Lancaster Physician Spring 2023

GORDON HUTT, MD

EMMA BATCHELDER, MD

BY CELESTE HECKMAN, MD, D ip ACLM

Second opinions are common and highly recommended. Never feel as though you are hurting the surgeon’s feelings. If a surgeon takes offense, consider that a red flag. Also, if a surgeon tells you they cannot help you or that nothing else can be done to help you, you should certainly get a second opinion.

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are common and highly recommended.”

2022/2023 BOARD OF DIRECTORS OFFICERS

Stacey S. Denlinger, DO President

UPMC Highlands Family Practice & UPMC Wound Healing Center

Sarah E. Eiser, MD President Elect

Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

Robin M. Hicks, DO Vice President

UPMC Supportive Care & Palliative Medicine

Christopher R. Scheid, DO Secretary

UPMC College Avenue Family Medicine

Stephen T. Olin, MD Treasurer

Penn Medicine Lancaster General Health

Walter L. Aument Family Health Center

Laura H. Fisher, MD

Immediate Past President

Lancaster Family Allergy

DIRECTORS

Robert K. Aichele, Jr., DO

Marco A. Cunicelli, DO | Resident

Kendall R. Dempsey, MD | Resident

Lena Dumasia, MD

David J. Gasperack, DO

Lauren M. Hammell, DO | Resident

James M. Kelly, MD

Karen A. Rizzo, MD, FACS

Susanne Scott, MD, MPH

Danielle Rubinstein, DO

As I write this, I am listening to the wind beat against the house. I cannot speak for everyone, but I am certainly welcoming the warmer months with open arms! Every February marks the low point in the year for me and it feels like the nadir for many staff members and patients as well. It is well reported that all facets of the healthcare team, including patients, nurses, and clinicians, have expressed a significant decline in general satisfaction with health care over the last five years. Articles in this issue will hopefully serve as a reminder for how we can restore the relationships most strained by the stressors we face on a daily basis. These issues are not limited to the office and exam room challenges; they include larger system issues like the drug shortages, too. It can be very overwhelming. Remember that self-care is not selfish. Taking care of yourself allows you to provide better care for those around you, whether it’s at home or at work. I hope as you read this issue of Lancaster Physician, you can reflect on how the topics impact you and the people with whom you interact.

This year, as we return to a more usual programming schedule, Lancaster City & County Medical Society is offering a number of events for both members and prospective members. Thank you to everyone who renewed their membership. If you missed the renewal period, look out for letters, e-mails, and calls from us encouraging you to rejoin for the year. We appreciate you continued support and hope you will make it a priority to attend upcoming events like our popular Walk & W(h)ine, our Lancaster County Women in Medicine and Early Career Physician events, the LCCMS Annual Dinner & Awards Celebration and more. There will be more information in upcoming issues of the magazine, in our E-newsletters, and in invitations coming your way!

As always, if there are topics you think are missing, or if you would like to be a contributor to the magazine or host one of our “Docs, Drinks, and Dialogue” small group discussions, please reach out to our executive director, Beth Gerber.

LG Health’s Street Medicine program, which began in spring 2022, seeks to engage unsheltered individuals who might be hesitant to pursue traditional medical care. The goal is to help people who are experiencing homelessness to avoid adverse health outcomes and ultimately improve their overall health and well-being.

The team of medical residents, attending physicians, and others make rounds on foot twice monthly at locations where potential patients might gather. In its first eight months, the team saw a total of 60 patients at those locations, providing basic physical exams and mental health care; treating acute concerns; performing minor procedures, such as podiatry services; and prescribing medications as needed.

The Street Medicine program is a partnership between the Lancaster General Hospital Family Medicine Residency Program and LG Health’s Community Health and Wellness department. The team also collaborates with community organizations that serve people who are experiencing homelessness.

Camden Towne, DO, a third-year family medicine resident, said the program provides accessible health care with an emphasis on compassion. The team members have completed trauma-informed trainings and use care to show respect for the individuals they approach. While they dress casually, the physicians wear stethoscopes so they are easily identifiable.

“As family physicians, we try to meet our patients where they are, even if it’s a place where most people don’t want to be,” he said. “We are providing basic medical care and establishing relationships with the folks who are out there, many of whom have unaddressed medical or social needs. Through this program, they are seeing that people really do care.”

Towne and his fellow residents saw the visible homelessness in the community

and wanted to respond in a meaningful way to help those in need. They partnered with Community Health to launch the program, ultimately receiving a $10,000 seed grant, as well as additional guidance and support, from the Pittsburgh-based Street Medicine Institute.

Jessica Klinkner, Manager, Community Health and Wellness, said LG Health’s Street Medicine program is funded solely through grants, including nearly $25,000 from the Pennsylvania Housing Finance Agency’s Home4Good Program. These initial grants cover supplies and medications, including prescriptions. Residents and attending physicians participate as part of their role at LG Health.

“Rounding with the Street Medicine team is really educational for our residents,” Towne said. “We talk a lot about social determinants of health in medical education. This gives our residents a front row seat to some very real and very raw life situations.”

On their biweekly rounds, the small team of residents sees people at a downtown park and a church that provides overnight shelter. They are joined by attending physicians from the Family & Community Medicine Department, a nurse, and an outreach worker. The team typically approaches people in pairs, introducing themselves and inquiring about potential healthcare needs. They focus on taking time to listen closely to each individual and gain a greater understanding of their needs.

“Relationship building is paramount for our team,” Klinkner said. “Even if we aren’t able to do anything to improve someone’s physical health on the first encounter, we are planting a seed so they might come to us in the future.”

For its first several months, the team focused on building trust through interactions with potential patients. Between April 2022 — when the team officially began documenting those interactions — and Dec.

31, 2022, the team saw 60 unique patients, for a total of 130 patient encounters.

Eleven of the 60 patients interacted with the team three or more times. Since engaging with the program, the average number of emergency department visits for those patients decreased 45 percent. After an encounter with the Street Medicine team, four patients established a primary-care relationship with LG Health. In addition, 29 patients have engaged with at least one related service, including LG Health social workers, a mobile hygiene unit staffed by community paramedics, and a local free clinic.

“We connect individuals who wish to be connected,” Klinkner said. “We also recognize that some people will never seek care in the traditional healthcare system, and we don’t place pressure on them to do so.”

Attending physician Jared Nissley, MD, who practices at LG Health Physicians Comprehensive Care, said the team hopes to secure additional grant funding to grow the program to include more team members, more frequent rounding, and coverage of a larger geographic area. The team also would like to expand the services it provides, including preventive care, lab work, and suboxone treatment for opioid use disorder.

“LG Health’s mission is to advance the health and well-being of the communities we serve, and that includes everyone living in those communities,” he said. “Our Street Medicine program removes barriers and increases access to personalized medical care, with a dose of dignity as well.”

Inspire Therapy to Treat Sleep Apnea

NOW AVAILABLE AT PENN STATE HEALTH LANCASTER MEDICAL CENTER

A small pulse generator, battery pack, and a respiratory sensor are implanted just under the skin in the chest during the Inspire therapy procedure.

Sleep apnea patients who have not significantly benefited from use of a continuous positive airway pressure (CPAP) machine or other therapies now have access to an alternative treatment in Lancaster County.

Dr. Guy Slonimsky, a head and neck surgical oncologist at Penn State Health and assistant professor of otolaryngology at Penn State College of Medicine, recently completed the first Inspire therapy procedure at Penn State Health Lancaster Medical Center.

The treatment involves the implantation of a small device that delivers mild stimulation to the hypoglossal nerve, which controls the movement of the tongue. This helps keep airways open to allow for normal breathing during sleep. It is the first such treatment to be approved by the FDA following a five-year clinical trial.

Inspire therapy is meant to reduce or eliminate the symptoms of obstructive sleep apnea (OSA), a condition that affects about 22 million Americans. If left untreated, OSA can cause serious health problems, including cardiovascular issues such as arrhythmia, heart failure, or stroke; increased blood pressure; instability of oxygen levels; changes in the body’s response to insulin and glucose; chronic fatigue; and changes in mood and ability to function.

Slonimsky, who has performed about 20 Inspire implantations at Penn State Health Milton S. Hershey Medical Center over the past year, said the treatment has proven to be safe and effective. An experienced surgical team prepares patients for the outpatient surgery, which generally lasts for between one and a half to two and a half hours.

During surgery, a small pulse generator, battery pack, and a respiratory sensor are implanted just under the skin in the chest. An electronic lead connects the device to the hypoglossal nerve under the jaw. The procedure requires two small incisions, one over the upper chest and another under the jaw.

Once connected, the device monitors the patient’s breathing, sending an impulse that keeps the airway open during every breath. Patients control the device with a small, handheld instrument, turning it on before sleep and off upon waking.

Patients generally experience minimal side effects, the most common being temporary pain at the incision sites, temporary weakening of the nerves controlling tongue movement, and soreness of the tongue — all of which improve over time.

Slonimsky said his patients to date have experienced negligible, if any, side effects from the procedure.

“All of my patients over the past year have gone home the same day with no significant side effects, and more than 95 percent have highly benefited from this treatment,” Slonimsky said. “I see this as a game changer in the treatment of sleep apnea.”

Inspire is not meant to replace CPAP therapy, but to provide an alternative for patients who are unsuccessful in their attempts to use CPAP, explained Dr. Daron Kahn, a Penn State Health pulmonary and critical care medicine specialist and board-certified sleep physician.

Prospective candidates for the Inspire treatment must have tried CPAP and found they were not successful in using it or that it did not improve their condition.

“Some patients just medically fail CPAP, and they need another option,” Kahn said. “The more choices we have for patients, the more likely it will be that they’ll choose a therapy and be successful in treating their disease. We’re happy to be able to bring this treatment to patients at our Lancaster hospital.”

Other requirements to be considered for the treatment include a sleep study within the past two years that resulted in a diagnosis of moderate to severe OSA, having a body mass index under 32, and being age 18 or older.

Prospective patients should consult a board-certified sleep physician to see if they qualify for the Inspire treatment. A primary care physician may be able to provide a referral. Many insurances will cover treatment costs for qualified patients.

Patients use a small, handheld instrument to control the device, enabling them to turn it on and off and adjust the strength of stimulation.

Best Practices

Inboxology

BEHIND-THE-SCENES HELP FOR WELLSPAN PROVIDERS AND PATIENTS

Meet the inboxologist.

WellSpan is one of the few health systems across the country employing inboxologists, who help patients get information faster and lessen the workload for providers. Here are four things you need to know about this new type of behind-the-scenes provider.

INBOXOLOGY, EXPLAINED

An inboxologist is on the front lines of medicine, helping to support other providers by working in their electronic health record inboxes. Working remotely, they assist with tasks such as answering patient questions, ordering tests, making referrals, refilling prescriptions, and doing other important time-sensitive tasks.

At WellSpan, inboxologists are primarily advanced practice providers — nurse practitioners or physician assistants — who support other providers at primary care practices. All WellSpan inboxologists have at least five years of clinical experience working in a primary care practice environment, so they understand the daily cadence of a clinical practice.

THE WHY BEHIND INBOXOLOGY

During the COVID-19 pandemic, WellSpan, like other health systems, shifted some of its primary care providers to hospitals to care for COVID-19 patients. Some of those primary care providers discovered they enjoyed hospitalist work and decided to permanently stay in that specialty. That shift was particularly acute in Franklin County, which was hit early and hard by the pandemic.

“At that time, the workload in primary care practices increased and the virtual workload went up significantly,” says Jeni Smith, director of operations for the WellSpan Medical Group in Franklin County. “Providers’ paperwork, the signatures that were needed, the forms, responding to messages on the patient portal — all of that grew more demanding.”

Providers often do these tasks after hours, at home, in a chunk of time that has been nicknamed “pajama time.” Physicians routinely take at least one to two hours of work home each night, according to a study in the Annals of Family Medicine. It’s a factor often cited in physician burnout.

Smith did some research and found a California health system that was using remote providers to help providers with the electronic work they were doing after hours. She thought the same type of provider would be helpful at WellSpan to relieve the load for primary care physicians, and that type of work also would be an attractive choice for medical professionals seeking remote positions in the pandemic and post-pandemic world.

“I woke up one day and thought I know how I can do this,” Smith says.

In August 2021, WellSpan started a pilot program of inboxologists in Franklin and Adams counties, where there are now six inboxologists working behind the scenes. The program is expanding across WellSpan’s system, with two more inboxologists now being sought: one in York and one in Lancaster/Lebanon counties.

Smith’s work on inboxology embodies many WellSpan values and strategies. Team members are encouraged to be problem solvers and to find a better way, and to reimagine health care and deliver it in a way that makes it easier for patients.

MEET AN INBOXOLOGIST

Carrie McMahon is an inboxologist who supports seven providers at WellSpan primary care offices in Greencastle and Carlisle. The physician assistant previously had worked for a dermatology and plastic surgery office but left due to the demands of her own “pajama time” and burnout, so she is glad that she can help relieve that problem for other providers in her new role.

“It’s a win-win-win,” she says. “I am helping patients get information in a timely fashion. I’m helping my colleagues sustain the vast demands of clinical practice. And

the flexibility of this position allows me to maintain my own work-life balance.”

WHAT PROVIDERS SAY

Dr. Ryan Crim, at WellSpan Family Medicine – Carlisle, is one of the physicians supported by McMahon. He has been impressed by her ability to match different providers’ styles, a subtle thing that has a significant impact because it makes life smoother for patients who are used to how their provider interacts with them.

“Her timely responses give patients the answers they need quickly, and that greatly improves patient satisfaction,” Dr. Crim adds. “I like having happy patients because it makes office visits so much smoother. Her work also allows me to enjoy my time away from work, especially when I am on vacation. I don’t have to worry about checking my inbox because Carrie has it covered.”

Dr. Keith Wright, WellSpan medical director of primary care in Lancaster County, said he is eager for inboxologists to come to his region. Some doctors are getting well over 100 messages a day from patients, he says. Dr. Wright, of WellSpan Family Health – Georgetown, does his own “pajama time” early in the morning, arriving at his practice by 6 a.m. so he can spend a few hours doing inbox tasks before he starts seeing patients.

“Those are the things that an inboxologist could do to relieve the pressure,” he says.

He likens an inboxologist to DAX, another recent tool being used by WellSpan providers that offers voice-activated technology to automatically transcribe patient visits, saving providers transcription time and allowing them to focus more and connect with the patients in front of them.

“When we can put the computer in the background, when we can alleviate some of those tasks, it allows us to shift so we can focus on the patient in front of us,” he says.

It All Starts With Culture

JEFF O’DONNELL Practice Administrator, Eye Associates of Lancaster

We’ve all been there…

We have teams that may perform well but are otherwise constantly in a state of negativity or drama that drains the morale of the entire organization and monopolizes everyone’s time and energy (not to mention burns out the supervisors trying to sort through it all).

Our teams need more support — or even just the normal amount of support — in this short-staffed decade we are living in! We hire new staff only to find out they are not suited for the role, the practice, or even the medical industry overall. We then must start the whole hiring process anew.

These situations are frustrating, time-consuming, unproductive, and ultimately ineffective for business growth. When trying to combat them, we seek out strategies that offer various methods to improve our workplaces, but the way these approaches are laid out in books or online can be confusing due to the complex steps involved. Choose the method that feels right for your practices, but to better integrate the recommendations for change, try to narrow down things to the simplest concepts to make them easier to understand. Simpler is better when it comes to improving the culture of our teams.

Start by deciding what type of basic work environment you need. Look at things with objective honesty. What strengths do your practices have, and what areas for growth are evident? Build on those strengths, and begin to weed out the negatives, whether they be processes, employees, etc. And accept ahead of time that it is going to be a long-game — the shift within your workplace culture will not happen overnight. Staying consistent with your approach and your messaging to staff will help you all get through periods of hopelessness when things seem like they are taking too long to improve.

True culture change brings hard decisions. Deciding when to take job action can be very difficult from a practical standpoint, even when it is fully clear from an objective standpoint. If underperformers exist within the team, coach

them towards acceptable paths for improvement, using specific, attainable goals. If they do not meet those goals, do not be afraid to terminate their employment. Letting someone go can temporarily put a strain on workflow, yet it is the right decision when you have given employees the tools to succeed but they do not use them. Employees need to be responsible and accountable just as much as we need to be supportive and empowering.

There are often employees whose attitudes, styles, demeanors, and even direct outbursts bring the rest of the team’s productivity and positive morale to a halt, as well as cause significant staff-retention issues overall. These employees are where the culture-change focus should start. Terminate staff based on their attitudes before any staff are terminated due to performance. We can train employees for skills, but we cannot train employees for personality. When in doubt about personnel choices, just use common sense. Do not over-complicate things. Look at what decision makes the most sense for the true betterment of your teams, and go with that, even if it feels strange. Doing what is right is often the hardest thing to accomplish in both business and in life, so if you feel even slight awkwardness, then chances are it is the right decision with which to follow through.

As you begin to reset the team after personnel changes, remember that just having a body come in to fill an employment vacancy does not usually work. Hire for the right fit instead, knowing you can then train for skills afterwards. Use the interview process to look for the factors that your practice culture needs from a behavioral standpoint, and then seek those traits out.

Getting the right type of character fit will automatically help with productivity, retention, and company growth down the road.

Throughout culture change, communicate with your teams as much as possible. Aim for transparency by explaining the “why” behind things, with the goal being to have employees respect the intent even if they do not necessarily agree with it. Document details so the staff can reference them later. And do not be afraid to be vulnerable with your teams — as long as you remain consistent overall with your approach and messaging, it is okay for staff to see areas where you yourself are struggling too. It creates common ground, and it also humanizes us as leaders, which can in turn go a long way toward creating buy-in for change.

By applying simplification to your approach, and by focusing first on resetting the culture within your practices, you can achieve true growth within your teams. Starting with the basics can help you build a practice that is not only what you want it to be but what you need it to be as well.

Does the candidate have a personable and positive presence?

Are they candid about their strengths and weaknesses, or at least willing to talk about them?

Do they seem to want to participate in personal and institutional growth?

HEART ATTACKS VS. CARDIAC ARREST

THERE IS A D IFFERENCE

GORDON HUTT, MD UPMC Heart and Vascular Institute

Heart disease remains the leading cause of death for men and women in the United States. Left untreated, it can lead to a myocardial infarction (heart attack), stroke, or congestive heart failure with high incidence of disability and mortality.

Heart attacks occur when a preexisting plaque present in the arterial walls of the coronary artery ruptures, causing occlusion or blockage of the blood vessel and subsequent heart muscle damage. Less frequently, the artery might occlude because of spasm or dissection of the artery. Coronary spasm can be a preexisting condition or can be caused by drugs such as cocaine.

Cardiac arrest, on the other hand, is the sudden disruption of a heart’s ventricular rhythm and fatal in 9 out of 10 patients.

Every year, about 805,000 people have a heart attack. Of those, about 600,000 are first-time heart attacks, and the other 200,000 are recurrent. More alarming, about one in five heart attacks are silent or undetected, meaning patients never knew they had a previous heart attack. The absence of this knowledge puts patients at higher risk for a future cardiac event.

While “cardiac arrest” and “heart attack” are often used interchangeably, the two are very different. Heart attacks can be grouped into a condition known as acute coronary syndrome (ACS). All are urgent cardiac conditions that require early diagnosis and treatment.

One form of ACS includes unstable angina with likely minimal heart muscle damage and no increase of cardiac enzymes in the blood. A Non-STEMI typically is diagnosed with elevated cardiac enzymes, but no acute ST elevation on an EKG. A STEMI typically presents with acute ST elevation or new left bundle branch block often with complete occlusion of the coronary artery; this is the most critical form of ACS and requires immediate coronary intervention.

TRANSFORMATIVE TREATMENTS

Decades ago, the jury was still out on the best treatment option. There were a lot of headto-head studies comparing stenting versus administering clot dissolving medication in the form of thrombolytic therapy.

Today, it is universally agreed upon that the most effective treatment for an acute heart attack is emergency catheterization to open the blockage with a balloon and/or stent. The challenge is getting the patient to the catheterization laboratory as soon as possible.

Sometimes medical therapy or early cardiac bypass surgery is indicated if there is coronary anatomy not appropriate for balloon or stenting. Medical therapy for coronary artery disease (CAD) often consists of antiplatelet agents such as aspirin, clopidogrel, or ticagrelor, statins to lower cholesterol, plus beta blockers and ACE inhibitors, which will affect heart rate, blood pressure, and cardiac function.

Cardiovascular disease also consists of carotid and peripheral arterial disease. Surgical and interventional techniques for these conditions might include carotid artery stenting and/or surgical endarterectomy, peripheral arterial surgery, or percutaneous intervention. Each is used to open arteries, remove plaque and blockages, and restore blood flow.

Knowing your risk factors and not ignoring symptoms are the first steps in preventing heart disease.

An EKG is a baseline test but can be normal even if a patient has significant CAD. Further evaluation often is suggested and may include stress testing, nuclear imaging, and echocardiogram. Typically, patients will first present to the emergency department or their PCP if symptoms occur with subsequent referral to a cardiologist. At times, patients do self-refer to see a specialist.

KNOW YOUR RISK FACTORS

Risk factors are classified as controllable and uncontrollable. Family history cannot be changed, but people can control their

cholesterol levels, blood pressure range, body mass index, waist circumference, and fasting blood sugar. In fact, 70 percent of major heart attack risk factors can be managed through lifestyle choices. Obesity, smoking, excessive alcohol consumption, and a sedentary lifestyle significantly contribute to many forms of illness, including cardiovascular disease.

Age and gender are also contributing influences; heart disease isn’t gender specific or exclusively tied to an older demographic. Numerous reports of cardiac events in younger men and women, including athletes, have proven it can happen to anyone, although the underlying causes may differ.

There’s a higher incidence of middle-aged and older men and women who experience heart attacks or suffer from congestive heart failure, but I’ve also seen women in their 20s and 30s with abnormal stress tests, extensive coronary disease, and who have needed heart surgery or coronary stenting. Regardless of gender, surveillance should always remain high, especially as patients age.

Men and women may experience different symptoms. Women’s warning signs may be more subtle, such as shortness of breath, nausea, fatigue, fainting, or indigestion. It is recommended that anyone with these symptoms should seek early medical attention most likely to include an EKG and further cardiac work up.

It’s important to note that not all chest pain is heart related or a heart attack. That’s one of the first things taught in medical school and residency. There’s a wide differential diagnosis such as myocarditis or pericarditis, which are inflammatory conditions that affect the heart muscle and outer lining of the heart. A patient may also be suffering from an aortic aneurysm or dissection, which are medical emergencies.

Pulmonary diseases like pleuritis, pleurisy, or a pulmonary embolus are also known causes of chest pain, along with GI conditions such as esophagitis, peptic ulcer

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Healthy Communities

disease or gastritis, and gallbladder disease/ gallstones. Other non-cardiac discomfort might include skeletal muscle or chest wall pain.

THE LINK BETWEEN CARDIAC ARREST AND HEART ATTACKS

There are more than 350,000 out-of-hospital cardiac arrests each year in the United States. While not everyone in cardiac arrest goes on to experience a heart attack, if they are having a heart attack, the risk of cardiac arrest increases.

A certain segment of patients in cardiac arrest will be in the midst of having a heart attack, which is a known complication. A heart attack can change the muscle’s electrical activity leading to ventricular tachycardia or ventricular fibrillation causing cardiac arrest.

Persons without preexisting heart disease also can have a cardiac arrest. This can occur in athletes following a chest trauma, which can disrupt the heart’s electrical system. Known as commotio cordis, the condition is recognized mostly in those playing contact sports, such as football, or sports with hard projectiles like hockey, baseball, or lacrosse.

Electrolyte disturbances, illicit drug use, or drug interactions also may trigger cardiac arrest and unstable ventricular arrhythmias.

GETTING AHEAD OF A DIAGNOSIS

There are approximately 700 million people worldwide with hypertension and 200 million living with coronary disease. Roughly half of those diagnosed with hypertension are unaware they have it and of those who are treated for it, nearly half are not adequately treated.

Symptoms are usually not present until hypertension is advanced with possible end-organ disease involving the kidneys, eyes, and heart. In rare cases, patients may experience headaches or blurred vision.

Treatment for coronary disease is considered primary or secondary depending upon whether someone already had a heart attack, is diabetic, or has familial hypercholesterolemia. Aggressively treating elevated blood pressure and cholesterol is indicated to reduce risks of future cardiac events.

It is important for everyone to follow up regularly with their PCP for regular blood work, including blood sugar and cholesterol levels, especially for those at risk.

Modifying what you can control — such as getting regular exercise, abstaining from smoking, and maintaining a healthy weight — and knowing the early signs and risk factors for developing coronary artery disease and heart attack are keys to staying ahead of heart disease.

VIGILANCE IS KEY FOR REDUCING THE RISK OF A CARDIAC EVENT, EVEN IF SYMPTOMS ARE MINIMAL. THE FIRST LEVEL OF CLINICAL SURVEILLANCE OFTEN IS THE PRIMARY CARE DOCTOR OR EMERGENCY ROOM PHYSICIAN, AND THEY NEED TO HAVE A STRONG INDEX OF SUSPICION TO FIND OUT WHY THIS PERSON’S COMING IN WITH THESE SYMPTOMS.

What Is Lifestyle Medicine?

CELESTE HECKMAN, MD, DipACLM Penn Medicine Lancaster General Health Physicians Family Medicine Strasburg

Lifestyle medicine is a medical specialty that uses evidence-based lifestyle interventions to promote well-being and treat chronic conditions, such as cardiovascular disease, type 2 diabetes, and obesity. Lifestyle medicine certified clinicians are trained to engage patients in a collaborative approach and prescribe lifestyle change as first line therapy in the treatment and prevention

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Healthy Communities

of chronic disease. The burden of chronic disease is growing in our society and is overwhelming our healthcare economy. Ninety percent of healthcare costs can be attributed to the treatment of chronic conditions. A western diet that is high in sodium, high in processed meats, and low in vegetables is the leading cause of chronic disease and disability in the United States.

Incorporating lifestyle medicine principles into practice can reduce the need for costly interventions and slow progression of disease — which will lead to a decreased reliance on prescription drugs and medical procedures. Since most modern diseases are caused by lifestyle factors, lifestyle changes can be part of the cure and serve as a fundamental philosophy to prevent disease.

pillars.

• A whole-food, plant-rich diet,

• Physical activity,

• Restorative sleep,

• Stress management,

• Avoidance of risky substances, and

• Positive social connections

Through a process that support the fundamentals of healthy behavior change, lifestyle medicine practitioners collaborate with their patients to identify ways to enhance these pillars of well-being in a way that is relevant and sustainable for the individual.

Research Supporting Lifestyle Medicine’s Benefits

The evidence for lifestyle medicine is growing as is our knowledge of the physiologic and genetic changes that can result with the adoption of a healthy lifestyle. The sentinel study that identified healthy lifestyle change as a viable treatment recommendation was the “Lifestyle Heart Trial.” That small study in 1998 of 48 participants concluded that comprehensive lifestyle change in individuals with moderate to severe heart disease lowered LDL,

reduced angina episodes, and resulted in regression of coronary atherosclerosis. Published in 2004, a Percutaneous Coronary Angioplasty vs Exercise Training study demonstrated that 20 minutes of stationary bicycling per day increased event-free survival, reduced hospital readmissions, and improved exercise capacity in those with coronary artery disease. The 2002 landmark study conducted by the Diabetes Prevention Program research group demonstrated, through a randomized control trial including 3,234 participants with prediabetes, that lifestyle intervention was more effective than metformin in decreasing the progression to diabetes. A possible explanation for how lifestyle changes impact physiologic change was offered in the GEMINAL study in 2008, which demonstrated that intensive nutrition and lifestyle changes may modulate the gene expression in the prostate. Other studies are looking at how healthy diet, physical activity, and meditation affect telomere length, expression of GLP-1, ghrelin, BDNF, and other gut and neuro hormones. This is a fascinating area of research that will help us further understand how lifestyle factors affect our biochemistry, physiology, and gene expression and impact our physical health and mental well-being.

The Lifestyle Medicine Practitioner: Patient Engagement, Challenges, and Education

Lifestyle medicine practitioners are trained in the spirit of motivational interviewing, using

positive psychology to support individuals in setting individualized health goals. Often health coaches, nutritionists, behaviorists, or exercises coaches are part of the team that helps to support healthy behavior change. This intervention can be delivered through individual encounters or through shared medical appointments during which providers see multiple patients simultaneously in a group setting. The advantages of the group setting for patients are many — lifestyle education, improved access to care, emotional support, more time with healthcare teams, and interpatient camaraderie. Shared medical appointments offer efficiency, increased patient capacity, and opportunities for lifestyle medicine interventions. Reimbursement models are emerging to allow for the coding and billing of group improvements. The American College of Lifestyle Medicine and the American Academy of Family Practice offer guidance for the development of group visits.

The challenges of instituting lifestyle changes are many which include not only individual factors (such as financial cost, time limitations, work stress, and lack of support) but also wider socioenvironmental factors (such as easy access to high-salt, high-sugar foods, limited insurance coverage for nutrition education, marketing of unhealthy products, technologies that increase sedentary behaviors, and social norms that make it difficult to sustain healthy behaviors). Systemic change is needed.

The foundation of lifestyle medicine is built upon six

Huge health and economic benefits could be achieved through healthy lifestyle changes. There is abundant evidence that lifestyle interventions can lead to reductions in obesity, diabetes, and cardiovascular disease. These initiatives should be supported with a systems approach in a new ecosystem that truly supports lifestyle intervention as first line therapy. Sustainable behavioral change requires a healthy environment that includes availability of healthy foods, access to safe areas for physical activity, strategies to reduce stress, improved social connections, and avoidance of risky substances. Providers should integrate the use of technology and health coaches to personalize care.

The American College of Lifestyle Medicine, in conjunction with the White House Conference on Hunger, Nutrition, and Health, is offering free CME/CE to health care professionals, introducing them to lifestyle medicine, a powerful treatment tool for chronic disease. You are invited to access the training via the

link below to learn more about Lifestyle Medicine, which encourages us to “eat plants, keep moving, sleep well, be present, stay calm, and love people.”

portal.lifestylemedicine.org/ACLM/ Education/Campaigns/White-House/ WHconference-SignIn.aspx

The course bundle offers 5.5 hours of content: CME/CNE/CPE/CE/MOC

• Introduction to Lifestyle Medicine  module (1 hr)

• Food as Medicine: Nutrition for Prevention and Longevity module (3 hrs)

• Food as Medicine: Nutrition for Treatment and Risk Reduction module (1.5 hrs)

EXPANDING MULTIPLE SCLEROSIS EXPERTISE IN LANCASTER

Neha V. Safi, MD, MS

RESOURCES

Ornish D., Schewitz L., Billings, J.H> et al. Intensive lifestyle changes for reversal of coronary heart disease, JAMA 1998: 280(23): 2001-2007.

Hambrecht R., Walter C., Mobius-Winkler S., et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004;109(11):1371-1378.

Ornish D., Magbauna M.J.M>, Weidner G., et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc NATL Acad Sci USA. 2008;105(24):8369-8374.

www.NEJM.org/doi/full/10.1056/NEJMoa012512 pubmed.mcbi.nim.nih.gov/21102320

Rejeski, JJ, Fanning, J., B.J. et al Six-month changes in ghrelin and GLP-1 with weight loss. International Journal of Obesity. 45,888-894 (2021)

You T. Ogawa E. Effects of meditation and mind body exercise on brain-derived neurotrophic factor. Sports Medicine and Health Science Vol2, Issue 1, March 202, 7-9.

Knaeppen K. Goekint, M., Heyman, EM et al. Neuroplasticity – Exercise-Induced Response of Peripheral Brain-Derived Neurotrophic Factor. Sports Med 40, 765-801(2010)

We are proud to welcome neurologist Neha V. Safi, MD, MS to our Neuroscience Institute team. Dr. Safi specializes in multiple sclerosis (MS) treatment.

Training:

• Fellowship: Multiple Sclerosis, Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai

Areas of Expertise:

• Multiple Sclerosis (MS)

• Myelin Oligodendrocyte Glycoprotein AntibodyAssociated Disease (MOGAD)

• Neuromyelitis Optica Spectrum Disorder (NMO or NMOSD)

• Residency: Neurology, NewYork-Presbyterian/ Weill Cornell Medical Center

• Abnormal Reflexes

• Arm or Leg Weakness

• Optic Neuritis

• Sensory Impairment

• Transverse Myelitis

• Trigeminal Neuralgia

• Unsteady Gait

Dr. Safi is part of LG Health Physicians Neurology and sees patients in Lancaster. To refer a patient, please call 717-396-9167.

Neuroscience Institute

EMMA BATCHELDER, MD Resident, Penn State Health Milton S. Hershey Medical Center

Picture this…you’re driving around town on your typical route during your day off. Overall, you’re feeling pretty good. Suddenly, out of nowhere, your heart starts pounding and you break into a sweat. You can’t breathe and your head is spinning. You feel dizzy and nauseous. You wonder, “Is this a heart attack? Am I dying?” It almost feels like you aren’t even present in your own body. Maybe you pull over and take some deep breaths until the feeling passes and you can safely drive home. Maybe you head to the emergency department, where medical evaluation, including blood work and cardiorespiratory workup, is largely unrevealing. You are told that you had a panic attack, and a short while later, perhaps after being treated with a benzodiazepine, you feel back to baseline. Does this story sound familiar? If it does, you’re not alone. Panic disorder is a common psychiatric illness affecting up to 5 percent of people at some point during their lifetime [1] and contributes significantly to health care cost and burden of disease [2] while greatly impacting a patient’s quality of life.

A panic attack, as defined by the Diagnostic and Statistical Manual of Mental Disorders, is an “abrupt surge of intense fear or intense discomfort that reaches a peak within minutes” and includes at least four of the following symptoms:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating, trembling, or shaking

• Shortness of breath or the sensation of smothering

• The sensation of choking

• Chest pain

• Nausea or abdominal distress

• Feeling dizzy, lightheaded, unsteady, or faint

• Chills or feeling overheated

• Paresthesia

• Derealization or depersonalization

• Fear of losing control

• Fear of dying [3]

Patients often describe feeling a “sense of doom.” Some patients feel as if they are going to die and may present to the emergency department for evaluation of symptoms that may be concerning for a heart attack or other life-threatening medical event. Panic disorder is characterized by recurrent, unexpected panic attacks with at least one panic attack followed by at least one month of consistent worry or concern about additional panic attacks or their consequences and/or significant maladaptive changes in behavior related to the panic attacks [3]. Not all panic attacks are suggestive of panic disorder. Panic attacks can also occur in the context of other anxiety, mood, psychotic, substance use, and trauma-related disorders. Similar symptoms can also occur in patients with specific or social phobias when exposed to a feared stimulus; however, in patients with panic disorder, the symptoms are unprovoked and come on suddenly [1].

The etiology of panic disorder has been described in several different models. Models point toward abnormalities in neurotransmitters including gamma-aminobutyric acid (GABA), cortisol, and serotonin, as well as

differences in neural circuity, and genetic, epigenetic, and environmental factors [5]. Adverse childhood experiences have been found to contribute to the development of panic disorder. A recent study has shown that patients with panic disorder may have hypermethylation of the IL-4 gene, and in patients with panic disorder, childhood trauma is associated with higher IL-4 methylation [4].

The course of panic disorder may be unpredictable, with patients experiencing fluctuating symptoms over time. The two mainstays in the treatment of panic attacks and panic disorder are psychotherapeutic and psychopharmacological interventions. In panic disorder, psychotherapy-based intervention often consists of cognitive behavioral therapy (CBT) or other therapy modalities, as well as mindfulness-based strategies. Many patients find benefit in relaxation techniques and breathing retraining. Panic disorder can also be treated pharmacologically with antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), which are first-line treatments, and benzodiazepines. Benzodiazepines may be used when symptoms are severe or if patients require symptomatic relief while waiting for antidepressant medications to take effect; however, given the side effect profile, addictive potential, and dangerous withdrawal syndrome associated with these medications, caution should be exercised when initiating and tapering benzodiazepines. The goal of pharmacologic treatment is to prevent panic attacks; lessen or eliminate associated anticipatory anxiety, avoidance, or other maladaptive behaviors; and to treat symptoms of comorbid conditions, such as other anxiety disorders, mood disorders, substance use disorders, or trauma-related disorders [1,5].

Overall, prognosis is individualized and can be unpredictable, with approximately 60 percent of patients experiencing remission of symptoms within six months. Pharmacotherapy and CBT are effective in approximately 80 percent of patients; however, relapses are common. Often, medication non-adherence can present challenges in terms of symptomatic control and lead to symptom recurrence. Various psychosocial stressors may also contribute to relapse of symptoms. There are several factors that may be associated

with poor outcomes, including having a chronic illness; low socioeconomic status; living alone; single marital status; and some personality traits, such as high interpersonal sensitivity and neuroticism. Panic disorder is also associated with development of cardiac disease; patients with panic disorder are at a higher risk of developing coronary artery disease and have an elevated risk of sudden death compared to the general population. Furthermore, patients with panic disorder are at a higher risk of experiencing suicidal ideation [5].

Panic disorder can greatly impact a patient’s health, quality of life, and overall functioning. As such, it is of high importance to identify panic disorder early in the illness course, educate patients on treatment options (both psychotherapy and pharmacologic interventions), encourage medication adherence, and conduct frequent screenings for suicidal ideation.

RESOURCES

1. Roy-Byrne, P. P., Craske, M. G., & Stein, M. B. (2006). Panic disorder. Lancet (London, England), 368(9540), 1023–1032. https://doi-org.ezaccess.libraries.psu.edu/10.1016/S0140-6736(06)69418-X

2. Deacon, B., Lickel, J., & Abramowitz, J. S. (2008). Medical utilization across the anxiety disorders. Journal of anxiety disorders, 22(2), 344–350. https://doi-org.ezaccess.libraries.psu.edu/10.1016/j. janxdis.2007.03.004

3. Association, A. P. (2022). DSM-5-TR(tm) Classification. American Psychiatric Publishing

4. Zou, Z., Huang, Y., Wang, J., Min, W., & Zhou, B. (2020). DNA methylation of IL-4 gene and the association with childhood trauma in panic disorder. Psychiatry research, 293, 113385. https://doi. org/10.1016/j.psychres.2020.113385

5 .Cackovic, C., Nazir, S., & Marwaha, R. (2022). Panic Disorder. In StatPearls. StatPearls Publishing.

Investing for a Higher Purpose:

MAKING THE MOST OF CHARITABLE CONTRIBUTIONS

BY AARON D. SHERMAN, CFP®, and S. DREW KAVANAUGH II, MBA, CFP® Odyssey Group Wealth Advisors

Philanthropy is a form of investing, but instead of capturing the returns for yourself, you’re investing money for a higher purpose. It’s not just a matter of giving money away, but rather investing it into a cause or an organization that is going to have the greatest impact. While charitable giving can be rewarding, navigating the process can be bewildering.

With the right strategy, charitable giving can be done in a tax-efficient manner that maximizes the impact of your dollars while minimizing your tax liability. We’ll explore how to make the most of the tax benefits available as you support the causes that you care about.

To dispel a commonly heard myth, tax benefits only partially offset the cost of charitable giving. There’s no magical financial maneuver that allows charitable contributions to result in a net positive financial benefit to you. So, don’t let tax benefits be the foundational reason for your giving. Rather, let your desire to do good take the lead, then make sure that your giving is supported by a beneficial tax strategy.

GIVING DURING YOUR LIFE –4 SIMPLE METHODS

There are a few simple ways you can make donations during your life that can benefit organizations you care about while reducing your tax liability.

CASH

Giving cash is the simplest and most common way of supporting charities. By “cash,” we mean physical cash, checks, credit cards, and other direct money transfers. The benefit of giving cash is the simplicity, particularly for smaller gifts. It is important, however, to keep a record of these gifts for tax purposes, as it’s the responsibility of the individual taxpayer to track and report donations.

Depending on your tax situation, you may not see any tax benefit from outright gifts of cash. Charitable deductions are only available as an itemized deduction, so if you don’t itemize your deductions and only make small cash gifts, it’s unlikely that you’ll see a tax benefit.

DONOR-ADVISED FUNDS

For those who don’t typically itemize their deductions but do give a fair amount to charities and want to take advantage of the associated tax breaks, donor-advised funds can offer a good solution. Donor-advised funds have taken off in popularity since the standard deduction was doubled at the end of 2017, which meant that fewer people see the benefit of itemizing their deductions. Donor-advised funds enable you to make large contributions that are immediately tax-deductible and can be used to fund giving in future years.

APPRECIATED ASSETS

Whether you’re giving directly or via a donor-advised fund, you may be able to reap even more tax benefits from your donations by gifting appreciated assets, which enables you to avoid paying capital gains tax. Adding that tax break to the itemized deduction that you would also have can create significant tax savings. The maximum amount that you can deduct for gifts of appreciated assets is limited to 30 percent of adjusted gross income, whereas you can deduct up to 60 percent of income for cash gifts.

QUALIFIED CHARITABLE DISTRIBUTIONS (QCDs)

For those over the age of 70½, QCDs can be a great strategy for giving and have also become increasingly popular since the standard deduction was doubled in 2017.

Although withdrawals from IRAs are fully taxable, QCDs allow you to make donations directly from your IRA to a qualified charity without those amounts being counted as taxable income. This means you can see a tax benefit without needing to itemize your deductions. And if you’re 73 or older, QCDs can also be counted toward your annual required minimum distribution.

PLANNED GIVING

For those who prefer to leave funds to charity upon death as part of their estate plan (often referred to as planned giving), this can be accomplished simply through your will or beneficiary designations. Planned giving can allow you to make significantly larger gifts at death than you otherwise would be able to afford during life. Such gifts are not tax deductible during your life, except for some trust strategies that we’ll cover later.

BEQUESTS VIA WILL

Bequests made in your will offer flexibility in terms of the source of funds used, the order of priority, and distributing either a specific dollar amount or a percentage of your assets. These assets do go through probate, however, so there may be some additional costs and delay in reaching your charitable goals. There are also certain tax benefits that can be more easily attained by direct beneficiary designations.

BEQUESTS VIA BENEFICIARY DESIGNATIONS

Bequests made via beneficiary designations enable your donations to bypass the probate process and go directly to the charities you choose. From a tax perspective, it can be particularly valuable to designate charities as beneficiaries of your IRA or other tax-deferred accounts — charities would not pay tax on those assets, whereas individuals would. Because account values fluctuate with markets, and accounts are typically allocated to beneficiaries in percentage terms, it can be difficult to specify exact dollar amounts with beneficiary bequests.

MORE COMPLEX GIVING STRATEGIES: TRUSTS AND FOUNDATIONS

For larger gifts that also incorporate elements of estate planning, charitable trusts

and foundations are useful tools. However, because of their complexity and legal and administrative costs, their use should be targeted to specific situations, typically involving very large gifts.

TRUSTS

As with other trusts, charitable trusts are legal arrangements that enable assets to be distributed to your desired beneficiaries under specific terms. They can be useful in some cases to guard inheritances for younger beneficiaries, protect assets from creditors and other parties, minimize taxes, and allow a degree of control over the assets after death. What distinguishes charitable trusts is that a charity benefits from the trust either during or after your life. Charitable remainder trusts and charitable lead trusts are two commonly used types of charitable trusts. Both types of charitable trusts can be complex to set up and usually require ongoing legal and administrative support.

PRIVATE FOUNDATIONS

A private foundation can also be part of a strong charitable strategy. A foundation is an actual qualified charity established by an individual, family, or corporation. It offers donors a great deal of flexibility and control over their gifts, but because of the costs associated with regulatory compliance, they are usually more appropriate if funded with at least $1 million. And since much of this work can be accomplished with donor-advised funds, foundations are generally better suited for those who wish to fund direct charitable work, rather than to fund other charities.

Both trusts and foundations are complex and costly to implement, but in the right situations, they can be powerful tools to increase your charitable impact and help with the execution of your estate plan.

PROFESSIONAL GUIDANCE

Charitable giving is a powerful way to invest for the benefit of others. A comprehensive strategy should be discussed with your financial advisor, accountant, and possibly your estate attorney to ensure that your giving is tax-efficient and impactful.

Jason A. Comeau, MD, FACS

Vascular Surgeon, UPMC Lititz

It’s our pleasure to highlight a Lancaster City & County Medical Society member’s “passion outside of practice” in each issue of Lancaster Physician. Beyond their commitment to health care, LCCMS members have many other talents, skills, and interests that might surprise you. In this issue, we’re thrilled to feature Jason A. Comeau, MD, FACS, and his passion outside of practice.

answer is usually “Oh, a little of this. A little of that.” Learning to make traditional family favorites was always fun. Whenever we get together with extended family there are those dishes that someone always makes, but each version is just a little different. (And there is always debate about whose is better.)

When we do decide to venture out into the community for a meal away from our own kitchen, some of our favorite restaurants include Josephine’s, Ciro’s, Bistro Barberet, and Mad Chef.

How long have you been participating in this activity?

I started learning to cook when I was young, say 9 or 10 years old. As I grew up, I started experimenting and trying out recipes of my own. Now some of my favorite recipes to cook for my family are classic French dishes, along with American contemporary, Italian, and Asianinspired meals.

Why is this pursuit special to you?

Cooking

Would you briefly describe your passion outside of practice for those who might be unfamiliar with it?

I would say that my passion outside of practice is cooking. I would consider myself something of a foodie, and I really enjoy learning about new or interesting foods and techniques in the kitchen.

How did you develop an interest in your passion outside of practice?

My father did the majority of the cooking in our house when I was growing up. He learned a lot of it from his father, and I was always fascinated watching him put together meals, generally without a defined recipe. To this day when you ask him what’s in something, the

It is special to me because it’s something that I can share with my family. I love cooking with and for them. Even after a long day of work, I don’t mind coming home and cooking dinner because it is another way that I can show them love and appreciation. It’s also something we can do together. My 9-year-old has started to show an interest as well. She loves to bake with my wife, and my wife and I have both done parent/ child cooking classes with her.

What else would you like readers to know about this passion?

For a lot of people cooking can be a chore, but I would say it can be so much more than that. It is a way we can learn about things that are unfamiliar to us, challenge us to try new things, and it can also provide a strong connection to family.

When it comes to MRI providers in Lancaster, there is a difference.

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• Abdomen

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3T is an advanced MRI machine that produces very high-resolution images. 3T MRI is especially useful for more complex imaging needs. It also makes the MRI exam less invasive for some studies, such as prostate scans.

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MRIGroup.com

Several locations in Lancaster County and Chester County

ROLE OF PHARMACISTS IN

Navigating Drug Shortages

It’s opening time at our little pharmacy, and the phone is already ringing off the hook. The first two callers are patients looking for Adderall XR. They live far from us, and they will probably not become regular customers if we fill their Rx today. Unfortunately, I must turn them away because my supply is very low, and I expect regular customers to need it this week. An hour later a

MELISSA KOEHLER, PHARM D.  Hillcrest Pharmacy and Compounding

new Rx comes in for cefdinir suspension. Cefdinir has been backordered from my primary supplier for months. It’s not available from any of my secondary suppliers either. I spend 25 minutes calling around to see if any colleagues have it, and BINGO — Rite Aid can help this little girl! I transfer her prescription and her business to a competitor. A few hours later, a patient calls looking for Concerta. After checking my inventory and the PDMP for her control record, I am happy to tell her we can help today.

After we get caught up with daily tasks, I log into each of my supplier’s websites and search for items that have been backordered. Our team keeps a list of items to order daily, either because our primary supplier has limited amounts that we can purchase, or because the medications are simply not available to us at all. Today I am lucky enough to order some cherry acetaminophen suspension — Score! Weeks ago, this same search unexpectedly yielded 80 bottles of children’s ibuprofen. Now, if I could just get my hands on some ipratropium/albuterol, it would be a great day!

Most pharmacies have one primary supplier. Companies like McKesson, Cardinal, or Value Drug ship to pharmacies daily and generally carry everything we need. At our small independent pharmacy, we are fortunate to also have several secondary suppliers. These smaller companies provide limited inventory but are sometimes able to get items the primary suppliers cannot. When we need a backordered item, the first thing we do is look at all our secondary suppliers. If it’s not available to us, the legwork begins. Depending on a patient’s preference, we will either call the physician to request a substitution for a stocked medicine or call a few pharmacies in the area to see if they are willing and able to share.

Many pharmacists simply do not have time to call around and instead ask the patient to search. The average hold time at a busy chain pharmacy is at least ten minutes. Patients are getting frustrated with the process. If the medicine needed

is controlled, it’s even harder to find by calling around because many pharmacists don’t feel comfortable disclosing controlled inventory over the phone. My customer today said I was the 16th store she called looking for her daughter’s Adderall XR.

This year, more medications have been on backorder than we’ve seen since 2014. The shortages are not limited to specific drug classes, disease states, or patient populations, and they are causing disruptions across all practice settings and patient groups. The most impacted drug classes are antibiotics, stimulants, anesthetics, basic hospital medicines, ophthalmic and otic medicines, and hormones. The shortages cause delays in care and inconvenience for patients while contributing to increased workload for pharmacies and physicians.

demand that comes from higher rates of diagnosis. Injectable diabetic medicines are currently backordered because the media has publicized their weight loss potential. Adding a new factory production line for drugs like Ozempic and Trulicity is expensive and time consuming, but our diabetic patients will struggle to find their medicines until this happens.

A portion of shortages are simply business decisions by the manufacturers. If the product is not profitable, companies have little incentive to produce. Patented medicines come from a single source and don’t respond nimbly to supply disruptions or unexpected demand changes. Generic medicines have a larger supplier pool, but low profit margins provide little motivation for over-production, and high up-front costs limit a manufacturer’s ability to increase production during a shortage.

Manufacturing issues like factory shutdowns or staffing challenges contribute to shortages as well. Many active pharmaceutical ingredients used to produce medications come from China or India, and both countries experienced workforce disruptions due to COVID. Lastly, a small number of shortages are due to regulatory issues or raw material shortages.

Last year’s baby formula shortage stemmed from a combination of these factors: baby formula was not very profitable, most US factories had closed or left the country, Congress regulated against importing baby formula from overseas, the last remaining U.S. factory had quality control issues in its manufacturing process, and building a new factory takes too long. The end result was empty shelves and hungry babies.

Why are so many medicines backordered? Several factors are in play. American Society of Health-System Pharmacists (ASHP) estimates supply and demand imbalances cause the most shortages. Manufacturing capacity for Adderall production is lagging behind the increased

Drug shortages certainly cause frustration to patients, pharmacists, and physicians. Until these drug shortages resolve, pharmacy and physician teams will have to work harder to serve patients by multisourcing inventory, communicating with each other to find products, and substituting medications with those available.

THIS YEAR, MORE MEDICATIONS HAVE BEEN ON BACKORDER THAN WE’VE SEEN SINCE 2014.

How the End of the Public Health Emergency for COVID-19 Will Impact Providers and Patients

PENNSYLVANIA MEDICAL SOCIETY

President Biden announced that the administration plans to end the public health emergency (PHE) for COVID-19 on May 11, 2023, which corresponds with the end of the PHE Extension by the Secretary of Health and Human Services (HHS), Xavier Becerra. The PHE has been in effect since January 2020. Throughout the PHE, there have been flexibilities for those in health care. Some of the flexibilities have been extended thanks to legislation, though some will end once the PHE is over. PAMED is here to prepare you for what is staying and what will not be around once the PHE is over after May 11.

Medicare: Physician Supervision Requirement: During the PHE, CMS temporarily modified the definition of direct supervision. This modification allowed for physicians to perform direct supervision virtually by way of telecommunication services (video and audio communications). This flexibility is currently set to return to pre-PHE rules at the end of the calendar year when the PHE ends.

Expedited Enrollment with CMS: During the PHE, physicians were given expedited enrollment into Medicare. When the PHE ends, this will no longer be in effect.

Signature Requirements: CMS has been waiving signature and proof of delivery requirements for Part B drugs and durable medical equipment (DME) when a signature cannot be obtained because of the inability to collect signatures. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19. After the PHE, signature and proof of delivery requirements will be reinstated.

The Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS): The Automatic Extreme and Uncontrollable Circumstances’ (EUC) policy that was created allowed for providers or groups to apply for their practice to be excluded or have performance categories reweighted given the extenuating

circumstances that were preventing them from achieving performance goals in this program. After the PHE, CMS will evaluate whether to continue to allow practices to apply for this exception or not. They recommend checking the qpp.cms.gov site for updates.

Telehealth: As a result of President Biden signing the 2023 Consolidated Appropriations Act, the flexibilities that were expected to be extended for 151 days after the PHE will now be extended through December 31, 2024. Keep in mind that these flexibility extensions only affect those who are rendering services to Medicare patients.

The first flexibility is a temporary suspension of the geographic site requirement. This suspension allows patients to receive telehealth services regardless of where in the United States they are located at the time of service. This allows patients to be in their homes when receiving telehealth care as well.

There was a requirement for mental health providers to have an in-person visit with a patient within six months before seeing the patient by way of telehealth. During the PHE, this requirement was waived and is also a part of these flexibilities. The ability for Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) providers to be reimbursed for non-mental health telehealth services as a distant-site provider will be extended under the telehealth flexibilities as part of the Consolidated Appropriations Act of 2023.

Under these flexibilities, specific services will continue to be covered when rendering audio-only telehealth services beyond the PHE. A list of these services can be found on the cms.gov website [1]. Once the extension of these flexibilities is over, one will see reimbursement pulled for audio-only telehealth services for physical health, FQHC and RHC telehealth services that were rendered, and distant-site telehealth services. Another change will be the in-person requirement

Continued on page 30

PAMED is here to prepare you for what is staying and what will not be around once the PHE is over after May 11.

for mental health services being rendered. Most private payors have separate policies and make their decisions on whether to follow Medicare’s golden standard or not.

PA Medicaid Continuous Coverage:  When the 2023 Consolidated Appropriations Act was signed into law, effective April 1, 2023, PA Medicaid will no longer provide continuous coverage to patients. This means that patients will need to reapply for Medicaid and will receive renewal applications in the mail.

FDA Emergency Use Authorization:  The FDA released a list of FAQs regarding what will happen to Emergency Use Authorizations (EUAs) that were authorized during the pandemic and what the ending of the PHE means for them. The FDA will issue a federal register notice regarding which EUAs they will temporarily extend or allow to expire once the PHE ends. EUAs, unlike the continued extensions of the PHE, will continue to be active until the Secretary of HHS terminates the EUA. For medical products, there will be a transition time period and time for the disposition of medical products that fall under the EUA for the COVID-19 Pandemic. For more information regarding these Emergency Use Authorizations please see the FAQs page on the fda.gov website [2].

Also, Kaiser Family Foundation (KFF) has created a chart regarding what will happen to COVID-19 vaccinations and treatments among payers once the PHE ends. For more information and to view the chart, visit the KFF website at kff.org [3].

The Office of Civil Rights (OCR): Under the Department of Health and Human Services, OCR released flexibilities in March 2020 that were to remain in effect till the end of the PHE. These flexibilities were:

OCR’s Notice of Enforcement Discretion is allowing providers to serve patients where they are through commonly used apps like FaceTime, Skype, and Zoom to provide telehealth remote communications. OCR also provided empowerment to first responders and others who receive protected health information about individuals who have tested positive or been exposed to COVID-19 to help keep both first responders and the public safe. And finally, the flexibility allowed health care providers to share protected health information with the CDC, family members of patients, and others, to help address the COVID-19 emergency. With the PHE ending in May, these flexibilities will not be in effect once the PHE is declared over.

RESOURCES

1. https://www.cms.gov/medicare/medicare-general-information/telehealth/ telehealth-codes?url=https%3A%2F%2Fwww. cms.gov%2Fmedicare%2Fmedicare-general-information%2Ftelehealth%2Ftelehealth-codes&data=05%7C01%7Cmmerkel%40pamedsoc. org%7Cb4818cbd83724c3ca45108db2a0a806b%7C4320565b470146a4b27b855c4ba de69b%7C0%7C0%7C638149996824827125%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=qf8FT1e1Eu4DnnxlcZKT6ulvLF5AU0aDggathbnTMng%3D&reserved=0

JVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=qf8FT1e1Eu4DnnxlcZKT6ulvLF5AU0aDggathbnTMng%3D&reserved=0

2. https://www.fda.gov/emergency-preparedness-and-response/ mcm-legal-regulatory-and-policy-framework/ faqs-what-happens-euas-when-public-health-emergency-ends

3. https://www.kff.org/coronavirus-covid-19/ issue-brief/what-happens-when-covid-19-emergencydeclarations-end-implications-for-coverage-costs-andaccess/#coverage-costs-and-payment

ADDITIONAL SOURCES

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/ Current-Emergencies-page

https://www.deadiversion.usdoj.gov/GDP/(DEADC-022)(DEA068)%20DEA%20SAMHSA%20 buprenorphine%20telemedicine%20%20(Final)%20 +Esign.pdf

https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/ emergency-use-authorization

https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html

https://www.hhs.gov/sites/default/files/ february-2020-hipaa-and-novel-coronavirus - PDF https://public3.pagefreezer.com/content/HHS.

gov/31-12-2020T08:51/https://www.hhs.gov/about/ news/2020/03/24/ocr-issues-guidance-to-help-ensurefirst-responders-and-others-receive-protected-health-information-about-individuals-exposed-to-covid-19.html

https://public3.pagefreezer.com/content/HHS.

gov/31-12-2020T08:51/https://www.hhs.gov/hipaa/ for-professionals/special-topics/emergency-preparedness/ notification-enforcement-discretion-telehealth/index.html

AI in Health Care

BY SUSAN SHELLY

ChatGPT has garnered a lot of attention since it was launched in late November 2022, with experts predicting it will influence the way people in many industries — including health care — work and learn.

There is general agreement that ChatGPT, a sophisticated, artificial intelligence (IA) chatbot developed by San Francisco-based startup OpenAI, can be employed in health care to perform tasks such as sorting and prioritizing information, generating patient records, writing reports, and improving patient information.

Despite the fact that a study in February revealed ChatGPT could answer enough practice questions to correctly pass the U.S. Medical Licensing Examination, there are many uncertainties regarding its accuracy, especially for applications such as diagnosing patients.

AI-based programs other than ChatGPT, however, are already employed in health care, including the systems serving Lancaster County.

Radiologists have used AI to help analyze x-rays and CT scans for years. AI-based programs are used in drug discovery and development, transcribing medical documents, remotely treating patients, and numerous other applications, with additional uses emerging.

Lancaster Physician reached out to the health systems serving Lancaster County to learn more about how they are currently using AI and their thoughts on how AI may impact the future of health care. Penn State Health, WellSpan Health, Penn Medicine Lancaster General Health, and UPMC responded.

PENN STATE HEALTH

Artificial intelligence can be used to enable medical providers to spend their time more effectively, allowing them to have more interaction with patients instead of sifting through data and dealing with administrative business.

That is the hope of Dr. Will Hazard, who specializes in neurocritical care and anesthesiology and serves as the medical director of Penn State Health’s Virtual Care Unit Center.

“I’m not looking for AI to take work away from me,” Hazard said. “I’m excited for AI to make me more efficient and a better physician for my patients. I’m looking for AI to let me do what I went into health care to do.”

Hazard said the use of AI in health care is not new but has shifted to a different level with the advent of recent technologies, including ChatGPT.

And while the quick rise of AI is energizing, it also raises some questions and uncertainty.

“It’s a really exciting time, but it can seem a little terrifying,” Hazard said. “What we’re seeing is that AI builds the need for more AI, and nobody is quite sure what all that’s going to look like.”

For example, he said, AI can be used to collect information from medical devices that monitor patient blood pressure or glucose levels at home and send it to a physician’s office or other location. But that data needs to be processed, signaling the need for additional AI that can do so in the absence of staff members to sift through the information and assess what it means.

“What are the medical ramifications of having all that data?” Hazard asked. “With all that data out there, what are you going to do with it?”

Penn State Health currently employs AI in a variety of ways, some of which have been in place for years.

Hazard cited a Viz.ai program that uses computer vision to determine whether a patient is having a stroke and identify whether the stroke is compatible with catheter treatment to remove clots. The program significantly reduces the amount of time it takes to administer and interpret a series of scans and identify and begin treatment.

“It’s a great time saver because it saves a doctor the time of sorting through a stack of images to determine the appropriate treatment,” Hazard said. “We always say ‘time is brain’ when it comes to a stroke, so this is an extremely valuable tool.”

Penn State Health utilizes natural language chatbots that enable patients to report symptoms and otherwise communicate with providers. AI is employed in the oncology department, and radiologists have been using AI to interpret images for years, reinforcing the fact that AI is a tool that can assist, not replace, medical providers.

“Radiology didn’t go away as a specialty when AI came on the scene,” noted Hazard. “I think of AI as a consultant, or a backup. It’s an extra safety net.”

As shortages of physicians and other health care professionals continue, AI will become increasingly important in assisting with important aspects of diagnosing and treating patients. It also is able to quickly analyze large amounts of data generated and stored by health care organizations, something that can help providers optimize their time with patients.

“We all went into this to take care of patients,” Hazard said. “I’m hopeful that AI will be a valuable tool to let us get back to doing just that.”

WELLSPAN HEALTH

Of all the artificial intelligence-based technologies already employed at WellSpan Health, a program known as DAX is a favorite of many providers, including Dr. Hal Baker, senior vice president and chief digital and information officer.

The Nuance Dragon Ambient eXperience technology captures dialogue between a physician and patient and converts the conversation into clinical notes, enabling the provider to focus solely on their patient.

Dr. Will Hazard

Dr. Hal Baker

Perspectives

Nearly 200 WellSpan Health providers currently use the program.

“‘Game changer’ is the phrase many doctors use after trying DAX,” Baker said. “They love that they can just listen to their patients and not worry about taking notes. It’s helping to battle the burnout problem, and patients like that their doctors can be more engaged and focused. It’s been one of the most rewarding programs I’ve been involved with.”

Other AI-based technologies in place at WellSpan Health include a program that reads CT scans of stroke patients, reducing time before treatment can begin, and one that scans electronic health records to identify patients at high risk for not showing up for medical appointments.

Another current use of AI is a machine learning tool powered by the EHR company Epic. The program, frequently used

in hospice care, picks up early signs of increased risk for medical deterioration, enabling providers to step up care for the patient and family members.

The program is able to analyze a wider set of data related to a patient’s condition than algorithms traditionally used.

“It identifies people whose vital signs, when combined with their medical history, show evidence of deterioration,” Baker explained. “That allows for a higher quality of care and comfort for the patient.”

AI also is used frequently in medical imaging, including an algorithm that triages a patient’s X-rays in order of their importance.

While those and other AI-based programs are already in place, Baker is looking forward to other technologies still on the horizon, including new uses for chatbot systems, including ChatGPT.

He envisions ChatGPT helping to manage patient information by scanning electronic medical records that include input from different health care systems and synthesizing the information into a summary of what is vital to a patient.

WellSpan also is looking into the possibility of using cameras that monitor patients in hospital beds and can alert nurses to someone who is a fall risk trying to get out of bed, or a sedated patient who needs to be turned to prevent pressure ulcers from occurring.

“We’re truly excited at WellSpan about what’s happening and what’s to come with AI,” Baker said. “But we want to invest thoughtfully, carefully and deliberately to make sure the technologies aren’t just neat toys, but really useful tools that can help us improve our care.”

AI-based technologies can enhance the work of providers, but are most effective when paired with humans, Baker said. He cited a quote by the late Leo M. Cherne, an economist and lawyer, who headed the International Rescue Committee for four decades.

“The computer is incredibly fast, accurate and stupid. Man is unbelievably slow, inaccurate and brilliant. The marriage of the two is a force beyond calculation.”

“I think that says it nicely,” Baker said.

PENN MEDICINE LANCASTER GENERAL HEALTH

The field of health care already benefits significantly from the use of artificial intelligence, with many more promising applications on the horizon. Health care systems, however, are mindful about when and how they employ various technologies.

“There’s a lot of experimenting and testing the water going on right now,” said Allen Cubell, executive director of innovation for Penn Medicine Lancaster General Health. “AI is going to continue to impact all industries in some way. The question is deciding when to jump in.”

ChatGPT is exciting and promising in its potential uses for the health care industry, but is by no means ready to be fully embraced as a foolproof tool.

“It seems like knowledge that you’re getting back, but really it’s language, and there’s the risk that the base-line premises could be wrong,” explained Dr. Michael Sheinberg, PMLGH’s Chief Medical Information Officer. “That means that for now, we certainly need validation on the human side.”

A growing opportunity for the use of AI in health care is in its ability to review, analyze and share large amounts of data. The amount of medical information generated has increased tremendously with the use of electronic medical records; personal

medical devices that collect information about patients; and data collection tools that track information regarding insurance claims, staffing schedules, supply chain metrics, and other procedures.

AI that’s already in use, and programs predicted for the future, can assist greatly in managing those large amounts of data, and can be particularly helpful for health care professionals who are tracking information about patients.

“The amount of information I have about a patient has increased exponentially,” said Sheinberg, who is an obstetrician-gynecologist practicing at LG Health Physicians Family & Maternity Medicine. “When done right, AI can help me focus and sort through all that information.”

AI programs can analyze information and alert providers to what is most relevant and pertinent.

“Maybe there’s something buried at the bottom of those records that the doctor might not see,” Cubell said. “A good AI program can ensure that gets called out and noticed.”

AI also shows increasing promise in the areas of precision medicine, ambient listening, imaging, radiology, syndromic surveillance, predictive analytics, and diagnosis. While AI is already employed in many areas of medicine, health care professionals are looking forward to expanding its reach.

“We can envision a lot of valuable applications that just aren’t yet available,” Sheinberg said.

Cubell noted that the medical field tends to move cautiously with its use of AI, knowing that the stakes are too high for mistakes.

“We can’t just throw in a technology and see what happens,” he said. “We need to be cautious and evidence-based in our use of AI.”

Continued on page 36

Allen Cubell

Dr. Michael Sheinberg

AI-based programs other than ChatGPT, however, are already employed in health care, including the systems serving Lancaster County.

Perspectives

He compared the use of AI in health care to technological advances that have occurred in aviation. Once there were two pilots in the cockpit, navigating with radio-based systems and hundreds of dials and gauges. Now there still are two pilots, but they rely on massive amounts of data interpreted by GPS, advanced weather models, and equipment monitoring systems to navigate and fly more safely than 50 years ago.

“AI isn’t going to eliminate the need for doctors anytime soon, just like we wouldn’t want to go back to flying the plane like we used to in the 1950s,” he said. “We’re fortunate to have teams that understand innovation as it applies to health care. I’m looking forward to seeing where we’re going with it.”

UPMC in Central Pa. already employs various applications of artificial intelligence, and it’s expected that its use will expand in the future, improving patient care while helping to reduce burnout among staff members.

“AI will play an important role in revolutionizing health care now and in the future,” said Dr. Salim Saiyed, vice president and chief medical officer for UPMC in Central Pa.

AI currently is used to help manage large quantities of data, making it easier for physicians to view and process information on which to base clinical decisions. AI

algorithms are routinely used in radiology to aid clinicians and improve clinical decision support, diagnosis, and ordering, Saiyed explained.

Using AI to perform these tasks saves time and money while giving providers a better understanding of the overall condition of their patients and of the many factors that contribute to complex health conditions.

Another role AI currently plays is improving outcomes by predicting which patients are at highest risk for developing certain conditions. The program, from Epic EHR, is used in emergency departments, hospitals, and clinics to identify patients at high risk for developing serious conditions such as sepsis. Having that information

UPMC

Dr. Salim Saiyed

enables providers to begin treatments such as administering antibiotics sooner, improving outcomes for patients.

UPMC in Central Pa is in the process of integrating ambient AI technology with electronic health records in a move intended to relieve burnout for physicians and nurses, according to Saiyed.

The technology, which can monitor and document conversations between patients and providers, eliminates the need for providers to manually keep records of those communications and allows them more time to spend with patients.

The health care system also is looking toward AI to automate health care system processes and routine tasks such as scheduling appointments, following up with patients, and refilling prescription orders.

“This frees up time for doctors and other clinicians to focus on patients and engage in other complex tasks,” Saiyed said.

The use of AI is not without concern, however, Saiyed noted, particularly in its potential for bias. Known as “algorithmic bias,” this occurs when health care systems depend on software powered by algorithms that contain racial biases.

Relying on those algorithms, which can be faulty if they are built on biased rules and data sets that are not reflective of the overall patient population, can reduce the effectiveness of care for certain groups of people, or even result in harm.

For instance, studies have shown that biased medical algorithms in some cases resulted in skewed wait lists for organ transplants, putting Black patients lower on the lists than white patients despite a much higher rate of kidney failure among Black patients.

“That type of bias, even though it’s unintended, is very concerning in health care,” Saiyed said. “It’s very important to ensure that AI algorithms are developed and tested using diverse patient populations and data sets.”

Generally, however, AI has been shown to be useful and beneficial in its many health care applications.

“AI isn’t perfect, but it will continue to change and improve health care in many ways,” Saiyed said. “I’m excited to see what’s in store for the future.”

Nested

atop the 101 N Queen building, The Point’s modern condos provide magnificent views of the historic Lancaster skyline and offer the best in luxury living in Central Pennsylvania. Four unfinished units are available for buyer customization including a Penthouse suite, two spec units and a resale unit, with 2 ensuite Bedrooms. The condos also feature a tax abatement program for a period of time, large outdoor terraces, two ground floor parking spaces with access to a private elevator, storage unit for each condo off garage and a community room on the condo floor.

THE EXCHANGE

reviewed by STACEY DENLINGER, DO

Korean Fried Cauliflower

PHOTO BY JENNY FOSTER @FOSTERJFOSTER

On a surprisingly lovely March evening, before heading to The Fulton, my husband and I stopped at The Exchange for drinks and dinner. The experience started with a trip up the exclusive-feeling elevator from the King Street entrance. The location is perfect for a short walk from multiple parking garages downtown. They offer an indoor/outdoor seating arrangement. The host assured us that it was a delightful evening to sit on the patio with the table fire pit and heaters surrounding us to keep away the chill. Despite being just above the bustling city, it was generally very quiet and, as promised, a warm and inviting atmosphere.

Our server quickly greeted us with a friendly smile and the menus. Unfortunately, we did strike out early with our first three beverage requests not being available. The server was able to offer comparable alternatives. We ordered a few shareable platters: the Iceberg Wedge Salad, Korean Fried Cauliflower and Crispy Pork Bao Buns. The wedge salad was small for two of us to share, but the dressing was very good. The pork bao buns were tasty, and the bun was light and fluffy. The cauliflower was not over battered and had a nice zing. The food was served hot, and the timing was excellent. We indulged in dessert, for the sake of Lancaster Physician readers. A cappuccino and the Japanese Cloud Cake rounded out our meal. The sauce on the cake had just the right amount of sweetness, but the cake itself was denser than I expected.

As we sat on the patio, overlooking the buildings of Lancaster and enjoying the sunset and our meal, we were pleased that we chose The Exchange for weekday date night. The server was friendly and attentive without being intrusive. Admittedly, we were disappointed by the missing drink-menu items and the food was good but not out of this world. However, the view and atmosphere are unmatched in Lancaster.

We are likely to return for a drink and appetizer just to again experience the al fresco dining.

Crispy Pork Bao Buns

The Exchange rooftop bar atop the Lancaster Marriott at Penn Square offers a scenic view of Lancaster City's historic district.

PHOTO BY JENNY FOSTER @FOSTERJFOSTER

For the start of the 2023-24 legislative session, we saw a new addition of 49 newly elected “freshman” legislators, not to mention a change in leadership in the State House as democrats take control of the chamber for the first time in just over a decade. PAMED’s legislative team is already at work getting to know members of this freshman class while continuing to work with incumbent lawmakers to reintroduce key pieces of legislation that died at the end of last year.

With the start of a new legislative cycle, the Board of Trustees considered the results of a survey conducted throughout January that asked members to rank potential PAMED legislative priorities.

Some of the issues PAMED will tackle include:

Scope of practice – PAMED continues to oppose efforts by non-physician providers to expand their scope of practice while treating them with the proper respect due their training. We continue to work to keep team-based health care delivery physician-led.

Noncompete clauses/restrictive covenants – PAMED supports reasonable limitations on restrictive covenants in physician contracts to ensure patients have access to a physician of their choice. However, PAMED also recognizes that the use of non-compete agreements by independent practices are critical to their long-term viability.

Reproductive rights – PAMED supports shared decision-making between a physician and their patients concerning reproductive health matters, including abortion. PAMED opposes legislative measures that expose

physicians to criminal or civil liability for sound reproductive health-related medical decisions, or that expose patients to criminal or civil liability for receiving medical care or a change in pregnancy status.

Telemedicine – Telemedicine reform would include mandated coverage, payment parity, and a requirement that the physicians providing care to a patient residing in the Commonwealth be licensed to practice medicine in Pennsylvania.

Mental health services access – PAMED supports increased access and funding for mental health services for all Pennsylvania patients.

PBM accountability – Pharmacy benefit managers or PBMs (corporate intermediaries that manage the prescription drug formularies for public and private health insurers) determine which medicines will be covered by health insurance plans and how much patients will pay for their prescription drugs. The marketplace often pays more than necessary because of the control PBMs have. PAMED will advocate for transparent competition among PBMs and address the ways PBMs profit at the expense of patients, employee health plans, and taxpayers.

This is not to say that other issues will not get addressed by our government relations team as they arise.

Several legislative bills that PAMED is keeping its eye on include:

Senate Bill 25, Legislation on Independent Practice

Legislation that would enable the independent practice of certified registered nurse practitioners (CRNP) was introduced as

Senate Bill 25. It would remove the collaborative agreement currently required to practice independently from physicians.

PAMED opposes this legislation and supports the need for physician oversight of all non-physician practitioners, including, but not limited to, CRNPs, CRNAs, nurse midwives, and physician assistants.

Senate Bill 521, Legislative Introduced on Noncompete Agreements

Senate Bill 521 was introduced, acknowledging the impact that noncompete clauses, or restrictive covenants, have on patient care. PAMED is reviewing this memo and will have more information in the future.

PAMED is also supporting a co-sponsorship memo from Senate Ryan Aument on legislation that will help expedite the health insurance credentialing process. PAMED expects the proposal to be introduced as a bill in the near future. The current proposal will lead to improved continuity in the credentialing process and provide predictability to medial practices trying to meet patient demand for care. PAMED will keep you informed when official action is taken.

For more information about any of the items mentioned above, please visit the Advocacy Section of PAMED’s web site at www.pamedsoc.org/advocacy

l e

For more than 30 years, the Lancaster Medical Society Foundation has awarded scholarships to Lancaster County residents, accepted or continuing a medical degree at an accredited medical school. Applicants must demonstrate academic achievement, exhibit good character and motivation, and show financial need.

“The scholarship fund is a great example of the impact of local philanthropy,” shared Beth E. Gerber, Executive Director of the Lancaster City & County Medical Society and the Medical Society Foundation. “We are pleased to continue to invest in what we hope will be the next generation of physician leaders in our community.”

Generously supported by the Lancaster County medical community — including local hospitals, group practices, and individual Medical Society members — and gifts from area businesses and individuals, the Foundation has awarded over $282,000 in funds since its establishment in 1991.

Scholarship applications are now available, and those pursuing a D.O. or M.D. degree are encouraged to apply. Awards for the 2023-2024 academic year will be announced in September.

For more information about how you may contribute, or to obtain a scholarship application, please visit lancastermedicalsociety.org or contact Lancaster City & County Medical Society at 717.393.9588. Applications must be postmarked by July 3, 2023, for consideration.

MORE THAN EVER, ACCESS TO QUALITY CANCER CARE IS ESSENTIAL.

A diagnosis of cancer is overwhelming. Locating an experienced cancer care team led by expert physicians without the added stress, time, and expense of unnecessary travel doesn’t have to add to the challenge. We offer patients the most advanced chemotherapy treatments, compassionate care, and support at our office which is conveniently located on Lampeter Road. New patients and second opinions will be seen within 24 hours, call 717.291.1313

H. Peter (Tracy) DeGreen III, DO and Lena Dumasia, MD

ELIZABETHTOWN FAMILY HEALTH CENTER

Patrick E. Gilhool, DO, acquired Elizabethtown Family Health Center in 2002 with a goal to provide the community with access to high quality health care. In 2018 he partnered with Family Practice Center, PC. (FPC) who shared the same values. Dr. Gilhool is a compassionate physician committed to serving the community with expert medical care. FPC shares these values as a physician-led organization that is committed to the health and well-being of every patient. FPC is an organization that has fulfilled its vision to be physician-led, community driven, and provide first-class care over the last 50 years.

The Family Practice Center Elizabethtown office, located at 300 Maytown Road, has had steady patient growth due to consistently high patient satisfaction levels. To meet the health care needs of their growing community, this office made it a priority to add professional staff to the team.

Patrick E. Gilhool DO, Christopher D. Brabazon, DO, and Caitlin Reeser, PA-C, work side by side with nursing staff and the front office team to provide a full spectrum of high-quality, comprehensive medical care. As a primary-care practice serving all members of the family from newborn to geriatrics, the goal is to always deliver firstclass quality medical care at every age and stage of their patients’ lives. This includes those in personal care home or nursing facility settings. Dr. Gilhool routinely visits and serves this population of patients at multiple different facilities in the surrounding areas.

While patient satisfaction and experience are the top priorities, the practice is also committed to maintaining a positive environment for the staff and physicians. Having an attitude of gratitude towards patients for choosing FPC, this office strives to exceed expectations in all aspects of care.

L to R: Patrick E. Gilhool, DO; Caitlin Reeser, PA-C; and Christopher D. Brabazon, DO

Where do you practice and why did you settle in your present location or community?

I practice at Penn State Health Medical Group – Prospect in Columbia, PA and have lived in Lancaster since 2014. My husband, Steve, and I are both Temple med grads and native to the Philadelphia area. Steve was a physician for the U.S. Army, and after graduation, we migrated south to the DC area and then down to Savannah, GA. After eight years of working in beautiful Savannah, having two children, and eventually adjusting to civilian life, we decided on a move to be closer to family. Job opportunities guided us to Lancaster, but we were quickly drawn to the area’s friendly culture and unique diversity. We knew Lancaster would be a wonderful place to raise a family and was going to be our home.

What do you like best about practicing medicine?

Patient education. Whether in the form of explaining to a patient what high blood pressure or diabetes is and how it affects their body or teaching about disease prevention, I believe helping patients understand their health is a vital responsibility of a family physician.

Are you involved in any community, non-profit, or professional organizations?

I am a member of the American Academy of Family Physicians, the Pennsylvania Medical Society, and I’m an active supporter of World Vision International.

What are your hobbies and interests when you’re not working?

I enjoy regular exercise with running/HIIT and weightlifting to stay active, healthy and balanced. I also love to cook and bake and am always on the lookout for new recipes. I really cherish family time with my husband and two girls, whether playing simple games at home, watching the Eagles (Go Birds!) or exploring the National Parks. We are looking forward to our upcoming trip to Yosemite in the spring!

For what reason(s) did you become a member of the Lancaster City & County Medical Society and what do you value most about your membership?

I joined to get to know more about and support other physicians in the community. I value the voice and opportunities the Society offers to its members.

Diane Donnelly, MD

Penn State Health Medical Group – Prospect

 Alere Family Health LLC

 Avalon Primary Care

 Campus Eye Center

 Carter MD Aesthetics

 Community Anesthesia Associates

 Community Services Group

 Conestoga Eye

 Dermasurgery Center PC

 Dermatology Associates of Lancaster Ltd

 Dermatology Physicians Inc

 The ENT Center

 Eye Associates of Lancaster Ltd

 Eye Health Physicians of Lancaster

 Family Eye Group

Family Practice Center PC –East Elizabethtown

 General Surgery of Lancaster

 Glah Medical Group

The Heart Group of Lancaster General Health

 Hospice & Community Care

 Hypertension & Kidney Specialists

Lancaster Arthritis & Rheumatology Care

 Lancaster Cancer Center Ltd

 Lancaster Cardiology Group LLC

 Lancaster Ear Nose and Throat

 Lancaster Family Allergy

 Lancaster Pulmonary & Sleep

 Lancaster Radiology Associates Ltd

 Lancaster Skin Center PC

 Manning Rommel & Thode Associates

 Nemours duPont Pediatrics Lancaster

 Neurology & Stroke Associates PC

 Patient First – Lancaster

Penn Medicine Lancaster General Health Care Connections

Penn Medicine Lancaster General Health Physicians Cardiothoracic Surgery

Penn Medicine Lancaster General Health Physicians Diabetes & Endocrinology

Penn Medicine Lancaster General Health Physicians Family Medicine Lincoln

Penn Medicine Lancaster General Health Physicians Family Medicine New Holland

Penn Medicine Lancaster General Health Physicians Family Medicine Norlanco

Penn Medicine Lancaster General Health Physicians Family Medicine

Susquehanna

Penn Medicine Lancaster General Health Physicians Lancaster Physicians for Women

 Pennsylvania Specialty Pathology

Randali Centre for Aesthetics & Wellbeing

 Retreat Behavioral Health

 Shady Grove Fertility – Lancaster

 Surgical Specialists–UPMC

 Union Community Care – Duke St

 Union Community Care – Hershey Ave

Union Community Care – KinzerChurch St

 Union Community Care – New Holland Ave

 Union Community Care – Water St

 UPMC Breast Health Associates

UPMC Plastic & Aesthetic Surgical Associates

 WellSpan Ephrata Cancer Center

 WellSpan Family Health – Georgetown

LCCMS EVENTS 2023

Thursday, May 4 Advocacy 101 7 - 8:30 a.m.

Wednesday, May 10

reinstatements

Lancaster County Women in Medicine: Sip. Shop. CME 5:30 - 8 p.m. Athleta (The Shoppes at Belmont)

Wednesday, June 14

Annual Dinner & Awards Celebration 6 - 9 p.m.

The Inn at Leola Village

Wednesday, June 28

Docs, Drinks & Dialogue Walk & W(h)ine

Time & Location TBD

Wednesday, August 2 Docs On Call WGAL

Friday, October 27Sunday, October 29

PAMED House of Delegates 7 - 8:15 a.m. hybrid event

Saturday, December 2 Holiday Social & Foundation Benefit 6:30 - 10 p.m. Lancaster Country Club

Brian C. Cronin, DO Surgical Specialists–UPMC

Fiona M. Gaunay, MD Penn Medicine Lancaster General Health Physicians Surgical Group

Brian R. Melamed, MD

Lahari Vudayagiri, DO Anya-Faye Roa Pacleb, DO UPMC Lititz

Life changing is... having a trusted partner

“The first thing I want my patients to know is that I am there for them. I can guarantee that.”

- Lori, RN Professional Care Manager