ACMS Bulletin February 2023

Bulletin Allegheny County Medical Society

February 2023

The Heavenly Christmas Card Medical History Vignette: Image Intensification 2023 ACMS Honors

Let’s Get Back Together!

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Allegheny County Medical Society

Bulletin February 2023 / Vol. 113 No. 2

Opinion Editorial....................................5 • On Love and Loss Deval (Reshma) Paranjpe, MD, MBA, FACS

Associate Editorial ..................8 • The Heavenly Christmas Card Anthony Kovatch, MD

Editorial ..................................12 • Medical History Vignette: Image Intensification Richard H. Daffner, MD, FACR

Open Letter to the Editor.......15

Departments

Society News .........................11 Materia Medica ......................28 • Debates and Dilemmas

Society News .........................22 • POS Members Gather January 12 to Welcome Peter MacIntosh, MD

ACMS and Bar Association Event.................19 Foundation Featured Grant Recipient ................................20 • Beverly’s Birthday

• Daridorexant (Quviviq™) Elisabeth Marker, PharmD and Lauren Sittard, PharmD, BCPS

Life Planning Fair...................31

Society News .......................23 Legal Summary.......................32 • POS Monthly Meeting Series.

• FTC Proposed Rule to Ban Most Joshua Teichman, MD, MPH, FRCSC—Featured speaker for the February 9th meeting

Non-Competes—Good for Physician Compensation?

Beth Anne Jackson

ACMS Honors .......................24

ACMS Welcomes Immunization Coalition................................34

ACMS Leadership Social ......26

Perspective ............................16 • Battling entrenched attitudes about ACMS Welcomes Elizabeth ‘Liz’ Yurkovich .......27 the value of racism in medical education: Perspectives from Third-Year Medical Students Zainab Balogun, Jeyani Narayan, Allie Heymann, Anna Li

Articles

Reportable Diseases..............35 ACMS Meeting Schedule ......36

On the cover

Pileated Woodpecker Mark E. Thompson, MD Mark E. Thompson, MD specializes in Cardiology

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2023 Executive Committee and Board of Directors

PAMED DISTRICT TRUSTEE G. Alan Yeasted

Douglas F. Clough (dclough@acms.org)

COMMITTEES

Richard H. Daffner (rdaffner@acms.org)

President-elect Raymond E. Pontzer, MD

Bylaws Raymond E. Pontzer

Kristen M. Ehrenberger (kehrenberger@acms.org)

Secretary Keith T. Kanel, MD

Finance William Coppula, MD

President Matthew B. Straka, MD

Treasurer William Coppula, MD Board Chair Peter G. Ellis, MD

Nominating Raymond E. Pontzer, MD

DIRECTORS Term Expires 2023 Michael M. Aziz, MD Micah A. Jacobs, MD Bruce A. MacLeod, MD Amelia A. Paré, MD Adele L. Towers, MD Term Expires 2024 Douglas F. Clough, MD Kirsten D. Lin, MD Jan B. Madison, MD Raymond J. Pan, MD G. Alan Yeasted, MD Term Expires 2025 Anuradha Anand, MD Amber Elway, DO Mark Goodman, MD Elizabeth Ungerman, MD Alexander Yu, MD

Anthony L. Kovatch (mkovatch@comcast.net) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF Executive Director Sara Hussey (shussey@acms.org) Vice President - Member and Association Services Nadine M. Popovich (npopovich@acms.org) Manager - Member and Association Services Eileen Taylor (etaylor@acms.org)

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ACMS ALLIANCE Co-Presidents

Corresponding Secretary

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Doris Delserone

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Sandra Da Costa

Justina Purpura Assistant Treasurer Liz Blume

Improving Healthcare through Education, Service, and Physician Well-Being.

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Editorial

On Love and Loss Deval (Reshma) Paranjpe, MD, MBA, FACS

I

hold it true, whate’er befall; I feel it when I sorrow most; ‘Tis better to have loved and lost Than never to have loved at all.

— In Memoriam A.H.H. Alfred, Lord Tennyson

Tennyson wrote these immortal lines in grief at the sudden and unexpected loss of his best friend, Arthur Henry Hallam, who was only 22 years old.

This stanza is part of a poem beloved

by Queen Victoria and published in 1849; it took 17 years to write and spans 133 cantos dedicated to the years long grieving process of those who loved young Arthur.

Last month, the unexpected and sudden loss of a very dear and best friend shattered me and all who knew and loved him—an incredibly large number of people. Losing a true friend is devastating at any stage of life. Every day brings questions and regrets, memories which are equal parts comfort and heartache. Losing a friend in midlife is especially hard because you have both such a deep and storied history together, and so many plans for your future in friendship. You treasure the thought of knowing each other when you’re 70 and 80, of sharing advice and gripes and memories, of comparing retirement plans. All of us who knew and ACMS Bulletin / February 2023

loved him feel robbed of his love for life, his humor, his booming cheerful voice, and the force of nature that he was in life. He was the personification of love, with a generous heart and a kind word for absolutely everyone. How can that love be erased from the world with such finality, so suddenly?

Another friend, ten years older, consoled me but warned me at the same time: it only gets worse from here.

With every passing year, he noticed more losses of classmates, friends, and colleagues in his own peer group.

Friends in their 70s and 80s tell me

of the horrible feeling of losing their classmates steadily and wondering: am I next, and when? We feel like fish in a barrel, waiting our turn, and do everything we can to feel alive and avoid that feeling.

This is the time when we all start wondering what comes after this life.

Depending on your religious and/ or spiritual beliefs, there may be an afterlife, or not. There may be a heaven and hell and purgatory, or not. There may be reincarnation, or not. There may be ghosts and guardian angels, or not.

Continued on Page 6

5

Editorial From Page 5

In my insomniac internet wanderings, I found a series of books on Amazon Kindle which have unexpectedly brought me comfort. The books are by Brian Weiss MD, Chairman Emeritus of Psychiatry at Mt. Sinai Medical Center in Miami. In 1988, he first published his experience with treating his own patients with past life regression and hypnotherapy in additional to traditional psychotherapy in his book Many Lives, Many Masters. He writes about soulmates and groups of souls who find each other again in many different lives through the ages, and the lessons they learn in lives both peaceful and problematic. Remembering traumas experienced in past lives appears to cure both anxieties and somatic

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problems in his patients’ current lives.

Knowing that you have known your loved ones in previous lives while learning soul lessons makes the present life more bearable in the face of loss as future lives will hold a reunion at some point. Whatever you may think of reincarnation, the concept reinforced endlessly in Weiss’s books is that we are called upon to love one another, and that love is the most important thing in the universe, trumping every other human emotion and desire and every material possession. Love never dies but endures in lives across centuries and millennia. And that people will surely see their loved ones again in another lifetime in some form of close relationship.

The thought that our loved ones are safe and happy and at peace is comforting, as is the thought that we will all see each other again despite transiently losing each other on earth.

In fact, Weiss contends that this knowledge gives us space to love each other without fear.

Love is everything, while life is fleeting. Love each other without hesitation in the present, and make sure your loved ones know you love them at every available opportunity. While love endures, it’s always good to be reminded in the current life while the gift of time is with us.

www.acms.org

Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support.

Your membership strengthens the society and helps protect our patients.

Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email acms@acms.org.

ACMS Bulletin / February 2023

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Editorial

The Heavenly Christmas Card Anthony Kovatch, MD

“

W

hen an old person dies, a great library burns to the ground”

—African writer Amadou Hampate Ba

I argued to myself over and over how I could possibly return the Christmas card; I finally concluded that writing her story for the City of Champions and all the world to cherish was the only way available to me.

Although I have begrudgingly admitted to myself that I am a writer who is “over the hill,” I believe that I have preserved a penchant for irony and for the conviction that “miracles” are more than chimerical figments of the imagination. For example, was the so-called “immaculate reception” of Franco Harris a miraculous event self-ordained because he would lead “an extraordinary life of leadership comprised of service, humility, and kindness”(1)? And if it was not, was there at least some irony in the fact that Franco passed on just days before its solemn 50th anniversary, taking “the express elevator to heaven”? Do we humans have any prerogative to claim to know the truth in these matters?

So I must confess that I may have been privy to an event bordering on the spiritual or supernatural that took place the week before this past Christmas--an event not distorted by the drinking 8

of too much spiked eggnog or by personal existential dread common to old age or the fear of premature senility.

I firmly believe that irony is a kind of symbolic magic, like that which occurs when a down-and-out, bewildered human soul surprisingly crosses paths with a dragonfly or a fluttering cardinal.

On the other hand, was it irony when Jack Donahue and Rhodora Jacob met during their freshman year of high school, and Jack—who I suspect was a classmate of my father-in-law Jack Lyons (father of 12 children—13 if you throw me in) at Central Catholic High School---took a streetcar by an aberrant route to school that detoured him through Rhodora’s neighborhood and on to Oakland Catholic High School which she attended? I also believe that the two of them sat side-by-side on the old streetcar and read (like I did in New Jersey) the tender poem “The Rhodora” by Ralph Waldo Emerson: Rhodora! if the sages ask thee why This charm is wasted on the earth and sky, Tell them, dear, that, if eyes were made for seeing, Then beauty is its own excuse for Being; Why thou wert there, O rival of the rose!

It was stressed by my sometimes overbearing Jesuit teachers at Saint Peter’s “Prep” High School in New Jersey that in analyzing this famous poem the rhodora is presented as a flower as beautiful as the rose, but which remains humble and does not seek broader fame. And so it was with Rhodora Donahue!

“I knew that I was going to marry him when I was 14 years old!”

Rhodora repeated candidly until she passed away at the age of 97 years on December 12, 2022. Jack would counter with his own conviction: “We got on that wonderful track (of the streetcar) when we were 14 years old and stayed on that track—we never got off.” Jack attended West Point and served as a pilot in the Air Force during World War II before co-founding www.acms.org

Editorial Federated Investors, a groundbreaking financial corporation which also specialized in magnanimity and philanthropy of the highest order.

“When we started out in Pittsburgh after the war, we lived “in a drawer,” quipped Jack. “At one point, we had 5 children and one bathroom---and that was mine”! As with most members of the “Great Generation,” growing up during the Great Depression left a lasting legacy. Loving discipline and attention to detail were prerequisites for domestic order. Sunday morning mass was the highpoint of the week, and the children were quizzed on the content of the gospel readings at lunch; our children were quizzed on what toy they wanted in their “happy meal” at McDonalds.

As the family grew, Rhodora played a pivotal role in the growth of the burgeoning corporation, hosting dinner meetings with potential clients and collaborators at their new home on Beechwood Boulevard, while the antics of the growing family and the pets were held at bay.

The fury of their love and devotion to each other and to their Creator recognized no bounds and the eventual marriage of 70 years produced 13 children (without fudging for in-laws), 84 grandchildren with their 46 spouses, and, at the time of this writing, 168 great grandchildren!

I was privileged to be pediatrician to many of the noble 168. I say “noble” because the Donahue family was loved and respected as Pittsburgh royalty, if not international royalty, because of their generosity. Life was guided by 3 pillars: Faith, Family, and Federated--in exactly that order. The family heirloom was the creed: ACMS Bulletin / February 2023

“Always remember that your goal in life is to go to Heaven and to help others in every way possible to get there.

A fixture in the Downtown Pittsburgh skyline since 1986, the Federated Building motions toward Heaven.

I’d like to get away from earth awhile And then come back to it and begin over.

May no fate willfully misunderstand me And half grant what I wish and snatch me away Not to return. Earth’s the right place for love: I don’t know where it’s likely to go better.

— from my favorite poem “Birches”

by American poet Robert Frost (1874-1963) However, it was essentially through my interactions with the grandchildren of Rhodora---the parents of the noble 168—that I received a glimpse into her

indomitable spirit. Legend has it that she never raised her voice, no matter how disruptive were the children--or the pets! To a man, the family members emphasized to me that, until the day they passed away, Rhodora and Jack remembered the name, hobbies, and aspirations of every individual in the family—down to the newest great grandchild (at the time I write this paragraph, it had increased to 169). It was like remembering the name of every star in the vast sky because you were exempt from senility and memory loss.

“Grandma (or Great Grandma D as the youngest generation called her) forgets nothing. She sends notes and birthday wishes to every single one of us” I heard to a man from every grandchild and great grandchild who could speak. “Our parents had the unmistakable gift of making each one of us feel that we were individually loved,” remembers the couple’s youngest daughter, Rebecca Foxhoven. A challenge to each and every one of us health care providers to do the same!

I appeared overwhelmed by these reports during the encounters, but became skeptical as Rhodora was in her nineties. However, time and time again she proved me wrong, sending cards and letters addressed directly to me. We became like pen pals. One year, I convinced the family member responsible for publishing the “Lyons Family Calendar” to add Rhodora’s photograph on her birthday April 18th as an honorary guest and celebrity.

Several years ago I asked my mother-in-law what advice a Continued on Page 10

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Editorial From Page 9

nonagenarian who raised a dozen children would give to the parents of today; Mary Irene explained with a serious expression that the parents must learn how to say “no” to their children’s demands. I asked Rhodora the same question and she wrote back to me “Live your values.” Wisdom of two sages, who agreed that the trials and tribulations of raising a large family during the socially turbulent 1960’s and 70’s required an unwavering faith in a Higher Power, described here in the influential poem “The Gate of the Year”

by Minnie Louise Haskins in 1908: ‘God Knows’ And I said to the man who stood at the gate of the year: “Give me a light that I may tread safely into the unknown”.

And he replied: “Go out into the darkness and put your hand into the Hand of God. That shall be to you better than light and safer than a known way”.

So I went forth, and finding the Hand of God, trod gladly into the night.

And He led me towards the hills and the breaking of day in the lone East.

I found out about Rhodora’s passing before Christmas from her obituaries in social media. I was astonished by the inscrutable irony of it all when several days later I received what seemed to me to be a “Heavenly Christmas card” directly from Rhodora in the mail at my home complete with the annual bulletin portraying the extended family lines of all 13 of her children.

The return Christmas card here presented requires no postage!

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The prophet Mohammed taught his followers that the most challenging task of the followers of Allah was combating the “forgetfulness” germane to the human condition, due to the distractions inherent in serving the individual ego and life’s weary considerations. I think Rhodora’s ultimate legacy will ironically be, not what she as the grand matriarch inspired her family to accomplish, but how she NEVER forgot the mundane but most critical human requisites of living the “good life.” When I opened the Heavenly Christmas card, I recalled the awe I experienced as a pediatrician-in-training beholding the inscription at the base of the Margarita Delacorte Memorial in New York City’s Central Park, featuring characters from “Alice in Wonderland,” which reads: “In memory of my wife Margarita Delacorte who loved all children”

“Live your values!” I can think of no better examples of “true love” and no better guardian angels than Rhodora and Jack Donahue; they loved all children and all children loved them even more.

While I give to you and you give to me True love, true love So on and on it will always be True love, true love For you and I have a guardian angel On high, with nothing to do But to give to you and to give to me Love forever true.

— from “True Love” by American songwriter Cole Porter I must thank Rhodora’s granddaughter Jennifer Gott for disclosing to me the quotes and historical memories of the Donahue’s early years together. Ironically, Jennifer started off 2023 by giving birth to noble great grandchild number 170!

Another star in the heavenly sky!

References 1. Paranjpe, Deval: I Am My Relationships. Allegheny County Medical Society Bulletin, January, 2023---pages 6-7

This iconic landmark was dedicated to his wife by publisher and philanthropist George Delacorte as a gift to the children of New York City; described as “a kind of slender Santa Claus,” he and his wife had six children in the years when he founded Dell Publishing Company (of comic book fame).

Ironically, like Rhodora, the great benefactor died at 97 years of age. www.acms.org

DEBATES & DILEMMAS Register Now!

WEDNESDAY MARCH 29, 2023 Monterey Bay Fish Grotto | 6:30 PM

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AGENDA 6:00 PM EXECUTIVE BOARD MEETING (Invite Only) 6:30 PM – 7:00 PM COCKTAILS 7:00 PM – 9:00 PM DEBATE & DINNER RULES & REGULATIONS ACMS Bulletin / February 2023 22

QUESTIONS? ETAYLOR@ACMS.ORG www.acms.org

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Editorial

Medical History Vignette: Image Intensification Richard H. Daffner, MD, FACR

W

ilhelm Conrad Roentgen’s discovery of x-rays in November 1895 significantly changed the practice of medicine by providing a way of looking inside a living body without cutting it open1.

The first medical x-rays were made in February 18962. These early practitioners of what would soon be called radiology had two methods of demonstrating their work. The first was to use photographic plates and the second was to use fluorescent viewers2 (Fig. 1). X-ray photographs, as they were first called, provided static images, while fluoroscopy permitted real-time viewing.

continued up into the 1960’s, when a major development—image intensification—occurred3.

Fluoroscopic images were always difficult to see, requiring a pitch-black examining room. Furthermore, the radiologist was required to “dark-adapt” his/her eyes by wearing red-tinted goggles for a minimum of 20 minutes before entering the fluoroscopy suite (Fig. 2) The goggles allowed the radiologist to work in a brightly lit room while the cones in their eyes adjusted to “darkness”.

Fig. 2. Radiologists “dark-adapting” their eyes with red goggles (1960)2.

Fig. 1. Early chest fluoroscopy (1910)2. The “radiologist” is holding a fluoroscopic screen. Note the exposed x-ray tube behind the patient.

Improvements in radiologic equipment, including safety shielding 12

I only experienced red goggle fluoroscopy twice (fortunately). The first time was in 1965, when I was a third-year medical student. My colleagues and I went down to the radiology department to watch one of our patients undergo chest fluoroscopy.

We were given heavy lead aprons and red goggles. I remember going into

the x-ray room that was pitch-black.

The radiologist, Dr. George Alker, (who later convinced me to become a radiologist4), started the exam and was pointing out the various findings to the members of my clinical team. “You see this?” he said, and my fellow team members answered affirmatively. “How about you, Dr. Daffner?”

I replied, “Dr. Alker, I can’t see s—t.”

He looked at me and said, “Good God, son, take off your goggles!” I thought they were needed to see the fluoroscopy screen.

Seven years later, while still a resident, I was doing locum tenens in a small community hospital in eastern North Carolina. The hospital radiology department had new fluoroscopic equipment with image intensification (as did the department at Duke, where I was doing my residency). However, the solo radiologist for whom I was covering also had a private office next to the hospital. I learned that he had scheduled upper GI exams at the office every day. And so, I went next door, where I discovered he had old fashioned fluoroscopy equipment that would require me to put on the red goggles. After “dark-adapting” for 20 minutes, I went into the fluoroscopy suite and stepped on the pedal (after removing my goggles). All I could see was a faint green glow. So, I put the goggles back on and went out to wait www.acms.org

Editorial another half hour. When I returned, I had the same result. Dr. Alker had told me that in radiology we only did things with three tries. So, after another half-hour with the goggles on, I went back for round three. This time, I could see! To improve the image, I manually turned up the milliamperage as high as it would go. I had the patient swallow some barium and, Hallelujah, watched it descend his esophagus.

Then, I lost the barium. After moving the fluoroscopy screen around I saw a dark curvilinear structure on the right and thought, “Ah, that’s the duodenal bulb.” I quickly took four spot films and told the technologist to give the patient more barium and get overhead films. Twenty minutes later the tech came and said, “Here’s your spot film, doctor.” I had four beautiful pictures of the patient’s right femoral head! Fortunately, the overhead films salvaged the study. I told the technologist to either send the other scheduled patients to the hospital or to reschedule the studies when the radiologist returned. So much for old-fashioned fluoroscopy.

My experiences with “red goggle fluoroscopy” gave me a greater degree of respect for the early practitioners of my chosen specialty. I was amazed that they were able to make the diagnoses they did using the existing equipment. Or were they really relying on the overhead radiographs? Image intensification, on the other hand, allowed us to see clear fluoroscopic images without having to “dark-adapt” our eyes, and without increasing the milliamperage (and hence the radiation dose to the patient) to see anything on the screen.

ACMS Bulletin / February 2023

There is an interesting series on the History Channel entitled “Tactical to Practical” that describes how technology that was developed for the military was adapted for everyday uses. Image Intensification, developed in the 1930’s, was one such effort.

The original purpose was to provide night-vision equipment for the military.

An Image intensifier is a device that converts low level light or x-ray photons of various wavelengths into electrons, amplifies their numbers and then converts those electrons back into light photons of a single wavelength.

Image intensification for night-vision equipment as well as medical imaging devices are variants of the devices illustrated in figures 3 and 4. Nightvision equipment is, of course, a miniature version. Early medical enhancement devices displayed the images on a mirror, limiting the number of viewers; later devices used a TV camera instead to project the images onto a CRT (TV) monitor (fig. 4).

Fig. 3. Image Intensifier. X-rays or faint light strikes the input phosphor, producing electrons that are multiplied by the photocathode, and then accelerated and focused on the output phosphor, which converts the electrons back into visible light.

Fig. 4. Modern fluoroscopy system showing the placement of the image intensifier.

Today, fluoroscopic examinations are performed in a room in which the lighting is only slightly dimmed.

Image intensifiers not only permit the images to be seen without the necessity to “dark-adapt” one’s eyes, but also allows significantly lower levels of radiation to be used to obtain those images. The digital images are stored on the Radiology and Hospital Information Systems for display throughout the institution.

Image intensification was one of the truly transformative developments in diagnostic radiology, ranking alongside of CT and MRI, for how they changed our way of diagnosing diseases.

Continued on Page 14

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Editorial From Page 13

References: 1. Daffner, RH: Roentgen and the discovery that changed medicine.

ACMS Bulletin, Nov 2020, pp 331 – 334.

2. American College of Radiology Photographic Archive. Reston, VA. 3. Kevles, BH: Naked to the Bone: Medical Imaging in the Twentieth Century. New Brunswick, NJ, Rutgers University Press, 1997.

Join the Media Contact List here We are fortunate to have over 2,000 local physicians, residents, and students as part of the ACMS membership.

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4. Daffner, RH: Finding my niche: Diagnostic radiology. ACMS Bulletin, Mar 2020, pp 78 – 80.

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 and is an amateur historian.

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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.

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www.acms.org

OPEN LETTER TO THE EDITOR Bruce Wilder MD, JD, MPH

After reading Dr. Lamb’s Perspective article “In the Battle,” I read the cited 2020 article by Ashley Andreou, “Unpacking Toxic Masculinity in the Medical Field,”1 that is referred to several times, and then had to go back and reread his article to see if there was anything I had missed.

Ms. Andreou is concerned about physician “burnout,” its causes, and its impact on quality of care and on the quality of life of physicians, and properly brings her perspective to the table. The significance of burnout among physicians (not to forget about nurses and other health care workers), including evidence-based study of its causes and efforts toward prevention, has only relatively recently gained the attention of organized medicine,2 and its science is still evolving.3 1 Ashley Andreou, Unpacking Toxic masculinity in the Medical Field, Women's Media Center, 10/23/20, https://womensmediacenter.com/fbomb/unpacking-toxic-masculinity-in-the-medical-field 2 Measuring and addressing physician burnout, 10/20/22, https://www.ama-assn.org/practice-management/physicianhealth/measuring-and-addressing-physician-burnout 3 Elizabeth Harry, MD, et al, Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey, The Joint Commission Journal of Quality and Patient Safety, 2021;47(2): 2/1/2021, available at https://www.jointcommissionjournal.com/article/S1553-7250(20)30246-4/fulltext (published 10/4/20, d.o.i. https://doi.org/10.1016/j.jcjq.2020.09.011

ACMS Bulletin / February 2023

Allegheny County Medical Society

Bulletin 15

Perspective

Battling Entrenched Attitudes About the Value of Racism in Medical Education: Perspectives from Third-Year Medical Students Zainab Balogun, Jeyani Narayan, Allie Heymann, Anna Li University of Pittsburgh School of Medicine In 1966, Martin Luther King Jr. stated, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Minority populations, particularly Black Americans and indigenous populations, have long carried a larger disease burden compared to non-minority populations, as measured by both quality of life and life expectancy1.

Medical biases intentionally introduced into health care to uphold systems of oppression hundreds of years ago have persisted and continue to contribute to injustices in health care. These include false beliefs such as the idea that Black people have thicker skin and thus higher pain tolerance, a belief which currently leads to Black people being prescribed less pain medication in the emergency room2. While it is well known that we have a problem, finding ways to measure and systemically eliminate racial bias in medicine has remained a challenge.

It begs the question: where does this bias originate? A 2016 study from the University of Virginia showed that students carry racial biases as they enter medical school, and these biases are present throughout the first two didactic years2. While bias has been demonstrated to improve over the four years of medical education, especially after clinical rotations, even resident doctors continue to believe and perpetuate falsehoods about race in medical care3. In that vein, we want to understand what factors endure in our

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educational system to allow racial bias to persist despite acknowledging that the problem exists.

Understanding the various sources of bias and the factors that perpetuate them in medical education is vital to targeting solutions to eliminate it. We have all been raised in a world built with racist systems that have shaped our core beliefs. It is therefore inevitable that these beliefs are held by students as they enter medical school. Prior to our own medical training, we had often heard in the news that certain diseases, such as cardiovascular disease, are more prevalent in Black people. There was, however, no discussion about how racism underlies the lack of access to care, environmental exposures, and socioeconomic inequality that predispose these populations to those diseases, leaving us to think that the underlying cause was instead a fundamental genetic difference. Medical education continues to facilitate racial biases even as it introduces curriculum discussing these complexities. Despite coursework focused on racism, the fundamental framework taught by medical schools for developing differential diagnoses is biased in the way it considers a patient’s race. When studying for board exams, for example, pattern recognition becomes an essential skill, and we are taught to automatically associate certain diagnoses with particular races. In a clinical vignette that presents a patient with Tay-Sachs

disease, we are implicitly programmed to identify an Ashkenazi Jewish patient.

While the genetic mutation that causes the disease is more common in this population, we fail to understand the nuances in the factors that contribute to this commonality and the fact that Tay-Sachs can also be found in FrenchCanadians and Cajun populations4.

Similarly, we are taught that when a vignette presents us with an immigrant, we can assume they are unvaccinated.

This particular association encourages the racist belief that health care and other services in the US are superior to those in other countries and that immigrants have poor health literacy and health care decision-making capacity.

Eliciting a medical history, including vaccination status, should involve seeking an unbiased understanding of each patient’s literacy and health care needs. Race is often used in medicine as a proxy for these other factors. While simple heuristics can help win students points in a timely fashion during an examination, they become hardwired into our brains as physicians. Ultimately these heuristics prevent us from producing a broad differential, leading to inaccurate or incomplete diagnoses made from premature conclusions. Coming off the first step of the medical board examination and transitioning into a clinical environment as third year medical students, we have to unlearn these simple mental maps to remove a patient’s

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Perspective race from the equation. Frustratingly, we are forced to maintain them for the standardized SHELF examinations that are licensed by the National Board of Medical Examiners (NBME) at the end of every clinical specialty rotation. By retraining medical students to take into account the direct factors influencing medical conditions rather than operating on heuristics, clinical outcomes will be improved.

There is an abundance of retroactive studies looking at the impact of racial bias, and they state that it is up to medical schools to take proactive steps to educate their students about the injustices of the past while equipping them to promote equitable practices in the future5. Our institution has taken strides to address historical racial and socioeconomic injustices and has been integrating solutions across the curriculum.

One example is a Racism in Medicine (RIM) course that we took in the spring of second year. This course discusses several ways in which structural racism bleeds into medical education and hospital care, and how it ultimately plays a role in poor health care delivery and clinical outcomes. Yet student discourse about the class was unsettling and accentuated issues with racism education in the medical school curriculum. Some individuals questioned the necessity of the course and thought that it was sufficient to simply be kind to all patients.

This kind of sentiment highlights the need for introducing a curriculum discussing racism significantly earlier than the end of second year. In addition, discussions of racism should not be compartmentalized and should be implemented in all clinical vignettes from Cardiology to Immunology.

This is what would best prepare us to ACMS Bulletin / February 2023

provide holistic care with consideration of social and environmental factors while crafting diagnoses and treatment plans.

Another sentiment that emerged from post-RIM discourse was that the course was badly timed because it was taught during medical board examination preparation. This further emphasizes the point that having discussions about racism incorporated into all coursework in medical school prevents it from being deemed less important than other subjects or somehow in conflict with study priorities. Finally, some felt there should be an actionable component to the course that facilitates immersion into the community to fully understand the experiences of our patients instead of limiting education to discourse. Overall, points raised by our class demonstrate that the discussion of racism in medicine has significant room for improvement.

It is up to the medical institution to optimize the efficacy of the racism curriculum to best challenge and eliminate the implicit biases that students with diverse backgrounds may possess.

Ideally, medical schools would start the first year with a medical racism course to illustrate errors perpetrated by the medical system in the past. This first-year course should also create an avenue to dispel any myths about minority health that have been perpetuated throughout the health care system. For example, it isn’t enough to dispel the notion that Black skin is thicker than other skin tones6. There needs to be deliberate education on why that is not the case using peer-reviewed evidence. It is also important to impress upon students the importance of considering how decisions made in developing scientific methodologies can disadvantage certain populations. For example, the MDRD

equation was developed by including race data in the model used to calculate eGFR. The equation reports a higher eGFR (by a factor of 1.210) if a patient is identified as Black. This type of calculation can result in a misguided clinical interpretation of a patient’s kidney function and may result in delayed referral to specialist care or listing for kidney transplantation3. While there are active calls to remove this algorithm from clinical decision making, this equation is still universally taught across medical schools. Students need to understand why algorithms like this have limitations and are inequitable.

Medical education must also demonstrate the difference between racial bias, which is based on falsehoods and prejudice and racial awareness, which is based on reliable scientific data. The goal should not be to provide everyone with the same medical care, but rather with the same quality of care. This requires tailoring medicine to the individual. The loose correlations between race, ancestry, socioeconomic factors, and other social determinants of health have led to doctors using race as a proxy, which at best is inaccurate and at worst leads to dangerous biases and suboptimal care. Racial bias and racial awareness can be easily confused, and doctors should take care to make sure their treatment of patients is based on authentic scientific research and not prejudice. These are just a few ways to encourage medical students to reflect on their implicit biases early in training.

Thus, every student starts medical school cognizant of their biased beliefs and motivated to actively challenge them.

Continued on Page 18

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Perspective From Page 17

And like any other disease, the disease of racism in medicine should be tested and measured in board examination questions to understand progress and measure competency.

Medical injustice to minority patients cannot be swept under the rug. Historical grievances and mistrust among minority populations have often been blamed for continued disparities in the quality of and access to health care, while in reality the health care system is solely responsible for these disparities. We must take steps beyond apologizing to ensure that every patient has access to equitable care without receiving a poor outcome due to their skin color. Medical schools bear a crucial part of this responsibility. As such, they must teach racial competency in a way that is appropriately nuanced and overturns long-held biases. In addition, they must measure the success of these interventions over time. The mark of a truly enlightened medical school will be graduates that are racially aware physicians and practitioners of equitable medicine.

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REFERENCES: 1. S ingh GK, Daus GP, Allender M, Ramey CT, Martin EK, Perry C, Reyes AAL, Vedamuthu IP. Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 19352016. Int J MCH AIDS. 2017;6(2):139164. doi: 10.21106/ijma.236. PMID: 29367890; PMCID: PMC5777389.

2. H offman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301. doi: 10.1073/pnas.1516047113. Epub 2016 Apr 4. PMID: 27044069; PMCID: PMC4843483.

3. V yas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020 Aug 27;383(9):874-882. doi: 10.1056/ NEJMms2004740. Epub 2020 Jun 17.

PMID: 32853499.

4. Preston, D. and Shapiro, B., 2022.

ClinicalKey. [online] Clinicalkey. com. Available at: <https://www. clinicalkey.com/#!/content/book/3s2.0-B9780323661805000316> [Accessed 17 September 2022].

5. Weiner, S. (2021, May 25). AAMC News. Medical schools overhaul curricula to fight inequities. Retrieved from https://www.aamc.org/newsinsights/medical-schools-overhaulcurricula-fight-inequities 6. Voegeli R, Rawlings AV, Summers B. Facial skin pigmentation is not related to stratum corneum cohesion, basal transepidermal water loss, barrier integrity and barrier repair. Int J Cosmet Sci. 2015 Apr;37(2):241-52. doi: 10.1111/ics.12189. Epub 2015 Jan 21. PMID: 25482263.

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.

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Volunteers Needed for ACMS/ACBA Advance Healthcare Directive Event The Allegheny County Medical Society (ACMS) and the Allegheny County Bar Association (ACBA) are holding a “Life Planning Fair” on March 31st. It is a first-of-its kind experience, where physicians, attorneys, medical students, and law students will come together to serve members of the local community in completing Advance Healthcare Directives and living wills. According to Dr. Todd Hertzberg, current Speaker of the Pennsylvania Medical Society and long-time ACMS member, “The Life Planning Fair is an incredible opportunity for physicians, attorneys and students to come together to learn, grow and engage one another, all while serving our community members, who otherwise would not be afforded these services.”

Many people do not understand advance The Life Planning event is completely free directives. Barriers to the completion of an to all participants and will be held on March advance directive form include: time con31st from 10 AM until 2 PM at the Kauffman MARCH 31, 2023 straints, education, culture, mis-information, Center. The event is particularly 10AM - 2PM seeking to and discomfort discussing end-of-life concerns. assist Hill District community members.

Recently, the ACMS and the ACBA collaboFood will be available for all participants and HAVE YOU EVER ASKED: rated to modernize the decades-old Advance volunteers.

Volunteers will also have access If I can’t make health decisions for myself who will?

Directives form, which was no longer compliant to brief training, as needed.

Will I need a guardian? with current PA statutes. Dr. Hertzberg and the What if I put my children on my deed? workgroup set 3 goals during the development How can I be sure my money and property end up with the right people process: 1) ensure that the form could beWho will pay my bills if I cannot?

What is a living will? completed without needing to hire a profesDo I need a power of attorney? sional 2) permit straightforward and easy designations for organ and tissue donations and 3) allow flexibility in fullness of completion, matched to the level of comfort of the individual ALLEGHENY COUNTY MEDICAL SOCIETY & (for example, the user could simply choose to ALLEGHENY COUNTY BAR ASSOCIATION only designate a healthcare agent, but has the option of also completing a living will and/or designating organ/tissue donations).

LIFE PLANNING FAIR

IF SO, PLEASE JOIN:

ACH Clear Pathways Kaufmann Center 1825 Centre Ave Pittsburgh PA 15219 STREET PARKING AVAILABLE

REGISTER NOW

The ACMS is looking for physician volunteers for the Life Planning Fair.

WALK-INS ALSO WELCOME

Please contact mmayer@acms.org for more details. Law students and medical students are encouraged to volunteer, as well.

ACMS Bulletin / February 2023

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ACMS Foundation | 850 Ridge Avenue | Pittsburgh, PA 15212

Featured Grant Recipient Beverly’s Birthdays | Beverly’s Babies At Beverly’s Birthdays there is one simple goal: to celebrate children and families. Every child, regardless of personal, or financial circumstances deserves to be celebrated. Beverly’s Birthdays provides birthday cheer for children experiencing homelessness and families in-need. Beverly's Babies division provides critical baby care items and life sustaining resources for expecting parents and new babies. From the “birth” to the 18th birthday, and special milestones in-between, Beverly’s Birthdays/Beverly’s Babies spread cheer 365 days a year!

The origins of Beverly’s Birthdays is one worth reading: In 2011, Beverly’s Birthdays founder, Megs Yunn, met a young girl named, Beverly, at a local afterschool program.

Megs was helping her with her reading homework and Beverly had to use the word accustomed to in a sentence.

Not knowing the meaning of the word, Ms. Megs asked, “Beverly, at birthday parties, people are accustomed to eating what?” Beverly responded that she had never had a birthday party of her own or even a slice of her own birthday cake. Inspired by this interaction, Megs decided to start the nonprofit, Beverly’s Birthdays, to provide meaningful birthday celebrations for children experiencing homelessness and families in need. Since 2012, the organization has supported thousands of birthdays, and expanded its mission to celebrate the “birth”day through a variety of baby and parent support initiative including, The Greater Pittsburgh Infant Formula Bank.

In addition to being a multi-year recipient of grant money from the ACMS Foundation, Beverly’s Birthdays also received a Baby Formula donation through the ACMS Foundation’s formula donation efforts in May, 2022. The Greater Pittsburgh Infant Formula Bank opened in June 2, 2022. It helped to support 479 unique babies and 942 total services. Over 130,000 ounces of formula were distributed, and $65,000 in formula product that was provided to the various formula banks has been available to the community.

To Learn More about Beverly’s Birthdays: Beverlysbirthdays.org 20

Donate to the ACMS Foundation to help support annual grant giving.

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To learn more about the ACMS Foundation visit: acms.org/acmsfoundation

ACMS Foundation | 850 Ridge Avenue | Pittsburgh, PA 15212

MISSION

Founded in 1960, the Allegheny County Medical Society Foundation has extended the reach of physicians into the community through grant giving to local organizations.

The mission of the Foundation is: Advancing Wellness by confronting Social Determinants and Health Disparities.

This mission works to fulfill an overall vision of a healthy and safe Allegheny County.

Throughout the ups and downs of the past few years, the Foundation’s work has become even more important in supporting local non-profit organizations.

The desire to give back to the community is an inherent trait of those who become physicians. In past year’s the ACMS has hosted an annual gala to help raise funds to support the Foundation. Due to COVID-19, just like many other organizations, the ACMS had to forego the inperson gathering. While we look forward to hosting a Foundation fundraising event in the near future, the work of the Foundation continues on. Please consider how you can personally help support the Foundation and, in turn, continue to support a healthy region.

Contact the ACMS team to learn more about how your organization can help support the ACMS Foundation.

ACMS Bulletin / January 2023

As physicians, you know that it takes a village to keep the community healthy and safe. Please consider a donation to the Allegheny County Medical Society Foundation.

Your donation will help the Foundation fund local non-profits in future grant cycles, and will help further the mission of the ACMS Foundation.

Donations can be mailed to: ACMS Foundation 850 Ridge Avenue Pittsburgh, PA 15212

Scan this QR Code to Donate via Qgiv:

The Allegheny County Medical Society Foundation is a 501(c)3 nonprofit organization with tax ID number 25-6064355. Contributions to the Allegheny County Medical Society Foundation may be fully deductible to the extent allowed by law.

To learn more about the ACMS Foundation visit: acms.org/acmsfoundation

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Society News

2023 POS Membership Renewal is Now Due!

POS Members Gather January 12 to Welcome Peter MacIntosh, MD

Several e-Invoices have been sent to members. Contact Nadine Popovich, administrator, to confirm the status of your membership or to receive an invoice. Membership dues support the society’s educational programs throughout the year.

Ms. Popovich may be reached by email: npopovich@acms.org or by phone: 412.321.5030 x110. 2023 membership dues must be in good standing for a physician to register under the “member” fee for the 58th Annual meeting, scheduled for March 10, 2023.

l to r: J. Peterson, MD (Resident Presenter), I. Ingle, MD; C. Kocasarac, MD, P. MacIntosh, MD (Guest Speaker); G. Bonhomme, MD; and M. Stafford, MD (POS President) An enthusiastic crowd attended the first meeting of 2023 and welcomed Peter MacIntosh, MD, Associate Professor, Director Ophthalmology Residency Program; Director Neuro-Ophthalmology Service & Fellowship; Director Global Ophthalmology Fellowship; Illinois Eye and Ear Infirmary UIC Department of Ophthalmology and Visual Sciences, Chicago, IL. Thank you to Can Kocasarac, MD for inviting Dr. MacIntosh and to Regeneron for sponsoring the program.

Jonathan Peterson, MD, Resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary by Dr. MacIntosh.

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Society News POS Monthly Meeting Series Joshua Teichman, MD, MPH, FRCSC—Featured Speaker for the February 9th Meeting February 9th Meeting: Pictured in the photo to your left: l to r: M. Stafford, MD (POS President); J. Teichman, MD, MPH, FRCSC (Guest Presenter); and Deepinder Dhaliwal, MD.

POS members gathered for the final meeting of the 2022-2023 monthly meeting series and welcomed Joshua Teichman, MD, MPH, FRCSC, Co-Director, Cornea, External Disease and Refractive Surgery Fellowship Assistant Professor, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON. Dr. Teichman delivered two interesting and well received presentations: Cataract surgery in challenging situations and Topography and tomography for the comprehensive ophthalmologist. Thank you to Deepinder Dhaliwal, MD for inviting Dr. Teichman and to Zeiss for sponsoring the program.

Bushra Usmani, MD, Resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary

by Dr. Teichman.

A reminder: POS members are invited to attend the 58th Annual meeting, scheduled for March 10, 2023 at the Omni William Penn Hotel, Pittsburgh, PA. Registration begins at 7:00 am with the first lecture at 7:35 am.

The POS is pleased to welcome Leon W. Herndon, Jr., MD, as the 42nd annual Harvey E. Thorpe Lecturer. Dr. Herndon is a Professor of Ophthalmology, Duke University Medical Center, Durham, North Carolina. Participating distinguished guest faculty include: Philip Custer, MD, FACS; Tom Oetting, MS, MD; Michele Pineda, MBA; and distinguished local guest faculty presenter José Alain-Sahel, MD. Registrants are also encourage to attend the Annual Banquet, scheduled for Thursday, March 9th at the Hotel Monaco, beginning at 6:00 pm.

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egistration and details for both the annual meeting and banquet can be found on the POS 58th Annual Meeting R website. www.pghoph.org/58thAnnual. The deadline to register is March 4. Nadine Popovich, administrator, is available to answer questions and can be reached at npopovich@acms.org or to 412.321.5030 x110.

ACMS Bulletin / February 2023

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APRIL 27TH, 2023 PLEASE JOIN US AS WE HONOR SOME OF OUR DISTINGUISHED MEMBERS AND CELEBRATE THE ACMS FOUNDATION!

TICKETS - $100.00 DINNER STATIONS & OPEN BAR ACCESS TO SPORTS EXHIBIT VALET PARKING

6:00PM-9:00PM *Business Attire* SENATOR JOHN HEINZ HISTORY CENTER 1212 SMALLMAN ST. PITTSBURGH, PA 15222

REGISTER Interested in sponsoring this event?

Contact etaylor@acms.org 24

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ACMS News

ACMS Announces 2023 “ACMS Honors” Fundraising Event By: Sara Hussey, MBA, CAE—ACMS Executive Director

Thursday, April 27, 2023 | 6:00 PM—9:00 PM Heinz History Center, Pittsburgh, PA On behalf of the Allegheny County Medical Society and ACMS Foundation, I cordially invite our members and community partners to the ACMS signature social event of the year! After a three-year in-person hiatus, the event previously known as the ACMS Foundation Gala, is making a return.

But, just like everything else over the last three years, the event has gone through a bit of a transformation.

This year we will host the “ACMS Honors” event. This event, while a little less formal than the ACMS Foundation Gala (no evening gowns or tuxedos required), will provide the same opportunity for connection (and reconnection) with colleagues, a chance to celebrate all our physicians, and most importantly, an evening of fundraising and awareness of the ACMS Foundation.

While you will not see all the traditional ACMS Awards being acknowledged this

year, we will be honoring many of our distinguished members who received prestigious recognition from PAMED in 2022 & 2023. We also look forward to highlighting several of the community partners who have been recipients of ACMS Foundation Grants.

As a bonus, ACMS has been working with the Heinz History Center to move many of the historical artifacts from our office basement in the Babb Building to the library at the Heinz History Center for safer keeping and preservation. At the April 27 event, guests can view the artifacts on display. Curious to know what was in the ACMS Bulletin in the early 1900’s?

We have you covered -- with over 100 years of bound Bulletins! You will also find hundreds of pictures of famous Allegheny County physicians and handwritten meeting minutes for the earliest days of the Allegheny County Medical Society.

This event is truly a celebration of the profession’s future while also honoring the rich and historical past.

Images of the new ACMS Building on the Northside – circa 1980s

We hope you will join us for this celebration. Tickets start at $100 and include dinner stations, open bar, valet parking, and access to the Heinz History Center Sports Exhibit. We are also offering a Circle of Friends ticket package for $500.

This includes: two tickets to the event and acknowledgement in the program and on the ACMS website. A portion of the ticket package is tax-deductible.

We are grateful to our sponsors as sponsorship is integral to the final donation to the Foundation. A full sponsorship package for community partners and healthcare organizations who wish to sponsor this event is available, with proceeds from the event going to the ACMS Foundation.

To register: visit www.acms.org/ acmshonors2023.

For information on sponsorship opportunities, please email Eileen Taylor at etaylor@acms.org.

Annual ACMS Banquet May 2, 1938

ACMS Bulletin / February 2023

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ACMS News

ACMS Hosts Leadership Social for Elected Delegates and Board Members On Thursday, January 26th, the Allegheny County Medical Society officially kicked off our 2023 year with our Leadership Social at Cioppino Restaurant. Over 30 of the ACMS Board Members and Elected House of Delegates members got together to discuss goals and plans for 2023. And of course, there was good food, some cocktails, and networking. Cheers to an amazing year ahead.

Alexandra Johnston, DO, Donald Bourne, Anuradha Anand, MD

Sara Hussey, Matt Straka, MD, Douglas Clough, MD, William Coppula, MD

Amber Elway, DO, Douglas Clough, MD

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ACMS News

The Allegheny County Medical Society is pleased to welcome Elizabeth ‘Liz’ Yurkovich to our team as of January 3, 2023. Liz joins ACMS as our part-time controller. In this role, Liz will manage the finance and billing activities for ACMS, ACMS Foundation, and the multiple specialty associations that ACMS manages. Liz will handle bookkeeping, accounts payable, accounts receivable, tax deposits, liaising with the accountants to coordinate annual audits, and preparing monthly/quarterly/yearly reports. Liz will ensure the delivery of effective, efficient, and cost-efficient coordination of financial services required to meet the organization’s goals.

Prior to joining the team at ACMS, Liz worked in public accounting.

She performed audits, prepared tax returns and researched tax questions for nonprofit and for-profit entities.

Liz is a graduate of University of Pittsburgh with a Bachelor of Arts in Business and a Juris Doctorate.

When not at work, Liz enjoys spending time with her husband, her three children and her dog. In her free time, she likes gardening, baking, and volunteering at her kids’ schools.

Liz can be reached at eyurkovich@acms.org or 412-321-5030 x108.

ACMS Bulletin / February 2023

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Materia Medica

Daridorexant (Quviviq™) Elisabeth Marker, PharmD and Lauren Sittard, PharmD, BCPS Background: Daridorexant is an orexin receptor antagonist approved by the FDA for use in adults with insomnia characterized with sleep onset and sleep maintenance difficulties. The orexin neuropeptide pathway plays a role in wakefulness. By antagonizing the OX1R and OX2R receptors, daridorexant disrupts this pathway and promotes sleep.

Safety: Daridorexant is contraindicated in patients with narcolepsy, as narcolepsy is associated with a loss of orexin neuron function.1 It is not recommended in patients with severe hepatic impairment.

Daridorexant is a CYP3A4 substrate, so strong inhibitors or liver failure may prolong its action and increase these effects.2 Of note, the first orexin receptor antagonist on the market, suvorexant, shows more daytime somnolence at 20 mg (5.1 percent) than either available dose of daridorexant.3 A 2020 randomized controlled trial found no evidence of withdrawal symptoms after treatment cessation.4 Compared to zolpidem, daridorexant showed significantly less cognitive impairment at all doses, and compared to suvorexant only doses exceeding FDA-approved doses produced more cognitive impairment. A dosedependent relationship was also seen in drug-liking effects for daridorexant, reflecting potential for abuse, though even at supratherapeutic doses this effect was lower compared to supratherapeutic doses of suvorexant and zolpidem.5 However, these studies did not enroll adults older than 65.

Tolerability: In a phase 3 clinical trial comparing daridorexant 25 mg and 50 mg to placebo, the most commonly reported

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adverse effects were nasopharyngitis (7 percent), headache (6 percent), fatigue (4 percent) and dizziness (2 percent).

Accidental overdose was reported in 3 percent of participants in the daridorexant 50 mg arm.6 Next-day somnolence has been reported at therapeutic doses, up to several days after discontinuing daridorexant, reportedly occurring in 4 percent of participants treated with 25 mg and only 2 percent of participants in the 50 mg arm. The rate of adverse effects was similar in adults older than 65 as in those younger than 65.6 Concomitant administration with other CNS depressants may increase this risk. Sleep paralysis, hypnagogic or hypnopompic hallucinations, and other complex sleep behaviors such as sleepwalking or sleep-driving have also been reported with daridorexant (<1 percent).2 A meta-analysis comparing several pharmacotherapies for insomnia showed slightly higher incidence of all reported adverse events in daridorexant (46 percent) compared to doxepin (40 percent) and melatonin (42 percent).7 Efficacy: The primary endpoints in the Phase 3 clinical trial were the change from baseline in Wakefulness After Sleep Onset (WASO) and Latency to Persistent Sleep (LPS) measured in minutes at months 1 and 3. This was assessed by polysomnography in a sleep laboratory.

Daridorexant showed a dose-dependent effect on both scores: at month 1 the 25 mg dose showed least squares mean of 18 minute reduction in WASO, and the 50 mg dose showed a 29 minute reduction compared to 6 minutes for placebo. After 3 months this effect persisted, with 25 mg maintaining 12 minutes less wakefulness

than placebo [95 percent CI: -17, -6] and 18 minutes for the 50 mg dose [95percent CI: -24, -13]. Latency to Persistent Sleep also improved by 8 minutes over placebo [95percent CI: -13, -4] for 25 mg and 11 minutes over placebo [95percent CI: -16, -7] for 50 mg after 1 month. This effect is also durable at 3 months: 25 mg dose maintaining a 7.6-minute reduction over placebo [95percent CI: -12, -3] and 50 mg showing 11.7 minute reduction over placebo [95percent CI: -16, -7]. Of note, participants were only permitted to continue Cognitive Behavioral Therapy (CBT) for any indication provided they had started CBT more than one month before the study period began and agreed to continue throughout the entire course of the study. This is considered first-line therapy but is often inaccessible or undesired by patients.6 Price: Currently there are no generic equivalents to Quviviq available in the U.S. The estimated retail cash price for a 30-day supply (30 tablets) is $560. There is currently a manufacturer coupon to reduce copays, but the benefit varies by insurance plan and is not available for Medicare or Medicaid beneficiaries.8 Simplicity: Daridorexant is available as brand name Quviviq in 25 mg and 50 mg oral tablets. It is dosed once daily within 30 minutes of bedtime and should only be taken when more than 7 hours remain before planned awakening.

Bottom Line: Daridorexant is an effective treatment for insomnia, showing a similar effect to suvorexant on WASO and LPS scores. Based on available data, its safety profile is more favorable compared to suvorexant or other hypnotics. The lack of

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Materia Medica withdrawal effects makes it an attractive alternative to benzodiazepines or zolpidem.

However, the cost may be too prohibitive for most patients. Non-pharmacologic therapies such as sleep hygiene and CBT should remain first-line therapy as per the American Academy of Sleep Medicine guidelines.9 At the time of authorship Elisabeth Marker, PharmD is a PGY-1 Pharmacy Resident at UPMC St. Margaret and can be reached at markerer@upmc.edu. Lauren Sittard, PharmD, BCPS is a PGY-2 Geriatric Pharmacy Resident at UPMC St. Margaret and can be reached at sittardl@upmc.edu.

Heather Sakely, PharmD, BCPS, BCGP provided editing and mentoring for this article and can be reached at sakelyh@ upmc.edu.

References: 1. Markham A. Daridorexant: First Approval [published correction appears in Drugs. 2022 May;82(7):841]. Drugs.

2022;82(5):601-607. doi:10.1007/ s40265-022-01699-y

ACMS Bulletin / February 2023

2. QUVIVIQ® (daridorexant) tablets, for oral use [prescribing information]. Available at: https://www.idorsia.us/documents/ us/label/Quviviq_PI.pdf. Accessed 24 October 2022.

3. Herring WJ, Connor KM, Ivgy-May N, et al. Suvorexant in Patients With Insomnia: Results From Two 3-Month Randomized Controlled Clinical Trials. Biol Psychiatry.

2016;79(2):136-148. doi:10.1016/j. biopsych.2014.10.003 4. Dauvilliers Y, Zammit G, Fietze I, et al. Daridorexant, a New Dual Orexin Receptor Antagonist to Treat Insomnia Disorder [published correction appears in Ann Neurol. 2020 Sep;88(3):647651]. Ann Neurol. 2020;87(3):347-356. doi:10.1002/ana.25680 5. Ufer M, Kelsh D, Schoedel KA, Dingemanse J. Abuse potential assessment of the new dual orexin receptor antagonist daridorexant in recreational sedative drug users as compared to suvorexant and zolpidem.

Sleep. 2022;45(3):zsab224. doi:10.1093/ sleep/zsab224

6. Mignot E, Mayleben D, Fietze I, et al.

Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials [published correction appears in Lancet Neurol. 2022 Jan 20;:] [published correction appears in Lancet Neurol.

2022 Jun;21(6):e6]. Lancet Neurol.

2022;21(2):125-139. doi:10.1016/S14744422(21)00436-1 7. De Crescenzo F, D’Alò GL, Ostinelli EG, et al. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis.

Lancet. 2022;400(10347):170-184. doi:10.1016/S0140-6736(22)00878-9 8. Quviviq prices, Coupons & Savings Tips. GoodRx. https://www.goodrx.com/ quviviq. Accessed October 29, 2022.

9. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. Published 2017 Feb 15. doi:10.5664/jcsm.6470

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Office: (412) 521-5500 Cell Phone: (412)370-3711

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LIFE PLANNING FAIR MARCH 31, 2023 10AM - 2PM

HAVE YOU EVER ASKED: If I can’t make health decisions for myself who will?

Will I need a guardian?

What if I put my children on my deed?

How can I be sure my money and property end up with the right people?

Who will pay my bills if I cannot?

What is a living will?

Do I need a power of attorney?

IF SO, PLEASE JOIN: ALLEGHENY COUNTY MEDICAL SOCIETY & ALLEGHENY COUNTY BAR ASSOCIATION

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WALK-INS ALSO WELCOME ACMS Bulletin / February 2023

31

Legal Summary

FTC Proposed Rule to Ban Most NonCompetes—Good for Physician Compensation?

By Beth Anne Jackson

If, like many (if not most) physicians in the Pittsburgh area, your employment contract contains a noncompete clause, the recent publication by the Federal Trade Commission (“FTC”) of a proposed rule may bring welcome news – or not. The proposed rule would prohibit most non-compete clauses as being anti-competitive under Section 5 of the Federal Trade Commission Act. But there is a potential trade-off for physicians: lower compensation.

The proposed rule makes it an “unfair method of competition” for an employer to enter into, attempt to enter into, maintain, or lead a “worker” to believe that they are subject to, a non-compete clause. In addition, employers must rescind existing non-compete clauses within 60 days of the publication of the final rule and provide paper or digital (text or email) notice to workers within 45 days of rescinding the non-compete clause.

The proposed rule contains specific

32

language for such notice that will act as a “safe harbor” for employers.

Interestingly, the term “worker” includes independent contractors. An important carve-out to the rule allows noncompete clauses related to the sale of a business (both stock and asset transactions) as long as the seller is selling all of his or her personal ownership in an entity and, in addition, the seller owns at least a 25% interest in the entity. Also, the proposed rule would not ban non-disclosure or nonsolicitation clauses.

The proposed rule contains a lengthy discussion of the rule and its anticipated effects. The specific effects on physicians is discussed extensively, citing several studies focusing on the relationship between the enforceability of non-competes on physician compensation and health care costs.

However, the FTC, while purporting to improve competition for workers, minimizes the potential negative effects on physician earnings and earnings

growth. For example, the FTC discussed a study published in 2020 that concluded that the use of noncompetes is associated with greater earnings growth for physicians. This study estimated that a physician with a non-compete clause would have 89% earnings growth over ten years, while a physician without one would have 36% earnings growth over the same period. But the FTC gave this “minimal weight” because correlation does not equal causality. It also discounted the correlation because it fails to take into consideration other confounding factors – “e.g., the value of trade secrets or client attraction, productivity gains associated with training, nearness of potential competitors” – and, further, does not factor in the “baseline effect of enforceability.” If such effect is large, it may, the FTC asserted, increase physicians’ compensation.

Enforceability of non-compete clauses can raise concentration in the health care sector which, under antitrust and basic economic principles, increases prices. The FTC estimated that the prohibition of non-competes against physicians would decrease health care spending by $148 billion annually. It acknowledged that the decrease would stem, in part, from a “transfer from physician practices to consumers.” The FTC did not, however, explain how the health care spending decrease could occur without a decrease in physician compensation, www.acms.org

Legal Summary especially in a state like Pennsylvania in which, outside of licensed health care facilities, no person or entity other than physicians can own physician practices due to the corporate practice of medicine prohibition.

While the FTC’s proposed ban on non-compete clauses, if finalized, will have positive effects for many workers, the economic effects on physicians and physician practices could be negative.

Comments to the proposed rule can be submitted until March 20, 2023. So, pick your poison: potentially lower compensation or assured job mobility.

No matter what your position is, make your voice heard.

DISCLAIMER: This article is for information purposes only and does not constitute legal advice. You should contact your attorney to obtain advice with respect to your specific issue or problem.

Ms. Jackson is a shareholder in the Health Care Practice Group of Brown & Fortunato, P.C., which is headquartered in Amarillo, Texas, and serves healthcare providers nationally.

She is licensed in both Pennsylvania and Texas and maintains an office in the greater Pittsburgh area. She may be reached locally at (724) 413-5414 or bjackson@bf-law.com. Her firm’s website is www.bf-law.com.

Check out the Bulletin Media Kit. Did you know members can post ads and more!

2023 Reaching the Most Physicians in Allegheny County THE UNIQUE OPPORTUNITY TO REACH THE NEARLY UNREACHABLE: PHYSICIANS, HEALTHCARE ADMINISTRATORS, A N D P R AC T I C E M A N AG E R S .

ACMS.org 850 Ridge Ave., Pittsburgh, PA 15212 Phone: 412-321-5030 Fax: 412-321-5323 January 1, 2023

Scan QR Code ACMS Bulletin / February 2023

33

The ACMS Welcomes the Allegheny County Immunization Coalition Introduction by: Melanie Mayer, ACMS Marketing and Administrative Assistant Article by Vice President of the ACIC Ashley Ayres MBA, BS, CIC Director, Infection Prevention UPMC Presbyterian Shadyside Infection Prevention and Control The Allegheny County Medical Society provides association management support to several specialty associations. ACMS staff members provide administrative support and resources to these smaller groups who do not require a full-time staff member to support operations.

Recently, the Allegheny County Immunization Coalition (ACIC) signed a contract to receive administrative services from the ACMS. The ACIC is a great resource for many physicians in Allegheny County. We asked Executive Committee member, Ashley Ayers, to share the history of the Immunization Coalition and how ACMS members can get involved in this local organization.

The Allegheny County Immunization Coalition (ACIC) was formed 17 years ago in 2006, after separating from the southwest coalition.

Since then, this group has focused its time and energy on understanding the current needs of immunization, educating individuals on the importance of immunization, and helping provide services to receive immunizations. The focus of this organization is to ensure Allegheny County is informed and protected from preventable diseases. Members of this coalition are physicians, nurses, pharmacists, teachers, and other health service staff.

The ACIC supports ongoing educational efforts to ensure that the public and health care providers are informed on the most up to date information. Since 2006, the ACIC has hosted an annual conference that provides a great educational opportunity to learn from experts in the field about vaccination and the science behind where it is needed. Past conferences have included medical representatives from the CDC, nationally recognized vaccine expert, Dr. Paul Offit, Allegheny County Health Department experts, and well-known local vaccine providers.

We look forward to announcing our 2023 Conference date in the coming weeks (tentative for the beginning of October 2023 at the Doubletree Monroeville).

In addition to the Conference, the ACIC spends time working with the underserved populations in Allegheny County, as well as children in schools, to help improve the vaccination rates. Year after year, the nation has seen a decline in vaccination rates in school age children.

The ACIC helps review the data that the county receives to help align resources where vaccine education is needed, and then coordinate ways to share the education with those communities.

The ACIC has provided so much to many individuals in Allegheny County, but it has also meant a lot to those who are members of the organization. I asked some of the other leaders of the ACIC what this group has meant to them. One of the key takeaways from several of the longtime members, was the value of working with interdisciplinary teams in other professional environments to help figure out the barriers in lack of compliance with vaccination. First and foremost, this has helped the community and increased vaccine awareness, but secondary to that, it has helped our members develop professional relationships with colleagues who they would not normally work. It’s created meaningful connections and better communication amongst those who truly wish to make a change in the way we discuss vaccinations in the county.

Seventeen years seems like a long time, and this group has done so much with that time, however there is much more that can be done to help promote the importance of vaccination. Membership is free and any interested person can become a member by visiting http://www.immunizeallegheny.org/. Together we can prepare the next generation to be safe and protected from preventable diseases.

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www.acms.org

REPORTABLE DISEASES 2022: Q1-Q4

Allegheny County Health Department—Selected Reportable Diseases/Conditions

Selected Reportable Disease/Condition*

2020

January to December** 2021

2022

AMEBIASIS

4

4

3

ANAPLASMOSIS

13

20

33

BABESIOSIS

0

1

2

BOTULISM INFANT

1

1

0

CAMPYLOBACTERIOSIS

96

106

115

CANDIDA AURIS***

0

0

2

CARBAPENEMASE-PRODUCING CARBAPENEM-RESISTANT ENTEROBACTERALES***

7

10

19

54,736

125,140

152,064

CRYPTOSPORIDIOSIS

12

21

31

DENGUE FEVER

0

1

1

GIARDIASIS

51

59

54

GUILLAIN-BARRE SYNDROME

5

5

2

HAEMOPHILUS INFLUENZAE

13

7

12

HEPATITIS A

5

1

1

HEPATITIS B ACUTE

6

0

1

HEPATITIS B CHRONIC

46

61

38

HEPATITIS C PAST/PRESENT

1036

965

833

LEGIONELLOSIS

53

64

42

LISTERIOSIS

3

7

1

MALARIA

0

5

3

MEASLES

0

0

0

MONKEYPOX

0

0

71

MUMPS

1

0

0

NEISSERIA MENINGITIDIS

0

0

1

PERTUSSIS

23

3

2

SALMONELLOSIS

87

102

110

SHIGELLOSIS

11

11

28

SHIGATOXIN-PRODUCING E COLI

17

29

18

STREPTOCOCCAL DISEASE INVASIVE, GROUP A

29

22

34

STREPTOCOCCUS PNEUMONIAE INVASIVE

27

18

44

TOXOPLASMOSIS

0

1

1

TUBERCULOSIS

15

18

15

TYPHOID FEVER

0

1

1

VARICELLA

7

11

10

WEST NILE VIRUS

0

3

1

ZIKA VIRUS

0

0

0

COVID-19

* 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. ***Newly reportable in 2022.

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 outbreaksor diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243.

or more complete surveillance information, see ACHD’s 10-year summary of reportable diseases: https://www.alleghenycounty.us/HealthF Department/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Epidemiology-Reports-and-Resources.aspx.

ACMS Bulletin / January 2023

35

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.

April 25, 2023 August 29, 2023 November 14, 2023

April 11, 2023 July 11, 2023 October 10, 2023

Committees

Finance Committee Tuesday Evenings

Board of Directors* Tuesday Evenings February 21, 2023 May 9, 2023 September 12, 2023 December 5, 2023

Dates to be announced

Delegation April, June, August, October Nominating May, August ACMS Honors April 27, 2023

Heinz History Center

ACMS Foundation March 14—Planning Meeting/Special Grants June 20—Prep for Grant Proposals October 24—Grant Proposal Review PAMED BOARD

PAMED HOUSE OF DELEGATES / HERSHEY

May 4 October 27-28, 2023 August 3 October 26-27, 2024 AMA HOUSE OF DELEGATES

June 10-14 Chicago, IL AMA Interim Meeting November 11-14 National Harbor, MD AMA Annual Meeting June 2024 Chicago, IL ACMS HOLIDAYS – OFFICE CLOSED January 2—New Year’s Day (Monday) September 4—Labor Day (Monday) January 16—Martin Luther King (Monday) November 10—Veteran’s Day (Friday) February 20—President’s Day (Monday) November 23—Thanksgiving Day (Thursday) May 29—Memorial Day (Monday) November 24—Thanksgiving Friday (Friday) June 19—Juneteenth Day (Monday) December 25—Christmas (Monday) July 4—Independence Day (Tuesday)