Allegheny County Medical Society - Bulletin - December 2021 by TEAM

Bulletin Allegheny County Medical Society

December 2021

In Memoriam Paul Warren Dishart, MD Who is covered under the CMS vaccination rule?

Allegheny County Medical Society

Bulletin December 2021 / Vol. 110 No. 12

Opinion

Departments

Articles

Editorial ................................345 Activities & Accolades.........355 Materia Medica .....................364 Stress Management Deval (Reshma) Paranjpe, MD, FACS

Editorial ................................348 Letters to Santa Richard H. Daffner, MD, FACR

Perspective ..........................353

Society News .......................359 • Pittsburgh Ophthalmology Society Upcoming Meetings

Dapagliflozin/Saxagliptin/Metformin (Qternmet XR®) Alexandria Taylor, PharmD Cassidy B. Williams, PharmD, BCPS

In Memoriam.........................362 Legal Report ........................368 Paul Warren Dishart, MD

The Doctor Never Examined Me Michael G. Lamb, MD

Who is covered under the CMS vaccination rule? Michael A. Cassidy, Esq

Special Report ....................370 Election Report

On the cover The Moon and Venus over Pittsburgh at Sunrise Mark E. Thompson, MD

Dr. Thompson specializes in Cardiology

For up-to-date resources on COVID-19, visit: www.acms.org/ covid-19-resources

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com)

2021 Executive Committee and Board of Directors President Patricia L. Bononi President-elect Peter G. Ellis Vice President Matthew B. Straka Secretary Treasurer Raymond E. Pontzer Board Chair William K. Johnjulio DIRECTORS 2021 Douglas F. Clough William F. Coppula David J. Deitrick Kevin O. Garrett Marcy L. Jackovic 2022 Ragunath Appasamy Mark A. Goodman Keith T. Kanel Maria J. Sunseri G. Alan Yeasted 2023 Steven Evans Bruce A. MacLeod Amelia A. Paré Maritsa Scoulos-Hanson Adele L. Towers PEER REVIEW BOARD 2021 Marcela BÖhm-Vélez Thomas P. Campbell 2022 Kimberly A. Hennon Jan W. Madison 2023 Lauren C. Rossman Angela M. Stupi

PAMED DISTRICT TRUSTEE G. Alan Yeasted COMMITTEES Awards Mark A. Goodman Bylaws Matthew B. Straka Finance Keith T. Kanel Gala Mark A. Goodman Membership Peter G. Ellis Nominating Bruce A. MacLeod

Associate Editors Douglas F. Clough (dclough@acms.org) Richard H. Daffner (rdaffner@acms.org) Kristen M. Ehrenberger (kehrenberger@acms.org) Anthony L. Kovatch (mkovatch@comcast.net) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Anna Evans Phillips (evansac3@upmc.edu) Maria J. Sunseri (mjsunseri@msn.com) Andrea G. Witlin (agwmfm@gmail.com) Managing Editor Meagan K. Sable (msable@acms.org)

ADMINISTRATIVE STAFF

ACMS ALLIANCE

Interim Chief Executive Officer Lisa Olszak Zumstein (lisa@acms.org)

Co-Presidents Patty Barnett Barbara Wible Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Sandra Da Costa Assistant Treasurers Liz Blume

Director of Publications Meagan K. Sable (msable@acms.org) Director, Medical Community Engagement Nadine M. Popovich (npopovich@acms.org)

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Improving Healthcare through Education, Service, and Physician Well-Being.

EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address. The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws, Articles 6, 8, and 11. The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication. Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted. The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted. Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products. Annual subscriptions: $60 Advertising rates and information available by calling (412) 321-5030 or online at www.acms.org. COPYRIGHT 2021: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212. ISSN: 0098-3772

Editorial

Stress Management Deval (Reshma) Paranjpe, MD, FACS

n old friend made an unusual request of me last month. He specializes in helping to rebuild the private sector economies of nations recovering from conflict, and has done work in Afghanistan, Southeast Asia, and Africa. This time his project involved Myanmar, where a military coup is currently in progress. Many of his team members were having trouble focusing on their critically important work due to the severe ongoing stress they were experiencing. My friend asked me, “Could you do a presentation on how surgeons manage stress? You’re a female surgeon, and my team is mostly female, and this message coming from you might resonate with them.” While I wasn’t sure anything I could say could materially impact women in a war-torn, Covid-ravaged country, my friend was convinced there would be a benefit. I’ve been making a concerted effort to pay things forward lately, and so, of course, I said yes. I learned a lot in the process, and I’d like to share these things in the hope that it could be helpful to you too. So how do surgeons manage stress? I considered my own coping strategies and those I had observed in colleagues and mentors from medical school onwards. I informally polled my

friends in various surgical specialties. Surgeons, as you know--or as you may be--are generally a stoic lot who characteristically internalize stress, grit their teeth and get the job done. Occasionally, the stress and toxicity that results flows downhill or laterally. Sometimes it regrettably comes home at night to family. Manifestations of stress include trouble with concentration and decision-making, fatigue, irritability/ anger, insomnia, rising early or sleeping more, decreased appetite/ eating more, hypertension, somatic complaints like headache/pain/ GI problems, loss of interest and anhedonia, and feeling sad, empty, hopeless or worthless. I would also add a sense of moral injury to this constellation. The high stress levels also lead to the highest suicide rates of any profession. A surgeon’s life involves long hours, little sleep, intense focus, high stakes, life-or-death missions, an unpredictable and never-ending workload, and no choice but excellence. In short, stress is a way of life. Every surgeon I know gives themselves some version of a pre-OR pep talk, usually at the scrub sink, that invariably includes some version of the following:

This is my purpose in life. The work I do is critically important to others. I have been trained to do this. If not me, then who? I am part of a team. I will get through this. Let’s visualize a successful outcome. Pray. Most surgeons I know are control freaks, because they must be in order to ensure good care. Many things are out of our control, especially in the heat of the moment. But if you have a plan, you can rely on the plan to get you through even though you may be panicking or frozen on the inside. So, the mantra becomes: Always be prepared for emergencies. Have contingency plans for every known contingency. Spend energy on things you can control. Make a solid plan before you start. Know you may have to quickly change the plan. Execute your plan without fear or hesitation. Remember: focus, speed, excellence. Most surgeons I know mentioned “leaving your troubles at the scrub sink,” and some enjoy the OR because it is a protected space where you could escape all the OTHER troubles in your life. Imagine that---embracing a high stress situation because it was an Continued on Page 346

ACMS Bulletin / December 2021

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Editorial From Page 345

escape from other stressful situations. It also works in reverse, though--some surgeons paradoxically choose high-risk or high-adrenaline activities for stress relief—be it racing cars or motorcycles, cutting down trees with chainsaws, or running marathons. (Some notoriously gravitate towards risky personal indiscretions). When asked why he liked to race cars for stress relief, one replied “You have to be so focused on driving that you can’t think about anything else; there’s no room for error.”

“Work hard, play hard” becomes a method of compartmentalizing. Benign stress relief options are more prevalent. Many surgeons run—a low risk but solitary activity that helps clear the mind and improve stamina. Exercise, meditation, dancing, social interactions with friends, humor, food and rest are all important. And a good family life is perhaps the most important as it provides a refuge against the world and is a protective factor in studies of surgeons and suicide while divorce is a risk factor. In many ways, surgeons are like highly trained soldiers with disease and trauma as the enemies. I wondered how Special Forces soldiers handled the insane amounts of stress and existential threat they face, so I did some research, i.e. reading Navy Seal Mental Toughness by Chris Lambertsen. What I found shocked me---their methods of coping are very much like the methods used by my surgeon friends outlined above.

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Lambertson outlines the secrets to mental toughness and how to achieve them. Motivation: Visualize a successful outcome. Confidence: You are well trained to do this. Focus: Hyper-focus on the task at hand. Composure: Keep calm and carry on. Resilience: Never give up. Overcoming Fear: Acknowledge your fear and keep going anyway. He also outlines seven ways to overcome fear and stress: Segment Your Goals: Break each task into manageable pieces and focus on each piece. Box Breathing Techniques: Inhale 4 counts, hold 4 counts, exhale 4 counts, hold 4 counts. Visualize Scenarios and Practice Solutions: Habituates you to possibilities of problems. Positive Self Talk: I can do this. Emotional Separation: Leave your troubles at the scrub sink. Contingency Planning: Always have a plan B, C, D…. Get in the Zone: No explanation needed!

The Navy Seals have a mantra to keep a positive mental attitude: Embrace the Suck. Lean into the discomfort and embrace it because it’s not going away soon. When things are at their most awful during Boot Camp Hell Week, laugh, sing and lead your compatriots in song to raise your spirits.

Find comfort in discomfort. Accept that every day is a challenge. Realize that you will grow, because confidence grows through challenge. Navy Seals’ survival is predicated on teamwork. So is ours. Nurture your family, and if you have no family, nurture your friendships so that you realize you are not alone. Geese flying south for the winter take turns being the “lead bird” in the V---no one can shoulder every burden alone. Help each other succeed; take turns resting and leading to avoid burnout. Finally, for everyone—no matter whether surgeon or physician, soldier or civilian: Notice and name your feelings. Most of us don’t realize why we are upset—just recognizing that you are scared or angry or lonely can help you deal better with distress. Try it. Self Care. Carve out time to eat, sleep, exercise, meditate, treat yourself, and just be. Therapy. It’s understandable to be stressed and depressed. A confidential therapist can help. Many take cash or credit cards, and some specialize in working with physicians

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Editorial with confidentiality concerns and can provide online/phone/zoom therapy. It is okay to take as well as to give care; give yourself permission to seek healing, receive care, and accept help. Also consider physiciansupportline. com at 1-888-409-0141 from 8 am-1am EST 7 days a week—a free confidential volunteer help line run by psychiatrists to support physician and medical student colleagues. This was started during the early days of the pandemic and is still going strong. Get help immediately if you feel suicidal. 800-273-8255 is the National Suicide Hotline for 24/7 confidential nonjudgmental help. Suicidal feelings will pass if you get help; you are worthy of love and too valuable to this world and to your loved ones and friends to lose.

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

ACMS Bulletin / December 2021

Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.

Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email membership@acms.org.

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Editorial

Letters to Santa Richard H. Daffner, MD, FACR “You can say there’s no such thing as Santa, But as for me and grandpa we believe.” Elmo & Patsy, “Grandma Got Run Over by a Reindeer”, 1979

o you believe in Santa Claus? Most children do. Most adults? I’m not so sure. I remember as a child, my friends and I eagerly awaited Santa’s annual visit to our houses to bring us presents. As I grew into my teens and then into adulthood, I, like so many others came to believe that the whole Santa story was a myth. Or was it? ***** It was December 15 and with ten days left until Christmas the scene at the old post office building was a beehive of activity. Although this was the busiest time of the year, it was also the happiest time for Postmaster John McMahon and his overworked staff. The spirit of the Season of Joy and Hope affected everyone, and all the postal employees handled their duties with a convivial air, surrounded by holiday decorations throughout the building. I’m Marty Buckley and I have 348

worked for the postal service for thirty years. McMahon and I began working at the post office at the same time and over the years we became best friends. We both started as route postmen. Mac, as we call him, rose steadily through the ranks to become Postmaster about ten years ago. I graduated from carrying mail on foot to driving one of the trucks. There were several aspects of this time of year which always amazed McMahon. First was the fact that no matter how hard economic times were, there was no scarcity of gifts being mailed. Some of them, he thought, must be expensive, judging by the sizes of the packages. Also, despite the rising cost of postage, there was no decrease in the number of holiday greeting cards being mailed. But most intriguing of all was the large number of letters children wrote to Santa Claus. “Hey, Mac. What do I do with these?” McMahon looked up from his desk and saw Harry Rogers, a postal clerk, holding a large plastic carrier box filled with letters. Mac took a handful of the letters and noted that each one was addressed in a similar fashion: Mr. Santa Claus North Pole, USA

McMahon sighed and said, “Kids will always believe in Santa. I know I did when I was their age. Sometimes I wish I could believe like that again. I guess we’ll just have to do the same thing we do every year; hold the letters until after Christmas and then burn them. Why don’t you put them in the large cart in the corner behind Parcel Post with all the other letters to Santa. They’ll be out of our way until we have time to dispose of them.” Harry shook his head and said, “It sure is a shame we can’t open them and see what the little ones are asking.” Mc Mahon nodded in agreement and added, “Yeah, they sure would be interesting. However, you know, as well as I that federal law prevents us from looking.” ***** Twelve-year-old Billy Johnson sat at the kitchen table in his home on the South Side of the city. He was bundled in two sweaters because the family had turned the heat down to save money. The pen in his hand had remained poised in mid-air above the letter he was trying to compose. Billy was the oldest of five children. He was aware www.acms.org

Editorial that this Christmas might be different from those past because his father had been out of work for many months after the local steel plant shut down. His three younger brothers and his sister were unaware of the seriousness of the family’s predicament, and he feared they would be suddenly jolted into reality on Christmas morning. He wondered if his siblings would notice that this year, they had a scrawny Christmas tree instead of the usual large plump one they had in the past. Finally, Billy found the words he needed: Dear Santa: I am 12 years old. Some of my friends say I’m too old to believe in you or even to be writing to you. Maybe they’re right, but what the heck. Anyway, my dad’s been out of work for a long time now. Mom says we won’t have any Christmas this year because we need to spend all our money on food and stuff. I have been working hard shoveling snow to earn some Christmas money, but with 3 younger brothers and a sister it just won’t go very far. If you could help us out in any way, it would be great. My brothers and sister would be happy with any toys. I could use a new pair of ice skates, as I outgrew my old ones and gave them to my younger brother Tommy. Mom and Dad could use some new clothes. I sure hope you can help us. Anyhow, Merry Christmas… *****

ACMS Bulletin / December 2021

At St. Theresa’s Orphan Home, seven-year-old Susie Baker stood at a window of the recreation room watching the snow fall. As Sister Maria approached, Susie jumped up and bubbled, “Ooh Sister Maria! Just look at that snow. Do you think we’ll have a white Christmas?” “Yes, Susie. I think we will.” Little Susie beamed and thrust forward a letter for Sister Maria to read. “I wrote it myself,” Susie said. “It’s to Santa Claus.” Dear Santa Claus, I live here at Saint Treesas Orfans Home with a lot of other kids. Father Murphy and the nuns take good care of us here. We were going to have a nice X-mas party this year but crooks came and stole our piano. Merry X-mas to you and Mrs. Santa and your elfs and your raindeer. Love, Susie…. ***** Across the city, Dr. Tom Jamieson stared at the woman on the bed in the intensive care unit of Good Samaritan Hospital. He shook his head in disbelief. According to medical theory, his patient, a 35-year-old mother of three should be responding to treatment for hepatitis. Instead, she had lapsed into a coma and was now visibly jaundiced. “I’m sorry. We’re doing the best we can, and she still not responding,” the doctor told the distraught husband, William Henderson and his three daughters.

“Doc, I know you’ve done everything. Is she going to die?” William asked. “I honestly don’t know,” replied Jameson. “I wish I knew why she is worse. All the tests say she should be getting better, but she isn’t.” “I suppose prayer wouldn’t hurt, said Henderson.” “Santa Claus could make mommy better,” said 9-year-old Amy Henderson, the youngest daughter. “Maybe if I wrote a letter to him…” Dear Santa Claus, I have never written to you before, but I always believed in you, even though I figured all those Christmas presents I got came from mommy and daddy. I know the ones I gave my parents and my sisters were bought by me. I’m not looking for presents Santa, but I have a big problem. My mom is very sick. The doctor says she has something that turned her all yellow. Anyway, they say she should be getting better but she isn’t and she’s getting worse. She sleeps all the time and won’t even jump if your stick her with a pin. The doctor says she may even die. I know you only give presents and maybe make some, too. But if you ever run into God at the North Pole, could you tell Him how sick my mom is and ask Him to make her better. I love you Santa Claus. PS if you see God tell Him I love Him too… Continued on Page 250

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Editorial On the South Side of town, George and Betty Johnson settled down in As the days neared December front of their scrawny Christmas tree 25,th the pace of work at the post after the children had finally gone to office quickened. More packages to be mailed; more cards to friends; more bed. Although it was Christmas Eve, there was an air of despondency in the letters to Santa. The pile of letters in household. George spoke first. “This is the cart in the corner behind Parcel the first time we haven’t been able to Post was growing. have a real Christmas. I’ve been laid off before, but it’s never been like this. “Those will make a nice bonfire,” Harry Rogers said as he added another Unless that foreign company buys the steel plant, it looks like I’ll be out of batch of letters to the cart. work for a long time.” From Page 249

December 24th. Christmas Eve was suddenly upon the city. Shoppers hurried from store to store to make last-minute gift purchases. In office buildings around town, parties were starting. At the post office the clerks were sorting the last batches of letters and packages before closing for the holiday. The large cart holding the letters to Santa was filled almost to overflowing. There must have been several thousand letters there. Postmaster McMahon was amazed at the number of people who still believed in Santa. As six o’clock came, the clerks began leaving the post office for home. It had been snowing since early afternoon and the ground was now covered with several inches of powdery snow. “A white Christmas after all,” Harry said to McMahon. “It’s perfect. Merry Christmas, Mac. And the same to your family.” “Merry Christmas, Harry.” Throughout the city, Christmas Eve was celebrated with traditional merriment. Carolers toured the neighborhoods serenading their friends with cheerful songs. Many parties were being held. 350

Betty looked at the few gifts they’d been able to buy for the children and replied, “I know honey, we always have hope. This is the season of hope. Maybe by next Christmas everything will be like it always was. You never can tell.” George shrugged. “Yeah, I sure wish I could share your optimism. I wish I could believe in Santa too. I understand Billy wrote him. I thought 12-year-old boys were too old for that. Maybe he knows something I don’t.” ***** At Saint Theresa’s Orphan Home, a bright fire burned in the large fireplace in the recreation room social hall. Festive decorations were hung throughout the old wood-paneled room. The children were gathered around the Christmas tree in the center of the room, where they were adding homemade decorations. The merriment of the children was tempered by the absence of the piano. Still, they sang Christmas carols without it.

Sister Maria looked at Father Murphy, wiped a tear from her eye, and said, “It’s so beautiful, Father. The piano would have made it perfect. The children miss it, as do I.” “I know, Sister. But we must make do with our lot,” he replied. “Cheer up we’re supposed to be happy. It is Christmas Eve, after all.” ***** Nancy Green, the nursing supervisor of the intensive care unit at Good Samaritan Hospital walked up to William Henderson and handed him a cup of hot coffee. “Mr. Henderson, I think it might be alright if you went home and spent Christmas Eve with the rest of your family. Your wife’s condition has been stable since this morning. We’ll call you if there’s any change. Henderson nodded and said, “You’re probably right. My staying here is not serving my family any useful purpose. Thank you for your kindness. Merry Christmas Ms. Green. Please wish the same to your staff for me and my family.” “Merry Christmas, Mr. Henderson.” ***** By midnight, the snow the stopped falling. Churchgoers attending midnight services were treated to a beautiful vista of a winter wonderland by the full moon that emerged from behind the clouds. It was a most inspiring sight and perhaps heralded the good tidings to follow later in the day. www.acms.org

Editorial In the old post office building, all was quiet. It was hard to believe that just a few hours ago this deserted place had been so alive with the Christmas spirit. As the moon came out, it shone through the rear window of the post office and a beam of light landed on the large cart filled with letters to Santa, sitting by themselves in the corner; letters that would never be delivered. As dawn rose over a perfect snowscape, church bells pealed, announcing the arrival of the natal anniversary of the Prince of Peace. Around the city most families awoke to the laughter and squeals as delighted children opened their new Christmas treasures. In some households, however, there was little joy because of the hard realities of serious everyday problems - poverty, unemployment, broken homes, and sickness. ***** “Mommy! Daddy! Mommy! Daddy! Come quick! Look what Santa brought us!” squealed three-year-old Lisa Johnson the youngest child. George, Betty, and the four boys, awakened by her cries of delight, ran into their living room. There, under the tree, which had been devoid of all but the most meager of gifts, stood a collection of brightly colored packages. There were toys and clothes for the children, new clothes for George and Betty, and in a box marked for Billy, was a new pair of ice skates. George and Betty stared in disbelief. Were they victims of a malicious joke? Or had Billy’s letter really been answered? ACMS Bulletin / December 2021

Just then the phone rang. George picked it up. “George! Merry Christmas!” Shouted the voice on the other end. It was Dave Farmer, George’s foreman at the plant. “George did you hear? They are going to reopen the plant next week. That foreign company has bought the plant and they’re rehiring everybody! Some Christmas present, eh? I’ve never believed in Santa Claus but I’m sure going to do it from now on. Wish the family a Merry Christmas for me. Bye.” George stared at the phone. “There is a Santa Claus,” he whispered. “There really is a Santa Claus!” “What did you say, George?” asked Betty. “There is a Santa Claus! There really is a Santa Claus!” he shouted. ***** “Father Murphy! Father Murphy! Sister Maria! Sister Maria!” came the chorus of fifty happy children’s voices. Look at what Santa brought us! Father Murphy rubbed his glasses clean and looked in the corner of the social hall recreation room of Saint Theresa’s. There, surrounded by the children, stood a brand-new piano. “How did it get here?” asked Sister Maria. “Santa brought it! Santa brought it! I wrote a letter to him!” squealed little Susie Baker. “I always knew he would.”

Father Murphy was prepared to dismiss Susie’s theory. However, as a man of faith he also believed in miracles. Almost instinctively, however, he gazed upon the ashes in the fireplace. And then he saw them, two distinct footprints. “Christmas is a time of miracles,” said Father Murphy, with tears in his eyes. “Children I believe we have seen one here today.” ***** “Merry Christmas, Dr. Jamison. This is Nancy Green in the ICU. Good news! Mrs. Henderson is out of her coma.” “Unbelievable. When did it happen?” “I’m not exactly sure when, sir. But not 10 minutes ago she walked up to the nurses’ station to ask where she was and when she could get breakfast. it scared the dickens out of us. We checked her over and she seems fine,” she said. “She’s sitting up in bed asking for her family and for something to eat. And, the jaundice is gone!” Doctor Jamison replied, “That’s the best Christmas present the Henderson family could ever have received. I’ll call them right away and then I’ll be right in to see her. Merry Christmas Mrs. Green. Merrrrrry Christmas! “ ***** December 26th is always anticlimactic. At the post office, work returned to its usual load. Who would have thought that just two days previously the place had been madhouse?

Continued on Page 352

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Editorial From Page 251

“Harry, I guess it’s time to get rid of those letters to Santa. Get a couple of the men on it right away.” “Right, Mac.” Harry Rogers “volunteered” two clerks to come with him to the corner behind Parcel Post where the cart filled with the undelivered letters to Santa stood. When he got there, he was quite surprised to see that the letters were gone. The cart was empty. “Mac those letters are gone. Did anyone move them?” asked Harry. A quick check of the other employees confirmed nobody had touched the letters. A call to Sam, the janitor, also revealed that the letters had been in the cart when he cleaned up on Christmas Eve. McMahon went to the scene of a possible mail theft.

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As he peered through the window expecting to find a trail left by the culprit, he was shocked by what he saw in the alleyway below. There were boot prints going from below the window to a set of parallel lines about three feet apart in the snow. The lines continued for about a dozen feet or so and then abruptly stopped. There were no other prints in the fresh snow. “Sure, it makes sense. Letters to Santa. Tiny sleigh tracks. Red suit. Mac, you’re

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The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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dreaming all of this aren’t you,” he thought to himself. “But on the other hand, maybe he really does exist. I wonder …” So, do you believe in Santa Claus? Most children do. Most adults? Well, we know some do believe in him. I certainly do. May your Holiday Season, however you celebrate it, be merry.

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“Impossible,” he said. “Who’d want to steal a pile of kids letters to Santa Claus. There must be a rational explanation for this.” Just then a cold draft caused him to direct his attention upward. The window above the empty cart was ajar. McMahon climbed up to the window on a chair. His eye caught notice of a small piece of red woolen cloth snagged on the latch. “So, there was a break in!” he muttered to himself.

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Perspective Perspective

“The doctor never examined me” Michael G. Lamb, MD

recently accompanied an elderly, former patient to the ER of one of Pittsburgh’s major medical centers. The patient was not skilled at navigating the modern medical maze, hence my attempt as a semiretired internist to help her. She was having episodes of positional dizziness and had just had a near syncopal episode. Her oral intake had not been good, she was urinating frequently and she appeared quite pale. I was concerned about several issues including fall risk, mild volume depletion, and possibly significant anemia. The ER was busy but not “crazy busy.” We were in an exam room in less than 20 minutes from arriving. A nurse came in and obtained vital signs. In the process of evaluating the woman, the ER physician took a brief history and agreed that the patient looked pale. A blood testing panel was obtained, as was an EKG, chest x-ray, and urinalysis. Intravenous D51/2NSS was also started because “she looks a little dry.” To my amazement, the ER physician never examined or even touched the patient. I wondered, shouldn’t one check for carotid bruits? What about heart murmurs? Might not aortic stenosis or aortic insufficiency present this way? Plus, she was urinating frequently. Was her bladder

distended? Was there CVA or bladder tenderness? What about checking her gait for fall risk? Was there any orthostatic change in vital signs? The amazing thing about this evaluation is that it is not unusual. Not too long ago, a resident or staff physician that failed to examine a patient properly would have been disciplined. I never in the past encountered a “no examination” case. I suspect that if that had occurred back in (those ancient times when I trained) (the 1980’s), the doctor would have been fired and justly so. About an hour later the doctor returned and briefly but kindly informed the patient that she was mildly anemic and a little dehydrated, but the rest of the testing was OK. That wasn’t quite true. She had pyuria and a mild leukocytosis. Then, the doctor left saying that the nurse will go over the rest and you can go home. That wasn’t quite true. She had pyuria and a mild leukocytosis. A stethoscope was hanging on her IV pole. A reflex hammer was in a nearby drawer, an otoscope and ophthalmoscope hung from the wall mount (they were dusty). I used the equipment to examine her myself and reassured her that nothing was missed but she probably also had a UTI (the bladder area was tender). I

told her I would order her an antibiotic for that. After this, she felt more confident in the overall evaluation.

The laying of hands on the patient remains a crucial part of the medical examination, even if only for the reassuring value of the physical contact. A few years ago, Artandi and Stewart wrote a seminal review article for Medical Clinics of North America on the value of physical examination. They concluded “The physical examination in the outpatient setting is a valuable tool. Even in settings where there is lack of evidence, such as the annual physical examination of an asymptomatic adult, the physical examination is beneficial for the physician—patient relationship. When a patient has specific symptoms, the physical examination in addition to a thorough history can help narrow down, or in many cases, establish, a diagnosis. In a time where imaging and laboratory tests are easily available, but are expensive and can be invasive, a skilled physical examination remains an important component of patient Continued on Page 354

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Editorial Perspective Perspective 399 Butler St., Etna evaluation”. Others bemoan howroad For a culinary cross-country physical is now “a lost trip, stopexamination in this converted auto service art” or “a declining skill” that can have station for a taste of roadside delights regrettable consequences. (2,3,4) Still from coast to coast from Chef Anthony others maintain that it is still one of Tripi. Twenty draft beers and fun the “4 pillars of cocktails to clinical boot. bedside medicine” andAdda that itBazaar, needs to725 be Penn reemphasized Ave., in clinical teaching. (5) Unfortunately, Downtown there not that manyCoffee really skilled Thearenewest of Adda & Tea clinical proficientcafes. in physical House’sexaminers multiple downtown Adda diagnosis that are still practicing. is the term for the long Bengali tradition We need to invest in thisdiscourse before it iswith of stimulating intellectual too late. friends over tea and coffee. Here’s your And oh yes, geta chance to try theour artpatient of Adda,didwith aselection call fromofthe ER about 50 hours fine teas and coffees. later. SheBakery was told she had a “bladder Three Square delights: infection” and that an ER physician AVP, Bakery Square, 6425 Penn was call in an antibiotic. Ave.,going EasttoLiberty Fortunately, that had already been Fans of Big Burrito’s Alta Via pizza started two days in Fox Chapel canearlier. venture to Bakery Square to try the casual California style Michael G. of Lamb M.D. AVP. Enjoy Italian cuisine its cousin, Medical Director seasonal vegetable-forward dishes atholic Charities Pittsburgh for as C well as pizzas andofsandwiches Medical Clinic lunch and dinner seven days a week. täkō, Bakery Square, 6425 Penn Ave., East Liberty Love the downtown Richard DeShantz jewel of a restaurant called täkō, but can’t get a reservation in the crowded space? Come enjoy its vast Bakery Square outpost, complete with 5000 square feet of space and both indoor and outdoor dining. Galley – Bakery Square, 6425 Penn Ave., East Liberty Galley – Bakery Square is the

latest branch of the Galley restaurant incubator concept, featuring the same References formula as its sister sites Federal Galley Artandi, K, Stewart, W, on1.the NorthMaja Side and theRosalyn Strip District “The Outpatient Physical Examination”, location. Four emerging chefs are Medical Clinics of North America 2018 selected to open their own restaurant May, 102(3); 465-473. within the space, with 12-18 months to win over an audienceVoin, andVlad, establish 2. B ilal, Muhammad, Topale,their brand. YouIwanaga, can tryJoe, a little of everything Nitsa, Loukas, Marios, R Shane, “The Clinical fromTubbs, all four restaurants duringAnatomy the of the Physical Examination of the same meal – heaven for foodies. Abdomen: A Comprehensive Tupelo Honey, 100 West Station Review; Clinical Anatomy 2017 Square Drive, South Side April;30(3):352-356. Craving fried green tomatoes, buttermilk biscuits, shrimp andHasan, grits 3. Asif, Talal, Mohiuddin, Amena, Badar, Pauly, Rebecca R, “Importance and banana pudding – and oh yes, Thoroughand Physical Examination: friedofchicken waffles? TupeloA Lost Art, Cureus 2017 May 1212-1214. Honey Café will open this fall in Station Square to remedy that,A.in“The style. 4. Feddock, Christopher Lost Art Con AlmaSkills”, Downtown, 613 Journal Penn of Clinical The American Ave., of Downtown Medicine 2007 April Vol 120, No. 4.pages The new374-378. jewel of the Downtown Cultural District features insanely good 5. Stanger,D., Wan,D., Moghaddam,N., Miami/Latin/Caribbean cuisine along Elahi, N., Argulian,E., Narula, J., and withAhmadi,A., live jazz. 2019 July. “Insonation Gaucho Parrilla Argentina, 146 versus Auscultation in Valvular DisorSixth St.,Is Downtown ders: Aortic Stenosis the Exception? A Systematic of The residentReview”, jewel ofAnnals the Downtown Global Health, 85(1), p.104.DOI://doi. Cultural District dazzles with an org/10.5334/aogh.2489. incredible array of steaks and wood fired meats with a variety of sauces and accompaniments. Takeout and dine-in available. Wild Child, 372 Butler St., Etna The brainchild of Chef Jamilka Borges, Wild Child emphasizes coastal and island cuisine and is sure to delight. Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver

Chef Kevin Sousa’s new project will combine a wine shop, bar and pizzeria in the former Kullman’s Bakery space. Sustainable, biodynamic and organic wines from around the world will be doctor, anyone featured Aalong withlike a down to earth, else who has to deal rustic menu. Nonalcoholic wines and cocktailswith alsohuman will be beings, showcased. each of them unique, G’s On Liberty, 5104 Liberty Ave., Bloomfield cannot be a scientist; G’s turns he isformer either,Alexander’s like the Italian Bistro into a seasonal scratch kitchen surgeon, a craftsman, with creative food and cocktails. or, like the physician Coming in the fall. and the psychologist, an And finally … artist.Gourmet, This means that Chengdu McKnight in order to be a good Road, Ross Township doctor a man (the mustbeloved also Chengdu Gourmet have a good character, James Beard-nominated Squirrel Hill hole-in-the-wall restaurant that is toSichuan say, whatever that regularly inspires pilgrimages weaknesses and foibles from all over he Western PA) is he planning may have, must an outpost love on McKnight Road at the site of his fellow human the former Oriental Market, in the plaza beings in the concrete next to Red Lobster. This will offer good a much and largerdesire diningtheir space – 6,000 before hisan own.” square feet – and expanded dining menu. Something to look forward to in — W. H. Auden early 2022. Enjoy, and be safe.

Quote Corner Perspective

“

FromRear PageEnd 353 Gastropub & Garage,

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@hotmail.com. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

Improving Healthcare through Education, Service, and Physician Well-Being. ACMS Bulletin / August 2021 354

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Activities & Accolades Perspective AAO Honors Pittsburgh Ophthalmology Society (POS) Members at AAO Annual Conference The Pittsburgh Ophthalmology Society congratulates the following members who received distinguished awards from the American Academy of Ophthalmology (AAO): 2021 Hall of Fame Award: Kenneth Cheng, MD 2021 Straatsma Award: Evan “Jake” Waxman, MD, PhD The AAO recognizes its members for several different types of achievements. These awards honor ophthalmologists in multiple stages of practice and for a range of activities, from humanitarian service and significant contributions to the profession, to mentorship and faithful volunteer service. Dr. Cheng and Dr. Waxman received their awards during the AAO Annual meeting in New Orleans, November 13-15, 2021.

ACMS Bulletin / December 2021

2021 Straatsma Awardee: Evan “Jake” Waxman, MD, PhD The American Academy of Ophthalmology (AAO) and the Association of University Professors of Ophthalmology (AUPO) are proud to present this year’s Straatsma Award for Excellence in Resident Education to Evan “Jake” Waxman, MD, PhD. The award recognizes and celebrates Dr. Waxman’s achievements as a residency program director in ophthalmology. Dr. Evan “Jake” Waxman is the vice chair for education at the UPMC Eye Center at the University of Pittsburgh. He has served as the director of medical student activities in his department since he started at Pitt in 1999 and as residency program director since 2004. He is proud to be a graduate of the MD, PhD program at Mount Sinai School of Medicine and to have had Steven Podos as a mentor. He is equally proud to be a graduate of the residency program at UC Davis and to have had the opportunity to have trained under AUPO members Drs. John Keltner and Mark Mannis. Dr. Waxman is the recipient of numerous medical student teaching awards including the William I. Cohen Award for Excellence in Teaching, the Kenneth Schuitt Award recognizing the Dean’s Master Educators and the AUPO’s own Excellence in Medical Student Education Award. He has received numerous resident teaching awards and is currently the chair of the AAO Resident Self-Assessment Committee. He served two terms on the AAO Committee for Resident

Evan “Jake” Waxman, MD, PhD Education and is a past president of the AUPO Program Director’s Council. He serves as the AUPO’s liaison to the Organization of Program Directors Associations. Dr. Waxman is the founder and director of Pitt Med’s Guerilla Eye Service (GES), an outreach effort that brings eye care to neighborhoods and people that would not otherwise have access. GES makes use of portable equipment and the energies of medical students, residents and faculty to provide complete eye exams at primary care clinics for indigent patients. Dr. Waxman has been recognized with the Pitt Chancellor’s Award for Service, the Jefferson Award, the Gold Humanism Society’s Leonard Tow Award and Carnegie Science Catalyst for Professional and Community Education Award for these efforts.

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Activities & Accolades Perspective Secretariat for State Affairs 2021 Hall of Fame Award Kenneth P. Cheng, MD Kenneth P. Cheng, MD has spent his entire medical career with a passion for patient advocacy. He has devoted himself over many years to protect ophthalmology as a profession and the high standards of surgical safety and quality eye care for patients. Throughout his 32 years as an ophthalmologist, Ken has publicly called for individual involvement in advocacy and has been an active leader in organizations at every level. As a board member of the Pittsburgh Ophthalmology Society where he served as president from 2003-2005, he continues to serve as its legislative chair. He has sat on the board of the Pennsylvania Academy of Ophthalmology since 2002 and served as its president from 20092011. He became their Secretary of Legislation and Regulation in 2014 and continues to be a strong advocate in the state legislature advising the board as its Secretary of Public Health. He has also held leadership positions in the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). He is an AAO Councilor Emeritus and served as both a member, and later chair of the Academy’s Surgical Scope Fund Committee where he proved himself repeatedly by strategizing, raising funds, and battling a rising number

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Kenneth P. Cheng, MD of scope of practice bills across the nation. He also served as a regional representative to the Secretariat for State Affairs representing the Metro East (DE, NJ, NY, PA). Dr. Cheng continues to work locally in Pennsylvania alongside state lawmakers to protect patient safety and preserve the ophthalmology-led eye care team. He was instrumental in the successful passage of 2020 legislation that defines and restricts surgical eye procedures to ophthalmologists in Pennsylvania.

Perhaps most impressive is Dr Cheng’s commitment to educating other ophthalmologists, starting from residency, in the importance and methods of effective advocacy. He has mentored, encouraged, and inspired numerous ophthalmologists to get directly involved in patient advocacy efforts and active in their ophthalmology societies, thereby helping to create future leaders in ophthalmology. Dr. Cheng attended the University of Pittsburgh for both his bachelor’s and medical degree. He went on to complete his ophthalmology residency at the Eye and Ear Hospital of Pittsburgh and completed his Pediatric and Strabismus fellowship at Children’s Hospital of Pittsburgh. He joined a group pediatric practice early on, but soon after launched a solo practice in suburban Pittsburgh where he continued to practice until retirement in June of 2021. The Secretariat for State Affairs is honored to present Dr. Cheng with its 2021 Hall of Fame Award.

Dr. Cheng championed a vision screening bill, also enacted in 2020, that provides necessary childhood vision screening without requiring multiple costly and often unnecessary comprehensive examinations for all school age children as required by a competing optometric supported bill. www.acms.org

Activities & Accolades Perspective Editorial Rear End Gastropub & Garage, 399 Butler St., Etna For a culinary cross-country road trip, stop in this converted auto service station for a taste of roadside delights from coast to coast from Chef Anthony Tripi. Twenty draft beers and fun cocktails to boot. Adda Bazaar, 725 Penn Ave., Downtown The newest of Adda Coffee & Tea House’s multiple downtown cafes. Adda is the term for the long Bengali tradition of stimulating intellectual discourse with friends over tea and coffee. Here’s your chanceJason to try the art of Adda, with Karlawish, MD a selection of fine teas and coffees. Three Bakery Square delights: Pennsylvania Geriatric AVP, Bakery Square, 6425 Penn Society Fall Program Ave., East Liberty Fans of BigJason Burrito’s Alta Via pizza featured in Fox Chapel can venture to Bakery Karlawish Square to try the casual California style Italian cuisine of itsGeriatrics cousin, AVP. Enjoy The Pennsylvania Societyseasonal vegetable-forward dishes Western Division virtual fall program as well pizzas and sandwiches was heldasWednesday, November for lunch and dinner seven days a week. 10, 2021. Thank you to Presbyterian täkō, Bakery Square, 6425 Penn SeniorCare Network who sponsored Ave., East Liberty the program and to the Jewish Love theFoundation downtown Richard Healthcare for providing DeShantz jewel of a restaurant called technical support. täkō, but can’t get a reservation in the Over 65 internists, crowded space? Comefamily enjoy its vast practitioners, geriatricians, Bakery Square outpost, complete with pharmacists, nurses, nursing 5000 square feet of space andhome both administrators and social workers indoor and outdoor dining. attended popularSquare, event to6425 welcome Galleythis – Bakery distinguished guest faculty and Penn Ave., East Liberty Galley – Bakery Square is the

author Jason of Karlawish, present latest branch the GalleyMD restaurant The Problem of Alzheimer’s: How It incubator concept, featuring the same Became A Crisis & What We Need formula as its sister sites Federal Galley To on Do theAbout North It. Side and the Strip District During his presentation, location. Four emerging chefs are Dr. Karlawish reviewed therestaurant history of selected to open their own Alzheimer’s beginning with start to within the space, with 12-18 the months of Alzheimer’s Association in their winthe over an audience and establish 1980 then proceeding to present day brand. You can try a little of everything medical news. from all four restaurants during the

same meal – heaven for foodies. HeTupelo emphasized theWest crisis Honey, 100 Station Square Drive, South Side based on the numbers - 6 Craving fried green tomatoes, million Americans are directly buttermilk biscuits, shrimp and grits affected the disease and bananabypudding – and ohplus yes, fried number chicken and Tupeloand the of waffles? caregivers Honey Café will open this fall in Station family members. Square to remedy that, in style. Conalso Alma Downtown, 613 Penn He reviewed the healthcare Ave., Downtown systems’ failures and potential The new jewel ofprovide the Downtown solutions in helping a better Cultural District features insanely good quality of life for all Alzheimer’s patients Miami/Latin/Caribbean cuisine along and caregivers. Questions were with live jazz. taken from the internet audience and Gaucho facilitated byParrilla Dr. NeilArgentina, Resnick and146 Dr. Sixth St., Downtown Judith Black. The resident jewel of the Congratulations to the (5)Downtown book Cultural District dazzles with an winners: Todd Goldberg, Elizabeth incredibleLinda arrayRoberts, of steaksRichard and wood Mohan, fired meats with variety Zhu. of sauces Hoffmaster andaSharon andInaccompaniments. Takeout and conjunction with the program, dine-in available. the annual fall business meeting was Wild 372 Butler St.,Black, Etna held andChild, conducted by Judith brainchild of Chef JamilkaPrior MD,The MHA, Secretary/Treasurer. Borges, Wild Child emphasizes coastal to the program, Amy Kowsinky with and island cuisine and is sure to delight. Presbyterian SeniorCare Network, Mount Oliver Bodega, 225 presented Dimension 360 to Brownsville Road, Mt. Oliver attendees.

Chef Kevin Sousa’s new project will combine a wine shop, bar and pizzeria in the former Kullman’s Bakery space. Sustainable, biodynamic and organic wines from around the world will be featured along with a down to earth, rustic menu. Nonalcoholic wines and cocktails also will be showcased. G’s On Liberty, 5104 Liberty Ave., Bloomfield G’s turns former Alexander’s Italian Bistro into a seasonal scratch kitchen with creative food and cocktails. Coming in the fall. And finally … Chengdu Gourmet, McKnight Road, Ross Township Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining menu. Something to look forward to in early 2022. Enjoy, and be safe. Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@hotmail.com. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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Activities & Accolades Perspective A graduate of the University of Dayton with a major in marketing, Mary Ellen serves as a member of POWER’s event committee and has volunteered as an ESL (English as a Second Language) tutor for Literacy Pittsburgh. Mary Ellen’s references describe her as…

• Close to being unflappable as anyone I’ve ever met!

Mary Ellen Muth

ACMS welcomes Mary Ellen Muth as new Association Manager Please join us in welcoming Mary Ellen Muth to the Allegheny County Medical Society Team! Mary Ellen brings more than 15 years of experience in communications and development, project management, community relations, stewardship, media relations, special events planning, and content development. Most recently, she was the Administrative Manager for The Denis Theatre Foundation and prior to that was the Assistant Director of Communications for POWER (Pennsylvania Organization for Women in Early Recovery). In these roles, she developed and executed strategic communications plans, coordinated event logistics, served as a liaison for corporate sponsors and produced outcome analytics.

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• A true pleasure to work with, always pleasant and approachable. •S omeone who came to our organization during a tough spot and got up-to-speed so quickly, it felt seamless. •S omeone who can be trusted with anything. • A wonderful team player. • Willing to wear many hats. • A clear thinker…knows how to make a plan and see it through from start to finish!! We look forward to her arrival on Dec. 8 and to announce her appointment as administrator for the association management groups that she will oversee; The Pennsylvania Geriatrics Society – Western Division and The Southwestern Pennsylvania Chapter of the American College of Surgeons.

LEGAL AND COMPENSATION ANALYSIS OF PHYSICIAN EMPLOYMENT AGREEMENTS Looking at a new position, or to renegotiate your current employment agreement? Physician Agreements Health Law is a Pennsylvania law firm that focuses on physician employment agreements in all 50 states. Get our comprehensive, fixed fee legal review and compensation analysis so you can get a fair deal and peace of mind. https://pahealthlaw.com/

www.acms.org

Society News Pittsburgh Ophthalmology Society—Upcoming Monthly Meetings The remaining guest faculty are set for the upcoming December, January, and February (2022) monthly meetings. All meetings take place at the Rivers Casino, centrally located on the North Side, with free parking. Valet parking is also available for a small fee. The ballroom, located on the second level is a non-smoking facility and provides ample social distancing space. The facility adheres to strict food and beverage serving guidelines and follows all CDC protocol. The Society’s top priority is the health and safety of all participants. We will continue to monitor regulations and recommended guidelines set forth by the Centers for Disease Control and Prevention (CDC) and notify members should a change in the meeting be deemed necessary To begin the new year, the POS will reconvene on January 6 and looks forward to welcoming Gregory S.H. Ogawa, MD, an ophthalmologist with Eye Associates of New Mexico, Albuquerque, NM.

ACMS Bulletin / December 2021

Dr. Ogawa specializing in problems involving intraocular lenses, irises, cataracts, and corneas. He manages complex patient cases, often for the underserved, routinely treating monocular patients and infants and children with cataracts as well as performing ocular reconstructive procedures for eyes that have experienced a range of injuries. At Eye Associates of New Mexico, he serves as the medical administrative officer in addition to his patient care activities. Dr. Ogawa has designed multiple surgical instruments with the goal of making eye surgery safer and more effective. He has also developed, presented, and published new surgical techniques in the area of iris reconstruction and suture fixation of intraocular lens implants. He helped advance and disseminate new surgeries such as endothelial keratoplasty—implantation of miniature telescopes for patients with macular degeneration—and soon, the implantation of custom artificial irises. Thank you to Zachary Koretz, MD for inviting Dr. Ogawa.

David A. Crandall, MD rounds out our 2021-2022 speaker series and will join POS members on February 3, 2022. Dr. Crandall is a staff ophthalmologist with Henry Ford Eye Care Services Department of Ophthalmology, Henry Ford Hospital, Detroit MI. Dr. Crandall is a graduate of University of Michigan in Ann Arbor and the Creighton University School of Medicine in Omaha, Nebraska. Thank you to Ian Conner, MD, PhD for inviting Dr. Crandall and to Aerie Pharmaceuticals for support of the program. Registration is handled on-line only. Please visit the POS website periodically for updates and to register, www.pghoph.org. Contact Nadine Popovich, administrator to confirm the status of your membership or to inquire about upcoming program. She can be reached by email: npopovich@acms. org or by phone: 412.321.5030.

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Society News

2020-2021 ACMS Foundation Gala Is a “Virtual” Success It was an evening of elegance and admiration when the Allegheny County Medical Society Foundation held its annual Gala fundraiser Thursday, October 7, 2021. Due to the pandemic restrictions, the event was a virtual gala that convened ACMS members and supporters via a live-streamed YouTube event. The Gala honored excellence among ACMS members and community organizations, celebrated the dedication and resilience of the region’s physicians, and raised funds for a very special purpose: supporting the development of Community Partners in Asthma Care, a comprehensive treatment and prevention program for children with asthma in the underserved Mon Valley region of Allegheny County. The program is the vision of pediatric asthma specialist Deborah Gentile, MD, and will establish local clinics that will transform access to care for children with asthma. Through generous sponsorships and individual donations, over $50,000 was raised in support of the asthma program.

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“The entire presentation was beautiful,” Dr. Gentile said. “I appreciate the support for my group’s work. It was uplifting for me to hear about the great work that the award winners are doing as well.” Patricia Bononi, MD, ACMS president, hosted the event along with Peter Ellis, MD, president-elect, in the historical restored Babb Insurance building, which houses the ACMS offices. The evening opened with a musical montage of sponsors, and included videotaped presentations from Dr. Gentile and celebrity guest Cameron Heyward of the Pittsburgh Steelers, who lived with severe asthma as a child. Despite being told that playing sports would be impossible for him, he became a successful and popular professional athlete. Heyward is passionate about this cause and has devoted himself to helping children with asthma through Heyward House, his own foundation. Awards were presented to 14 physicians, individuals and organizations in recognition of their outstanding achievements and contributions to the health and well-being of the region. Award recipients from 2020 were honored along with those for 2021. In addition, the Gala honored physicians with

fifty or more years of service and those in Allegheny County chosen as Pennsylvania Medical Society’s Top Physicians Under 40. Acceptance speeches by the award recipients were the highlight of the evening. “The Gala was a very classy and dignified event. The videos and acceptance speeches were outstanding. We reached people across the country who tuned in to attend,” said John T. Wisneski, MD, the 2021 recipient of the Nathaniel Bedford Primary Care Award. More than 300 viewers tuned in to watch the Virtual Gala. “A virtual event is complicated, but the staff worked hard and their efforts paid off. The virtual gala event turned out to be beautiful and it generated a lot of donations,” stated Dr. Bononi. Mark Goodman, MD, chair of the 2021 Gala, paid tribute to the ACMS staff who pulled together many resources in order to present the first virtual ACMS Gala. “It was a pleasure to work with everyone involved,” he said.

www.acms.org

Society News

Annual Greater Pittsburgh Diabetes Club Features Anne L. Peters, MD The Greater Pittsburgh Diabetes Club (GPDC) hosted their annual fall program, in a hybrid format, on Wednesday, November 10, 2021 in the Babb Building located on the North Side, a historical landmark and new office space for the Allegheny County Medical Society. Over 30 in-person attendees and 29 virtual attendees participated in the annual meeting which featured Anne Peters, MD, Professor of Clinical Medicine, Keck School of Medicine of USC and Director, USC Clinical Diabetes Programs. . Dr. Peters presented, “When to Use SGLT-2 Inhibitors and GLP-1 RA’s in the Management of Type 1 Diabetes.” Her research has focused on testing new approaches for diagnosing and treating diabetes and developing systems of care to improve outcomes in diabetic populations. Not only has Dr. Peters published over 200 articles, reviews, abstracts and three books on diabetes, but she has been an investigator on over 40 research studies and has spoken at

ACMS Bulletin / December 2021

Anne L. Peters, MD over 400 programs throughout the US and internationally. She has served on many committees for the ADA and other organizations. Currently, she is the chair of the Endocrine Society Committee on Diabetes Devices and is on the EASD/ADA Technology Safety Committee. In person guests enjoyed a lively vendor showcase, featuring eleven exhibitors. The Society would like to thank the following who participated in the vendor showcase: Abbott, AstraZeneca, Bayer, BoehringerIngelheim, Corcept Therapeutics, NASH kNOWledge, Novo Nordisk, Sanofi, Tandem Diabetes Care, Xeris Pharmaceuticals, and Zealand Pharmaceuticals. Their support was instrumental in providing this quality educational program to members and guests of the Club. Planning for the 2022 Spring meeting will begin in January. Members will receive notification by email once plans are finalized. Information is also available on the GPDC website.

In-person attendees participating in Vendor Showcase

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In Memoriam Perspective “ This Was Good Medicine” In Memoriam of

Paul Warren Dishart, MD:

By Nancy Kennedy

aul Warren Dishart, MD, died on November 5, 2021 at the age of 88. Dr. Dishart leaves a legacy of excellence in medicine, medical education and human relationships. A beloved physician, teacher, mentor, and leader, he worked with grace and passion to heal, educate and inspire others. He was the visionary founder and director of medical education at UPMC St. Margaret; he practiced medicine for 62 years, specializing in family medicine and internal medicine. Dr. Dishart believed that it was an honor to serve others as a medical doctor. Paul Warren Dishart grew up in the Lawrenceville section of Pittsburgh. He attended Duquesne University and earned his medical doctorate from the Medical College of Wisconsin in 1959 (Marquette University) and returned to Pittsburgh, to the former St. Francis Hospital in his home neighborhood, to complete an internship (1960) and residency (1963). In 1965, he completed a fellowship in internal medicine at Boston University School of Medicine and Boston Veterans Administration Hospital. To Donald Middleton, MD, his close friend and family medicine colleague, Dr. Dishart was a truly great physician and a man who lived a model life. 362

Dr. Dishart “Paul’s training was superlative,” Dr. Middleton says. “He even spent a couple of years in Boston training with physicians such as George Thorn who went on to be editor of Harrison’s Textbook of Medicine, the most widely used resource in medicine. I met Paul in 1964 and began working with him in 1978. He was a mentor to me; we worked closely, rounding and teaching together. Paul recognized that the new specialty of family medicine would become much bigger, and the program he founded in 1965 at St. Margaret with his partner James Ferrante, was one of the first family medicine programs in the U.S. It became certified in 1971. Paul helped to formulate what was necessary to train Family Medicine physicians; he worked with the board of the American Academy of Family Practice. He stated that the key to family practice was to know what you know, and know where to turn when you don’t. “Paul and Jim turned a 1-year rotating internship into a premier three-year family medicine residency. Recruits come from all over the United States. At the beginning, they

renovated an old car barn outside of the hospital into what the American Board of Family Practice touted as the model family practice center. The residency was so impressive that we even got a visit from Senator Ted Kennedy. We now have three major health centers including our newest 5 million dollar building in New Kensington. Paul had no guideline as to how to go about accomplishing these tasks. He just did them.” Today, the Family Medicine Residency Program at UPMC St. Margaret enrolls both medical and pharmacy residents every year. Dr. Middleton points out that over the years, Dr. Dishart trained over 500 residents and Pharm D.s through the program. “Hundreds of thousands of people have better health because of Paul. His residents practice in locations all over the U.S. so his influence has been far reaching. The program recently marked its 50th year of accreditation and is nationally recognized for excellence in medical education.” In 2017, eighty graduates of the residency program gathered in Pittsburgh for the 45th anniversary of the program’s founding. The reunion was a joyful occasion that honored Dr. Dishart for his 50 years in family medicine. “The residents came back to see Paul. They were dearly loved by him and they reciprocated that love and affection,” Dr. Middleton recalls. Dozens of the graduates commented on their experiences as students of Dr. Dishart, and sent tributes to him: “Dr. Dishart is that perfect blend of brilliant, wise, warm, funny and passionate. Many thanks for all of your tireless efforts and commitment to the www.acms.org

In Memoriam Perspective residents and education!” wrote Brian Primack, MD, class of 2002. “Dr. Paul Dishart had a major impact on my life and my professional development. He is a great physician, a great teacher, and a great friend,” said Cynthia Napier Rosenberg, MD, class of 1985. And Keith Sinusas, MD, class of 1980, summed it up with this: “Dr. D. was the most kind and caring teacher and role model a resident could ever ask for. His impact on a generation of family physicians is immeasurable.” Dr. Dishart also developed an annual, nationally recognized family medicine refresher course, giving credit to the region’s family medicine residencies and to the University of Pittsburgh School of Medicine. When a Certificate of Added Qualifications in Geriatrics was developed, he helped 28 staff family physicians from UPMC St. Margaret to become certified, and established a geriatric fellowship. Dr. Dishart’s commitment to education was unwavering. He believed that education should continue throughout life, and encouraged his students to always “Read one article every single day.” When he was very ill, and the residents came in his room to make rounds, he asked them questions, continuing to teach to the end of his life. He was often heard to ask his residents his benchmark question, “Is this good medicine?” He was a master of the art of listening, and was known for frequently saying, “Listen to the patient, and then listen again.”

ACMS Bulletin / December 2021

For those who worked with Dr. Dishart, he will be remembered as a kind and gentle man who had respect for all and gave generously of his time and counsel. He was dedicated to Allegheny County Medical Society (ACMS), and served as the 136th president of the organization. He was a recipient of the ACMSF Nathan Bedford Award for outstanding clinical care. John “Jack” Krah, MBA, CAE, executive director of ACMS from 1989 to 2018, had a close working relationship with Dr. Dishart and recounts his active participation in ACMS. “Dr. Dishart was admitted in 1970; he served in many capacities, as treasurer, secretary, vice-president and eventually president in 2001. He contributed to numerous committees and was chairman of the ACMS Foundation board of trustees in 20012003. He also served PAMED as 13th District trustee from 2005-2012. He was wonderful to work with. Paul was a wonderful human being: thoughtful, reasonable, always positive, extremely level-headed and steady. He sought to bring people together.”

Dr. Dishart lived a full and fulfilling life. At St. Margaret, he organized social activities and outings for the medical staff, including ski trips, so that the doctors got to know and trust each other, and develop strong professional relationships. He enjoyed skiing, golf, and basketball, and was a pilot who loved flying. He was a family man who was married for 57 years to Maureen McBride Dishart. They have three children, Mark, Brad and Jill, plus five grandchildren: Veronica, Landon, Ellis, Maria and Sofia. Paul Dishart was the son of Urban Dishart Sr. and Helen Bright Dishart; he had two brothers, the late Urban Dishart and Ken Dishart. Paul Dishart was an exceptional man whose unflinching integrity and deep humanity set him apart. He has had a profound and enduring impact on his patients, his colleagues, his students and those who were fortunate enough to work with him.

“ To be the best, you need to learn from the best. Thank “you, Dr. D., for making us all better doctors.” —Eric Frankel, MD; Class of 2005

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Materia Medica

Dapagliflozin/Saxagliptin/Metformin (Qternmet XR®) Courtney Simpkins, PharmD Amisha Mehta, PharmD, BCPS INTRO Qternmet XR® (dapagliflozin/ saxagliptin/metformin hydrochloride extended release (XR)) is the combination of dapagliflozin, a sodiumglucose cotransporter-2 inhibitor, saxagliptin, a dipeptidyl peptidase-4 inhibitor, and metformin, a biguanide. All three active ingredients are already FDA-approved as single agents to lower HbA1c in type 2 diabetic patients, but when given together, they have a synergistic effect on A1c lowering and reduce the pill burden for patients.1,2 Qternmet XR® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes and is only intended to be initiated in patients currently taking metformin.3

SAFETY Each active ingredient has already been proven to be safe by the FDA: dapagliflozin was approved in 2014, saxagliptin, in 2010, and metformin, in 1995. Two randomized control trials included in this review were conducted to determine the safety and efficacy of this combination product in adults with type 2 diabetes. Both dapagliflozin and saxagliptin require dose adjustments in patients with an eGFR < 45 mL/minute due 364

to increased risk of renal damage and drug accumulation, respectively. Metformin dose adjustments are recommended with an eGFR of < 60 mL/minute to a maximum of 1.5 grams per day.4 Because of the potential for further renal damage and toxic accumulation, Qternmet XR® is contraindicated in patients with an eGFR < 45 mL/minute, end-stage renal disease (ESRD), or patients on dialysis. Because metformin carries a boxed warning for lactic acidosis, Qternmet XR® also carries this warning. A systematic review found that that 69% of lactic acidosis cases in patients on metformin had risk factors for lactic acidosis such as liver failure (ALT > 3x the upper limit of normal), excessive alcohol intake, or renal failure (serum creatinine > 1.5 mg/dL in men and 1.4mg/dL in women), so if patients have additional risk factors for lactic acidosis, they should be more closely monitored.5 The considerations and monitoring parameters for Qternmet XR® are in alignment with the three active ingredients. Saxagliptin has been correlated with increased rates of pancreatitis and hospitalizations for heart failure, therefore patients should be counseled to monitor for exacerbations of these disease states.6,7 Kidney function and LDL should be assessed before initiation and throughout therapy because dapagliflozin increases serum creatinine, decreases eGFR, and can increase LDL. When these medications

were given in combination, increases in creatine kinase and decreases in serum bicarbonate were observed, so these values should be monitored as well.3 Strong inhibitors of CYP3A4/5 enzymes such as ketoconazole and clarithromycin significantly increase saxagliptin exposure and should not be administered with Qternmet XR®. Co-administration with carbonic anhydrase inhibitors such as topiramate or acetazolamide can cause a decrease in serum bicarbonate leading to a non-anion gap, hyperchloremic metabolic acidosis, which can increase the risk for lactic acidosis.3

TOLERABILITY Qternmet XR® is a generally welltolerated medications in adults with type 2 diabetes. The most commonly reported adverse effects from the previously mentioned clinical trials were upper respiratory tract infections (13.6%), urinary tract infections (5.7%), and dyslipidemia (5.1%). In these clinical trials, patients experienced a mean percent increase from baseline LDL-cholesterol ranging from 2.1 to 6.9%. Other adverse effects included headache (4.3%), diarrhea (3.7%), and genital infections (3.0%).3 Although diarrhea, nausea and vomiting is usually expected with metformin, the lower incidence of diarrhea and unreported incidence www.acms.org

Materia Medica of nausea or vomiting, is likely due to the requirement that patients must already be on ≥1500 mg metformin a day for at least 8 weeks. Side effects were not reported during metformin monotherapy. The risk of genital mycotic infections is increased because of dapagliflozin’s effect on increased urinary excretion of glucose and should be closely monitored in patients who have previously developed these infections.

EFFICACY Two double-blind randomized placebo-controlled clinical trials were performed to demonstrate the efficacy of this combination product. Both trials required patients to be on ≥ 1500 mg metformin daily for ≥ 8 weeks and were performed over 24 weeks. In a RCT, Rosenstock et al. compared the addition of dapagliflozin 5 mg and saxagliptin 5 mg to placebo (N = 883) in type 2 diabetic patients with a HbA1c ≥7.5% and ≤10.0%. Patients who received triple therapy experienced a significantly decreased HbA1c compared dual therapy (-1.03% vs. -0.63% [dapagliflozin] vs. -0.69% [saxagliptin]; P < .0001). Patients who received triple therapy had a higher percentage of patients who achieved an HbA1c <7% (42.6% [95% CI 36.0, 47.1]) compared to those who received dual therapy with dapagliflozin, placebo, and metformin (21.8% [95% CI 17.2, 26.4]) and saxagliptin, placebo, and metformin (29.8% [95% CI 24.9,34.9]).1 In a RCT, Rosenstock et al. compared the addition of dapagliflozin 10 mg and saxagliptin 5 mg to placebo (N = 534) type 2 diabetic patients ACMS Bulletin / December 2021

with a HbA1c ≥8% and ≤12.0% with a c-peptide ≥1.0 ng/mL and a BMI ≤45.0 kg/m2. Patients who received triple therapy experienced a larger decrease in HbA1c from their baseline (-1.5%) compared to dual therapy with saxagliptin, placebo, and metformin XR (-0.9%) and dapagliflozin, placebo, and metformin XR (-1.2%). The difference (95% confidence interval in change from baseline in HbA1c) between triple therapy versus saxagliptin, placebo, and metformin XR was -0.59% (-0.81%, -0.37%, P < 0.0001) and triple therapy versus dapagliflozin, placebo, and metformin XR was -0.27% (-0.48%, -0.05%, P < 0.0200).2 Despite the benefit that dapagliflozin exhibits in heart failure, there have been no studies to demonstrate a cardiac benefit with Qternmet XR®.8 There is evidence that saxagliptin may lead to an increase in hospitalizations for heart failure. In a large RCT (N = 16,492) performed to evaluate the effect of saxagliptin on cardiovascularrelated events, saxagliptin was not found to have an increased risk for cardiovascular events. But, more patients in the saxagliptin group were hospitalized for heart failure than the placebo group (3.5% vs 2.8%) indicating that its use may be more limited in patients with heart failure.6

PRICE The price of Qternmet XR® in the United States is currently unknown. Despite its FDA approval in May 2019, it is not yet available to order. Qtern®, a combination product of dapagliflozin and saxagliptin, is available to order from wholesalers at $600 for a bottle of 30 tablets.

SIMPLICITY Qternmet XR® is optimal for patients who forget to take their medication due to multiple dosing times or would benefit from a reduced pill burden. Patients should take this tablet once daily in the morning with food. The simple once-daily dosing regimen and combination of three medications into one tablet optimizes the chance for patient success and positive patient outcomes. There are four different dosage forms including dapagliflozin 2.5 mg/ saxagliptin 2.5 mg/metformin XR 1000 mg, 5 mg/2.5 mg/1000 mg, 5 mg/5 mg/1000 mg, and 10 mg/5 mg/1000 mg respectively. If patients are not currently taking dapagliflozin, the recommended starting dose is dapagliflozin 5 mg/saxagliptin 5 mg/ metformin XR 1000 mg. None of the single tablet dosage forms allow the patient to receive the target maximum dose of metformin 2000 mg daily. If patients are indicated to receive the target dose of metformin, they would have to take an additional metformin 1000 mg tablet daily for a total dose of metformin 2000 mg daily.9 Equally, they could take two of the lower dose Qternmet XR® tablets. Either way, reaching the maximum dose of metformin 2000mg daily with Qternmet XR® diminishes the benefit of the single tablet dosing regimen and can also lead to confusion for the patient.

BOTTOM LINE Qternmet XR® is a combination medication containing dapagliflozin, Continued on Page 262

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Materia Medica From Page 261

saxagliptin, and metformin hydrochloride XR taken by mouth daily to improve glycemic control in adults with type 2 diabetes. In patients who are already on metformin, this triple therapy combination has been shown to lower HbA1c by an additional 1-1.5% over 24 weeks and may cause mild to moderate adverse effects including upper respiratory tract infection, urinary tract infection, and dyslipidemia. Because of its current unavailability, likely high price, and inability to achieve a target metformin dose with this tablet alone, it would be most beneficial in patients who can obtain the medication at an affordable price, would benefit from a decreased pill burden, and cannot tolerate or are not indicated to receive the maximum dose of metformin. Dr. Courtney Simpkins is a PGY1 Pharmacy resident at UPMC St. Margaret and can be reached at simpkinsca@upmc.edu. Dr. Amisha Mehta is a PGY2 Ambulatory Care Pharmacy resident at UPMC St. Margaret and can be reached at mehtaap@upmc.edu. Dr. Heather Sakely, PharmD, BCPS, BCGP, the Director of Geriatric Pharmacotherapy and Director of the PGY2 Geriatric Pharmacy Residency served as editor and mentor for this work and can be reached at sakelyh@upmc.edu.

Resources: 1. Rosenstock J, Perl S, Johnsson E, et al. Triple therapy with low-dose dapagliflozin plus saxagliptin versus dual therapy with each monocomponent, all added to metformin, in uncontrolled type 2 diabetes. Diabetes Obes Metab. 2019 Sep;21(9):2152-2162. 2. Rosenstock J, Hansen L, Zee P, et al. Dual add-on therapy in type 2 diabetes poorly controlled with metformin monotherapy: a randomized double-blind trial of saxagliptin plus dapagliflozin addition versus single addition of saxagliptin or dapagliflozin to metformin. Diabetes Care. 2015 Mar;38(3):376-83. 3. Qternmet XR® [Package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals; 2019 4. Lalau JD, Kajbaf F, Bennis Y, et al. Metformin Treatment in Patients With Type 2 Diabetes and Chronic Kidney Disease Stages 3A, 3B, or 4. Diabetes Care. 2018;41(3):547-553. 5. van Berlo-van de Laar IR, Vermeij CG,

Doorenbos CJ. Metformin associated lactic acidosis: incidence and clinical correlation with metformin serum concentration measurements. J Clin Pharm Ther. 2011;36(3):376-382. 6. Scirica BM, Bhatt DL, Braunwald E, et al. SAVOR-TIMI 53 Steering Committee and Investigators. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med. 2013 Oct 3;369(14):1317-26. 7. Buse JB, Bethel MA, Green JB, et al. TECOS Study Group. Pancreatic Safety of Sitagliptin in the TECOS Study. Diabetes Care. 2017 Feb;40(2):164-170. 8. McMurray JJV, Solomon SD, Inzucchi SE, et al. DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995-2008. 9. Garber AJ, Duncan TG, Goodman AM, et al. Efficacy of metformin in type II diabetes: results of a double-blind, placebo-controlled, dose-response trial. Am J Med. 1997 Dec;103(6):491-7.

Allegheny County Medical Society www.acms.org • (412) 321-5030

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Editorial Where to turn…

Domestic Abuse Palm Cards Available at ACMS

calling, is meant in a benign fashion, it adjacent lumbar vertebra, explaining is considered harmless. her pain. My resident, from Georgia, However, in today’s politically upon seeing the findings said, in his divisive atmosphere, it is best to use deep southern drawl, “Fellahs, there’s humor only when you truly know a lesson here. Crocks daah (die), audience. As a good example, I too.” Unfortunately for the patient, CT Where-to-Turn cardsyourgive remember the not so “good old days,” scanning and ultrasound exams had important information and when it was expected that a speaker not been developed. The important at a conference or a refresher course lesson is thatphone for most numbers patients with afor victims would tell jokes. Many of the “old diagnosis of psychosomatic illness, the of domestic violence. timers” were very colorful characters. symptoms are real, and in fact a small fortunately, speakers are number of these patients indeed have The cards are the size ofToday, a business business-like and jokes are tacitly real abnormalities accounting for their card and are discreet enough to carry forbidden, since they are bound to symptoms. in view a wallet or purse. offend someone. Finally, we should Sigmund Freud’s of humor was that it was a conscious expression always remember that no matter how Call ACMS at (412) 321-5030 unpleasant some of our patients are of thoughts that society usually 2 to us, they are still our fellow human suppressed or was forbidden. As for more information. beings. long as the humor, in this case name-

Dr. Daffner, associate editor of the ACMS Bulletin, is a retired radiologist who practiced at Allegheny General Hospital for more than 30 years. He is emeritus clinical professor of Radiology at Temple University School of Medicine and is the author of nine textbooks. He can be reached at bulletin@acms.org. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

References 1. Shem S. The House of God. Richard Marek Publishers 1978. 2. Freud S, (Strachey J, Trans.). Jokes and their relation to the unconscious New York: W. W. Norton, 1960 (Original work published 1905).

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Three Penn Center West Pittsburgh, PA 15276 fennercorp.com ACMS Bulletin / August 2021 ACMS Bulletin / December 2021

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Legal Report

Who is covered under the CMS vaccination rule? Michael A Cassidy, Esq As I discussed in a previous article, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule requiring COVID-19 vaccinations for workers in most institutional care settings. A copy of the CMS press release can be found at https://www. cms.gov/newsroom/press-releases/ biden-harris-administration-issuesemergency-regulation-requiring-covid19-vaccination-health-care. However, on November 30, 2021, implementation of the CMS Rule was halted through a preliminary injunction issued by a federal district court in Louisiana. So, what does this mean for healthcare facilities? Presently, they can operate without needing to comply with the CMS Rule. But what happens if the CMS Rule is reinstated as written? What facilities are covered by the CMS Rule? When do these facilities need to comply by? These are all important questions to ask. In this article, I will focus on what facilities are covered. The CMS Rule does not apply to all healthcare settings. As a threshold matters, only facilities that participate in Medicare or Medicaid billing are potentially covered; those that do not are not covered by the CMS Rule. Next, in defining “CMS regulated facilities,” the CMS Rule limits its applicability to specific categories of providers that are regulated under the

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Medicare health and safety standards known as Conditions of Participation (CoPs), Conditions for Coverage (CfCs), or Requirements. Even though this language uses the word “providers,” the CMS Rule is a “facilityspecific” rule, meaning that each facility under a larger overseeing entity (such as SPHS) must be analyzed on a caseby-case basis to determine if each facility is individually required to comply with the CMS Rule. There are two general ways to determine if a facility qualifies as a CMS regulated facility (and is therefore required to comply with the CMS Rule). First, the facility in question must comply with the CMS Rule if it clearly operates as any of the following: • ambulatory surgery centers; • hospices; • psychiatric residential treatment facilities; • programs of all-inclusive care for the elderly (PACE programs); • hospitals (including acute care hospitals, psychiatric hospitals, long term care hospitals, and children’s hospitals); • long term care facilities (including skilled nursing facilities and nursing facilities); • intermediate care facilities; • home health agencies; • comprehensive outpatient rehabilitation facilities;

• critical access hospitals; • clinics, rehabilitation agencies, and public health agencies as providers of outpatient physical therapy and speech-language pathology services; • community mental health centers (CMHCs); • home infusion therapy suppliers; • rural health clinics; • federally qualified health centers (FQHCs); and • end stage renal disease facilities. The following are specifically carved out by CMS Rule as NOT being subject to the CMS rule: • individual therapists or group practice outpatient facilities; • physician offices; • organ procurement organizations; • assisted living facilities; • group homes; and • home and community-based service providers. The above appears to be a cut and dry method of determination, but what if a facility operates as only an alcohol clinic or outpatient facility that does not quite check all the CoP boxes? If that is the case, evaluating whether a facility is regulated by CMS can be achieved through a review of the facility’s Medicare or Medicaid enrollment and billing. www.acms.org

Legal Report A facility is considered a CMS regulated facility if it obtained a CMS Certification Number for billing Medicare by completing a survey from the State Agency or a CMS-approved Accrediting Organization. A facility is not considered a CMS regulated facility if it was not surveyed and was issued a Provider Transaction Access Number for Medicare billing purposes. Additionally, the CMS Rule does not apply to those facilities that are totally state-licensed and state funded through state Medicaid. This can be a hard determination to make

without doing a deeper analysis of licensure, certification and operations. Remember that the CMS Rule is a “facility-specific” rule. That means a facility-by-facility analysis of all the above is necessary to ensure compliance. For now, facilities can rest easy as the CMS Rule is still stayed nationwide. However, should it be reinstated as written, facilities will need to prepare themselves for how to move forward and the first step is to determine if they must comply.

at mcassidy@tuckerlaw.com or Anthony Judice at ajudice@tuckerlaw. com from Tucker Arensberg, P.C. Mr. Cassidy is a shareholder at Tucker Arensberg and is chair of the firm’s Healthcare Practice Group; he also serves as legal counsel to ACMS. He can be reached at (412) 594-5515 or mcassidy@tuckerlaw.com.

For more information on this, please feel free to reach out to Mike Cassidy

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ACMS Bulletin / December 2021

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Special Report Perspective

Election Report For ACMS Officers and Delegates November 22, 2021

The Allegheny County Medical Society conducted its election from November 1, 2021, 8:00 AM to November 12, 2021, 12:00 PM EST. The following are the official results of the election: President-elect Matthew B. Straka, MD Vice President Raymond E. Pontzer, MD Secretary To be Appointed by the Board of Directors Treasurer To be Appointed by the Board of Directors Directors Douglas F. Clough, MD Three Year Term – 2022-24 Kirsten D. Lin, MD Jan B. Madison, MD Raymond J. Pan, MD

Other Directors currently serving:

Term Expires in 2022 Term Expires in 2023 Patricia L. Bononi, MD, will Chair 2022 Ragunath Appasamy, MD Steven Evans, MD Peter G. Ellis, MD, President 2022 Mark A. Goodman, MD Bruce A. MacLeod, MD Keith T. Kanel, MD Amelia A. Paré, MD Maria J. Sunseri, MD Maritsa Scoulous-Hanson, DO G. Alan Yeasted, MD Adele L. Towers, MD Peer Review Board Marilyn Daroski, MD Three Year Term - 2022-24 David J. Levenson, MD

Other members currently serving: Term Expires in 2022 Term Expires in 2023 Niravkumar Barot, MBBS Lauren Rossman, DO Kimberly Hennon, MD Angela M. Stupi, MD 370

www.acms.org

Special Report Perspective Delegates Niravkumar Barot, MBBS, MPH Keith T. Kanel, MD Two Year Term 2022-23 Weston F. Bettner, MD Bruce A. MacLeod, MD Coleen A. Carignan, MD Jan W. Madison, MD David J. Deitrick, DO Raymond J. Pan, MD Mark A. Goodman, MD Nadia K. Sundlass, MD Richard B. Hoffmaster, MD Adele L. Towers, MD Micah A. Jacobs, MD Matthew A. Vasil, DO

Other members currently serving: Ragunath Appasamy, MD Deborah A. Gentile, MD Angela M. Stupi, MD Douglas F. Clough, MD Scott L. Heyl, MD Rajiv R. Varma, MD Amber R. Elway, DO Barbara S. Nightingale, MD David S. Webster, MD Joseph C. Paviglianiti, MD Alternate Delegates Michael Matean Aziz, MD Richard A. Fortunato, DO One Year Term - 2022 Vint R. Blackburn, MD Michael Hu, MD William F. Coppula, MD James T. McCormick, DO Patricia L. Dalby, MD Alexander Yu, MD Marilyn Daroski, MD The ACMS Board of Directors congratulates all the newly elected officers and delegates and looks forward to your active participation as we continue our mission for the Society. Thank you for your dedication to our profession. Bruce A. MacLeod, MD Chair, Nominating Committee

ACMS Members:

Retiring? New Address?

Professional announcement advertisements are available to ACMS members at our lowest prices.

Call (412) 321-5030 for more information. ACMS Bulletin / December 2021

New Partner? Congratulatory message?

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Editorial Index Perspective Volume 110 No. 7 Volume 110 No. 8 Volume 110 No. 9 Volume 110 No. 10 Volume 110 No. 11 Volume 110 No. 12 A ACMS Alliance News: Allegheny County Medical Society Alliance Holiday Party and Dinner December 9.............................................28 Activities & Accolades ..............206, 268, ......................................................295, 365 B C Career Opportunity ...............................338 Executive Director, Allegheny County Medical Society Classifieds ..................................231, 326 Community Notes................................204 D E Editorial: Vigilance................................................193 Deval (Reshma) Paranjpe, MD, MBA, FACS Medical history vignette: Ancient Egypt........................................195 Richard H. Daffner, MD, FACR Sartorial choices....................................198 Anna Evans Phillips, MD, MS Fall nourishment....................................222 Deval (Reshma) Paranjpe, MD, MBA, FACS The ‘talk’ – circa mid-2021.....................224 Andrea G. Witlin, DO, PhD Name-calling..........................................227 Richard H. Daffner, MD, FACR Heart and soul.......................................259 Deval (Reshma) Paranjpe, MD, MBA, FACS ‘Reading Room Rules’...........................260 Richard H. Daffner, MD, FACR

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July 2021 August 2021 September 2021 October 2021 November 2021 December 2021

Mercy and wisdom ...............................280 Deval (Reshma) Paranjpe, MD, FACS You can’t go home again ......................282 Richard H. Daffner, MD, FACR Grace .................................................. 312 Deval (Reshma) Paranjpe, MD, FACS The Slingshot .......................................314 Joseph Paviglianiti, MD Medical historic vignette: Child abuse ..........................................316 Richard H. Daffner, MD, FACR Stress Management……………...……..345 Deval (Reshma) Paranjpe, MD, FACS Letters To Santa…………........…………348 Richard H. Daffner, MD, FACR Executive Committee: COVID-19 updates: Boosters and variants............................221 Raymond E. Pontzer, MD, FACP F Feature: 2020-21 ACMSF award winners............236 Nancy J. Kennedy G H I In Memoriam: Freddie Fu, MD.....................................297 Paul Warren Dishart..............................362 J K L Legal Report: COVID-19 vaccines: What Can You Ask? What Can You Require?

Pages 189-216 Pages 217-252 Page 253-276 Pages 277-308 Pages 309-340 Pages 341 -376

What Can You Disclose?.......................212 William H. Maruca, Esq. The continuing saga of Hospital Price Transparency and surprise billing.........273 Michael A. Cassidy, Esq. Mandatory Opioid Training – Know the Requirements........................304 William H. Maruca, Esquire Anatomy of a False Claims Act Suit: U.S. ex. rel. D’Cunha v. Luketich et al...332 Beth Anne Jackson Who is covered under the CMS vaccination rule?...................................368 Michael A. Cassidy, Esq Legal Summary: The end of balance billing? ..................249 Beth Anne Jackson, Esq. Letter to the Editor.................................282 M Materia Medica: Relugolix: One new drug, many new indications.............................................208 Alexandra N. Marshall, PharmD Karen M. Fancher, PharmD, BCOP Lyumjev (insulin lispro-aabc).................247 Alexandria Taylor, PharmD ..................... Cassidy B. Williams, PharmD, BCPS Rimegepant (NurtecTM ODT)...............270 Alicia G. Faggioli, PharmD Nolan R. Schmitz, PharmD, BCPS Management of Endocrine Therapy Adverse Effects in Breast Cancer Survivors: A New Guideline...................299 Sam Aronson, PharmD Candidate and Karen M. Fancher, PharmD, BCOP Semglee® (Insulin Glargine) ................330 William Beathard, PharmD and Samantha DeMarco, PharmD, BCPS Dapagliflozin/Saxagliptin/Metformin (Qternmet XR®)……………….........…..364

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Editorial Index Perspective Courtney Simpkins, PharmD, Amisha Mehta, PharmD, BCPS Membership Benefits:........202, 234, 264, 292, 324 Miller Time: A Viral Ode............................................335 Scott Miller, MD, MA, FAAHPM N O P Perspective: Restricted medical license.....................200 Jorge Lindenbaum, MD Yesterday’s woman doctor......................262 Christine Martone, MD What’s in a name? Down syndrome.....285 Kristen Ann Ehrenberger, MD, PHD Reimagining bone and joint health while reducing disparities in care......... 287

Anthony M. Digioia III, Md Dr. Helana Pietragallo Gina Edwards Gigi Crowley Angela DeVanney The madness of groups: Is there a place for the public health psychiatrist?......................................... 290 Bruce L. Wilder, MD, MPH, JD Let’s talk about prior auth!.................... 319 Sharon L. Taylor, MD Barriers to hospice in the United States........................................ 322 Keith R. Lagnese, MD, FAAHPM, HMDC The Doctor Never Examine Me….........353 Michael G Lamb MD Q R Reportable Diseases.....................250, 336

S Society News ......201, 230, 266, 294, 328 Special Report: PAMED: Women Physicians Section..................................................251 Ingrid Renberg, MD WPS Communications Committee Nominating Committee Report..............306 2021 PAMED House of Delegates Report .................................334 Election Report ....................................370 T U V W X Y Z

Advertising Index Perspective

2021 Bulletin Advertising Index: July-December Accounting

Kline Keppel & Koryak PC.......................... (412) 281-1901

Billing/Claims/Collections

Fenner Consulting ...................................... (412) 788-8007

Clinical

Allegheny Health Network .......................... (724) 933-1445 Tri Rivers Musculoskeletal Centers............. (866) 874-7483

Legal

Fox Rothschild LLP.......................................(412) 391-1334 Houston Harbaugh PC................................ (412) 281-5060 Tucker Arensberg PC.................................. (412) 566-1212

Real Estate

Berkshire Hathaway: Deb Arrisher...............(412) 548-1518 Berkshire Hathaway: Julie Wolff Rost .........(412) 521-5500

The Bulletin depends on its advertisers. Be sure to tell them you saw their ad here. ACMS Bulletin / December 2021

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POS welcomes Edwin Ryan, MD

l to r: D. Mora-Boellstorff, MD (Resident Presenter); E. Waxman, MD; Thierry Verstraeten, MD; E. Ryan, MD (Presenter); M. Stafford, MD (President);and K. Cheng, MD The Pittsburgh Ophthalmology Society’s December 2nd program featured Edwin H. Ryan, MD, Vitreoretinal Surgery, PLLC, associate clinical professor, Ophthalmology, University of Minnesota Department of Ophthalmology, Edina, Minn. Thank you to Thierry Verstraeten, MD, board member, for inviting Dr. Ryan and to Regeneron for support of the program. Dr. Ryan was awarded his Doctor of Medicine degree from the University of Minnesota. He completed a residency in Ophthalmology at Northwestern University and a fellowship in Diseases and Surgery of the Retina and Vitreous at Washington University in St. Louis. He directed the Retina Service at the University of Minnesota Department of Ophthalmology from 1989 to 1992 and is currently an associate clinical professor of Ophthalmology. Dr. Ryan presented two exceptional lectures, Management of Patients with Vitreous Opacities and Management of Primary Rhegmatogenous Retinal Detachment – Lessons from the PRO Study. Both lectures provided a stimulating question and answer segment. David Mora-Boellstorff, MD, Resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary by Dr. Ryan.

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ACMS Foundation Awards More than $175,000 to Local Charities During its Fall 2021 funding cycle, The Allegheny County Medical Society Foundation provideds a total of $175,754 in grants to 16 local organizations addressing social determinants of health. Since its inception in 1963, the Foundation has awarded more than $3 million in grants. The past two years have been especially active with the annual grants cycle being supplemented by more than $100,000 raised for the COVID-19 Front Line Relief Fund.

The diversity of awards for the Fall 2021 grant cycle

exemplifies the breadth of the Foundation’s impact.

• Angels’ Place, Inc., Showcase of Scholars

• Beverly’s Birthdays, Beverly’s Babies - Material Good and Emotional Support for Expecting Women and Newborns • Blind & Vision Rehabilitation Services of Pittsburgh, Free Vision Screenings for Children • Blood Science Foundation, Give Blood & Give Back (in Partnership with UPMC Children’s Hospital of Pittsburgh Foundation’s Free Care Fund) • Catholic Charities Free Health Care Center, ECG Machine for Catholic Charities Free Health Care Center • Church Union, Serving Vulnerable Children in the COVID-19 Era: Reader Mentor Program • Community Partners in Asthma Care, So A Child Can Breathe • Faith United Methodist Church/ Roots of Faith, Roots of Faith (ROF) addresses Social Determinants of Health (SDH) • Family House, Family Assistance fund at Family House • Family Medicine Education Consortium, Inc., Resident Student Education • Footbridge for Families Footbridge for Families, Emergency Aid to Address SDoH • Jeremiah’s Place - Pittsburgh Relief Nursery and Strong Families Program • Strong Women, Strong Girls. Skills-Based Mentoring Program • The Children’s Home & Lemieux Family Center, Child’s Way, a daycare for medically fragile children at The Children’s Home & Lemieux Family Center • The Ronald McDonald House Charities of Pittsburgh and Morgantown, Inc., The Ronald McDonald Care Mobile, Serving Pittsburgh Communities • The Samaritan Counseling Center of Western Pennsylvania, Samaritan Cares Program

ACMS Bulletin / December 2021

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Legal Report

SURPLUS MEDICAL OR OFFICE ITEMS?

the time of the announcement, DOJ had charged 474 defendants with criminal offenses based upon fraud schemes connected to the COVID-19 pandemic. DONATE THEM TO GLOBAL LINKS! Of most interest to physicians will be the actions the Department of Justice has taken against medical providers charged with PPP fraud. The cases involve a range of WE CAN ACCEPT: conduct, from business owners who have inflated their payroll SUPPLIES, EXAM TABLES, expenses to obtain larger loans than legally available, to serial C HThe AIR S , F I Lpresidency E C A B I NofE Dr T SJohn , Dr. Larry was honored for his service as president for PAMED. PAMED fraudsters whoJohn revived dormant corporations and submitted was timely because the theme was Physician BurnOut. His presidency was concerns about multiple identical loan applications. D Ebombarded S K S A N Dwith MO RE! the• onset the pandemic. participated with numerous newspapers, shows and events mostly virtual that JusticeofDepartment TakesHe Action Against COVID-19 highlighted the information that was known at the time about the COVID virus and potential mitigation. Fraud: https://www.justice.gov/opa/pr/justice-departmentCONTACT US: His tireless efforts on behalf of Physicians in the Commonwealth increased awareness of the role that takes-action-against-covid-19-fraud physicians would play in the epidemic. His leadership as a primary careINFO@GLOBALLINKS.ORG physician from the North Hills of

Pittsburgh has increased communication between large health care entities across the state and empowered 412.361.3424 Mr. Cassidy is a shareholder at Tucker Arensberg and is physicians to get the help that they need to be the best providers for their patients. The PAMED Foundation is chair of the firm’s Healthcare Practice Group; he also serves thrilled tohave him join their efforts and continue to care for the physician while the physician cares for the as legal counsel to ACMS. He can be reached at (412) 594community. These photos that were taken at the new state of the art PAMed facility highlight Dr John’s 5515 or mcassidy@tuckerlaw.com. achievements on behalf of the PA Med family.

Tucker Arensberg lawyers have experience in all major healthcare law issues including: • Compliance • Cybersecurity • Reimbursement • Mergers & Acquisitions • Credentialing & Licensing for Individuals & Healthcare Facilities • Employment Contracts and Restrictive Covenants • Tax & Employment Benefits For additional information contact any of the following attorneys at (412) 566-1212:  Mike Cassidy - Compliance; Contracts, Peer

Review, Stark/AKS

 Ryan Siney - Cybersecurity, Compliance

 Paul Welk - Mergers & Acquisitions  Danielle Dietrich - HIPAA, Collections &

Litigation

tuckerlaw.com ACMS Bulletin / June 2021

 Jerry Russo - Investigations  Rebecca Moran - Mergers & Acquisitions and

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