BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...

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BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...
Allegheny County Medical Society

Bulletin                           July 2021

Legal update:
COVID vaccines
Medical history vignette:
Ancient Egypt
BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...
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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
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BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...

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
BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...
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
BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...

                       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
BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...
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
BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...
                                                                                         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
BulletinJuly 2021 - Legal update: COVID vaccines Medical history vignette: Ancient Egypt - Allegheny ...

                                Sartorial choices
Anna Evans Phillips, MD, MS
    “The dress code is at least business    centers, suggested that in the realm        for physicians, where does attire
casual. Make sure that your earrings        of patient satisfaction, physician attire   rank? A physician’s ability to complete
aren’t too big, and your makeup is not      indeed matters.1 More than 50% of           their professional responsibilities is of
too loud.” These were the instructions      patients indicated that this made a         clearly greater import than what they
I received from a young production          difference in their experience of care      wear. But attire, just like all contexts of
assistant during a mandatory audio-         and overall satisfaction. Preferred         medical encounters, is a traditional part
visual check. I was presenting as an        attire in the primary care setting was      of the patient experience.
expert at a virtual national medical        formal attire (collared shirt and slacks        For male physicians, iconic
conference – and I was taken aback          for both men and women, with tie for        representations of physician attire
by these details. I politely thanked the    men); in the emergency department,          are available going back through the
representative, and proceeded back          scrubs; and in the inpatient setting,       ages. Norman Rockwell paintings,
to my day of patient encounters and         formal attire. White coats with these       representations of country doctors
virtual meetings.                           options were preferred everywhere           visiting sick children, images of surgical
    Patients and colleagues comment         except for with surgeons; there was         theaters – almost all contain only
to me frequently on my clothing; to my      no significant difference for female        representations of men. A piece in
great relief, it is mostly complimentary.   surgeons to wear or not wear a white        the Gentleman’s Gazette even offers
I take careful note of the fact that        coat, whereas male surgeons were            helpful tips on obtaining the classic
people not only notice my sartorial         preferred to wear scrubs alone. The         physician wardrobe.3 For women,
choices, but feel the need or desire to     study was notably limited by the fact       there are fewer historical visual
comment on them as well. I observe,         that all physicians pictured were young,    representations. Though television is
for example, that my male colleagues        slim and Caucasian.                         making headway in its representation
receive far less commentary on their            Perhaps just as tellingly, there        of female physicians, the true diversity
clothing, but not because they dress        was acknowledgement of variations           of ages, races, shapes and sizes
any less notably or professionally than     in attire: The female and male              present in the female physician
I tend to. The recommendation from          counterparts are dressed in the same        workforce is at best only partially
my production colleague before a            limited attire. But attire is always        represented.
virtual presentation to particularly pay    gendered; in a separate 2020 study of           So, it comes back around to
attention to my jewelry and makeup not      orthopedic surgeons, it was found that      the question: What to wear? Many
only irked me because of its specifically   female surgeons who wore feminine           corporate health care organizations
gendered nature, but due to the fact        business attire instead of scrubs were      maintain general guidelines mostly
that it came at all.                        perceived as significantly less likely to   aimed at trainees but inclusive of
    Does it matter what physicians          excel at performing the physical part       employees that include ideas of
wear? A 2018 BMJ Open Study,                of surgery than female surgeons in          modesty and appropriateness (avoid:
which surveyed more than 4,000              scrubs.2                                    tight-fitting clothing, bare midriffs,
U.S. patients across 10 tertiary care           In the grand scheme of priorities       low necklines, strapless tops and

198                                                                                                              www.acms.org
Editorial                                                         Let us be the key to your future ...
miniskirts), and encouragement for appropriate grooming
is included. Interestingly, the United Kingdom’s National
Health Service additionally offers the caveat that skirts
are not to be higher than 5 cm above the knee.4 Advice                                                                Specializing
from peers on this subject is highly varied in both content                                                           in physician
and quality. The blog Corporette (a self-described blog                                                               practices
for “overachieving chicks”) maintains a conversation
about appropriate female physician attire, which focuses
                                                                                                                      since 1978
on the experience of several individual physicians and
their preferences for casual knits or certain brands of
flat shoes.5 The not-incorrect-but-hardly-helpful advice
is offered to maintain a neat hairstyle. In short, there is a
vacuum of guidance on a subject of great import for the
everyday experience of female doctors.
    The reality is that the female physician workforce is
growing constantly – and increasing in relative proportion
every year. The choice – or preconceived notion – of
what female physicians should wear has not been
already circumscribed or dictated by generations of
female physicians in front of us. Female physicians –
many of us the first in our families – are living a bit of an                 412-281-1901 • www.3kcpa.com
experiment, trying on clothing every day that speaks to
our professionalism and capabilities, but that seeks also                 References
to express some of who we are and how we steered our                      1. Petrilli, C. M., Saint, S., Jennings, J. J., Caruso, A., Kuhn,
course to this profession.                                            L., Snyder, A., & Chopra, V. (2018). Understanding patient pref-
    The multitude and competing nature of many societal               erence for physician attire: a cross-sectional observational study
expectations for professional women makes the choice of               of 10 academic medical centres in the USA. BMJ Open, 8(5),
attire particularly difficult. Sartorial choices for all physicians
                                                                          2. Goldstein, S. D., Klosterman, E. L., Hetzel, S. J., Grogan,
convey a tone to patients, other providers and academic               B. F., Williams, K. L., Guiao, R., & Spiker, A. M. (2020). The Effect
audiences that are important and individual all at once.              of an Orthopaedic Surgeon’s Attire on Patient Perceptions of
Ability and knowledge remain the core substance of the                Surgeon Traits and Identity: A Cross-Sectional Survey. J Am Acad
foundation of any physician role. What we wear remains an             Orthop Surg Glob Res Rev, 4(8), e20 00097-00011.
                                                                          3. Schneider, S. R. (2017). Dressing the Doctor: A Physician’s
essential signal about who we are, particularly so as women
                                                                      Guide to a Classic Wardrobe. Retrieved June 13, 2021, from
continue to establish standards for generations of physicians         https://www.gentlemansgazette.com/dressing-the-doctor-clas-
yet to come.                                                          sic-wardrobe/
                                                                          4. National Health Service Foundation Trust Uniform and
   Dr. Evans Phillips is associate editor of the ACMS Bulletin        Dress Code Policy. (2020). Retrieved June 13, 2021, from https://
and assistant professor of Gastroenterology at UPMC; her              www.ncic.nhs.uk/policies/navigate/6904/339
                                                                          5. Griffin, K. Fashion for Doctors. Retrieved June 13, 2021,
research is focused on pancreatitis and genetic cancer                from https://corporette.com/fashion-for-doctors/
syndromes. She can be reached at evansac3@upmc.edu.

     The opinion expressed in this column is that of the writer
    and does not necessarily reflect the opinion of the Editorial
                                                                       For advertising information, contact
   Board, the Bulletin, or the Allegheny County Medical Society.       Meagan Sable at msable@acms.org.

ACMS Bulletin / July 2021                                                                                                                199

                      Restricted medical license
Jorge Lindenbaum, MD

F   ifteen years ago, I attended a
    large convention on Health Care
Management. After listening to a
                                          provide standard care for my patients.
                                          Even worse, many of my patients are
                                          paying (out of a pocket they can ill
                                                                                           In all fairness, the insurance
                                                                                       companies are not the only ones
                                                                                       who have failed their subscribers.
lecture detailing cost savings by         afford) for prescriptions and testing        Big Pharma, inflated administrative
restricting medication prescribing, I     necessary for optimal treatment.             salaries, government regulations and
began a spirited conversation with the        If the goal of restricting our medical   lack of a collective physician backstop
gentleman seated beside me.               license is to contain and lower health       have all made contributions to the
    “This won’t be good for patients,”    care costs, it is failing miserably. Allow   current state of rising health care costs.
I quipped. “How can I assure them of      me to elaborate.                             I could go on, but Voltaire said it well,
the best treatment available if I can’t       1. There’s been a steady increase        “The secret of being a bore is to tell
prescribe it?”                            of emergency room visits.                    everything.”
    He responded, “No problem, you            2. Hospitalizations are on the rise.         Instead, I prefer to be optimistic.
prescribe any medication, order any           3. We are referring to more              I am thankful to be a practicing
test, do the follow-up … we just won’t    specialists.
                                                                                       physician in the United States. I’ve
pay for it.”                                  4. Diagnostic delays make illnesses
                                                                                       trained at the best institutions and
    What a perfect combination of         more difficult and costly to treat.
                                                                                       had many opportunities to advance
arrogance and total disregard for             5. There are fewer office visits and
                                                                                       my knowledge and skill set. And yes,
patients subjected to (in my mind)        preventative appointments due to
an inconceivable notion of health         providers and staff using their valuable     I know we face numerous challenges
care. As the seminar droned on, I sat     time doing prior authorizations and          in the health care industry, but as
dejectedly in the crowded room of         other non-medical paperwork.                 physicians, we need a much louder
physicians who listened attentively,          6. More distractions at visits while     voice. We know what is best for our
but voiced little feedback to this        a provider wastes time sorting through       patients ... we always did, we always
radical new concept designed to           what is/isn’t covered, which varies with     do and we always will put the patient’s
reduce health care costs.                 each patient.                                needs first. Our patients deserve
    It puzzles me how a “one size             7. Medical errors and malpractice        nothing less.
fits all” care package benefits any of    cases are increasing.
us. I’ve spent countless hours trying         8. Additional stress, frustration           Dr. Lindenbaum is an internist and
to get approval for appropriately         and irritation for physicians and staff.     hypertension specialist. He can be
prescribed medications and testing that   (We’re only human!)                          reached at bulletin@acms.org.
were denied arbitrarily by insurance          9. Demoralizing burnout.
providers. Too many times I left the          10. Frequent staff turnover: We are       The opinion expressed in this column is that
office feeling completely drained,        losing experienced, compassionate             of the writer and does not necessarily reflect
                                                                                       the opinion of the Editorial Board, the Bulletin,
and I must admit, angry, because of       providers to early retirement; many             or the Allegheny County Medical Society.
the unnecessary burden required to        are changing careers.

200                                                                                                                  www.acms.org
   Society News
POS 2021-22 Monthly Meeting                  with a primary clinical interest in optic   and glaucoma specialist in 2000
Series schedule announced                    neuropathy and vasculitis. She sees         and was director of the Glaucoma
                                             a full range of neuro-ophthalmologic        Service and fellowship from 2012–20.
    Marshall Stafford, MD, newly             conditions, but specializes in adult        He became medical director of the
elected president of the Pittsburgh          autoimmune optic neuropathy                 Cincinnati Eye Institute in 2019.
Ophthalmology Society (POS), is              syndromes, diplopia, headache and           He is a volunteer clinical assistant
pleased to announce the 2021-22 POS          multiple sclerosis (MS).                    professor at the University of Cincinnati
Monthly Meeting Series. A total of six           Her main research interests             College of Medicine, Department of
meetings are scheduled, beginning in         include preventative treatment trials       Ophthalmology, and was voted teacher
September and concluding with the            for autoimmune optic neuropathies           of the year by his residents in 2011. He
Annual Meeting in March.                     and neuroprotection. Dr. Lincoff            has been selected by his peers to Best
    All meetings are scheduled               presents annually at national and           Doctors in America since 2001.
for Thursday, except for the Oct.            international conferences regarding             Dr. Khatana uses the latest cataract
5 meeting, which will be held on             MS and the use of ocular coherence          surgical technology, including the
Tuesday.                                     tomography and imaging specific to          use of toric and multifocal intraocular
    Mark Your Calendar – Monthly             her field. She also is involved in the      lenses, and specializes in the
Meeting Dates will be held:                  “Hopeful Ways Nicaragua Eye Care            management of various complicated
    Sept. 9                                  Mission Project,” an annual medical         and advanced forms of glaucoma, as
    Oct. 5 (Tuesday)                         mission to Nicaragua to prevent             well as all the newer minimally invasive
    Dec. 2                                   blindness. Working together with            glaucoma surgeries. As an investigator
    Jan. 6, 2022                             a group of medical professionals,           in various clinical trials, Dr. Khatana
    Feb. 3, 2022                             local interpreters and Peace Corps          is able to provide his patients access
    March 11, 2022 - 57th Annual             volunteers, the project provides free       to new drugs and technologies at an
Meeting and 42nd Ophthalmic                  vision care to more than 2,600 patients     earlier stage.
Personnel meetings. The Pittsburgh           a year.                                         The POS
Marriott City Center will host the               During the social portion of the        welcomes Edwin
concurrent event.                            program, the POS welcomes exhibitors        H. Ryan, MD,
    Guest faculty who confirmed details      who sponsored the 56th Annual Virtual       Vitreoretinal Surgery,
prior to the print deadline are below.       meeting. The Society is grateful for        PLLC, associate
When available, updated speaker              continued support from this select          clinical professor,
information will be posted on the POS        group, especially during last year’s        Ophthalmology,
                                                                                                                      Dr. Ryan
website at www.pghoph.org.                   unprecedented time.                         University
    We begin the                                 The Oct. 5 meeting                      of Minnesota Department of
series Sept. 9 and                           features Anup                               Ophthalmology, Edina, Minn., to
welcome guest                                K. Khatana, MD,                             speak at the Dec. 2 meeting. Thank
speaker Norah                                medical director,                           you to Thierry Verstraeten, MD, board
S. Lincoff, MD,                              Cincinnati Eye                              member, for inviting Dr. Ryan.
professor, Department                        Institute, Cincinnati,                          Dr. Ryan was awarded his Doctor of
of Neurology, Jacobs                         Ohio. Thank you to                          Medicine degree from the University of
                            Dr. Lincoff                                  Dr. Khatana     Minnesota. He completed a residency
School of Medicine                           Ian Conner, MD, PhD,
& Biomedical Sciences, University at         POS board member, for inviting Dr.          in Ophthalmology at Northwestern
Buffalo, Buffalo, N.Y. Thank you to          Khatana. Please note this meeting is        University and a fellowship in Diseases
Pamela Rath, MD, president-elect, for        scheduled on Tuesday.                       and Surgery of the Retina and Vitreous
inviting Dr. Lincoff.                            Dr. Khatana joined Cincinnati           at Washington University in St. Louis.
    Dr. Lincoff is a neuro-ophthalmologist   Eye Institute (CEI) as a cataract                               Continued on Page 204

ACMS Bulletin / July 2021                                                                                                     201
2021 ACMS Membership Benefits


                                                                   EF ME D
   A EN UR

                                                                IC PL 20
         ES T

                                                                     IT M
     TI EN

                                                              BE IAN OY
                                                              YS EM 20
    C D



      Get the support your                                    PH
                                                                   Advocacy. Education.
      practice needs.                                              Resources.
  EDUCATION. ADVOCACY. SAVINGS.                                    Allegheny County Medical Society.
  Your Allegheny County Medical Society Membership
  is enhanced with a $624 credit that can be applied to an              Membership benefits ($1792 value)
  annual subscription to our Group Purchasing Organization,
  IndePractice. We empower independents to deliver                      ACMS Bulletin
  exceptional care.                                                     • Free annual subscription, 12 monthly issues.
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                           For information, contact Terri Dowd
                          at terri@acms.org, or (412) 321-5030.
2021 ACMS Membership Benefits

                                              Empowering independents.
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Valid for 12 months                           Platinum    Gold            Silver

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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.org
   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
    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
  Community  Notes                                                                        POS website periodically for updates
                                                                                          and to register, www.pghoph.org.
                                                                                              Contact Nadine Popovich,
HIV awareness training available for providers, public                                    administrator, to confirm the status of
    AHN/Highmark collaborated with the Positive Health Clinic to create an HIV            your membership or to inquire about
awareness training, which caters to all staff as well as the public. It is a free         upcoming programs. She can be
and informational resource for providers. The link to the training is: https://bit.       reached at npopovich@acms.org or
ly/HIVawarenessPGH.                                                                       (412) 321-5030.

204                                                                                                               www.acms.org
                   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.


      Patricia L. Bononi, MD

                                                Nominations for 2022 Office

                                I am interested in being a candidate for the ACMS:

        BOARD OF DIRECTORS                 DELEGATION TO PAMED                 PEER REVIEW BOARD
       Three-Year Term                    Two-Year Term                     Three-Year Term

       ♦    Represents physicians         ♦    Represents the physicians    ♦   Investigates written
            on issues impacting                of Allegheny County              allegations of ethical
            the practice of               ♦    creating statewide policy        violations or
            medicine and makes                 on issues impacting              unprofessional conduct on
            policy decisions for the           physicians, patients and         the part of a member of
            Society.                           the practice of medicine.        the ACMS made by a
       ♦    Meets four times per          ♦    Meets as necessary prior         physician or physicians.
            year, special meetings             to attending the House of
            as needed.                         Delegates in October in
                                               Hershey, PA.

       Circle:           YES              Circle:        YES                Circle:       YES

    Name ____________________________________                  Email ____________________________________
    [Please Print]             Phone ___________________________________

    I would like to recommend ___________________________________________________________for

                 ________ Board of Directors        ___________ Delegate.        __________ Peer Review

      Please enclose a copy of your CV. Fax the completed form to 412-321-5323 by Monday, August 9, 2021.
                                                  Thank you.

ACMS Bulletin / July 2021                                                                                         205
 Activities & Accolades
ACMS member receives
Distinguished Service Award
    ACMS member Leo R. McCafferty,
MD, FACS, was recently bestowed
the Distinguished Service Award by
The Aesthetic Society. The award was
presented to Dr. McCafferty May 2
at the Society’s annual international
meeting, held as a hybrid of virtual and
in-person meetings in Miami, Fla.
    According to Dr. McCafferty, “I had
not planned to attend the meeting
this year due to upcoming family
commitments. When I was in my office
on Thursday afternoon, I joined the
meeting virtually and was informed
that my colleagues had chosen me                                                                                Photo provided
for this honor. This was a complete        Leo R. McCafferty, MD, FACS, left, accepts the Distinguished Service
surprise to me! I felt so honored but      Award from Herluf G. Lund Jr., MD, FACS, immediate past president of The
also disappointed that I was not with      Aesthetic Society.
my colleagues. My wife, Susan, and
I made the quick decision to get a         reserved only for someone who truly       and honor. He is a true role model for
flight to Miami the next day so that I     rises to the pinnacle in service to the   all of us to emulate. He is one of my
could accept the award, in person, on      society.                                  heroes not just in plastic surgery but
Sunday. It is such a special recognition       “The Distinguished Service award      in life. It is one of my highest honors
that I was honored to accept, as the       is presented to a member of The           of my presidency to present Dr. Leo
organization has given me far more         Aesthetic Society whose dedication,       McCafferty with the Distinguished
than I have taken.”                        service, and/or contributions to the      Service Award.”
    The Aesthetic Society is an            development, wellbeing and success            Dr. McCafferty currently serves as
organization of approximately 2,600        of the society have been demonstrated     medical director in Shadyside at his
plastic surgeons worldwide devoted to      over many years and have exemplified      private practice, Leo R. McCafferty,
the advancement of cosmetic surgery.       action above and beyond the expected      MD, FACS, and Associates Plastic
    Dr. McCafferty was nominated for       or ordinary. Leo McCafferty not only      Surgery, PC. He has a long career
the award by Herluf G. Lund Jr., MD,       meets the criteria for this award, he     that has always specialized in plastic
FACS, a plastic surgeon practicing in      personifies it.                           surgery. Early in his career, he served
St. Louis. Dr. Lund is the immediate           “Leo has served as a President        as chief of Plastic Surgery Staff
past president of The Aesthetic            of The Aesthetic Society under the        Services at the University of Miami
Society.                                   most challenging of times. After his      School of Medicine/Jackson Memorial
    According to Dr. Lund, “The highest    term of office ended, Leo continued to    Medical Center, where he also was
award The Aesthetic Society can            dedicate himself to the society serving   assistant professor of Clinical Surgery.
bestow on one of its members is the        on numerous committees, task forces,      Dr. McCafferty serves currently as
Distinguished Service Award. This is a     and every capacity asked of him. He       clinical assistant professor of Plastic
very special award. It is not an annual    has always answered the call and          Surgery at the University of Pittsburgh,
award given out yearly, but an award       he has done so with humility, grace       School of Medicine.

206                                                                                                          www.acms.org
 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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                                                  Pittsburgh, PA 15276

ACMS Bulletin / July 2021                                                                                                    207
Materia Medica

Relugolix: One new drug, many new indications
Alexandra N. Marshall,                     cardiovascular effects than GnRH              three clinical disease presentations that
PharmD                                     agonists. For the treatment of pain           would qualify a candidate for the trial:
                                           associated with uterine fibroids, it is       biochemical or clinical relapse after
Karen M. Fancher, PharmD,                  given in combination with estradiol           local primary intervention with curative
BCOP                                       and norethindrone. In endometriosis,          intent, prostate specific antigen (PSA)

R    elugolix, a hormone receptor
     antagonist, has recently received
U.S. Food and Drug Administration
                                           relugolix could either be given as
                                           monotherapy for the first 12 weeks
                                           followed by combination therapy, or
                                                                                         levels increasing after treatment with
                                                                                         curative intent, newly diagnosed
                                                                                         hormone-sensitive metastatic disease,
(FDA) approval for two different           combination therapy only.                     or advanced localized disease that is
disease states and is under                                                              not likely to be cured. Key exclusion
investigation for other conditions as      Treatment of prostate cancer                  criteria included patients who had a
well. This oral agent provides new             After skin cancer, prostate cancer        major cardiovascular event (myocardial
alternatives for the treatment of          is the most common cancer in                  infarction, transient ischemic attack,
common conditions in both men and          men in the United States. Prostate            brain hemorrhage, or stroke) within six
women.                                     cancer is the second leading cause            months prior to the start of the trial.3
    Relugolix is an orally acting,         of cancer death in American men,                  This study was conducted for 48
selective antagonist of the                behind lung cancer.1 For advanced             weeks, and the primary endpoint
gonadotropin-releasing hormone             disease, the backbone of therapy is           was sustained castration rate, which
(GnRH) receptor. It suppresses             androgen deprivation therapy with             was defined as less than 50 ng/dL
the release of gonadotropin from           LHRH agonists. However, these                 of testosterone. The results of the
the pituitary gland, leading to a          agents cause an initial testosterone          trial revealed that relugolix reached
reduction in estradiol, progesterone       surge that may result in an increase          sustained testosterone suppression
and testosterone levels.1,2 This           of symptoms. Therefore, an oral               below castrate levels from days 29
mechanism is in contrast to GnRH           antiandrogen is often prescribed for          through 48 weeks in 96.7% of patients,
agonists/luteinizing hormone-              the first weeks of treatment with an          compared to 88.8% of patients who
releasing hormone (LHRH) agonists          LHRH agonist.3 Injectable GnRH                received leuprolide, thus showing
such as leuprolide and goserelin,          antagonists such as degarelix may be          both superiority and non-inferiority
which result in initial up-regulation of   used to avoid such tumor flare, but the       of relugolix. In addition, a PSA level
hormone levels prior to suppression.2      clinical utility of degarelix is limited by   decrease by more than 50% by day
Further, since relugolix is a GnRH         frequency of injections, injection-site       15 of the trial occurred in 79.4% of
antagonist, it causes the suppression      reactions and cost.3                          patients in the relugolix arm compared
of both luteinizing hormone (LH) and           In the randomized phase III HERO          to 19.8% in the leuprolide arm.
follicle-stimulating hormone (FSH),        study, 934 men with advanced prostate         Testosterone suppression to castrate
whereas GnRH agonists only cause a         cancer were assigned in a 2:1 ratio to        levels occurred by day four in the
suppression of LH.                         relugolix 120 mg daily (after a single        relugolix group, in contrast to the
    Relugolix has shown promise in         loading dose of 360 mg) or leuprolide         leuprolide group, in which a surge
the treatment of prostate cancer,          22.5 mg injection every three months.         in testosterone levels was observed
endometriosis and uterine fibroids.        Eligible patients had to be at least          before decreasing to castrate levels
In prostate cancer, it is used as          18 years old, had confirmed prostate          on day 29. The authors of the study
androgen deprivation therapy, without      cancer and were candidates for at             also noted that a subgroup of patients
the need for concurrent antiandrogen       least one year of continuous androgen-        was followed for testosterone recovery
therapy. In addition, it may have fewer    deprivation therapy. There were one of        after therapy discontinuation, with

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