BulletinApril 2021 - COVID-19: FAQs Doctor, heal thyself - Allegheny County Medical Society
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Allegheny County Medical Society Bulletin April 2021 COVID-19: FAQs Doctor, heal thyself
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03/21 Z MX517136
ACMS April 2021 Bulletin 7.5”w x 9.75”h
Allegheny County Medical Society
Bulletin April 2021 / Vol. 111 No. 4
Opinion Departments Articles
Editorial ..................................94 Membership Benefits ..........106 Materia Medica .....................112
America the fortunate Lemborexant (Dayvigo®): A new orexin
Deval (Reshma) Paranjpe, MD, MBA, Society News .......................111 receptor antagonist
FACS • ACMS members award Science Fair Aileen Dauz, PharmD
winners
Editorial ..................................96 Legal Report ........................115
Illness and architecture Classifieds ...........................111 Regulatory Sprint to Coordinated Care
Joseph C. Paviglianiti, MD tackles HIPAA obstacles
William H. Maruca, Esq.
Editorial ..................................99
My strangest ‘patient’ Special Report .....................118
Richard H. Daffner, MD, FACR COVID-19: Frequently asked questions
Allegheny County Health Department
Editorial ...............................101
Misconstrued lyrics Special Report .....................121
Andrea G. Witlin, DO, PhD Allied Community Health opens clinic,
laboratory
Perspective .........................103 Amelia A. Paré, MD, FACS
21st century gender science, society
and the compound question
Bruce L. Wilder, MD, MPH, JD On the cover Correction
Perspective .........................108 Pittsburgh Zoo In the March 2021 edition of the
Doctor, heal thyself ACMS Bulletin, in the
Wendy Palastro, MD Aquarium Legal Report on page 84, the
Alexanndra Kreps, MD Medicare conversion factor
Perspective .........................110 Dr. Kreps specializes in psychiatry. for 2021 should be $34.8931.
Meeting new friends
Harry Null, MD
For up-to-date resources
on COVID-19, visit:
www.acms.org/covid-19-resources
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Editorial
America the fortunate
Deval (Reshma) Paranjpe, MD, MBA, FACS
A s I write this, one quarter of U.S.
adults have been fully vaccinated,
while half have had at least one dose.
setting children back educationally, but
it is setting the entire generation back
equally; they will not be disadvantaged
at all. Some people are refusing to
take vaccines even when vaccines are
available and offered to them. What
If the vaccines offer us significant relative to their peers. an embarrassment of riches we have!
protection against the assorted variants We have proof. Children survived Consider the rest of the world popu-
in world circulation, there is hope that the restrictions of the 1918 influenza lation, most of which has little access
we may entertain a gradual return to epidemic, the polio epidemic, and to vaccines. The vaccines that are
pre-pandemic life once the vast ma- evacuations into the arms of strang- within reach may not be as effective, or
jority of the population has been fully ers in the English countryside during may have been withdrawn over safety
vaccinated. Here in the United States, the London Blitz during WWII and concerns, or may be fakes provided
debates about re-opening businesses still became productive citizens and by a criminal enterprise. The countries
and schools still rage, but a pervasive went on to have families and good of Western Europe, which one would
sense of “giving up” also is in the air. lives. Separations from friends and expect to be organized and orderly,
“We’re tired of being under restric- family and education are undeniably have had surprisingly terrible vaccine
tions, and some people are vaccinated, traumatic, but as we often are told rollouts. As a result, there are still
and other people don’t care, so let’s during pediatrics rotations, children are national lockdowns in European coun-
just reopen,” is the rallying cry. No one resilient. They adapt, and survive and tries. Consider the situations in Brazil
wants their kids at home anymore; thrive. Thankfully, we are not in a crisis and India, where there are vaccine
parents are exhausted. “The kids where bombs are falling overhead, or shortages and poor logistics. COVID
aren’t learning,” complain the parents, the death rate is astronomical due to variants are burning through these two
and this is partly true. Kids are always the absence of modern medicine, or countries at record paces with case
learning though; it is the nature of where the majority of the ill and dead fatalities far in excess of the numbers
childhood to absorb knowledge and are children. While I do not downplay reported by the governments. Political
skills. They are learning patience, and the serious of the depression and leaders are holding rallies there with
closeness to their families, and sac- the suicides that are occurring now, tens of thousands of closely packed,
rifice. They are learning that life and the PTSD from those other scenarios unmasked supporters and encouraging
people and systems aren’t perfect. would be far worse in aggregate than mass religious festivals/superspreader
Looking back in 20 years, this learning emotional disturbances brought on by events. Unchecked COVID gives rise
experience may be judged an unex- the current pandemic. Simply said, we to further variants which can then mi-
pected benefit even if unwanted now. should be grateful it isn’t worse. grate and threaten the rest of the world
Perhaps it will inspire these children to People in some parts of our country with more contagious and deadlier
fix the problems they saw during this have intellectual discussions about disease. Think of the entire continents
pandemic as they mature into adults, which vaccine to take, even as people of Africa and Asia and South America
and make this a better world for the in other areas are still desperately wait- and the many countries therein where
rest of us. Yes, home schooling is ing for their chance to take any vaccine access to care and access to vaccines
94 www.acms.org
Editorial
are both poor for the common man. pharmacies and then hand them to the pandemic. This is the modern version
How lucky we have it in comparison! nurse to administer. If you can’t pay for of “Finish your dinner. There are chil-
India has a double mutation variant the drug or fetch the oxygen yourself, dren starving in Africa.”
which is sweeping across the country. your family member dies. If you are the In the case of a sudden drop in air-
Young people in their 20s and 30s are patient and you have no family to fetch/ craft cabin pressure, we are told to put
making up the bulk of the inpatient ad- carry/pay for you, you die. It is fee-for- on our own oxygen masks first in order
missions and the dead. Hospitals have service medicine at its most cruel. Think to be better able to help those around
been instructed to downplay the num- of how much better we have it. Our sys- you put on their masks. We are a great
bers of actual COVID related deaths tem may bankrupt us eventually rather nation, yes, and part of that greatness
and only report deaths from pneumonia than immediately, but at least our loved comes from our propensity to help
rather than deaths from other COVID ones get the care and medicines they the rest of the world. Let us quickly
complications (PE, MI, CVA, etc.). The need to save their lives when saving get our house in order. Let us get our
crematorium numbers tell the real story; their lives is possible. population vaccinated and protected,
investigative reporting by local newspa- Remember that there are people the better to help the rest of the world.
pers suggest that the actual deaths are in the rest of the world who would kill Let us appreciate and be thankful for
likely five to 10x what the government for a dose of the Moderna or Pfizer our considerable advantages, and let
figures state. India’s health system, vaccine that some people in the United us keep our guard up: The variants are
such as it is, is collapsing. There are no States have the luxury of refusing. For already here.
more hospital beds, let alone ICU beds. that matter, people elsewhere in the
Patients are dying routinely because world might fight tooth and nail for the Dr. Paranjpe is an ophthalmologist
the hospitals are out of oxygen. Family Johnson and Johnson vaccine, despite and medical editor of the ACMS Bul-
members have to travel miles and fill the rare reports of blood clots. Believe letin. She can be reached at reshma_
oxygen canisters to bring to the bed- it or not, we would likely do the same paranjpe@hotmail.com.
side to keep their loved ones alive. in the same situation. We are in the
The opinion expressed in this column is that of
Critical drugs are too expensive for the greatest country in the world, and we the writer and does not necessarily reflect the
common man to afford; in India, family need to understand just how good we opinion of the Editorial Board, the Bulletin,
or the Allegheny County Medical Society.
members must buy the drugs from have it, even in the middle of a global
ACMS members:
Moving? We want to hear your
opinions on important
Be sure to let us know .... topics affecting healthcare.
Email Meagan Sable
We can update our system to better
serve you! When your patients call, at msable@acms.org
we will know where to send them. to learn more about
Call (412) 321-5030 to update submitting a Perspective
your information. column to the Bulletin.
ACMS Bulletin / April 2021 95
Editorial
Illness and architecture
Joseph C. Paviglianiti, MD
S ometimes in the pediatric ophthal-
mology clinic, things just don’t go
my way. While we all love our patients,
floor plans as a kid, and I often wonder
if I have some sort of latent maniacal
tendency toward architecture that went
them over the elevator?). WELL theory
is sort of like the Danish concept of
“hygge” (defined on Wiki as a quality of
some of them can be a little (OK, a lot) unsatisfied, deep down in repressed coziness and comfortable conviviality
more draining than others: the uncoop- parts of my soul that I have long since that engenders a feeling of contentment
erative 6-year-old who could read the buried. Right now, though, architec- or well-being). I didn’t get the feeling of
smallest line of the eye chart in 10 sec- ture is a job, any job, that isn’t trying hygge this morning from any of the three
onds last time, but decides to stubborn- to refract this screaming, tantrummy patients above, but when they get older,
ly dig in his heels and make me beg for 3-year-old currently in my exam chair, we will laugh about it together. Not now,
every Snellen letter over 15 agonizingly winning the battle of my draining medi- though. And I think I need a Band-Aid
slow and oppositionally defiant min- cal resolve. for my arm.
utes. Next door is the 4-year-old with But are architecture and medicine But with so much emphasis on
supposed low tone who suddenly has so far apart? architectural health and wellness (both
more strength (and appendages) than Currently, two of the leading archi- to the environment, and more recently,
John Cena when I try to put eyedrops tectural building certifications are LEED to its occupants), it is striking that it is
in. Should it really take four of us to put (Leadership in Energy and Environ- human “un-wellness” that has driven
eyedrops in this kiddo? Yet it does, and mental Design) and the WELL Building most architectural change in the mod-
we could have used a fifth. Next door Standard (surprise, WELL isn’t an ern world.
is the 3-year-old who was having a acronym to my understanding). LEED Prior to Pasteur’s Germ Theory in
tantrum when she walked in the office, ratings tell us how friendly a building 1861, which postulated that microor-
continued it all during our “less-than-re- is toward the environment. How much ganisms could cause a lot of bad stuff,
liable-but-we-gave-it-a-really-good-try” carbon footprint does the building cast? Earthlings really had no idea what
dilated exam, and is still screaming on How energy efficient is it? Maybe it started certain pandemics, or how they
the way out the door. My eardrums are even generates some extra energy for miraculously ended. The Black Plague/
ringing. And those were just the first the 1970s building next door? Is waste- Bubonic Plague (Y. pestis) killed 30-
three patients this morning. water repurposed? Were the building 60% of Europe’s population between
As I have gotten older and a little materials created sustainably? 1346-1353. No one knew how it came
less patient, I may catch myself taking Conversely, but adjunctively, the or why it ended. Most assumed it was
a deep breath while rubbing kid snot more recently devised WELL certifica- God’s will. Similarly, the Yellow Fever
off my pre-pandemic tie and stopping tion ratings tell us how friendly a building Epidemic of Philadelphia (1793) killed
the bleeding on my arm from what felt is toward its occupants. How does your 5,000 of the then-nation’s capital (now
like a dog bite, but was likely more building or office affect your mood? Your cheesesteak capital) of 50,000 inhab-
human in origin, whilst silently musing nutrition? Your comfort? Your fitness? itants (the biggest city in America at
to myself, “Pav, you should have been (Example: Are stairwells placed where the time). It is estimated that 20,000 of
an architect.” I used to love to draw occupants will preferentially choose those who could, including President
96 www.acms.org
Editorial
George Washington, evacuated steamy was discharged into the same River I likely wouldn’t have been a
Philadelphia that summer, while 15% Thames, is a story for a different day. successful architect, because all my
of those unable to leave died. Again, It was someone else’s problem down- designs would have been college
nobody knew how the fevers came or stream, and London’s cholera epidemic gothic or church gothic. Those building
why they went away. If you don’t know ended. Cheerio! styles soothe my “hygge,” but, unfor-
about germs, you cannot prevent them. New Yorkers at that time were tunately, not everyone else’s. Different
Therefore, no changes were made to dealing with cholera, too. Immigrants architectural styles have evolved over
the general population’s living condi- were arriving by the thousands and the years, many surprisingly due to
tions and, therefore, more pandemics were living in squalor, 10 or more to medical reasons. For example, the
came and went. a room in tenement housing, with Modernist Architectural movement
Even in 1858, during the London apartments crammed tightly together. of the early 1900s was pioneered by
Cholera Outbreak (just three years Nobody knew that the stagnant water LeCorbusier (France), the Bauhaus
before Pasteur’s Germ Theory) no one from the poor sanitary conditions, lack movement (Walter Gropius and Mies
had a clue that the excreta of 3 million of sewage systems, poor drainage van der Rohe) in Germany, Alvar Aalto
Londoners was making themselves and unpaved alleyways where wa- in Finland and Frank Lloyd Wright in
sick. Fortunately, however, with all that ter accumulated were the breeding America. Modernists used innovative
poop came a lot of stink, as it all ended grounds of cholera, which is estimated technologies in their construction,
up in the River Thames … and it was to have killed 15,000 New York city using steel, glass and tons of concrete
the Thames stench in 1858 that got inhabitants in 1849 alone (2.5% of the in buildings that are distinctive for their
Parliament to take action. Evidently, 1849 population of 600,000)! Compare functionalism, minimalism and total
the smell in London was so bad that that to COVID-19, which has killed lack of ornamentation. If you see a
summer that Parliament approved 2.5 30,000 NYC residents out of a 2020 concrete slab with windows, that’s a
million British pounds (about $416 NYC population 18.8 million (0.16%). modernist building.
million U.S. dollars in today’s money) Cholera in 1849 was 15x more deadly But architectural historians have
after just three days of debate, to fund than COVID-19 in 2020. postulated that many of these mod-
the London Sewer System. Fortunately, NYC had an archi- ernist innovators may have had some
Granted, the bricklayers for the brick tectural breakthrough that helped. mental health diagnoses that favored
underground sewers were only paid a Frederick Olmstead, regarded as the this particular type of building style that
maximum rate of 25 pence (33 Amer- founding father of American landscape they designed and fostered. Indeed,
ican cents) a day, so it was quite a architecture, proposed that NYC psychiatrists have posthumously
bargain by today’s standards to create needed more protected green space. diagnosed LeCorbusier with Autism
a city saving system. It wasn’t the fear In his words, these parks would be Spectrum Disorder, with his prefer-
of V. cholerae that created the impetus the “lungs” of the city where citizens ence for social isolation, avoidance of
for the architectural wonder that was could breathe easily, separated from visual stimuli (lots of plain gray con-
the London Sewer System of 1858, but their cramped tenement lives. Hence, crete) and minimalism. His buildings
as the London Times reported, it was Olmstead proposed and designed are “comforting” to someone seeking
the “force of sheer stench” that created what later became Central Park (and to avoid interpersonal contact and
the political and economic drive to de- also Prospect Park) in NYC. Countless interaction. Gropius, of Bauhaus fame,
sign and build the sewer system. Either cities, including Pittsburgh (in 1931 was a German veteran of WWI who
way, an architectural answer (unknow- with North and South Parks) followed was badly wounded in the trenches
ingly) helped end the London cholera suit. Another example of an architec- and later thought to suffer from PTSD,
epidemic by improving sanitation. The tural leap forward to help fight medical a term not officially coined until 1980,
fact that the new sewer system just disease. And a place for Macaulay many years after his death, but a
transported the excretory goo 10 miles Culkin to catch the bad guys in “Home disease that has namelessly existed
downstream from London, where it Alone 2.” Continued on Page 98
ACMS Bulletin / April 2021 97
Editorial
From Page 97 that the architecture itself is part of the buildings that are instantly changeable,
since people learned to fight. Gropius’ treatment plan, or at least makes the with pods and cubes that can be added
architectural buildings after WWI often patient feel that way. or subtracted to a building as needs
resembled military battlefield pill boxes: COVID-19, quarantining, social arise, such as the infamous Nakagin
concrete slabs with narrow windows distancing, masking, remote learning/ Capsule Tower in Tokyo, which may
and hidden doorways. Like a concrete working are all new lifestyle modifica- have been ahead of its time. Maybe
bunker, but above ground … safe for tions borne out of survival this year. future buildings shouldn’t be “forever”
the battlefield or the office. Maybe not American architecture will have to re- but should be planned as “changeable”
the most comforting and convivial, but spond, in many ways reversing course. and adaptable, just like human metab-
functional, nonetheless. That is Mod- Will urbanization, in full steam until olism. As always, while we might not
ernist Architecture. March 2020, give a rebirth to suburban- like the change, architects will rise to
These modernist buildings turned ization and ruralization? The wide-open the challenge that our changed medical
out to be just what the doctor ordered floor plans of the 1980s and 1990s are status has created. Alas, time for me to
in the fight against tuberculosis in the suddenly not conducive to six people put away my “wanna-be” architectural
early 1900s. Before Waksman and the on separate zoom calls simultaneously. hat, and hand it over to my daughter,
discovery of Streptomycin in 1943, the Walls and “places to isolate oneself” my “gonna-be” architect. I will have to
only “treatment” for TB was convales- are in, both at home and work. Shared live vicariously through her. Time to go
cence in a sanatorium. TB patients break rooms are out. Plexiglass find another Band-Aid. My next patient
were sent off to isolate, rest and sit in dividers are in. School superintendents is waiting.
the sun (one of the few things known across the country note one positive
to kill TB germs at the time). Aalto, in to come out of the pandemic: the end Dr. Paviglianiti is a pediatric oph-
1933 Finland, designed a modernist of the school cafeteria and the subse- thalmologist and associate editor of the
sanatorium with long walls of windows, quent “cafeteria anxiety” that middle/ ACMS Bulletin. He can be reached at
large terraces to fall asleep outside high schoolers face. Outside is “in,” jcpmd@pedstrab.com.
in the sun, and light-colored ceilings with more outside space for learning
The opinion expressed in this column is that of
to promote peace and quiet. Empty and working. Another reason for that is the writer and does not necessarily reflect the
white walls, bare floors, everything that one of the major weapons against opinion of the Editorial Board, the Bulletin,
or the Allegheny County Medical Society.
clean and sterile. Wide open spaces. the exploding myopia epidemic is “time
Patients “felt” clean due to the wide- spent outdoors” to let the eyes “defo-
cus” on the horizon. References
open architectural space and the open
1. Chayka, K. How the Coronavirus Will
floor plans. It is no accident that most Anyway, the list goes on. It will be Reshape Architecture. The New Yorker.
hospitals since that time follow these interesting to see how American ar- June 2020.
modernist principles, such that today’s chitecture changes due to COVID-19, 2. Stinson, E. Health and Disease Have
hospital buildings conjure up ideas of and the realization that there may Always Shaped Our Cities. What Will Be
cleanliness, order, functionality, safety be a different pandemic around the the Impact of COVID-19? Architectural
Digest. April 2020.
and improved health to the inpatient corner with a different mode of spread. 3. Sussman, A. and Chen, K. The
occupant. No hygge here, though one Perhaps the “Metabolism Architectural Mental Disorders That Gave Us Modern
could argue there ought to be. But Movement” from the 1960s and 1970s Architecture. Common/Edge. August 2017.
modernist hospitals are designed such will regain prominence. These are
Allegheny County Medical Society
www.acms.org • (412) 321-5030
98 www.acms.orgEditorial
My strangest ‘patient’
Richard H. Daffner, MD, FACR
T his is not an April Fool’s story. One
morning, Linda, our chairman’s
secretary, came to me in the reading
the Board of Directors of the zoo and
asked if he could convince one of our
radiologists to come to the zoo and do
room. “I know you’re going to do this,” a barium enema. And so, I took the
she said. resident who was on my service along
“Do what?” I replied. with two bags of barium to the zoo.
“Go to the Pittsburgh Zoo to do a When we arrived at the zoo’s med-
barium enema.” ical building, the gorilla had been se-
“OK. On what?” dated and was lying on an x-ray table.
She paused for a beat and then They had no fluoroscopy equipment Fig. 1. Characteristic puckering at
said, “A Gorilla.” at the time. A veterinary dentist was the recto-anal junction (arrow) in a
“OK. But why not one of the folks cleaning Sultan’s teeth while he was human patient with Hirschsprung
who ordinarily do barium studies.” sedated. (I told my resident that Sultan disease.
“I asked all of them. They’re not would be one unhappy gorilla when he
interested. I know you have a collection told him the diagnosis. He had never
woke up.) In addition to the dentist and
of animal x-rays in your teaching file.” the zoo’s vet, there also were several heard of it and disappeared into his
“OK, but it’s been some time since visiting veterinarians who wanted to office to consult his books. (This was in
I’ve pushed barium.” Our group was watch, having never seen a barium the days before the Internet and Goo-
specialized, and my areas of expertise enema performed on a gorilla. gle). After several minutes, he returned
are bone and joint imaging and trauma We began by taking a “scout” and said, “Well, a gorilla’s anatomy is
imaging. “I’ll take one of the residents,” radiograph to get the correct technique. identical to ours. Hirschsprung disease
I added. Then, after inserting the rectal tube, is rare, but it occurs. Now, how is it
“I thought you would agree,” she we let half a bag of barium flow into treated?” I told him about the “pull-
said. “But you must tell me why.” Sultan’s rectum and took a radiograph. through” procedure that was used at the
“Well, Linda, just think of the stories After the film was developed, I looked time, where the lining of the diseased
I’ll get to tell.” at it and noted a colon full of stool, part of the colon is stripped away, and a
The back story is that Sultan, an much like that seen in an unprepared normal section is pulled through the co-
18-year-old gorilla, had been consti- human patient. However, there was a lon from the inside and attached to the
pated since birth and was more and very characteristic finding, puckering, anus. I suggested he call his surgical
more uncomfortable. (And you don’t right at the recto-anal junction (Fig. 1, friend at AGH and ask him to “assist”
want to imagine how ill-tempered a at right). with the surgery. And that was what was
constipated 450-pound gorilla can be). I turned to my resident and said, done, with curative results.
The veterinarian at the zoo called one “What’s your diagnosis, doctor?” My sojourn into veterinary radiolo-
of our general surgeons (whose name “Hirschsprung disease,” she replied. “I gy began when I was an attending at
I have forgotten) at AGH who was on agree,” I said. I turned to the vet and Continued on Page 100
ACMS Bulletin / April 2021 99Editorial
From Page 99 problems. That episode earned me the an inveterate skeptic, was giving me a
Duke. One of the vets from the animal right to become the “official” veterinary look as if to say, “Yeah, that’s the tallest
lab came into the reading room one radiologist for Duke and allowed me to tale I’ve heard yet.” After we sent the
see a wide variety of abnormalities in boys to their tents, Jim came up to me
day and put up a Waters’ view of a
the various lab animals they had. and said, “Is that really true?” One of
baboon’s face. The animal had facial
I am hardly the first radiologist to the other dads present, a veterinarian,
swelling. My first response was, “That’s
x-ray animals and have a good story said, “Jim, it’s true. I was there.” He
a funny-looking kid.” The vet kindly told
to accompany the event. The late Dr. happened to be one of the visitors the
me what his patient was and asked day we did the barium enema! From
Benjamin Felson, one of the giants of
if I saw anything to account for the that day forth, Jim never doubted my
radiology, who chaired the Department
facial swelling. I noted a lucent area stories. Like many of the tales we told
of Radiology at Cincinnati General
surrounding the root of the left maxil- Hospital, wrote about his experience about the crazy things our scouts did,
lary canine tooth. I told the vet that his with a cow in the x-ray department.1 He you just can’t make this stuff up.
patient had a root abscess. He didn’t was asked by a colleague who owned
believe me (since most radiologists, a cow that had been feeding in fluo- Dr. Daffner, associate editor of the
indeed most physicians, ignore the ride-contaminated grass whether her ACMS Bulletin, is a retired radiologist
dentition). I suggested we walk down to bones showed any evidence of fluoride who practiced at Allegheny General
the oral surgery clinic for a consult. poisoning. The story is hilarious, as Hospital for more than 30 years. He is
The oral surgeon looked at the film only Dr. Felson, well-known for his emeritus clinical professor of Radiology
and said, “That’s a funny-looking kid.” humorous anecdotes could tell.1 (I can at Temple University School of Medicine
“Do you see anything wrong?” I e-mail copies, on request). and is the author of nine textbooks. He
asked. But, back to my gorilla story. True can be reached at bulletin@acms.org.
“Yeah. He has a root abscess in his to my comment to Linda, I had many
left maxillary canine tooth.” opportunities to share my experience The opinion expressed in this column is that of
the writer and does not necessarily reflect the
As we walked back to the radiology at the zoo. It fell into the category of opinion of the Editorial Board, the Bulletin,
or the Allegheny County Medical Society.
department, the vet asked me why I “What’s the most unusual thing you
looked at the teeth. I told him that I have done?” My Boy Scouts loved the
was aware that monkeys and apes Reference
story. One night at summer camp, I
1. Felson B. The cow in the x-ray room.
have a diet high in carbohydrates and, was telling the story at our campfire Medical Economics, June 10, 1968.
as a result, frequently have dental and Jim, one of the other leaders, and
Help your patients talk to you about their BMI
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Allegheny County Medical Society
100 www.acms.orgEditorial
Misconstrued lyrics
Andrea G. Witlin, DO, PhD
I was introduced to the phrase “mis-
construed lyrics” more than 50 years
ago in my high school English class.
course, I didn’t let my husband live
down this gaffe for many years.
Years later, we both routinely miss
instructions – the new “critical” med
was to be taken BID starting with dinner
that evening when we arrived home
Irrefutably, I was a nerd and far from words in song lyrics, commercials and at breakfast the following morning.
conversant with pop artists, songs and and TV broadcasts. Missing an occa- Two separate scripts were supposedly
lyrics. I recall being uncomfortable and sional lyric or promotion is cute. We sent – one to be filled at a pharmacy
taciturn during that class. Despite my mock each other for our perceived on our drive home (for the evening and
personal disinclination, I was attentive diminished hearing proficiency. But it’s early morning dose) and the second
and still remember the verse used not so innocuous when the words we one to be filled at our regular pharmacy
as an example: “I’m not talkin’ bout misconstrue or miss entirely are crucial when it opened the next day. I even
the linen.” Admittedly, I had to search daily interpersonal interactions or called the pharmacy on the drive home
for the artist (England Dan and John critical health explanations or instruc- to confirm that all was well. Fortunately,
Ford Coley) and the precise verse for tions. The positive trend in medicine we made it through the drive thru just
this article: “I’m not talkin’ bout movin’ to include written documentation and before closing. Once home, I focused
in.” Retrospectively, confusing “linen” instructions is helpful, but nothing is on getting my husband into the house
with “movin’ in” seems implausible, failsafe... safely, getting us dinner and, of course,
especially when we remember the ’60s In addition to auditory lapses, visual handing my husband his needed med-
lyrics as being comprehensible! deficits accrue with age as well. Many ication. I was cock sure (and so was
I had forgotten about that class, of us need readers. But depending he) that we had the instructions correct.
song and topic until the mid-’80s when upon my need for expediency, I don’t So certain that neither of us re-read the
my husband and I argued playfully always use them. Thus, the predic- instructions on the prescription bottle.
about the lyrics to the Genesis song, ament that I found myself in several The two pills were inside the bottle just
“Invisible Touch.” My husband was con- months ago when my husband was as we expected. Except…
vinced that the lyrics were “she seems being discharged from the hospital. The Following breakfast and after my
to have a physical attraction.” Although discharge instructions included his new husband ingested the second pill the
I was still a bit of a nerd, I had started meds and emergency phone numbers. following morning, I called our local
paying more attention to popular music. But I couldn’t read the details without pharmacy about the “waiting prescrip-
Retrospectively, I can’t say that I really my glasses. His RN was thorough and tion.” The second, 30-day supply was
heard things more clearly, but I de- spent a lot of time with us reviewing never sent. I was now fully alert, had
duced that given the name of the song, all the new findings and instructions. my readers on and scrutinized the
the words must be different than what Ditto for the nurse practitioner who printed instructions. The pill was to be
my husband was convinced he heard. worked with the doc who had done his cut in half! However, none of the verbal
Indeed, after searching high and low, procedure. I also had spoken to the instructions in the hospital included that
I found the correct lyrics: “She seems doc post-procedure. We “thought” we nuance about cutting the pill in half!
to have an invisible touch, yeah.” Of understood. We even reiterated the Continued on Page 102
ACMS Bulletin / April 2021 101Editorial
From Page 101 chastised me/us for not reading the All eventually worked out.
Neither the pharmacist nor pharma- small print about cutting the pill in half. I reminisced about the story of
I admitted that I screwed up and didn’t the misconstrued lyrics. It’s still an
cy tech said anything either. Why were
read the instruction sheet until the next interesting memory from an awkward
two pills dispensed if we only needed
morning. I apologized and explained adolescence. But I wonder retrospec-
one pill cut in half for the two needed
that neither of us had slept much over tively, how many of my well-intentioned
doses? Even if it had been discussed instructions have been misconstrued?
the past 72 hours, how the triggering
(and we would have remembered that), We all tend to worry about the proto-
event, hospitalization and procedure
it was physically impossible to cut the were quite stressful. The conversation cols and the big stuff, but sometimes
miniscule pill evenly and safely. But the ended by her volunteering to call in the it’s the small touches that matter.
worst – unwittingly, I had overdosed my missing script to our pharmacy.
husband – and I panicked! The emer- Fortunately, I used some “tricks” to Dr. Witlin, associate editor of the
gency numbers on the discharge pa- navigate the system and after several ACMS Bulletin, is a retired maternal/
pers didn’t work anymore. The holiday hours found a sympathetic nurse prac- fetal medicine physician and research-
weekend was over, and it was a normal titioner who called back on her day off, er. She can be reached at agwmfm@
workday “of sorts.” and sent in a new script for a different gmail.com.
It took some time, but I finally (but similar) med that didn’t need to be
reached a supervisor from the unit cut in half. My husband survived my The opinion expressed in this column is that of
the writer and does not necessarily reflect the
where my husband had been hospital- error and is still on that same new medi- opinion of the Editorial Board, the Bulletin,
or the Allegheny County Medical Society.
ized. Instead of helping, she promptly cation and is doing well.
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102 www.acms.orgPerspective
Perspective
21st century gender science,
society and the compound question
Bruce L. Wilder, MD, MPH, JD
L ike many, I was at once stunned
and disappointed in the questions
asked by Sen. Rand Paul regarding
part of the compound question not
explicitly asked, i.e., in this case,
whether transgender students should
recognize and respect the humanity of
the individuals themselves.
But we’re not there yet.
participation of transgender students be recognized as such. The classic It was 99 years ago when Jim
in school athletic programs and example is “When did you stop beating Thorpe was stripped of his Olympic
competition during the recent your wife?” medals because he had played minor
confirmation hearings of Miguel So, the form of Sen. Paul’s question league baseball. It was 85 years ago
Cardona,1 who subsequently has been referred to above (asked 10 times over when Jesse Owens embarrassed
confirmed as Secretary of Education. the course of five minutes) seems to Hitler in the 1936 Berlin Olympics.
While Sen. Paul’s concern about be an implicit denial of what we have It was 73 years ago when Jackie
discrepancies in physical traits that learned about the psychology and Robinson integrated Major League
may put some at an advantage and biology of transgender youth, namely Baseball. While these occurrences
others at a disadvantage is a valid one that those individuals are people are traditionally looked upon as
– although appearing to be in his case who have anxieties and insecurities, reflections of racism – and they were
almost an obsession – and shared by just as others do. They are people – they also were likely driven by fear
many students and parents, it became with feelings and emotions just like that people of color might possess
clear that he is not going to be part of everybody else, tempered, of course some innate physical advantage, or
any resolution of concerns in this area. by the fact that their gender identity that their achievements should not
Which brings me to the compound doesn’t fit neatly into the traditional receive recognition, lest the supposed
question. Sen. Paul expressed model of male-XY chromosomes-male inferiority of people of color be
concern about competition between eternal genitalia vis a vis its female disproved. It was only recently that a
a (“boy that’s 6’2,” and later on in counterpart of XX chromosomes and 79-year-old man was awarded a high
his questioning, “hulking 6’4” guys”) matching female genitalia. school letter that he was denied at the
transgender girl and his 5’4” niece. But Transgender individuals are age of 16 because he was correctly
the form of his compound question, more and more being recognized believed to be gay.2 He said that at
asked repeatedly, was essentially, “Do and accepted as individuals in our the time, “If it was discovered that
you think it’s OK for boys to compete society. There also are (admittedly you were a gay kid there were two
with girls in school athletics?” The rare) instances of XX/XY mosaicism alternatives: psychiatry because they
concept of the compound question or chimerism. There are genetic thought you were nuts, or the cops
boils down to that of question that is abnormalities that may blur because it was illegal.”
really two or more questions contained classification of gender at birth or later Just in the last few years, a 2016
in what sounds like a simple question, in life. We as a society, and in the law, Olympic Gold Medalist, Caster
that if answered as a response to the are gradually beginning to understand Semenya, a woman who was
apparent simple question suggests these things and are learning to deal identified as female at birth, and who
or implies an answer to the other with them in ways that increasingly Continued on Page 104
ACMS Bulletin / April 2021 103Perspective
Perspective
From Page 103 prevalence of psychological problems, dress and show up for try-outs of
has lived her entire life as a woman, suicide, substance abuse and sports teams in schools – something
was ordered to take testosterone- victimization of transgender individuals that Sen. Paul’s line of questioning
reducing medication as a condition or individuals with indeterminate suggests would happen if we recognize
to compete, after it was discovered genitalia is well-documented, and the need for some accommodation of
that she had abnormally high levels much of that may be due to the societal transgender students. The need for
of endogenous testosterone and attitudes about gender, sometimes participation of transgender athletes in
eventually a finding that she was XY foisted on the child by their parents or school sports, whether interscholastic
but had 5-alpha-reductase deficiency, by their peers, a phenomenon that can or intramural, is not going to go
a rare condition that leads to failure of exacerbate those problems. away and cannot be dismissed as
in-utero development of male genitalia. We have begun to recognize the if it doesn’t exist. Indeed, there are
Her case is now pending before the terms non-cisgender (meaning that mounting pressures from within the
European Court of Human Rights.3 one’s gender identity is different from athletic community to make reasonable
We do classify athletes by weight what they were determined to be at accommodations.6
(boxing and wrestling), and in youth birth) and non-binary (meaning that the It is probably still true today that
sports by age, and by gender. Are we individual identifies as being neither most people feel threatened by ideas
to classify athletes by testosterone male or female). that challenge traditional notions of
levels? There are likely wide variations As a society, we tend to fear others gender and sexuality, but I believe the
in testosterone levels among boys in who are different from ourselves, trend is for more of us to understand
Little League Baseball, and in many not only because of skin color and these issues with the passing years.
of these leagues, girls are allowed associated traits and the complex So, it is distressing that we have folks
to participate with boys. Boys and history of the groups with which they in our legislatures who, either out
men who are, say 6’8,” have a clear are associated, including individuals of their own fear and ignorance, or
advantage in basketball; we don’t (as who do not nicely fit into our notions a belief that their careers are better
far as I know) have separate leagues of the male-female duality, including advanced by validating fear and
for different height ranges. We have expectations of sexual preference. And ignorance in some of their constituents,
handicaps in some golf leagues. Senior too often that fear is manifested by hold fast to ideas that deny the
athletes are grouped by age. All of hatred or marginalization. existence of what we have learned
these examples are reasonable, but We are making progress. The about gender identity. Some have even
they are rough estimates imposed to U.K. enacted the Gender Recognition gone so far as to say that allowing
approximate a level playing field – and Act of 2004,4 legislation that officially participation of transgender children in
they are never precise. When Tom recognizes a person’s gender for all scholastic sports will destroy girls’ and
Dempsey kicked the longest field purposes, when it has changed from women’s sports. Such a statement is
goal in NFL history, many wanted to what it was at birth, subject to certain reminiscent of the claim that same-sex
disqualify the record because he had requirements. A number of states marriage would destroy the institution
a special square-toed shoe made have enacted legislation that permits of marriage.
because he was born without toes on reissuing of birth certificates and official Vince Lombardi’s oft-quoted mantra,
that foot. identification documents, such as the “Winning isn’t everything: it’s the only
In the 1950s, Dr. John Money, driver’s license, to reflect an acquired thing,” may make sense in the high-
a psychologist at Johns Hopkins gender. We may soon see the ability of stakes money-ball of professional
University Hospital, advocated early individuals to be identified in keeping sports, but it seems to disorder
intervention of “corrective” surgery on with their perceived gender, including priorities when one is talking about
infants with ambiguous genitalia and nonbinary, at the federal level.5 sports in school-age children.
designation of a conforming gender, No one wants to endorse the idea So, while debates about
an approach since discredited. The that a male student could put on a participation of transgender students
104 www.acms.orgPerspective
Perspective Let us be the key to your future ...
in school sports will, and should, continue, we need to be
thinking more in terms of what Mr. Cardona expressed so
well in his responses to Sen. Paul,7 rather than, for the sake Specializing
of simplicity, maintaining a rigid adherence to outdated views
of gender and gender identity that may adversely affect in physician
people who live among us. practices
since 1978
Dr. Wilder practiced neurological surgery in the Pittsburgh
area. He currently is of counsel in the law firm of Wilder,
Mahood, McKinsley and Oglesby. He can be reached at
bulletin@acms.org.
The opinion expressed in this column is that of the writer and
does not necessarily reflect the opinion of the Editorial Board,
the Bulletin, or the Allegheny County Medical Society.
References
1. See https://www.c-span.org/video/?c4943022/senator-paul-
clashes-education-secretary-nominee-transgender-students-girls-
sporting-activities.
412-281-1901 • www.3kcpa.com
2. Carol Pogas, Denied a Varsity Letter For Running Track at 16,
Gay Man Will Get It at 79, New York Times, 3/2/21, https://www.nytimes.
com/2021/02/28/nyregion/tom-ammiano-gay-varsity-letter.html.
3. Sara Spary, Caster Semenya appeals to European Court of
Human Rights over ‘discriminatory’ testosterone limit, https://www.cnn.
com/2021/02/26/sport/caster-semenya-appeal-scli-intl-spt/index.html. SURPLUS MEDICAL
4. Gender Recognition Act of 2004, https://www.legislation.gov.uk/
ukpga/2004/7/contents.
5. Valeriya Safronova, Passports Could Include a New Option
for Gender Identity, New York Times, 3/4/21, https://www.nytimes.
OR OFFICE ITEMS?
com/2021/02/24/style/gender-neutral-x-passport-ids.html. DONATE THEM TO GLOBAL LINKS!
6. Gillian R. Brassil, Athletes Push Back as States Move to Bar
Transgender Women in Sports, New York Times, 3/12/21, https://www.
nytimes.com/2021/03/11/sports/transgender-athletes-bills.html.
7. See note 1, at 1:58, “I think it’s the legal responsibility of schools WE CAN ACCEPT:
to provide opportunities for students to participate in activities and this
includes students who are transgender.” SUPPLIES, EXAM TABLES,
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ACMS Bulletin / April 2021 1052021 ACMS Membership Benefits
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info@prosuranthealth.com | Phone: 412-321-5030 | Fax: 412-321-5323 | prosuranthealth.comPerspective
Perspective
Doctor, heal thyself
Wendy Palastro, MD
B eing a physician, I strive to put my
patients’ needs first, to provide the
best care I can. And with marriage
provider at the time of my routine
checkup. After further investigation, I
was diagnosed with hyperthyroidism
care of myself and give myself grace.
If I do not, my body may give me more
signs in the future that it is not well.
and motherhood, I focus on caring secondary to Graves’ disease. In ret- I am not perfect, and I don’t think
and serving my family. Though this rospect, this health condition was my any of us can be. In the journey of
commitment and devotion to others is body’s manifestation of all the stress in going through the rigors of high school
laudable, I realize now that this singu- my life, much self-imposed. education, college education and
lar dedication to others without focus- Though hard to admit, I am get- medical training, I realize there was
ing also on myself has led to negative ting older (and hopefully wiser in the a constant self-directed aim toward
consequences for my well-being. I am process), and my body is providing perfection. (And I am probably not the
trying to get better at caring for myself. constant reminders that I am not young only one.) Seeing the vast amount of
I am trying to change my behavior anymore. With these reminders, I am knowledge out there, I am humbly real-
through diligent practice and attention. making a concentrated effort each izing all of the things that I do not know
I am meditating, journaling, reading, day to slow down and let my body talk and will never know due to my limited
exercising, focusing on hobbies and to me and guide my efforts to work resources of time and energy. I have
outside interests, sleeping more and more efficiently. Gone are the days of come to appreciate and recognize my
looking more mindfully at the nutrition limitless energy and perceived invinci- own shift from a fixed mindset in col-
and fuel I am putting into my body. If bility. Now I must conserve – be it with lege/early years post college (“I know
something will not serve me and make my time, my energy, or my focus. I see almost everything and have all the
me better, I now question, “Why am I how fast time has passed already, as answers now that I have this degree!”)
doing it?” my children grow and the years tick to a growth mindset in the past several
A few years ago, I was struggling by in my marriage and in my career. I years (“Uh oh … there is a lot left to
with intense fatigue. My two children realize that time is finite, and health is learn. And I am not going to have time
were around 3 years old and 6 months not something to be taken for granted. to learn it all!”).
old at the time, give or take. I felt ex- Looking back on those years in my 20s Besides physical care, such as
hausted and attributed it to the “go-go- of not getting enough sleep, not eating striving for more sleep, more exercise
go” and numerous competing pres- the right nutrients and not getting near- and better eating (the last one is still
sures of being a full-time working mom ly enough exercise, I definitely have admittedly very much a work in prog-
with two very young children. I took it regrets. And I feel those health choices ress), I also am working on my mental
as “normal” to feel worn out. Looking at least in part led to my hyperthyroid- and emotional care. I spend some
back, though, I realize my time spent ism. My hyperthyroidism, thankfully, is of my free time reading, listening to
focused on my career and serving my well controlled currently with medica- podcasts and audiobooks, meditating
family (and not enough time spent on tion and lifestyle. Though I would rather and journaling. I am learning how to
myself) was having consequences. not have the condition, I think it serves play the guitar. I work on continuing
I shared this feeling with my health as a constant reminder that I must take medical education consistently, but
108 www.acms.orgYou can also read
