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Allegheny County Medical Society Bulletin July 2021 Legal update: COVID vaccines Medical history vignette: Ancient Egypt
Online Registration Now Open! Management Professionals in Health Care MPHC Enhance your practice September 22, 2021 8:30 a.m. - 4:15 p.m. Wednesday, September 22, 2021 The Mayernik Center, Pittsburgh, PA Join us at MPHC 2021, Highlights include: a premier educational event • Opening Keynote by Joe Mull, M.Ed., CSP for medical practice • Help Support Desk – an exclusive administrators and their office opportunity to meet with personnel. The full day payor representatives from programs offers a Highmark, UnitedHealthcare and UPMC Health Plan to discuss your practice’s robust engagement pain points. Time slots must be reserved opportunity to discuss and open only to MPHC 2021 attendees. the challenges facing • Legislative and Regulatory Update – presented by the medicine and provides Pennsylvania Medical Society. innovative strategies • Breakout Sessions – to customize your to improve practices! meeting experience. TO REGISTER: https://mphc.wildapricot.org/event-4346853 EVENT AT A GLANCE: https://mphc.wildapricot.org/resources/Documents/Agenda.pdf This program is made possible by the generous support from:
Allegheny County Medical Society Bulletin July 2021 / Vol. 111 No. 7 Opinion Departments Articles Editorial ................................193 Society News .......................201 Materia Medica .....................208 Vigilance • Pittsburgh Ophthalmology Society Relugolix: One new drug, many new Deval (Reshma) Paranjpe, MD, FACS indications Membership Benefits .........202 Alexandra N. Marshall, PharmD Editorial ................................195 Karen M. Fancher, PharmD, BCOP Medical historic vignette: Ancient Egypt Community Notes ................204 Richard H. Daffner, MD, FACR Legal Report ........................212 Activities & Accolades ........206 COVID-19 vaccines: What Can You Editorial ................................198 Ask? What Can You Require? Sartorial choices What Can You Disclose? Anna Evans Phillips, MD, MS William H. Maruca, Esq. Perspective ..........................200 Restricted medical license Jorge Lindenbaum, MD 2021 ACMS Bulletin Please see the Photo Contest 2022 ACMS office • Deadline: nominations Friday, October 1 information and On the cover • Send your photos to: form on page 205. Amalfi Coast bulletin-contest@acms.org Louis A. DiToppa, DO, FAAFP • Look for more For up-to-date Dr. DiToppa specializes in primary care. information via email resources on and in future issues COVID-19, visit: of the Bulletin. www.acms.org/ covid-19-resources
EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS Bulletin #072920. PUBLISHER: Allegheny County Medical Society at above address. Medical Editor The Bulletin of the Allegheny County Deval (Reshma) Paranjpe Medical Society is presented as a (reshma_paranjpe@hotmail.com) report in accordance with ACMS 2021 PAMED DISTRICT TRUSTEE Associate Editors Bylaws, Articles 6, 8, and 11. Executive Committee G. Alan Yeasted Douglas F. Clough The Bulletin of the Allegheny and Board of Directors (dclough@acms.org) County Medical Society welcomes COMMITTEES Richard H. Daffner contributions from readers, physicians, President Awards medical students, members of allied (rdaffner@acms.org) Patricia L. Bononi Mark A. Goodman professions, spouses, etc. Items may Kristen M. Ehrenberger President-elect Bylaws be letters, informal clinical reports, (kehrenberger@acms.org) Peter G. Ellis Matthew B. Straka editorials, or articles. Contributions Anthony L. Kovatch Vice President Finance are received with the understanding (mkovatch@comcast.net) Matthew B. Straka Keith T. Kanel that they are not under simultaneous Joseph C. Paviglianiti Secretary Gala consideration by another publication. (jcpmd@pedstrab.com) David L. Blinn Mark A. Goodman Anna Evans Phillips Issued the third Saturday of each Treasurer Membership (evansac3@upmc.edu) month. Deadline for submission Raymond E. Pontzer Peter G. Ellis Maria J. Sunseri of copy is the SECOND Monday Board Chair Nominating (mjsunseri@msn.com) preceding publication date. Periodical William K. Johnjulio Bruce A. MacLeod postage paid at Pittsburgh, PA. Andrea G. Witlin (agwmfm@gmail.com) Bulletin of the Allegheny County DIRECTORS Medical Society reserves the right to 2021 Managing Editor edit all reader contributions for brevity, Douglas F. Clough Meagan K. Sable clarity and length as well as to reject William F. Coppula (msable@acms.org) any subject material submitted. David J. Deitrick Kevin O. Garrett The opinions expressed in the Marcy L. Jackovic ADMINISTRATIVE STAFF Editorials and other opinion pieces are those of the writer and do not 2022 Chief Executive Officer necessarily reflect the official Ragunath Appasamy Jeremy T. Bonfini policy of the Allegheny County Mark A. Goodman (jbonfini@acms.org) Medical Society, the institution with Keith T. Kanel ACMS ALLIANCE Manager, Medical Community which the author is affiliated, or Maria J. Sunseri Co-Presidents Engagement and Society the opinion of the Editorial Board. G. Alan Yeasted Patty Barnett Governance Advertisements do not imply 2023 Barbara Wible Michelle Besanceney sponsorship by or endorsement of Steven Evans Recording Secretary the ACMS, except where noted. (mbesanceney@acms.org) Bruce A. MacLeod Justina Purpura Amelia A. Paré Director of Publications Publisher reserves the right to exclude Corresponding Secretary any advertisement which in its opinion Maritsa Scoulos-Hanson Meagan K. Sable Doris Delserone does not conform to the standards of Adele L. Towers (msable@acms.org) Treasurer the publication. The acceptance of Director, Medical Community Sandra Da Costa advertising in this publication in no PEER REVIEW BOARD Engagement Assistant Treasurers way constitutes approval or endorse- 2021 Nadine M. Popovich Liz Blume ment of products or services by the Marcela BÖhm-Vélez (npopovich@acms.org) Kate Fitting Allegheny County Medical Society of Thomas P. Campbell any company or its products. 2022 Annual subscriptions: $60 Kimberly A. Hennon www.acms.org Jan W. Madison Advertising rates and information 2023 available by calling (412) 321-5030 or Lauren C. Rossman online at www.acms.org. Angela M. Stupi COPYRIGHT 2021: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address Improving Healthcare through Education, Service, changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, and Physician Well-Being. Pittsburgh, PA 15212. ISSN: 0098-3772
Editorial Vigilance Deval (Reshma) Paranjpe, MD, MBA, FACS W hen I was a child, my summers were spent in a magical land by the sea in the care of my grandmother American eyes. “The mosquitos like you more because American blood is sweeter,” she’d say as she rubbed all the larger birds. Now this was a lovely way to wake up. The milkman rang the doorbell, followed by the softer and uncle. At that time, the city was lemongrass-scented mosquito repellent kerthunk in the mailbox of the daily known as Bombay, and we lived in a on me. flower packet. I always thought the wild flat in a seaside suburb of Old Bombay. It was a quarantine of sorts. city roosters were lazy as they didn’t The sun beat down hard on the stone If I couldn’t sleep in the hot join the fray of calling birds until seven, and concrete buildings from the early afternoons, I would amuse myself but then, they strolled about crowing hours of the morning, and it was far by sitting in the balcony reading randomly all day. At eight o’ clock, the too hot to venture out during most while listening to the rain. If the sun roving neighborhood vendors would of the day. During the monsoon, the was out, I’d scan the large courtyard start calling up to the balconies above, rains poured down relentlessly for below. I had found a 10 cc syringe in hoping to be summoned up. The days on end, pausing briefly now and a cupboard (my grandfather was a fishmonger would make her rounds at then for a day or so of oppressively physician and my uncle the department nine, and the lady who would collect humid but sunny respite before the head of medical biochemistry), and bottles and cans for recycling would faucet reopened. If you’ve never seen used it to perfect my aim. I would announce herself from the pavement the monsoon firsthand, you wouldn’t fill it with tap water and deploy it around 9:30 a.m. know that it stays dark and cool and from three stories above to break up At 10 sharp each day, a wondrous wet every day for weeks on end, fights between cats below who were thing happened. You knew never to with blowing winds that noisily test squabbling over the shade of a Fiat. It be on the telephone at 10, because the shutters and the latches on the also was fun for squirting roosters who you wouldn’t be able to hold a windows. You wouldn’t imagine that were trying to bully chickens. conversation. The neighborhood air you could be cold enough to need a I taught myself to tell time by the raid siren would conduct a test. (It sweater and pile on the blankets. Even sounds I heard. At five o’clock in the always worked.) All human activity the mosquitoes seek refuge indoors. morning, it was crow time. All the crows stopped, because no one could hear So picture me, as a little girl, curled of Bombay would wake simultaneously themselves think over the din of the up under shawls under a palanquin of on the rooftops and raucously caw their siren. I wondered why there was an air mosquito netting with my grandmother, morning greetings to each other. The raid siren at all. Was it a vestige from who kept me entertained with stories soft kerthunk in the mailbox meant the World War II? Or, more likely, from the of her own childhood and our relatives. morning papers had been delivered. India-Pakistan conflicts? Or was it a After lunch, there was naptime, and The cacophony of crow time would drill for an impending nuclear attack? story time, and tea time with Marie give way to the cooing of pigeon time In any case, there were no bomb biscuits and strong Indian tea with hot around six. Six-thirty was my favorite shelters, and to my knowledge there milk and delicious sugar that looked time, because melodious waves of was no evacuation plan no matter the like crushed rock candy to my young sweetly chittering sparrows drove back Continued on Page 194 ACMS Bulletin / July 2021 193
Editorial From Page 193 lower case rates and higher vaccination Few Good Men,” shouting “You can’t threat. The siren was basically a daily rates. Restrictions are easing all over handle the truth!” reminder that you could face attack the country (whether wise or unwise It is such a sweet temptation to and death, and that there was little given local vaccination rates). Much ignore the daily air-raid siren of news you could do about it. (And eight-year- of America is soothing itself with the reports about the rise in Delta variant old me mused that if the enemy were platitude that “the pandemic is over!” spread and to believe the blissful REALLY devious, the attack would just as it soothed itself in the early story that the pandemic is over. The come at 10 a.m., when everyone was days with “it’s just the flu!” or defended Delta variant is sweeping the country, complacently waiting out the air raid defying mask orders with “I’m tired of pockets of unvaccinated people are siren test.) this!” Humans need solace, even when going to be hotspots, not only for All of this was good preparation it means ignoring an inconvenient disease but for further mutations, and for COVID quarantine: the habit of truth. I learned that too in India from unvaccinated children are going to solitude, the need to work and amuse experience. The average citizen there be reservoirs at a minimum as school oneself, the ability to observe and thinks that the best doctor is not the opens. We may be about to witness a appreciate nature, and realizing that one who accurately diagnoses them frightening illustration of Darwinism in disaster could strike at any time without with a serious illness, treats them action as the unvaccinated or under much recourse, and that humans aggressively and thoroughly and keeps protected are exposed to Delta. And become desensitized to daily warnings them informed at every step. No, this then there’s the news that Epsilon of an existential threat, no matter how is a troublesome doctor who causes variant has been reported to evade all strident. them unnecessary stress and worry. In current vaccines. A mutation that adds Time in the last year had a strange their eyes, the finest doctor is the one the increased transmissibility of Delta quality; either it passed too quickly who reassures them that “it’s nothing to the evasive capability of Epsilon or too slowly. Every day was like the serious” and tells them everything will would start the pandemic from square next; besides the weather, only bits be OK, even when the actual diagnosis one again. One must remember that of seasonal holiday décor served to is pancreatic cancer. COVID is a devious enemy which will tie events to months. It drove home Most humans would rather go think nothing of striking during the the point of how much social events blithely to their graves, panicking only air raid siren tests when we are all (birthdays, anniversaries, weddings, in the last few seconds. Few care desensitized and complacent. births, graduations, holiday parties, to have their eyes opened and be Stay vigilant, my friends. travel) anchor us in temporal reality. an active and intelligent participant “Oh yes, that happened two weeks in the fight against illness, danger Dr. Paranjpe is an ophthalmologist ago, right after we came back from the and death. This is perennial human and medical editor of the ACMS trip!” Even now, in this strange time nature, illustrated in the stories of Bulletin. She can be reached at which we hope is the tail-end to the most religions as well as in the Matrix reshma_paranjpe@hotmail.com. pandemic, time passes both too quickly movies. Ignoring the regrettable and too slowly. politicization of the term, humanity has The opinion expressed in this column is that always preferred the “blue pill” in order of the writer and does not necessarily reflect We’ve all learned the skills of the opinion of the Editorial Board, the Bulletin, survival in solitary confinement and are to avoid psychological discomfort and or the Allegheny County Medical Society. finally tasting bits of freedom thanks to pain. There’s also Jack Nicholson in “A ACMS members: We want to hear your opinions on important topics affecting health care. Email Meagan Sable at msable@acms.org to learn more about submitting a Perspective column to the Bulletin. 194 www.acms.org
Editorial Medical historic vignette: Ancient Egypt Richard H. Daffner, MD, FACR T he medical profession traces its roots to before the dawn of recorded history. Throughout the millennia, early medicine was associated with magic and religious practices. Early physicians often were priests of the various deities that early people worshiped. Once recorded history dawned (around 3000 BCE) medicine was already a respected profession. The earliest written medical treatises date to ancient Egypt during the period of the Old Kingdom (3400-2500 BCE). These were contained in hieroglyphic recordings both on papyrus as well as records of surgical operations on the walls in the tombs of the pharaohs, dated by Egyptologists as early as 2500 BCE.1 Herodotus, the “Father of History,” traveled to Egypt and described how medicine was practiced there: “The art of medicine is divided so that each physician treats just one illness and no more. Figure 1. Ancient Egyptian physician/priest treating Doctors are everywhere, as there are specific physicians for a patient with tetanus. Note additional priests in fore- the eyes, the head, the teeth, the abdomen, and still others ground. From: Great Moments in Medicine.1 for illnesses that are invisible.”2 One of the earliest named physicians was Imhotep, who was a multi-talented advisor (chancellor, architect, poet, magician and priest) to Pharaoh Djoser (also spelled and pronounced Zoser). Imhotep is credited with construction of the famous step pyramid of Sakkarah, (the first pyramid) near Memphis, the capitol of Lower Egypt (along the Nile nearest to the Mediterranean Sea). While little else was known about him during his lifetime, in the Greco-Roman period of Egypt’s history (13th Dynasty 380- 343 BCE) Imhotep was represented as a physician and assigned the status of the God of Medicine.1 Figure 1, a painting by Figure 2. Case 33 original hieroglyphs Robert Thom, shows a physician/priest treating a patient with tetanus. Note the two other priests reciting incantations Rosetta (modern day Rashid, just east of Alexandria). The in the foreground.1 stone was carved around 196 BCE with writing in three Fast forward to 1799, when French soldiers serving different languages, hieroglyphic script (Hieratic) on top, in Egypt during the Napoleonic Wars discovered a large Demotic script in the middle and ancient Greek on the fragment of a stele buried in the mud near the port city of Continued on Page 196 ACMS Bulletin / July 2021 195
Editorial From Page 195 bottom. The Rosetta Stone, as it was subsequently called, served as the key to decoding Egyptian hieroglyphs, after a complete translation of the Greek text was published in 1803. It was found that the stone offered three versions of the same text. The Western world first became cognizant of medical skills of the ancient Egyptians with the purchase, in 1862, of a surgical papyrus by Edwin Smith (1822-1906), an Figure 3. Case 33 Breasted’s transliteration (in black) of American collector and dealer in antiquities, from a dealer hieroglyphics in Figure 2 with glosses in red. in Luxor, Egypt. Smith’s limited knowledge of Hieratic was from that ailment. Each diagnosis ends with the words, “An insufficient to allow him to translate the papyrus. This had to ailment which…”, followed by three therapeutic possibilities: wait until after Smith’s death, when James Henry Breasted “An ailment which I shall treat,” “An ailment which I shall (1895-1935), an archaeologist, Egyptologist and historian at contend with,” or, “An ailment which I shall not treat.”1, 3, 6 the University of Chicago translated it in 1930.3 The Edwin Thus, we have classic medical doctrine: history, examination Smith Papyrus, as it was called, is unique among four of the patient, diagnosis, prognosis and treatment. principle medical papyri that survive today, in that it is based Each section is in cursive hieroglyphs, written from on a solid knowledge of anatomy and pathology and shows right-to-left, like modern day Hebrew and Arabic (Figure 2). that the author used a rational and scientific approach. The Breasted provided a transliteration in black ink interspersed other documents are based in magic and religious beliefs. with explanatory comments (glosses) in red ink (Figure 3). Breasted dated the Smith papyrus to approximately So, what did Egyptian physicians know? The ancient 1700 BCE (the pyramid age), but stated that it is a copy of Egyptians were familiar with human (and animal) anatomy a document at least one thousand years older.1,3 It appears from their practice of embalming the deceased (people and to be a manual for military surgeons, since many of the 48 [sacred] animals). Their examinations of patients included surgical dissertations pertain to injuries or diseases that may visual and olfactory clues, palpation and taking of the pulse. be encountered in war. I was first made aware of the Edwin Smith Papyrus How accurate were the descriptions, compared to modern when my mentor and friend Dr. John Gehweiler published medical knowledge? Case 33, (column XI 9-17) (Figures 2, his landmark book, “The Radiology of Vertebral Trauma,” in 3) is illustrative: 1980. The insides of the front and back covers of the book “Title: contain excerpts from the Smith papyrus. In addition, the Instructions concerning a crushed vertebra in his chapters on individual injuries contain excerpts from the neck. papyrus.4 My own interest in vertebral injuries5 led me to Examination: purchase a copy of Breasted’s book. If you examine a man having a crushed vertebra in his The Edwin Smith Papyrus contains 48 cases of injuries, neck and find that one vertebra has fallen into the next fractures and dislocations, wounds, and tumors on the front one, while he (the patient [italics are mine]) … cannot side (recto) of each page, and eight magic spells and five speak; his head falling downward has caused that one prescriptions on the verso (back). The arrangement of the vertebra to crush into the next one (mechanism of injury – entities is systematic, beginning with head wounds and hyperflexion [italics are mine]); and should you find that he is proceeding downward in the rest of the body. Each topic unconscious of his two arms and his two legs (quadriplegia begins with a superscription, giving the name of the illness [italics are mine]) because of it, (conclusion follows in or injury. This is followed by a description beginning with diagnosis). the words, “If you examine a man who…” has the specific Diagnosis: illness or injury. This is followed by the diagnosis, that You should say concerning him: ‘One having a crushed always begins with the words, “You should say” he suffered vertebra in his neck; he is unconscious of his two arms and 196 www.acms.org
Editorial Figure 4. Cervical flexion-dislocation of C6 on C7 from diving into shallow water. A. Sagittal CT reconstruction shows complete displacement of C6, which now lies in front of C7. B. Sagittal MR image shows complete spinal cord transection (arrow) and cord hemorrhage and edema above (arrowhead). The patient is quadriplegic. his two legs and is speechless. An ailment not to be treated.’ as punishment for turning away from God’s commandments Gloss A: As for ‘A crushed vertebra in his neck,’ he is are “all the diseases of Egypt” (“The Lord will strike you speaking of the fact that one vertebra of his neck has fallen with the Egyptian inflammation (the same boils that plagued into the next, one penetrating into the other, there being no the Egyptians), with hemorrhoids, scars, and itch, from movement to and from. which you will never recover. The Lord will strike you with Gloss B: As for ‘His falling head downward has caused madness, blindness, and dismay”). Specific diseases, such that one vertebra to crush into the next,’ it means that as leprosy, also are mentioned. We can only conclude that he has fallen head downward upon his head driving one the ancient Egyptians knew much more about medicine than vertebra of his neck into the next.” they are generally credited with. What the ancient Egyptian physician described here is a classic flexion-dislocation of the cervical spine, frequently Dr. Daffner, associate editor of the ACMS Bulletin, is encountered in a diving accident (Figure 4). a retired radiologist who practiced at Allegheny General Other examples of ancient Egyptian medical knowledge Hospital for more than 30 years. He is emeritus clinical may be found in the Hebrew Bible (Old Testament) where professor of Radiology at Temple University School of various diseases are accurately described. Biblical scholars Medicine and is the author of nine textbooks. He can be argue that Moses, whom the Bible says was raised in reached at bulletin@acms.org. the pharaoh’s household, would have been exposed to the medical practices of the day and these were later The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, incorporated into the holy scriptures. Furthermore, in the Bulletin, or the Allegheny County Medical Society. Deuteronomy 28:27-28, among the curses to be suffered References 4. Gehweiler JA, Jr, Osborne RL, Becker 1. Bender GA, Thom RA. Great RF. The Radiology of Vertebral Trauma. Moments in Medicine. Detroit, Northwood Philadelphia, W B Saunders, 1980. Institute Press, 1966, pp 8 - 12. 5. Daffner RH. Imaging of Vertebral 2. Strassler RB, ed. The Landmark Trauma, 3rd ed. New York, Cambridge Herodotus, the Histories. Book 2, 2-84. New York, Pantheon Books, p 152, 2007. University Press, 2011. 3. Breasted JH. The Edwin Smith Sur- 6. Breasted JH. The Edwin Smith Sur- gical Papyrus. Chicago, The University of Chicago Press. 1930, pp 1 - 29. gical Papyrus. Chicago, The University of Chicago Press. 1930, pp 339 – 342 www.acms.org ACMS Bulletin / July 2021 197
Editorial Sartorial choices Anna Evans Phillips, MD, MS “The dress code is at least business centers, suggested that in the realm for physicians, where does attire casual. Make sure that your earrings of patient satisfaction, physician attire rank? A physician’s ability to complete aren’t too big, and your makeup is not indeed matters.1 More than 50% of their professional responsibilities is of too loud.” These were the instructions patients indicated that this made a clearly greater import than what they I received from a young production difference in their experience of care wear. But attire, just like all contexts of assistant during a mandatory audio- and overall satisfaction. Preferred medical encounters, is a traditional part visual check. I was presenting as an attire in the primary care setting was of the patient experience. expert at a virtual national medical formal attire (collared shirt and slacks For male physicians, iconic conference – and I was taken aback for both men and women, with tie for representations of physician attire by these details. I politely thanked the men); in the emergency department, are available going back through the representative, and proceeded back scrubs; and in the inpatient setting, ages. Norman Rockwell paintings, to my day of patient encounters and formal attire. White coats with these representations of country doctors virtual meetings. options were preferred everywhere visiting sick children, images of surgical Patients and colleagues comment except for with surgeons; there was theaters – almost all contain only to me frequently on my clothing; to my no significant difference for female representations of men. A piece in great relief, it is mostly complimentary. surgeons to wear or not wear a white the Gentleman’s Gazette even offers I take careful note of the fact that coat, whereas male surgeons were helpful tips on obtaining the classic people not only notice my sartorial preferred to wear scrubs alone. The physician wardrobe.3 For women, choices, but feel the need or desire to study was notably limited by the fact there are fewer historical visual comment on them as well. I observe, that all physicians pictured were young, representations. Though television is for example, that my male colleagues slim and Caucasian. making headway in its representation receive far less commentary on their Perhaps just as tellingly, there of female physicians, the true diversity clothing, but not because they dress was acknowledgement of variations of ages, races, shapes and sizes any less notably or professionally than in attire: The female and male present in the female physician I tend to. The recommendation from counterparts are dressed in the same workforce is at best only partially my production colleague before a limited attire. But attire is always represented. virtual presentation to particularly pay gendered; in a separate 2020 study of So, it comes back around to attention to my jewelry and makeup not orthopedic surgeons, it was found that the question: What to wear? Many only irked me because of its specifically female surgeons who wore feminine corporate health care organizations gendered nature, but due to the fact business attire instead of scrubs were maintain general guidelines mostly that it came at all. perceived as significantly less likely to aimed at trainees but inclusive of Does it matter what physicians excel at performing the physical part employees that include ideas of wear? A 2018 BMJ Open Study, of surgery than female surgeons in modesty and appropriateness (avoid: which surveyed more than 4,000 scrubs.2 tight-fitting clothing, bare midriffs, U.S. patients across 10 tertiary care In the grand scheme of priorities low necklines, strapless tops and 198 www.acms.org
Editorial Let us be the key to your future ... miniskirts), and encouragement for appropriate grooming is included. Interestingly, the United Kingdom’s National Health Service additionally offers the caveat that skirts are not to be higher than 5 cm above the knee.4 Advice Specializing from peers on this subject is highly varied in both content in physician and quality. The blog Corporette (a self-described blog practices for “overachieving chicks”) maintains a conversation about appropriate female physician attire, which focuses since 1978 on the experience of several individual physicians and their preferences for casual knits or certain brands of flat shoes.5 The not-incorrect-but-hardly-helpful advice is offered to maintain a neat hairstyle. In short, there is a vacuum of guidance on a subject of great import for the everyday experience of female doctors. The reality is that the female physician workforce is growing constantly – and increasing in relative proportion every year. The choice – or preconceived notion – of what female physicians should wear has not been already circumscribed or dictated by generations of female physicians in front of us. Female physicians – many of us the first in our families – are living a bit of an 412-281-1901 • www.3kcpa.com experiment, trying on clothing every day that speaks to our professionalism and capabilities, but that seeks also References to express some of who we are and how we steered our 1. Petrilli, C. M., Saint, S., Jennings, J. J., Caruso, A., Kuhn, course to this profession. L., Snyder, A., & Chopra, V. (2018). Understanding patient pref- The multitude and competing nature of many societal erence for physician attire: a cross-sectional observational study expectations for professional women makes the choice of of 10 academic medical centres in the USA. BMJ Open, 8(5), e021239. attire particularly difficult. Sartorial choices for all physicians 2. Goldstein, S. D., Klosterman, E. L., Hetzel, S. J., Grogan, convey a tone to patients, other providers and academic B. F., Williams, K. L., Guiao, R., & Spiker, A. M. (2020). The Effect audiences that are important and individual all at once. of an Orthopaedic Surgeon’s Attire on Patient Perceptions of Ability and knowledge remain the core substance of the Surgeon Traits and Identity: A Cross-Sectional Survey. J Am Acad foundation of any physician role. What we wear remains an Orthop Surg Glob Res Rev, 4(8), e20 00097-00011. 3. Schneider, S. R. (2017). Dressing the Doctor: A Physician’s essential signal about who we are, particularly so as women Guide to a Classic Wardrobe. Retrieved June 13, 2021, from continue to establish standards for generations of physicians https://www.gentlemansgazette.com/dressing-the-doctor-clas- yet to come. sic-wardrobe/ 4. National Health Service Foundation Trust Uniform and Dr. Evans Phillips is associate editor of the ACMS Bulletin Dress Code Policy. (2020). Retrieved June 13, 2021, from https:// and assistant professor of Gastroenterology at UPMC; her www.ncic.nhs.uk/policies/navigate/6904/339 5. Griffin, K. Fashion for Doctors. Retrieved June 13, 2021, research is focused on pancreatitis and genetic cancer from https://corporette.com/fashion-for-doctors/ syndromes. She can be reached at evansac3@upmc.edu. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial For advertising information, contact Board, the Bulletin, or the Allegheny County Medical Society. Meagan Sable at msable@acms.org. ACMS Bulletin / July 2021 199
Perspective Perspective Restricted medical license Jorge Lindenbaum, MD F ifteen years ago, I attended a large convention on Health Care Management. After listening to a provide standard care for my patients. Even worse, many of my patients are paying (out of a pocket they can ill In all fairness, the insurance companies are not the only ones who have failed their subscribers. lecture detailing cost savings by afford) for prescriptions and testing Big Pharma, inflated administrative restricting medication prescribing, I necessary for optimal treatment. salaries, government regulations and began a spirited conversation with the If the goal of restricting our medical lack of a collective physician backstop gentleman seated beside me. license is to contain and lower health have all made contributions to the “This won’t be good for patients,” care costs, it is failing miserably. Allow current state of rising health care costs. I quipped. “How can I assure them of me to elaborate. I could go on, but Voltaire said it well, the best treatment available if I can’t 1. There’s been a steady increase “The secret of being a bore is to tell prescribe it?” of emergency room visits. everything.” He responded, “No problem, you 2. Hospitalizations are on the rise. Instead, I prefer to be optimistic. prescribe any medication, order any 3. We are referring to more I am thankful to be a practicing test, do the follow-up … we just won’t specialists. physician in the United States. I’ve pay for it.” 4. Diagnostic delays make illnesses trained at the best institutions and What a perfect combination of more difficult and costly to treat. had many opportunities to advance arrogance and total disregard for 5. There are fewer office visits and my knowledge and skill set. And yes, patients subjected to (in my mind) preventative appointments due to an inconceivable notion of health providers and staff using their valuable I know we face numerous challenges care. As the seminar droned on, I sat time doing prior authorizations and in the health care industry, but as dejectedly in the crowded room of other non-medical paperwork. physicians, we need a much louder physicians who listened attentively, 6. More distractions at visits while voice. We know what is best for our but voiced little feedback to this a provider wastes time sorting through patients ... we always did, we always radical new concept designed to what is/isn’t covered, which varies with do and we always will put the patient’s reduce health care costs. each patient. needs first. Our patients deserve It puzzles me how a “one size 7. Medical errors and malpractice nothing less. fits all” care package benefits any of cases are increasing. us. I’ve spent countless hours trying 8. Additional stress, frustration Dr. Lindenbaum is an internist and to get approval for appropriately and irritation for physicians and staff. hypertension specialist. He can be prescribed medications and testing that (We’re only human!) reached at bulletin@acms.org. were denied arbitrarily by insurance 9. Demoralizing burnout. providers. Too many times I left the 10. Frequent staff turnover: We are The opinion expressed in this column is that office feeling completely drained, losing experienced, compassionate of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, and I must admit, angry, because of providers to early retirement; many or the Allegheny County Medical Society. the unnecessary burden required to are changing careers. 200 www.acms.org
Perspec- Perspective Society News POS 2021-22 Monthly Meeting with a primary clinical interest in optic and glaucoma specialist in 2000 Series schedule announced neuropathy and vasculitis. She sees and was director of the Glaucoma a full range of neuro-ophthalmologic Service and fellowship from 2012–20. Marshall Stafford, MD, newly conditions, but specializes in adult He became medical director of the elected president of the Pittsburgh autoimmune optic neuropathy Cincinnati Eye Institute in 2019. Ophthalmology Society (POS), is syndromes, diplopia, headache and He is a volunteer clinical assistant pleased to announce the 2021-22 POS multiple sclerosis (MS). professor at the University of Cincinnati Monthly Meeting Series. A total of six Her main research interests College of Medicine, Department of meetings are scheduled, beginning in include preventative treatment trials Ophthalmology, and was voted teacher September and concluding with the for autoimmune optic neuropathies of the year by his residents in 2011. He Annual Meeting in March. and neuroprotection. Dr. Lincoff has been selected by his peers to Best All meetings are scheduled presents annually at national and Doctors in America since 2001. for Thursday, except for the Oct. international conferences regarding Dr. Khatana uses the latest cataract 5 meeting, which will be held on MS and the use of ocular coherence surgical technology, including the Tuesday. tomography and imaging specific to use of toric and multifocal intraocular Mark Your Calendar – Monthly her field. She also is involved in the lenses, and specializes in the Meeting Dates will be held: “Hopeful Ways Nicaragua Eye Care management of various complicated Sept. 9 Mission Project,” an annual medical and advanced forms of glaucoma, as Oct. 5 (Tuesday) mission to Nicaragua to prevent well as all the newer minimally invasive Dec. 2 blindness. Working together with glaucoma surgeries. As an investigator Jan. 6, 2022 a group of medical professionals, in various clinical trials, Dr. Khatana Feb. 3, 2022 local interpreters and Peace Corps is able to provide his patients access March 11, 2022 - 57th Annual volunteers, the project provides free to new drugs and technologies at an Meeting and 42nd Ophthalmic vision care to more than 2,600 patients earlier stage. Personnel meetings. The Pittsburgh a year. The POS Marriott City Center will host the During the social portion of the welcomes Edwin concurrent event. program, the POS welcomes exhibitors H. Ryan, MD, Guest faculty who confirmed details who sponsored the 56th Annual Virtual Vitreoretinal Surgery, prior to the print deadline are below. meeting. The Society is grateful for PLLC, associate When available, updated speaker continued support from this select clinical professor, information will be posted on the POS group, especially during last year’s Ophthalmology, Dr. Ryan website at www.pghoph.org. unprecedented time. University We begin the The Oct. 5 meeting of Minnesota Department of series Sept. 9 and features Anup Ophthalmology, Edina, Minn., to welcome guest K. Khatana, MD, speak at the Dec. 2 meeting. Thank speaker Norah medical director, you to Thierry Verstraeten, MD, board S. Lincoff, MD, Cincinnati Eye member, for inviting Dr. Ryan. professor, Department Institute, Cincinnati, Dr. Ryan was awarded his Doctor of of Neurology, Jacobs Ohio. Thank you to Medicine degree from the University of Dr. Lincoff Dr. Khatana Minnesota. He completed a residency School of Medicine Ian Conner, MD, PhD, & Biomedical Sciences, University at POS board member, for inviting Dr. in Ophthalmology at Northwestern Buffalo, Buffalo, N.Y. Thank you to Khatana. Please note this meeting is University and a fellowship in Diseases Pamela Rath, MD, president-elect, for scheduled on Tuesday. and Surgery of the Retina and Vitreous inviting Dr. Lincoff. Dr. Khatana joined Cincinnati at Washington University in St. Louis. Dr. Lincoff is a neuro-ophthalmologist Eye Institute (CEI) as a cataract Continued on Page 204 ACMS Bulletin / July 2021 201
2021 ACMS Membership Benefits R BE 1 PR EP R O ! EF ME D 2 W A EN UR IC PL 20 ES T IT M E 20 TI EN IN FO NE BE IAN OY YS EM 20 C D S C N D Get the support your PH Advocacy. Education. practice needs. Resources. EDUCATION. ADVOCACY. SAVINGS. Allegheny County Medical Society. Your Allegheny County Medical Society Membership is enhanced with a $624 credit that can be applied to an Membership benefits ($1792 value) annual subscription to our Group Purchasing Organization, IndePractice. We empower independents to deliver ACMS Bulletin exceptional care. • Free annual subscription, 12 monthly issues. • $60 value INDEPRACTICE INCLUDES: Physician Wellness Program • Confidential assistance Professional Liability, Patient Acquisition • $800 value Population Health Management Insurance Programs: term, whole, long-term Revenue Cycle Management care, and disability Payer Relations, Health Insurance • Personal coverage • Group discounts not available on the public market HIPAA Compliance, OSHA Compliance Liberty Mutual Auto & Homeowners Insurance Legal, PA State Required Training • Up to 20% savings Staffing, Recruiting, IT Services • $782 value Hardware/Software Solutions Educational Programming • State-mandated training programs for license renewal Medical and Office Suppplies • $150 value Personal Benefits (Home, Auto, Legal Advice from Tucker Arsenberg Life Insurance, Physician Wellness) • Resident/Fellow contract review • Flat rate — even with multiple contracts And More! • Salary negotiation. Save over $150 indepractice.org | acms.org For information, contact Terri Dowd at terri@acms.org, or (412) 321-5030.
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Perspec- Perspective Society News From Page 201 Dr. Ryan directed the Retina Service at the University of Minnesota Department of Ophthalmology from 1989 to 1992 and is currently an associate clinical professor of Ophthalmology. To begin the new year, the POS will reconvene Jan. 6, 2022, and looks forward to welcoming Gregory S.H. Ogawa, MD, an Photo provided ophthalmologist with Dr. Ogawa Outside view of the Ohio Room at the Rivers Casino Eye Associates of effective. He also has developed, fee. The ballroom, located on the second New Mexico, Albuquerque, N.M. Thank presented and published new level, is a non-smoking facility and you to Zachary Koretz, MD, for inviting Dr. Ogawa. surgical techniques in the area of iris provides ample social distancing space. Dr. Ogawa specializes in problems reconstruction and suture fixation The facility adheres to strict food and involving intraocular lenses, irises, of intraocular lens implants. He beverage serving guidelines and follows cataracts and corneas. He manages helped advance and disseminate all Centers for Disease Control and complex patient cases, often for new surgeries such as endothelial Prevention (CDC) protocol. the underserved, routinely treating keratoplasty – implantation of The Society’s top priority is the monocular patients and infants and miniature telescopes for patients with health and safety of all participants. We children with cataracts as well as macular degeneration – and soon, the will continue to monitor regulations and performing ocular reconstructive implantation of custom artificial irises. recommended guidelines set forth by procedures for eyes that have the CDC and notify members should NEW! Ohio Room new venue experienced a range of injuries. At Eye a change in the meeting be deemed Associates of New Mexico, he serves for monthly meetings necessary. as the medical administrative officer in The POS will host all in-person Registration for each meeting addition to his patient care activities. meetings in the Ohio Room at the Rivers begins at 4 p.m. with the first lecture Dr. Ogawa has designed multiple Casino. The venue is centrally located on to commence at 4:30 p.m. Members surgical instruments with the goal of the North Side and offers free parking. will receive registration information making eye surgery safer and more Valet parking also is available for a small one month prior from the date of each scheduled program. Registration will be handled online only. Please visit the Perspective Community Notes POS website periodically for updates and to register, www.pghoph.org. Contact Nadine Popovich, HIV awareness training available for providers, public administrator, to confirm the status of AHN/Highmark collaborated with the Positive Health Clinic to create an HIV your membership or to inquire about awareness training, which caters to all staff as well as the public. It is a free upcoming programs. She can be and informational resource for providers. The link to the training is: https://bit. reached at npopovich@acms.org or ly/HIVawarenessPGH. (412) 321-5030. 204 www.acms.org
ALLEGHENY COUNTY MEDICAL SOCIETY 850 RIDGE AVENUE • PITTSBURGH, PA 15212-6098 P: 412-321-5030 • www.acms.org May 2021 Dear Colleague: The Allegheny County Medical Society is seeking candidates for the 2022 ACMS Board of Directors, Delegates to the Pennsylvania Medical Society and Peer Review Board; we invite your nominations. All members are asked to participate. We especially encourage our resident and young physicians to get involved. The future of medicine depends on you. If you are interested in participating in ACMS leadership, or if you would like to recommend a colleague, please e-mail michelle@acms.org or fax this memo back to 412-321-5323. Questions, please call ACMS at 412-321-5030 and speak with our Chief Executive Officer, Jeremy Bonfini. Sincerely, Patricia L. Bononi, MD President ========================================================================= Nominations for 2022 Office I am interested in being a candidate for the ACMS: BOARD OF DIRECTORS DELEGATION TO PAMED PEER REVIEW BOARD Three-Year Term Two-Year Term Three-Year Term ♦ Represents physicians ♦ Represents the physicians ♦ Investigates written on issues impacting of Allegheny County allegations of ethical the practice of ♦ creating statewide policy violations or medicine and makes on issues impacting unprofessional conduct on policy decisions for the physicians, patients and the part of a member of Society. the practice of medicine. the ACMS made by a ♦ Meets four times per ♦ Meets as necessary prior physician or physicians. year, special meetings to attending the House of as needed. Delegates in October in Hershey, PA. Circle: YES Circle: YES Circle: YES Name ____________________________________ Email ____________________________________ [Please Print] Phone ___________________________________ I would like to recommend ___________________________________________________________for ________ Board of Directors ___________ Delegate. __________ Peer Review Please enclose a copy of your CV. Fax the completed form to 412-321-5323 by Monday, August 9, 2021. Thank you. ACMS Bulletin / July 2021 205
Perspective Activities & Accolades ACMS member receives Distinguished Service Award ACMS member Leo R. McCafferty, MD, FACS, was recently bestowed the Distinguished Service Award by The Aesthetic Society. The award was presented to Dr. McCafferty May 2 at the Society’s annual international meeting, held as a hybrid of virtual and in-person meetings in Miami, Fla. According to Dr. McCafferty, “I had not planned to attend the meeting this year due to upcoming family commitments. When I was in my office on Thursday afternoon, I joined the meeting virtually and was informed that my colleagues had chosen me Photo provided for this honor. This was a complete Leo R. McCafferty, MD, FACS, left, accepts the Distinguished Service surprise to me! I felt so honored but Award from Herluf G. Lund Jr., MD, FACS, immediate past president of The also disappointed that I was not with Aesthetic Society. my colleagues. My wife, Susan, and I made the quick decision to get a reserved only for someone who truly and honor. He is a true role model for flight to Miami the next day so that I rises to the pinnacle in service to the all of us to emulate. He is one of my could accept the award, in person, on society. heroes not just in plastic surgery but Sunday. It is such a special recognition “The Distinguished Service award in life. It is one of my highest honors that I was honored to accept, as the is presented to a member of The of my presidency to present Dr. Leo organization has given me far more Aesthetic Society whose dedication, McCafferty with the Distinguished than I have taken.” service, and/or contributions to the Service Award.” The Aesthetic Society is an development, wellbeing and success Dr. McCafferty currently serves as organization of approximately 2,600 of the society have been demonstrated medical director in Shadyside at his plastic surgeons worldwide devoted to over many years and have exemplified private practice, Leo R. McCafferty, the advancement of cosmetic surgery. action above and beyond the expected MD, FACS, and Associates Plastic Dr. McCafferty was nominated for or ordinary. Leo McCafferty not only Surgery, PC. He has a long career the award by Herluf G. Lund Jr., MD, meets the criteria for this award, he that has always specialized in plastic FACS, a plastic surgeon practicing in personifies it. surgery. Early in his career, he served St. Louis. Dr. Lund is the immediate “Leo has served as a President as chief of Plastic Surgery Staff past president of The Aesthetic of The Aesthetic Society under the Services at the University of Miami Society. most challenging of times. After his School of Medicine/Jackson Memorial According to Dr. Lund, “The highest term of office ended, Leo continued to Medical Center, where he also was award The Aesthetic Society can dedicate himself to the society serving assistant professor of Clinical Surgery. bestow on one of its members is the on numerous committees, task forces, Dr. McCafferty serves currently as Distinguished Service Award. This is a and every capacity asked of him. He clinical assistant professor of Plastic very special award. It is not an annual has always answered the call and Surgery at the University of Pittsburgh, award given out yearly, but an award he has done so with humility, grace School of Medicine. 206 www.acms.org
Perspective Activities & Accolades Notably, Dr. McCafferty lent his board, in multiple executive committee When asked what appealed skills to several professional sporting positions, and as president. He is a most to him about the field of plastic events and teams, including the Men’s past president of the Allegheny County surgery, Dr. McCafferty said, “It is one and Women’s U.S. Open at Oakmont Medical Society. He also has served on of the few fields that allow a doctor to Country Club. He also has been the the board of the American Association deal with every body part. Additionally, Plastic Surgeon Consultant for the for Accreditation of Ambulatory Surgery it is very gratifying to be able to Pittsburgh Steelers for the past 28 Facilities and the Aesthetic Surgery solve problems and a true privilege years. Education and Research Foundation. to help someone feel better about Dr. McCafferty always has believed Dr. McCafferty also has been themselves.” in the importance of services to the named to numerous publication’s Best Dr. McCafferty received his field of plastic surgery. His passion for Doctors lists over the last 20 years. undergraduate degree from advancing the field has been primarily His significant contributions to Pennsylvania State University and his through the avenues of education, the field include nearly two dozen medical degree from Temple University credentialing and patient safety. To scientific presentations at national and Medical School. His post-doctoral support this work, he lent his talents international meetings. He also has training was at Cedars-Sinai Medical and knowledge to several professional been the principal author of a half-dozen Center, the University of Miami School organizations, including The Aesthetic scholarly articles and contributing author of Medicine, and the Jackson Memorial Society, where he served on the to another half-dozen articles. Medical Center. OUR SYSTEM or YOUR SYSTEM? It’s up to you. • Physician Billing Services for All Specialties We would use OUR billing system or YOUR billing system based on YOUR preference. • Credentialing Services for All Specialties • Accounts Receivable Follow-Up for Practice Support We would work your accounts on your system to maximize cash flow. NEW Billing Client Example: A new client (a 6-physician family medicine group) liked their EHR, so the group asked us to bill using their billing system. Besides the benefit of keeping their EHR, the group is now experiencing greater efficiency and stability in their office by eliminating problems caused by biller turnover, vacations, diversion, and other time off. Contact Ruby Marcocelli, Vice President at 412-788-8007 or rmarcocelli@fennercorp.com Three Penn Center West Pittsburgh, PA 15276 fennercorp.com ACMS Bulletin / July 2021 207
Materia Medica Relugolix: One new drug, many new indications Alexandra N. Marshall, cardiovascular effects than GnRH three clinical disease presentations that PharmD agonists. For the treatment of pain would qualify a candidate for the trial: associated with uterine fibroids, it is biochemical or clinical relapse after Karen M. Fancher, PharmD, given in combination with estradiol local primary intervention with curative BCOP and norethindrone. In endometriosis, intent, prostate specific antigen (PSA) R elugolix, a hormone receptor antagonist, has recently received U.S. Food and Drug Administration relugolix could either be given as monotherapy for the first 12 weeks followed by combination therapy, or levels increasing after treatment with curative intent, newly diagnosed hormone-sensitive metastatic disease, (FDA) approval for two different combination therapy only. or advanced localized disease that is disease states and is under not likely to be cured. Key exclusion investigation for other conditions as Treatment of prostate cancer criteria included patients who had a well. This oral agent provides new After skin cancer, prostate cancer major cardiovascular event (myocardial alternatives for the treatment of is the most common cancer in infarction, transient ischemic attack, common conditions in both men and men in the United States. Prostate brain hemorrhage, or stroke) within six women. cancer is the second leading cause months prior to the start of the trial.3 Relugolix is an orally acting, of cancer death in American men, This study was conducted for 48 selective antagonist of the behind lung cancer.1 For advanced weeks, and the primary endpoint gonadotropin-releasing hormone disease, the backbone of therapy is was sustained castration rate, which (GnRH) receptor. It suppresses androgen deprivation therapy with was defined as less than 50 ng/dL the release of gonadotropin from LHRH agonists. However, these of testosterone. The results of the the pituitary gland, leading to a agents cause an initial testosterone trial revealed that relugolix reached reduction in estradiol, progesterone surge that may result in an increase sustained testosterone suppression and testosterone levels.1,2 This of symptoms. Therefore, an oral below castrate levels from days 29 mechanism is in contrast to GnRH antiandrogen is often prescribed for through 48 weeks in 96.7% of patients, agonists/luteinizing hormone- the first weeks of treatment with an compared to 88.8% of patients who releasing hormone (LHRH) agonists LHRH agonist.3 Injectable GnRH received leuprolide, thus showing such as leuprolide and goserelin, antagonists such as degarelix may be both superiority and non-inferiority which result in initial up-regulation of used to avoid such tumor flare, but the of relugolix. In addition, a PSA level hormone levels prior to suppression.2 clinical utility of degarelix is limited by decrease by more than 50% by day Further, since relugolix is a GnRH frequency of injections, injection-site 15 of the trial occurred in 79.4% of antagonist, it causes the suppression reactions and cost.3 patients in the relugolix arm compared of both luteinizing hormone (LH) and In the randomized phase III HERO to 19.8% in the leuprolide arm. follicle-stimulating hormone (FSH), study, 934 men with advanced prostate Testosterone suppression to castrate whereas GnRH agonists only cause a cancer were assigned in a 2:1 ratio to levels occurred by day four in the suppression of LH. relugolix 120 mg daily (after a single relugolix group, in contrast to the Relugolix has shown promise in loading dose of 360 mg) or leuprolide leuprolide group, in which a surge the treatment of prostate cancer, 22.5 mg injection every three months. in testosterone levels was observed endometriosis and uterine fibroids. Eligible patients had to be at least before decreasing to castrate levels In prostate cancer, it is used as 18 years old, had confirmed prostate on day 29. The authors of the study androgen deprivation therapy, without cancer and were candidates for at also noted that a subgroup of patients the need for concurrent antiandrogen least one year of continuous androgen- was followed for testosterone recovery therapy. In addition, it may have fewer deprivation therapy. There were one of after therapy discontinuation, with 208 www.acms.org
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