Berks County Medical Society Medical Record | Winter 2016 by Hoffmann Publishing Group

Medical record BERKS COUNTY MEDICAL SOCIETY WINTER 2016

My Surgical Internship

Cedric C. Jimerson, MD

BERKS OWN OPIOID CRISIS

Richard Elliot Kim Simmonds & Savoy Brown

East Bay Soul

Devon Allman

April 1-10, 2016 Reading, PA

Michael Lington

Bobby Caldwell

Najee

Spend 10 jazz- and blues-filled days and nights in the Greater Reading area! Over 120 scheduled events, plus great shopping and dining in one area, make the 25th annual Boscov’s Berks Jazz Fest your perfect spring getaway. For tickets, call Ticketmaster toll free at 1-800-745-3000 or visit www.ticketmaster.com to order online. CHICK COREA & BÉLA FLECK • THE SUMMIT: THE MANHATTAN TRANSFER & TAKE 6 • KEB’ MO’ WITH SPECIAL GUEST GERALD ALBRIGHT • MAVIS STAPLES BONEY JAMES • RICHARD ELLIOT WITH SPECIAL GUEST BOBBY CALDWELL • PHIL PERRY & HOWARD HEWETT • NAJEE FEATURING CHANTE MOORE, NICK COLIONNE THE RIPPINGTONS FEATURING RUSS FREEMAN • JOEY ALEXANDER TRIO • GOSPEL ACCORDING TO JAZZ CELEBRATION: KIRK WHALUM, DONNIE MCCLURKIN, JONATHAN BUTLER, KEVIN WHALUM, JOHN STODDART, DOXA GOSPEL ENSEMBLE • JACKIEM JOYNER & SELINA ALBRIGHT • KEIKO MATSUI • BWB: RICK BRAUN, KIRK WHALUM, NORMAN BROWN • MICHAEL LINGTON FEATURING TAYLOR DAYNE • JAZZ FUNK SOUL: CHUCK LOEB, EVERETTE HARP, JEFF LORBER • ROBBEN FORD • JAZZ MEETS JAMES: NICK COLIONNE, KIM WATERS, ERIC DARIUS, MARION MEADOWS, JEFF BRADSHAW, JEANETTE HARRIS, JAY ROWE • BRIAN BROMBERG BAND WITH THE BERKS HORNS FOUR80EAST FEATURING MATT MARSHAK, ART SHERROD • POPA CHUBBY • PIECES OF A DREAM • GREG ADAMS & EAST BAY SOUL • DAVID BROMBERG BIG BAND BLIND BOY PAXTON • KIM SIMMONDS & SAVOY BROWN • ERIC MARIENTHAL • ANDY SNITZER • GERALD VEASLEY & FRIENDS FEATURING BOBBY LYLE, NELSON RANGELL, CHIELI MINUCCI • THE MUSIC OF DAVE BRUBECK: BRUBECK BROTHERS QUARTET AND THE READING POPS ORCHESTRA • CRAIG THATCHER BAND & FRIENDS • THE ROYAL SCAM SHERRIE MARICLE & FIVE PLAY • LIVE AT THE FILLMORE: TRIBUTE TO THE ORIGINAL ALLMAN BROTHERS • ZOE’ • DAVID P STEVENS & DEE LUCAS • ERICH CAWALLA QUARTET FEATURING BENNIE SIMS, CLIFF STARKEY, MARKO MARCINKO • DEVON ALLMAN BAND • PHILADELPHIA FUNK AUTHORITY • THE ORIGINAL GROOVEMASTERS & FRIENDS • UPTOWN BAND FEATURING ERICH CAWALLA & JENIFER KINDER • BLITZ DYNETTE • GREG HATZA & TIM PRICE ORGAN QUARTET • DJANGOHOLICS ANONYMOUS AMY HELM & THE HANDSOME STRANGERS • KUTZTOWN UNIVERSITY JAZZ ENSEMBLE I • U.S. NAVY BAND COMMODORES • U.S. AIR FORCE RHYTHM IN BLUE JAZZ ENSEMBLE BERKS HIGH SCHOOL ALL-STAR JAZZ BAND AND CHORUS • STOLEN MOMENTS: THE FIRST 100 YEARS OF JAZZ FEATURING JAZZREACH’S METTA QUINTET AND MORE!*

berksjazzfest.com * LINEUP AS OF 2/13/16. SUBJECT TO CHANGE

PROUD SPONSOR OF THE BOSCOV’S BERKS JAZZ FEST

Editor’s Comments

I Christina M. Ohnsman, MD, Editor

n my last year of residency, I was called to see a man who had been involved in a bar fight. The junior resident had called me in because one eye was so badly injured that he thought it would need immediate enucleation. The patient was an unpleasant drunk and hadn’t been an innocent bystander. I spoke with him and his wife at length about the need to remove the eye that night, and we proceeded to do the surgery. The smell of alcohol from his blood during surgery—heightened by my sixth month of pregnancy--was overwhelming. We admitted him to the hospital, and had a series of long conversations with him after he had sobered up. Upon discharge, I wrote a prescription for enough pain meds to last for 10 days, and emphasized that he needed to make them last until his first outpatient visit. He showed up in two days, saying that he had run out of pills and needed more. He became extremely belligerent and demanded to see my boss when I suggested that he might have a substance abuse problem. I called the oculoplastics attending, who took it from there. Months later, the patient returned and thanked me for helping him overcome his addiction. During med school and residency, I had been taught to be on the lookout for drug-seeking behavior. At times, most of my inner-city university hospital patients were IV drug abusers, unlike the community hospital patients I saw. Many years later, long after it seemed that my days of interacting with heroin addicts were over, heroin started making headlines again. This time, it had spread to the suburbs. It started with celebrities dying of heroin overdoses: Cory Monteith and Philip Seymour Hoffman. Then, articles about the epidemic of heroin-related deaths among teens started to appear on a regular basis. I had the attitude that this wasn’t something I needed to worry about. After all, my kids and their friends wouldn’t have any interest in hardcore drugs. I asked their opinions about how and why people start to use heroin, despite knowing that it was so often deadly. Did they believe that they would be the exception, that it would be safe for

them? The thought that anyone would inject a lethal drug into their vein for the first time was mind-boggling to me. But of course, I was looking at the problem from my own paradigm of waking up sober in the morning, able to think clearly and not powerless to addictive cravings. By the time someone uses heroin, they’ve been using other drugs for some time. Sometime later, I read Wild: From Lost to Found on the Pacific Crest Trail, a memoir by Cheryl Strayed. The author, who had been an intelligent, responsible, and trustworthy teenager, started using heroin as her life spiraled more and more out of control after her mother’s death. That made me think. Here was someone who seemed similar to my kids and their friends, yet she went down paths that I would never envision for them. Shortly after I finished reading the book, a patient’s mom—a farmer living the most wholesome life imaginable--mentioned that her teenage sister was addicted to heroin. Here were two completely unexpected addicts. Since then, I’ve read more and more about this scourge that reminds me it is a disease, and that many innocent people are suffering from it, directly or through their loved ones. A Facebook page called “The Addict’s Mom” describes in heartbreaking detail the fear, shame, secrecy, and loneliness experienced by the loved ones of addicts.

So what does this have to do with us? It’s essential that physicians understand the scope of the problem and our role in it, as outlined in this issue’s feature article by Lucy Cairns. We should take advantage of the educational resources offered by the PA Medical Society, listed in their companion piece. We must learn to balance adequate pain control with addiction prevention, as described by Gus Geraci. We need to stop and think before we use the term “addict,” as powerfully explained by Bill Santoro. Perhaps most importantly, we need to accept that this IS our problem, right here in Berks County, affecting our patients and their loved ones, as Kyle Robinson reminds us. Let’s help them know that they are not alone.

WINTER 2016

Medical record BERKS COUNTY MEDICAL SOCIETY

A Quarterly Publication

To provide news and opinion to support professional growth and personal connections within the Berks County Medical Society community.

THE BERKS COUNTY MEDICAL RECORD Whether your loved one needs high-tech treatment or just a helping hand at home, let our family help care for yours. Berks VNA and Advantage Home Care offer compassionate, complete care from the best nurses, therapists and caregivers around. All in the comfort of your own home. For more information, or to schedule care, call 1.855.THE.VNAs, or visit everythinghomecare.org.

1.855.THE.VNAs Learn more at EverythingHomeCare.org

Challenging Cases... Perhaps We Can Help? Do You Have Patients With: • Chronic Headaches • Tinnitus • Jaw Pain • Insomnia • Ear Pain without Signs of Infection If so, they may be suffering from TMJ Dysfunction and/ or Sleep Disordered Breathing, such as snoring and obstructive sleep apnea. We offer comprehensive diagnosis and treatment. Our many years of experience have resulted in a high rate of successful outcomes. Our philosophy involves a conservative, non-surgical, non-pharmaceutical approach to management with an emphasis on multidisciplinary care. Tammy Balatgek, DDS, MS

2433 Morgantown Road, (Route 10), Suite 200 Reading, PA 19607 www.tmjsleepcenter.com  610.796.2835

Christina M. Ohnsman, MD, Editor

EDITORIAL BOARD

D. Michael Baxter, MD Lucy J. Cairns, MD Daniel B. Kimball, MD, FACP Betsy Ostermiller

BERKS COUNTY MEDICAL SOCIETY OFFICERS

Andrew R. Waxler, MD, President Gregory T. Wilson, DO, President Elect D. Michael Baxter, MD, Chair, Executive Council Michael Haas, MD, Treasurer & Chair, Finance Committee Anne Rohrbach, MD, Secretary Lucy J. Cairns, MD, Immediate Past President T. J. Huckleberry, Executive Director Betsy Ostermiller, Executive Assistant Berks County Medical Society 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610 Phone: 610.375.6555 | Fax: 610.375.6535 Email: info@berkscms.org

The opinions expressed in these pages are those of the individual authors and not necessarily those of the Berks County Medical Society. The ad material is for the information and consideration of the reader. It does not necessarily represent an endorsement or recommendation by the Berks County Medical Society. Manuscripts offered for publication and other correspondence should be sent to 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. The editorial board reserves the right to reject and/or alter submitted material before publication.

The Berks County Medical Record (ISSN #0736-7333) is published four times a year by the Berks County Medical Society, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610. Subscription $50.00 per year. Periodicals postage paid at Reading, PA, and at additional mailing offices. POSTMASTER: Please send address changes to the Berks County Medical Record, 1170 Berkshire Blvd., Ste. 100, Wyomissing, PA 19610.

PUBLISHER:

Reading, Pa | 610.685.0914 | hoffmannpublishing.com

For advertising information contact Tracy@Hoffpubs.com or visit hoffmannpublishing.com/media

Table of Contents WINTER 2016

FEATURES

Berks County Medical Society BECOME A MEMBER TODAY!

Go to our website at www.berkscms.org and click on “Join Now”

Cover Feature

Cedric C. Jimeson, MD 22 Surgical Internship-The New York Hospital Installation Brunch Recap Berks Own Opioid Crisis

My Story

Comments by William Santoro, MD

The Pit and Pendulum of Narcotic Prescribing 19 Fighting Opioid Abuse in Pennsylvania The Scope of ‘Scope of Practice’ Issue

20 29

Dr. Ed Zobian Tribute 36

Welcome New Member Justin M. Shaw, M.D.

DEPARTMENTS

Editor’s Comments

Foundation Update

Executive Director’s Message President’s Inauguration Speech

Legislative Update Alliance Update

6 7

32 35

Content Submission Medical Record magazine welcomes recommendations for editorial content focusing on medical practice and management issues, and health and wellness topics that impact our community. However, we only accept articles from members of the Berks County Medical Society. Submissions can be photo(s), opinion piece or article. Typed manuscripts should be submitted as Word documents (8.5 x 11) and photos should be high resolution (300dpi at 100% size used in publication). Email your submission to info@berkscms.org for review by the Editorial Board. Thank YOU!

Executive Director’s Message

The Panic Before the Storm! Timothy J. (T.J.) Huckleberry, M.P.A. Executive Director

The following content was written two days before Winter Storm Jonas. The author is not responsible for the two feet of snow that accumulated. January 21, 2016

y the time you are reading this, the whole situation will most likely be over and hopefully everything went according to plan. Today’s date is January 21, 2016—two days from our Installation Brunch and a few hours until the beginning of a potential blizzard. Late yesterday afternoon, our office ceased being the Berks County Medical Society and took on the role of Winter Storm Jonas Observation Center for the region. At no time in our Society’s 192-year history has the words “Doppler,” “snow depth totals,” “high pressure system” and “white-out possibilities” ever been used as frequently as the last two days. And while Betsy and I continue to debate the validity between the European and Canadian Models, the overwhelming thought continues to center around the possibility of postponing the Installation Brunch. Outside of the centerpiece and linen fees we would have to swallow if we postponed, the very idea of rescheduling an event of this scale is unheard of. Heck, last year’s event went on as scheduled in the middle of a horrible ice storm! From day one as Executive Director, the importance of the Installation

6 | www.berkscms.org

Brunch has been drilled into me. As one physician described it: “It’s like the Oscars combined with the State of the Union…with a breakfast.” This year, the stakes are raised even higher as the BCMS welcomes new leadership (Dr. Andy Waxler as our 168th President, Dr. Greg Wilson as our President-Elect, and Dr. Anne Rohrbach as Secretary) and applauds the efforts of our outgoing President, Dr. Lucy Cairns. On behalf of the Society I would like to give a big “thank you” to Dr. Cairns for her excellent work during a difficult transition year. I think I can also speak for BCMS that we are all looking forward to Dr. Waxler’s … quiet and stoic leadership skills in the coming year. In addition to our ceremonial installation, this year’s brunch will be presenting several awards recognizing the outstanding efforts in our healthcare community.

Our first award is the re-introduction of the William Alexander, M.D., Community Service Award, which was given most deservingly to the Western Berks Free Clinic for their outstanding and invaluable care for those in need in the region. The second award will be one of our newest—The President’s Internship Award. Our revamped internship program provides our selected intern with one-on-one access to local physicians throughout the summer, culminating with a feature article in our fall Medical Record. This year’s internship recipient was Sara Radaoui,

who crafted an incredibly well written article entitled “Access to Mental Health Care in Berks County.” The last award I am excited to see is our inaugural BCMS Compass Award. This award recognizes a physician whose work and commitment embody the ideals of our four point compass— advocacy, professionalism, education and collegiality. It is fitting that BCMS decided to honor both Dan and Eve Kimball as the first recipients of this award. Together, they have given years to forward both the practice of medicine and patient care for our community.

Considering our brunch’s tradition and the excitement of the new awards, we are left with some very tough questions: How safe will the roads be by Sunday morning? How much snow will we actually get? Who will be able to attend if we reschedule? Why do most of my articles revolve around breakfast?

WHAT DO WE DO?? January 22, 2016, 10:00AM We just made the decision. It’s smarter to postpone the event than ask dozens of physicians to make some Revenantlike trek to the Berkshire Country Club. It turns out that we are able to postpone the date by one week, and thankfully a large number of invitees can still join us. Now if you would excuse me—I have to rush to Giant for bread and milk!

BCMS Inauguration Speech

ood morning. I am humbled to be here standing before you this morning taking on the role of President of the Berks County Medical Society(BCMS). Before I move into my thoughts and goals, I want to thank and honor my remarkable predecessors who have paved the road for me to get here. The Berks County Medical Society is the 2nd oldest county medical society in the commonwealth of Pennsylvania, founded in 1824, with a rich and proud tradition. BCMS has been blessed with fantastic leaders over the years, I am honored to have my name listed among these men and women. I want to thank our outgoing president, Lucy Cairns, for all the great work that she has done this past year. Over the past 192 years, our BCMS has evolved to keep pace with the ever-transforming health care world. However, in many ways, it appears that we are definitely living in a particularly complex time in healthcare, nationally as well as regionally and locally. In the words of Bob Dylan, “The times, they are a-changin’…” and even when change is meant to be good, the path we have to take can prove unpleasant or uncomfortable at times, as most of us are creatures of habit and don’t like those habits to be disturbed. As our complex healthcare system is transforming , we physicians and other healthcare providers often feel a subtle and sometimes not-so-subtle pressure to change our practice patterns in various ways. Long gone are the days where the typical doctor, like my grandfather who was an oldfashioned “GP”, would see his/her patients from cradle to grave, both in the hospital and in the office. While there are still a few old-school docs left , the vast majority of physicians have had to start making hard choices including “hospitalist” vs. “office doctor”. Moreover, the era of independent “private practice” doctors is in decline and rapidly becoming obsolete, as most physicians are being drawn by an inexorable force to link up with some type of large health system as an employee; whether it’s a PHO, ACO, CLIO, we are all being swept up in an alphabet soup of entangling alliances. Yes, the times are changing and while we are busy taking care of patients, we rely on organizations such as the Berks County Medical Society to be our voice in the world. In today’s world, all of us are – and should be - held accountable by the phrase best vocalized by Janet Jackson: “What have you done for me lately?” For the BCMS and its parent organization, the Pennsylvania Medical Society(affectionately known as PAMED), the answer is “a lot”. On a state level, several of our members both past and present have held key positions in the leadership of our PAMED, and, thus humble little county medical society has influenced healthcare policy to some degree statewide. With regard to Advocacy, t has often been said that “It’s better to be at the table than on the menu”. Working through PAMED, members of the Berks County Medical Society have contributed to many key “victories” over the past several years one of which is various components of important tort reform( which has led to a 46.5% decline in malpractice cases over the past 15 years). We participated in the successful effort to reverse the MCARE debacle; this settlement resulted in the of $200 million to doctors that had been inappropriately diverted away from the MCARE fund by Governor Ed Rendell. We also played a role in the reversal of the excessive Maintenance of Certification(MOC) program.

On a national level, many of us met with various U.S. legislators and/ or their key advisors to help get a favorable outcome – finally – in the vote to end the horrible Sustainable Growth Rate(SGR). Current hot topics in which the BCMS and PAMED are heavily involved include: 1.) Advocating for a team-based approach incorporating physicians and “mid-level providers” working in unison, 2.) Recommending further study, including scientifically-rigorous trials, to determine the risks and benefits of so-called “medical marijuana”(as opposed to just legalizing it “willy-nilly”), and finally, 3.) Weighing in on the use of naloxone given in-the-field to promptly reverse opiate overdoses but equally importantly trying to explore both the root causes of opiate addiction as well as the complexities of successful treatment. One particular piece of advocacy that is near and dear to my heart is the BCMS/PAMED Pre-Authorization Legislation; it simultaneously represents both patient and physician advocacy. On an almost-daily basis, we health care providers are forced to struggle through the unnecessarily onerous process created by our friends in the insurance industry just to obtain proper testing for our patients. This laborious system not only causes tremendous administrative waste and costs, but adversely impacts patients’ access to care and thereby puts their health at risk. In the coming days, this important legislation, part of which was written right here in Berks County, will be introduced in Harrisburg. Key components of our mission are education and communication, involving both the community of patients as well with fellow doctors. To this end, we are very proud our weekly “Healthtalk” call-in radio show; for more than a decade now, this unique program provides an opportunity for health care providers and patients to interact in an easily-accessible public forum. Our “Medical Record” is a wonderful quarterly publication which does an excellent job of keeping our members abreast of current trends and news in the medical field. We are currently exploring other – more modern – ways to connect both with members as well as the general public, investigating various social media options including Facebook, Twitter, internet “message boards” like Quicktopic, among others. BCMS has participated in a meaning ful way in important local community events such as “Berks Senior Expo” and “Guts and Glory”. We have fostered an important relationship with legislators – both state and federal – and I always look forward to our annual Legislative Breakfast; for those of you who have never been to it, I strongly recommend attending it. We offer a Grievance committee, giving patients a safe venue to settle any dispute with a physician or hospital before it grows and leads something bigger – and usually not better. We have a keen interest in patient advocacy, fighting the never-ending battle for access to care. In a time of physicians becoming more “compartmentalized”, we offer several events during the year to promote networking and healthy social interaction. Medicine is not just a job, it is our life. It is all consuming, which can be a double-edged sword. When we work together, we all benefit: physicians, patients, and society as a whole. We currently live in a particularly complex time in medicine and I believe that BCMS is the perfect vehicle to help doctors and patients navigate these choppy waters. I invite you to join me on the journey and to help me in strengthening the organization put in place to support us along the way. William Butler Yeats said “Do not wait to strike till the iron is hot; but make it hot by striking” WINTER 2016

Installation Brunch Recap The 168th President of the Berks County Medical Society was installed one week later than originally planned, due to a huge snow storm that hit the entire East coast, including Berks County. We lost a few of the original guests due to the cancellation and change in date, but several new members were able to attend. Following a wonderful brunch and time to socialize with friends and colleagues, Dr. Mike Baxter took over as our Master of Ceremonies for the occasion, introducing our guests who included John Morahan, President & CEO, Penn State Health St. Joseph; Heather Wilson, Executive Director, PAMED Foundation; Mike Fraser, Executive Vice President, PAMED; and Senator Judy Schwank, 11th Senate district. The first award of the day was presented by Dr. Waxler to the volunteers of the Western Berks Free Clinic and was accepted by Lori Small, RN. This award, the William Alexander, MD, Community Service Award, is presented to a person or organization for outstanding community service. Secondly, the newly created Compass Award was presented to Dr. Eve and Dr. Dan Kimball by Dr. Baxter. The Compass Award recognizes a physician whose career and commitment embody the ideals of our Societyâ&#x20AC;&#x2122;s four point compass emblem â&#x20AC;&#x201C; advocacy, professionalism, education and collegiality. This was the inaugural presentation of the award. To honor the recipient, money was also generously donated into our Educational Trust to further our scholarship program, community outreach endeavors, and weekly educational talk show.

8 | www.berkscms.org

Those who chose to honor the Kimballs with their donations were Anne Ambarian, MD Dr. Margaret & Mr. Jerrold Atwell Maria Braun, MD Patti Brown, MD & Michael Brown, MD Lucy J Cairns, MD Christie Ganas, MD Michael Haas, MD Cedric Jimerson, MD J. Frederick Hiehle, MD Gerald Malick, MD Jerome Marcus, MD P.V. Pathanjali Sharma, MD William Sweet, MD Andrew R. Waxler, MD If you would also like to make a tax deductible donation to our Trust, please contact the Berks County Medical Society. continued on next page >

The Greenberg Memorial Grand Rounds is a weekly CME program for the physicians and health care providers in the region in honor of the late Dr. Robert Greenberg. The weekly grand rounds, funded by a donation from the Greenberg family, will serve the medical community with the opportunity to have easy access to clinically relevant and current CME locally on a regular basis. Continental breakfast is provided.

Grand Rounds are held most Fridayâ&#x20AC;&#x2122;s from 7:00 to 8:00 AM in the Franciscan Room at Penn State Health St. Joseph St. Joseph Regional Health Network is accredited by the Pennsylvania Medical Society to provide continuing medical education for physicians. AOA Category 1A CME credits were requested through our co-sponsor, Philadelphia College of Osteopathic Medicine.

Please access the schedule at...

www.thefutureofhealthcare.org/ grandrounds

QUESTIONS, PLEASE CONTACT THE CME OFFICE AT PENN STATE HEALTH ST. JOSEPH AT 610-378-2176. WINTER 2016

Dr. Cairns then introduced the recipient of the 2015 Presidentâ&#x20AC;&#x2122;s Internship, Sara Radaoui, whose article on access to mental health care in Berks county was published in the fall issue of the Medical Record. Physicians who celebrated 50 years of service in medicine this year were also introduced if in attendance, and presented with their awards. Recipients included Joseph A. Girone, MD, Peter A, Schwartz, MD, Ray Smith, MD (in attendance), William Sweet, MD (in attendance), and Carol Szarko, MD. David Zobian, MD, accepted a posthumous award on behalf of his father, Edward Zobian, MD. One new member in attendance, Dr. Collette Simon, was presented with a membership plaque. Dr. Cairns, outgoing President, then gave her parting words to the group, and the new officers were installed. Dr. Anne Rohrbach was installed as Secretary, Dr. Gregory Wilson as President-Elect and Dr. Andrew Waxler as the 168th President of the Berks County Medical Society.

10 | www.berkscms.org

WHY READING HEALTH SYSTEM?

WE’LL GIVE YOU

101 REASONS. Like... Reason 18:

Top 10 Best Value Hospitals in PA, or

Reason 51:

Rated #1 in PA for Knee and Hip Replacements, or

Reason 94:

Top 5% Nationally for Clinical Excellence, or

Reason 29:

Award Winner for Women’s Health Excellence.

...To name a few. Reading Health System delivers value and top-quality care in so many ways. Discover all the reasons to choose us at:

101ReasonsWhyRHS.com

WINTER 2016

BERKS OWN OPIOID CRISIS I

t will come as no surprise to anyone who pays attention to Berks County news outlets (such as the Reading Eagle newspaper) that our community has not proved immune to the epidemic of opioid drug abuse currently affecting the U.S. In recognition of the severity of this crisis, the Berks County Medical Society has formed a task force to examine the factors contributing to this crisis locally and to work with community partners towards finding solutions. This article is the first of a series we will publish with the aim of increasing awareness of the nature of this problem, its extent, and strategies for addressing opioid abuse and addiction.

What are we talking about? Opioid use vs. abuse vs. addiction

Lucy J. Cairns, MD

Opioids are drugs whose ability to relieve pain is one of many effects on the brain and body. Some opioids are derived directly from the opium poppy and others are synthesized. Opioid drugs include morphine, oxycodone, heroin, hydrocodone, and methadone, among others. These substances exert their effects by binding to specific molecules (receptors) on the surface of cells in the brain and elsewhere, thus imitating a natural chemical messenger and causing a range of changes in brain chemistry. While reducing the perception of pain, opioids also affect mood, motivation, cognition, decision-making ability, and locomotion. Respiratory depression, constipation, and changes in the neuroendocrine system also occur. People who use opioids for nonmedical reasons report achieving a state of temporary euphoria and relaxation due to a rapid increase in levels of dopamine in the brain. Prescription opioids play a vital role in alleviating pain caused by trauma, surgery, and a wide range of medical conditions. Taking an opioid as prescribed by a medical professional for relief of pain is the legitimate use of these powerful drugs. Use becomes abuse when a person takes prescription drugs for non-medical reasons or uses drugs obtained illegally. With continued use, tolerance may develop as a higher and higher dose is needed to achieve the same effect. Tolerance is the direct result of changes in brain chemistry and function due to exposure to the drug, and such changes can be very long-lasting. Drug dependence is the need to continue taking a drug in order to avoid withdrawal symptoms. People who become dependent on opioids may eventually no longer experience the euphoria that initially prompted continued drug-seeking, but rather find themselves needing drugs primarily to avoid the opposite of euphoria (dysphoria) and a host of other extremely uncomfortable withdrawal symptoms.

12 | www.berkscms.org

According to the Director of NIDA (National Institute on Drug Abuse), Nora D. Volkow, MD, addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences to the addicted individual and to those around him or her. In a June 2015 blog post on the NIDA website, Dr. Volkow proposes regarding drug addiction as a disease that alters the brain in ways that rob a person of free will. She argues that such a concept is the only way to explain the behavior exhibited by those who are addictedâ&#x20AC;&#x201D;their willingness to give up everything they care about, and risk severe punishment, in order to continue drug useâ&#x20AC;&#x201D;and is supported by current scientific understanding of brain changes in addiction. However, we know that some people do achieve long-term recovery, which at least in part

WHY READING HEALTH SYSTEM? involves making a series of choices to alter their behavior. This fact argues against the total eradication of free will in this condition. To better understand addiction and the conditions which support recovery from it, acknowledgment of both the physiologic disease process and the possibility of exerting a degree of control over it are equally important. Models of disease have consequences, and so do the words used to describe disease states and the people afflicted with them. To refer to a person as an addict risks denying the fullness of their humanity and implies that their state of addiction is the defining fact of their being. One consequence could be to reinforce that person’s feelings of being powerless to change, and therefore less likely to attempt recovery. In the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the term ‘addiction’ does not appear. The terms previously used-- substance abuse and substance dependence—have been combined into a single term: substance use disorder. Further distinction is made by classifying the disorder as mild, moderate, or severe. Therefore, ‘severe substance use disorder’ is the current diagnostic term for what is commonly referred to as addiction.

Why do only some people who use opioids become addicted?

No one is immune to addiction. Anyone exposed to a high enough dose of an opioid over a long enough time period will develop tolerance and dependence, but individuals vary tremendously in their risk for abusing drugs and for developing full-blown addiction. As with most diseases, genetics is thought to explain much of the variability (40-60%), but the complex interplay between genetic, biologic, social, and environmental factors plays a major role as well. Factors associated with increased risk include having a mental illness, younger age at first drug use, poor social skills, lack of parental supervision, stress, availability of drugs at school, male sex, and living in a poverty-stricken community. Adolescents are especially vulnerable due to peer pressure, normal developmental tendencies to express independence, and lack of maturity of the pre-frontal cortex of the brain (important for the ability to assess situations, exercise good judgment, and control emotions and impulses). Factors associated with reduced risk include parental monitoring and support,

REASON

18:

Can you measure the value of healthcare? Industry experts did and rated us Top 10 Best Value Hospitals in PA. That’s value you can measure.

Getting the most for your healthcare dollars is important. So knowing your hospital is on top when it comes to quality, service and cost-efficiency is essential to making the smart choice for your care. And according to an independent measure of healthcare value, we’re one of only 10 Best Value Hospitals in PA. That’s value you can measure. If that’s not reason enough, go to 101ReasonsWhyRHS.com

continued on next page >

WINTER 2016

academic competence, good impulse control, positive relationships, school anti-drug programs, and community pride. What factors have contributed to the increase in opioid addiction?

• A push for more aggressive treatment of pain began about 20 years ago. In 1996 the President of the American Pain Society, James Campbell, M.D., summed up a new approach to pain management in his Presidential Address as follows:

“Vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated.” Pain became the 5th Vital Sign, and the expectation became that people with pain should have their pain eliminated. • Pharmaceutical companies developed new opioid formulations to treat pain, marketed them as being safe and effective, and the number of prescriptions dispensed increased dramatically. Some of the opioids dispensed in pill form could be crushed and used in ways that delivered a higher concentration to the brain at a much quicker rate compared to swallowing the pill, thus lending them to abuse and the development of addiction.

• Insufficient oversight allowed illegitimate prescribing for profit in so-called ‘pill mills,’ and lack of mechanisms to help prescribers spot ‘doctor shoppers’ made obtaining prescription drugs for nonmedical use relatively easy. • Barriers to accessing treatment keep more people addicted for longer. Such barriers include the shame that results from the stigma attached to addiction, lack of insurance coverage or coverage insufficient to pay for long-term treatment, and limited availability of inpatient beds and recovery housing in some areas.

Drug overdose deaths in Berks County

(Sources: Berks County Coroner’s Office and Detective Pat Leporace of the District Attorney’s Drug Task Force) Drug-related overdose deaths are just the tip of the iceberg when it comes to trying to understand the extent of this crisis, but such deaths are a significant indication of the toll this epidemic is taking on our community and who is most affected. 14 | www.berkscms.org

Total deaths related to heroin overdose almost tripled between 2010 and 2014 (from 11 to 29). The total for 2015 stands at 28 as of the date of this writing (01/28/2016) but could rise when the results from the 7 autopsies whose results are still pending are known. The average purity of heroin for sale in Berks County has increased dramatically, from <20% purity in the 1970s to approximately 70% today. As the purity has increased, the price of heroin has decreased. A bundle of heroin (10 unit-doses) costs about the same as a single black-market oxycontin.

2015 Data • Total drug-related overdose (OD) deaths: 75 (up from 62 in 2014) • Illicit drugs present in 33 instances (in 28 instances the drug was heroin) • Specific prescription opioids identified in 10 instances • Prescription drugs (opioids and/or benzodiazepines) present in 20 instances • Percent of decedents female: 39% (up from 29% in 2014) • Racial breakdown of decedents: 79% White, 19% Hispanic (and 1 Black and 1 Hispanic/White) • Age breakdown: 0-17 (1); 18-30 (18); 31-45 (22); 46-60 (29); 61+ (5). o In the 18-30 y.o. group, heroin was the drug present most often, with only 3 instances of prescription drugs. In the 46-60 y.o. group prescription drugs were found in 17 instances. In many of the cases involving prescription drugs, the decedent had a valid prescription. o All 5 deaths in those 61 years and older involved prescription medications. • Manner of death is listed as ‘Accident’ for all but 2 cases of suicide, 7 undetermined, and the 7 pending cases. • Place of death was ‘Own Residence’ in 2/3 of cases. • Deaths occurred in 21 Berks County townships and boroughs, in addition to the City of Reading. The city was the site of 32 deaths, with West Reading/RH next with 12 deaths and then Bern Township/SJMC with 6. Between 1 and 3 overdose deaths occurred in the remaining localities.

As stated earlier, the destructive effects of opioid abuse and addiction cannot be measured just by counting overdose deaths. The number of people in the grip of addiction and the horrific effects on their loved ones and the wider community is a much larger problem. It deserves a focused and sustained effort from the medical profession in cooperation with those battling this crisis in the drug treatment organizations, law enforcement, education, and public policy arenas.

My Story By: Kyle Robinson - Recovering Addict Since 5/15/06

“So Kyle, tell me what is your daily intake of drugs,” said the intake specialist at

the Bowling Green Rehab Center. “Well, Bob,” I said, “I am doing about an 8 ball of cocaine and right around 40-50 painkillers a day.” Mostly Percocet, but I would take anything at that point: Vicodin, OxyContin …but not heroin ‘cause heroin means that I am a drug addict. It’s funny how you think things like that at this point. I think it has to do with the way society looks at these things nowadays. I always thought of a drug addict as someone in Philly living on the streets with a sign out asking for loose change, or the lady walking down the street with no teeth shouting at herself. Definitely not the person I saw when I looked in the mirror. I had a great childhood, my parents were still together, I was never abused as a child, and I came from an upper middle class family. So how am I stuck here talking to Bob about my daily drug intake? The scary part is, this isn’t even where my drug addict story stops. That would be about 3 weeks later, after I got caught stealing Vicodin from my neighbor’s house after they had invited me over to dinner.

The reason why my story doesn’t stop here is because, if you can believe it, I was told that my insurance company wouldn’t pick up the cost of inpatient treatment. I had to try—and fail—outpatient treatment before my insurance company would even consider covering any form of inpatient treatment. Yes, you are reading this right—I was doing an 8 ball of cocaine and around 40-50 5mg pills of Percocet a day and that wasn’t enough for my insurance company to pay for inpatient treatment. I am just telling you about this because I find it insane how insurance companies look at this thing and just how far behind the times we are when it comes to the treatment of drug addiction. I1 often think how lucky I was that I didn’t overdose during those 3 weeks of outpatient treatment before I was finally approved for inpatient treatment. I showed up to my 3-times-a-week scheduled outpatient group pretty much high every single time and went through the motions. I talked about how I wanted to be sober and change my life around and things like that, yet never once stopped taking pills.

WHY READING HEALTH SYSTEM?

REASON

23:

You expect performance, innovation and efficiency in a new car. They come standard in our health system. That’s value you can depend on.

At Reading Health System, delivering top-quality clinical outcomes is what drives us – every day. And our recognitions as America’s 100 Best Hospitals for Specialty Care and Top 10 Best Value Hospitals in PA prove it. From the latest technology and procedures to being awarded Healthcare’s Most Wired, our standard of care comes fully loaded. That’s value you can depend on.

If that’s not reason enough, go to 101ReasonsWhyRHS.com

1 y story of drug addiction started, I think, about 5 years M before that when I first tried cocaine with the girl I was dating at the time. I was around 22 and had never been a

continued on next page >

WINTER 2016

RH15-07_ReadingHealthSys_BerksCountyMedRecord_3.5625x9.875_Reason23_012016.indd 112/18/15 12:33 PM

big drinker growing up. I figured “Hey—all my friends drink to excess on the weekend, so why can’t I do something different? Who is this hurting?” Don’t get me wrong, I drank here and there and smoked pot every once in a while, but didn’t really start the harder drugs until I was 22 or 23. I don’t really know when I went from socially doing drugs to being a full-on addict. I guess it just kind of snuck up on me at some point. I mean, no one starts off saying, “Hey! I want to be a drug addict when I grow up.” It just kind of happens to us addicts.   1 he main difference between myself and a casual user is one T major thing: I can’t just have one—it has to be all or nothing. I tried explaining this to my friends one time, because they didn’t understand how I was an addict and they weren’t. They didn’t understand why anyone would want to do painkillers or cocaine first thing in the morning or when at work, and I didn’t understand how you could hold onto pills or cocaine if you had it. To me it’s ‘let’s do all the pills and cocaine I have and then go try and find some more’. What I told them was as simple as this: it’s like stepping over an invisible line that, once it is crossed, you can never go back. Once you cross that line into addiction you are done. You can’t cross back to the nonaddiction side after taking some time off. It has become a one way street and there is no turning around. 1 he hard part is I honestly can’t tell you when I hit that T invisible line when I went from taking one or two Percocet on the weekend to help with sleep to taking upwards of forty a day. It just happened. One day I woke up and the most important thing to me was getting painkillers. It stayed that way for a very long time. The hard part about painkillers is that you become dependent upon them to function and will do anything to get them. In the beginning it was super easy to get pills. I had about 7 different doctors that I saw once a month and 7 different pharmacies. Yep, we seem to be just a 16 | www.berkscms.org

bit behind in that area, which is great for addicts. I would go to Giant on Monday, CVS on Tuesday, Rite Aid on Wednesday, Target on Thursday, Walmart on Friday, Walgreens on Saturday, and the local mom and pop pharmacy on Sunday. As long as I was willing to pay cash, no one was any the wiser. Plus, being from an upper middle class family these were some pretty smart doctors I was seeing. Not the ‘hey pay me 100 bucks and I will write you a script’ doctors. What I found was that as long as you were nice, well dressed, and had a small idea of what to tell them, you could get them to write a script for a lot of different things. Right now, if I was to walk into a psychiatrist’s office and say that I get nervous and stressed out at work and also have a hard time sleeping, I can almost guarantee you I will be walking out with prescriptions for Xanax and Ambien. I can’t blame it all on the doctors either. We live in such a quick fix society that it has become the norm. It’s like, “Take a pill it will make everything better.” Also, I wonder how much time is really spent on addiction and the signs to look for in medical school. I am not a doctor, so I really don’t know, but from what I have heard it isn’t very much. Hope I am wrong on that one.

1 ven having doctors on speed dial and all the different E pharmacies, I still had to resort to some other things to get pills. Problem was, once I started taking a whole month of prescriptions in one day and crossed over that invisible addict line, all I thought about was how I was going to get drugs. As a kid, I was always afraid to do anything wrong. I never wanted to get in trouble or let anyone down. But that all changes when you don’t have any pills. In a one-month time period I got arrested for forging fake prescriptions, breaking into a pharmacy, and stealing pills from my neighbor. All of which were the best possible ideas I could come up with at the time to get what I needed. 1 hat’s the problem with drugs. They don’t care if you are a T CEO or work in the mailroom, if you are a doctor or a student, a judge or a criminal. They don’t discriminate against anyone,

they take any and everyone. The new face of addiction is the person sitting across from you at work, your doctor, lawyer, even your priest. My small group at the Caron Treatment Center was myself, a 26-year-old bartender, the CEO of a Fortune 500 company, A Monsignor from the Catholic Church, and a state Supreme Court justice. All of us were battling addiction to painkillers and other drugs. I spent close to seven months in continuous treatment, progressing from inpatient to extended care to halfway house facilities. Through treatment I discovered how little I knew about addiction when I started using drugs, and how many people in all walks of life are affected by it.

1 ne of the biggest problems that I feel we are dealing with O in this battle of addiction is lack of knowledge. We have not even scratched the surface in understanding how to deal with this new epidemic. Doctors are prescribing these drugs at an alarming rate without knowing the side effects. I honestly feel that if you take narcotics for pain or anxiety, it is only a matter of time before you become dependent on them. Once the physical dependency kicks in or you find yourself needing more due to tolerance changes in your body, things start to slide downhill. Now, I do know plenty of people that have had injuries, had to take pain medicine, followed the directions, and were fine. I even know people that have to take pain meds every day for long periods of time who have not crossed that addict line, so I can’t quite tell you exactly when it begins. But once it does, that’s when the trouble starts. When you really break it down, when you are prescribed a painkiller you are being prescribed heroin, once the body breaks it down. I can’t help but think if we labeled these drugs as heroin instead of Vicodin, Percocet, or OxyContin, there would more of a backlash against them.

1 nother big problem is the stigma attached to addiction, A which makes people reluctant to talk about it. I was ashamed of being a drug addict and didn’t want anyone to know. What I have found out, after opening up and talking about it, is that almost everyone knows someone who is affected by addiction in one form or another. The more I talked about it, the easier it was for me to accept the fact that I was an addict, and that there is nothing morally wrong with being one. It doesn’t make me a bad person or a ‘drain on society.’ After all, we don’t say such things about people with cancer or other life altering diseases, do we? I can’t help but think that if more people learned the facts about addiction, starting from the top down, we might be able to get a better grip on this epidemic. If doctors, politicians and insurance companies were to become educated, I feel that we would have a much better chance at tackling this. 1 ne place that I feel is at the forefront in this field is the O Caron Treatment Center. It wasn’t until I went to treatment there that I fully grasped what I was dealing with. First, they bypass insurance restrictions in that, once you are admitted

to treatment there, you are locked in to a full 30 days. They will work with you to try to get reimbursed by your insurance company, but you don’t have to worry about being told that you are only getting 10 days of treatment They understand that addiction can’t be taken care of in a week or two. It was at Caron that I learned exactly what was going on inside my body and why I could not recover from addiction on my own. Caron also strongly recommends extended care to most of its patients, and brings in the families of the addicts to better educate them as to what is really going on. Tackling addiction by providing long-term treatment and education, and with involvement of the families, increases the odds of success. Thanks to the treatment approach used at Caron, I have been in successful recovery for almost ten years now. 1 y hope is that the upcoming articles you are about to read M shed a light on what is really going on with this problem today. No longer is being a drug addict synonymous with the homeless person on the corner or the alcoholic uncle who could never get his stuff together. The disease of addiction is now completely in the main stream and can affect anyone, including you or your family.

JUMP

Get a on the Real Estate Market …with G-r-r-reat Values this Spring As the Premier Realtor In Berks County, I’ve used my Professional eye, Marketing savvy, Enthusiasm for the business to more quickly match Buyers and Sellers. My Passion combined with my Sales and Marketing skills have made me the most Successful Agent in Berks County. I would love to have the Opportunity to Share that Success with You. When you are ready to Buy or Sell, Team up with the Tiger!

Lisa Tiger

LisaTigerHomes.com 610.779.2500 • 610.207.6186 (direct)

WINTER 2016

Comments by William Santoro, M.D.

Chief, Section of Substance Use Disorder The Reading Health System

or every story like Kyle’s there are numerous other stories that do not turn out as well. I think it is time that we discussed the full spectrum of treatment. I run a 12 step based program, a methadone maintenance program, a buprenorphine maintenance program and a naltrexone maintenance program. Each of these forms of treatment is valuable, however, I acknowledge not any one single program will work for every patient. Many times I have gone to a symposium on addiction and some person will get up and tell a story similar to Kyle’s. To hear stories like this give all of us hope and reassurance that recovery is possible. After the applause someone typically comes over to me and says, “That story is wonderful and I am glad for that person, but it is not my story.” I think we need to tell these other stories. One such story is that of a patient who came to see me for admission to the Drug and Alcohol Center, a 12-step based treatment program. I asked him how many times he had been through a treatment program such as this. He told me this was his 30th attempt. He had recently completed a 6-month inpatient program and relapsed 2 weeks after his discharge. He told me that he had contacted the place he had most recently been in asking for advice. When he told them that he had relapsed their answer was that he needed more

18 | www.berkscms.org

time in treatment. I asked him if anyone ever talked to him about medical assisted treatment (MAT) and he said, “no.” He told me in the past he had asked several treatment providers about methadone but was discouraged from pursuing it. He then half asked and half told me that being on medication was not truly being in sobriety. We talked about the myths surrounding medical assisted treatment. We talked about the way some MAT programs are run well and others are not. We talked about different MAT options (methadone, buprenorphine and naltrexone) and the different success rates of each. He asked me why no one else has ever offered him this type of information.

During our conversation this patient used the term “addict.” He used the word to describe himself and then complained to me about the stigma of this disease. He questioned me why there is no stigma attached to other chronic diseases such as cancer. My answer to him was, “If you want to stop the stigma start with the label.” I gave him the following fictional story as an example. I told him I had a patient in the office complaining of pain in the back of his head, just above his shoulders. Over the course of 5 office visits I ordered medications, X-rays, an MRI and physical therapy. At the 5th visit I told this patient that I had the answer to his problem. I looked him in the eye and told him, “The problem is that you are a pain in the neck.” Of course I have never told a patient they were a pain in the neck. I used this fictional story to point out how inaccurate and wrong it is to label a patient as being the disease. We do not call anyone else by the disease they have. Everyone, especially the person with the illness, needs to stop referring to themselves as the disease. A person is not cancer, or back pain, but rather they have cancer, or they have back pain. In the same vein a person is not an addict, they have an addiction. A person has leprosy, the person is not a leper. The illness a person has does not define who they are.

THE PIT AND PENDULUM OF NARCOTIC PRESCRIBING

By: Dr. Gus Geraci, MD, FAAFP, FAIHO, CHCOM, CPE

’ve got enough grey hair now that I can see a few patterns in how things have worked over time. Estrogens for menopausal symptoms came and went; mammograms, pap smears, PSA tests, and other strenuous recommendations came out strong, faded, and had a resurgence, sometimes only to fade again.

All of these changing recommendations remind me of the Edgar Allen Poe story, “The Pit and the Pendulum.” An unnamed character is sentenced to death, and finds himself in a cell in complete darkness. Then, after apparently being drugged, he awakens tied to a table with a pendulum swinging above his body, set to lower slightly with each pass until it ultimately mortally wounds him.

We who practice medicine are laying on the table with a slowly lowering pendulum above us, but that pendulum is also moving slowly from side to side. Recommendations change and swing, based upon or supported by the solid scientific reasoning of the day, and sometimes, its social justification. If you fail to follow these recommendations, you might be wounded.

Or at least that’s how it is with prescribing narcotics. A few years ago, using our own judgment on pain relief became insufficient. The public outcry was that we weren’t treating pain well enough. We were given guidelines, pain was declared a vital sign, and comfort was of utmost importance; the presence of pain — however minor — was a bad thing. That perspective is still supported by surveys used in hospitals today. Our job became to eradicate pain, and narcotics were the secret when lesser medications did not work. The potential abuse of narcotics was tempered by opiate agreements, questions, and surveys, but largely overridden by the primary directive: eliminating pain. And we therefore unwittingly created addicts out of more than the absolute minimum number of people who “really” needed narcotics. The pendulum made a swing back shortly thereafter. A surge in narcotic use, abuse, and addiction brought demands for “sensible prescribing.” Physicians who were a bit too eager to eliminate pain as directed by the guidelines started to be prosecuted for a lack of medical necessity or “proof ” that the patient was in pain. A 10-out-of-10 unhappy face was no longer sufficient; there had to be some evidence that the pain was real, and physicians were now directed to minimize the

use of narcotics. They were only to be used as a last resort when all other — even a few very expensive and unaffordable — interventions had failed.

Some of us reacted too harshly, prescribing so cautiously that patients began to complain they were getting no relief, or being treated as abusers when a previous regimen of three narcotic pills a day had kept pain at bay, and kept them productive, for years. Many were asked to attend rehab, physical therapy, or subject themselves to interventions that they didn’t have the time or money to complete as their drug therapies dwindled. For some, the only resort that would allow them to keep working was to turn to street drugs. It was a bad solution, to be sure, but it was the only answer until they got caught, got a bad dose, or died. PAMED, state departments, and stakeholder groups from dental, emergency, primary care, oncology, and other fields have worked diligently for the last year to craft new voluntary guidelines in Pennsylvania. Guidelines exist for the treatment of chronic, non-cancer pain, treatment of pain in the emergency department, and treatment of pain in dental practices; others are in the works. The guidelines include numerous devilish details, and you can download them at www.pamedsoc.org/opioidresources.

The hope is that the guidelines will minimize unnecessary prescribing, while providing effective pain relief to people who respond only to narcotics. With best practices and limitations outlined, they can help the pendulum swing back to a happier place. A few more years, and we’ll see. Dr. Gus Geraci, MD, FAAFP, FAIHQ, CHCQM, CPE, is consulting chief medical officer for PAMED. He has worked in emergency, occupational, and family medicine; in management and quality improvement for health systems, insurers, and health care vendors; as a physician educator with Harrisburg Hospital’s Family Practice residency program; and in state government as the inaugural chair and a current board member of the Pennsylvania eHealth Partnership Authority. Read his blog at www.pamedsoc.org/qualityblog, and email him at gcgeraci@ drgeraci.com. Learn more about PAMED’s efforts to address the opioid abuse crisis in Pennsylvania, and get tools and resources designed to help Pennsylvania physicians, at www.pamedsoc.org/ opioidresources.

WINTER 2016

Fighting Opioid Abuse in Pennsylvania INTRODUCING PAMED’S INNOVATIVE EDUCATIONAL SERIES AND OTHER RESOURCES HEALTH CARE TEAMS CAN USE TO ADDRESS THE OPIOID CRISIS

THE PROBLEM: Opioid abuse, misuse, and overdoses are increasing, both in Pennsylvania and nationally. While some requests for pain medication are legitimate, others are likely to be from pill scammers who have become addicted to opioids. THE SOLUTION: A multi-pronged approach that includes physicians, patients, and health care organizations like the Pennsylvania Medical Society (PAMED) working collaboratively to address this growing epidemic.

20 | www.berkscms.org

o help prescribers combat this problem, PAMED, in collaboration with the Pennsylvania Department of Health and 11 other health care associations, is creating a comprehensive online educational resource for prescribers. “Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know” is a four-part course that examines all the tools prescribers can use to identify patients with addiction issues and get them help.

The first session of the course addresses how prescribers can use the statewide voluntary opioid prescribing guidelines, and the second session takes a deeper dive into the state’s naloxone law. Both are available at www.pamedsoc.org/ opioidresources. Upcoming sessions (Parts 3 and 4) will address the controlled substances database and the warm hand-off. This educational series features:

• Videos and interviews with physicians, other 1 prescribers, and state officials working on the front lines 1 of the crisis • The latest statistics and data

• Details on how to use opioid prescribing guidelines 1 for physicians, emergency departments, and other 1 providers

• Scenario-based learning to help implement the lessons 1 into daily practice

This crisis spans nearly every state in the U.S., but has hit Pennsylvania particularly hard. Nearly 2,500 deaths were reported in Pennsylvania as a result of drug overdoses in 2014, and more people die from drug overdoses than in car accidents.

No one disputes the magnitude of the prescription drug abuse crisis in Pennsylvania and the nation at large. The question is, how do we combat the problem?

“I think that we have to understand this is a

public health crisis and we all have a role to play in terms of solving this,” said PAMED member and Pennsylvania Physician General Rachel Levine, MD.

FOUR WAYS TO INCREASE YOUR CONFIDENCE IN MANAGING OPIOID THERAPY 1.1Familiarize yourself with these state-endorsed, voluntary guidelines for opioid prescribers in Pennsylvania: • Guidelines on the Use of Opioids to Treat Chronic 1 Non-Cancer Pain

• Emergency Department Pain Treatment Guidelines • Prescribing Guidelines for Dentists

2. 1Get involved with grassroots advocacy and initiatives by having a discussion with the physicians in your county or region. Call PAMED’s Speakers Bureau at (800) 228-7823, ext. 2620 for details.

3.1Have a conversation with your chronic pain patients using PAMED’s Opioid Prescription Checklist to help facilitate the pain-management discussion.

4.1Access even more PAMED opioid education and receive patient safety and risk management CME credits. Take PAMED’s six-part, online course designed to educate physicians and other health care providers on the appropriate use of long-acting and extended-release opioids.

Visit www.pamedsoc.org/opioidresources to access these resources and more.

A community bank. Funding community projects.

Sounds like a good formula to us.

“We need to get past the idea that these are

somehow just drug abusers that are miscreants and throwaway members of our society,” says Dr. Levine. “The substance use problem and

opioid problem touches all of the families in our state and in the country.”

Offering a wide variety of business banking services.

PAMED’s education seeks to address the many layers and complexities of the crisis. Learn more and get CME credit by visiting www.pamedsoc.org/opioidresources.

1-888-238-3330 | www.VISTBank.com Member FDIC

WINTER 2016

EDITOR’S INTRODUCTION Cedric C. Jimerson was born in August 1919 in Hornby, NY. His father was a farmer who had graduated from Alfred College. In addition to working his 110-acre farm, he was head of the vocational shop at a high school in nearby Corning and was a home-builder. When Cedric was 13, his father died of tetanus, leaving his mother with four children under the age of 14. She began teaching for a dollar a day in one-room schools in the county and told the children they would have to work their way through college. Cedric proceeded to do just that, at Cornell University, and was one of seven students admitted to Cornell Medical College after his junior year. After graduating in 1943, he began his surgical training at The New York Hospital in New York City. His training was interrupted after his first year by military service, and he spent the next 2 ½ years as Captain and surgeon with the U.S. Army Medical Corps. He resumed formal training in 1946, first back at The New York Hospital in general surgery, then in thoracic surgery at the Bronx VA Hospital and at a VA hospital in upstate N.Y. Finally, he completed a senior resident year at New Britain General Hospital in New Britain, CT, followed by a 6-month pathology residency at the same institution. 22 | www.berkscms.org

Dr. Jimerson’s search for a position in general surgery, upon completion of his training, led him to Reading, where he joined the staff at Community General Hospital as the only board-eligible surgeon who had completed a formal surgical residency at an approved university hospital. He maintained a grueling pace of practice there for the next 35 years and became a beloved figure in the community. Despite the demands of practice, Dr. Jimerson made time to advocate for physicians and patients as a member of the Berks County Medical Society and the American College of Surgeons. His life and career have spanned changes in medicine, surgery, and society that would likely amaze any young person beginning a career as a physician in the 21st century. Dr. Jimerson has written in great and fascinating detail about his experiences, in part to preserve some important Berks County history, and he recently contacted the Medical Record to offer selections of his memoirs for publication. The following selection is a description of his internship year in general surgery at The New York Hospital. Additional selections will appear in future edition of the Medical Record.

Cedric C. Jimerson, MD Surgical InternshipThe New York Hospital

graduated in April, 1943, and I started my internship the very next week. Arthur Chenowitz was the senior resident on the seventh floor. Gardiner Childs, who later became Chairman of the Department of Surgery at the University of Michigan Medical College and who became renowned in biliary tract and pancreatic surgery, was the senior resident on the sixth floor, Eugene Clifton was senior resident on the fifth floor. I was assigned to Dr. Clifton and to the fifth floor.. He was a “slave driver” and a “son of a gun.” He worked us so hard we had little time to eat or sleep. My classmate Harold Miles from Olean, NY had married the weekend before we started the internship, and Clifton did not give him time off to see his new bride for one month. Prior to World War II, there was a rule that nobody in surgical training at NYH could be married, because of the belief that a wife and married life interfere with work and training. Because it was a seven-year residency in surgery, this meant that the survivors of the highly competitive pyramidal system were thirty years old before they could marry. Dr. George Heuer patterned his surgical residency after that of Dr. William Halsted, the “Father of Modern Surgery,” at Johns Hopkins Hospital in Baltimore, MD. Dr. Heuer had trained under Halsted, and he was one of many surgical residents whom Dr. Halsted had turned out of the famous residency at Johns Hopkins. Later Dr. Heuer performed a cholecystectomy for acute cholecystitis on Dr. Halsted. Many of the Halsted trained surgeons became professors of surgery at the most prestigious university hospitals in this country, including Dr. Heuer, formerly Chairman of the Surgical Department at the University of Cincinnati, Dr. John Morton, Chairman of the Department of Surgery at Strong Memorial Hospital in Rochester, NY, Dr. Harvey Cushing, the famous Professor of Neurosurgery at Harvard, and the Professor of Surgery at Yale School of Medicine in New Haven, CT, and the University of Virginia in Richmond, VA. These Halsted residents learned, taught, and practiced the Halsted principles of surgery, including: asepsis and sterile technic, thorough hand scrub, careful preparation of the skin

with washing and application of antiseptics, proper draping and walling off the sterile field, the use of cap and mask and sterile gown, and the use of sterile gloves. Dr. Halsted was the first surgeon to use sterile gloves, although all the credit goes to his wife who was his suture nurse. She had suggested that he employ rubber gloves to protect his hands which were affected with a skin disease. Dr. Halsted taught slow meticulous dissection, gentle handling of tissues, careful hemostasis, clamping and ligating individual blood vessels, avoiding trauma to tissue, and the accurate apposition of wound edges.

Remember Dr. Halsted was at Johns Hopkins in the day of its glory when it proudly boasted of its great medical men including: Dr. Welsh, and Dr. William Osler, the great physician who advocated putting a finger into every orifice during a complete physician examination. Both Dr. Halsted and Dr. Heuer believed a preceptorship had no place in the making of a surgeon. They firmly believed that a long disciplined formal residency training program which included all of the branches of surgery was the only way to prepare a young surgeon to handle all types of surgery involving all of the body cavities and the extremities, including brain surgery, thoracic surgery, abdominal surgery, and pelvic surgery. Indeed, while I was in residency training in surgery, orthopedics, neurosurgery, pediatric surgery, urology, plastic surgery, thoracic surgery, gynecology, and cardiovascular surgery were all taught in the general surgical residency. At the time I took my American Board Examinations in Surgery, questions in both the oral Part 1 written and in the Part II oral examination included all of these surgical specialties. A work ethic was instilled into us that the longer and harder one worked, the better surgeon he would become. Dr. Clifton treated us like slaves. At the New York Hospital there were three entire floors devoted to the ward services of general surgery. Most of my internship I worked on the fifth floor. Female patients were on the east wing and male patients were on the west wing of the fifth floor. Each wing had one large ward divided into four sections of six beds each and there

continued on next page >

WINTER 2016

were draw curtains for each bed. There were two private rooms near the nurses station which was located just outside the big ward, which could be seen through large windows. In addition there were semi-private rooms, each with four beds. Each wing had its own dressing or treatment room.

We were expected to finish breakfast and to be on the floors to make rounds by 6:30 A.M. and to be in the operating room by 7:30 A.M. The operating suite was on the tenth floor, and the private operating rooms were on the eleventh floor. As interns, we “scrubbed” on every “case” from our respective floors. The OR schedule was heavy, and it was always filled. Daily we operated from 7:30 A.M. until 4:00 P.M. or 5:00 P.M. with or without a short break for lunch. We had a daily conference with the members of the house staff assigned to each floor. The concept of the surgical residency training was that senior members of the house staff were responsible for teaching and training the assistant residents and the interns under them. Usually the senior resident assisted the professor of surgery with his operations, and occasionally the professor or one of the assistant professors assisted the senior resident with his more difficult operations. It was a pyramidal system which meant that some members of the house staff were eliminated each year until there were only three senior surgical residents in the seventh year of the residency.

Award-Winning Answering Services

Advantage TeleMessaging, Inc. knows that running a medical practice in today’s fast-paced, competitive environment is tough enough. Since 1994, we have provided affordable and professional telephone answering services, and HIPAA/HITECH-compliant call management solutions that give you the competitive advantage you need for your practice to succeed!

Call us today at 610.372.5551 to find out how we can improve your business!

www.AdvantageTeleMessaging.com 24 | www.berkscms.org

For the most part the senior seven year residents operated independently without the help or interference of a junior or senior attending surgeon. He was assisted by the members of his house staff. There were always plenty of assistants. Frequently there were so many assistants that the lowly intern was out in “left field.” Either he couldn’t see what was going on, or he really wasn’t needed. No one ever left the operating table unless he was specifically excused by the superior resident. Even if nature called, the intern was expected to pull on those retractors, until he was excused.

The senior resident was responsible for arranging the OR schedule. He determined which patients needed surgery, and the operation they would receive. Then he assigned the operating team. He determined which operations he would perform and which operations he would “turn over” to the first assistant, second assistant or third assistant residents. If the fourth year resident was the assigned surgeon, the assistant resident on the ladder above him and the one below him would assist him-and the intern was always the “fifth wheel.” In reality the intern was there to “hold the hooks,” to provide retraction of the surrounding viscera and exposure of the operative site. He was constantly being commanded to pull harder, or not to pull so hard or to replace the retractors or rakes. Somebody should have invented a better handle for those big Deaver retractors which gave the intern blisters and callouses on his hands.

After a long day in the operating room, and after the afternoon conference reviewing the care of the surgical patients, and after reciting from memory the blood counts and urinalyses of the patients, because many of them were on sulfa drugs, the intern was excused for supper. After supper we were expected to perform complete histories two or three pages long (the medical interns had to do four or five page histories) and physician examinations. These had to be written up in long hand before presenting them for review to the assistant residents who in turn wrote up a shorter history and physical examination. The senior resident reviewed the histories and physical examinations of the assistant resident and the intern, and then he wrote a paragraph about the patient on the chart. After evening visiting hours, we were expected to be on the floor to discuss the patients’ conditions with the relatives and visitors. Then we made our own evening rounds and ordered medications. We sat near the chart rack, and wrote progress notes on each patient’s chart. Also we wrote operative notes on the charts of the patients operated upon that day, and preoperative notes on the patients to be operated the next day. Under the supervision of one of the assistant residents we wrote the orders for the patient.

Dr. Clifton insisted that the intern, and not the nurses, do all of the daily colostomy irrigations daily, and there were many of them. We were not allowed to do the colostomy irrigations in the morning before surgery, and he forbid us to have BM’s before surgery, because he felt these activities could affect the postoperative infection rate. In the late evenings we went down to the record room where we dictated on the old dictaphones lengthy discharge summaries of all the discharged patients.

We were on first call for all surgical emergencies in the E.R. one night out of three, and we were on second call one night out of three—the third night was theoretically free. That third night “off” was frequently the busiest of the three nights—catching up with the ward work, the dressings and the chart work. In the record room there was always a pile of discharge summaries to be dictated. We seemed to have a lot of cases of intestinal obstruction, and Clifton had a rule that no intern would go to bed until the Miller Abbott tube had been successfully passed through the pylorus into the jejunum to decompress the small bowel. This was easier said than done. We placed the patient lying on his right side, elevated the head of the bed, manipulated the long tube, and took repeated

x-rays throughout the night to check the position of the tube. This made us very unpopular with the x-ray technicians and the x-ray department. Clifton must have set his alarm clock, because routinely at 2:00 A.M. and 4:00 A.M. he would phone the floor to be sure the intern was with the patient, and to check on the progress of the naso-gastric tube.

Dr. Clifton had another strange idea. He felt that no patient on his service should die, and he insisted that if a patient was critical or in extremist, the intern should not leave the patient at night. Thus, one of the two of us interns assigned to his floor and his service had to stay with a dying patient all night on the remote chance that his life could be salvaged.

We were working more than 110 hours per week, and we kept our adrenals pumping out the adrenaline. A few years ago there was much publicity given to the fact that in New York State many hospitals were working members of their house staff more than sixty hours per week. There was controversy over whether the house staff was alert and functioning well after so many hours of work and so little sleep. Believe me, we were putting in forty and fifty hours more work per week than the proposed cap. continued on next page >

It’s like having 21 of the best ophthalmologists and eye care professionals right in your practice.

Adam J. Altman, MD Helga S. Barrett, OD Leslie P. Brodsky, OD Jennifer H. Cho, OD Michael Cusick, MD Gary L. Dietterick, OD David S. Goldberg, MD Dawn Hornberger, OD Y. Katherine Hu, MD Lawrence E. Kenney, MD Edna Z. Mahmood, MD Barry C. Malloy, MD Michael A. Malstrom, MD Martin F. Miller, OD Mehul H. Nagarsheth, MD Jonathan D. Primack, MD Mitchell M. Scheiman, OD Justin M. Shaw, MD Monica Wang, OD Denis Wenders, OD Elliot B. Werner, MD

AT EYE CONSULTANTS OF PENNSYLVANIA, providing the best possible patient care begins with our board-certified professionals, clinical excellence and evidenced based practice. In fact, when it comes to comprehensive eye care, our ophthalmologists and optometrists are some of the best that you’ll find anywhere. But more than that, our entire practice is committed to cooperative management of your patient. It means that we communicate and consult 360˚. We share information, and we provide direct cell numbers to our partner physicians. It means that we listen carefully to patients and their physicians and provide a wealth of patient and physician education materials. And ultimately, it means better outcomes for your patients. For Consultations and Referrals, call 610-378-1344.

www.EyeConsultantsOfPA.com Wyomissing | Pottsville | Pottstown | Blandon

WINTER 2016

Dr. Wangensteen in Pittsburgh became famous for his pioneer work in intestinal obstruction, and the merits of nasogastric suction, and intestinal decompression which he published in his outstanding book on “Intestinal Obstruction.” Everyone was awakening to the importance of long tube intubation with the passage of a long intestinal tube (either the Miller-Abbot tube, the Cantor tube or the Lyons tube) through the nose, through the stomach, and into the small bowel, and connecting it to nasogastric or Wagensteen suction to decompress the bowel either before surgery or after surgery or both times, and in the presence of intestinal obstruction. Incidentally, in those days because there was no wall suction or other suitable suction available, we used Wangensteen’s suction which consisted of two large jugs, one at a higher level than the second, and one filled with water, so that the water flowed by rubber tubing from the upper to the lower jug, continuous low suction was obtained. Later, we did not have to lift the individual jugs because they were mounted onto a rotating assembly which could be turned when the top bottle was empty. Next portable suction machines operated by electric motors appeared in the hospitals. Of course, the Wagensteen

26 | www.berkscms.org

suction bottles and drainage seemed primitive now that we have suction piped into every patient room and into every operating room.

One out of three Sunday mornings we were expected to be in the Surgical Follow-up Clinics. On the north wing of the “Whistle-Works” or “Ivory Towers” there were four or five large floors devoted entirely to our patient clinics. In those huge clinics we examined and conducted follow-up studies on all postoperative patients for the past five years. The patients were notified by mail which Sunday to report, and there were usually over fifty patients to be seen every third Sunday morning. This Sunday morning assignment to the Surgical Follow Up Clinic happened to fall on the third Sunday when the surgical intern was theoretically “off duty.” Remember we were “on duty” two out of three nights a week and two out of three weekends. This was really “slave labor.” Granted we were seeing huge volumes of patients and gaining a lot of experience; but the pace was grueling.

Some surgical interns “dropped out” and “switched” to ophthalmology or dermatology, because it was “madness,” and they sought an easier life. We all began to realize that after one completed his arduous surgical residency training, the practice of surgery would be very strenuous, difficult and demanding.

Although we all had our M.D.’s and our licenses to practice, we received no pay and our total remuneration during our internship was our board and room. I had a nice single room on the twenty-first floor of the hospital. We did eat like kings the first six months. We ate in the private dining room on the fourteenth floor where they served fantastic meals, including delicious steaks and fancy desserts. This luxury ended when the hospital authorities decided to open the hospital cafeteria, and require all members of the house staff to eat there. In order to determine how much food allowance they should pay us there was a one month trial of tabulating the cost of the food the house staff ate. The entire house staff was “up in arms.” Dr. Clifton stood at the cafeteria lines, and made us all take several meat dishes and double desserts and return for

“seconds” and “thirds” during this evaluation period in order for us to win a good food allowance.

For the two years following the internship the assistant resident received twenty-five dollars per month, plus room and board allowance. The salary was then progressively increased until the senior seven year residents received one hundred dollars per month. The internship was a great educational and a fantastic learning experience with huge numbers of patients with a wide variety of surgical conditions. I’ll never forget it, but I would never want to go through it again. That Fall I received my “Greetings and Salutations” letter from Uncle Sam. I was notified to report for active duty in the U.S. Army Medical Corp. AUS by midnight on 12/31/43. I must confess that I looked forward to the end of my internship and to going into the army.

Technology Solutions to Help Your Healthcare Organization Deliver Better Care Berks County Medical Society members trust Stratix Systems to take care of their technology pains. IT Support & Network Services

Document Management

Managed & Cloud IT Services

Printing & Imaging Systems

Learn more. Call (610) 374-1936 or visit www.stratixsystems.com.

No one knows technology solutions like Stratix.

WINTER 2016

As fellow clinicians—

what inspires you, inspires us. Penn State Hershey’s MD Network serves as a resource to referring providers at any stage of the referral relationship. For more information, please visit the MD Network web page at PennStateHershey.org/mdnetwork. MD Network is reserved for clinicians and office support staff only.

U.Ed. MED 16-8459 MC

For the Berks County families you serve Now, one call is all you need to get into the Penn State Hershey system via MD Network:

1-800-233-4082 (WANT TO CONNECT TO PEDIATRIC PROVIDERS? SIMPLY PRESS ‘4’ FOR KIDS TO BE CONNECTED TO PENN STATE HERSHEY CHILDREN’S HOSPITAL.)

The Scope of the ‘Scope of Practice’ Issue By: Heath Mackley, MD, FACRO

n October 22nd, the Pennsylvania House Professional Licensure Committee received testimony on HB 765, a bill that would grant certified registered nurse practitioners (CRNPs) an unrestricted license to practice medicine in the commonwealth. PAMED was well represented, not only by then-President Karen Rizzo’s expert testimony, but also by dozens of physicians from near and far who showed up in their white coats. There were so many that everyone attending couldn’t be accommodated in the room!

The message of PAMED was articulate and compelling, and can be found in their “Keep the Team” campaign materials. They include: 1) The best and most effective care occurs when a team of health care professionals with complementary, not interchangeable, skills work together. 2) The education and training of CRNPs falls significantly short of the education and training of a physician. 3) Current licensing standards serve an especially important function in supporting critical safety and quality objectives. For these reasons and more, the majority of states still require a physician’s collaboration or supervision in order to practice. The chief arguments of those in favor of the bill were also taken on with hard facts. 1) The collaborative requirement between CRNPs and physician supervisors enhances, rather than impedes, the ability of CRNPs to deliver quality patient care. 2) Granting unrestricted licenses does not significantly improve access in rural and underserved areas. 3) Ultimately, underserved areas need more physicians, and increasing the responsibility of CRNPs does not help that. This debate, over who should be allowed to practice medicine, has been going on in America since medical licensing laws were instituted in the American colonies. During

the 1800s, most of the laws were abolished, leading to the legal equality between “allopathic physicians” and “nontraditional physicians” of that time, such as Homepaths and Eclectics. This also led to a proliferation of medical schools, many private and for-profit, of various quality and enrollment standards. The AMA, with its state-level partners such as PAMED, lobbied for the reintroduction of medical licensing laws with standardized testing for individual physician candidates and national accreditation of medical schools. Although there is clearly a public interest behind these measures, for public health and safety, and in support of a consumers’ right-to-know, it would be easy for a cynic to view this as a monopolistic tactic with self-interest at heart. But history tells us a different story. Doctors of Osteopathic Medicine (DOs) became viewed as equal to Medical Doctors (MDs) when both sides could agree on the criteria for accreditation of medical schools, residencies, and medical licensure. Other philosophies of medicine, such as homeopathy, are not illegal. Patients can receive counseling and advice from those practitioners. So what does this history say to CRNPs, or Naturopaths, or anyone else? If you create schools, tests, and post-graduate programs that are similar to what MDs and DOs currently have, we can work with you. If not, you do not have our support to practice medicine independently. That being said, the debate, then and now, will always be influenced by economics. Large health systems have trouble filling the primary care “provider” (their word, not mine) positions they have, and hiring CRNPs for those positions might be easier if out of state CRNPs are attracted by an unrestricted license, but it will certainly improve their bottom line for multiple reasons. CRNPs command a lower salary than physicians, and there is an added administrative cost

continued on next page >

WINTER 2016

to documenting the collaborative agreements, but CRNPs also order more tests and make more specialist referrals than primary care physicians, so that increases corporate revenue, at the expense of global health costs. Mike Young, CEO of Pinnacle Health, while speaking in favor of the CRNP bill, bemoaned his institution’s inability to hire primary care physicians. This is a real problem, one that can’t be fixed with a sound bite. But if he believes that giving CRNPs an unrestricted license is going to improve his institution’s ability to provide primary care, why not allow Pinnacle to also hire MDs from unaccredited foreign schools that can’t pass the United States Medical Licensing Exam (USMLE)? Wouldn’t that be a good idea too? If CRNPs aren’t expected to pass the USMLE or train in a residency, why should anyone be required to do so?

with bottom lines. But that isn’t what practicing medicine is. Practicing medicine is seeing a patient, diagnosing an illness, and prescribing a treatment based on scientific principles. Managers don’t do that. Physicians do. PAMED will continue to advocate to keep it that way.

Dr. Mackley is a radiation oncologist in the Penn State Hershey Cancer Institute and serves as the 5th District Trustee on the PAMED Board, representing physicians of this county.

Medicine will always be delivered by a team, with the majority of the care being delivered to one individual patient at a time. PAMED feels that a physician, the most highly trained professional, should be the leader of the team. There are other alternatives. Mr. Young, near the beginning of his testimony, said, “I’ve heard a great deal of discussion today about who should lead the healthcare team. With all due respect, according to the Joint Commission and the Department of Health, <sic> the doctors and the nurse practitioners in this room, I, as CEO of Pinnacle Health, I lead the team.” No one would argue that corporations do not need effective managers, or that firms that engage in health care are not businesses

SAVE THE DATE!

Saturday, aPrIL 16, 2016 10th Annual CARDIOVASCULAR

SYMPOSIUM

7:00 am – 1:00 pm | Crowne Plaza Hotel

1741 Paper Mill Road, Wyomissing, PA 19610 Presented by: Penn State Health St. Joseph Heart Institute Course Director: Andrew R. Waxler, MD, FACC Featuring Locally and Nationally Recognized Speakers. Continental Breakfast and Lunch Served.

Application will be made for an anticipated 5 CME & CEU Credits

For more information check www.StJoesCardiovascular.com or call 610-378-2176. Program brochure to follow. 30 | www.berkscms.org

Physicians’ HEALTH Program The Foundation of the Pennsylvania Medical Society

30 Years of Change – Transforming Lives

“ONE IN TEN

people suffer from addiction. At any time, there could be as many as 3,000 doctors in the state whom we could be helping.” Raymond Truex Jr., MD, FAANS, FACS

“Physicians, like the rest of the population, are vulnerable to chemical dependency, physical disability or breakdowns in mental health. Your support of the 30 Years of Change Campaign will make sure the Physicians’ Health Program will always be available to our fellow health care providers.” Raymond Truex Jr., MD, FAANS, FACS, Honorary Chair of 2016 PHP 30 Years of Change Campaign

•

WHY SHOULD I SUPPORT THE PHP?

For 30 years the PHP has provided confidential support, monitoring and advocacy to those who may be struggling with addiction or physical or mental challenge. • The PHP relies on contributions from physicians, hospitals and others so that the cost to the participant can be kept as low as possible during challenging times. • Your gift TODAY is an investment in an established endowment ensuring that the PHP will have funding support in perpetuity. • Your gift provides a transformational opportunity for your fellow health care providers who deserve a chance to live life in recovery and good health.

HOW CAN I HELP? PHP is a program of The Foundation of the Pennsylvania Medical Society – the charitable arm of PAMED. The program assists all physicians (MDs and DOs), physician assistants, medical students, dentists, dental hygienists, and expanded function dental assistants.

Please consider a gift to the PHP in honor of this anniversary to ensure that physicians will always have a place to go to when help is needed. Let’s make it the most of it! In celebration of this milestone, the campaign has received a $30,000 challenge grant from an anonymous physician – by making your gift TODAY you will help us to take full advantage of this generous matching fund opportunity! Go to www.foundationpamedsoc.org to see true stories of transformation and recovery.

Contact the PHP at (717) 558-7819 or php-foundation@pamedsoc.org.

If you want to learn more about how to make a contribution to the PHP Endowment, visit www.foundationpamedsoc.org. You can also contact Director of Philanthropy Margie Lamberson, CFRE, at mlamberson@pamedsoc.org or 717-558-7846.

The official registration and financial information of the Foundation may be obtained from the Pennsylvania Department of State, Bureau of Charitable Organizations, by calling toll-free within Pennsylvania, (800) 732-0999. Registration does not imply endorsement.

777 East Park Drive • Harrisburg, PA 17105-8820 SUMMER

2014

Legislative Update

2. More on Drugs: Prescription Monitoring Database and Medical Marijuana If all goes according to plan, the state’s ABC-MAP Prescription Monitoring Program should be launched sometime in late 2016. This long awaited tool to address opioid abuse in the Commonwealth is something PAMED has been advocating for as part of our “Pills for Ills, Not Thrills” program.

The EVP Crystal Ball: The Top Ten Things to Watch in 2016 PAMED’s Executive Vice President Mike Fraser, PhD, CAE, FCPP, shares his list of “Top Ten Things to Watch in 2016.”

he end of the year always brings out the “lists,” so here is my list of those things I foresee as top 10 Pennsylvania Medical Society (PAMED) issues and priorities in 2016. While there are certainly many other issues than the ones listed below, if 2015 is any indication of where we may go in 2016, these 10 (and a few others I’m sure) are certainly going to involve significant investments of time and energy by PAMED members and staff. Stay tuned!

1. CRNP Independent Licensure

The recent decision by the Hospital and Healthsystem Association of Pennsylvania (HAP) to support CRNP independent licensure after a certain numbers of hours of collaborative practice is disappointing given PAMED’s continued support for physician-led, team-based care. Despite HAP’s decision, PAMED will continue to oppose legislation that eliminates collaborative agreements between physicians and CRNPs. PAMED believes that team-based care is the most cost effective and clinically appropriate way to deliver patient care. The PAMED Board will be discussing this development at its February Board meeting and developing a response to HAP’s position based on Board discussion. Look for more activity on this issue early in 2016.

32 | www.berkscms.org

Once the database is established, PAMED is planning to work with partner groups across the state to develop physicianspecific training on how to use the database, address some unresolved issues related to privacy concerns, and address some of the process and system changes that these systems entail. The legalization of marijuana for medical use could see legislative action in the House of Representatives before the end of the year (the State Senate has already approved a legalization measure). PAMED has been consistent in its call for FDA approved clinical trials and other patient safety concerns before the legislature moves forward on legalizing the drug. If the legislature moves in this direction, what will the final legislation regulating marijuana look like? We could find out in the coming year.

3. Volume to Value, MIPS, Meaningful Use

The move toward reimbursing for “value” and not “volume” continues. PAMED will be tracking the implications of these initiatives on Pennsylvania physicians. Look for continued educational sessions, research briefs, and physician advocacy to make these new programs less onerous to physician practice.

PAMED will also be coordinating more closely with the American Medical Association (AMA) through our federal affairs consultant and share Pennsylvania-specific feedback on these programs with our Congressional Delegation and related federal agencies. Look to PAMED for resources and information on the alphabet soup of federal initiatives and programs and calls to action to help make these programs less onerous for physicians.

4. Hospital and Health System Consolidations and Impact on Physicians

The trend toward consolidation of health systems continues and PAMED will be tracking the impact of mergers and affiliations on patient access and physician practice. With the FTC’s decision to reject the Pinnacle-Penn State Hershey affiliation here in Central Pennsylvania, we know that 2016 will come with continued efforts to merge systems and address federal and state concerns over market share and access to care. continued on next page >

5. Primary Care Workforce and Physician Supply Issues PAMED will be taking an aggressive stance on ways the physician community can help address physician distribution across the state and program and policy decisions to encourage physicians to practice in underserved areas. We will be forming a new Member Advisory Panel on the issue to help inform PAMED Board policy and ways that PAMED and its members can collaborate with other state and national efforts to increase the physician supply and address the shortage of primary care and medical specialists in some parts of the state.

6. Focus on Employed Physicians and Academic Affairs

PAMED starts the year welcoming two new staff members to our Physician Leadership, Engagement, and Outreach team who will be working early in 2016 to better understand the ways that PAMED membership can add value to several specific segments of our membership.

Look for new program development in the areas of physician employment by hospitals, health systems, and large physician groups as well as medical students, residents, academic affiliated physicians, including residency program directors, and early career physicians. We will also be reformulating our Employed Physician Task Force and looking for ways to address issues raised by PAMED members who are employed by hospitals, health systems, and large physician groups.

7. Task Force on Regional Medical Societies

An outcome of the 2015 House of Delegates was the formation of a PAMED Task Force to look at developing multi-county, regional medical societies. A member task force to discuss the pros and cons of forming regional societies will be appointed in early 2016 and hopes to have a report back to the House in 2016.

8. Addressing Administrative Barriers to Patient Care

PAMED continues to move forward in seeking legislative reforms to several health insurance practices that create barriers to effective patient care. Our physician credentialing legislation was introduced by Rep. Matt Baker late last fall and is expected to be considered by the House Health Committee early in 2016. PAMED will also continue our work with the state’s Department of Human Services to improve the physician 34 | www.berkscms.org

credentialing process used by the Medical Assistance program. A task force has been formed to work with the state to better understand the barriers to Medical Assistance credentialing and develop efficiencies and improvements. Rep. Marguerite Quinn is poised to introduce legislation on PAMED’s behalf that will address health insurers’ prior authorization processes.

PAMED is actively working to more efficiently engage physicians on these two very important pro-patient issues.

9. Support for Physician Innovation

The sale of PAMED’s KePRO subsidiary helped PAMED create an “Innovation Fund” to support new, emerging and priority projects across the state. PAMED will be forming a work group to help develop review criteria and determine support for various project requests and initiatives, including eligible applicants and levels of support. Look for those opportunities as we move into 2016 – we are just getting started now and there is a lot to do before we are ready to fund projects, but the opportunity is an amazing one to support physician innovation and membership development in 2016 and beyond.

10. PAMED Technology Upgrades

A new app and website are coming soon. We will be refining and enhancing the app in the months to come, but we are excited to share this great resource for members and look forward to your feedback on how to make it even better.

A new, customizable website will make it easier to tailor the information and resources you need to thrive in the business, practice, and life of medicine. Visitors to the new site will be able to take advantage of the ability to track favorites, tag articles, and more. These 10 are just some of the things I anticipate in 2016. Clearly there are many more policy and advocacy priorities as well as new programming that we are developing. And I didn’t even mention some of our ongoing priorities such as Mcare refunds, working to make Maintenance of Certification (MOC) work better for PA physicians, or predictions on the 2016 elections! So, stay tuned for more and let me know which of these priorities excite you – and where else we should be getting engaged in the future. Happy New Year!

See more at: http://www.pamedsoc.org/MainMenuCategories/ Laws-Politics/Analysis/EVP-Crystal-Ball-2016.html#sthash. CTGmIp5S.dpuf

Alliance Update It has been a wonderful and busy few months for the Berks County Medical Society Alliance!

s many know, part of the Alliance’s multi-faceted mission is to welcome new medical families to the area and help them acclimate and transition with ease. To this end, we kicked off our 2015-2016 year with a New Member Coffee hosted by member Kalpa Solanki, in which we welcomed several new physicians’ wives who have recently moved to Berks County. In October, Past President Emily Bundy invited the members to her home for what we have coined the Second Annual “Say It Out Loud” Presentation. Last year, President and local author Amy Impellizzeri shared her own journey from corporate attorney to published author. This year, Emily wow’d the crowd with her fascinating story of turning her dream of becoming a backyard beekeeper into a reality. Emily shared the trials and tribulations and hard work of beekeeping, and also the sweet successes. Members had a chance to sample, and even purchase, locally grown honey. As a delicious bonus, Emily worked with local caterer Bravo for Rose to create a honeyinspired menu.

In November, President Elect Allison Wilson hosted the Fall Meeting, which focused on local gem, It’s a Gift (formerly known as The Woman’s Exchange). It’s a Gift Board President Sallie Weaver and Community Volunteer Brittany Decker, were on hand to discuss the unique history of It’s A Gift and also to answer questions about the local fundraising initiatives by this upscale retail boutique. (Did you know that The Woman’s Exchange is the oldest retail chain in America?

Only 20 stores still remain open in the country, and we are lucky to have one thriving boutique here in Berks County!) What many don’t know is that local organizations can partner with It’s a Gift to raise money for their causes – 10% of purchase proceeds with original receipts will be rebated to participating organizations quarterly. In addition, every year, the volunteerrun, non-profit store chooses a local charity recipient of store proceeds. This year, It’s a Gift has designated Breast Cancer Support Services for its annual donation. In support of this partnership, at the Fall Meeting, the Alliance presented It’s a Gift Board members with donations of women’s health books and book store gift cards to help Breast Cancer Support Services’ mission of expanding its women’s health care library. At the November meeting, we also met Wilfriede Axsmith, a local artisan whose hand-painted scarves are sold exclusively at It’s a Gift. We are spellbound by Wilfriede’s talents, and the talents of all of the artisans who sell their designs at It’s a Gift. Note that the the Alliance does indeed have a fundraising contract with It’s a Gift. Anyone interested in donating their original It’s a Gift receipts to the Alliance so that we can benefit from a 10% rebate should contact President Amy Impellizzeri via President@ berkscmsa.org. The additional funds will be directed at year’s end toward philanthropic grants and our scholarship program. We said goodbye to 2015 with our annual Holiday Brunch, breaking bread in the home of gracious hostess and member Jenni Mueller. After the brunch, a car-load of diapers, wipes, and formula was collected and delivered to the Reading YMCA for their daycare clients.

In closing, thank you to all who supported our annual Holiday Card fundraiser. It was a record-breaking year, and we will be using the collected funds to help many local organizations and students. For more information about BCMSA, please check out: http://berkscmsa.org or “Like” us on Facebook! WINTER 2016

Dr. Ed Zobian TRIBUTE

A Son’s Tribute By David Zobian, M.D.

y earliest memories of dad’s work are visiting his office and wanting to play with the toys he kept in his exam rooms to distract his pediatric patients. One of the toys was a Disney character, Pluto, that would collapse when you pushed a button on the underside and it would reassemble when the button was released. I wonder how many Berks Countians had their vision checked using that toy. Sometimes, he let me tag along his post-op rounds on the Reading Hospital “eye floor.” The nurses and patients were very kind; I could tell my dad was important and he was helping people. Service to others and the application of scientific skills was magical to me and is the main reason why I went into medicine.

For as long as I can remember, my dad ran with his friends on most mornings. On Sundays, they would go out for breakfast afterwards. The restaurant staff might have enjoyed the raucous laughter but probably winced at some of the political and social commentary. As he and his friends got older, the runs became walks. Eventually, they simply met for Sunday breakfast. Dad treasured his friends and family; his career was more of a hobby. He loved the challenge of learning new surgical techniques. For the fun of it, he decided to start doing surgeries with his non-dominant hand in his 50s. And in the year before retirement he led his medical practice into the digital age by being the first to use electronic medical records at Eye Consultants of Pennsylvania. He had wisdom, humor, and a seemingly endless fund of knowledge. His comprehensive understanding of medicine was likely formed while a battalion surgeon in Vietnam, before he started his ophthalmology residency at Wills Eye. He taught me about carpentry, gardening, politics, finance, music, mechanics, chemistry, medicine, life, and love. The only person I called more often than my dad was my wife, Megan Souders-Zobian. I miss my dad and I’m sure his friends and colleagues do as well. I thank the Berks County medical community for your support in this time of sadness and for your many years of bringing joy to my father and my family. This wonderful community is why my wife and I practice medicine here. 36 | www.berkscms.org

A TIME TO LIVE…… By Dr. Larry Rotenberg and Dr. Franco Toso

ne day, when Ed first got sick, I visited him in the Reading Hospital, at the N Building. As it happened, Dr. Ray Truex, his neurosurgeon, was there with him. I said I would come back later, but at Ed’s insistence I stayed and overheard the conversation between Ray and Ed. Dr. Truex said that he would gladly send Ed to Jefferson, where they had the latest equipment. Ed, who knew the prognosis as well as anyone, said he wanted to be treated close to home, where he could see his dear wife, Barbara, as well as his children, grandchildren, and his friends.

Ed then gave a spontaneous precis of his heroic life story. He talked about his mother, who barely escaped the Armenian Genocide to come to America. Ed’s father died when Ed was only three, and so his Mom dedicated the rest of her life to raising Ed, then age three; and his two older sisters. Ed was selected to attend Central High, a place for gifted students. And he described how he would have to get up early to take a bus to a train, take the train into 30th Street Station, and then another bus to get to his high school. Ed, of course, went on to great accomplishments, both personally and professionally. But as long as his mother was alive he devoted a portion of many weekends to her. He would drive to her house in Upper Darby, cut her lawn, buy her groceries, and in general he made sure, together with his sisters, that his aging mother was never without care. At the end of the visit by Dr. Truex, Ray reassured Ed that anything he wanted by way of treatment, here or any other place, would be available. And Ray said as he was leaving….”the Zobian name is Golden…..Golden.” And so it has remained.

Let our family

SECURE

your family

The area’s leading residential & commercial security services company.

Visit our website!

610.372.8872 • SAHinc.com

50 South Museum Rd., Reading, PA 19607

WINTER 2016

WELCOME NEW MEMBER

Justin M. Shaw, M.D. T

he Berks County Medical Society is pleased to welcome Dr. Justin M. Shaw, an ophthalmologist who joined Eye Consultants of Pennsylvania in 2015 upon completing a Glaucoma Fellowship at the prestigious Bascom Palmer Eye Institute of the University of Miami, FL. Dr. Shaw is a Pennsylvania native who graduated from Millersville University of Pennsylvania in 2006 and earned his M.D. degree from Penn State College of Medicine. After completing a year of Internal Medicine training at the Sinai Hospital of the Johns Hopkins University, he remained in Baltimore for his ophthalmology residency at the Krieger Eye Institute. During his academic career, Dr. Shaw authored or co-authored a series of papers and presentations on a wide range of topics in ophthalmology, and in March 2013 he was awarded an Innovator’s Fund Grant for his work on the project “Development of an ‘In Vivo’ Model for Using Stem Cells as a Therapeutic Modality in Anterior Ischemic Optic Neuropathy.”

Justin M. Shaw, M.D.

Patient education is a top priority for Dr. Shaw in his daily patient care, and to reach a wider audience he has given educational presentations on topics in eye health to community groups. He has also served the wider community by volunteering at free medical clinics and vision screening events, working on a task force developing solutions to health care disparities, and participating in an ophthalmology mission trip to Peru to provide eye surgery to underserved Peruvians.

Dr. Shaw resides in Lancaster, his home town, with his wife Erin and their children—Micah (age 5), Jackson (age 3), and Eva (age 1). Erin is a 4th-grade teacher who is currently home-schooling their children. The family attends Calvary Church in Lancaster, and they enjoy many outdoor activities together. Dr. Shaw enjoys running and hiking, as well as acting, with past credits in both theater and minor film productions.

Please join the Berks County Medical Society in welcoming Dr. Shaw to our community. We wish him a long and rewarding career.

Editor’s note: If you have joined the BCMS in the last 12 months and would like to introduce yourself to your colleagues and the community by providing material for a New Member Welcome, please contact us at: info@berkscms.org. Thank you!

38 | www.berkscms.org

WINTER 2016

At HealthSouth, REHABILITATION IS ALL WE DO. When you choose HealthSouth Reading Rehabilitation Hospital for your recovery after an illness, injury or surgery, you’re choosing a higher level of care. That’s because rehabilitation is all we do, supported with the latest technologies, certified rehabilitation specialists and comprehensive programs to help patients reach maximum independence. Our patients receive one-on-one personalized care for a variety of conditions, including: • Amputee • Brain injury • Hip fracture • Multiple sclerosis • Parkinson’s disease • Spinal cord injury • Stroke Call for more information, and get the higher level of care you need.

The Joint Commission Disease-Specific Care Certification in Amputee Rehabilitation, Parkinson’s Disease Rehabilitation, Spinal Cord Injury Rehabilitation, Stroke Rehabilitation and Traumatic Brain Injury Rehabilitation

1623 Morgantown Road • Reading, PA 19607 610 796-6000 • healthsouthreading.com

“

Health Care Reform offers an opportunity for employers to rethink how health care benefits should be designed and delivered. – Mark Kunkle

We’re experts at benefits consulting. We’ll perform a Health Care Reform Readiness Analysis for your organization. • We’ll review your existing benefit programs and determine which will be affected by the health care reform provisions now and in the future.

”

There will be dramatic changes in the future of the employee benefits landscape. is your company prepared and complying with new regulations? What do you need to know? What plan do you have in place? Are you heading in the right direction? Contact us today. We’ve gained the confidence of

over 450 local employers.

• We’ll determine the financial impact of healthcare reform to your organization. We’ll steer you in the right direction and help you implement your company’s health care reform strategy.

610-685-1790 | www.pkbenefits.com | 999 Berkshire Blvd., Wyomissing L e A d e R s H i p | s u p p o R t | s o L u t i o n s