Tick-borne Diseases and Why They are so Important in 2018
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Physicians’ Bi-Monthly Volume 2, 2018
Tick-borne Diseases and Why Summer has come to
New Hampshire…Don’t
They are so Important in 2018 blink… but also don’t
forget sun protection.
By Frank Hubbell, MD*
Today tick-borne illnesses are one It is estimated that By Peter Sands, MD
of the most important issues for The defense against skin cancer
anyone who ventures outdoors in ticks exceed all other is two pronged. I recommend
New England. Whether you are patients perform a full self-skin
a gardener, hiker, biker, birder,
spelunker, paddler, or day-trek- arthropods in the exam on each national holiday
(on days when one might have
ker, it doesn’t matter. Anyone who a few extra minutes). Of course,
enjoys the outdoors has at one number and variety of skin cancer is more commonly
time or another, had to endure found on sun exposed areas, but
the concerns associated with being diseases that they can I remind patients to look at non
a meal for a tick (ugh) and with it, sun-exposed skin as well. Skin
the chance of developing a tick-
borne illness. transmit. cancer can lurk on the bottom of
the feet as well as on the face.
The problem is simple: ticks I am often asked about sun pro-
All tick-borne diseases are parasitic
are little cesspools, and they can tection. I am a big fan of wide
illnesses. A parasite is an animal
spread a wide variety of poten- brimmed hats (as much as I
that lives in or on another animal,
tially serious illnesses. Ticks are like the Red Sox, a baseball cap
the host, at the expense of that
the leading cause of insect vector- lacks good coverage). Visors, for
animal. In parasitic infections, it
borne disease in the United States those who do not want to mess
is only the parasite that benefits
and second only to mosquitoes up their hair are an acceptable
from this relationship, causing
worldwide. In fact, 95% of all in- second choice. I am also a fan
illness, disease, and even death in
sect vector-borne diseases in North
the host animal. Summer has come, cont. on page 6
America are spread by ticks.
What is a tick?
A tick is a small arachnid ectopara-
site that survives and thrives by
Also in this issue...
taking blood meals, hematophagy,
from mammals, birds, and occa- Review of AMA Annual
sionally reptiles or amphibians. Meeting
Tick-borne Diseases, cont. on page 5 Environmental Safety in
the Physician Office
Understanding the
Teenage Brain
Responsive Practice
Training
Legislative wrap-up
Physicians’ Bi-Monthly
New Hamphire Medical Society
7 North State Street President’s Perspective
Concord, NH 03301
603 224 1909 Report from the AMA Annual Meeting in
603 226 2432 fax
nhmedicalsociety@nhms.org
Chicago, June 9-13, 2018
www.nhms.org
ing medicine, and less concerned
Leonard Korn, MD.................... President with social issues that were more
James G. Potter, CAE.......................... EVP of my personal and professional
Mary West........................................ Editor interest. However, times have
changed and I think the AMA
New Online Training Offers Strategies
has changed dramatically as well.
to Facilitate Health Care for Patients
with Disabilities.....................................3 My perspective of the AMA first
Understanding the Teenage Brain..........4 began changing only recently
Help Rename the NHMS Bimonthly when I learned that the AMA
Newsletter!...........................................7
was strongly advocating passage
2017-2018 NHMS Council..................... 11
NHMS Welcomes New Members........... 11
of the Affordable Care Act in
Environmental Safety in the Physician 2010. I suspect that the change in
Office Practice....................................12 the AMA becoming progressive
Sugar-sweetened beverages: good, Leonard Korn, MD
and socially relevant probably
bad or just ugly?.................................14 occurred long ago and I only
Corporate Affiliate Program..................14 I wrote about my experience at
2018 NH Legislative Session the AMA Annual Meeting in my learned of the change recently. I
Wrap-Up.............................................18 blog recently. However, there wonder in that context whether
was so much more to discuss that other NHMS members and
I want to focus on the AMA and physicians in general know of
Mission: Our role as an organization in creating the
world we envision. the AMA Annual Meeting in this today’s AMA as the major advo-
The mission of the New Hampshire Medical Society edition of President’s Perspective cacy organization representing
is to bring together physicians to advocate for the well-
being of our patients, for our profession and for the as well. the voice of medicine throughout
betterment of the public health. the United States and in Wash-
I am a new member of the AMA,
Vision: The world we hope to create through our ington, D.C. My participation in
having joined in preparation
work together. the AMA Annual Meeting in Chi-
The New Hampshire Medical Society envisions for my role as NHMS presi-
cago, June 9-13, as your NHMS
a State in which personal and public health are dent this year. Full disclosure: I
high priorities, all people have access to quality president, has convinced me of
healthcare, and physicians experience deep satisfaction never thought much of the AMA
the importance of the AMA to all
in the practice of medicine. when I was a medical student
physicians in our country and to
Do you or a colleague need help? at University of Chicago from
The New Hampshire Professionals’ Health the public health of our country
1964-1968, intern and first year
Program (NH PHP) is here to help! as well. The motto of the AMA is
The NH PHP is a confidential resource that psychiatry resident at Maine
assists with identification, intervention, referral “Members Move Medicine” and I
Medical Center from 1968-1970,
and case management of NH physicians, for one have become a believer.
physician assistants, pharmacists, and and then finishing my residency
Please check out the AMA on
veterinarians who may be at risk for or affected at the University of Wisconsin in
by substance use disorders, behavioral/mental their website www.ama-assn.org
health conditions or other issues impacting Madison, WI, from 1970-1972.
for details of the Annual Meeting
their health and well-being. NH PHP provides In those days I was focused on
recovery documentation, education, support as well as general information on
learning medicine/psychiatry
and advocacy – from evaluation through the AMA. Consider joining if you
treatment and recovery. and dealing with the craziness
For a confidential consultation, please call are not a member because we are
of our country’s war in Vietnam,
Dr. Sally Garhart @ (603) 491-5036 or email clearly stronger together.
sgarhart@nhphp.org. as well, of course, as trying to
*Opinions expressed by authors may not grow up myself in those turbu- The AMA has been advocating
always reflect official NH Medical Society lent times. Through those years for policies to curb the epidemic
positions. The Society reserves the right to
edit contributed articles based on length and/ and more to follow I did not pay of gun violence in our country
or appropriateness of subject matter. Please
much attention to the AMA. I for years. I am proud to report
send correspondence to “Newsletter Editor,”
7 N. State St., Concord, NH 03301. thought it was mostly concerned that the gun violence prevention
with the economics of practic-
President’s Perspective, cont. on page 9
2
Volume 2, 2018
New Online Training Offers Strategies to Facilitate
Health Care for Patients with Disabilities
The New Hampshire Disability & Public Health Dr. Plotnik notes, “This training reminds us that all
(DPH) project’s training, Responsive Practice: Pro- patients want and deserve to be treated with respect
viding Health Care & Screenings to Individuals with and compassion. It also demonstrates that commu-
Disabilities, is now available online, on-demand, nication can happen in many different ways, and it
and free for a limited time. A Responsive Practice is important for practices to be able to accommodate
enhances health care providers’ ability to deliver these different forms of communication.”
disability-competent care that is accessible to people The Responsive Practice training is eligible for con-
with intellectual, mobility, and other disabilities. tinuing education and continuing medical education
The training provides much-needed insight into the credits. Learn more and register for the training
challenges that patients with physical and intellec- at www.ResponsivePractice.org or by contacting the
tual disabilities may face when accessing health care. project at dph.iod@unh.edu.
Many people take access to high quality, compre- The NH Disability & Public Health Project (DPH),
hensive care for granted, but this is not necessarily funded by the U.S. Centers for Disease Control and
the case for people with disabilities. The Responsive Prevention (CDC) cooperative agreement number
Practice training teaches strategies to both anticipate 1NU27DD000007, is a collaboration between the
and address barriers in order to facilitate better Institute on Disability at the University of New
care. It is relevant for the entire team of people Hampshire and the NH Division of Public Health
coming into contact with patients at a health care Services. The project goal is to improve the health
facility, including administrative staff, medical as- and quality of life of people with disabilities in New
sistants, nurses, and health care providers. Hampshire. �
“Responsive Practice builds on knowl-
edge that providers already have and
identifies opportunities to maximize
wellness for individuals with dis-
abilities,” explains Kimberly Phil-
lips, DPH Principal Investigator and
co-author of the training. “The great
thing about this training is that it is
not only applicable to people with
disabilities – a Responsive Practice is
person-centered and inclusive for all
patients, including patients with dis-
abilities.”
NHMS member, Dr. Lisa Plotnik, an
Internal Medicine/Pediatrics provider
at Dartmouth-Hitchcock, consulted
on the training and appears through-
out the training video to share her
experience with patients with varying
disabilities and their family members.
3
Physicians’ Bi-Monthly
Understanding the Teenage Brain
By David Schopick, MD This takes place in young adult- Second, as we all know, teens are
Any parent of a teenager has hood. undergoing significant hormonal
probably been mystified at some Are the teen years a hazardous changes. Reproductive hormones
point by how their child’s mind period? shape not only sex-related de-
works. “What were you think- velopment and behavior but also
Yes, they can be. Adolescents are social behaviors. Our hormones
ing?” is a common refrain when nearly at the peak of their physi-
learning of certain teen activities also influence our response to
cal health, strength and mental stress, which can increase the
or decisions. The fact is, a teen- capacity, yet for many teens this
ager’s brain IS different from an tendency to be very emotional,
is a dangerous time. Mortality act out, have mood swings, and
adult’s. Understanding some of rates jump between early and late
those differences may help im- so on. And adolescence IS stress-
adolescents. Rates of death by ful– young people are struggling
prove communications between injury between the ages of 15 and
teens and adults, as well as any to navigate changes in their
19 are six times those of children bodies, relationships, school and
efforts at offering guidance. between the ages of 10 and 14. social circles, and planning their
How is the teenage brain differ- Crime rates are highest among futures. Suddenly, there are
ent? young males during this time, as more responsibilities–whether it
Research has also shown that dif- are the rates of drug and alcohol is driving a car or earning money
ferent parts of the brain mature abuse. Many teens come through for school or working to achieve
at different rates. Areas involved adolescence unscathed, but un- good grades.
in more basic functions mature derstanding the factors that can
put them at risk during this time Also impacting behavior is the
first, such as those controlling fact that while the part of the
movement and feedback from can go a long way towards ensur-
ing that this transition is a safe brain driving emotional response
your senses. The last parts of the is heightened, the part of the
brain to mature are those con- and healthy period.
brain controlling impulses is not
trolling impulses and planning How does the teenage brain af- fully developed. This is why ado-
ahead, both of which are seen as fect behavior? lescents often seem to try things
hallmarks of adult behavior. The impact is multi-faceted. First or do things without considering
of all, the brain circuitry involved the risk or evaluating possible
in emotional response is un- outcomes.
dergoing changes during this How does the brain influence
time. Teens are operating at a teenage drinking?
higher pitch emotionally than
children or adults. Because Drinking to excess can put any-
of different circuit patterns one at risk, but while adults drink
and molecular more frequently than teens, teens
changes, they tend to drink in larger quantity.
actually This tendency seems to be influ-
enced by the lack of fully devel-
oped impulse control within the
brain. Overdrinking can lead to
alcohol poisoning, severe injury
or worse in the short-term, and
do ex- to alcoholism in the long-term.
perience Why is sleep important?
things more
intensely, It’s been well documented that
which can most adolescents need more
then drive sleep than they are getting, and
their behav- that adolescent sleep patterns are
ior. The Teenage Brain, cont. on page 7
4
Volume 2, 2018
Tick-borne Diseases, cont. from page 1
Tick-borne Diseases in North America: appear anywhere on the body,
and there can be multiple spots.
Disease: Cause: That being said, EM does not
Lyme Disease Borrelia burgdorferi always appear.
Southern Tick-associated Rash Illness (STARI) Borrelia lonestari Incubation: From bite to the start
Anaplasmosis Anaplasma phagocytophilum of symptoms is 3 - 30 days.
Human Monocytic Ehrlichiosis Ehrlichia chaffeensis Erythema migrans occurs 50 -
80% of the time.
Human Ewingii Ehrlichiosis Ehrlichia ewingii
Other symptoms include: fe-
Cat Scratch Fever Bartonella hensaelae ver, headache, myalgias (muscle
Rocky Mountain Spotted Fever Richettsia richettsii pain), arthralgias (joint pain),
Colorado Tick Fever RNA coltivirus and lymphadenopathy (swol-
len lymph nodes). The swollen
Tularemia Francisella tularensis lymph nodes are regional, and
Tick-borne Relapsing Fever Borrelia species they tend to occur near the tick
bite more often than being gen-
Babesiosis Babesia microti
eralized.
Tick Paralysis neurotoxin
The infected person can also be as-
Q Fever Coxiella burnetti ymptomatic.
Powassan Encephalitis Flavivirus Diagnosis is clinical:
How do ticks spread disease? ing information, it is generally The patient has a history of a tick
If ticks only fed on disease-free believed that the tick has to be bite or tick exposure.
animals, or if they only took one attached to the host for at least
Rash: Erythema migrans, diag-
meal in a lifetime, there wouldn’t 24 hours to transmit the Lyme
nostic if >5cm in diameter.
be any problems. Unfortunately, spirochete.
The rash is the only absolute in-
they do not; they have multiple Most commonly, Lyme Disease
dicator of Lyme Disease; it is only
hosts. As they feed and take a is spread by the nymph, simply
seen in 50 - 80% of the cases.
blood meal, they also pick up because they are so small and
any bloodborne pathogens in the hard to see. There are blood tests for Lyme
host’s blood. These pathogens Titer and Western Blot.
Symptoms of Lyme Disease:
remain in the gut of the tick as It may take one month to devel-
it ages and molts. When the tick The classic sign of Lyme Disease
op serologic antibody titers, that
attaches itself to its next unsus- is erythema migrans (EM), a red,
will produce a positive test.
pecting victim and begins to feed, circular rash with clearing in the
center, giving it a target-like ap- If suspicious of Lyme Disease,
it will pass on the pathogens that
pearance. EM is considered to be and the initial blood test for
are in its gut to the new host.
diagnostic if greater than 5cm in Lyme antibodies is negative, re-
LYME DISEASE: Borrelia burg- diameter. EM does not have to peat the test in two to four weeks.
dorferi present at the tick bite site; it can
Tick-borne Diseases, cont. on page 10
Etiology: Lyme Disease is caused
by the bacterial spirochete - Bor-
relia burgdorferi. It is, unfortu-
nately, a relatively common and
significant infectious disease that
can cause lifelong problems.
All of the life stages of the tick
– larva, nymph, or adult – can
spread disease by taking a blood
meal. Although there is conflict-
5
Physicians’ Bi-Monthly
Summer has come, cont. from page 1
of sun protective clothing. I always recom-
mend that patients stay under the umbrella
at the beach and reserve the beach walks for
before 10 am and after 4 pm, when the rays
are much less intense.
I always stress three things about the choice
of sunscreen. It should read “broad spec-
trum” to ensure coverage against both UVA
and UVB rays. The SPF factors refers to the
UVB protection and should be the highest
one can find. Patients rarely apply as much
sunscreen or re-apply often enough to get
the advertised SPF. I also recommend that
it read waterproof so that it is resistant to
sweating.
Many men are resistant to putting any
creamy products on their skin. For them I
recommend a gel based sunscreen. I am not
a proponent of the spray sun screens just
because I think too much of the product
gets lost before it lands on the skin. I am
also unsure of how good it could be for the
lungs to inhale the sunscreen ingredients. �
Ready to help in the Boardroom or the Courtroom
Michael Pignatelli Steve Lauwers Ken Bartholomew Adam Varley
Barbara Greenwood Adam Pignatelli Larry Smith Lindsey Dalton
RN Paralegal
ADVOCATES FOR THE MEDICAL PROFESSION
Rath, Young and Pignatelli, P.C. www.rathlaw.com
Concord Nashua Boston Montpelier
(603) 226-2600 (603) 889-9952 (617) 523-8080 (802) 229-8050
6
Volume 2, 2018
The Teenage Brain, cont. from page 4
different than those of children Knowing he has someone to parents can try to find environ-
and adults. The changes in the talk to can help him cope with ments or activities that allow
teenage brain have it “wired” to relationships, school, work or that freedom, but reduce the
want to stay up later at night and planning the future. If he or risk. Hiking, sports, music, art
sleep later during the day–pat- she has goals, try to work with and travel can all help satisfy
terns that tend to conflict with them to make plans that get the those urges while allowing
most current school and work desired outcomes. Seeing how independence and self-expres-
days. (This can also sometimes planning can achieve results sion; at the same time, such
be diagnosed as Delayed Sleep builds a good foundation for interests and experiences will
Phase Syndrome, a circadian future decision-making. provide lifelong benefits.
rhythm disorder.) No one does * Stress the importance of avoid- The good news is that the teen-
their best work or makes the best ing alcohol and drugs. Make age brain has the greatest capac-
decisions when sleep deprived, sure the risks are well-known. ity for learning. Its intellectual
but when you combine this with At the same time, adults need power is incredible. By channel-
the other factors influencing the to make sure that their child ing that capacity into the right
teenage brain, then risks can be knows that if he or she is in areas, parents can enrich their
magnified. A tired teenager has trouble, their parents are al- child’s life for years to come. �
greater difficulty paying atten- ways there.
tion and making good choices,
and can also be more vulnerable * Parents can also aid their child
to depression. in getting good rest. Parents
can try to keep teens from get-
How can parents help their teen- ting overscheduled; make sure
age children? there is balance and adequate
With a greater understanding of time for schoolwork, friends
the physiological factors that are and activities but also for rest.
influencing their children’s be- Many schools are looking into
havior, parents can try some new later starts for teens–parents
approaches with their teens: might consider supporting this
* Make an extra effort to keep effort.
communications open. This * Teens are natural risk-takers,
helps teens get answers and but need to understand that
information that can aid in bet- there are places where risks
ter decision-making and reduce never pay off–such as behind
the risk of impulse decisions. the wheel of a car.
* Good communication can help * Because teens have a need
reduce stress in your teen’s life. to explore and experiment,
Help Rename the NHMS Bi-monthly Newsletter!
We’re making some changes to the NHMS Physicians’ Bi-monthly, starting
with a new name. Please tell us what newsletter title would catch your eye.
Who can resist a one-question survey?!
https://conta.cc/2JYlRDM
7
Physicians’ Bi-Monthly
Vacant positions on the Board of Medicine and
Medical Review Subcommittee.
The Board of Medicine has The Medical Review Subcommittee (MRSC) to the Board of
two (2) vacant public mem- Medicine, pursuant to RSA 329:17, V-a, is looking for two (2)
ber positions on the Board. physician members and one (1) public member to serve on the
MRSC. For the physician members, the MRSC is in need of
the following specialties: General Surgery and Internist/Hospi-
RSA 329:3 Eligibility for Board
Membership states “All appoint- talist.
ed members who are physicians
or surgeons shall be residents RSA 329:17, V-a states “A medical review subcommittee of 13 mem-
of the state, regularly licensed bers shall be nominated by the board of medicine and appointed
to practice medicine and shall by the governor and council. The subcommittee shall consist of one
have been actively engaged in member of the board of medicine and 12 other persons, 3 of whom
the practice of their profession shall be public members, one of whom shall be a physician assistant,
within the state for at least five and 8 of whom shall be physicians. One of the physician members
years. The other members of the shall practice in the area of pain medicine and anesthesiology. Any
board shall have been residents public member of the subcommittee shall be a person who is not,
of the state for at least 5 years.” and never was, a member of the medical profession or the spouse
RSA 329:2, I states, in part, “Any of any such person, and who does not have, and never has had, a
public member of the board material financial interest in either the provision of medical ser-
shall be a person who is not, vices or an activity directly related to medicine, including the rep-
and never was, a member of the resentation of the board or profession for a fee at any time during
medical profession or the spouse the 5 years preceding appointment. The terms of the public mem-
of any such person, and who bers shall be staggered so that no 2 public members’ terms expire in
does not have, and never has the same year. The subcommittee members shall be appointed for
had, a material financial interest 3-year terms, and shall serve no more than 2 terms. Upon referral by
in either the provision of medi- the board, the subcommittee shall review disciplinary actions report-
cal services or an activity directly ed to the board under paragraphs II-V of this section, except that
related to medicine, including matters concerning a medical director involved in a current internal
the representation of the board or external grievance pursuant to RSA 420-J shall not be reviewed
or profession for a fee at any until the grievance process has been completed. Following review
time during the 5 years preced- of each case, the subcommittee shall make recommendations to the
ing appointment.” board. Funds shall be appropriated from the general fund for use
If you meet the criteria above by the subcommittee to investigate allegations under paragraphs I-V
and wish to apply for the va- of this section. The board shall employ through the office of profes-
cancy on the Board, please send sional licensure and certification a physician as a medical review sub-
your letter of interest and a committee investigator who shall serve at the pleasure of the board.
current resume or curriculum The salary of the medical review subcommittee investigator shall be
vitae to: established by RSA 94:1-a.
His Excellency, If you meet the criteria above and wish to apply for the public mem-
Governor Christopher T. Su- ber vacancy on the MRSC, please send your letter of interest and a
nunu current resume or curriculum vitae to:
and The Honorable Council Emily Baker, M.D., President
State House NH Board of Medicine
Concord, New Hampshire 121 South Fruit Street, Suite 301
03301 Concord, New Hampshire 03301
8
Volume 2, 2018
President’s Perspective, cont. from page 2
policies that NHMS approved high capacity magazines and mestic assault or stalking.
on March 14, and that the New armor piercing bullets. 7. Advance research in gun vio-
England Delegation of the AMA 2. Support banning the pur- lence by repealing the Dickey
approved on May 5, were debat- chase or possession of guns Amendment and encourag-
ed and approved overwhelmingly and ammunition by people ing research by the CDC on
by the AMA House of Delegates under 21. gun violence.
(HOD) on June 12. The debate
on those policies and other gun 3. Back laws that require licens- 8. Advocacy of schools to re-
violence policies were the most ing and safety courses for main gun-free zones except
intense and controversial of all gun-owners and the registra- for school-sanctioned ac-
the issues debated at this years’ tion of all firearms. tivities and professional law
meeting. The AMA also ap- 4. Support legislation (gun enforcement officials.
proved several other important violence restraining orders) to 9. Oppose requirements or
gun violence policies this year, so allow relatives (and others) of incentives of teachers to carry
that the AMA now has a compre- suicidal people or those who weapons.
hensive policy to advocate against have threatened violence to 10. Support for gun buyback
gun violence. seek court-ordered removal programs.
Let me summarize the newest of guns.
11. Oppose “concealed-carry
AMA policies on gun violence. 5. Encourage better training of reciprocity” federal legislation
The AMA agreed to: physicians in how to recog- that would require all states
1. Support a ban on owning nize patients at risk of suicide. to recognize concealed-carry
and purchasing assault-type 6. Support gun violence re- firearm permits granted by
weapons by the public, as straining orders for persons other states.
well as banning bump stocks, charged or convicted of do- President’s Perspective, cont. on page 16
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9
Physicians’ Bi-Monthly
Tick-borne Diseases, cont. from page 5
Treatment of Lyme Disease:
Tick Bite Prophylaxis – within 72 hours if the tick
has actually attached.
Lyme Disease prevention is doxycycline 200mg by
mouth once.
Treatment of Lyme Disease:
Doxycycline 100mg po bid for a minimum of 21
days Or Amoxicillin 500mg po tid for a minimum
of 28 days.
If younger than eight years old, use amoxicillin
50mg/kg/d in three doses.
Alternative: cefuroxime (Ceftin) 500mg po bid x 6
weeks.
Parenteral: ceftriaxone (Rocephin) 2g IV once daily
for two to six weeks.
Prevention of tick-borne diseases:
Use insect repellents or insecticides.
The insecticide Permethrin is very effective. It kills
the ticks. But, it does not adhere well to the skin, so it
should be applied to clothing, either by spraying ar-
ticles or washing them in the insecticide. Permethrin
can also be used on tents and mosquito netting.
The insect repellant DEET can be applied directly
to the skin. It is a “repellent” and helps to keep the
bugs away, but does not kill them.
Use DEET with caution on children; it should be
less than 30% concentration.
Wear protective clothing, which includes shoes and
socks with the long pants tucked into the socks. A
long sleeve shirt would also be appropriate. Thousands of families have
Do frequent tick checks. Several times a day, stop
and check your skin for ticks, remembering to check
put the creation of their trusts
in places where the sun doesn’t shine. Ticks like to and the management
be warm, dark, and moist.
Co-morbid factors: of their estates in our hands.
Other infectious diseases that are spread by the
same deer tick, the Ixodes species, that can occur
TRUSTED A DV ISOR S FOR CH A NGING TI M E S
along with Lyme Disease:
Anaplasmosis: Anaplasma phagocytophilum
Babesiosis: Babesiosis microtis
Sulloway & Hollis P.L.L.C.
Cat Scratch Disease: Bartonella henselae
Headquarters: Concord, New Hampshire
Keep hiking, biking, climbing, and enjoying, but
603-224-2341 | www.sulloway.com
please DON’T FEED THE BUGS!
*Dr. Hubbell will be speaking at the 2018 NHMS Annual Scientific NEW HAMPSHIRE | MASSACHUSET TS
Conference, Trending Topics this November. See the back page of this RHODE ISL AND | MAINE | VERMONT
issue for more information. �
NH_Medical_Society_3.625x9.75_FA.indd 1 7/18/17 2:11 PM
10Volume 2, 2018
2017-2018 NHMS Council NHMS Welcomes
President Leonard Korn, MD New Members
President-Elect Tessa J. Lafortune-Greenberg, MD Adam P. Androlia, DO
Gregory A. Bonci, MD
Immediate Past President Deborah A. Harrigan, MD
Erik S. Diebolt, DO
Penultimate Past President John R. Butterly, MD Neil T. Dion, MD
Vice President John L. Klunk, MD Ryan K. Duffy, MD
Khumara Huseynova, MD
Secretary Eric A. Kropp, MD
Wandana Joshi, DO
Treasurer Stuart J. Glassman, MD Fuad Khan, MD
Speaker Richard P. LaFleur, MD Tad P. Lanagan, DO
Vice Speaker Daniel M. Philbin, MD Douglas R. Mailly, MD
Suzana K. Makowski, MD
AMA Delegate William J. Kassler, MD, MPH
Isabella W. Martin, MD
AMA Alternate Delegate P. Travis Harker, MD, MPH Samantha Rebien Pawlowski, MD
Chair, Board of Trustees Charles M. Blitzer, MD Syed M. Peeran, MD
Raja A. Rehman, MD
Trustee Richard B. Friedman, MD
Marie-Helene Sajous, MD
Trustee P. Travis Harker, MD, MPH Saira C. Tekelenburg, MD
Medical Student Soham C. Rege Brian T. Trezak, MD
Physician Assistant Linda L. Martino, PA-C Rebecca A. Zuurbier, MD
Osteopathic Association Rep. Maria T. Boylan, DO
Young Physician Reps. Kenton Allen, MD
Young Physician Reps. Anthony M. Dinizio, MD
Members-at-Large Diane L. Arsenault, MD
Members-at-Large Albert L. Hsu, MD
Members-at-Large Seddon R. Savage, MD
Members-at-Large Doris H. Lotz, MD, MPH
Members-at-Large
Physician Member of Board of Medicine
Linda Kornfeld, MD
Nick P. Perencevich, MD
WANTED
Lay Person Lucy Hodder, JD Internal Medicine, Orthopedic,
Neurologic, General or Family Practice
Physician Representatives
Physicians interested in providing
Dept. of Health & Human Services Benjamin P. Chan, MD
part-time or full-time staff medical
Specialty Society Representatives: consultant services for the Social
• NH Chapter of Security Disability program, through
American College of Cardiology Daniel M. Philbin, MD the state Disability Determination
• NH Chapter of Services office in Concord, NH. Staff
American College of Physicians Richard P. Lafleur, MD work involves reviewing disability
claims on-site and requires no patient
• NH Academy of Family Physicians (2) Gary A. Sobelson, MD
contact. SSA Training is provided.
Molly E. Rossignol, DO
OR
• NH Chapter of Emergency Physicians Thomas J. Lydon, MD
Physicians interested in performing
• NH Society of Eye Physicians & Surgeons Lauren Branchini, MD
consultative examinations in
• NH Pediatric Society Skip M. Small, MD their office for the Social Security
• NH Radiology Society Terry J. Vaccaro, MD Disability program, through the state
• NH Psychiatric Society Jeffrey C. Fetter, MD Disability Determination Services
office. Compensation is provided per
• NH Society of Anesthesiologists Steve J. Hattamer, MD
exam. All administrative aspects are
• NH Society of Pathologists Eric Y. Loo, MD performed by the DDS and no billing is
• NH ACOG Oge H. Young, MD required. Free dictation service and a
• NH Orthopaedic Society Glen D. Crawford, MD secure web portal is provided for report
Invited Guest: MGMA Representative Dave Hutton
submission. Any interested physician
must be licensed by the state of NH and
in good standing. Please email inquiries
to: Anne.Prehemo@ssa.gov
11Physicians’ Bi-Monthly
Environmental Safety in the Physician Office Practice
Life Safety: Grounds and Parking Fire Safety
Areas • Check for signage warning
• Remove snow from parking that elevators are not to be
areas and walkways as needed. used in a fire emergency.
Proactive safety management helps • Frequently sand/treat icy areas. • Place fire alarms and fire
to ensure a safe environment in the • Repair uneven surfaces, pot- extinguishers in an accessible
physician office practice. Use the fol- holes, cracks. area.
lowing recommendations as a guide • Service fire extinguishers an-
in the development of an environ- • Remove debris.
nually.
mental safety program. • Maintain adequate lighting
to minimize shadows; replace • Install No Smoking signage in
I. Environmental Safety Plan designated areas.
burned out bulbs.
Operational • Routinely inspect sprinkler
• Install signage to identify
• Develop a safety plan that de- parking entrances and exits. system.
scribes how to maintain a safe Hazardous Materials
environment. Include the role Fall Prevention
of the physicians and employ- • Closely monitor occupants of • Label and store hazardous
ees. waiting areas. products in appropriate con-
tainers in a locked storeroom.
• Conduct walk-around inspec- • Clearly identify wet floors and
tions on a regular basis to steps with a warning sign. • Provide personal protective
identify potential risks. Correct equipment.
• Seat the patient in a chair in
identified risks. Emergency Preparedness
the exam room, not on the
• Encourage physicians and exam table, while awaiting • Ensure federal, state and local
employees to report unsafe or the physician. Do not leave a standards have been met re-
potentially hazardous condi- patient alone if they are at risk garding disaster preparations.
tions. Immediately remedy for a fall. Medical Emergency
high risk situations.
• Use chairs and examination • Inspect emergency equipment
II. Plan Elements tables appropriate to the needs for accessibility, proper func-
Life Safety: Office Setting of the patient. tioning. Resupply at designat-
• Arrange furniture away from • Assist unstable patients with ed intervals and after each use.
traffic areas. accessing the exam table, III. Education
opening doors or maneuvering
• Remedy sharp table corners through corridors. • Educate new physicians and
and worn carpeting. staff on safety practices and
Electrical Hazards expectations.
• Install call bells and safety bars
in patient restrooms. • Keep electrical outlets in good • Provide annual safety educa-
condition. tion to physicians and employ-
• Remove clutter, equipment
and obstacles from walkways. • Store electrical cords appro- ees.
priately to prevent tripping • Train physicians and staff on
• Limit height of stacked materi- hazards.
als to prevent collapse. the proper use of equipment
• To maintain child safety, uti- and recognition of product
• Maintain stairwells with firmly lize plugs for electrical outlets hazards.
attached handrails and ad- or install child safe outlets. Medical Mutual’s “Practice Tips” are offered
equate lighting.
Equipment Safety as reference information only and are not in-
• Identify glass doors with em- tended to establish practice standards or serve
blems. • Properly ground equipment. as legal advice. MMIC recommends you ob-
• Inspect office equipment for tain a legal opinion from a qualified attorney
• Clearly mark all exits. Post for any specific application to your practice.
evacuation routes. functionality and integrity.
• Check emergency exit signs • Follow manufacturer require-
for visibility and lighting. ments for safe usage.
• Test emergency lighting. • Secure oxygen cylinders.
12Volume 2, 2018
Partners in
patient safety
& medical liability
protection
www.medicalmutual.com
13Physicians’ Bi-Monthly
Sugar-sweetened beverages: good, bad or just ugly?
The NH Comprehensive Can- factors for many types of can-
cer Collaboration (NH CCC), cer. Most (65%) adults in New
in partnership with Dartmouth- Hampshire drink an SSB at least
Hitchcock Norris Cotton Cancer monthly; 1 in 5 adults drink SSBs
Center and its NCI National Out- daily. SSB intake is also frequent
reach Network Educator Com- among high schoolers. Addition-
munity Health Educator Site, ally, SSB intake is more common
recently released a new emerging among those with lower household
issue brief on the health impacts income levels, suggesting that the
of sugar-sweetened beverage health risks related to high SSB
consumption. Sugar-sweetened intake may have a disproportion-
beverages, or SSBs for short, are ate effect based on socioeconomic
drinks that have added sugar. status.
This includes sodas, fruit drinks Cutting SSBs out of the diet
like punch and lemonade, sports can be an effective step towards
drinks, energy drinks, and even weight management, which is
sweetened tea and coffee. important for reducing cancer
Strong evidence links SSB intake risk. Healthier beverages include
to a greater weight gain over time water, unsweetened iced teas, or
in children and adults. For exam- seltzers. Learn more in the full
ple, just one SSB per day may lead version of the brief, which can be
to a weight gain of one-quarter found under “Quick Links” on
to one-half a pound per year for the NH CCC home page, http://
adults. Being overweight, obesity, www.nhcancerplan.org. �
and diabetes are established risk
AF F IL I ATE S E RV I C E S
Billing Services Electronic Payment Systems Pharmaceuticals
Business Management Employee Benefits Practice Management
Financial
Collection Service Telecommunications
Insurance
Dental Benefits Legal Uniforms, Apparel & Linens
Electronic Medical Records Office Supplies Web-based Billing
NHMS CAP is a paid membership program whose members meet criteria as posted at www.nhms.org
14Volume 2, 2018
15Physicians’ Bi-Monthly
President’s Perspective, cont. from page 9
These new AMA gun violence which now has separated more At the AMA Annual Meeting
policies enhance already ap- than 2000 kids from their par- we also inaugurated Dr. Barbara
proved AMA policies such as ents, “will do great harm” to chil- McAneny as AMA president. Dr.
support for universal back- dren and could “create negative McAneny gave a moving speech
ground checks on all gun pur- health impacts that will last an in- at her inauguration, encouraging
chases including gun shows and dividual’s entire lifespan.” AMA us to “step up and create a system
private sales even from one fam- Board Member Bobby Mukkama- of healthcare that is worthy” of
ily member to another and sup- la, MD, stated “children leaving our patient’s trust. During the
port for safe storage of firearms. the chaos of their home countries meeting we had powerful speech-
The new policy on registering all should not be further trauma- es by Dr. McAneny, Dr. Barbe
firearms is one I am very proud tized by the U.S. government pol- and our Surgeon General Dr. Je-
of as it will hopefully allow for icy of separating children from rome Adams. We also elected as
tracing of stolen firearms that their caregiver. It’s inhumane president-elect Dr. Patrice Har-
so often end up in the hands of and risks scarring children for ris. When she assumes the AMA
criminals and become involved in the rest of their lives.” This immi- presidency in June 2019, she will
gun-related violence and crimes. gration policy is so inimical to our be the first African-American
There were many other policies shared humanity and traditions female to hold that office. Once
debated and approved by the as a welcoming society, formed again I would encourage every-
AMA at their Annual Meeting. through immigration throughout one to check the AMA website
In particular, I am so pleased our countries’ history. The AMA www.ama-assn.org for details of
with the AMA opposing the cur- will forcibly advocate ending this the meeting including the reports
rent government policy of sepa- barbaric policy, which cannot of the elections and summaries of
rating kids from their parents be supported by anyone with a the various speeches. And consid-
at our southern border. The conscience. er joining if you are not already a
AMA emphasized that this policy, member of the AMA. It is truly
withdrawal management • individual counsel- the “voice of medicine.” �
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17Physicians’ Bi-Monthly
2018 NH Legislative Session Wrap-Up
By James Potter
The Medical Society formally
tracked over 150 bills during
the 2018 legislative session of
the New Hampshire General
Court. Though all of these bills
impacted physicians and their
patients in some manner, the fol-
lowing are the highlights of some Banning Electroconvulsive Maintenance of
bills prioritized by our Legisla- Therapy (SB 480, SB 584) Certification
tive Committee for advocacy. A Opposed – Bills Did Not Pass Reform (HB 1769)
comprehensive spreadsheet and Two bills banning the use of ECT Supported – Bill
summary of all of the legislation on minors and some involuntary Did Not Pass
followed and acted upon by the patients were filed in the state HB 1769 prohibited
Medical Society can be found at Senate. After extensive outreach maintenance of
http://www.nhms.org/legislative- with the NH Psychiatric Society, certification (MOC)
reports and in the July 4 edition the bills’ sponsors agreed that from being used as a
of the NHMS Pulse. physician guided ECT is being mandatory requirement for
Requiring Insurance Coverage conducted in a cautious, profes- insurance reimbursement, li-
for 3-D Mammography (SB 189) sional and responsible manner. censure or hospital privileges.
Supported – Bill Passed, Signed into Both bills were subsequently Polls indicate that over 90% of
Law defeated in the Senate. Granite State physicians do not
Extending Medicaid Expansion believe that MOC meaningfully
SB 189 requires health insurance contributes to their practice or
policies to cover 3-D mammogra- (SB 313)
patients. Though the bill passed
phy tests. Most hospitals and im- Supported – Bill Passed, Awaiting the House, it was not able to
aging providers offer 3-D mam- Governor’s Signature overcome opposition raised by
mography as the standard of SB 313 reauthorized Medicaid the hospitals and the ABMS in
care and many insurance carriers Expansion. To date, Medic- the Senate. The Medical Society
already cover the service, but it is aid Expansion has helped over plans to urge that similar legisla-
strenuously opposed by Harvard 130,000 Granite Staters gain tion be refiled next session, and
Pilgrim and AHIP. NHMS over- access to health care. Addition- continues to push for substantial
came negative recommendations ally, the program has been reforms in relevance, alternatives
of both chamber’s Commerce instrumental in supporting the to high stakes exams and reduc-
Committees to help overturn and statewide Drug Court system and ing MOC costs.
pass the bill (21-1) in the Senate other substance use treatment
and (178 to 154) in the House. Limiting Pharmacy Board
programs. The NHMS strongly Oversight of Infusion Products
supported SB 313 to allow New (SB 581)
Hampshire’s residents access to
necessary health care services. Supported – Bill Passed, Signed by
Governor Sununu has pledged to Governor
sign SB 313 when it reaches his The NH Board of Pharmacy
desk. (BOP) determined that certain
infusion services being provided
in physician offices or infusion
centers, which had been widely
performed for years with no
adverse incidents, were subject to
Legislative Session, cont. on page 19
18Volume 2, 2018
Legislative Session, cont. from page 18
BOP oversight as compounding include network adequacy re- The Medical Society concluded
activities and began conducting quirements for the four services another very successful session in
surprise inspections and fining listed above, a prudent layperson no small part due to your partici-
several offices. The bill clarified standard, and mediation with in- pation in testimony, emails and
that these types of activities were surance carriers to the legislation. conversations with NH lawmak-
not compounding activities and Requirements for Lyme Disease ers. Unfortunately, space does
therefore not under the Pharma- Testing (HB 1388, SB 475) not permit me to thank all of you
cy Board’s jurisdiction. NHMS is who were involved in the leg-
exploring legislation to formally Opposed – Bills Did Not Pass islative process this year. Your
exclude BOP oversight from phy- Two nearly identical bills related continued engagement and sup-
sician practices. to Lyme disease required spe- port is so very much appreciated.
Eliminating Balance Billing cific statements on Lyme disease Thank you. �
(HB 1809) antibody testing be distributed by
practitioners. The Medical So-
Opposed Original Version – ciety urged a more comprehen-
Amended Bill Passed, Awaiting sive patient education approach
Governor’s Signature focusing on prevention and early
In its original form, HB 1809 intervention.
only banned the practice of Another series of bills challenged
balance billing by health care immunizations, reproductive
providers performing anesthe- rights of women, increasing avail-
siology, radiology, emergency- ability of contraceptives, prevent-
medicine or pathology services. ing childhood lead poisoning,
Knowing the bill was likely to and adding a new licensure
pass due to public demand, category of “graduate” physicians
NHMS convened and worked which will be featured in the July
with the four specialty societies to 4 edition of the NHMS Pulse.
GET HELP NOW!
The NH Professionals Health Program (NHPHP) is a confidential
resource available to all NH licensed physicians, PAs, dentists,
pharmacists and veterinarians who are experiencing difficulties with:
alcohol, drugs or other substances of abuse
depression, anxiety or other mental health issues
professional burnout or work-related conflict
marital or family life matters
For a confidential discussion call Dr. Sally Garhart at (603) 491-5036
LEARN MORE @ WWW.NHPHP.ORG
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Concord, NH
Permit No. 1584
7 North State Street
Concord, NH 03301
603 224 1909
603 226 2432 fax
nhmedicalsociety@nhms.org
www.nhms.org
ADDRESS SERVICE REQUESTED
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NHMS Annual Scientific Conference
Fri.-Sun., November 9-11
Wentworth by the Sea Hotel and Spa, New Castle, NH
Registration and Room Reservation Info at:
http://www.nhms.org/2018conferenceYou can also read
