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moral inj ury plus Teaching with Simulation
Opening the Door to a New World of Education in Latin America
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(833) 770-1541 • dauphincms.org 2021 DCMS BOARD OF DIRECTORS Shyam Sabat, MD President Jaan E. Sidorov, MD Immediate Past President Joseph Answine, MD President-Elect Andrew Lutzkanin, III, MD Vice President Everett C. Hills, MD Secretary/Treasurer
MEMBERS-AT-LARGE Mukul Parikh, MD Michael D. Bosak, MD John Forney, MD Virginia E. Hall, MD FACOG FACP Andrew J. Richards, MD, FACS, FASCRS
FALL 2021
Contents Features
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Teaching with Simulation
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Stepping Into Retirement
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8
Earn CME For Learning About Moral Injury
When is Freedom of Choice Over?
22
12
Pennsylvania Act 60 of 2021 Solidifies the Anesthesia Care Team into Law
When to Consider Palliative Care For Your Patient
Andrew R. Walker, MD Saketram Komanduri, MD John C. Mantione, MD
EDITORIAL BOARD Joseph F. Answine, MD, Editor in Chief Ariel Jones, Executive Director Robert A. Ettlinger, MD Gloria Hwang, MD Puneet Jairath, MD Heath B. Mackley, MD
In Every Issue From the Editor . . . . . . . . . . . . . . . . . . . . 4
Legislative Updates. . . . . . . . . . . . . . . . 26
Restaurant Review. . . . . . . . . . . . . . . . . 24
DCMS News. . . . . . . . . . . . . . . . . . . . . . 30
Mukul L. Parikh, MD Meghan Robbins, MS2 Shyam Sabat, MD The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Dauphin County Medical Society. All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the editor.
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terility is important for the surgical field, but it’s not necessary within the entire hospital. When I was a youngster in medicine in the early ’90s before tablets, cell phones and EMR, we talked in the operating room. We joked with each other, high-fived and hugged when we brought a patient from the jaws of death back to the living. We were colleagues and friends. When we argued about anything, it stayed there, it was worked out immediately and we moved on. We would rent buses and take group trips to concerts and the like.
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Even when Google and Yahoo realizes that freedom of thought and time to relax and enjoy each other’s company within a work environment is beneficial, medicine has gone the opposite direction. We demand sterility of thought and action. Some of this has been created by email, text messaging and everything else involved with the computer age where we can hide behind a computer screen and voice complaints and concerns instead of dealing with problems face to face. Plus, innocent until proven guilty has been replaced by immediately guilty until proven maybe less guilty. Other inciting events are the great turnover of staff throughout hospitals making it relatively impossible to develop tight friendships with our coworkers. Furthermore, we rarely see or talk with the “bosses.”If you want to talk with the CEO of UPMC, you must make a 3.5-hour car trip to the west; or if you want a discussion with the president of Penn State, you are heading to Happy Valley. Lancaster General’s CEO is in Philadelphia. Other institutions may be run by hedge fund managers. Who knows? But it’s unlikely you will be having a sit down with them discussing work or shared interests. Of course, all sites have middle management, and they obviously do their best to communicate with staff, but they still take their orders from those far away. I published a paper in Anesthesiology Clinics in 2019 (1) entitled “Burnout, Wellness, and Resilience in Anesthesiology.” What I learned when writing it was that the symptoms of burnout are consistent, but the causes are not. Many of us long-in-the-tooth in this business see the “sterile” environment as a stressor taking something away from the enjoyment of the job. Now, I understand the concern. Maybe, the individuals in a subordinate position wouldn’t feel free to step in and say, “enough is enough” at the time of the incident. However, back in the “old days” the nurses, scrub techs, and OR aides dished it out as well as they took it. And we all protected each other. Maybe not all situations ended up with a quick and perfect resolution, but generally all were involved with the jokes, arguments and make-ups. Don’t think your colleagues will come to your defense in today’s world. Collateral damage is a real fear. They will and must keep the blinders on and move forward with their day and careers. And I wouldn’t expect a level playing field because bottom lines are bottom lines, therefore, high earners or those that bring in significant business may be given some leniency not necessarily available to all.
more unstable throughout the day. The student thought we could have done more earlier, possibly avoiding ICU care. He voiced that complaint on rounds confessing to us that his mom suffers from the same disease. The attending talked us through the case and asked me if I could have done more. I said that now I don’t know. We learned, the student and I remained friends for years after and it ended there. Today, both of those events could be emails, peer review and department or institution-wide meetings, and who knows what outcomes would be today because of a joke and a misunderstanding. But don’t fret. If there is a punishment for your actions, you go from physician to victim, and the institution goes from protector to big business. Then, Anne Howe, your legal counsel from Dewey, Cheetum, and Howe, can write up the papers for a wrongful something.
I remember two incidents from my past. The first was on rounds as an intern in IM. It was a tough morning after pager call for everyone. The mood was somber to say the least. My attending, a great IM doc, infection specialist and mentor, looked at me and said, “What position did you play in football?” I said offensive guard. He then SOURCES said, “Now you are just offensive.” The whole group laughed, I got a 1. Answine JF, Lu AC, Levy TSM. Burnout, Wellness, and pat on the back, and we moved on. The second was a Sunday call day Resilience in Anesthesiology. Int Anesthesiol Clin. 2019 also during my intern year. We were getting hit hard with admissions. Summer;57(3):138-145. doi: 10.1097/AIA.0000000000000235. A lady came in with a leukemia variant and the Med student and I PMID: 31577244. admitted her. I then moved on to many more admissions. We later transferred the leukemia patient to intensive care as she became
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S T E P P I N G I N TO R E T I R E M E N T Top Items to Help You Prepare By ANGIE M. STEPHENSON, CFP®, CPA/PFS Partner, Senior Wealth Advisor, Domani Wealth
Are you ready to retire in the next several months or upcoming years? If you are looking ahead with joy and expectation to realizing your retirement in the near future – congratulations! You may also be asking yourself: What do I need to do to be ready for this next step? If you, your friend, or a loved-one is reaching the finish line on the career stage of life, here are some items for you to review and share!
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HOW TO PREPARE FOR RETIREMENT: Ownership Transition: If you are a physician who owns a practice, it’s important to have a plan in place to transition your practice and work with professionals who may assist you in valuing the practice. It’s possible you will sell the practice to another group, who will take care of your patients and transition the ownership. This review and planning should begin a few years before retirement. Health Insurance: You will need to determine how you will receive health insurance after retirement. You will likely have the option of Medigap coverage or Cobra available to you. Will you have Medicare available, and will supplemental health insurance be needed? Medicare Premiums: You will need to understand how Medicare premiums work. As you retire, you can file a life event change of status for your Medicare premiums. By doing this, your monthly payment will not be based on your previous, paycheck-based income from two years prior, but rather will be adjusted to your current income, which could save you hundreds of dollars a month.
Social Security: Are you eligible to begin taking Social Security, and if so, when is the optimal time? Collecting these payments at the right time can affect several financial factors in your life. Pension Plans: Learn the details of any pension payments or defined benefit plan payments you are eligible to receive. The details surrounding your payout can be complex, and there are often several options to structure the payout. If you are married, should you select the joint payout option to also include an annuity for your surviving spouse if something were to happen to you? Is there a guaranteed term to the plan? Reviewing the risks and benefits of each payout plan will be beneficial. Employer Retirement Plans: Take the right steps for any employer-based 401(k) or 403(b) plans: What elections do you need to make? Do you plan to rollover the amount from those plans into an individual IRA, and how might that help you with the investment options available to you? Do you have any employer stock in a stock purchase or stock option plan? There could be tax-efficient ways to distribute that stock to you.
Retirement Income: Make sure you are comfortable and understand where your cash flow will come from each month when a paycheck will no longer be deposited automatically. Knowing the tax consequences of where your cash flow comes from is incredibly helpful. You will be affected differently if you pull funds out of your IRA vs. a Roth IRA or Part-Time Work: Many physicians retire your personal investments. A tax planning and work on a part-time basis. The arrange- strategy coordinated between your financial ment can help provide coverage for other planner and your accountant will be key. physicians during their paid time off, or Income Taxes: What is your plan to pay to assist with a high case load at a hospital your income taxes moving forward, since or medical practice. If this is what you are they will no longer be withheld from a considering, think through the amount of paycheck? You may need to estimate taxes, income you will earn as a part-time employee. determine what needs to be withheld from This will be an important factor in whether pension payments, IRA withdrawals, and you want to begin taking social security or Social Security payments. In the early delay the payments until after you are no years of your retirement, there may be a longer working. There are earnings limitapossibility for a Roth Conversion between tions in place that may require you to repay your retirement date and age 72, when your part of your social security if you are not at Required Minimum Distributions will begin. “full retirement age.” This is something to be carefully reviewed and planned for with your financial planner. Disability Policies: It’s possible you may have a supplemental disability policy as a physician available to cover your income in the event you became disabled. If you are retiring, it is important to cancel the policy upon retirement, since you should no longer need this coverage.
Charitable Giving: You should work with your financial planner and your accountant to determine how your charitable giving can impact your financial picture in retirement. Should you consider “bunching” contributions for tax deductions? Is a donor-advised fund something to consider? Home Equity Line of Credit: Consider a home equity line of credit (HELOC) loan before you retire, if you own a home. Banks often lend more readily to those with regular paycheck-based income. Having a HELOC may enable you to be more flexible with access to cash during an emergency, or if markets may be volatile. This access can also help you balance income to minimize tax consequences or help you manage Medicare premium costs. Professional Management: Decide if you feel comfortable managing your retirement plans and investment funds yourself or if you would like professional help. Working with a financial planner to manage your portfolio can help you ensure your retirement needs are met and improve your overall risk to match your goals. You will be able to answer questions such as – will your tax rate change? When should you begin pension or Social Security income? What risk level and investment options are the best for your specific plans and goals? How will charitable giving and tax planning affect your retirement? As you, your friends, or a loved-one approaches retirement, you can use this list to review and plan for entering retirement feeling confident and comfortable. Each item needs evaluation and a thoughtful approach.
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Earn
CME for learning about
moral injury By ROBERT P. LENNON, MD, JD, FAAFP; BRENDA M. WILSON, MS, CHCP; and PHILIP G. DAY, PHD
Moral injury happens when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.1,2 Recognized in combatants for thousands of years,2 in 2018 Drs. Wendy Dean and Simon Talbot were the first to suggest that physicians may experience moral injury as a function of practicing medicine.1,3 Moral injury is a particular risk to uniformed healthcare workers as a function of their military medical service and the professional obligation to maintain “usual level of medical care” in the absence of adequate supplies in a military setting.4,5
The authors developed the educational module discussed. Use of the module and assignment of Continuing Medical Education credit is free of charge. 8
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After a year of mostly academic debate, the practical outcome differences between what care patients need but being unable to moral injury as a source of clinician distress moral injury and burnout. (For a detailed provide it due to constraints that are beyond received formal recognition from the Na- comparison of moral injury, burnout, and our control.”3 We experience a moral injury tional Academy of Medicine and the National moral distress, see Day et al.’s, “Physician when we are unable to adhere to our oaths to Academies of Sciences, Engineering, and moral injury in the context of moral, ethical provide care (a core moral value) because of Medicine. In their landmark 2019 consensus and legal codes.”)10 external contraints (e.g., unwieldly electronic report on clinician burnout,6 they identify medical records or insurance restrictions). Burnout is a syndrome with three compoclinician burnout as a major problem im- nents: exhaustion, inefficacy, and cynicism/ Comparing moral injury and burnout pacting clinicians and their patients, calling depersonalization.11 It describes the physical, during the COVID-19 pandemic highlights for immediate action, including research emotional, and intellectual exhaustion that the differences between these contructs. into factors that contribute to burnout.6 occurs in the face of unrelenting stressors Mantri et al. found that during the first The report identifies “moral distress” as and a pathological response to the stressors six months of COVID-19, physicians one contributing factor, and mentions in one’s work environment, and is linked to experienced no change in burnout, but an “moral injury” in this context.6 While moral alcohol and other substance abuse, broken increase in moral injury.13 This is expected distress has been studied, especially in relationships, suicidal ideation, increased from the definitions above – the pandemic nurses,7 since the 1980s, relatively little medical errors, and diminished quality of came with marked external constraints on research had been done to describe, define, patient care.11 Most institutional remedies care (e.g., lack of personal protective equipand understand moral injury in healthcare for burnout focus on increasing resiliency.11 ment)14, increasing moral injury, but over a workers. A year later, Dr. Sneha Mantri and Moral injury is the harm one suffers upon short time (not long enough for burnout). colleagues published the first validated moral These differences have a practical impact injury inventory for medical professionals.8 violation (as a result of their own or others’ 12 actions) of one’s moral boundaries. Moral on practicing physicians experiencing distress. They found that moral injury had a lower injury is associated with substance abuse, While those suffering distress from burnout prevalence than burnout, but had a greater suicidal ideations and attempts, dysphoria, 9 may benefit from burnout treatments like negative impact. Now that moral injury 12 anhedonia, sociopathy, guilt and shame. resiliency or work-hours reduction,11 those has moved from a theoretical construct to a documented hazard of the medical profession, In clinical practice, “Moral injury describes Continued on page 10 it is important for physicians to understand the challenge of simultaneously knowing Central PA Medicine Fall 2021 9
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suffering from moral injury will not. In fact, resiliency training may increase harm among those suffering from moral injury.15 In combat veterans, healing moral injury has been described through reconnecting the injured with the moral network. Since much of veteran moral injury occurs in combat, this treatment occurs where there is not ongoing injury.16 Hence, this treatment may be less effective among healthcare workers. Dr. Brett Litz and colleagues have developed “Adaptive Disclosure” therapy to treat moral injury, but to date this has been studied only in those with Post Traumatic Stress Disorder.17 A better understanding of moral injury empowers physicians to recognize it in themselves and colleagues, and avoid improper labels and treatments. To facilitate this, we worked with the Division of Academic Innovation at the University of North Texas Health Science Center at Fort Worth to create an online education module, “Differentiating Moral Injury, Moral Distress and Burnout.” The module is built around a compelling narrative by Dr. Tyson Garfield describing events in his professional life that led to significant distress. These events are reviewed through the lenses of burnout and moral injury, giving learners a clear understanding of similarities and differences in these constructs. Successful completion of the module earns continuing education credit for physicians, nurses, pharmacists (and others!). To earn credit, users must register and take brief pre- and post-assessments.
References 1. Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019;36(9):400-02. 2. Litz BT, Kerig PK. Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications. J Trauma Stress. 2019;32(3):341-49. doi: 10.1002/jts.22405 [published Online First: 2019/06/05] 3. Talbot S, Dean W. Physicians aren't 'burning out.' They're suffering from moral injury. Statnewscom, 2018. 4. Baker MS, Armfield F. Preventing post-traumatic stress disorders in military medical personnel. Mil Med. 1996;161(5):262-4. [published Online First: 1996/05/01]
7. Jameton A. Nursing practice : the ethical issues. Englewood Cliffs, N.J: Prentice-Hall 1984. 8. Mantri S, Lawson JM, Wang Z, Koenig HG. Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. Journal of religion and health. 2020;59(5):2323-40. doi: 10.1007/ s10943-020-01065-w 9. Mantri S, Lawson JM, Wang Z, Koenig HG. Prevalence and Predictors of Moral Injury Symptoms in Health Care Professionals. The journal of nervous and mental disease. 2020;209(3):174-80. doi: 10.1097/ NMD.0000000000001277 10. Day P, Lawson J, Mantri S, Jain A, Rabaga D, Lennon R. Physician moral injury in the context of moral, ethical and legal codes. Journal of Medical Ethics. 2021:medethics-2021-107225. doi: 10.1136/ medethics-2021-107225 11. Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Medical teacher. 2017;39(2):160-63. doi: 10.1080/0142159X.2016.1248918 12. Callaway KL, Spates CR. Moral Injury in Military Members and Veterans: Oxford University Press, 2016. 13. Mantri S, Song YK, Lawson JM, Berger EJ, Koenig HG. Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic. The journal of nervous and mental disease. 2021;Publish Ahead of Print doi: 10.1097/NMD.0000000000001367 14. Williamson V, Murphy D, Phelps A, Forbes D, Greenberg N. Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry. 2021;8(6):453-55. doi: 10.1016/s2215-0366(21)00113-9 [published Online First: 2021/03/21] 15. Card AJ. Physician Burnout: Resilience Training is Only Part of the Solution. Ann Fam Med. 2018;16(3):267-70. doi: 10.1370/afm.2223 [published Online First: 2018/05/16] 16. Meador KG, Nieuwsma JA. Moral Injury: Contextualized Care. J Med Humanit. 2018;39(1):93-99. doi: 10.1007/s10912-017-9480-2 [published Online First: 2017/10/14] 17. Litz BT, Rusowicz-Orazem L, Doros G, et al. Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Research 2021;297:113761. doi: https://doi.org/10.1016/j. psychres.2021.113761
5. Hooft FB. Legal framework versus moral framework: military physicians and nurses coping with practical and ethical dilemmas. J R Army Med Corps. 2019;165(4):279-81. doi: 10.1136/jramc-2018-001137 [published Online First: 2019/03/25] 6. Committee on Systems Approaches to Improve Patient Care by Supporting Clinician W-B, National Academies of Sciences E, Medicine, et al. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being: National Academies Press 2019.
There is no cost to register, use the module,,or receive credit.,The module can be accessed here:,: https://unthsc.rievent.com/a/OVIAMY 10 Fall 2021 Central PA Medicine
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Pennsylvania Act 60 of 2021
Solidifies the Anesthesia Care Team into Law
By JOSEPH F. ANSWINE, MD, FASA 12 Fall 2021 Central PA Medicine
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ct 60 was signed into law by Governor Wolf on June 30, 2021. It provides statutory recognition of nurse anesthetists in Pennsylvania. Prior to Act 60, Pennsylvania was one of only two states (the other being New York) that did not recognize certified registered nurse anesthetists (CRNAs) in statute. Interestingly, it does not give them the designation of “advanced practice nurse” because that designation does not exist in current law in our state.
Senate bill 416, now act 60 of 2021, accomplishes both.
It also strengthens the anesthesia care of anesthesia care by a physician from team consisting of a physician and CRNA. Department of Health regulation into As stated in the law: A certified registered law. Until now, nurse anesthetists have nurse anesthetist shall have the authority to not been recognized for their excellent perform anesthesia services in cooperation abilities as anesthesia providers in statute in with a physician, podiatrist or dentist in- Pennsylvania. Furthermore, no law stated volved in a procedure for which anesthesia that a patient receiving anesthesia must be care is being provided if the anesthesia under the direction of a physician, dentist, services are performed under the OVERALL or podiatrist whether in a hospital, surgical DIRECTION of any of the following: center, or office. Both have been made into A physician licensed by the State Board of bills (dozens of them) only to be defeated Medicine or the State Board of Osteopathic at some point in the process over decades Medicine who has completed an accredited of legislative sessions in Pennsylvania. They residency training program in anesthesiology. were defeated because the anesthesiologists and nurse anesthetists have not agreed on A physician licensed by the State Board of these issues and have been able to convince Medicine or the State Board of Osteopathic members of the legislature to defeat the bills. Medicine who is performing the procedure Anesthesiologists were concerned that giving for which the certified registered nurse the nurse anesthetists titling in law would anesthetist is performing anesthesia services. open the door for independent practice, and A podiatrist licensed by the State Board of the nurse anesthetists were concerned that Podiatry who is performing the procedure putting physician oversight into law would for which the certified registered nurse restrict their ability to practice in the state. anesthetist is performing anesthesia services. However, the current leadership of the
Overall direction is defined in the law as Pennsylvania Society of Anesthesiologists “oversight of anesthesia services and medical (PSA) and Pennsylvania Association of management of patient care by a qualified Nurse Anesthetists (PANA) put differences individual who is present and available onsite, aside to agree to support legislation that but not necessarily present in the same pro- provides statutory recognition of the great cedure room as a certified registered nurse skills of the nurse anesthetists and to place anesthetist performing anesthesia services the overall direction of the anesthesia care for the duration of the services provided.” by a physician, dentist, or podiatrist from regulation into law. For decades, anesthesiologists and nurse Senate bill 416, now act 60 of 2021, anesthetists in Pennsylvania have attempted to convince legislators to pass legislation accomplishes both. into law to provide statutory recognition This was not an easy process, and it took of nurse anesthetists, and to place oversight a lot of man-hours debating the points and
getting approval from each society’s membership. But, in the end, years of struggle between the groups finally has come to an end and patients undergoing the risky process of anesthesia in Pennsylvania are the beneficiaries. The efforts to pass such legislation is by no means a small feat, but rather a long steady diligent course taken up by physicians, nurses, legislators and ultimately the Governor. To put this into perspective, the Pennsylvania Medical Society and all its resources continue to struggle to maintain physician oversight of the care of nurse practitioners and physician assistants. But direct physician involvement of anesthesia care is now a statutory requirement. For over 27 years, I have participated in what seemed to be endless attempts to solidify this accomplishment. I commend the current leadership and members of the PSA, PANA, legislators, and the governor in our state for setting differences aside and putting patients first.
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Teaching with Simulation O P E N I N G T H E D O O R TO A N E W W O R L D O F E D U C AT I O N I N L AT I N A M E R I C A By ELIZABETH SINZ, MD, MED, ELIANA ESCUDERO, BSN, MED, DAVE RODGERS, EDD, KAREN VERGARA, BSN, NATACHA CRUDI and NADIR AYRAD
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medical simulation in the Spanish language Abstract Simulation Education has become one and very few courses available in Latin of the pillars of healthcare education. This America to train all those who want to teach manuscript describes the steps to bring using this modality. healthcare simulation education to a new Simulation has been adapting to the language and culture using Kern’s Curric- educational needs of the institutions and ulum model for curriculum development. participants. More and more educational institutions in Latin America have been creating their own simulation centers and Introduction Simulation has become an important tool gathering the proper equipment to cover all over the past five decades, but it has been areas of the simulation from low fidelity to used for learning for much longer in all high fidelity. Technology undoubtedly has branches of healthcare education. In 1911, become an indispensable part of manikin Mrs. Chase was developed to help nursing simulation. student education. Almost everyone has met Penn State University has a long history Resusci Anne, a life-sized doll that was first using simulation for clinical education from introduced by the Laerdal Toy Company to undergraduate, graduate and post graduate help teach mouth-to-mouth ventilation for levels. There is also a long history in the drowning victims. In 1969, Sim One, the first institution offering basic and advanced main frame computer-controlled simulator, training for faculty involved in teaching was introduced to teach anesthesia students. with Simulation. Faculty anesthesiologist One of the biggest challenges for advancing healthcare simulation is the constant need for faculty development as more professionals utilize simulation for teaching due to the safety, effectiveness, and availability of this modality. Many educators are assigned the role without prior preparation or adequate training. There is little literature related to
Hershey, Sally Rudy and Tara Jankouskos, also attended a Harvard CRM course. Dr. Murray and Sally Rudy then partnered to run weekly CRM courses for nurses, surgeons, and anesthesiologists. Their cases started with a patient (manikin) in trouble and the nurse entered the case to uncover the patient’s problem. When he or she called for assistance, a surgeon came to help, and that team worked together to manage the case. The patient would continue to deteriorate, and when additional help was needed, an anesthesiologist was sent to help, creating another team dynamic. After a few years of weekly CRM training in 2002, Dr. Murray created and delivered the first fully multiprofessional CRM Instructor Course with individuals from pediatrics, plastic surgery, nursing, emergency medicine, anesthesiology, and surgery.
The need to improve and grow as educators Dr. Bosseau Murray, an early innovator in Simulation has been one of the greatest and leader in simulation-based learning, passions of Dr. Elizabeth Sinz, anesthesiolattended an early course for simulation ogist by profession and educator by heart. instructors at the Center for Medical Sim- She joined Sally Rudy, neonatology nurse ulation at Harvard in 1999 with Hershey educator, and Dr. Margaret Wojnar, pulsurgeon Dr. Jerry Glenn. These courses were monary medicine, to create the Penn State focused on training anesthesiologists to use Hershey Simulation Instructor Course that simulation-based training for Crisis Resource is currently the cornerstone of simulation Management (CRM). Nurse educators from education in this institution (Sinz, et al).
Penn State Hershey Simulation Instructor Course 1. 2 002 First Multiprofessional CRM Course (based on Harvard Center for Medical Simulation Course) led by Dr. Bosseau Murray at Penn State Hershey 2. 2 007 First Penn State Course led by Dr. Elizabeth Sinz (with advisory assistance from Harvard faculty) Multiprofessional (8 MDs, 6 RNs, 2 RTs, 1 PhD) 3. 2017 First Penn State Spanish Course in Santiago, Chile led by Dr. Angel Diaz-Sanchez
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in Cuba and at that time in the process of validating my medical degree in US. During the Fellowship I had the opportunity to present a workshop at the Global Meeting of Simulation in New Orleans 2015. As I met Spanish-speaking participants from numerous countries, it became apparent that there was a need for more education for instructors in Latin America. I connected with well-known simulation personalities from Latin America to develop this project. Key simulation educators were invited to Hershey to complete the Penn State Sim Instructor Course. This group worked together to translate the course into Spanish in 2016 and developed all the resources to be able to bring the Instructor Course to Latin America. Educators from Mexico to Argentina were invited to attend a course that was able to integrate learning theory in a hands-on session with constructive feedback from the faculty.
Figure: Kern’s 6-Step Method of Curriculum Development (5) The most rewarding evaluation of the course so far is the continuous communication of the students who participated up to this day, Four years after the first course students in that first class continue to communicate, they share their work and experiences between them and even seek advice in the different platforms created at the time. Nothing better than seeing that their network works as we planned it.
The course was designed to convey key aspects of simulation for participants over five days. With important topics such as learning theory, curriculum development, and a lot of hands-on practice sessions with faculty supervision and orientation, the course gives a “jump start” to faculty who want to use simulation with their students in any discipline. At the end of the course the participants play the role of both student and instructor as they deliver and debrief a high-fidelity simulated case emphasizing teamwork and resource management. They 16 Fall 2021 Central PA Medicine
also take turns as “meta-instructor” to introduce and practice giving and receiving peer feedback for continued improvement after the course. Over the years, the course has become an important part of the preparation to those who want to use the magnificent facilities that opened in 2010 for the Clinical Simulation Center at Penn State Hershey. In 2014, the Clinical Simulation Center launched the Clinical Simulation Fellowship in its endeavors to continue growing the preparation in Simulation Education. I was the first fellow, having trained in anesthesia
Materials and methods There is a lot of preparation and information-gathering for the faculty teaching the course. Each course is tailored to the needs of the participants and the facilities and equipment that they use with their students. For this reason, all materials and methods are in constant evolution. Needs Analysis and Course Setup Faculty for the course assess the needs of participants by reviewing a survey that is emailed ahead of time. We match their concerns with the material planned to be taught to assure that the course meets their needs. Participants are recruited from multiple professions to create a truly interprofessional participant group. This creates an environment where the participants can learn from each other as well as from the course faculty. This attention to the participants’ goals is intended to not only optimize the learning experience but also to demonstrate best practice for simulation-based training in healthcare.
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We also found that some words do not need This method is described in the book The Language Our participants are from various countries to be translated. For example, the word, Reflective Practitioner [Ref-Schon]. The probof Latin America from Mexico in the North “Debriefing” is better left in English since lems identified during the day are constantly to Patagonia in Southern Argentina. One its translation to Spanish is far from the discussed by the faculty, an action plan is developed and starts running immediately, of our first challenges was coordinating the meaning intended in the course. and meta-debriefers (the more experienced translations of all the documentation to a version of Spanish that would be understood Participant input and the “One faculty) are responsible for observing that changes have the desired effect. (4) This in the same way by all the participants. To Minute Paper” method is one way to assure that the material accomplish this goal, core course faculty from Not only is the “regular” course adapted Cuba, Argentina, Chile, and Colombia who ahead of time, but it can also be altered in the course is providing the learning desired had completed the Penn State Simulation throughout the week. One tool for daily by the participants. Instructor Course worked together to input is called the “one minute paper” and reach a consensus about the most neutral this is completed by participants at the end and understandable words and the most of every day. This document is on a card Watchman Another tool created for quality control appropriate use of particular phrases. and has two questions; one question that of the course as well as to maintain the We quickly realized that changing a course focuses on what they found most useful or schedule for each particular activity is the into another language is not simply the thought-provoking and the other to indicate watchman. The watchman is invited from the result of literal translation. The same word what left them with more questions or pool of students from previous courses that does not convey the same meaning from was unclear. The faculty meet each day to have an interest in becoming course faculty country to country, so it takes time and a review these cards as part of the planning in the future. This role allows them to not lot of thinking about the different meanings for subsequent learning. Continued on page 18 for Spanish in all Latin American countries.
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Features
Kern’s 6-Step Method of Curriculum Development Step 1: Problem Identification:
Step 4: Educational Strategies
Based primarily on discovering the problem in question or need, for this course the problem was the need for more available and affordable training for instructors in Latin America.
Several strategic changes were made to adapt our regular course for this particular audience:
The course was implemented for the first time in May 2017 at the Simulation Center of the University Finis Terrae in Santiago de Chile. They - The course was restructured and shortened to be given over 3 ½ days provided the facilities, the simulation center and all the equipment needed instead of 5 days. to carry out the course. There was - The course was organized to no cost to the Penn State Hershey accommodate 24 participants by Simulation Center since Penn State running duplicate hands-on sessions. faculty used vacation time to attend This allowed the size of the group to and the South American Team paid be expanded without diminishing for travel from the course charges. the quality of the education. - The number of faculty teaching Step 6: Evaluation the course was doubled after appropriate training. Evaluation occurs throughout the course as described above and is - Didactic lectures and workshops continuous and interactive. were shortened to provide extra
Step 2: Targeted Needs Assessment For this step we relied on the knowledge of Latin American simulation experts. These individuals are recognized worldwide, and they were able to inform the development team about the situation around simulation education and faculty development from a variety of perspectives.
time for simulation and hands-on practice to be our primary teaching technique.
Step 3: Goals and Objectives Our main goal was to take a successful course in the English language and transform it to meet the needs of the instructors in Latin America.
Step 5: Implementation
On the last day a comprehensive evaluation is completed including a question about how the participants plan to implement what they have learned in their teaching.
only see the course again, but to also see the course from within. This time around they have the chance to dissect all the activities and understand any topics or activities that were not clear when they took their course.
the watchman’s understanding of the course and engage them in the process of continuous improvement so they are better prepared to eventually become course instructors.
Their role is to carefully observe everything Developing The course is structured according to the that happens from the body language of students and faculty to the level of student well-known Kern’s model for curriculum engagement. They provide immediate development. (5) feedback to faculty during student breaks, and they provide a summary to the students of the topics covered at the end of each Outcomes/Results day. Importantly, during the daily faculty Some of the key outcomes of developing debriefing, they provide feedback and sug- and delivering this course were immediately gestions to the faculty to help them improve. apparent. The process of translation and This role is designed to improve the course the collaboration and discussion required for the participants, improve the skills and to correctly capture the essential elements awareness of the course faculty, and enhance and intention in the course materials gave 18 Fall 2021 Central PA Medicine
all members of the Latin American course faculty a much better understanding and intuition about the concepts and goals of the course. Even the American faculty leads developed a stronger perception of these concepts leading to improvements that were integrated into the Hershey course. Coaching & Feedback was certainly one of the sessions that was initially controversial. During the first year many students and even the faculty confused coaching & feedback with evaluation. In training activities, we use coaching & feedback, making sure the student does not feel they are being “tested.” The main goal is for the student to learn, and the instructor is there to coach them to success with constructive feedback, using techniques such as deliberate practice. Many
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faculty initially did not recognize this skill as both important and difficult, however as we drew more attention to this topic, the faculty and students discovered that these skills can be considerably improved with understanding and practice.
by the COVID pandemic that limited travel. Since a key part of course development is adaptability, the local leader of the course was able to create a hybrid learning strategy that included remote assistance and feedback from the US team with active learning and practice with peer feedback at the site. Many Some of our high-level or “meta-meta” more courses are being offered with the same instructors don’t speak the Spanish language. initial format that still allows for ongoing Nevertheless, they have a key supporting updates, improvements, and adaptations role for the instructors leading the different for the participants of the course. activities. They have been able to provide feedback by watching the level of engagement of the students and their participation in the Conclusion different activities. Their detailed knowledge In Latin America we encounter a strong of every session in the course gives them a outspoken and uninhibited group of learnunique prospective; there is no doubt they ers that at times posed a challenge to the can tell when details are not clear to the instructors. We learned that developing our students, and this can impact their learning Simulation Instructor Course for a different experience. (7) language and culture in Latin American
The design of this course was a major departure from the usual way that faculty and students traditionally interact in Central America. There was some anxiety amongst the course developers that this method would not be well-received. It is not common to have a course with teachers from different specialties and different professions working together in the same time and place. Nevertheless, there is evidence of success in that subsequent courses have continued to use our multiprofessional approach. This has led to new partnerships that have extended beyond just the Simulation Instructor Course. The most important indicator of success is that there have been continued courses that are spreading throughout portions of Latin America. For example, a group in Costa Rico that attended our first Latin American course has continued to conduct Simulation Instructor courses regularly and the use of simulation has markedly increased in this small country. Ongoing programs in Chile and Argentina are quite robust and several of the faculty from the original course are highly sought-after as speakers in national and international conferences on simulation education.
countries provided benefits to our own faculty as we became more flexible and open to input from our students. Translating was more than simply changing English words to Spanish, and the impact was greater than simply telling them what we know. Just as in the US courses, every learner brings their own knowledge, attitudes, and experiences as well and their cultural background to the group. Bringing different professions together was an enriching experience for us as much as for the students in all courses we have taught. There is work to be done but the rewards are wonderful and ongoing.
References 1. Cheng, Adam MD, FRCPC, FAAP; Grant, Vincent MD, FRCPC; Huffman, James MD, FRCPC; Burgess, Gavin MD, FRCPC; Szyld, Demian MD; Robinson, Traci RN; Eppich, Walter MD, MEd Coaching the Debriefer, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: October 2017 - Volume 12 - Issue 5 - p 319-325 doi: 10.1097/SIH.0000000000000232 2. McGaghie, William C. PhD; Harris, Ilene B. PhD Learning Theory Foundations of Simulation-Based Mastery Learning, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: June 2018 Volume 13 - Issue 3S - p S15-S20doi: 10.1097/ SIH.0000000000000279 3. Schon, D. A. (1983). The Reflective Practitioner: How Professionals Think in Action. Basic Books, NY. 4. Sinz, Elizabeth; Rudy, Sally; Wojnar, Margaret; and Bortner Tammi (2014). “Teaching Simulation Literacy in Adult Healthcare Education: A Qualitative Action Research Study.” 5. Kern, D, E. (1998). “Curriculum Development for Medical Education: A six step approach. Baltimore: John Hopkins University Press.” 6. Brookfield, S. (2011). Teaching for Critical Thinking: Tools and techniques to help students question their assumptions. 7. Caffarella, R. & Daffron, S. (2013). Planning Programs for Adult Learners. San Francisco: Jossey-Bass.
Future Directions: Caminando al futuro. Over the past year the Instructor Course was interrupted by the Worldwide Pandemic caused by the Coronavirus. Work is already underway to bring back the course as soon as the health conditions allow it. In addition, some remote learning has been surprisingly successful. The faculty continue to prepare and plan ahead so we can once again join our colleagues from Latin America to share our mutual love of simulation education.
This process is also being used to translate the course into Portuguese. Several introductory sessions have been given there already, although progress was interrupted Central PA Medicine Fall 2021 19
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Features
WHEN IS FREEDOM OF CHOICE OVER? COVID-19 May Change Emmeline Pankhurst’s Statement “Freedom or Death” to “Freedom and Death” By JOSEPH F. ANSWINE, MD, FASA
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ur society is struggling both medically and politically over whether forced vaccination is in order to control the spread of COVID-19 and its devastation. Mandating vaccinations is not new to the United States. Those that know the history of smallpox in this country understand this to be true. So, mandating vaccination against COVID-19 is not without precedent.
For transparency, at the time of writing this editorial, I have received the COVID vaccine three times. As a person of science, the available data are too compelling not to be vaccinated. Especially since my exposure to the virus and its variants is high. Based on the most recent CDC reports, an unvaccinated person is 6.1 times greater to test positive for the virus and 11.3 times greater to die from its effects than a fully vaccinated individual. This is not just significant but overwhelmingly significant. This puts vaccinating into the “no brainer” range for a country doctor like me. In plainer numbers, there are 736.72 infections per 100,000 unvaccinated persons versus 131.28 infections per 100,000 vaccinated persons when averaging the data from the three available vaccines. Those that are anti-vaccinators may say “See, even vaccinated people get COVID!” Of course they can. Immune responses vary but they are 11.3 times less likely to die if they get it. Should individuals have a choice to take such risk? I suppose as a mentally competent adult, one would say “yes.” But what if that choice puts others at risk? Studies show that those vaccinated individuals that develop COVID have lower viral loads as compared to the infected unvaccinated people. A higher viral load is associated with a higher ability to transfer the virus and the disease. That is from virology 101. This is supported by regional outbreaks and percentage of those vaccinated in those regions. But they will more likely infect others that choose to be unvaccinated. That still doesn’t make it ok! And you can also infect those vaccinated individuals that are less immune competent. The safety of the vaccine has been reasonably established. No, science doesn’t support that it decreases fertility or increases the risk of Alzheimer’s disease, and so on. Some say that it is wrong for a business to require vaccination for employment. Is that against a person’s rights as a citizen? I don’t think so. They have a choice to be vaccinated or not as well as to be employed or not at least by that business. I try to be impartial when it comes to medical decisions but it’s hard to be with this one. Get vaccinated please for your safety and the ones around you.
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Sponsored Content
WHEN TO CONSIDER PALLIATIVE CARE
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ommunity-based palliative care is a growing specialty, as the need for palliative care is increasing locally in Central Pennsylvania and in communities throughout the United States.
According to a report by the Center to Advance Palliative Care and the National Palliative Care Research Center, 94 percent of our nation’s hospitals with more than 300 beds now have a palliative care team. Even among smaller hospitals, with 50-299 beds, 62 percent have palliative care programs. As the cost of health care continues to rise, that same report also shows that palliative care reduces direct hospital costs by as much as $3,000 per admission. For patients with four or more diagnoses, costs are lowered even more – by upwards of $4,800 per admission. Physicians and their patients typically seek out palliative care to assist with symptom management, communication regarding goals-of-care discussions and decision-making, and end-of-life or hospice care. Inpatient palliative care is usually managed by either a hospital team or a single palliative care practitioner. Palliative care focuses on relief of physical, emotional and spiritual symptoms related to chronic and/or serious illness. Symptoms such
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as pain, anxiety, insomnia, shortness of breath, fatigue, nausea, and appetite loss can often significantly impact a patient’s quality of life. Palliative medicine specialists aim to reduce the burden of these symptoms by focusing on individualized treatment strategies, addressing the “whole patient” and not just the disease process. When palliative care is provided using a team approach, a variety of specialists is involved including physicians, nurses, social workers and chaplains. The team works collaboratively alongside the patient, family and other professionals who are providing the patient’s care. Palliative care specialists see patients in hospitals, in their offices, in long-term care facilities and even in patients’ homes. Sometimes palliative care is confused with hospice care; however, palliative care is not the same as hospice care. Whereas hospice care is provided at end-of-life, palliative care may be provided at any time during a person’s illness. It is often offered to patients at the same time they are receiving potentially life prolonging or curative treatments. Receiving palliative care does not prevent patients from pursuing other services, treatments or procedures.
values and goals are fully understood and appreciated, so they are able to make the best decisions possible for their care. A referral to a Palliative Medicine physician does not mean a patient or their medical provider is “giving up hope.” On the contrary, patients who receive palliative care early on in their disease process often benefit from improved symptom management, greater emotional support and overall improved quality of life. Homeland at Home provides quality care and support to patients in 14 counties throughout Central Pennsylvania, either in their home or wherever they reside including nursing facilities. Services include compassionate end-of-life hospice care; daily non-medical assistance and companionship; and at-home physician-ordered medical treatment. Homeland at Home’s proud tradition of exceptional care began 150 years ago, when Homeland Center opened its doors in Harrisburg. Today, Homeland Center is a licensed Continuing Care Retirement Community offering exceptional personal and skilled nursing care. For more information, visit homelandathome. org or call 717-857-7400.
Palliative care also is designed to help patients and families better understand an illness and to assist with complex medical decision-making. Paramount to palliative care is that a patient’s Central PA Medicine Fall 2021 23
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RESTAURANT REVIEW
LAPU LAPU
FILIPINO FUSION By ROBERT ETTLINGER, MD
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ur world has over a hundred nations. Since we can’t get anywhere close to visiting them all, it can be fun to at least experience them by trying their foods. Lemoyne can add the Philippines to the list with the newly opened Lapu Lapu Filipino Fusion.
Filipino cuisine is a fusion unlike any other in Asia, reflecting their history of colonialism. The Magellan-led Spanish, who ruled the Philippines from much of the 16th through 20th centuries, introduced Iberian ingredients and styles. Chinese migrated there in the 16th century, and the United States also shaped their food habits after the arrival of shipping and military following the Spanish-American War of 1898. All of them combined with the indigenous use of tamarind, mango, coconut, plantain, banana, and abundant seafood to shape a unique vibe for our palates. Vinegar is often used to help preserve food in their hot climate. While the flavors are bold, heat is not a defining characteristic.
Brightly adorned by artwork, furniture, and a food counter all created by its owner, Lapu Lapu is a nice place to share dishes with friends and family, as customary in the Philippines and many other Asian nations. And it’s BYOB. We started with the entire list of appetizers, including Lumpia (a national dish, like spring rolls), Lapu Lapu Rolls (lumpia with a mild cheese), marinated skewers, Asian Zing Wings (with a sweet and tangy tamarind dipping sauce), and a plate of Sisig Fries topped with pork belly, onions, cilantro, and a mildly acidic house sauce. Next came the big plates and bowls. From the Spanish influence, Adobos came in pork or chicken, roasted in a soy sauce/garlic/bay leaf/onion/vinegar baste, spicy but not overwhelmingly so. Sisig Tacos had crunchy and melt-in-your-mouth fillings, with avocado, cabbage, and lime, served with a ramekin of Spanish rice. The Birria Tacos were cheesier, with a consommé dip. Lechon Kawali was a nicely presented loin of pork belly with balanced seasoning. Chicken Bicol Express had mild heat from a shrimp paste, tempered with coconut milk and ginger. Garlic lover that I am, Topsilog was my favorite...pork marinated with tocino (Filipino bacon), garlicky rice, crowned with a fried egg. If in the mood for meatless, veggie sides to choose from are rice, fries, Tortang Talong (roasted eggplant and egg) and main plates such as Pancit (noodles, cabbage, snow peas, and carrots in a soy/lime dressing) and Ginatang Kale (with coconut milk, ginger, and onion). Desserts to cleanse your palate after the savory dinner include mango, strawberry, or cantaloupe smoothies, and tall glasses of Halo-Halo, with layers of jellied fruit and mung beans, shaved ice with condensed milk, and a purple yam ice cream. Funky and fabulous. For a fun and tasty experience from the South China Sea by way of Spain, Lapu Lapu can be found across the street from the Lemoyne Post Office, minutes from the river.
LAPU LAPU FILIPINO FUSION 324 Market Street | Lemoyne, PA | 717-571-5223
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LEGISLATIVE UPDATES
PENNSYLVANIA MEDICAL SOCIETY Quarterly Legislative Update
RETURN TO HARRISBURG The 3rd quarter is typically the “quietest” time of the legislative year as there is a long break in session during the months of July and August, followed by a shortened September session scheduled post the Labor Day Holiday. Both chambers of the Pennsylvania General Assembly returned to Harrisburg to continue work in the 2021 Regular Session. The legislature is currently in year one of the two-year legislative session and will now have another condensed schedule as they have a short window before the upcoming election cycle taking place on Tuesday, November 2, 2021.
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Despite the limited number of session days, the Pennsylvania Medical Society (PAMED) still saw a few priority issues get some attention and advance in the legislative process. Most notably, legislation to streamline the process through which physicians must navigate on behalf of their physician assistants (PAs) received final passage and was signed into law by the Governor. These were SB397-398 (Pittman – 41st Senate District) and were signed into law as Act 78 of 2021. The stakeholder process leading to the final passage of this legislation included the broader provider community across the Commonwealth and Hospital and Health System Association of Pennsylvania. Specifically, these bills significantly decrease the “start-up” time required to employ a PA by no longer requiring Medical or Osteopathic Board approval of PA agreements. However, the boards will be required each year to review 10% of agreements filed after the bill’s passage. The measure will also allow physicians to determine the degree of oversight they wish to employ over their PAs as it relates to medical chart reviews, though the legislation continues to require a 12-month 100% chart review for new PAs entering the workforce and for those who may be changing medical specialties. Neither bill expands a PA’s scope of practice, nor do they diminish a physician’s responsibility to appropriately supervise the care PAs are providing to patients. While we often report on the legislation that is front and center and “moving” through the legislative process, PAMED’s advocacy goes beyond the bills that get voted. During much of the time leading up to the legislature’s return, PAMED’s advocacy team focused intensely on a proposed bill to allow expanded access to the Prescription Drug Monitoring Program (PDMP). Having conducted multiple district visits to meet legislators and having PAMED physician leaders directly engage, among other efforts, at this time we have yet to see this legislation advance through the legislative process. Other bills that PAMED is following through the law-making process…
THESE INCLUDED:
• House Bill 1774 (PAMED supports) – This was necessary legislation to extend the • House Bill 245 ( PA M E D s u p sunset date for the Achieving Better Care ports) – Legislation to modernize the by Monitoring All Prescriptions Program. process by which International Medical (Signed into law by the Governor as Act Graduates (IMGs) become licensed. (Passed 72 of 2021) out of Senate Consumer Protection & Prof. Licensure) While the legislation listed above reflects PAMED’s legislative efforts and the efforts • House Bill 1082 (PAMED supports) – of engaged physicians, there are several bills An effort to establish an education program that we continue to oppose and actively for providers on early diagnosis of dementia monitor. It is important for legislators and incorporates information about the to hear from their physician constituents disease into existing public health outreach on all these pieces of legislation to either programs. (Passed out of Senate Aging and thank them or explain why specific legislaYouth; awaiting final consideration) tion is not in the best interest of patient care. Continued on page 28 Central PA Medicine Fall 2021 27
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LEGISLATIVE UPDATES
PAMED IS CLOSELY MONITORING AND ENGAGING IN THE FOLLOWING:
Your Choice. Our privilege. We believe the care a person receives makes a difference in his or her quality of life.
717-857-7400 | HomelandatHome.org Hospice volunteers are always welcome.
MAY 15, 2022 ~ HOMELAND 155TH ANNIVERSARY CELEBRATION Honoring Betty Hungerford
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• Senate Bill 225 (PAMED supports) –This bill is a multi-session effort to reform prior authorization. Simply, this bill streamlines and standardizes the process of prior authorization of medical services in the Commonwealth. PAMED continues to engage with a broad provider coalition to advocate for the advancement of this legislation, after being introduced for the fourth consecutive legislative session. This bill has been voted favorably out of the Senate Banking and Insurance Committee and is awaiting further action by the full Senate. • House Bill 681 (PAMED supports) – Another long-discussed issue, restrictive covenants in physician employment contracts, this legislation aims to set parameters for when restrictive covenants are utilized and seeks to limit them in situations where they are deemed not appropriate. Having advanced overwhelming out of the House Health Committee with bi-partisan agreement on pursing a “middle ground approach” this legislation is awaiting final approval from the full House. PAMED encourages physicians to set aside time to reach out to their local legislators and begin to develop a personal relationship. For those who already know their representative or senator, it is a good time to simply touch base. The first lesson in effective advocacy is to avoid your first meeting with lawmakers to be the one where you are asking for help. Physicians interested in engaging in the issues above, or on any legislative proposal, are encouraged to reach out to PAMED’s Government Relations staff for assistance at 800-228-7823. Stay up to date on PAMED’s legislative priorities at www.pamedsoc.org/Advocacy.
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FRONTLINE GROUPS The Dauphin County Medical Society thanks the following for their 100 percent membership commitment and their unified support of our efforts in advocating on behalf of physicians and the patients they serve.
Allergy Asthma & Immunology
Morganstein De Falcis Rehabilitation Institute-Harrisburg
Brownstone Dermatology Associates
Patient First-Harrisburg
Central PA Surgical Associates Ltd
Penn State Health Medical Group-Hershey
Cummings Associates PC
PinnacleHealth Express
Elena R Farrell DO
PinnacleHealth Radiation Oncology
Family Internal Medicine
Premier Eye Care Group
Family Practice Center PC-Lykens B
Saye Gette & Diamond Dermatology Assoc PC
Family Practice Center PC-Millersburg
Schein Ernst Mishra Eye
Forti & Consevage PC
Stratis Gayner Plastic Surgery
Gastroenterology Associates of Central PA PC
Tan & Garcia Pediatrics PC
George M Kosco III DO & Associates
UPMC Arlington Group
Harrisburg Gastroenterology Ltd
UPMC Heart and Vascular Institute-LCV
Hershey Pediatric Center
UPMC Pinnacle Colon & Rectal Surgery
Hershey Pediatric Ophthalmology Associates PC
UPMC Pinnacle Harrisburg Transplant Services
Hershey Psychiatric Associates
Urology of Central PA-Harrisburg
Houcks Road Family Practice
Woodward & Associates PC
James R Harty MD Jatto Internal Medicine & Wellness Center PC John E Muscalus DO
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NEW MEMBERS Alexandra Chahwala
Christian Morris, MS
Angela Derobertis, MD
Abdullah Osme, MD
Kathy Engle
Lydia Smeltz
Chikezie Ikechukwu Eseonu, MD
Mara Trifoi
Jacquelyn Marie Kohler, MD
Min Yao, MD
Anish George Mammen, MD
Eric Michael Zimmerman
R E I N S TAT E D MEMBERS Salim Baghli, MD Jeffrey J. Miller, MD Matthew Scott Redclift, MD Thomas Trieu, MD
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Expanding urology expertise for your patients – right here, close to home. Penn State Health Urology has expanded to a new location at Penn State Health Hampden Medical Center to better serve your patients on the West Shore. Urologic oncologist Dr. Jaime Herrera-Caceres, urologist Dr. William Daiber, and certified registered nurse practitioners Stephanie Marencic and Sambina Roschella provide comprehensive urologic care. As an academic medical center with the connection to the College of Medicine, patients also have access to clinical trials at Penn State Health Milton S. Hershey Medical Center – offering improved outcomes and new hope.
Penn State Health Urology on the West Shore Penn State Health Hampden Medical Center 2200 Good Hope Road, Suite 1076 Enola, PA 17025 Refer a patient: 717-981-8160
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