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Allegheny County Medical Society Bulletin July 2021 Legal update: COVID vaccines Medical history vignette: Ancient Egypt
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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
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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.orgEditorial 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 199Perspective
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.orgPerspec-
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 2012021 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.
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is enhanced with a $624 credit that can be applied to an Membership benefits ($1792 value)
annual subscription to our Group Purchasing Organization,
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To learn more, contact Terri Dowd at 412-321-5030 or email terri@acms.org.
info@indepractice.org | Phone: 412-321-5030 | Fax: 412-321-5323 | indepractice.orgPerspec-
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.orgALLEGHENY 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 205Perspective
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.orgPerspective
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.
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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
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ACMS Bulletin / July 2021 207Materia 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.orgYou can also read
