Philadelphia County Medical Society 2100 Spring Garden Street, Philadelphia, PA 19130
(215) 563-5343 www.philamedsoc.org EXECUTIVE COMMITTEE
Features
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Michael DellaVecchia, MD, PhD, FACS
An Election Year Checkup on the Affordable Care Act Many Sing Its Praises, While Many Others Want It Dead
PRESIDENT
Daniel Dempsey, MD PRESIDENT ELECT
Anthony M. Padula, MD, FACS IMMEDIATE PAST PRESIDENT
Max E. Mercado, MD
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Do No Harm How Physicians Must Change Their Approach to Treating Pain
SECRETARY
J. Q. Michael Yu, MD, FRCPC TREASURER
BOARD OF DIRECTORS Angel S. Angelov, MD Martin Brown Richard J. Cohen, PhD, FCPP Donald M. Gleklen Enrique Hernandez, MD Cadence Kim, MD Harvey B. Lefton, MD Henry Lin, MD Curtis T. Miyamoto, MD Ricardo Morgenstern, MD Natalia Ortiz, MD, FAPA, FAPM Stephen R. Permut, MD, JD Dane Scantling, DO John Vasudevan, MD
12 Duty to Warn in Pennsylvania A Look at the Legal Obligations Physicians Have to Prevent the Spread of Communicable Diseases to Third Parties
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A Philadelphia County Medical Society Summit Confronts the Opioid Epidemic
20 The Wistar Institute: A Look at the Legacy of a Leader in Biomedical Research
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A Conversation with Philly’s Top Doc Dr. Thomas Farley
FIRST DISTRICT TRUSTEE Lynn Lucas-Fehm, MD, JD EXECUTIVE DIRECTOR Mark C. Austerberry EDITOR Alan J. Miceli The opinions expressed in this publication are for general information only and are not intended to provide specific legal, medical or other advice or recommendations for any individuals. The placement of editorial opinions and paid advertising does not imply endorsement by the Philadelphia County Medical Society. All rights reserved. No portion of this publication may be reproduced electronically or in print without the expressed written consent of the publisher or editor.
In Every Issue Letter From the President. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Young Physicians Insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Upcoming Events & Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 PAMED updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 PCMS & Community News. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
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Summer 2016
Contents
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Letter from the president
Just in Time for the Democratic National Convention in Philadelphia—
A Look at the Affordable Care Act
Michael DellaVecchia, MD, PhD, FACS President
We Welcome Your Comments! They should be sent to our email address at editor@philamedsoc.org. If you would like your comments considered for publication, they must include your name, town, and phone number.
This issue of Philadelphia Medicine addresses the debate on the Affordable Care Act, an issue that will no doubt be part of the platform of this summer’s Philadelphia Democratic Convention, and a hotly debated topic in the national election. The article focuses on both the patient and experts in the field. It includes the insights of Gail Wilensky, PhD, an economist who headed Medicare for President George H.W. Bush, and Dr. David Nash, dean of Jefferson College of Population Health. Wilensky gave this year’s Dr. Raymond C. Grandon lecture at Jefferson University. The article also includes an interview with the nationally noted medical economist from Robert Morris University, Stephen Forster, PhD, JD. Our Philadelphia medical students continue to provide great insight into critical medical-social concerns, and are strongly represented in this issue. In a debate forum, Temple and Jefferson students discussed the pros and cons of physician assisted suicide. Drexel University School of Medicine held the first local Ted Med Talk with enthusiastic participation and attendance from throughout the city. The world-renowned Wistar Institute is our featured Philadelphia institution in this summer quarterly issue. PCMS will host an on-site HIV/AIDS Day on June 28th at 5 P.M. There will be special recognition of the memorable former United States Surgeon General and staunch Philadelphian, Dr. C. Everett Koop. This cooperative effort which at press time includes the Mayor’s Office of LGBT Affairs, Action AIDS, the Mazzoni Center, and Philadelphia Fight. Everyone is welcome to attend this noteworthy event, which will include distinguished speakers, up-to-date information, and free HIV testing. PCMS is holding to its mission of advocacy for physicians and quality of care of patients. Pennsylvania legislators are considering allowing nurse practitioners to practice totally independent from the physician based team. The Philadelphia County Medical Society and the Pennsylvania Medical Society are in unison in opposing Senate Bill 717. PCMS continues actively to pursue state indemnity for physicians who volunteer their skills whenever and wherever needed. Please check our website to remain current, as these issues quickly change and move forward. There may even have been modifications in the interim between writing copy and going to press. For clarification and updates, you can contact Mark Austerberry, Executive Director, or Eileen Ryan, Executive Secretary, at the Philadelphia County Medical Society. As always, we welcome your comments, and hope you enjoy the summer and the summer issue of Philadelphia Medicine! EDITORIAL BOARD • Michael DellaVecchia, MD • William S. Frankl, MD • Corina Graziani, MD
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• Alan Miceli, MA • Susan Robbins, MD, MPH, FAAP
• Stephen L. Schwartz, MD • Paul D. Siegel, MD
You are cordially invited to the...
HIV/AIDS Awareness Reception Hosted by the Philadelphia County Medical Society (Est. 1849) 2100 Spring Garden Street, Philadelphia, PA 19130
Tuesday, June 28 5:30 – 7:00 PM
Please RSVP on or before June 24th since space is limited. For Program Information & to Register go to: www.philamedsoc.org or call (215) 563-5343 x113
The Philadelphia County Medical Society is hosting this reception in recognition of the 30th Anniversary of Public Health efforts headed by the late U.S. Surgeon General, C. Everett Koop, MD, (1916 – 2013) in the centennial year of his birth. Dr. C. Everett Koop is renowned for his work as Surgeon General in efforts with HIV/AIDS. Noted speakers to include:
Rachel Levine, MD; Physician General of Pennsylvania Thomas Farley, MD; Commissioner of Health, City of Philadelphia Cora (Mrs. C. Everett) Koop With support and representation from:
Mazzoni Center (Free HIV testing on site) Mayor’s Office of LGBT Affairs Action AIDS Philadelphia Fight
Refreshments will be available. Additional activities throughout the day are still being developed.
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AN ELECTION YEAR CHECKUP ON THE AFFORDABLE CARE ACT
Many Sing Its Praises, While Many Others Want It Dead Alan Miceli, MA
ail Wilensky has a PhD in economics and ran Medicare for the first President Bush. She knows something about America’s health care problems. She has carefully followed the birth, baby steps and awkward toddler stage of the Affordable Care Act (ACA), the law signed by President Obama in 2013 that’s designed to get everyone—except illegal immigrants—covered by health insurance. Wilensky focused much of her Dr. Raymond C. Grandon lecture at Jefferson University Hospital in May, on the ACA. She told the hundreds of doctors, medical students and other health care personnel at the talk, that she’s puzzled by polls that consistently show a strong plurality of Americans still opposed to the law. She said the latest polling indicated that 49% of those surveyed were opposed to the ACA, with 38% in favor. “Interestingly, that number (those opposed) is up 7% since January,” she said, “but not because of Republicans, but Democrats who have been listening to Bernie Sanders trash the ACA.” She said when the poll asked people what we should do, “32% said we should repeal (ACA), 30% say expand, 11%, make it smaller…Those numbers are certainly not a mandate for repeal.” 6
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You might think that this polling data indicates that the American people are conflicted but knowledgeable about the ACA. Conflicted, sure, but knowledgeable, not really, according to Dr. David Nash, Dean of Jefferson College of Population Health. “A Kaiser Family Foundation survey has shown that 18% of Americans believe the ACA has already been repealed,” Dr. Nash said. “The ignorance is staggering. There’s an incredible lack of knowledge and understanding about this issue.”
Gail Wilensky
Photograph Courtesy: David Lunt, Thomas Jefferson University.
Dr. Nash added that “the real experts who have studied this, like Dr. Wilensky, all agree that the nation has no choice but to make these changes.” There are plenty of ordinary people who have become experts on the ACA. They’re the ones who now have health insurance because of it. Heni Hagain Goss, a 64-yearold Philadelphia resident, sees the new law as a life saver. She lost her employer-run health insurance in 2011, when she was laid
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An Election Year Checkup on the Affordable Care Act
off. She has a pre-existing condition that made it virtually impossible for her to buy health insurance. So, she ended up going to a city health clinic that gave her very spotty care. She said at one point a doctor misread complications from asthma that ended up making her very sick. Then, the ACA came along. Goss calls it affectionately by the name given to it by its critics, “Obamacare,” she said, “offered me good coverage with the money I was earning from a part time job.” Her monthly premium was just $124, with a $5 co-pay for doctors’ visits. Goss said the health insurance she now has with her new full time job is not as good as the ACA coverage. “I hope the next president doesn’t change things, because this (ACA) is a good thing.” If you’re below the poverty line, or on the bubble, or hovering in the lower middle income strata of American society, the ACA is, for the most part, a very good deal. Many of the 16 million previously uninsured Americans who now have health insurance are in this category, and have reasonable coverage, premiums and co-pays. But if your income puts you on a middle rung of the economic ladder, health insurance becomes a complicated and often expensive issue. An Ohio woman told Democratic presidential candidate Hillary Clinton at a town hall meeting in March, that before she had health insurance under the ACA, her monthly premium was $490. Despite the fact that she was not earning any more money, her monthly health premium under ACA ballooned to $1,081. Stephen Foreman, a PhD in economics and an associate professor of health care administration at Robert Morris University, described to Philadelphia Medicine the financial hill that a family of four with a median income (about $63,000), has to climb, when it has a typical Affordable Care Act policy. The family could pay a very reasonable $300 monthly premium, but be shackled to an annual deductible
Gail Wilensky and Dr. David Nash
Photograph Courtesy: David Lunt, Thomas Jefferson University.
of $10,000—a deductible that the family has to meet before the insurance company spends its first dime. “I just don’t think they could afford to pay that,” Foreman said. “A lot of people out there can’t afford this.” The Kaiser Family Foundation survey of ACA enrollees found that those with high deductibles are, not surprisingly, pretty unhappy with them. Only 37% of those surveyed rated their plans a good to excellent
value, while 60% rated the plans fair to poor. The figures flipped for those with low deductibles—68% rating their plans good to excellent, and 31%, fair to poor. Many moderate income Americans who were surveyed say they are finding deductibles and co-pays so high that they can’t afford to use the insurance. A lot of them said if they got sick they would have to borrow or go into credit card debt to pay their deductible. Continued on page 8 Summer 2016 : Philadelphia Medicine
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Add to this, the fact that health insurance exchanges offered through the ACA often have a much smaller pool of doctors and hospitals than plans offered by employers. The New York Times reported that as of late last year none of the New York exchanges included one of the world’s premier cancer hospitals, Memorial Sloan Kettering Cancer Center. That’s because insurers tend to exclude from the exchanges, high cost, high end hospitals that are not open to negotiating discounts. Insurers typically work with a smaller pool of hospitals where they can get discounts that help keep premiums lower.
“Even if Donald Trump were elected, he would not be able to end Obamacare,” [ Foreman said ]
“I see no way that the Republicans are going to repeal this thing. It’s like Social Security.”
An Obama administration official countered that the reason UnitedHealthcare is pulling out of many states is because it did not do a good job of competing for customers. The company, by the way, is doing very well with its other health insurance business. It made $1.6 billion in the first quarter of this year. But insurers in 41 states have reported losses through the exchanges, many citing problems with the risk pools. Twenty-one Blue Cross/Blue Shield insurers said that the average ACA customer has 22% higher medical costs than the traditional customer. A Health and Human Services spokesman responded that many of the people buying a policy in the exchanges have pre-existing conditions, so, “it’s no surprise that people who newly gained access to coverage under the ACA needed health care.” It’s clear, however, that not enough healthy people are signing up, despite the tax penalties they face for not doing so. A recent Washington Post editorial said that the system needs higher exchange enrollment to ensure markets are stable and sustainable, then blamed the problem in part on Republicans in Congress. “A different Congress would debate nudging up premium subsidies, increasing the penalty (for not signing up for health insurance), or both.” Dr. Nash said an awful lot of people, including healthy young adults, “don’t understand what health insurance is about. They don’t understand the concept of shared risk, shared responsibility. I think we’re on the right path, it’s just taking a long time.”
Dr. David Nash
Photograph Courtesy: David Lunt, Thomas Jefferson University.
Analysts say another reason some premiums and deductibles are so high, is that the ACA risk pools—the balance of healthy and sick enrollees in a plan—are sicker and costlier than insurers had hoped.
insurer lost $475 million last year in the ACA exchanges, and expects to lose another $650 million this year.
CEO Stephen Hemsley told investors, “the smaller overall market size and shorter UnitedHealthcare is blaming these unbal- term, higher risk profile within this market anced risk pools, in part, for its decision to segment continue to suggest we cannot pull out of the exchange markets for most broadly serve it in an effective and susof the country. The nation’s largest health tained basis.”
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The complications surrounding the new law have become a political goulash in the hands of the presidential candidates. Hillary Clinton wants to improve on the system, saying the costs of such items as deductibles have to come down. She recently proposed that people 55 to 65 be allowed to buy into Medicare, which is accepted by virtually all hospitals. She also wants to negotiate drug prices for Medicare. Wilensky doesn’t see the point. “Medicare has never negotiated
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An Election Year Checkup on the Affordable Care Act
a price in its existence. The position of Medicare is ‘this is what it is. Take it, or leave it.’” Democrat Bernie Sanders wants to create a single payer national health care system that would guarantee that everyone has health insurance. Clinton and other Democratic critics say the plan would cost too much. The only Republican still in the race, Donald Trump, wants to repeal and replace the Affordable Care Act, and turn Medicaid into state block grants. Medicaid, by the way, is an essential player in the ACA, growing dramatically, despite a dozen Republican governors refusing to offer the fully funded federal Medicaid option to their citizens. Trump wants to also keep the guarantee of health insurance for people with pre-existing conditions, and allow people
to shop across state borders for insurance. Wilensky said that idea won’t work, because each state has different laws governing health insurance. So, what will happen to the ACA after the November election? “Even if Donald Trump were elected, he would not be able to end Obamacare,” Foreman said. “I see no way that the Republicans are going to repeal this thing. It’s like Social Security.” Dr. Nash agrees. “Is it ever going to go back to the good old days? Never. No matter who wins the presidency, this horse is out of the barn. He will not come back. And my view of that is—outstanding.” Wilensky says November will most likely not produce a White House and Congress
controlled by both parties, so any changes to the ACA will require bipartisan actions, and she thinks that’s a good thing. She said the Affordable Care Act has not reformed health care in this country, but it has done a great deal of good. Wilensky said the percentage of uninsured in the country has dropped from 16% to about 10.5%, and people with pre-existing conditions can get health insurance at the same price as healthy people. “There’s no historical precedent, once you have a major benefit, for rolling it back, repealing it,” Wilesnky said. “Usually you make it bigger, but you never take it away.” She predicted that “repeal is not going to happen, but some pretty big changes should start happening…clean up legislation, to fix mistakes.”
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Do No Harm How Physicians Must Change Their Approach to Treating Pain Michael Ashburn, MD, MPH, MBA Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania, Director of the Penn Pain Medical Center, University of Pennsylvania Health Systems
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here is significant scrutiny on physician prescribing decisions since the recent release of the CDC guidelines on the use of opioids to treat chronic pain. Over and over again physicians are being told that the decisions we make regarding the use of opioids often lead to patient harm, and that physicians are responsible, in no small part, for the significant uptick in prescription drug abuse that now plagues our community. Rather harsh words for a group of individuals dedicated to improving the health and lives of the people we serve.
It is hard to ignore the statistics related to prescription drug abuse. According to a December 2015 CDC report, 47,055 drug overdose deaths occurred in the United States in 2014. This was a 6.1% increase from 2013, and more people died from drug overdose deaths in 2014 than in any year on record. In 2014, 1.5 times more people died from drug overdose deaths than died in automobile accidents. More than seven people a day die in Pennsylvania from drug-related causes. Opioids have been reported to have been involved in over 60% (28,647) of these deaths. 10 Philadelphia Medicine : Summer 2016
And the toll does not stop there. The presence of prescription drugs in our homes often is the source of nonmedical use by our children. Indeed, in 2009, six of the top 10 substances used by 12th graders within the last 12 months for nonmedical purposes were pharmaceuticals, most often obtained from medications in the possession of friends and family. Our prescribing of opioids has come into sharp focus by politicians and policy makers, who feel that the decisions we make are a major contributor to the explosion of prescription drug abuse. CDC guidelines suggest that physicians often prescribe excessive amounts of opioids to treat acute pain, contributing both to an increased risk of addiction in the patient, and an increased risk of diversion for nonmedical use within the patient’s home. Our decisions regarding chronic opioid prescribing has also come into question, since this prescribing appears to often be done in a manner inconsistent with published clinical guidelines, increasing the risk of harm to our patients. During the recent
primary campaign for Pennsylvania Attorney General, Republican candidate Joe Peters made prescription drug abuse a top issue, and stated that while he wanted to work with physicians to address the issue, he was more than willing to take “other measures” to stop physicians from excessively prescribing controlled substances. Physicians often report inadequate training and experience in the area of pain management, and significant pressure from patients and regulatory bodies to aggressively treat pain. Unfortunately, pain treatment all too often devolves into opioid prescribing, rather than integrated, interdisciplinary pain care which has been demonstrated to be much more effective than any single modality treatment, including opioids. Access to integrated care is often very limited, and health insurance firms often decline to pay for interdisciplinary care. Likewise, these same firms often require extensive paperwork to obtain prior authorization for non-opioid pain medications. The tension we now face regarding the proper use of opioids may provide an
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opportunity to carefully review our process of care, and implement improvements to this process of care that ultimately lead to improved patient outcomes. Guidelines can provide important information on what the scientific evidence and expert opinion have to suggest with regard to best practices. The challenge, of course, is figuring out a way to actually provide this care within the real world environment we find ourselves. New efforts are underway to provide physician leaders with the information necessary to guide efforts to change practice, then track the impact of these changes on patient outcomes. This data comes in many forms, including patient-reported outcomes (patient-reported pain intensity, as well as validated measures of physical and mental functioning), and process measures (such as use of opioid agreements, use of urine drug screens, compliance with opioid dose prescribing guidelines). This data can be used to track efforts by practices as well as individual prescribers to improve the process of care. Going forward, this data can be used to create registries, allowing for providers and practices to benchmark their efforts against other providers who also are working hard to improve patient outcomes. We will need to address access to care issues to ultimately move away from opioids as a “stand alone” pain treatment option, and towards the use of integrated interdisciplinary pain care. In addition, we have a great deal of work ahead of us to ensure that patients with substance use disorders receive proper evaluation and treatment, again in the face of severely limited resources for the provision of these specialty cares. Pennsylvania secretary of Drug and Alcohol Programs, Gary Tennis, stated at the recent PCMS drug epidemic summit that, “cages and coffins are not an acceptable response of an advanced society to a public health crisis.” There are several state-based initiatives that should assist physicians in their efforts to improve patient outcomes. These include the development of provider education material that will be available through the Pennsylvania Medical Society later this
year. This material may allow providers to fill “knowledge gaps” that may make improving the process of care difficult. In addition, the Pennsylvania state prescription drug monitoring program will go live later this year, perhaps as early as August. This program will provide valuable information to providers to guide prescribing decisions. The prescription drug abuse problem we find ourselves in is real, and is causing real harm to our community. While it may be
important to consider the causes, it is even more important to develop effective steps that can be taken to improve pain care, and lower the risk of harm associated with chronic opioid therapy. Dr. Ashburn has developed a six part CME series through the Pennsylvania Medical Society to help educate physicians and other health care providers on the appropriate use of long-acting and extended-release opioids. The series is available at: https://www.pamedsoc.org/tools-you-can-use/ topics/opioids/OpioidResources Summer 2016 : Philadelphia Medicine 11
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Duty to Warn I N P E N N S Y LV A N I A
A Look at the Legal Obligations Physicians Have to Prevent the Spread of Communicable Diseases to Third Parties
Steven J. Alles, MD, MS, MFA
hysicians who practice in Pennsylvania diagnose and treat patients with infectious diseases regularly. Understanding the route of transmission, period of communicability, incubation period, and treatment options for many pathogens is part of standard medical training and practice. It is well described that most infectious organisms can be spread to others through common human activities, and that certain populations may be at increased risk of exposure and adverse health outcomes. Currently, there is no statutory regulation in Pennsylvania that addresses a physician’s duty to warn patients about the potential 12 Philadelphia Medicine : Summer 2016
transmission of their communicable illnesses to protect third parties. There have been cases decided by the Supreme and Superior Courts in Pennsylvania, however, that found that physicians do in fact have a duty to protect third parties within the foreseeable orbit of risk of harm, thus establishing common (or case) law precedence. The main objective of this article is to raise awareness among the clinical community in Pennsylvania of this duty to warn by describing the rationale and implications of two Pennsylvania court decisions. The first involves the provision of inaccurate guidance to prevent transmission of hepatitis B virus (HBV) to a sexual partner after an occupational exposure, which introduces the concept of foreseeable orbit of risk of harm by the Pennsylvania Supreme Court. The second case involves failure to provide information on the infectious nature of Cytomegalovirus (CMV) to protect the unborn child of a close contact. Foreseeable orbit of risk will be further defined as previously described by the Pennsylvania Supreme and Superior Courts, to provide clinicians with a framework for the recognition of when
the duty to warn may apply during routine clinical practice. Information contained in this article was derived from research conducted by legal experts at the University of Pittsburgh Center for Public Health Practice and Philadelphia Department of Public Health, that addressed practitioners’ ability to provide preventive medication to third parties during a public health emergency (e.g., antiviral medications to household contacts of an influenza patient). It is not meant to be an extensive review of all relevant case decisions in Pennsylvania, and therefore is based on the case reports of the Supreme and Superior Courts and above mentioned research. The Pennsylvania courts found that the notion to warn to protect third parties is beneficent and relies on the medical knowledge of practicing physicians as a key source of accurate information. Moreover, this duty shapes clinical practice toward a more population focused approach, potentially decreasing incidence of communicable diseases. Consideration of this duty comes at a time when healthcare reform emphasizes
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Duty to warn in Pennsylvania
reducing preventable illnesses and complications and improving patient outcomes, and stresses a more judicious use of medical resources. Therefore, the duty to warn needs to be contemplated seriously as an integral component of the standard of care by the Pennsylvania State Medical Board and its affiliate organizations. Both rulings found that a duty existed between the physicians and the third parties, even though a physician-patient relationship did not exist. In Pennsylvania, the standard of medical practice under routine circumstances (non-emergency) for services including medical evaluation, counsel, and treatment requires a physician-patient relationship. It has been interpreted that providing the above medical services to persons where no physician-patient relationship exists is against accepted medical practice as defined by the Medical Board of Pennsylvania. Therefore, the notion that a duty exists to third parties in this context, absent a physician-patient relationship, is unfamiliar and potentially problematic to most practicing clinicians in Pennsylvania.
unexplored. In light of this, it behooves clinicians to further consider their roles in the prevention of communicable illnesses beyond their patients at the time of care. Many details related to the core of these issues are not fully described in the court decisions and leave areas for additional consideration and refinement. This article also discusses where guidance on the duty to warn is lacking or unclear (e.g., dependence on a definitive diagnosis, general public understanding about common infectious illnesses, considerations for reportable diseases), and outlines what future discussions and direction need to occur to make clear to physicians their duty to third parties. These judgments do not address a duty to protect third parties who may have already been exposed to a communicable disease before the time of the patient encounter; this information pertains only to future
exposures. Finally, the court deliberations described here explicitly pertain to physicians, however, the issues related to the provision of clinical services in this article may apply to all licensed medical practitioners in Pennsylvania. Introducing the Duty to Warn & Accuracy of Warning: Transmission of HBV to Sexual Partners Following Occupational Exposure In 1990, the Superior Court of Pennsylvania found that physicians who treated a young female phlebotomist potentially infected with hepatitis after an accidental needle stick from a known hepatitis B positive patient had a duty to warn to prevent secondary transmission to at-risk third parties. In Dimarco v. Lynch Homes-Chester County Inc. the sexual partner, who the treating physicians knew about, became infected after the phlebotomist’s physicians failed Continued on page 14
The concept of the duty to warn to protect third parties is contemplated individually by each state. Public health legal experts acknowledge a lack of case law in Pennsylvania that addresses harm to third parties from communicable diseases. However, this article presents two relevant cases that begin to set a standard for the protection of persons lacking professional medical knowledge from preventable illnesses and severe consequences. As such, case law in Pennsylvania provides compelling guidance for future actions within the state. Delaware absolves physicians of this duty whereas New York has established case law that supports this responsibility (failure to provide information on infectiousness of tuberculosis following a positive occupational chest x-ray resulting in infection of spouse). Out of state rulings while not considered law in Pennsylvania become advisory and therefore are worth some attention when courts are faced with infectious disease issues that are complex, variable, and previously Summer 2016 : Philadelphia Medicine 13
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to warn her to take necessary preventive actions long enough to assure that she had not contracted the disease. The Pennsylvania Supreme Court also reviewed this case and held that: “When a physician treats a patient who has been exposed to, or who has contracted a communicable and/or contagious disease, it is imperative that the physician give his or her patient the proper advice about preventing the spread of the disease.”1 The court reasoned that: “Physicians are the first line of defense against the spread of communicable diseases, because physicians know what measures must be taken to prevent the infection of others.” The court further held: “Such precautions are taken not to protect the health of the patient, whose well-being has already been compromised, rather such precautions are taken to safeguard the health of others. Thus, the duty of a physician in such circumstances extends to those ‘within the foreseeable orbit of risk of harm.’ ” In addition to identifying that a duty to warn third parties exists and that sexual partners fall into the class of foreseeable orbit of risk, this court also clarified that the information imparted to patients must be accurate to prevent disease transmission. The court stated: “If a third person is in that class of persons whose health is likely to be threatened by the patient, and if erroneous advice is given to that patient to the ultimate detriment of the third person, the third person has a cause of action against the physician, because the physician should recognize that the services rendered to the patient are necessary for the protection of the third person.” This statement obligates physicians to have a working knowledge of the routes of transmission, at-risk populations, and correct preventive actions of potentially all communicable diseases and to actively provide this information to patients at the point of care. In its review of the case, the Pennsylvania Supreme Court upheld the opinion of the 1
525 Pa. at 561-2 (1990).
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Superior Court which determined that the duty to warn third parties exists and rests with the medical profession which understands the infectious nature and adverse outcomes of communicable diseases. The Supreme Court further opined that physicians must provide accurate information to prevent infection, and have an understanding and awareness of a class of persons at increased risk. Failure to do so subjects clinical practices in Pennsylvania to litigation. While most physicians possess knowledge of more common infectious diseases, specialists in infectious diseases, infection control and public health are more likely to understand such detailed information on a wide variety of pathogens. Clarifying the Duty to Warn, Public Awareness of the Disease & At-risk Populations: CMV Transmission and Pregnant Women In 1995 the Pennsylvania Superior Court (appellate level) deliberated a case brought by a woman who delivered a son infected with CMV, who died at two months of age from the disease. During gestation, this woman contracted CMV from an infant daughter of a close friend while providing routine infant care. The mother of the infant girl initially diagnosed with CMV did not receive any information about the infectious nature of CMV from her daughter’s treating physicians, nor did she receive information on methods to decrease spread to others including avoidance of people at greater risk for severe illness. Because of this, her daughter continued to have close contact with her female friend of childbearing age who contracted CMV after becoming pregnant. After review of the previous case involving hepatitis B, the Superior Court of Pennsylvania upheld that the treating physicians did have a duty to warn the infant girl’s mother to protect persons within the foreseeable orbit of risk of harm from CMV infection. In reference to pregnant women, the court reasoned that the treating physicians should have
450 Pa. Super. 85; (1996).
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450 Pa. Super. 89; (1996).
known: “that a class of persons very likely to come in contact with a young mother and her new baby were at risk, and that the risk was deadly.” 2 The expectation that physicians warn patients with all communicable diseases and the potential liability for spread of these diseases was challenged during the deliberation of this case. The magnitude of this responsibility was addressed as the court made the distinction between common illnesses where the public has some general understanding, from less common illnesses where specific information about risks and methods of transmission are more exclusively understood by medical professionals. The court stated: “In the case of viruses such as the flu or the cold, such information is common knowledge. In contrast where certain risks regarding the spread of certain diseases may only be known within the medical profession, it is essential that correct information be disseminated by the physician” (three specific diseases received mention: AIDS, hepatitis [assumed infectious types though not specified ], CMV).3 A comprehensive understanding of those communicable diseases that necessitate a warning, as opposed to those that are generally understood by the public, has not been developed in this context. Exploring Foreseeable Orbit of Risk & Patient Approaches In both of these cases, the courts provided examples of populations within the foreseeable orbit of risk respective to the index patients. The case involving hepatitis B transmission included sexual partners at-risk: information that is often known when conducting a thorough history, and therefore likely known by the treating physician. In the case where CMV was transmitted to a pregnant woman, the ruling infers that physicians make less certain judgments about the type of people their patients would likely have close contact (e.g., new mothers associating with other
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Duty to warn in Pennsylvania
Communicable Diseases & Public Health The categories listed above are basic public health considerations for disease control routinely practiced by state and local health departments. However, the precedence set in these court rulings should influence clinical practice to adopt a public health (population-based) focus when addressing patients with infectious diseases. Many, but not all, communicable diseases are reportable by law to the appropriate public health authority in Pennsylvania. Both the Supreme and Superior Courts in the rulings above inferred that reportable diseases because they are reportable by law, confer a duty on physicians to protect third parties, and thus further obligate clinicians to counsel patients to protect at risk populations.4
women likely to conceive). This variation causes ambiguity when considering at-risk populations, and would best be refined by a review of public health recommendations to control the spread of reportable diseases and conditions. Foreseeable orbit is a term used by the courts and is interpreted as an awareness of persons who the physician knows about, conceivably suspects, or where some hypothetical relationship may exist where future activities could occur during the period of communicability with the index patient. The statement that describes an awareness of deadliness in the CMV case infers that the orbit of risk must include third parties who have a higher likelihood of contracting the disease and more importantly would suffer severe or fatal outcomes. This may seem like a large volume of information for practitioners to know and obtain during the patient encounter where a communicable disease is suspected. The following is a non-inclusive list of general categories to consider when thinking through specific disease parameters important for constructing appropriate patient warnings.
related to vaccine preventable diseases. Other vulnerable populations may include people with underlying medical conditions including immune compromise, pregnant women, and the elderly. Occupational and recreational exposures need also be considered here (healthcare, agriculture, veterinary, school/ daycare, sexual partners).
• Method of transmission to third parties: This is pathogen dependent and is well described for most infectious organisms. These include 1) Close contact (e.g., household, daycare), 2) Fecal-oral (e.g., food handlers, healthcare, daycare attendees, household contacts, sexual partners), 3) Blood borne (e.g., healthcare, intravenous drug users, sexual partners), 4) Lesion/direct contact (e.g., sexual partners, sports team members/other close activities, shared personal items).
• Period of Communicability: This is important, as the orbit of risk should only include activities when the index patient is capable of spreading the disease. This is also organism dependent and must consider when in the duration of illness the patient exists at the time of the clinical encounter. This information is necessary when providing accurate time periods for preventive measures.
• At-risk third party populations: Also pathogen dependent, this is a core feature when considering foreseeable orbit of risk and applies to people who are likely to be affected by the method of transmission or who are at increased risk for illness and severe disease. Unvaccinated populations including infants and young children are at increased risk as
• Activities to reduce transmission: Based on the disease, preventive measures may include exclusion from work, school, and other select activities, avoidance of at risk populations or close contacts, isolation, abstinence, increased hand washing and other hygienic activities, cough etiquette, and appropriate handling of infectious material.
Reporting notifiable diseases is mandatory and elicits some follow up by state and local health departments. While reporting notifiable diseases is always good practice, it is unclear whether this absolves physicians from providing the appropriate information to protect third parties. Neither court decision addressed this as sufficient warning. Moreover, public health follow up does not apply to non-reportable diseases (e.g., CMV, Parvo virus B19, coxsackie viruses, Epstein-Barr Virus) therefore physicians need to integrate the duty to warn into routine practice regardless of whether the disease is reportable. Another complication that needs consideration is whether the duty to warn exists if the disease has not been definitively diagnosed. Both cases above relied on conclusive pathogen-specific tests to confirm the diagnosis. Does the duty to warn apply when dealing with a patient with a suspect or probable communicable disease but no conclusive test? This has not been described previously in the legal review. From a public health standpoint, protection of third parties should occur when a disease is highly Continued on page 16
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450 Pa. Super. 89; (1996). Summer 2016 : Philadelphia Medicine 15
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suspected or suspected enough that the clinician prescribes a specific treatment (e.g., macrolide antibiotic for suspect pertussis). Further interpretation by lead public health authorities in the Commonwealth should occur to clarify this issue. Conclusions & Recommendations While no statutory law exists in Pennsylvania that defines a clinician’s duty to counsel patients with communicable diseases to protect third parties, case law demonstrates that this duty does exist and failure to provide preventive information accurately is actionable. This duty draws on a physician’s oath of beneficence by acting within a window of opportunity to prevent illness and death to vulnerable populations. The obligation is imposed on physicians because they possess an understanding of communicable diseases and the appropriate actions to decrease transmission for many uncommon illnesses not typically understood by the general public. Consistently exercising the duty to warn during patient care increases encounter times and adds responsibility to an often busy clinical setting. However, providing preventive information to patients who pose serious risks to others has far reaching health benefits which can greatly improve many population-based health outcomes in the future. Incorporation of the duty to warn into formal medical training could influence clinical practice to adopt a more public health focused approach. This shift would raise clinical practice to a judicial standard that already exists in Pennsylvania based on case law. As stated by the Superior Court of Pennsylvania: “The standard of care for a physician who is treating a patient with a communicable disease is to inform the patient about the nature of the disease and its treatment, to treat the patient, and to inform the patient how to prevent the spread of the disease to others.” 5 Additional consideration for the training and inclusion of the duty 5
450 Pa. Super. 90; (1996)
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Duty to warn in Pennsylvania
to warn among practicing clinicians in Pennsylvania is paramount given current healthcare reform policies that emphasize preventing illnesses and injuries, and improving patient outcomes. Partnering with state and local health departments is encouraged to successfully provide accurate information to limit disease transmission. Reporting is strongly recommended and may share the burden of third party protection, however, reporting notifiable diseases will not likely alleviate the physician of this duty to warn. Common illnesses such as influenza may not apply as the public may have some general knowledge about at-risk populations and infectivity and therefore understands how illness is transmitted. This distinction must be made with caution, as there is no existing list of diseases that is generally well understood by the public and great variability exists among the general population regarding knowledge of common and uncommon diseases. For example, the 2009 H1N1 influenza pandemic strain would not likely have been well understood by the public in respect to its increased proclivity to cause severe disease among pregnant women or its lack of infectivity among elders. Other considerations that practitioners may have regarding the duty to warn include documentation. The level of detail for recorded information to demonstrate satisfactory fulfillment of warning to protect third parties has not been provided. To synthesize the large volume of information relevant to protecting third parties for all communicable diseases, public health and relevant health professional organizations could collaborate to develop a resource tool that describes these recommendations. This information could be provided in a web-based Learning Management System
(LMS), presented at statewide conferences for continuing medical education, and condensed into a user-friendly pocket guide for clinicians to use during clinical practice. In closing, this article introduces the concept of the duty to warn to Pennsylvania practitioners, and reviews the state of this concept as currently set by legal precedence. It is not meant to steer physicians away from identifying at-risk individuals related to their patients, rather to provide information, to clarify the issues, and to offer support for clinicians to practice with confidence when counseling patients on reducing disease transmission. Additional action is required to further refine and integrate this standard and its recommendations to reach the goal of decreasing incidence of communicable illnesses.
Acknowledgements The author wishes to acknowledge Rebecca Chatta-Morris, Esq., and Patricia Sweeney, JD, MPH, RN (University of Pittsburgh Center for Public Health Practice), and Danielle Deery, JD, MURP (Philadelphia Department of Public Health), for their previous research that identified the duty to warn in Pennsylvania contained in case law.
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A Philadelphia County Medical Society Summit
Confronts the
Opioid Epidemic Alan Miceli, MA
ary Tennis, Pennsylvania secretary of the Department of Drug and Alcohol Programs, leaned forward in his seat in the main hall of the Philadelphia County Medical Society building, to drive home his point to the more than two dozen physicians and health care providers flanked on his right and left, who are devoting much of their time to tackling the opioid epidemic. Tennis talked about the nation’s drug epidemic to the April 12 gathering, as if he were an army general discussing a guerilla war. It’s a war in which the enemy consists of small innocuous-looking pills that have enslaved millions of Americans and killed thousands of them. “In 2016 alone we’re going to lose as many Americans to drug overdose, as we lost in the entire 12 years of the Vietnam War.” There were 47,242 American combat deaths in Vietnam. Tennis said the prescription drug and heroin epidemic is the most lethal health crisis in the United States since the 1918 flu pandemic. Pennsylvania, alone, loses more people to overdoses than to handguns or traffic accidents.
The Vietnam War spurred hundreds of thousands of Americans to march on our nation’s capital. But Tennis is not calling on physicians to gather in massive numbers around the Washington Monument. Instead he wants them to enlist in a widespread effort to gain control of a drug supply that is causing so much pain and suffering. The group Tennis addressed was made up of regional physicians who are rethinking how they prescribe pain medication and how they can get their peers to do the same. They have seen firsthand what an overabundance of opioids has done to many patients who were guilty of nothing more than taking the drugs their doctors prescribed for them, following, for example, a surgery. The group included the president-elect of the American Medical Association, Dr. Andrew Gurman, an orthopedic surgeon in Altoona, Pennsylvania, who over the years has prescribed thousands Continued on page 18 Summer 2016 : Philadelphia Medicine 17
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of painkillers for his patients; Dr. Rachel Levine, Pennsylvania’s physician general, who has made it relatively easy for first responders, patients and third parties to get prescriptions for naloxone, the drug that reverses overdoses of opioids, including heroin; and Dr. Michael Ashburn, an anesthesiologist who has carried out ground-breaking work as the director of the pain medication program for the University of Pennsylvania. The gathering also included the heads of local emergency rooms and dedicated health care providers working on the streets of Philadelphia—two groups whose typical day at the office includes trying to save the lives of overdose victims. The presidents of the Pennsylvania Medical Society and county medical societies, including PCMS president, Dr. Michael DellaVecchia, also came to listen, to learn, and to contribute. They each had stories to tell that described the near overwhelming nature of the crisis, and what physicians and other health care providers must do to try to stanch the bleeding. One speaker after another echoed what Dr. Ashburn said early on. “We now have a generation of people who have substance abuse disorders caused by physicians, including myself, who thought they were doing the right thing when they wrote opioid prescriptions.”
One expert after another at the meeting talked about the need to greatly expand the effort to save the lives of overdose victims, by creating a field hospital approach on streets and in emergency rooms. The group called for dramatically increasing the supply of naloxone to first responders. Only seven counties in Pennsylvania—including Philadelphia, Chester and Delaware—provide the life-saving drug to all of their patrol officers. Most of the other counties, including Bucks and Montgomery, have only partial coverage. Dr. Levine has issued two standing order prescriptions to get naloxone into the hands of those who can use it. One prescription allows first responders to receive naloxone. The second lets patients or third parties—family members or friends of persons with an addiction—buy naloxone at any of the state’s 2,800 pharmacies. The Wolf administration is also supplying all public schools in the state with the drug. Dr. Levine said there isn’t a danger of the drug becoming attractive to addicts. Naloxone causes an instant and uncomfortable withdrawal. “No one is going to deliberately overdose to get naloxone,” she said. “We’re saving people’s lives.”
Since the first overdose patient in Pennsylvania was saved in 2014 by an officer in Ridley “The message has to be heard louder and stronger in our profes- Township, Delaware County, about 750 others have been saved in sion,” internist and AMA Board Chair, Dr. Stephen Permit, added. the state. Tennis said one first responder was heard on police radio, “That is where the prescriptions arise and where our patients come exclaiming, “this sh*t really works!” Summit participants said many needing help and relief.” police officers have found that reviving someone is a transforming moment for themselves. Dr. Gurman gave an example of how doctors have been unknowingly overprescribing. He cited an Iowa hand surgery practice, Sylvana Mazzella of Prevention Point Philadelphia said we should where four physicians were doling out Tylenol Codeine #3 to try to get as much naloxone as possible out on the street. She said patients who had fairly minor surgeries to correct such ailments she faces overdoses every day and loses people every week. “It’s as trigger finger and carpel tunnel. The doctors typically wrote a going to take every system that touches people, to be involved in 30-day prescription for the drug. safe prescribing, dispensing naloxone where possible, and talking to each other and raising awareness of this as the public health But after surveying about 250 of their patients they discovered emergency it is.” that 80% of them did not use more than 15 pills. The practice now routinely writes a prescription for 15 days, with one refill. But naloxone is only one weapon that’s needed in the drug-fighting That change has taken about 4,000 pills out of circulation every effort. After the overdose patients recover at an emergency room month—pills that could have led to a patient’s addiction, or landed they must be transported to a treatment facility. Such facilities are in the hands of a teenager who raided the medicine cabinet, or often not available. ended up somehow being sold on the street. Dr. Priya Mammen, emergency medicine physician at Jefferson Tennis also put much of the blame for the epidemic on the University Hospital, said the effort to help patients just resuscitated pharmaceutical industry, that he said presented to doctors, “an in the ER faces one road block after another. “I have been quite extraordinarily skilled and deceptive program.” frustrated by the limitations in the emergency department about 18 Philadelphia Medicine : Summer 2016
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A PCMS SUmmit confronts the Opioid epidemic
what we can do with these people we’ve just seen who have had potentially life-altering moments, while not having access to drug treatment, not having a lot of resources we need to really help them in the moment.” Tennis said that funding for treatment facilities right now covers only about 10% of the need, and Congress is to blame for much of the shortage. He said in the last 10 years, Congress has cut drug prevention and treatment programs by 25%. Dr. George Avetian, family physician from Upper Darby, Pennsylvania, who is on the Delaware County heroin taskforce, told the gathering that the lack of treatment options has produced situations in which patients treated for an overdose in the morning, end up back in the ER that night. These patients have been nicknamed “frequent flyers,” for their repeated trips to the ER. The gathering also discussed the difficulty of discerning whether a patient who is asking for painkillers is hooked. The Pennsylvania Department of Health is aiming to unveil in September a new tool to help identify these patients. It’s called the Prescription Drug Monitoring Program (PDMP). It will allow physicians and pharmacists to track a patient’s opioid prescription history in a matter of seconds. But Dr. Ashburn said in other parts of the country PDMP has often had lethal consequences. “I think most physicians are not aware that PDMP use and implementation leads to increased heroin use and death. We’ve seen this over and over again. Pennsylvania has a unique opportunity to do it right. We really have to teach our physicians to use this properly so as to get our patients the proper treatment.” So, how do you help this person in front of you, who you have just found out has a drug addiction? Dr. Levine said, “the worst thing you could do is say, ‘Mrs. Smith, I see that you are getting many prescriptions for opioids. I will not write you a prescription. Please leave the office.’ Because then she’s going to go right down the street and get heroin.” Dr. Levine said the Department of Health is working on what she called “warm handoff” guidelines. “There needs to be a firm warm handoff, not a fuzzy one. Not a ‘gee, I see you’ve overdosed a dozen times, maybe you’d like to get some treatment.’ It’s more like ‘you’ve overdosed and this is what you need to do now.’” Tennis added, “this is an intervention tool, not a gotcha.” Dr. Gurman added that the AMA’s opiate taskforce calls for universal and near instantaneous availability of PDMP for doctors and pharmacists. That item is at the top of the AMA taskforce’s recommendations on how to confront the drug epidemic. The recommendations also call for physicians to educate themselves and their colleagues on how to prescribe opioids and what
to look for in their patients who are taking them; support overdose prevention and treatment efforts; reduce the stigma of substance abuse disorder, and drive home the fact that addiction is a brain disorder and those with it need to get treatment. Tennis cited an example of what the stigma looks and feels like. He read a newspaper article on addiction not long ago, in which someone commented that “overdose is nature’s way of taking out the trash.” Tennis said we wouldn’t view others who have brain disorders in the same way. Dr. Gurman said we will know we have been successful in blunting the epidemic when, “all who need treatment for substance abuse have access to it, without barriers from insurers and society; when patients at risk for overdose receive prescriptions for naloxone; when people are no longer becoming addicted to these drugs as a result of overprescribing.” He concluded that “doctors have a great part in this, but we cannot do it alone.” Dr. DellaVecchia drove home the point. “We own part of the problem,” he said, “and recognize we are part of the solution.” Summer 2016 : Philadelphia Medicine 19
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The Wistar Institute: A Look at the Legacy of a Leader in Biomedical Research Past, Present & Future of a Local Biomedical Research Institute with Global Reach
Darien Sutton Senior Media Relations Associate, The Wistar Institute
W
estward expansion across the U.S. in the late 1800s was a boundless time for adventurers, visionaries and scientists. As travelers manifested their destinies across the North American continent, in the heart of Philadelphia The Wistar Institute started on its own scientific path of exploring uncharted territories.
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Wistar is the first independent, biomedical research institute in the nation. Founded in 1892, it specialized in comparative anatomy, investigative and experimental biology and the training of national and international scientists. Today, Wistar is a global biomedical research leader in cancer, immunology and infectious diseases, and
continues training the next generation of scientists. The Wistar Institute is a National Cancer Institute (NCI)-Designated Cancer Center with a long history of contributions to the study of cancer biology and vaccine research. Wistar scientists have pioneered the development of vaccines for diseases such as rubella, rabies and rotavirus, and
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Eyeball (center) made from wood, papier-mâché, leather and paint, is a large-scale anatomical model created by William Rush in 1808 at the behest of Caspar Wistar, M.D. Of the 21 created, this is one of seven that has survived and is on view today at Wistar.
continue to make important, cutting-edge immuno-oncological research strides. The Institute’s story of scientific contributions began with the Wistar family in Philadelphia. In 1717, 21-year-old Caspar Wistar emigrated to Pennsylvania from Germany, and established the Wistarburgh Glass Manufactory company—the first prosperous glass factory in the American colonies. In 1727, he married Catherine Jansen of a prominent Quaker family. Wistar became a very successful manufacturer and wholesale trader, but made his fortune in real estate and land speculation. He began acquiring land four years after arriving in Pennsylvania, and ended up owning more land than anyone else in the commonwealth, except for William Penn. In 1761, Caspar Wistar’s son Richard Wistar and wife Sarah Wyatt became parents to Caspar Wistar the Younger. Young Caspar studied abroad and received his medical degree at the University of Edinburgh, in Scotland, then returned to Philadelphia and became a well-respected physician and professor of anatomy at the University of Pennsylvania. Wistar treated victims of the yellow fever epidemic of 1793 that killed 5,000 people
in Philadelphia. He established Bush Hill Hospital between 12th and 19th Streets to treat victims of the disease. By his late 40s, Wistar was considered a great orator, teacher and innovator. In 1808, he commissioned prominent American sculptor William Rush to construct three-dimensional, larger-thanlife-sized anatomical models for his students to better see during anatomy lessons held in vast amphitheaters. In 1811, Wistar wrote and published System of Anatomy, the first American textbook on anatomy. Wistar also built an immense collection of wax-injected human limbs and organs for his anatomy class. Dr. Wistar was a scientific visionary whose vast scope of knowledge made him a highly-respected intellectual. He later became chair of the Anatomy Department at the University of Pennsylvania and worked with Lewis and Clark, giving the pioneers a crash course in paleontology prior to their planned expedition west. Wistar was elected president of the American Philosophical Society (founded by Ben Franklin), succeeding his friend President Thomas Jefferson. Active in the social and intellectual life of Philadelphia, Wistar threw parties that attracted scholarly conversation among the most brilliant minds and leading intellectuals of the time.
Before his death in 1818, Wistar appointed William Edmond Horner, M.D., as caretaker of his collection of wax-injected human limbs and organs, which Horner would maintain and eventually expand into what would become the core collection of the Wistar Horner Museum. Today, three Rush models and a first edition copy of Systems of Anatomy, Volume One are on display at The Wistar Institute. Nine years after Caspar Wistar’s death, his nephew Isaac Jones Wistar was born. Isaac was a restless youth whose pursuit of adventure took him on a path to independence. He attended Westtown Friends School and Haverford College before moving westward in his 20s. Isaac Wistar was an American Renaissance man—a frontiersman, a trapper who briefly worked for the Hudson Bay Company, a gold rusher, rancher, lawyer, and a Union army captain. During the Civil War, he was a lieutenant-colonel in the 71st Regiment of Pennsylvania Volunteers in the Union Army, where he was responsible for recruiting a company of soldiers.
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He was wounded during the battle of Ball’s Bluff and again at Antietam. Promoted to Brigadier General, Isaac Wistar occupied the former major Confederate stronghold of Yorktown, Virginia, and established a haven for escaped slaves.
the Pennsylvania Railroad Company, and oversaw the Pennsylvania Canal System. Like his great uncle, he served as president of the American Philosophical Society, and also became president of the Academy of Natural Sciences.
After the Civil War, Wistar resumed his law practice. He became vice president of
Wistar also devoted much of his work to prison reform, writing articles on prison
policy and inmate reform and writing books on penology. He is responsible for funding an endowment and research building in honor of his great uncle Caspar Wistar. Originally called The Wistar Institute of Anatomy and Biology, today it is simply known as The Wistar Institute. At the end of the 19th century, Isaac Wistar reached an agreement with the University of Pennsylvania to create an independent institution—with small ties to the University—that would house his great-uncle Caspar’s anatomy collection. In 1894, The Wistar Institute was built in a rural, yet expanding, West Philadelphia. The University of Pennsylvania provided the plot of land and the original Wistar Horner collection of anatomical items, in exchange for Isaac Wistar providing an endowment and building to house the collection. A Victorian-style building, designed by influential architects, The Hewitt Brothers (whose other notable buildings include The Bellevue Hotel and The Philadelphia Bourse), was created and equipped with numerous laboratories, facilities and an anatomy museum with tens of thousands of anatomical teaching aids, skeletons, and wax-injected organs. Science transitioned away from the study of anatomy and the need for anatomical collections that required costly maintenance and care. The Wistar Institute reflected the trends of medical science based in research and what is now modern medicine. In 1906 under the leadership of Wistar’s third director Milton J. Greenman, M.D., and Wistar director of research Henry H. Donaldson, Ph.D., Sc.D., the institute prioritized research in experimental, creative, investigative biology.
Dr. Warren Lewis and Dr. Margaret Reed Lewis joined Wistar in 1940 and specialized in tissue culture and cancer studies. They are Wistar’s earliest example of married scientists who both worked and lived at the Institute. 22 Philadelphia Medicine : Summer 2016
In the early 20th century, Wistar became a center for American biology. Major steps were taken to train students in Wistar labs and publish and circulate scientific journals. International scientists came for yearly sabbaticals to learn from Wistar’s faculty. The first of these luminaries was Shinkishi Hatai, Ph.D. In 1906 he was the first international scientist to join the
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Wistar faculty and later became known as the father of Japanese biology. From 1909 until her retirement in 1950, Helen Dean King, Ph.D., the Wistar Institute’s first female scientist, along with other Wistar scientists, bred the Wistar rat, the first standardized lab animal from which more than half of all present-day laboratory rats trace their genealogy. King was one of a handful of women scientists working in the largely male-dominated field of science at the turn of the 20th century. In 1936, Edmond J. Farris, Ph.D., known for his work on human fertility, became director and served Wistar for two decades. During this time, Warren Lewis, M.D., and Margaret Reed Lewis, Ph.D., joined Wistar in 1940 and specialized in tissue culture and cancer studies. They are the earliest example of married scientists who both worked and lived at the Institute. The modern era of biomedical research at The Wistar Institute began with the appointment of Hilary Koprowski, M.D., as director of Wistar in 1957. He went on to lead the Institute for 34 years. Koprowski brought a clear scientific direction and emphasis on virology, immunology and cancer research, and, under his direction, the Institute embarked on a major effort to create vaccines against viral diseases. In 1965, Wistar scientist Leonard Hayflick, Ph.D., developed the concept “Hayflick Limit” from a historic discovery he made that normal human cells do not replicate infinitely. He found that cells grown in culture will divide 52 times—with each division shortening the protective telomeres at the ends of the chromosome—before death occurs, or division stops. Prior to Hayflick’s discovery, it was thought that cells could divide indefinitely in culture. This biological process protects against cellular/genetic instability that leads to cancer and is an essential principle in cancer and aging research. Hayflick developed a number of human diploid cell strains that allowed for the development
The Wistar Institute’s first female scientist photographed with five Wistar rats. The Wistar rat is a strain of Albino rat Dr. King helped to breed. Today, more than half of all rats are descendants of the Wistar rat. From 1909 until her retirement in 1950, Dr. King was a research associate studying the effects of inbreeding. She was one of a handful of women scientists working in the male-dominated field of science at the turn of the 20th century.
of the modern polio and rubella vaccines as well as other live viral vaccines. Today, these stable cell lines are the basis of many routine childhood vaccines. During these years, Wistar scientists and leadership devoted themselves to the conquest of cancer, and in 1972 the Institute became an NCI-designated cancer center, a distinction it has continuously held ever since. Of the more than 1,500 cancer centers in the U.S., Wistar is one of 69 that have earned the NCI distinction. In 1975, a new cancer wing was built at the institute, which marked an evolution for cancer research. Wistar led in the development of monoclonal antibodies—protein molecules able to detect and destroy foreign invaders including cancer cells. This Wistar technology showed the effectiveness of monoclonal antibodies as a research tool that became used for the study of molecular virology and tumor biology. Researchers soon saw their potential as a new sort of targeted therapeutic, one that could be developed to bind to, say, a protein involved in cancer.
During this era, Wistar scientists Carlo Croce, M.D., and Walter Gerhard, M.D., developed hybridomas: cells made by fusing antibody-producing B cells of the immune system with myeloma cells creating a form of cancerous B cell. These hybridomas served as tiny factories for producing a single variety of antibody that could bind to a specific target in the body, such as a particular protein. The Wistar Institute rapidly moved to the forefront of this research and, in 1979, the Institute licensed its monoclonal antibody technologies to Centocor—a suburban Philadelphia drug company, now Janssen, the immune biotechnology subsidiary of Johnson & Johnson—for drug development. Founded out of Wistar technologies, Centocor became one of the most exciting biotechnology companies of the late ‘80s and ‘90s. By developing diagnostic assays using monoclonal antibody technologies, cofounders Koprowski, Hubert J.P. Schoemaker, Ph.D., Michael Wall, and Vincent Zurawski, Continued on page 24 Summer 2016 : Philadelphia Medicine 23
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Ph.D., cemented Wistar’s footprint in building the biotechnology landscape.
to help these countries develop affordable vaccines to protect their populations.
Today, numerous drugs against cancer and other diseases, both in use and in development, resulted from the monoclonal antibody revolution introduced by Wistar and its contemporaries. For example, monoclonal antibodies against Il-12, a signaling molecule discovered by Wistar’s Giorgio Trinchieri, M.D., have led to Stelara, a medication to treat the skin disease plaque psoriasis, and potential cancer drugs.
The second vaccine created at Wistar was against the rabies virus, and became licensed for human and animal use in Europe and the U.S., starting in the late 1960s. This Wistar vaccine improved upon earlier vaccines used during the early 20th century that had a direct lineage to the first human rabies vaccine administered by Louis Pasteur in the late 1800s which were not always effective, caused multiple side effects, and were extremely painful to administer.
The first vaccine developed at Wistar was against rubella, also known as German measles, which led to birth defects including blindness, deafness and severe mental retardation as well as miscarriages and stillbirths across Europe and the U.S. in the 1960s. Several labs worked to create a vaccine, but Wistar Professor Emeritus Stanley Plotkin, M.D., and Koprowski made the vaccine of choice in 1969. Today, rubella still remains a threat in developing nations, and Wistar has licensed the rubella vaccine seed stock to companies in China, India and Russia. The agreements do not bring significant royalties to the Institute, but are designed
Wistar scientists led by Drs. Koprowski, Plotkin, and Tadeusz Wiktor, V.M.D., developed a therapeutic vaccine nearly 100 percent effective in preventing infection when given promptly as part of post-exposure treatment. It is also given to people at high risk of exposure, including veterinarians and wildlife officers. Today, it is widely used in the U.S. and Europe.
Stanley Plotkin 24 Philadelphia Medicine : Summer 2016
Ca. 1743 engraved drinking goblet of Caspar Wistar the Elder. One of 12, this glass was supposedly made upon specific commission by Caspar Wistar by an unidentified German manufacturer. It is 6” tall, blown in a single section of clear glass with a pedestal stem of the “Silesian” type. The engraving on the bowl was done with a wheel showing a large WW cursive monogram. There is a “crest-coronet ducal” above the monogram signifying the Wistar’s historic status of the landed gentry.
In response to an emerging rabies crisis among raccoons along the East Coast, William Wunner, Ph.D., who currently serves as Wistar’s director of Educational Outreach and Technology Training programs, Peter J. Curtis, Ph.D., and other Wistar scientists created an oral rabies vaccine that could be administered through bait, a breakthrough that has protected and saved countless animals, and as a result, most likely, human lives. First approved in 1995 to prevent raccoon rabies, it is used worldwide to protect wild animals and indirectly, neighboring human populations. Currently, Wistar is in development of new rabies vaccines that could potentially produce long-lasting or even lifetime rabies immunity and Wistar researchers are also creating an inexpensive test for diagnosing rabies in the field. The rotavirus vaccine was co-developed by Wistar researchers Plotkin, H. Fred. Clark, D.V.M., and Paul A. Offit, M.D., to protect newborns from a highly contagious virus with symptoms of diarrhea, vomiting, fever, and abdominal pain. Rotavirus research that began in the ‘80s under Plotkin and Offit
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was further developed through Merck & Co., Inc. and came to fruition as ROTATEQ®, a lifesaving vaccine recommended for infants since 2006. Through partnerships like this between industry and research, Wistar discoveries have reached the public as vaccines and diagnostics and therapeutic agents against cancer. The Wistar Institute has also served as a training ground for researchers and a hub for established and emerging scientists conducting trailblazing research. From high school and community college students to postdoctoral researchers and visiting scientists, Wistar is committed to offering educational programs and experiences in the lab and classroom that prepare students for job opportunities in biomedical research. Wistar investigators are leading basic science discoveries for prostate, ovarian, breast, skin, and melanoma cancers; understanding infectious diseases and advancing vaccines for HIV, influenza, and numerous other viruses; creating cancer vaccines for HPV, head and neck, and other cancers; and pushing the envelope to bridge the gap between research and the clinic. The past truly does inform the future and Wistar’s record of success has put it in the scientific frontline. The Wistar Institute continues to make great strides at the bench to move important discoveries into promising therapies. Wistar’s Melanoma Research Center is one of the largest melanoma centers outside of the National Institutes of Health, bringing together a diverse group of scientists working collaboratively to develop new treatments. Wistar researchers are also hard at work developing new, easy-to-use diagnostics with the hope of detecting lung cancer before it spreads. They have been on the infectious disease front for more than 20 years, creating alliances with the Philadelphia scientific community in search of an HIV cure, and currently leading a multi-institutional scientific team to test whether residual HIV in previously-treated patients can be eliminated permanently. Finally, Wistar has
Tea time at The Wistar Institute. Shinkishi Hatai, Ph.D., second from left, and Henry Donaldson, Ph.D., Wistar Scientific Director, third from left.
Hilary Koprowski
formed a partnership—a hallmark of Wistar science—with the Helen F. Graham Cancer Center in Delaware that is advancing Wistar discoveries into clinical cancer treatments for patients. As Wistar grows into its new Robert and Penny Fox Tower—increasing Wistar’s footprint by 33 percent—new scientists recruited with leading-edge immunology and vaccine research are harnessing the power of the immune system to better treat cancers and infectious diseases. Through collaboration and innovation, and staying true to its mission to train the future generation of
scientists, biomedical researchers at Wistar set out to solve the most challenging fundamental questions to curing many diseases. Wistar’s science continues to evolve and pave the way for innovative biomedical research buoyed by the institute’s historic achievements. By accelerating innovative cancer and vaccine research and nurturing young scientists and their commitment to biomedical discovery, Wistar’s advances push the envelope of scientific discovery as it continues on its historical trajectory to harness science for the betterment of humanity.
Summer 2016 : Philadelphia Medicine 25
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A Conversation with
Philly’s Top Doc Philadelphia’s new health commissioner, Dr. Thomas Farley, is a pediatrician who has spent decades working as a public health official. While he led New York City’s health department from 2009 to 2014, he helped raise the legal age for buying cigarettes to 21, and pushed for a soda tax. Philadelphia Medicine recently spoke to Dr. Farley about what he hopes to accomplish in Philadelphia.
What are your top concerns for the city? I see in public health our job is trying to prevent as much early death and disease as possible. And so I start looking at the rankings at what causes the most mortality, what causes the most years of potential life lost. And if you think of that in terms of diseases, you end up with chronic diseases and injuries—heart disease, cancer, diabetes, homicides.
There are good people in Philadelphia already doing this work, but it is not being done for every kid in the city who has asthma. So I want to see what we can do to make it more of a routine thing, especially for children living below the poverty line, where the greatest risk lies.
Our job is prevention, so I tend to look at risk factors that can contribute the most mortality—they’re smoking, unhealthy diet, activities such as alcohol, drug abuse and guns. That would be the list of things that I think we should be focusing on. I should be clear that much of that doesn’t fall traditionally under the Health Department. And so we in public health always build partnerships and look for opportunities to work with others on health problems. So, we’ll be looking for partnerships to address those sorts of issues.
What, practically speaking, can you do? Go after indoor smoke, indoor antigens, in light of cockroaches and mice and clutter that ends up leading to dust and dust mites. Those in-home environmental interventions address those irritants, and have been shown to be effective and have also shown to reduce health care costs. So it’s something for which health plans are increasingly paying, because they save by reducing hospitalizations down the line.
That’s a pretty ambitious list you want to tackle. A lot of it focuses on adult health. But you also have to think about pediatrics, you have to think about asthma. That’s the leading cause of hospitalization. That’s something I really want to make progress on. I think we have an opportunity to do that.
You’re interested in finding ways to confront obesity— the proposed soda tax, being one of them. Mayor Kenney proposed the soda tax and he’s very clear that he’s interested in it as a way to support pre-K, community schools, and rebuilding our parks and recreation centers. All of those are wonderful for health from my perspective. They address social determinants—pre-K giving kids a good start in life, obviously building rec centers is good for physical activity.
If you look at asthma rates, they are strongly correlated with poverty. So it’s not genetics there. It means there’s something within the environment of low income kids that causes them to have, to trigger asthma. And it probably is mostly indoors. Housing is often not good for people of low incomes. But there are proven interventions that work in homes to reduce allergens and irritants and reduce asthma hospitalization. 26 Philadelphia Medicine : Summer 2016
All that’s great for health, then the tax itself is something which I supported for a long time. It’s good for health in its own right. It provides people with an incentive to switch from sugary drinks, which are the biggest contributor to the obesity epidemic.
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A Conversation with Philly’s Top Doc
We’re not forcing anybody to do anything. People can continue to drink sugary drinks if they want, but the tax gives them a good financial reason to cut down or eliminate them.
In New York City you helped create a law that did not allow anyone under 21 to buy cigarettes. Are you considering something like that for Philadelphia? That requires state action. We can’t do it here in the city, on our own. So, whether that’s doable here, I just don’t know.
What effect did that have in New York City? I don’t think they’ve done a full evaluation on it yet. There are models done on what impact it has. And in the short term it has a pretty big impact on smoking in teenagers. In the long term, looking at decades, it has an impact on adults, but it takes time. Here’s the rationale—90% of smokers start before the age of 21. So if you increase the legal age to 21, maybe they’ll never start. And if that happens, they have of course a big benefit over the long term. But how it actually has played out in New York City, it’s just too early to say.
What can the Department of Health do when it comes to gun violence in the city? I don’t know, but I can tell you that it’s something that I’m worried enough about that I want to see what we can do to contribute to a solution. There are many people working on the problem from many different angles. Maybe when we look at the landscape we might say that everything that could be done is being done, or we might see a niche where we can help. Even if we can reduce gunshot fatalities by 5% or 10%, that’s huge. That saves that one child. That saves perhaps your child. That’s all the difference in the world.
Are you concerned about the epidemic of STDs in the city? I started public health working on STDs. I was in the Louisiana Health Department. I was responsible for administering the statewide effort to battle sexually transmitted diseases. We have an STD clinic here. We have a program to distribute condoms. We are in schools, screening for gonorrhea and chlamydia. All of that is very successful. The gonorrhea and chlamydia rates are generally stable or are going in the right direction. I am very much concerned about the rising rates of syphilis and the potential impact of HIV transmission among certain segments of our population. In
those categories we are seeing an increase in sexual risk, and I worry about that quite a bit. So in the population overall we are making progress, in the sub-population we have a lot of reason to focus more attention.
The Pennsylvania Department of Health website states that the best way for teens to avoid STDs is to abstain from sex. Let’s separate teenagers from adults. Most of the transmission of STDs is happening in adults, certainly for syphilis and HIV. And obviously for teenagers, for anybody, if you don’t have sex you’re not going to get a sexually transmitted disease. But we quickly recognized that the vast majority of adults and an awful lot of teens are sexually active. And so we want to encourage them as much as possible to be using condoms every time they are having sex. And to stick with one partner—which also reduces risk. And for HIV specifically, we’ve learned over the years that if we treat people who have HIV infection we lower the likelihood that they will spread it to their partners. Treating people who are HIV-positive has been shown over the years to be the most successful way to reduce the spread of HIV. We are improving the effort to identify HIV-infected people through screening and get them into care early and get them to stay in care, but we still have a ways to go with that.
Do you have concerns about teenagers having sex? Sure. When teenagers have sex there’s the risk of STDs, there’s also the risk of pregnancy, which they’re usually not ready for. We certainly want to reduce the number of teens who are having unprotected sex. And if we can reduce the number of kids who are sexually active, also, that’s wonderful. That’s not easy to do in the environment we’re in.
We are in the midst of a prescription drug epidemic in the city. Twice as many people die from drug overdoses as die from gunshot wounds. What can you do about it? I should point out it’s not just prescription opioids, it’s also heroin and fentanyl. And they’re related. The drug markets interact. We don’t know for sure, but certainly it makes you worry that people started out using prescription opioid and later shifted to the illegal drugs. I think we need to do a few things. We need to reduce the number of people who are becoming newly-addicted by changing Continued on page 28 Summer 2016 : Philadelphia Medicine 27
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physicians’ prescribing habits. Physicians have been prescribing opioids too liberally in recent years. Now they’ve been encouraged to do that, so it’s difficult to blame them for that. But now the results are in. The large increase in prescriptions for oxycontin and Percocet have really led to an awful lot of people who are currently victims. So we need to have physicians to prescribe opioids more judiciously. And then for all the people who are currently addicted, we need to get more of them into treatment. And we need to educate people on the combinations of drugs that can lead to overdoses and death. And we need to make naloxone more widely available, to help prevent deaths from drug overdoses.
What are you planning to do to deal with the threat of the Zika virus? We are tracking it very closely. Right now we don’t think Philadelphia is a likely place where we’re going to see the spread of Zika, but the consequences of this are so severe that we’re absolutely following the issue very closely and making sure that we’re not
A Conversation with Philly’s Top Doc
missing something. Right now we’re not aware of the mosquito that spreads it, being in the Philadelphia area, but we’ll be testing to see if it appears.
Are you going to be doing aggressive spraying this summer? If we have a Zika case we will spray in the area where the case surfaces. We do larva sighting right now for mosquito control. We will continue to do that. If we have any reason to suspect that the mosquito that transmits the disease is appearing in Philadelphia, we absolutely would need to be scaling that up to control that particular appearance of mosquito.
Why did you come to Philadelphia? Because city health departments are where the most excitement is happening with public health right now. The federal government as you know right now is paralyzed in partisan warfare. So it’s very difficult for my wonderful friends at the Centers for Disease Control to be very effective in public health. State health departments are kind of removed from the action. But city health departments are places where you can see a problem with your own eyes, put in place a solution, then measure its impact in a reasonable period of time. And a city health department like this one has the resources to have expertise in developing new and innovative solutions. We don’t have to wait to be told by the CDC or somebody else how to solve our own problems. So I think this is where all the action is happening.
Has your experience as a pediatrician prepared you in any way for this kind of job? Pediatrics is by its nature, prevention oriented. An awful lot of docs in public health started as pediatricians. But the greater preparation for me has been all my years in public health. I started in public health in 1987. I worked for the CDC. I worked at the state health department level, obviously worked in New York City. I’ve worked as a professor, so I’ve had a chance to see public health from many different angles. And all of those years of experience will help in this position. Philadelphia is a wonderful city. I’m really excited to be here. It’s a city that has its share of urban problems. We have a higher poverty rate than any other big city in America. That in a way, to me as a public health guy, creates an exciting opportunity. If we do a good job with public health, then there are an awful lot of people in poverty we’re going to help.
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Young Physicians Insights
The First Ever
MEDTALKS @Drexel Aleesha Shaik, Student, Drexel University College of Medicine
T
here is no dearth of education on the basic sciences, pathology, and pharmacology in medical school classes, but topics on health policy and medical humanities are often cut for time. Recognizing that such subjects are just as essential for patient care, the Drexel University College of Medicine’s chapter of the American Medical Association organized its first ever MEDTALKS @Drexel.
Third year medical student Winifred Wolfe spoke about her research on “Living ProACTively with HIV.”
Inspired by the TEDMed conference supported by the AMA, our slightly smaller scale version on February 25 aimed to bring forth ideas that are revolutionizing the face of medicine. The event featured experts in five different categories: health policy, technology and innovation, public health, humanities in medicine, and mental health. We also selected four student speakers to discuss their research in these fields. The final lineup of speakers (pictured below) included the former health commissioner for the city of Philadelphia, the co-founder of GraphWear Technologies, a former president of the Pennsylvania Medical Society, a laughter yoga therapist, and the deputy secretary for health promotion at the Pennsylvania Department of Health. Rajatesh Gudibande, co-founder of GraphWear Technologies, explained how smart sweat patches will impact fitness.
Speakers and Drexel AMA Board members from L to R: Rajatesh Gudibande, Adam Taylor, Tyler Barnum, Jessica Nambudiri, Winifred Wolfe, Yetunde Fatade, Dr. James Buehler, Shaharyar Ahmad, Mark Austerberry, Aleesha Shaik, Yoon Sung, Peggy Tileston, Dr. Marilyn Heine, Dr. Diane Gottlieb, Brandon Chu, Dr. Loren Robinson, Anamika Saha, Joy Fatunbi, Brian Park, Dr. Amy Fuchs, and Molly Russo.
Since February was Heart Health Month and Black History Month, we asked our speakers to incorporate cardiovascular health and racial disparities in medicine into their talks. Our goal was to showcase important current issues and innovative solutions to cultivate medical student and physician perspectives, and to gain a deeper understanding of the career that medical students are entering. Drexel AMA would like to thank all of the amazing speakers, the nearly 200 attendees, many of whom were students of other Philadelphia schools, and the faculty and staff at Drexel, PCMS, and PAMED for their support. It was a memorable night of learning and entertainment, and we can’t wait to make next year’s event even bigger and better.
Peggy Tileston, a professor at Temple University, showed the audience firsthand how laughter yoga can improve mental health. Summer 2016 : Philadelphia Medicine 29
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JEFFERSON, TEMPLE MED STUDENTS
THE ISSUE OF
Physician Assisted Suicide M. Tucker Brown Jefferson University Medical Student
f you think the question of physician assisted suicide (PSA) has pretty cut and dried answers, then you must have missed the March 16 debate at Jefferson University between Temple and Jefferson medical students. The two teams revealed the issue’s wide-ranging complications in a formal faceoff before a large crowd of their peers and professors.
Graeme Williams and Qinglan Huang presented the opening statements for Temple and Jefferson, respectively. Temple asserted that physician assisted suicide is “consistent with the basic principles of medical practice. That a patient’s right to informed consent recognizes that a patient of sound mind and
understanding has the right to determine their own medical course.” Jefferson put forward the following two points: “physician assisted suicide corrupts the entire practice of medicine, and the majority of patients seeking suicide can be much better treated via alternative means compatible with life.”
Moderator Ludwig Koeneke, a Jefferson medical student, chose Temple to argue in favor of legalizing physician assisted suicide, and Jefferson to present the rebuttal. The Temple team was composed of Graeme Williams, Diane Huang, Jigesh Baxi and Abe Khan. The Jefferson team consisted of Nithin Paul, Qinglan Huang, Jarett Beaudoin. I was also on this team. Before opening statements, members of the audience were given a brief background of physician assisted suicide in the United States, then asked to give their position on the matter. The anonymous polling results (disclosed following the post-debate poll) were 68% Yes, 24% No, and 8% Abstain. 30 Philadelphia Medicine : Summer 2016
The Teams for Temple and Jefferson pose for a photo opt following the debate. L to R: From Temple: Graeme Williams, Diane Huang , Jigesh Baxi, Abe Khan and from Jefferson: Quiglan Huang , Nithin Paul, Jarrett Beaudoin, Tucker Martin
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Med Students debate PSA
Koeneke then asked Temple to respond to Jefferson’s claims that PAS is unethical and contradicts the Hippocratic Oath. Temple cited a modern version of the oath which states: “‘most especially must I tread with care the matters of life and death. If it is given me to save a life, all thanks, but it may also be within my power to take a life. ...Above all, I must not play God.’” Jefferson responded: “So you talk about playing God; isn’t determining someone’s right to live or die, isn’t that playing God, by ending their lives?” Temple: “We put the decision in the hands of the patient. ...Our role is simply to offer the patient the information and allow them to make the decision. So ultimately it’s not the physician playing God, it’s allowing the patient to express their right of autonomy.” Jefferson: “You’re saying that as the doctor, we’re just trying to respect the patient’s wishes. Is that what we do when a patient walks in the ED and says, ‘Hey listen, I know I have pain, I want my pain med.’ Do we just give them the pain med? No. The doctor is involved in the decision-making process. Yes, we respect the wishes and the thoughts of the patient, but we are responsible for judging whether they are in the right state of mind... It’s not so simple as to say it’s just the patient’s choice and the doctor is just supposed to do what they want.” Temple: “...We very specifically support a position where physician assisted dying has many safeguards in place.” Temple went on to explain the regulatory mechanisms already in place in Oregon to ensure that lethal doses are only prescribed to those who truly meet the Oregonian requirements. To this, Jefferson stated that in Oregon “less than 6% of these patients were actually referred for psychiatric evaluation” and that the cause of death of as many as 15% of the patients’ prescribed lethal doses is unknown.
Team Temple makes a point that physician aid in dying is legal in certain states.
Team Jefferson points out that physician assisted suicide is a slippery slope with regards to vulnerable populations.
Temple: “I agree there are problems with the medical system; that doesn’t mean I’d get rid of all hospitals. ...So maybe we haven’t been doing it that well. Again, that doesn’t mean that the option should be removed from the table.”
through that process and have a happy life, get a law degree, get married, get divorced, get married again. He had a good life after that, but he still said ‘I wish they would have listened to me at that point, listened to me, respected my wishes and let me die.’”
The moderator then moved the debate back to the question of morality of physician assisted suicide.
Jefferson: “There is a clear distinction between allowing someone to die naturally, from natural causes—so not prolonging their death—and actively prescribing them lethal medication. Again, it goes back to the trust that our patients have for us. If they know that we are using our skills to kill individuals, how is it that they can put their reliance on us to cure them? The option of death is always going to be lingering in their minds. And that’s something we don’t want, to corrupt the medical profession.”
Jefferson: “Most of the arguments that you hear in favor of physician assisted suicide are regarding autonomy. ...But there are some critiques to that. There are patients who seek medical care, seek physician assisted suicide, that are totally mentally competent, they have good reasons, they are not being coerced, they meet all the criteria for physician assisted suicide; but they happen to go to a physician who is not willing. That physician says ‘look, I see value in you, let me help you, let me show that value to you’ and the patient also comes to see that value. So their autonomy, their choice, which we’re taking as a constant, their choice for physician assisted suicide changes? If we allow this system to go through, how many people who could have been saved and been with their families will be lost?” Temple: “It’s true that peoples’ decisions can change and situations can change. One perfect example of this is Dax Cowart. He had burns over 65% of his body and he wished to die. He told his physicians this over and over, but he was forcibly treated for ten months. After that, he was able to get
A final factor introduced by the moderator was the influence of financial burdens at the end of life. Temple: “In the clinic you can prescribe the medication you think is best, and someone will say ‘my insurance doesn’t cover that, that’s $300 a month. I can’t do it. I will suffer whatever consequences result from that.’ That’s unfortunate, but that’s a reality, and a reality that only the patient can decide. ...Is it my decision as the provider to step in and say money shouldn’t be part of this decision, or do I throw that decision to the patient and let them make that decision in the context of their own lives and their own economic situations.” Continued on page 32 Summer 2016 : Philadelphia Medicine 31
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Jefferson: “So you’re saying that the patient decides how they want to spend the money, right? ...It’s not that the insurance companies are the ones who decide which treatments are covered, maybe which incentives to give doctors? What is the goal of private insurance companies? We all know: trying to make profits. ...Now you have two options: one, prolong life; the other is quick death with a very cheap option: prescribing barbiturates. What do you think is gonna happen? Do you agree that market forces are going to come into play? ...Doctors are human beings; we’re susceptible to the structures within which we work. I think the flaw in your argument is that you’re presenting this whole thing solely from the patient’s perspective... when you bring all those other factors in you realize it’s not as clear-cut as ‘let’s just give the patients the chance to decide where to put the money.’”
The floor (and the twitter world) was opened for questions from the audience. The first question was directed to the Temple debate team.
Jefferson: “When you look at the aggregate data, it shows that yes, there is a slippery slope. The Netherlands went from it first saying that we’re okay with physician assisted suicide, to then doing euthanasia, to now advocating for infanticide for kids who they think will not have good quality of life. ...It’s happened in the Netherlands. America is no different. [The slippery slope argument] is a good point to keep in mind.”
Temple: “Finances go both ways and it’s kind of impossible to predict how it’s gonna work out. ...There’s a lot of money to be made on both ends: there’s a lot of money to be made by people who provide palliative care services, intensive care services, the hospital gets money. People get money from treatment and people can also save money from not treating. So it’s a little more complicated, it’s not that clear-cut. You can make that same argument about financial pressures on either side.” Jefferson: “Right now [with physician assisted suicide] you’re allowing people to make the decision to save their families’ money by choosing to end their life. There’s a difference between choosing not to get a pill or a vaccine…because of a lack of finances, there’s a difference between that and choosing to kill yourself because you are worried about being a financial burden on your family. ...And that’s what’s going on right now. 40% of people who are being assisted with suicide, the major motivation for them is they don’t want to be a financial burden. We value life so much more than that. And we don’t want people to die solely because they know that there’s an option to save their families money.” 32 Philadelphia Medicine : Summer 2016
Temple: “Frankly, [the slippery slope argument] is not one I’m a big fan of because it harps on fears. ...We’re not saying stop cancer research because there are a number of terminal cancer patients out there; continue with all that, but provide these patients with another option that is reasonable, that is consistent with medical ethics, that allows them the choice to decide that if their disease is so severe that they would be better off passing instead.”
To Temple: “How do you establish a metric for hopelessness of prognosis or unbearableness of pain before death that allows you to decide not whether or not death is the right option for somebody, but when it is the right option?”
To Temple: “[Jefferson] mentioned that Oregon does not adequately fund palliative care, but they more than adequately fund the death drugs. California has just passed the law that was part of a special session called together by the governor to determine how to cut healthcare costs. The only bill that was signed by the governor that came out of that special session was this assisted suicide bill. And California doesn’t adequately fund palliative care, but is adequately funding this process for lethal drugs. Aren’t we on a slippery slope here when it comes to this kind of care?”
Temple: “Every single day a part of our job is to sit there and talk with patients and hear what they tell us and interpret it through our medical lens, really to get a sense of where that patient is coming from and what they want based on how well we know them. As far as establishing a scale, I don’t think that can happen. I don’t think that’s a realistic option. I don’t think that would be fair to patients. What we can do is be there and support them and provide them options.” Jefferson: “What Temple has just told you is that there is no way to have a standard to measure that subjectivity. And that’s what we’re saying—there is no way that we can judge objectively whether someone should or should not die. ...That power cannot be in our hands as physicians because we are not playing God.”
Med Students debate PSA
THE PHILADELPHIA COUNTY MEDICAL SOCIETY
Temple: “Even considering the data regarding how often assisted suicide is not the product of an autonomous choice, isn’t there still a need for society to provide an outlet for planned, dignified death for the members of the population who are inevitably going to commit suicide? And who can be counted on to provide that outlet if not doctors? Jefferson: “I would argue against there being people who are inevitably going to commit suicide. ...Never should we say ‘Okay, we’ve tried five times, 10 times, 100 times. We’re done, we’re going to plan a nice death and end your life now.” Another member added: “That’s why we are really trying to promote palliative care. We’re not trying to promote this thing of do nothing as they have kind of presented us as. We’re saying that there are other options.” Temple: “[Patients seeking PAS] are people who are at the cusp of their pain. They’ve tried a lot of options, they’ve tried palliative care and they’re not having the best quality of life. As physicians, one of our duties is to provide the best quality of life.” With that, the debate concluded and the audience was polled for their second time. And these are the results: 49% Yes, 40% No, and 11% Abstain. The 19% shift away from supporting and the 15% shift toward opposing physician assisted suicide gave Jefferson the victory in the first ever Second Opinion debate of the Medical College Debate League. As pleasing as it is for Jefferson medical students to beat Temple students, bragging rights are far from the primary purpose of the debate. Rather, we hope that by presenting multiple perspectives on relevant medical issues, especially to future physicians, we can spark ongoing discussions that will lead to better care and protection for the patients entrusted to us. Drexel University College of Medicine and the Philadelphia College of Osteopathic Medicine are planning to debate in the fall. Topic suggestions are welcome.
2016 Upcoming Events & Programs All programs held at PCMS HQs unless noted
JUNE 9 PCMS Board of Directors Meeting
5:00 PM – 6:30 PM
28 HIV/AIDS Awareness Reception
5:30 PM – 7:00 PM
Meets quarterly to make financial decision on behalf of the Society.
Reception in recognition of the 30th Anniversary of Public Health efforts headed by the late U.S. Surgeon General, C. Everett Koop, MD (1916- 2013) in the centennial year of his birth.
JULY
7:00 PM – 8:30 PM
Women in Medicine Program Program on Gender Inequality.
20 PCMS Executive Committee Meeting
Meets once a month to plan PCMS meeting, agenda; conduct business between quarterly Board of Directors meetings.
5:00 PM – 6:00 PM
AUGUST 29 PCMS Resolution Review Committee Meeting
6:00 PM – 7:30 PM
SEPTEMBER
7 PCMS Board of Directors Meeting
Meets quarterly to make financial decision on behalf of the Society.
24 PCMS President Inaugural & Awards Night
Philadelphia Country Club, Gladwyne, PA
28 PCMS Executive Committee Meeting
Meets once a month to plan PCMS meeting, agenda; conduct business between quarterly Board of Directors meetings.
5:00 PM – 6:30 PM 6:00 PM – 10:00 PM 5:00 PM – 6:00 PM
OCTOBER 18 First District Caucus Meeting
6:00 PM – 8:30 PM
19 PCMS Executive Committee Meeting
5:00 PM – 6:00 PM
Meeting to review PAMED House of Delegate resolutions and reports.
Meets once a month to plan PCMS meeting, agenda; conduct business between quarterly Board of Directors meetings.
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PAMED UPDATES
Medicaid to Begin Reimbursing for Observation Services on July 1 Observation services happen when a patient is in the hospital, but not actually admitted as an inpatient. The Pennsylvania Department of Human Services (DHS) will now pay physicians for such work that takes place starting on July 1. PAMED has strongly supported the move, arguing that observation services are vital to determining whether a patient should be admitted to a hospital. DHS will now pay for medically necessary observation services provided in the hospital outpatient setting, when prescribed by a practitioner. You can find more details on this issue by visiting: www. pamedsoc.org/QuickConsult.
Urge Your State Senator to Vote “No” on CRNP Independent Practice Legislation The Pa. Senate Consumer Protection and Professional Licensure Committee has moved SB 717 one step closer to passage, by sending it to the full Senate. The bill would let Certified Registered Nurse Practitioners (CRNPs) become a separate profession that would be allowed to test, diagnose and treat patients without any consultation with doctors. The Philadelphia County Medical Society along with the Pa. Medical Society are strongly opposed to SB 717. Nurse practitioners do wonderful work, but we do not believe they are qualified to treat patients without physician oversight. Nurse practitioner training involves several hundred hours, compared to about 17,000 hours for physicians. Please contact your state Senator to express your strong opposition to SB 717, with or without amendment, and urge him or her to vote NO when this legislation comes up for a vote. Go to www.pamedsoc.org/TeamBasedCare to find talking points.
New App for Pennsylvania Physicians: Download to iPhone and Android Staying up to date on the latest news and advocacy issues impacting Pennsylvania physicians just became easier with the launch of the Pennsylvania Medical Society’s new mobile app. Go to: www.pamedsoc.org/app to download this app to your iPhone or Android device to receive daily news updates and act on important advocacy issues.
34 Philadelphia Medicine : Summer 2016
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PAMED UPDATES
PAMED Kicks Off Program to Address Safe Use of Opioids The Pennsylvania Medical Society (PAMED) recently met with lawmakers and the news media to make them aware of its latest effort to address the drug prescription epidemic—an initiative called “Opioids for Pain: Be Smart. Be Safe. Be Sure.” The program was introduced during PAMED’s daylong opioid symposium on May 17. The gathering discussed ways to help both patients and physicians understand the tools available to fight opioid abuse. The tools described, included the use and availability of naloxone, the opioid-reversal drug; how to conduct a warm handoff referral for drug treatment; an introduction to Pennsylvania’s prescription drug monitoring program that’s set to begin in August, and alternative drug treatment for chronic, non-cancer pain.
Here’s a Quick Summary of
“Be Smart. Be Safe. Be Sure.” The Physician Call to Action — All Pennsylvania physicians should take these five steps: 1.
Know the prescribing guidelines. They are available on PAMED’s website at www.pamedsoc.org/OpioidResources. The first module in PAMED’s online CME series focuses on the guidelines. Get the CME at www.pamedsoc.org/ OpioidsCME.
2. Use the prescription drug monitoring program (PDMP) once it’s up and running (it’s expected to be operational in August). The fourth module in PAMED’s online CME series will address common physician questions regarding governance, user access, and provider and dispenser reporting requirements. Watch PAMED’s Daily Dose email for when this is available. 3. Refer patients who have a substance use disorder to treatment. Referral into treatment is covered in the third module in PAMED’s online CME series. Get the CME at www.pamedsoc.org/OpioidsCME. 4. Discuss alternatives to opioids with patients. 5. Ask patients to keep their pills safe, and properly dispose of a prescribed medication when they no longer need it. A list of drug take-back locations is available at apps.ddap.pa.gov/GetHelpNow/PillDrop.aspx.
Symposium attendees came away with a greater understanding of the need to treat addiction like any other disease as well as the importance of physician education when it comes to fighting the opioid abuse crisis. In addition to hearing from several experts, attendees also watched a short video clip and learned more about the response to the opioid abuse issue from county and specialty medical societies. PAMED offers an online CME series on the drug abuse epidemic—“Addressing Pa.’s Opioid Crisis: What Health Care Teams Need to Know.” PAMED members can access this series for free at: www.pamedsoc. org/OpioidsCME.
Patient Empowerment— Patients should ask these seven questions when prescribed a pill for pain: 1.
Is this prescription an opioid?
2. At what level of pain should I take this prescription? 3. Do I have to take every pill in the prescription? 4. Where can I safely dispose of remaining pills? 5. What can I do to avoid addiction? 6. What are possible warning signs of dependence or addiction? 7.
What can I do if I believe that I might have developed a dependence on this drug?
Resources for physicians, patients, and lawmakers are available at www.pamedsoc.org/OpioidInfo. Summer 2016 : Philadelphia Medicine 35
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PCMS & Community News
We have presented two extensive articles in this issue of Philadelphia Medicine, on the overdose epidemic in our city. In the spirit of those articles, we are urging you to do your part to help save lives from overdoses by making yourself familiar with the naloxone protocol we are making available. Pennsylvania, like the rest of the nation, is currently suffering the worst overdose epidemic in history. Philadelphia is, unfortunately, working its way towards leading the nation in fatal overdoses—from 493 in 2013, to 655 in 2014—a 33% increase. Preliminary data shows that 2015 is even higher. To help combat this terrible loss of life and help save the lives of Pennsylvania’s most vulnerable, the General Assembly enacted Act 139, which became effective Nov. 29, 2014. This legislation, along with a standing order authorized in October of 2015, allows people to obtain and administer the antidote medication, naloxone—a medication that can reverse an overdose caused by an opioid drug, such as prescription pain medication or heroin. The standing order is intended to ensure that residents of the Commonwealth who are at risk of an overdose, or who are family members, friends or other persons who are in a position to assist a person at risk, are able to obtain naloxone. The standing order addresses the biggest barrier to responding to the overdose crisis —lack of access to life saving medication —by more explicitly encouraging health 36 Philadelphia Medicine : Summer 2016
care professionals to prescribe naloxone to eligible persons. The standing order may be used by eligible persons in lieu of a prescription, and expands the definition of those eligible for naloxone prescribing. This order also serves as authorization for pharmacists to dispense naloxone and devices for its administration in certain forms. Medical providers, however, are best suited to prescribe naloxone to their patients who are at risk of opioid-related overdoses. Eligible persons include people who voluntarily request naloxone, or who are at risk of overdose, including those who are: taking prescription pain relievers (i.e., Vicodin, Percocet, oxycodone) for more than three months; taking methadone or burprenorphine (Suboxone) for the treatment of opioid use disorder; having concurrent prescriptions for opioids and benzodiazepines; having experienced a previous non-fatal opioid overdose; any individual who is at risk of experiencing an opioid-related overdose; any family member, friend or other person who may assist an individual at risk for an opioid overdose.
As those best positioned to screen for overdose risk and address it, medical providers are uniquely positioned to help reduce overdose deaths. They can do this by assessing their opioid prescribing practices, with attention to duration and concurrent prescriptions, and actively prescribing naloxone HCl (Narcan, naloxone HCl or other generic equivalents) to at-risk patients or their friends and family members, and educating them on the proper use of these products. We understand that this new legislation may be confusing in terms of what is permissible and how prescriptions should be written. For this reason, we have written a naloxone dispensing protocol for prescribers to understand the proper administration of intranasal and intramuscular naloxone HCl. You can find the protocol on our website at: http://philamedsoc.org. Please help us address this health epidemic and significantly reduce unnecessary deaths from fatal opioid overdose.
Michael A. DellaVecchia, MD, PhD, FAC, FICS 154th President Priya E. Mammen, MD, MPH PCMS Public Health Committee
CONSIDER MEMBERSHIP in The Philadelphia County Medical Society
Membership in the Pennsylvania Medical Society and the Philadelphia County Medical Society go hand-in-hand, addressing the many issues facing the medical profession today and preserving the patient-physician relationship. PCMS Membership is available to all opathic (MD) and osteopathic (DO) physicians residing or practicing in Philadelphia County, who are in good moral and professional standing. Membership is also available to residents, fellows, medical students, and practice managers. The PCMS physician leadership and staff are committed to addressing the issues confronting medicine today, and we are pleased to have you as part of that effort. By making the choice to be a part of organized medicine, you are choosing to have a voice in the way you practice medicine every day.
Member Benefits Understand Regulatory, Licensing, & Reimbursement Changes...
Community Health...
We’re here to answer your questions about health system reform, licensure requirements, scope-of-practice, and reimbursement issues. One call could pay for your dues many times over.
PCMS takes an active role in the health of our local community. Our Block Captain Program provides education and access to primary care for residents who cannot afford healthcare. We also work with the Philadelphia Department of Public Health to develop and meet sound public policies.
Stay Current...
Discounted Rates...
Stay up-to-date on local, state, and national issues through our monthly member emails, quarterly magazine, legal and regulatory manuals, regular practice management meetings, and continuing medical education physician seminars.
Members get excellent rates on legal and business reviews of contracts through our legal referral program. We also provide group rates on liability, disability, long-term care, health, term life, and workers’ compensation insurances.
Advocacy...
Networking & Community Improvement Opportunities...
PCMS and PAMED have been committed to being your voice in state and national matters affecting the practice of medicine in our community.
PCMS provides opportunities throughout the year for physicians, residents, and medical students to meet, including a formal Awards Night. Join our speaker’s bureau, or participate in our “Docs on Call” live television program.
Apply Today Join the Philadelphia County Medical Society, and become more engaged in the decisions that impact your livelihood and the future of healthcare. Member Application:
http://philamedsoc.org/index.php/members/ pcms-application/
Resident & Fellows Application:
http://philamedsoc.org/index.php/members/ resident-fellows-application/
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PCMS & Community News
The Strittmatter Award: Recognizing Medical Excellence Over More Than Four Decades
I
n 1923 The Philadelphia County Medical Society (PCMS) created the Strittmatter Award, one of the most high prestige prizes in US medicine.
It all started when Dr. Isidor Strittmatter established a trust fund from whose income the PCMS was able to present each year a gold medal, and a citation acknowledging a physician who has made the most valuable contribution to remedial measures, surgical or medical, or to one of the fundamental sciences of medicine, having a beneficial influence on either medicine or surgery. By those exacting standards, Dr. Strittmatter himself would have been extremely well-qualified to receive the award for which he is named. An esteemed local gynecologist and surgeon, he received his M.D. at Jefferson in 1881, became a life member of PCMS in 1926 and its 67th president in 1928; adding a doctorate in law in 1930. Dr Luther Brady, who won the prize in 1999 and now chairs the Strittmatter Awards Committee, has described the process by which recipients are nominated and selected. I am impressed, he says, with the breadth and depth of the contributions winners have made; but he feels that the Award needs to be more widely known and celebrated.
This year’s Strittmatter Award winner is Dr. Julia Haller, who will receive her citation and gold medal during the PCMS annual meeting and presidential installation on September 24.
Dr. Haller is Ophthalmologist-in-Chief at Wills Eye Hospital and chair of the department of ophthalmology at Jefferson. One of the world’s most renowned retina surgeons, she has published over 300 scientific articles and book chapters and serves on the editorial boards of eight ophthalmological journals.
Among the 96 physicians who have received the Award: • Dr.George Pfahler, a diagnostic radiologist who did groundbreaking work in treating patients with benign fibrocystic disease of the breast, and whose name is immortalized by the Pfahler auditorim at PCMS headquarters. • Dr.Henry O.Bockus, a world-renowned gastroenterologist. • Dr. Isadore S.Ravdin, chair of the University of Pennsylvania’s Department of surgery and a major surgeon in the operation on President Dwight D. Eisenhower.
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• Dr.Katharine R. Sturgis, internationally recognized expert in preventive medicine and the first woman president of the College of Physicians of Philadelphia. • Dr.Baruch Blumberg, 1976 Nobel Prize winner for his discovery of the virus that causes hepatitis B, and who went on to become director of NASA’s Astrobiology Institute. • Dr. John H. Gibbon, the major developer of the heart and lung machine. • Dr. Jacob Gershon Cohen, who recognized the potential for mammogram examination, and for teleradiology.
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Recipients of the Strittmatter Award 1923 – William W. Keen, MD 1924 – Albert P. Brubaker, MD 1925 – James M. Anders, MD 1926 – J. Chalmers DaCosta, MD 1927 – Chevalier Jackson, MD 1928 – David Riesman, MD 1929 – George A. Knowles, MD 1930 – George E. Pfahler, MD 1931 – John A. Kolmer, MD 1932 – Lawrence A. Flick, MD 1933 – Philip F. Williams, MD 1934 – Charles W. Burr, MD 1935 – Seth A. Brumm, MD 1936 – William G. Turnbull, MD 1937 – Leonard G. Rowntree, MD 1938 – Samuel McC. Hamill, MD 1939 – John J. Shaw, MD 1940 – Rufus S. Reeves, MD 1941 – Joseph McFarland, MD 1942 – Hubley R. Owen, MD 1943 – Edward A. Strecker, MD 1944 – J. Parsons Schaeffer, MD 1945 – Francis F. Borzell, MD 1946 – Robert H. Ivy, MD 1947 – Pascal F. Lucchesi, MD 1948 – Catherine MacFarlane, MD 1949 – Esmond R. Long, MD 1950 – Charles L. Brown, MD 1951 – Henry L. Bockus, MD 1952 – W. Edward Chamberlain, MD 1953 – William Bates, MD 1954 – Isidore S. Ravdin, MD 1955 – Louis H. Clerf, MD 1956 – Stanley P. Reimann, MD 1957 – Lewis C. Scheffey, MD 1958 – Richard A. Kem, MD 1959 – Truman G. Schnabel, MD 1960 – William N. Parkinson, MD 1961 – T. Grier Miller, MD 1962 – John H.Gibbon, Jr., MD 1963 – Bernard P. Widmann, MD 1964 – Thomas M. Durant, MD 1965 – Eugene P. Pendergrass, MD 1966 – John Royal Moore, MD 1967 – Jonathan E. Rhoads, MD 1968 – William F. Irwin 1969 – David A. Cooper, MD 1970 – Joseph Stokes, MD 1971 – Jacob Gershon Cohen, MD
1971 – Samuel B. Hadden, MD 1972 – Herbert R. Hawthorne, MD 1973 – Katharine R. Sturgis, MD 1974 – William A. Sodeman, MD 1975 – Harold G. Scheie, MD 1975 – George E. Farrar, Jr., MD 1976 – Francis C. Wood, MD 1977 – George P. Rosemond, MD 1978 – Robert C. Austrian, MD 1979 – Baruch S. Blumberg, MD 1980 – William Likoff, MD 1981 – Brooke Roberts, MD 1982 – Richard M. Nelson 1983 – Robert S. Pressman, MD 1984 – John V. Blady, MD 1985 – Sol Sherry, MD 1986 – Herman Beerman, MD 1987 – Henry J. Tumen, MD 1988 – Lewis W. Bluemle, Jr., MD 1989 – Joseph Lee Hollander, MD 1990 – William Weiss, MD 1991 – John Y. Templeton, III, MD 1992 – Edward S. Cooper, MD 1993 – R. Robert Tyson, MD 1994 – Harold J. Isard, MD 1996 – John Helwig, Jr., MD 1997 – Donald Kaye, MD 1998 – Sylvan H. Eisman, MD 1999 – Luther W. Brady, MD 2000 – Francis E. Rosato, MD 2001 – Clyde F. Barker, MD 2002 – Doris Gorka Bartuska, MD 2003 – Paul C. Brucker, MD 2004 – William S. Frankl, MD 2005 – William Tasman, MD 2006 – Alton Sutnick, MD 2007 – Robert E. Campbell, MD 2008 – Hillary Koprowski, MD 2009 – Gerald J. Marks, MD 2010 – Carol L. Shields, MD 2010 – Jerry A. Shields, MD 2011 – Arthur H. Rubenstein, MBBCh 2012 – Edward D. Viner, MD 2013 – Audrey E. Evans, MD 2014 – Alfred A. Bove, MD 2015 – Bernard L. Segal, MD 2016 – Julia A. Haller, MD
J U N E 2016 (1– July 4) Fireworks Safety Month Cataract Awareness Month Men’s Health Month Myasthenia Gravis Awareness Month National Aphasia Awareness Month National Congenital Cytomegalovirus Awareness Month National Safety Month National Scleroderma Awareness Month (5) National Cancer Survivors Day® (19) World Sickle Cell Day
J U LY 2 0 1 6 Cord Blood Awareness Month International Group B Strep Awareness Month Juvenile Arthritis Awareness Month National Cleft & Craniofacial Awareness & Prevention Month (28) World Hepatitis Day
AUG UST 2016 Children’s Eye Health & Safety Month National Breastfeeding Month National Immunization Awareness Month Psoriasis Awareness Month (7 – 13) National Health Center Week (22 – 26) Contact Lens Health Week
Summer 2016 : Philadelphia Medicine 39