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SUMMER 2022
Official Publication of the Dauphin County Medical Society
The Amish and H e a lt h c ar e PLUS DISABILITY INSURANCE CAN BE CLUTCH FOR PHYSICIANS PAGE 10
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Central PA
Dauphin County Medical Society
400 Winding Creek Blvd. • Mechanicsburg, PA 17050
(833) 770-1541 • dauphincms.org 2022 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 Andrew R. Walker, MD Saketram Komanduri, MD John C. Mantione, MD
SUMMER 2022
Contents Features 6
The Amish and Healthcare
10
Disability Insurance Can Be Clutch for Physicians
13
Future-Proofing Your Career in Medicine
14
The 21st Century Healthcare Crisis
EDITORIAL BOARD Joseph F. Answine, MD, Editor in Chief Kaela Luchs, County Executive
In Every Issue
Robert A. Ettlinger, MD Gloria Hwang, MD Puneet Jairath, MD Heath B. Mackley, MD
Editor's Message. . . . . . . . . . . . . . . . . . . 4
Restaurant Review. . . . . . . . . . . . . . . . . 18
Legislative Updates. . . . . . . . . . . . . . . . 16
DCMS News. . . . . . . . . . . . . . . . . . . . . . 20
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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EDITOR’s Message
Why Are Young Physicians
so apathetic? By JOSEPH F. ANSWINE, MD, FASA 4
Summer 2022 Central PA Medicine
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t is a common question at society meetings or sitting around They successfully complete their training and easily get a job a table of older physicians. The youngsters do not seem to in the medical world because we are thousands of doctors short engage in activities to promote or protect their profession. in this country. Most likely, they will be employed by a large Society boards are getting long in the tooth, and physician visits healthcare system that could care less about or discourage society to the capitol include walkers and wheelchairs. Furthermore, membership and physician advocacy. The young docs are not this periodical struggles to get students and young physicians to introduced as new physicians but as new providers. And, their contribute. So why the apathy? “colleagues” are other physicians, PAs, midwives, CRNAs and NPs. Let us look at the path to physician-hood today. They work hard If they are lucky, there is a provider dining room to rest and get to get into the best colleges for a pre-medical education like the a snack. They are shown the physicians’ parking area, and that older docs did. However, their education costs, just at this level, structure way way over there is the hospital. Good, incentivized are multiples of what we paid. And the loans are far less forgiving patient care is spelled RVU. Their patients love them, and they at all levels of education. The plan is to get the “A” and sit for the are healthy as ever, but not enough ECGs have been ordered so dreaded MCATs. Then they decide whether to become an allopathic “shame on you.” Remember, those are the print outs with the physician or a doctor of osteopathy, Coca-Cola or RC cola. I will squiggly lines that kind of mean something. On “Doctor’s Day” break ranks and tell you that I have always preferred RC cola. It they will get a gift card to use in the cafeteria to buy a pack of gum. is a well-known joke, but it demonstrates the continued conflict There will be time off granted from clinical duties to attend a root cause analysis or an M&M to explain their poor performance. within our ranks when it should be well behind us. Pats on the back are replaced by knives, but only the best cutlery, So, the young, soon-to-be physicians get into medical school nonetheless. They are asked to do a QI initiative that demonstrates with a current average yearly tuition rate of $54,698 (as per major advances in patient care, however, most of the required time, educationdata.org). My last year of medical school in 1989 equipment and medications are too expensive, so they carry on was $17,000 to give some perspective. They take classes geared with the status quo that is “pretty good” care. Finally, they realize toward scoring well on the USMLE exams which have become they are not in charge of patient care by making decisions; they much more predictable of residency outcome than ever before. make suggestions. They are, however, content because they have The classes are less camaraderie and more competition. Their a job, not a vocation or way of life. And, they have a paycheck 4th years are for auditions and not sub-internships. They fill to pay down their crushing debt. their last year with repeats of the specialty they are interested in So, that is the problem, but what are the solutions? The young instead of broadening their medical education. Why? Because physicians want to see that we, the old guard, have their backs. there is no time to learn when auditioning. That’s why on the We fight for their freedom to make decisions for their patients first day of internship, they learn that the squiggly lines on an as well as the decision to be advocates for themselves, their paECG mean something. tients, and their profession. We still gas up our wheelchairs and Next comes the match! I remember how much I feared the ride to the capitol and attend our society meetings, but more match because I was not sure I would get my first or second importantly, we demand that the healthcare systems respect the choice. The young physicians now are concerned about whether young as physicians and provide encouragement and time to be they will get a residency or not. They now plan for the match as the next generation of physician leaders. Leaders in society and well as the scramble afterwards. They may have to apply for a more importantly, the patient care team. post-doctoral master’s degree before starting residency. So, why are our young physicians apathetic about advocating for Now, they (the 90% that obtain a residency as determined by their profession, or have a lack of interest in “giving back”? I guess fuzzy math) are training in their specialty of choice or whatever they are just selfish and only think of themselves. Go figure. they could get into. In this “sellers’ market,” the residents feel less wanted and more lucky to be there.
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Features
The Amish and H e a lt h c ar e A Cultural Review and Communication Considerations for Healthcare Providers
Tuesday, July 5, 2022
DCMS Central PA Medicine
Name
Sarah Hershberger
Credentials
BS, BA
shershberger@pennstatehealth.psu.edu
Bio Sarah Hershberger is a fourth-year medical student at Penn State University. She is interested in primary care, combating healthcare disparities, and improving communication strategies with patients.
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By SARAH HERSHBERGER, BS1, AND BERNICE HAUSMAN, PHD1 Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, U.S.A. 6
Summer 2022 Central PA Medicine Article Information: Article Title
The Amish and Healthcare: A Cultural Review and Communication Considerations for Healthcare Providers
Article Topic This article shares a personal narrative from a formerly-Amish medical student about her family's struggle accessing healthcare. A literature review of common cultural practices is included to discuss 1
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Introduction
Origin and Demographics
I still vividly remember the first train ride of my life. I was just a child and baffled by the sights, the speed, and the diversity of the people. My family and I were on our way to Tijuana, Mexico, and it was the first time I had left my home community in rural Indiana. This was not a traditional family vacation, though; it was a journey to access medical care for my father, who urgently needed a kidney operation. In Tijuana, the costs of care were lower, and the physicians had previously worked with other members of our community. We lived in a country with one of the most esteemed medical systems in the world, but we had no trust in it. We were an Amish family who did not feel understood or cared for by our Western medical system.
The Amish are direct descendants from the Swiss Anabaptists, a group originating during the Radical Reformation of the seventeenth century. Their distinguishing beliefs included living simplistic lives and opposing infant baptism.1 The Amish became a distinct group in 1693 when Jacob Amman and his followers shunned excommunicated members to maintain a strict community within the church.2 Persistent persecution in Europe resulted in a mass emigration of the Amish to North America in the early eighteenth century, where, over time, they divided into Old Order and New Order Amish.1,2 A second wave of immigration then occurred during the nineteenth century.
It would be years before I realized the implications of this story. As a medical student now evaluating the effects COVID-19 has had on our surrounding communities and their trust in medicine, I am reminded of the cultural differences that continue to impact how Amish populations access care and their attitudes towards mainstream medicine. As healthcare in rural contexts draws increased attention and rural healthcare workers interact more with these growing Amish communities, it is important for providers to understand both the shared features and differences between various Amish communities. There is still much to be explored about providing culturally competent care to and preventing misunderstanding about the Amish, especially their relationship to modern Western medicine. This article aims to review the common cultural themes and practices of Amish communities, and then discuss approaches to improving communication and healthcare. My experience of having grown up Amish affords me the unique perspective of a cultural insider, which is especially useful now as a medical student enrolled at an institution in a rural area with large adjacent Amish communities.
Amish population studies have shown that their overall population doubles nearly every twenty years.3 2020 estimates found there are approximately 345,000 Amish in the United States, most notably within rural Pennsylvania, Ohio, and Indiana 3. Much of this growth is explained by the average Amish family having seven children and communities retaining over 80% of their youth.4 With this growth, over 2,500 different Amish districts now exist within this larger subculture across the United States.3 The districts that share similar beliefs and lifestyle regulations form more than 40 “affiliations,” which are groups of districts interlinked by shared practices across many geographic locations.5
Core Beliefs The Amish are a religious and community-oriented group, with many shared values and a shared primary language (Pennsylvania German). They follow traditional Christian beliefs that prioritize accepting simplicity, humility, and nonviolence as core biblical teachings, believing that separation from the “outside world” is necessary to ensure these virtues are achieved.6,7 Shunning, where all contact is terminated with individuals who willfully and repeatedly violate Amish guidelines, is practiced by most districts. Shunning is believed to help excommunicated members recognize their errors, while also preventing unaccepted beliefs or actions from infiltrating and harming others within the community.8 The Amish are known for their strict rejection of modern technology and their plain dress. They regulate the use of any electricity, automobiles, tractors, phones, televisions, and other modern technologies. They aspire to avoid any “worldliness” within their communities, which they define as anything that seeks convenience, praises material things, or self-enhances.7 Yet modern conveniences are all evaluated for their potential uses, and some are even integrated into communities. Community members reach Continued on page 8
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a consensus about how something would impact their community and collective social patterns to form a decision about whether or not it can be utilized within their district.9 Districts near each other often reach different agreements, ranging from if they will allow members to have landline phones, bicycles, or even different clothing designs. This adds to the diversity within the overall Amish community and allows districts to have independence on their respective lifestyle decisions.
Amish churches provide no direct guidance on culture generates a broad definition of “family,” vaccination, but a variety of cultural and personal which emphasizes communal activities.25 Social-disbeliefs result in Amish communities having tancing and isolating for periods of quarantine are lower rates of vaccination than non-Amish.16,17 therefore not always possible, especially due to the Lower vaccination rates have been correlated large and multigenerational families who often with well-documented outbreaks of preventable live together. When considering their foundational, infections, such as the outbreaks of measles, rubella, community-based social organization, public Haemophilus influenzae, polio, and pertussis, in health guidance and vaccination campaigns for various Amish communities.18-22 High vaccination Amish communities should center on the benefit uptake in response to prior community outbreaks these actions have for others within the community. Amish schools serve as a major socialization has occurred historically, suggesting Amish families For long-term connections, open and nondomain, alongside community and family, and may be more inclined to receive vaccinations if judgmental communication about healthcare is the essential for establishing and maintaining trusting are essential for reinforcing Amish values and the direct benefit to their community and 18 potential to endanger others is apparent. beliefs.10 Amish children are formally educated relationships with Amish patients. Consider to an eighth-grade level by attending parochial A 2011 study focusing on the largest Amish conversations pertaining to use of complementary schools taught by members of the community; settlement in the United States (Holmes County, and alternative medicine (CAM), which Amish a Supreme Court ruling in Wisconsin v. Yoder in Ohio) found that only 45% of members were patients utilize at high rates. Most physicians 1972 provided a religious exemption from further fully vaccinated, compared to 85% of the non- only receive training on the limitations of these education.10,11 After finishing school, most Amish Amish population, and only 14% of Amish approaches. Providers in areas that include Amish men work in construction or agricultural jobs families denied all vaccines at that time.17 An communities should educate themselves about while women are primarily homemakers and updated study in 2021 found that now 59% of common forms of CAM: herbal medicines, caregivers for children.7 Amish families in the same community refused acupuncture, chiropractic, or naturopathy. These all vaccines, and only 25% were open to receiving therapies are integral to many Amish communities Healthcare and Vaccinations COVID-19 vaccinations.23 In both periods, the and understanding their use and limitations may The Amish view health in terms of ability most common reason for nonvaccination was be key to maintaining open communication with to work and contribute to the community, parental concern of adverse effects.17,23 The drastic patients.26 Being dismissive of CAM without a and it is considered a gift from their God.12 increase in nonvaccination highlights the flawed medical justification can impair developing trust Preventative medicine, such as vaccinations, outreach of our medical system towards Amish in allopathic medicine for patients who are more cancer screenings, and prenatal care, is not communities, who do not refuse vaccination comfortable with CAM. generally prioritized. If nonemergent problems categorically based on religious belief, as is Cost of care often influences how Amish do arise, Amish are likely to initially use com- often surmised. patients choose to access care since most Amish plementary and alternative medicine, like salves, communities opt for mutual aid funding instead herbs, supplements, and spiritual practices.12,13 Approaches to Care of insurance.15 Costs of CAM are often upfront Modern medicine may be concurrently used if The COVID-19 pandemic has highlighted and known by the patients, while allopathic the benefit is clear and understood.6,12 However, disparities in healthcare access across many medicine can be difficult to predict. Being open functional health literacy has also been found communities, but reactive responses during an and mindful of cost considerations of treatment to be lower within the Amish than the general ongoing pandemic are insufficient for lasting options with Amish patients is therefore imperative population, which may contribute to their solutions. After a COVID-19 outbreak in an for establishing trust. lower rates of healthcare utilization.14 Amish community in May 2020 brought these Extra caution should also be used when assessing The Amish have a religious exemption from disparities to the forefront, the Centers for Disease patient understanding to account for potentially Control and Prevention (CDC) issued a call for traditional insurance and social security, so most lower health literacy and use of English as a second will utilize mutual aid within their immediate improving longitudinal relationships with Amish language. Practitioners may falsely assume that community leaders, which involves ensuring and nearby districts to finance medical costs.15 In disagreements about care can be swayed with educational materials, testing, and care can be addition to paying out-of-pocket costs, securing 24 facts and medical information, but Amish people travel arrangements can be a complicating logistic accessed and interpreted by Amish individuals. often use a different value system that centers their To achieve this goal, healthcare personnel and in accessing care. They often must hire drivers as an community’s beliefs when making decisions.27 alternative to their horse-drawn carriages. While institutions need to approach these communities While allopathic medicine is based on objective cost of access may be one reason Amish frequently with culturally competent solutions. data, Amish patients may instead center their prefer to use CAM, there is also an underlying COVID-19 provides important lessons about community’s acceptance and social beliefs in their distrust of American medical institutions, doctors, existing obstacles. Most of the guidelines intended decision-making. They often do not compare and pharmaceutical companies.12 to slow the spread of COVID-19 have been less the relative trustworthiness of sources using the feasible for Amish communities. Their collectivistic scientific method physicians are taught, but instead 8
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a values system instilled through their religious and social groups.27 Framing the importance of these values into discussions with Amish patients can help establish trust without overshadowing the influence of their community. My own family’s experience seeking medical care continues to resonate today and proves to be a common experience for many Amish families. While there is no instantaneous solution, ongoing effort and outreach are necessary to reach the underserved communities our healthcare system often neglects. This starts at the level of individual providers prioritizing communication with Amish patients that is culturally informed with the intention of developing mutual trust.
References:
1. Guss J. Persecution, division, and opportunity: The origins of the Old Order Amish. Pennsylvania Center for the Book; 2007. 2. Amish in America. PBS; 2012. 3. Young Center for Anabaptist and Pietist Studies EC. Amish Population Profile, 2020. http://groups.etown.edu/amishstudies/statistics. 4. Meyers TJ. The Old Order Amish: To remain in the faith or to leave. The Mennonite Quarterly Review; 1992. p. 1-22. 5. Studies YCfAaP. Organization. http://groups.etown.edu/ amishstudies/social-organization/organization/: Elizabeth College; 2021.
6. Banks MJ, Benchot RJ. Unique aspects of nursing care for Amish children. The American Journal of Maternal Child Nursing; 2001. p. 192-6. 7. Hostetler JA. Amish Society: Fourth Edition. The Johns Hopkins university Press; 1993. 8. Young Center for Anabaptist and Pietist Studies EC. Church Discipline. Elizabeth College. 9. Kidder RL, Hostetler JA. Managing ideologies: Harmony as ideology in Amish and Japanese societies.: Law and Society Review; 1990. p. 895-922. 10. Anderson C. Amish education: A synthesis. Journal of Amish and Plain Anabaptist Studies; 2015. p. 1-24. 11. McConnell DL, Hurst CE. No “Rip van Winkles” Here: Amish Education since “Wisconsin v. Yoder”. Anthropology & Education Quarterly; 2006. p. 236-254. 12. Anderson C, Potts L. The Amish health culture and culturally sensitive health services: An exhaustive narrative review. Social Science & Medicine; 2020. 13. von Gruenigen VE, Showalter AL, Gil KM, Frasure HE, Hopkins MP, Jenison EL. Complementary and alternative medicine use in the Amish Complementary Therapies in Medicine; 2001. p. 232-233. 14. Katz ML, Ferketich AK, Paskett ED, Bloomfield CD. Health literacy among the Amish: Measuring a complex concept among a unique population. 2013. p. 753-8. 15. Rohrer K, Dundes L. Sharing the load: Amish healthcare financing. Healthcare. 2016;4(4)doi:10.3390/ healthcare4040092 16. Yoder JS, Dworkin MS. Vaccination usage among an old-order Amish community in Illinois. Pediatric Infectious Disease Journal; 2006. p. 1182-3.
17. Wenger OK, McManus MD, Bower JR, Langkamp DL. Underimmunization in Ohio’s Amish: Parental Fears Are a Greater Obstacle Than Access to Care Pediatrics; 2011. p. 79-85. 18. Gastañaduy PA, Budd J, Fisher N, et al. A measles outbreak in an underimmunized Amish community in Ohio. New England Journal of Medicine; 2016. p. 1343-1354. 19. Briss PA, Fehrs LJ, Hutcheson RH, Schaffner W. Rubella among the Amish: resurgent disease in a highly susceptible community. Pediatric Infectious Disease Journal; 1992. p. 955-959. 20. Fry AM, Lurie P, Gidley M, et al. Haemophilus influenzae Type b disease among Amish children in Pennsylvania: Reasons for persistent disease. Pediatrics; 2001. 21. Prevention TCfDCa. Poliovirus infections in four unvaccinated children— Minnesota, August-October 2005. Journal of the American Medical Association; 2005. p. 2689-91. 22. Etkind P, S.M. L, Macdonald PD, Silva E, Peppa J. Pertussis outbreaks in groups claiming religious exemptions to vaccinations. 1992. p. 173-6. 23. Scott EM, Stein R, Brown MF, Hershberger J, Scott EM, Wenger OK. Vaccination patterns of the northeast Ohio Amish revisited. Vaccine; 2021. p. 1058-63. 24. Ali H, Kondapally K, Pordell P, et al. COVID-19 Outbreak in an Amish Community - Ohio, May 2020. US Department of Health and Human Services/Center for Disease Control and Prevention: Morbidity and Mortality Weekly Report; 2020. p. 1671-74. 25. Kraybill DB, Johnson-Weiner KM, Nolt SM. The Amish. Johns Hopkins University Press; 2013. 26. Steyer T. Complementary and alternative medicine: A primer. Family Practice Management: AAFP; 2001. p. 37-42. 27. Saudner M. Choosing whom to trust: Autonomy versus reliance on others in medical decision making among plain Anabaptists. Journal of Amish and Plain Anabaptist Studies; 2020. p. 59-64.
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Angie Stephenson, CFP®, CPA/PFS angie.stephenson@domaniwealth.com
Ken Eshleman, CFP® ken.eshleman@domaniwealth.com
855.855.5455 domaniwealth.com
Domani Wealth, LLC (“Domani”) is an SEC registered investment adviser with its principal place of business in Lancaster, Pennsylvania. Domani and its representatives may only transact business in states where they are appropriately notice-filed and registered, respectively, or exempt from such requirements. For information pertaining to the registration status of Domani, please contact the SEC or the state securities regulators for those states in which Domani maintains a notice-filing.
Central PA Medicine Summer 2022 9
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D
SA
SUR N I TY I L BI
ANCE CAN BE CL U
for P hysicians
Tuesday, July 5, 2022
DCMS Central PA Medicine
Name
Angie Stephenson
Credentials
CFP®, CPA/PFS
holly.white@domaniwealth.com
Bio Angie Stephenson is a CFP® professional, CPA/PFS and trusted wealth advisor for many individuals and families throughout Central Pennsylvania. She enjoys helping clients develop customized financial plans to meet their goals. Angie works closely with many physicians in the Central PA area to make sure they are on the right path to reaching their retirement goals.
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By ANGIE STEPHENSON, CFP® Article Information: Article Title Article Topic
Disability Insurance Can be Clutch for Physicians
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Especially for physicians in prime earning years and relatively good health, disability insurance might be an important consideration. Not only does this benefit offer income protection, it can also play into your overall financial planning strategy.
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ong-term disability insurance isn’t front-of-mind for many of us, managing busy work lives, time with family, and other responsibilities. docx
Disability Insurance Can be Clutch for Physic…
Especially for physicians in prime earning years and relatively good health, disability insurance is certainly not pinging on any radar.
10 Summer 2022 Central PA Medicine
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However, unfortunately accidents and illness do not discriminate. Thousands of people each year are unable to work due to an unexpected incident, whether recovering from major surgery or experiencing debilitating effects of a developing disease. Many of our members see these cases firsthand in their work. In fact, the U.S. Social Security Administration reports that more than 25 percent of people currently in their twenties will experience a debilitating illness or injury before their typical retirement age. Being proactive about personal and household finances has always been wise; however, the global COVID-19 pandemic is perhaps a stark reminder to always be prepared for the unexpected. With that in mind, it may be beneficial to consider taking a closer look at your disability insurance options. Not only does this benefit offer income protection, it can also play into your overall financial planning strategy. DISABILITY INSURANCE: WHAT YOU NEED TO KNOW Disability insurance replaces a percentage of your income should you become unable to work because of an injury or prolonged illness. Many organizations offer short- and long-term disability plans as part of an employee benefits packages. CAUSES OF LONG-TERM DISABILITY CLAIMS If you have healthy savings, short-term disability claims (such as pregnancy or a broken limb) might not affect your longterm financial health. However, longer-term claims could significantly impact your overall financial picture. Especially in a time when inflation continues to be of concern, and costs for just about everything seem out of hand, protecting your financial stability is paramount. According to the Council for Disability Awareness, the most common causes of long-term disability in 2020 included: • Musculoskeletal disorders (27.6%) • Cancer (15%) • Injury, such as fractures and sprains (12%)
• Mental health, such as depression (9.3%) • Circulatory issues, such as heart attack or stroke (8.2%) DISABILITY DEFINED: OWN OCCUPATION VS. ANY OCCUPATION One important distinction among disability insurance policies is how a disability is defined. Providers will typically offer either “own occupation” or “any occupation” coverage: Any Occupation: Provides coverage for when someone is unable to work in a job suitable for their education, experience, and age. This means if the insured person could find work elsewhere, even at a lower wage, the policy would not pay benefits. Typically, any-occupation policies cost less and, as such, are often the norm in group disability insurance plans (like your employer may offer you). Own Occupation: Provides coverage for the insured person’s specific occupation at the time of the claim; this means if the person is unable to perform the duties of that position, their benefit claim would most likely be approved. Further, the person could still receive the long-term disability benefit even after finding employment in a completely different occupation. Disability insurance can be a critical benefit of employment, particularly for a household’s primary earner. However, typical group policies have limitations that could adversely impact high-income earners. DISABILITY INSURANCE CONSIDERATIONS FOR PHYSICIANS While you may have employer-provided group disability insurance and don’t think much about it, it’s good to learn exactly what’s covered if you are a major breadwinner in your household. Group disability insurance often has a maximum coverage amount, which is a percentage of your income – 60 percent is typical. However, it’s important to note this is based on a salary and does not include
bonuses, income from practice ownership, or other forms of pay. Also, there’s usually a monthly cap on payments, which means those in higher salary situations might suddenly find themselves compensated at a much lower percentage rate. Someone earning $250,000 per year might have long-term disability insurance through their employer that caps a monthly payment of $5,000, which amounts to only 24 percent of their salary. A mix of employer-paid and individual disability insurance policies may help maximize supplemental income should a long-term disability occur. HOW DISABILITY INSURANCE FITS INTO AN OVERALL FINANCIAL PICTURE Disability insurance can play a significant role in a financial plan. For example, if a professional is out of work due to a disability claim, they might not be able to contribute to a retirement or savings plan in the same way they had been. They also might not have access to other group benefits, such as health insurance for family members. A disability claim may also increase the burden on family members, as they may have to step into a role with higher earnings potential while also helping to manage your care if you are disabled for a period of time. Disability insurance can help mitigate risk, planning for potential income gaps to help maintain overall financial wellbeing. Someone on a long-term disability claim might need to dip into savings to cover everyday living expenses or needed care while out of work. As you learn more about the disability insurance your workplace provides, ask specifics about how much income would be replaced and what a claim might look like for your finances. Continued on page 12
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YOU CAN ALSO CONSIDER: • Own-occupation vs. all-occupation policy options • Percentage of income replaced • Cap on annual benefits • Maximum length of benefit period • Portability • Taxes – properly structured benefits can be tax free To find supplemental insurance options, you can consider the following: • Add additional disability insurance coverage through your employer’s group plan. You may be able to elect voluntary coverage, such as cost of living benefits, at an additional premium.
• Purchase your own policy: You can go to market and find a self-pay disability insurance plan that fits your needs, budget, and long-term goals. It’s important to note that individual policies need to go through the underwriting process – that is, your premium will depend on your health.
through companies that specialize in business insurance.
None of us want to think about unexpectedly finding ourselves out of work for an extended period of time, especially during years we know we are supporting our family and earning for our futures. • Ask about executive disability carve-outs: This generally means we don’t think about Some employers participate in group disability disability insurance. However, fully uninsurance programs that have multiple layers derstanding how injury or illness would of coverage. Executive disability carve-out affect a physician’s income (and livelihood) offers a “guaranteed issue benefit” for high-in- in the short- and long-term can help you come earners that might otherwise be capped make better proactive decisions for you and your family. out of income replacement. If you are a business owner at a practice, you can also look into a range of disability and income replacement insurance options
Disclosure: Domani Wealth, LLC (“Domani”) is an SEC-registered investment adviser with offices in South Central Pennsylvania. Domani and its representatives may only transact business in states where they are appropriately notice-filed and registered, respectively, or exempt from such requirements. For information pertaining to the registration status of Domani, please contact the SEC or the state securities regulators for those states in which Domani maintains a notice-filing.
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Future-Proofing Your Career in Medicine
Tuesday, July 5, 2022
DCMS Central PA Medicine
Name
Alyson Rich
Credentials
Medical Student, MS4
arich1@pennstatehealth.psu.edu
Bio Alyson Rich is a MS4 at Penn State College of Medicine. She worked in IT during her undergraduate studies at University of Michigan, and is planning to specialize in Neurology.
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By ALYSON RICH, B.S. University of Michigan MS4 at the Penn State University College of Medicine Article Information: Article Title
Future-Proofing Your Career in Medicine
Article Topic Discusses how emerging technologies will impact the healthcare field, and that medical students should consider these impacts when selecting a specialty.
ormally, when we hear the term “future-proofing,” we medical specialties could even become obsolete. If a robot could are talking about buying the latest smartphone or laptop spot a brain tumor or a cancerous cell, why would you pay for to ensure that we will not be left behind as technology a neuroradiologist or pathologist? Furthermore, if an AI could continues to move forward. However, this same concept of fu- monitor a patient’s vital signs and has a robust enough code to ture-proofing can also be applied to selecting a medical specialty. “know” what medications to administer in different circumstances, Technology and medicine have always been intertwined, with why would you pay for an anesthesiologist? advancements in one often inspiring a synergistic advancement in The short answer to those questions: experience and empathy. the other. The largest leap forward was in the 1960s-1980s when In the future, we may see AI progress to the level of being able health systems began using electronic medical records (EMRs) to make decisions rather than follow explicit code. However, the instead of paper records. The 1970s also saw the development of diagnosis is often not clear. Or, frustratingly, the patient could the computed tomography (CT) and magnetic resonance imaging have multiple underlying medical problems and the treatments (MRI) scanners, which are now considered essential for diagnosing could conflict. At that point, when it becomes necessary to rely many diseases. Now, artificial intelligence (AI) is on the horizon. on clinical judgment fostered with experience, a physician has Currently, our coding abilities are only to the level where we the upper hand on AI. Then there are the hardest conversations could design a program to perform certain functions if they are of all – when the prognosis is poor and it is necessary to prepare given specific inputs. For example, if a patient’s blood pressure is the patient and their families for the end. In learning how to care below a set point, provide “X” dosage of “Y” medication. While for patients, we are taught to approach them with the same care this may sound sufficient, nothing in the real world is ever that you would want shown to your loved ones if they were in the simple. Did the program consider that the patient just woke up same position. This is another situation in which an AI would fall or that their blood pressure is usually low or that they just had short. How could it approach the painful conversation of allowing abdominal surgery and could be bleeding internally? Unless someone to pass with as much dignity as possible without truly specifically programmed to consider these options, then the living, and thus lacking the intimate understanding of death? robot did not. But the human doctor would because that is how Given these examples, it should be clear that replacement we are trained. of our human workforce with AI in healthcare will not occur.
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While the development of AI is exciting, we are all wondering what the integration of AI into medicine will mean for those working in healthcare. It can be safely assumed that just as the integration of EMRs, CTs, and MRIs radically changed medicine, the use of AI will also have a substantial impact on the field. Some healthcare workers fear that as AI technology improves, certain
However, medical students need to consider the near-certainty of technological advancements significantly altering the landscape of medicine. Specifically, how and the extent to which different specialties will be impacted should be considered as we prepare to join the healthcare field.
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Features
The 21 Century Healthcare Crisis st
The Dichotomous Dilemma and War Between Modern Medicine and Intragenomic Evolution Friday, June 24, 2022
DCMS Central PA Medicine
Name Credentials Email Bio
Theodore Miller
Incoming MS1 at Penn State College of Medicine tjm7147@psu.edu
Theodore Joseph Miller (Joey Miller) is an incoming MS1 at the Penn State College of Medicine. He is interested in pursuing medicine with a focus on the social determinants of health and public health equity/policy for vulnerable populations. His clinical interests include medical genetics, pediatric hematology/oncology, emergency medicine, and medical education pedagogy. Theodore's future goal after training at the Penn State College of Medicine is to become a pediatric oncologist and research investigator that promotes equitable, holistic, and preventative healthcare practices for communities with unpredictable clinical and social needs.
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By THEODORE MILLER, MS1 at Penn State College of Medicine
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rom the invention and discovery of and innate immunity, as any remaining luxuries. Even automobile transportation penicillin to more specialized antibiotics bacteria are disposed of by the pairing to and from work or our daily interactions like vancomycin and linezolid, human of helper B-cells and cytotoxic T-cells (as with our friends and classmates exposes beings live in an unprecedented envi- well as other immunity components like us to the potential of resistant-bacteria ronment of personal health security and neutrophils). However, if any resistant cells introduction. Any singular bacteria can comfort that has never been previously seen were to remain or “escape” detection, they also spread resistance to other non-resistant or experienced. Maybe you got scraped by would exponentially divide and pose a severe bacteria in numerous ways, including transa rusty pipe on your walk home or you fell problem for that infected person. While duction, transformation, or conjugation. off your bike and broke both your arms; if the magnitude of virulence is significant for We have increased the velocity by which you were unfortunate enough to grow up in the individual, healthcare professionals can infection can proliferate and share this the early 19th century, you would certainly only throw so many antibiotic medications resistant-information with other cells, and be dissatisfied with the surrounding level at a particular infection while maintaining we have even allowed for so-called superbug of treatment and care. The tetanus vaccine an ethical, financial, and effective balance. “incubation-centers,” or what we know today was essentially nonexistent until the 1890s, This issue is exacerbated further when as the common hospital setting where this and the repair process of any bone fracture someone with a minor cold takes antibiotics problem is of central concern due to excessive would be limited by the sub-optimal anti- unnecessarily or its customary usage across antibiotic use. It is this linked association septic and pain-management applications the globe for livestock protection. That we have built across the world that makes available. We take our general well-being pounding headache, intense fever, and superbugs a real threat, but fortunately this is for granted due to the seemingly limitless constant stomachache may make you jump not a glass half-empty situation. As one side supply of antibiotic and antiviral medica- to the most potent solution to resolve these evolves, so does the other, and despite the tions. We fail to acknowledge the impact symptoms, yet you are unknowingly increas- evolutionary adaptive potential of bacteria of federal legislation and implementation ing the likelihood of stimulating bacteria that cells for resistance, resistance can also be lost of financially accessible healthcare policies carry resistant alleles against that antibiotic. over time when its energy expenditure is no and social/educational campaigns within The same idea applies for our cattle, pig, and longer needed. We also cannot forget the our world, as well as the foundation these chicken populations; substantial amounts of resilience on our side as well, as new vaccines programs have laid in providing practical, antibiotics, with varying degrees of strengths and antibiotics are being researched and relevant information that has equipped and targets, are given to these animals which discovered constantly; the fight may currently modern households with tools to fight enhance these superbug organisms. While be in favor of our pathogenic neighbors, but against virulent pathogens. Modern med- generally beneficial for those animals that the never-ending war will continue to rage icine has provided the human race with may be at risk for combating illness and on between humans and bacteria. unparalleled biological stability, yet we’ve allowing for that $1 fast food burger or It may sound contradictory to state become complacent in our victory over Chick-fil-A spicy sandwich (YUM), they that we live in the most technologically illness and disease and, without proper pass on these superbugs to humans that and medically advanced and innovative intervention, will fall back into historical consume them. Both situations may seem time period in human history and that patterns of death and reduced longevity. inconsequential at first glance; humans resistant bacterium should be a focal point The deadly superbug, the typical refer- have invented hundreds of antibiotics that, for medical attention as a potential global ence of any bacterium that has developed through proper combinations and allotted pandemic, but it’s ingrained within human resistance against a multitude of antibiotics, time periods, can eliminate these deadly nature to avoid highlighting issues that has been given the perfect opportunity for foes. Yet, it is because of our creative spirit do not appear to be of immediate priority. growth in the 21st century. Despite the and intelligent advancements that have We have forgotten previous eras in human paradoxical nature of medical access across made the perfect platform for this issue to history where amputation and bloodletting the globe, as evident in the comparison become catastrophic. were primary approaches against illness, and between first and third world countries, From air travel to densely populated it is this willful ignorance that has given antibiotics are taken constantly and for cityscapes, our expansion as a species and bacteria an opening in our co-evolved war some genuinely inappropriate reasons. This our inherent social connectivity introduces that may just return us to an age of historical, allows for bacterium with plasmid or chro- the fundamental reason behind the gravity heightened morbidity and mortality. mosomal resistance to proliferate against of the “superbug.” There are approximately their non-resistant counterparts, which in 100,000 flights within any given day as of turn accelerates their growth because of 2013, and, coupling that number to counthe heavily reduced biological space that tries like India and Brazil with staggering has now been freed for occupancy. It is populations, transmission of disease is an important to note the relevance of adaptive inevitable consequence of our manufactured Central PA Medicine Summer 2022 15
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LEGISLATIVE UPDATES
PENNSYLVANIA MEDICAL SOCIETY
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Summer Recess
or those engaged in the daily grind to hammer out language that could pass the Though the child vaccine issue was of the legislative process, summer has senate. These meetings were often contentious, sidelined, PAMED along with PAFP and PAfinally arrived with the passage of a as one might expect, with the industry pushing ACP did agree to allow pharmacists to provide $39.8B state budget. In the days lead- back on nearly every provision of the original seasonal flu and COVID-19 vaccines to indiing up to the June 30 budget deadline—and bill. Again, PAMED remained focused on viduals aged 5 and above. This “compromise” a few days afterwards—we saw activity on an how prior auth impacts patient care. Happily, should serve to keep the issue of child vaccines unusually large number of legislative proposals her efforts, along with the efforts of key staff off the table for the foreseeable future. on which PAMED has been actively engaged. and our coalition partners, resulted in the Speaking of the future, PAMED was sucA number of them made it across the finish line unanimous approval of SB 225 by the full cessful during the recent budget process in and to the Governor’s desk, while a few could senate on June 29th. The bill now moves to the securing additional funding for the state’s still see passage when the General Assembly House Insurance Committee for consideration. Primary Care Loan Repayment Program. This returns in the fall. In the past, legislative activity during fall program provides loan forgiveness, presently Suffice it to say legislative activity has been sessions have been robust as lawmakers work up to $80,000, for physicians who choose to somewhat contentious over the past few to wrap up their business before the end of the practice in a rural or underserved community months as lawmakers positioned themselves year. This year may prove different as there are for two years. PAMED secured an additional politically for either the recent primary election only twelve legislative session days currently $2.5M to bring the program’s total allocation or the upcoming election this fall. While scheduled with rumors that a few additional to $7M. This is the first time in more than a PAMED’s government affairs staff is always days may be cut. With that in mind, PAMED decade that the legislature has increased this sensitive to the “politics” that drives the will be aggressively pushing for the House of line item. development of public policy, we do our best Representatives to approve SB 225 before they PAMED was also engaged in advocating for to limit our focus on the impact legislation break for the November election…which will the passage of HB 2660, a legislative resolution has on physicians and the patients they treat. ostensibly end the legislative session. that would have been the first step in potentially While the list below reflects the entirety When it comes to legislation addressing amending Pennsylvania’s constitution to place of legislation that has been “active” since the scope of practice, PAMED has always viewed the question of judicial “venue” in the hands current legislative session began in January patient safety as our number one concern… of the legislature instead of the state Supreme of 2021, there are several items that deserve not as competition against our non-physician Court. Unfortunately, efforts by PAMED, special recognition. colleagues. As a result of the COVID-19 the Hospital Association, and a number of waivers that granted pharmacists with ex- business groups, all of which are members of Prior authorization reform (SB 225) has panded authority to provide COVID-19 the Pennsylvania Coalition for Civil Justice been a priority issue for PAMED and our 40+ vaccines, pharmacists began efforts in early Reform (PCCJR), were unsuccessful. Though member coalition of physician organizations January to further expand their role into the the bill only won committee approval in the and patient advocacy groups for over six realm of childhood immunizations, seeking House of Representatives, it was successful in years. Earlier this session, Senator Kristin the authority to provide this service to their getting the issue before the legislature. PAMED Phillips-Hill introduced SB 225, and has since “customers” over the age of 5. Working in will continue to work within the framework been championing the effort to achieve senate concert with the PA Academy of Family of PCCJR to ensure that Pennsylvania’s legal passage before this year’s summer recess. Physicians (PAFP) and the PA Chapter of climate is improved. Over the past 6 months, various coalition the American College of Pediatrics (PA-ACP), At this point, the state Supreme Court has partners met countless times with senate staff that effort was stopped before it even became not taken any formal action to change venue and representatives of the insurance industry part of a legislative proposal. thresholds. However, we continue to keep 16 Summer 2022 Central PA Medicine
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our ear to the ground in the event a potential change is once again made public. PAMED encourages all physicians to engage in the legislative process by getting to know your individual representatives in Harrisburg. Nothing is more important than developing a trusting relationship with lawmakers so that your concerns are heard and respected.
HB 2604 SB 225 Allows name badges to have the health Amends the Insurance Company Law of system a healthcare provider works for on 1921 to standardize and streamline the practices the badge. Previously name badges had to of prior authorization. be specific to the location where the pro- Current Status—Unanimously passed the vider was working, becoming an issue for Senate on June 29, 2022. Referred to House providers who work in multiple locations. Insurance Committee. Signed by Governor as Act 79 of 2022
SB 317 HB 2679 Provides health care practitioners the authority Amends the Pharmacy Act to allow phar- to prescribe or personally furnish antibiotics to macists, and supervised pharmacy interns, treat sexually transmitted infections, without to administer influenza and COVID-19 having examined the individual for whom SB 818 vaccines to children ages five and older. the drug is intended, in accordance with the Amends the Health Care Facilities Act to Signed by Governor as Act 80 of 2022 Expedited Partner Therapy (EPT) in the allow ambulatory surgical facilities to perManagement of Sexually Transmitted Diseases form certain permitted surgical procedures guidance document issued by the United States without seeking a waiver/exception from the SB 106 Center for Disease Control (CDC). A Joint Resolution proposing five sepDepartment of Health. The bill creates an updated waiver/exception process for surgical arate and distinct amendments to the PA Current Status—Unanimously passed the Senate in April 2022. Reported out of procedures not on the 2022 CMS ASC-CPL Constitution. House Health Committee on April 26 but list or otherwise prohibited by state regulation. • Establishes that the PA Constitution does no further movement. Signed by the Governor as Act 87 of 2022 not grant any right to abortion or taxpayer funding for an abortion. HB 1421 Provides additional funding for the Primary • Allows the General Assembly to disap- HB 1280 Amends the Patient Test Results InformaCare Loan Repayment Program. Raises prove regulations by its own vote with tion Act. Provides for certain exclusions, and funding from $4.5 million to $7 million. no signature by the Governor required. definitions within the Patient Test Results Signed by the Governor as Act 54 of 2022 • Eliminates separate election for Lieutenant Information Act. Governor. Allows the gubernatorial HB 1563 candidate to select his own running mate. Current Status—Waiting consideration from the Senate Health and Human Services Amends the Pennsylvania Drug and Al• Requires all voters, whether in person or Committee. cohol Abuse Control Act (DAACA). This not, to present a government-issued form legislation brings DAACA into alignment of identification prior to voting. HB 1393 with HIPAA to create a consistent and easily Amends the Controlled Substance, Drug, • R equires the General Assembly to provide understandable standard and revises outdated Device and Cosmetic Act to legalize the use of by statute for the auditing of elections regulations. The bill also provides consistency drug testing products like fentanyl test strips and election results. between statutory and regulatory language. for personal use. Signed by the Governor as Act 33 of 2022 Current Status—Passed the General Assembly on July 8, 2022. Identical language must Current Status—Passed the House on June 20, pass again next session and then the ballot 2022. Referred to Senate Judiciary Committee HB 2419 questions can be presented to the voters at but no further movement. Allows psychiatrists, and other mental the next statewide election, possibly as early health providers, to provide telehealth services. as the 2023 Primary Election. Signed by the Governor as Act 76 of 2022 HB 2660 Proposed Constitutional amendment that would put the current Venue Rule into the Pennsylvania Constitution. The following are legislative initiatives that either made it to the Governor’s desk thus far this year or are still “in play” between now and the November General election.
Current Status—Referred to House Rules. Stay up to date on PAMED’s legislative priorities at
www.pamedsoc.org/Advocacy Central PA Medicine Summer 2022 17
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RESTAURANT REVIEW
ONE13 SOCIAL
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By ROBERT ETTLINGER, MD
otwithstanding the price of gasoline lately, a close drive to Carlisle can make for a special evening to relax. A short walk away from the Dickinson University campus, the neighborhood around High and Pitt Streets includes the Carlisle Theater (with talented and oft-times famous performers), Cafe Bruges (great Belgian food), and the Hamilton Restaurant (if you’ve never had a Hotchee Dog, you are sorely missing out on one fabulous tube steak). Joining them since January, One13 Social brings a New American menu that’s upscale yet casual.
In remodeling the building with the help of Carlisle Design, the wood- and leather-accented, sound-proofed rooms feature both a main bar with patio seating for sunshiny days, and a Scotch bar. After spending many years at the Boiling Spring Tavern, owner Kevin Rockwood and Chef Ross Graham took six months to work on the globally inspired menu. Small plates shared were Tuna Tartare Tostada, Korean BBQ Ribs (in a kimchi aioli that’s not too hot), and the popular One13 Fries (julienned Russets done in duck fat, with tasty shots of salsa verde and garlic-parmesan aioli). Our server also recommended the She Crab Bisque and the Oven-Roasted Oysters with chipotle-garlic butter. Their reportedly best-selling entree is Salmon Au Poivre, in a peppercorn-cognac cream with sauteed spinach. Scampi Gnocchi, with a perfect bite, was done with gulf shrimp and saffron. Chicken Florentine was served with shiitakes and feta in a sherry cream. Notable among the four sandwich choices was the Chicken Torte, with moist thigh meat, queso fresco and Pico de Gallo on an excellent ciabatta from Talking Breads Bakery on Lisburn Road in Mechanicsburg. Argentinian Flank Steak with rosemary chimichurri and Pork Roulade in a mulled wine coulis looked good at a nearby table. House cocktails are inventive, and the wine and beer lists are long but well organized. It was hard to choose, but you just don’t see Chimay Belgian on menus very often. Desserts are house-made and crafty...a dinner-mate described the Key Lime Pie as having “just the right pucker.” If you live anywhere near the Capitol area, a ride to One13 Social is well worth the trip.
ONE13 SOCIAL 113 W. High Street | Carlisle, PA 17013 | 717-706-3514 open Tuesday-Saturday 11 am-10 pm
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DCMS NEwS
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
Patient First-Harrisburg
Brownstone Dermatology Associates
PinnacleHealth Express
Conestoga Eye-Hershey
PinnacleHealth Radiation Oncology
Cummings Associates PC
Premier Eye Care Group
Elena R Farrell DO
Saye Gette & Diamond Dermatology Assoc PC
Family Internal Medicine
Schein Ernst Mishra Eye
Family Practice Center PC-Millersburg
Stratis Gayner Plastic Surgery
F orti & Consevage PC
Tan & Garcia Pediatrics PC
Gastroenterology Associates of Central PA PC
Todd R Fisher MD Family Medicine
Harrisburg Gastroenterology Ltd
UPMC Heart and Vascular Institute-LCV
Hershey Pediatric Ophthalmology Associates PC
UPMC Pinnacle Colon & Rectal Surgery
Hershey Psychiatric Associates
UPMC Pinnacle Harrisburg Transplant Services
Houcks Road Family Practice
UPMC Pinnacle Harrisburg-Emergency Room
James R Harty MD
U PMC Pinnacle PHCVI Cardiovascular & Thoracic Surgery
Jatto Internal Medicine & Wellness Center PC John E Muscalus DO Morganstein De Falcis Rehabilitation Institute-Harrisburg
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SUMMER TOURS AVAILABLE AT LANCASTER COUNTRY DAY SCHOOL challenging academics are only the start of each student’s opportunities for personal discovery and growth. From preschool to 12th grade, LCDS students are able to develop established passions or try new activities in a supportive independent school environment. Schedule a tour today!
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The Latest Advances in Neurosurgery for Your Patients— Right Here, Close to Home
The Penn State Health Neurosurgery team provides comprehensive treatment for common to complex conditions of the brain, spine and nervous system. Our world-class neurosurgeons have specialized expertise in many neurosurgical subspecialties to bring both children and adult patients lifesaving care tailored to their specific needs. Patients also benefit from research conducted at Penn State College of Medicine, with access to innovative clinical trials – with the latest treatments and new hope.
Contact a Penn State Health neurosurgical expert near you: Penn State Health Neurosurgery Milton S. Hershey Medical Center 30 Hope Drive, Entrance B, Suite 1200 Hershey, PA 17033 717-531-3828 American Office Center (on the Holy Spirit Medical Center campus) 423 N. 21st Street, Suite 300 Camp Hill, PA 17011 717-763-2559 St. Joseph Medical Center Medical Office Building 2494 Bernville Road, Suite 201 Reading, PA 19605 610-378-2557
pennstatehealth.org/neurosurgery
NEU-16797-22 166047 040522 CPAM
