn’t believe how glad I was when I found out about the opportunity to intern at ACMS. Yes, it is a job that teens like me dream about because of the experience with real world expectations, the dynamics of a workplace, the communication with colleagues and people at large, and a peek into the medical field. But, even more so than that, ACMS fights, along with physicians in our area, for a common goal and good. That’s value added.

My time here was enlightening in every way possible. Thanks to the entire ACMS staff for welcoming me and showing me how it’s done; this has been an experience that I will never forget!

—Isabella Lin

Isabella Lin with her mom, Kirsten Lin, MD (ACMS Member and Board Member)

REPORTABLE DISEASES 2022: Q1-Q2

Allegheny County Health Department—Selected Reportable Diseases/Conditions

* Case classifications reflect definitions utilized by CDC Morbidity and Mortality Weekly Report.

** These counts do not reflect official case counts, as current year numbers are not yet finalized. Inaccuracies in working case counts may be due to reporting/investigation lag.

NOTE: Disease reports may be filed electronically via PA-NEDSS. To register for PA-NEDSS, go to https://www.nedss.state.pa.us/NEDSS. To report outbreaks or diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243.

For more complete surveillance information:

• On influenza: Influenza (Flu) Information | Health Department | Allegheny County

• On mpox: https://www.alleghenycounty.us/Health-Department/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Mpox.aspx

• On COVID-19: COVID-19 Dashboards (alleghenycounty.us)

ALLEGHENY

COUNTY MEDICAL SOCIETY — 2023 MEETING SCHEDULE

ALL MEETINGS BEGIN AT 6:00 PM

Upcoming Events

No upcoming events Executive Committee*

Tuesday Evenings—2nd Tuesday at the start of each new quarter.

October 10, 2023

Finance Committee

Tuesday Evenings

August 29, 2023

November 14, 2023

Board of Directors*

Tuesday Evenings

September 12, 2023

December 5, 2023

Committees

Delegation

Nominating

ACMS Foundation

Dates to be announced

August 30, 2023 6:30 PM

August/September 2023

October 24 Grant Proposal Review

PAMED BOARD

August 3

AMA Interim Meeting

AMA Annual Meeting

PAMED HOUSE OF DELEGATES / HERSHEY

October 27-28, 2023

October 26-27, 2024

AMA HOUSE OF DELEGATES

November 11-14

June 2024

ACMS HOLIDAYS – OFFICE CLOSED

January 2 New Year’s Day (Monday)

January 16 Martin Luther King (Monday)

February 20—President’s Day (Monday)

May 29—Memorial Day (Monday)

June 19—Juneteenth Day (Monday)

July 4—Independence Day (Tuesday)

National Harbor, MD

Chicago, IL

September 4 Labor Day (Monday)

November 10 Veteran’s Day (Friday)

November 23

Thanksgiving Day (Thursday)

November 24 Thanksgiving Friday (Friday)

December 25 Christmas (Monday)