Allegheny County Medical Society BULLETIN, October 2021 by TEAM

ALLEGHENY COUNTY MEDICAL SOCIETY

Bulletin October 2021

Renowned orthopedic surgeon Dr. Freddie Fu remembered

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

ADMINISTRATIVE STAFF Interim Chief Executive Officer Lisa Olszak Zumstein (lisa@acms.org) Vice President, Operations and Physician Services Nadine M. Popovich (npopovich@acms.org)

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)

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

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

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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

ALLEGHENY COUNTY MEDICAL SOCIETY

Bulletin

OCTOBER 2021 / VOL. 111 NO. 10

Opinion

Departments

Articles

Editorial ..............................280 Membership Benefits.......... 292 Materia Medica ....................299 Mercy and wisdom Deval (Reshma) Paranjpe, MD, FACS

Society News ...................... 294 • Pennsylvania Geriatrics Society hosts

Editorial ..............................282 fall program November 10 You can’t go home again Richard H. Daffner, MD, FACR

• Greater Pittsburgh Diabetes Club to host Hybrid Fall Program November 10

Perspective ........................ 285 What’s in a name? Down syndrome Kristen Ann Ehrenberger, MD, PHD

Perspective ........................ 287 Reimagining bone and joint health while reducing disparities in care Anthony M. Digioia III, Md Dr. Helana Pietragallo Gina Edwards Gigi Crowley Angela DeVanney

Activities & Accoades......... 295 • Allegheny County Medical Society Foundation Virtual Gala held Oct. 7 • ACMS member receives Gold Medallion honor

Management of Endocrine Therapy Adverse Effects in Breast Cancer Survivors: A New Guideline Sam Aronson, PharmD Candidate and Karen M. Fancher, PharmD, BCOP

Legal Report ......................304 Mandatory Opioid Training – Know the Requirements William H. Maruca, Esquire

Special Report ....................306 Nominating Committee Report

In Memoriam .......................297 Freddie Fu, MD

Perspective ........................ 290 The madness of groups: Is there a place for the public health psychiatrist? Bruce L. Wilder, MD, MPH, JD

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

On the cover Midnight, Gulf of Finland James W. Boyle, MD Dr. Boyle specializes in internal medicine.

Editorial

Mercy and wisdom DEVAL (RESHMA) PARANJPE, MD, MBA, FACS Doggerel: Mercy I did not hit you with my shoe. I could have, you know, and sprayed you too. An exhausted inch of brown with many legs: I wondered if you were spent from laying eggs. You sat there, panting long and well, So still I thought you but a shell. Then I saw a little flicker (Made me glad you weren’t quicker) What deadly poison did you hold, or not? In that instant, I forgot. I could not bring myself to take your life. And though I’d only seen it done on film, I’ve Trapped you over paper, under glass, Set you free on distant mulch and grass. Please spread the word among your brood: Don’t bite me; I’m trying hard to do more good. -Reshma Paranjpe

ctober is spider season. They drop down unexpectedly from ceilings and eaves, from doorways and lampposts. Their webs are everywhere, and their little egg cases are everywhere too. We have a love-hate relationship with them as we grow older. We realize that they do good by catching and eating the insects that would harm us; a sort of natural pest control. We also realize that some of their brethren could kill us

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(looking at you, Brown Recluse and Black Widow) or maim us quite unexpectedly. So we wisely tell our loved ones not to go poking around boxes, and not to stick hands in dark corners or alcoves. Spiders are fragile, easily dispatched with a firm whack from a shoe or a quick blast from a vacuum cleaner. And yet they are tenacious, like the itsy-bitsy spider who climbed the legendary water spout. Their silk is incredibly strong, and their webs are beautifully complex. They have surprising intelligence. When given LSD, their webs become as “trippy” as you might expect of a human drawing a picture while on a psychedelic substance. They can take to the wind and fly—many hundreds of miles—using their silk to make hang-gliders of sorts. And who can forget E.B. White’s beautiful novel “Charlotte’s Web,” which focused on the motherly, lifesaving love a spider named Charlotte expressed for a piglet named Wilbur? Anyone who read this tale as a youngster has grown up with a slight secret affection for spiders. “Careful, that could be Charlotte.” Which child hasn’t dreamt of being Spider-Man? There are spiders in many forms all around us. Afraid to think how many spiders you’ve accidentally ingested in

your lifetime? Think of an Alaskan King Crab–it’s the Spider of the Sea! And what is a drone but an airborne spider with rotors? Wisdom is associated with the Greek Goddess Athena, who sprang fully formed from her father’s head, thereby causing perhaps the first headache a daughter ever gave to her father. Athena was also the best spinner of textiles in the universe; she angrily turned the poor boastful mortal Arachne, who dared insist she could spin better than Athena, into a spider as punishment for her pride. Wisdom is also knowing the difference between a giant but harmless Huntsman and a tiny but deadly Funnelweb spider in Australia. To a spider, we are nonsensical animals. We generously provide them with dark corners to spin their webs, and access to all the little insects in our homes for food. We leave them alone when we don’t see them, and mercilessly kill them when we do. We scream when we brush against a spider web, and then endlessly attempt to replicate their silk in our labs to make stockings (and fail). We’re glad when we see harmful insects stuck in a spiderweb, but then thanklessly vacuum up the web, along with the spider. And lastly, at Halloween, we www.acms.org

Editorial take down real spiderwebs, only to hang up fake ones as decorations. Spiders must be convinced that we’re insane. Are we so different from spiders? We toil endlessly at our work our entire lives, pausing to rest occasionally in the middle of it. Some of us actually are web designers by profession. We find ourselves a nice corner and perhaps a nice mate, set up our webs and catch our dinners, and devote our energy to making sure our young have a good life. Sometimes we go unnoticed and have a wonderful life. Sometimes, for no good reason, we are suddenly flattened by a proverbial shoe. Painful is the thought that sometimes we may be squashed because it was less trouble than saving us. Think of that next time you see a spider: a little mercy and wisdom can make a difference in all of our lives.

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Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at lissamine@gmail.com.

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Editorial Perspective

You can’t go home again RICHARD H. DAFFNER, MD, FACR ou Can't Go Home Again1 is a novel by Thomas Wolfe published posthumously in 1940 about author George Webber, who wrote a successful novel about his family and hometown. However, when he returned to that town, instead of being hailed as a local celebrity, he was greeted by outrage and hostility. Family members and lifelong friends objected to how he had portrayed them in his book, and their fury drove him away, never to return. Webber realizes, "You can't go back home to your family, back home to your childhood ... back home to a young man's dreams of glory and of fame ... back home to places in the country … back home to the old forms and systems of things which once seemed everlasting, but which are changing all the time …”1 The title soon became a cliché meaning that you can't truly go back to the place where you once lived because so much will have changed since you left. In short, it is no longer the same place you remembered anymore. I first experienced this concept when I returned to my hometown, Troy, NY, after my first year of medical school. My family’s house was on a quiet street that bordered the municipal park/golf course on the north side and an undeveloped tract on the east. This tract began as a large hill immediately behind our house

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and tapered down behind the neighborhood to a large flat area that was mainly sand. At the top of the hill there was a huge oak tree, which, as boys, my friends and I climbed and on which we built an observation platform. In one section of the hill and undeveloped area, immediately behind our houses we played “army” and dug foxholes in the sandy soil as part of our games. A larger area was flat, and we used it as our baseball field. The land belonged to the Clemente family who owned the largest concrete business in the area and had excavated the surrounding hillside for the sand. The Clementes had moved their business to a site on the Hudson River, where they had easy access for receiving the gravel and other raw materials needed for making their concrete. The excavation of the hillside allowed us to play baseball using the hill as the end of the outfield, so we never lost any balls. The site also contained a large, abandoned fortress-like concrete structure that had been used for loading stones and gravel into trucks, which in our childhood imaginations, we used as a “castle” or “the Alamo.” In addition, there was a large collection of scrap lumber that had been dumped on the site. We used this to build small forts. In addition, a small stream ended in a pond that, once

frozen in the wintertime, became a hockey rink for us. A significant part of my leisure childhood had been spent in the hills and in the sandlots. I was shocked to find out that the Clemente family had sold the land to a developer, and that apartments were being constructed on my old playground. I walked through the site. There was new construction where our ball field had been. The “castle” was gone; the pond had been drained after the stream was diverted underground. Most shocking, the old oak tree was gone. I remember telling my parents how disappointed I was that “my childhood had been stolen.” My father simply said, “Well, that’s progress. You still have the memories.” That was an important life lesson. I was fortunate to have had a successful academic career that included membership in several professional societies, including the American College of Radiology (ACR), The American Roentgen Ray Society (ARRS), The International Skeletal Society (ISS), and the Society of Skeletal Radiology (SSR). I was privileged to have served as a member of various committees in each of these organizations and was a frequent presenter of scientific papers as well as faculty of various refresher courses. www.acms.org

Editorial Perspective When I retired in 2013, I continued to attend the annual meetings of these societies and to do presentations for the first two years. I had also been asked by my chairman to continue giving didactic conferences to my now, former residents. I told the chairman that I would commit to doing the lectures for two years. However, without regular access to new material, I felt that my material could become stale if I continued showing the same PowerPoint® images. Fortunately, my former partners were gracious enough to provide me with new material whenever I asked for it. Also, when I retired, I requested Emeritus Member status in the societies I belonged to. The advantage of Emeritus status is waiving of the membership dues (assuming you had been a member in good standing for at least ten years). Emeritus members still received free digital access to the societies’ journals. The only downside was that I could no longer vote, nor could I be a committee member. I decided, after the first two years that I would attend meetings every few years to learn what was new in the profession, instead of yearly attendance. I no longer needed the CME because of my “Active Retired” medical license designation. And so, I was surprised when, in 2018, I received an e-mail from the Program Chairman of the ISS asking me to present a talk on imaging of spine injury at their upcoming meeting in Vancouver the following year. I wrote him back to point out that I had been retired for five years. He responded, “Yes, but you wrote the definitive book on the subject2.” That stroked of my ego and convinced me to accept the invitation. The ISS is a diverse society serving three groups of medical specialists: ACMS Bulletin / October 2021

radiologists, pathologists, and orthopedic surgeons, all of whom have an interest in musculoskeletal diseases. The first part of each annual meeting is for members only, during which interesting cases exhibiting a variety of bone and/or soft tissue pathology are presented. Prior to the formal session, imaging studies and pathology slides are sent along with the clinical history to the members. The latter half of the week is dedicated to the refresher course, where the members teach the non-member attendees. The first night of the meeting has a welcoming cocktail party. My wife and I were shocked at seeing so many strange faces and very few of the many friends we had made over the years in the ISS. Many of our friends were also retired and chose not to attend; sadly, some were deceased. Fortunately, there were a few of the “old-timers” including a former partner from my Duke days, with whom we could share our memories and catch each other up on what we were doing in retirement. Another observation I made at that meeting, as well as at a previous SSR meeting was that many of the younger (radiologist) members’ interests were mainly in the expanded applications of magnetic resonance (MR) imaging, to the detriment of their expertise in interpretation of radiographs. Whereas my generation trained in the era before CT, ultrasound, and MR, and, subsequently were masters (mistresses) of diagnosing bone diseases primarily from x-ray images. Our generation learned the new technologies and used them to augment and confirm the findings suspected on the patients’ radiographs. What is interesting is that old-fashioned x-rays, despite a low sensitivity (50% of a bone must be

destroyed before it will show on a radiograph) had a high specificity. (CT has high sensitivity and specificity and MR imaging has high sensitivity and low sensitivity for bone lesions, but high sensitivity and specificity for soft tissue lesions). Is it possible to remain relevant when participating in professional societies after retirement? The answer is yes and no, depending on how the specialty has evolved. I remember that when I was a medical student in the 1960’s, a couple of old retired surgeons attended most of our hospital conferences. One was an orthopedic surgeon and the other was a urologist. Aside from newer antibiotics and a few other drugs, little had changed in either of their fields, and as a result, they were both able to contribute their opinions at our conferences and share the wisdom of their experiences. On the other hand, I remember a meeting of the ISS at which one of the founding members of the Society, a highly respected radiologist insisted on speaking, even though he was clearly showing early signs of dementia. I had invited my son Scott, then a medical student, and now an orthopedic spine surgeon, to attend to hear the great man speak. I remember Scott turning to me and saying, “He’s kinda lost it, hasn’t he, dad?” Sadly, I had to agree. I made myself a promise that I would not make the same mistake and stay beyond my “do not use” date. So, if you can’t go home again, what do you do? One solution is to find a new community in which to make a “new” home. For me, that new community is the Osher Lifelong Learning Institute at Carnegie Mellon University (CMU). Continued on page 284

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Editorial Perspective From page 283 ––––––––––––––––––– (Pittsburgh is blessed with another Osher program at the University of Pittsburgh.) Osher is a non-profit organization offering continuing education courses. At CMU most of the members are seniors, mature students, who are highly motivated to learn (unlike some of the medical students and residents I have encountered). In addition to taking courses, I have given three medically related courses. This summer and fall, I embarked to new territory with two courses that reflect my interest in history (not just medical). I have also made myself available to mentor other Osher members on the use of PowerPoint® and Zoom®. The fifty-year reunion of my high school class was held in the school for nostalgia reasons. We toured the school,

visiting our old classrooms, the cafeteria, the gym, and the swimming pool. Physically, little had changed. However, I commented to several classmates how “small” the facility looked, even though it had not changed. They agreed that they had the same reaction. Even though it was the same physical plant, to our observation, it was different. I periodically visit my hometown whenever I attend a Trustee meeting or when vacationing. I still have a small number of family members in the area as well as a lifelong friend, whom I also visit. No trip is complete without a visit to the cemetery where my parents and many of our family friends are buried. And, on occasion, I’ll pass by the house where I grew up and drive through downtown, where my father’s pharmacy was. But,

while the buildings are still there, the people who enriched my life are long gone. It is true, you can’t go home again, but, as my father told me many years ago, the memories live on forever. Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine and is the author of 9 textbooks. 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. Wolfe, T. You Can’t Go Home Again, New York, Harper and Row, 1940. 2. Daffner RH, Imaging of Vertebral Trauma, 3rd ed. Cambridge, UK, Cambridge University Press, 2011.

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Editorial Perspective

What’s in a name? Down syndrome KRISTEN ANN EHRENBERGER, MD, PHD ctober is Down Syndrome Awareness Month, when we celebrate the abilities of the more than 400,000 people living with the condition in the United States. The most common human chromosomal anomaly has had many names over the century and a half since its recognition, some of which were once accepted medical terms and are now offensive: Down’s Syndrome, mongolism, Down Syndrome, Up Syndrome, Trisomy 21. Let’s take a careful historical exploration of them. Son of an apothecary, John Langdon Down (1828-1896) studied medicine, surgery, pharmacy, and physics. While serving as superintendent of the Earlswood Asylum in Surrey, just south of London, Dr. Down wrote a paper entitled “Observations on an Ethnic Classification of Idiots [sic]” (1866). He proposed that most of the “mental lesions” in children brought to his attention were not due to accidents that happened after birth—such as head trauma or a nurse giving an overdose of calomel powders (e.g. opium to make the baby quiet)—but rather to a congenital insult that occurred before birth, such as parents who intermarried or suffered from tuberculosis. Dr. Down reported that more than 10% of his patients shared physical characteristics

such as epicanthal folds, midface hypoplasia, and even skin color that he described as “mongoloid,” using Johann Friedrich Blumenbach’s terminology. Blumenbach (1752-1840) tried to reconcile Judeo-Christian teaching about “Adam and Eve” with observed phenotypic variation through comparative anatomy. From his study of skulls, the German naturalist separated all of humanity into five groups, one for each continent: what he called Ethiopians in Africa, Malayans in South Asia and the Pacific, Americans in the Americas, Caucasians in Europe, and Mongolians in Central and East Asia. Blumenbach was a “monogenist” who believed that the two Biblical progenitors of the single human race were Europeans whose descendants had “degenerated” into different racial forms due to unfavorable environmental factors such as climate, diet, and lifestyle. In the twenty-first century it is hard to believe that this was a progressive position compared to the rival “polygenist” stance that there were multiple human races, each from a different genetic origin and with immutable traits that no amount of reform or better breeding (“eugenics”) could improve. A monogenist and a

reformer, Dr. Down interpreted his patients’ appearance as evidence that a white Englishwoman could give birth to an “Asian” baby, and therefore that all humans were ultimately related. He was also an early feminist and left his position at Earlswood because he wanted his wife to draw her own salary for contributing to care at the asylum. The Downs went on to found their own home for the children of wealthy families with intellectual and developmental disabilities, called Normansfield. While there, he published the first description of what we know as Prader-Willi Syndrome. After his death, one of his grandsons was born with the condition that bears his name. Normansfield is now headquarters for the British Down’s Syndrome Association and a museum. Genetic discoveries in the 1950s demonstrated that it was not “degeneracy” but the presence of extra DNA material from chromosome 21 that explains the syndrome. In the 1960s, conscientious scientists and the Mongolian People’s Republic lobbied for less stigmatizing language, and in 1965, the World Health Organization approved “Down’s Syndrome.” The British continue to use the possessive form, but in 1975, the National Institutes of Health Continued on page 286

ACMS Bulletin / October 2021

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Editorial Perspective From page 285 ––––––––––––––––––– standardized American nomenclature to drop the “’s” if the name-giver did not have the eponymous disease (i.e. “Lou Gehrig’s Disease”). Unfortunately, the term “mongolism” remained common parlance into the 1980s. It was brought (back) into public consciousness with Sapphire’s novel Push (1996), in which the main character’s first child is a little girl named “Mongol,” Quishay Powell played her in the movie version entitled Precious (2009). More balanced media representations of individuals with

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Trisomy 21 include the television show Life Goes On (1989-1993), whose sensitive portrayal of a character with HIV/AIDS sometimes overshadows its normalization of Chris Burke’s character, Corky. Lauren Potter played sassy cheerleader Becky on the high school musical dramedy Glee (2009-2015). Unscripted reality show Born This Way (2015-2018) followed seven young adults with Trisomy 21 developing relationships, working jobs, and pursuing hobbies. Finally, a low-budget biopic of director Duane

Graves’s next-door neighbor and childhood friend Rene Morena used the accident of Dr. Down’s name to give Trisomy 21 a positive spin: Up Syndrome (2001). So that’s what’s up with the history of the name Down(‘s). Dr. Ehrenberger, MD, PhD (History), is assistant professor of Internal Medicine and director of the Progressive Evaluation & Referral Center (PERC) at UPMC. She is secretary of the C.F. Reynolds Medical History Society and can be reached at bulletin@acms.org.

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Perspective Perspective

Reimagining bone and joint health while reducing disparities in care e know that bone and joint health is critical to maintaining mobility. To stay active and engage in life fully for as long as possible, patients, providers, and the community alike must be aware of the importance of preventing and treating chronic conditions like arthritis and osteoporosis. Everyone has a role to play in improving bone and joint health. Exemplifying this belief is the new Center for Bone and Joint Health at UPMC Magee-Womens Hospital. By pulling together providers, resources, and services that better meet patients’ personal and specific needs, the Center is addressing the crisis threatening to disable a significant portion of the U.S. population and that is placing growing, burdensome costs on the healthcare system. More personalized care begins to address and reduce disparities along the lines of gender, socioeconomic, ethnic, and cultural considerations in bone and joint health. With unique collaborations between integrated care teams of providers driven by a mission to personalize care, the Center for Bone and Joint Health is an innovative care model that empowers everyone to take charge of their journey to wellness by actively participating in co-designing better care experiences for all while reducing known disparities in care.

ACMS Bulletin / October 2021

It’s the right time to focus on bone and joint health disparities When it comes to bone and joint health, we need to get people’s attention. ANTHONY M. Despite the DIGIOIA III, MD precipitously growing number of doctor-diagnosed arthritis cases in the U.S., projected by the CDC to increase 49% by 2040, from 54 million to 78 million, arthritis and other musculoskeletal health concerns often go overlooked by patients and providers for years, until painful symptoms worsen to the point of being unbearable, and we lose the ability to positively influence the course of the disease early. It is only at this later-than-ideal juncture do many patients even consider seeking treatment, and even then, the journey to improved wellness and overall function is not always a coordinated effort. When it comes to bone and joint health, women are already at a greater disadvantage than their male counterparts. As one example, women comprise a larger share of the arthritis population, at 26% compared to 18% in men. Treatment timelines also differ between women and men, as women are more likely to wait longer to seek medical evaluations and treatment, allowing their condition to progress, and

DR. HELANA PIETRAGALLO

GINA EDWARDS

GIGI CROWLEY

ANGELA DEVANNEY

deteriorate their bone and joint health in the meantime. The disparities only worsen for women from underserved communities. Black women are more likely to develop osteoarthritis than white women, and when they do, also have a higher prevalence of severe pain attributable to arthritis. Overall, women from underserved communities are less likely to seek care in the first place, meaning that they miss the opportunity for evaluation and treatment that may prevent or slow progression of the disease, while making them feel better Continued on page 288

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Perspective Perspective From page 287 ––––––––––––––––––– and manage their day to day lives. In cases of “silent diseases” like osteoporosis, many people live for years with the condition unknowingly until this leads to “fragility fractures,” which cause significant disability and pain. Of the estimated 10 million in the U.S. with osteoporosis, about eight million or 80% are women. Menopause significantly speeds bone loss and increases the risk for osteoporosis. This condition presents a unique challenge for providers and healthcare professionals, as many people are not screened for it. In fact, more than 70% of people over 65 with osteoporosis have never been screened and don’t know they have osteoporosis. Beyond the bone and joint health disparities found in patient populations, provider representation, or lack thereof, also plays a part in the disparities. Only about 6% of orthopaedic surgeons are women, and the number of women with adult reconstruction training as an area of sub-specialization is even less (<1%). Ideally, providers should demographically mirror the communities that they serve, so that there is a greater understanding of the unique challenges faced by different populations. Supporting the increased inclusion and advancement of women in orthopaedics, specifically adult reconstruction surgery, must also factor into the larger strategy to reduce health disparities.

Learning from patients using experience-based design science Viewing care through the eyes of patients and families is a basic tenet of the Patient Centered Value System and 288

guides our process improvement methodology. Rooted in the experience-based design sciences, this strategy offers an alternative to the traditional view of patients and families as passive recipients of care and provides a methodology to integrate patient and staff input into the innovation process. Patient engagement tools like “What Matters to You?” help us discover and empathize with what’s important to patients as the starting point. By asking this question, we can begin co-designing care delivery and personalize care while identifying and then reducing disparities. To develop and co-design the Center, we used the person-centered What Matters to You? approach with patients and staff, through which we identified patient priority areas of focus within bone and joint health. Feedback included requests for services like physical activity guidance, nutrition counseling and ways to reduce anxiety. When asked to identify barriers to caring for their health and wellness, respondents cited low motivation, insufficient time, competing priorities, and lack of direction, among others. Diving deeper through direct patient engagement, we gained insights to how lifestyle factors, (dis)trust of health care providers, mental health status, social and community engagement, and attitudes about certain conditions and treatments made a significant impact on patient’s willingness to seek intervention. Our findings replicated those of the wider research: a patient’s individual characteristics and circumstances have a profound impact on both physical well-being and

healthcare spending, sometimes even more so than clinical factors. In addition, using multiple follow-up focus groups with age-based subsets of the population, we also learned about what participants would really want to get out of a bone and joint health program. Far and away, their responses centered around similar themes –– wanting to feel heard and understood by their providers, having time to talk with their provider and ask questions, and receiving guidance and support along the journey. Just as bone and joint health care is multidisciplinary and overlaps with other services and areas of care, so too are the patients’ needs. Their lifestyles, behaviors, family systems, communities, and cultures all play a part in how they approach care.

The journey to wellness roadmap at the Center for Bone and Joint Health As evidenced in musculoskeletal research and replicated in our local data, for millions in the U.S. with bone and joint conditions, the path to wellness is confusing, challenging and mostly uncoordinated between providers. The barriers to figuring out what to do about one’s own bone and joint health can be frustrating and intimidating enough to make patients postpone care for far too long. But within this problem, there lies an opportunity: arthritis and bone degeneration can be slowed if diagnosed early and appropriately addressed with individualized treatment plans. In other words, earlier screenings (like simple X-rays and DEXA scans) help patients learn where www.acms.org

Perspective Perspective they stand with their bone and joint health so that they can make appropriate lifestyle choices that optimize their mobility and overall wellness. From there, arthritis and osteoporosis sufferers can learn to manage pain and symptoms at earlier stages, and with their provider, design a personalized self-management program to decelerate disease progression and continue living life to the fullest. At the Center for Bone and Joint Health, we are developing ways for patients to have earlier evaluations and therefore get diagnosed early, engage in their own care, pursue non-operative treatment options, and personalize a plan based on their needs. In our program, patients work as a team along with providers to actively take charge of their bone and joint health, according to their priorities. Trained in Motivational Interviewing and drawing from Cognitive Behavioral Therapy techniques, the Clinical Coordinators at the Center develop trusting, therapeutic relationships with patients early in the journey. A critical and ongoing component of this person-centered approach is continuing education, learning, and action planning around the areas most important to patients, like exercise, strength training, nutrition, pain management, weight management, emotional wellness, goal setting, decision making, and others. As patients advance through the program and work through various checkpoints, the Clinical Coordinators serve as ongoing supporters and accountability partners that can also connect patients with other services and support that they require to succeed. ACMS Bulletin / October 2021

Exporting and scaling our model Our interdisciplinary teams co-create programs intended to not only work in and for our own community, but that also serve as replicable and reusable models to scale and spread change in neighborhoods and communities around the world. More holistic and comprehensive resources and strategies for individualized treatment plans are necessary in care settings across the country. As part of our innovative program, we are collaborating and creating infrastructure and guidelines to support other ‘champions’ interested in modeling after our approach. In developing the Center for Bone and Joint Health, we have had the good fortune to learn from and connect with programs emerging at Duke, Yale, UNC Chapel Hill, and others. We are also following the lead of champions in this field by partnering with Movement is Life, a national coalition addressing musculoskeletal health disparities, and Operation Change, a proven community-based and culturally-specific movement program. Closer to home, we will also be presenting our approach next month the at the Magee-Womens Summit, a biennial event that brings together world-class scientists, clinicians, thought leaders and advocates to explore women's health research across the lifespan. Successful healthcare systems of the future will be powered by patient-centered and personalized care approaches that provide a holistic view of an individual’s health status and

data to inform early individualized preventive and treatment plans that shape lifetime health. As the Center for Bone and Joint Health evolves, we will continue to adapt, tailor, customize and refine our approach for maximum impact and portability. We believe that our adaptable care delivery model will not only work in and for our own community, but can also guide scaling and spreading similar change in neighborhoods and communities around the world to support improved bone and joint health for all people. Dr. DiGioia is medical director of the Bone and Joint Center at UPMC Magee-Womens Hospital and UPMC Innovation Center as well as co-medical director of Operation Walk Pittsburgh. Dr. Helana Pietragallo leads the Midlife Health Center at UPMC Magee-Womens Hospital, and is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of Pittsburgh. Ms. Edwards is a project analyst at the UPMC Innovation Center, where she coordinates the Center for Bone and Joint Health. Ms. Crowley is the director of Outpatient Orthopaedics at the Bone and Joint Center at UPMC Magee-Womens Hospital. Ms. DeVanney is the founder of goShadow, a technology startup focused on end-user engagement, experiential redesign, process mapping and improvement. 289

Perspective Perspective

The madness of groups: Is there a place for the public health psychiatrist? BRUCE L. WILDER, MD, MPH, JD “Insanity in individuals is something rare - but in groups, parties, nations and epochs, it is the rule.” – Friedrich Nietzsche

hen I was a college student I had a face-to-face conversation with the poet and historian Peter Viereck. The most memorable topic was that of how the German nation under Hitler could have become so horrifically barbaric and cruel, and we talked about his book, Metapolitics: The Roots of the Nazi Mind, originally published in 1941, and just then re-published in 1961. Since, or perhaps even before, then I have had a life-long obsession with the idea of how individuals that would otherwise not seem to have any significant psychopathology could nonetheless as members of a group commit such horrible atrocities. Of course, the history of the human race is filled with stories of mass cruelty to the point of loss of lives and infliction of physical and emotional trauma, some of which may be passed on from generation to generation in ways that we do not fully understand. Just to mention in the history of our nation, the mistreatment of native Americans and the evils of slavery and its stepchildren, The Lost Cause and white supremacy. In fact we have a long history of what, with the detachment of time and place, seems almost universally like utterly bizarre behavior – for instance the

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Salem witch trials. Not so universally for contemporary phenomena with comparable behavior. We have seen cults come and go for centuries, and most recently groups like QAnon, the Proud Boys, the Oath Keepers, and the Three-Percenters are on the radar. As I am writing this piece, we are wondering how a demonstration at the U.S. Capitol planned for September 18 to honor those who committed violent crimes in an attempt to sabotage the United States government – something unimaginable just a few short years ago – and demand their release will play out. It can, of course, be difficult to draw a line between “insanity” of a group and political extremism. But a group that is so divorced from reality that its resultant behavior is destructive and harmful to others can be likened to that of such an individual who needs to be confined to protect the public. But how do we deal with members of such a group that claims to be merely exercising its right to free speech, and can’t be shown in the eyes of the law to be inciting violence, or to have caused harm? Social psychology as a scientific and academic discipline has been around for about 150 years. One of its premises is that “individual psychology studied in the laboratory by physiological psychologists could not account for the type of higher

mental processes exhibited during social interaction,” and group behavior can be analyzed as “more than the sum of the individuals’ mental activities.” In the past few years, interactions among members of these groups has gone from leaflets, group meetings, and spontaneous mobs to deliberate and ongoing encrypted communications on social media, and thereby taken the dynamics of group psychology to a whole new level. One of the most bizarre proposals to deal with the threat of violent demonstrations was that of Mark, et al, who suggested that psychosurgical procedures may have a place in controlling urban violence in the 1960s. I am not suggesting any such thing. But is there some role for psychiatrists – who are trained in understanding aberrations of mental health in individuals – in studying a group’s psychodynamics toward the end of formulating governmental policy? If social psychology is an academic science, its inclusion in public health infrastructure at the highest levels of government could apply that science and play a significant role in formulation of public policy. In the world of banning mask mandates, and crusading against mandatory COVID vaccination or even COVID vaccination itself, for example, we may be seeing the beginning of such www.acms.org

Perspective Perspective an approach. Misinformation promoted by licensed physicians can have a real cost in human lives – who knows how many – but in the case of the COVID pandemic, to the extent that it enables misguided policy by state governors, quite likely many more than died in 9/11. State medical licensing boards are being urged to consider disciplinary action, including loss of licensure in some cases. The trick is in proving causation. That is where the public health psychiatrist or psychologist comes in. Gun violence is, of course, another major public health concern, and mass shootings are, at least in part, likely another manifestation of group madness. Federal funding for research on gun violence has been long overdue until quite recently.

Making applied social psychology or group psychopathology part of our public health infrastructure may be an important step forward in managing propaganda and misinformation that has grown from Goebbels’ recognition of the Volksempfänger program (government-subsidized radios) as a propaganda tool to today’s internet-based social media, where foreign and unknown actors can play a significant role. This is different from the epidemiology of mental illness in individuals, which has long been part of our public health mission. I would envision the role of the public health experts on group psychopathology in developing policy to be, as in the case of other public health problems, advisory. There will,

References: Peter Vierick, Metapolitics: THE ROOTS OF THE NAZI MIND, Capricorn Books, NY, 1961. Kurt Anderson, FANTASYLAND: HOW AMERICA WENT HAYWIRE: A 500-YEAR HISTORY, Random House, New York, 2018. Bearing in mind, though, that reality has been somewhat cynically described as “nothing but a collective hunch.” – Lily Tomlin (her writer was Jane Wagner). History of Social Psychology, https://psychology.iresearchnet.com/social-psychology/history-of-social-p sychology/ See also, https://www.apa.org/education-career/guide/subfields/social. Mark VH, et al, Role of Brain Disease in Riots and Urban Violence, JAMA. 1967;201(11):895. doi:10.1001/jama.1967.03130110121050, Abstract available at https://jamanetwork.com/journals/jama/article-abstract/335394. Incidentally, the author of Terminal Man (a novel about psychosurgery for violent behavior gone wrong), Michael Crichton, was a student at Harvard Medical School and likely had some personal contact with these authors at the time. An earlier, similar, but true story about a compulsive cat-burglar is recounted in former Pittsburgh neurosurgeon Yale David Koskoff’s The Dark Side of the House, Dial Press, Inc., New York, 1968. Janette Wider, Medical Boards Warn Against Physicians Spreading COVID Misinformation, 9/13/21, https://www.hcinnovationgroup.com/covid-19/news/21238045/medical-bo ards-warn-against-physicians-spreading-covid-misinformation American Psychological Association, A thaw in the freeze on federal funding for gun violence and injury prevention research, 4/2/21, https://www.apa.org/monitor/2021/04/news-funding-gun-research. See https://en.wikipedia.org/wiki/Volksempf%C3%A4nger.

of course, always be the tension between freedom of expression and the dissemination of false information that causes disease or injury, and the infection of the political process by moneyed interests. And there will always be controversy, manufactured or otherwise, about government-backed attempts at mind-control. The answer to these concerns should lie in public debate in the media, in the legislatures, and in the courts, as it is now, albeit imperfectly. Dr. Wilder practiced neurological surgery in the Pittsburgh area. He currently is of counsel in the law firm of Wilder, Mahood, McKinsley and Oglesby. He can be reached at bulletin@acms.org.

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Society News Perspective Pennsylvania Geriatrics Society hosts fall program November 10 The Pennsylvania Geriatrics Society – Western Division will host their annual fall program on Wednesday, November 10, 2021. It will be conducted virtually using the Jason Zoom platform, in Karlawish collaboration with the Jewish Healthcare Foundation. The program is scheduled to begin at 6:00 pm with a Vendor Showcase. Attendees who virtually visit all vendors will be entered into a drawing to win a copy of Dr. Jason Karlawish’s book: The Problem of Alzheimer’s: How Science, Culture, and Politics turned a Rare Disease into a Crisis and What We Can Do About It. The society is pleased to welcome physician and writer, Jason Karlawish, MD; Professor of Medicine, Medical Ethics and Health Policy, and Neurology; Co-Director, Penn Memory Center; Director, Penn Healthy Brain Research Center; Director; Outreach, Recruitment, and Retention Core of the Penn Alzheimer’s Disease Research Center. Dr. Karlawish researches and writes about issues at the intersections of bioethics, aging, and the neurosciences. He is the author of The Problem of Alzheimer’s: How Science, Culture, and Politics Turned a Rare Disease into a Crisis and What We Can Do About It* and the novel Open Wound: The Tragic Obsession of Dr. William Beaumont and has written 294

essays for The New York Times, The Washington Post, Forbes, The Hill, and the Philadelphia Inquirer. The program is open to members and non-members, with a nominal registration fee for guests. CME/CE credits will be offered to participants. The society gratefully acknowledges support for the program from Presbyterian SeniorCare Network. Registration and program details will be posted on the society website at www.pagswd.org, with members receiving notification via email. For further information, or to become a member of the society, please contact Nadine Popovich at npopovich@acms.org.

Greater Pittsburgh Diabetes Club to host hybrid fall program November 10 The Greater Pittsburgh Diabetes Club (GPDC) will host their annual fall program, in a hybrid format, on Wednesday, November 10, 2021. Attendees can Dr. Peters participate in-person or virtually. The in-person event will be held in the Babb Insurance Bldg., 850 Ridge Ave, Pittsburgh, PA, beginning at 6:00 pm with the popular Vendor Showcase. Dr. Anne L. Peters will be joining the meeting virtually at 7:00 pm. The meeting is open to members of the Club and non-members (guest fee will apply).

The GPDC is pleased to welcome guest speaker Anne L. Peters, MD, Professor of Clinical Medicine, Keck School of Medicine of USC; Director, USC Clinical Diabetes Programs. Dr. Peters will present, When to Use SGLT-2 Inhibitors and GLP-1 RA’s in the Management of Type 1 Diabetes. Thank you to the following who provided support for the program: AstraZeneca, Bayer, Boehringer-Ingelheim, Corcept Therapeutics, Novo Nordisk, Inc., Sanofi, Tandem Diabetes Care, Xeris Pharmaceuticals, Abbott, and Zealand Pharmaceuticals. Dr. Peters’ research has focused on testing new approaches for diagnosing and treating diabetes and developing systems of care to improve outcomes in diabetic populations. She has published over 200 articles, reviews, and abstracts and three books on diabetes. Dr. Peters has been an investigator on over 40 research studies and has spoken at over 400 programs throughout the US as well as 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. For more information and to register for the program, visit www.pghdiabetesclub.org. Registration is open with a fee of $15 for members and a guest fee of $40.00 (which includes 1 year of membership in the GPDC). Questions can be directed to Nadine Popovich, by email to: npopovich@acms.org or to (412) 321-5030.

Activites & Accolades Perspective 2020 Award Recipients

Allegheny County Medical Society Foundation Virtual Gala held Oct. 7 Live-streamed event honored Freddie H. Fu, MD, and featured Cameron Heyward of the Pittsburgh Steelers in initiative to support children with asthma in the Mon Valley The Allegheny County Medical Society Foundation (ACMSF) hosted a “Virtual Gala” for members and friends at 7 p.m. Thursday, October 7, 2021, in order to honor excellence in individual physicians and community groups, raise funds to expand and improve pediatric asthma treatment in the Mon Valley, and celebrate the dedication and resilience of the region’s physicians throughout the COVID-19 pandemic. The live-streamed event included a remembrance for Freddie H. Fu, MD, Pittsburgh’s world-renowned sports medicine and orthopedic surgery pioneer, who died on September 24, 2021. ACMS mourns the loss of Dr. Fu, who was a longtime ACMS member. The Gala program included a video of Dr. Fu’s acceptance speech as he received the prestigious 2021 John G. Krah Executive Leadership Award. The Gala presented speakers who shared personal stories. First among them was Cameron Heyward of the Pittsburgh Steelers, whose philanthropic and humanitarian endeavors are as renowned as his exploits at Heinz Field. A native Pittsburgher, Heyward suffered throughout his childhood with asthma, enduring multiple hospitalizations. Deborah Gentile, MD, a pediatric allergist and asthma specialist, also

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Brother’s Brother Foundation

2021 Award Recipients

Dr. Fu

Dr. Starz

Dr. Rozel

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Dr. Humphrey

Women for a Healthy Environment

Continued on page 296

ACMS Bulletin / October 2021

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Activites & Accolades Perspective From page 295 ––––––––––––––––––– appeared on video describing the severe impact of asthma on children and families. Dr. Gentile described the challenges and unmet needs that are faced by hundreds of families in the Mon Valley region of Allegheny County. Since its inception in 1960, ACMSF has granted more than $3 million to a variety of programs focused on creating a healthier region. This year’s Gala was a fundraiser for the establishment of Community Partners in Asthma Care, an expanded and improved asthma treatment center for the Mon Valley where childhood asthma is pervasive. The region experiences triple the rate of child asthma as compared to the national average reported by the Centers for Disease Control. These clinics will transform access to specialty asthma care, which is an essential aspect of bringing the condition under control and enabling children to live healthier, happier lives. A highlight of the evening was the presentation of awards to physicians, individuals, and community organizations that have excelled in their efforts to improve the health and environment of Allegheny County residents. Award recipients from 2020 were honored along with this year’s awardees, as last year’s Gala was cancelled due to pandemic restrictions. 2020 award recipients are: Mark DeRubeis, MBA, John G. Krah Executive Leadership Award; Kurt R. Weiss, MD, Richard E. Deitrick Humanity in Medicine Award; Brad W. Butcher, MD, Ralph C. Wilde Leadership Award; Jonathan Weinkle, MD, Nathaniel Bedford Primary Care Award; Justin J. Vujevich, MD, Physician Volunteer Award; Maren L. 296

Cooke, PhD, Benjamin Rush Individual Award; and Brother’s Brother Foundation, Benjamin Rush Community Organization Award. The 2021 award recipients were: Freddie H. Fu, MD, John G. Krah Executive Leadership Award; Terence W. Starz, MD, Richard E. Deitrick Humanity in Medicine Award; John S. Rozel, MD, Ralph C. Wilde Leadership Award; John. T. Wisneski, Jr., MD, Nathaniel Bedford Primary Care Award; Carlos M. Perez-Ruiz, MD, Physician Volunteer Award; Victoria S. Humphrey, Benjamin Rush Individual Award; and Women for a Healthy Environment, Benjamin Rush Community Organization Award. ACMSF also paid tribute to a group of distinguished physicians who have practiced medicine for 50 years, and to those outstanding Allegheny County physicians who have received the Pennsylvania Medical Society Top Physicians Under 40 award. ACMS president Patricia Bononi, MD, hosted the Virtual Gala, along with Gala chair Mark A. Goodman, MD, and President-elect Peter Ellis, MD. Necessitated by the restrictions of the COVID-19 pandemic, the ACMSF Virtual Gala is a creative response that reflects the very same ingenuity and dedication that has characterized the healthcare community as they have coped and strategized throughout this unprecedented time. Donations are being accepted until October 31 to support pediatric asthma treatment in the Mon Valley. To donate, visit www.acms.org or text ACMS to 50155. In case you missed the Gala, visit https://www.youtube.com/ watch?v=vGkblKqtEug.

ACMS member receives Gold Medallion honor Radiologist Thomas S. Chang, MD, FACR, has been selected to receive the Dr. Chang Pennsylvania Radiological Society’s highest honor, The Gold Medallion. Dr. Chang has made contributions to the PRS at virtually every level and he continues that work today. For nine years, Dr. Thomas Chang specialized in women's imaging at Magee-Women’s Hospital (part of the University of Pittsburgh Medical Center), briefly serving as Interim Medical Director. He was honored as “Teacher of the Year.” Since 2000, he has been with Weinstein Imaging Associates, an independent, multi-office practice in Pittsburgh, dedicated to breast imaging, ultrasound, and bone densitometry. He has been included on Pittsburgh Magazine’s list of “Pittsburgh’s Best Doctors” numerous times. Dr. Chang is a manuscript reviewer for the American Journal of Roentgenology and Ultrasound Quarterly, and was a film reviewer for the Mammography Accreditation Program of the ACR for 19 years. He has served as president of the Pittsburgh Roentgen Society and the Mammographers’ Society of Pittsburgh. Within the Pennsylvania Radiological Society, his positions have included President, chair of the Bylaws and Technology Committees, Editor, and Councilor. He spearheaded the development of the Society's first website and oversaw the transition from paper to digital versions of the Bulletin. www.acms.org

In Memoriam Perspective

Freddie Fu, MD BY NANCY KENNEDY ioneering orthopedic surgeon Freddie Fu, MD, died on September 24, 2021, surrounded by his loving family. Acclaimed throughout the world and cherished in his hometown of Pittsburgh, Dr. Fu founded UPMC’s world-renowned sports medicine program, served as long-time chairman of the University of Pittsburgh School of Medicine’s Department of Orthopedic Surgery and as head team physician for Pitt’s Department of Athletics. He was recognized worldwide for his innovative research and teaching, leading to many clinical advancements in sports medicine and orthopedic care, particularly in treating knee injuries. Throughout his life and career, Dr. Fu worked passionately to always set the bar higher for his local, national and international medical/surgical colleagues, thousands of medical students, surgical residents and fellows who came to Pittsburgh to learn from the best, and most of all, for his tens of thousands of patients - elite, professional and amateur athletes from around the globe as well as non-athletes from around the corner who sought Dr. Fu’s expert care. Dr. Fu performed over 20,000 knee surgeries and saved the careers of many famous athletes, including Zlatan Ibrahimovic, the Swedish soccer player who is considered one of that sports greatest players of all time. Ibrahimovic credits Dr. Fu with saving his career following a ruptured ACL in 2017. Following Dr. Fu’s death, Ibrahimovic tweeted, “Freddie Fu gave me a second

ACMS Bulletin / October 2021

Dr. Fu chance in my career. I’m still on top just because of him. I owe him everything. Thank you Freddie Fu, rest in peace.” For Matt Langton, Dr. Fu was much more than a top-notch orthopedic surgeon. He was an inspiration and the restorer of a boyhood dream. In the summer of 2000, Matt was about to begin his freshman year at Mt. Lebanon High School, where he was set to join the soccer team. Matt had been playing competitive soccer since age 12 and was passionate about the sport. But he began having excruciating pain in his leg when he tried to run. An orthopedic surgeon told Matt and his parents that Matt needed surgery on his knee but he was still growing. The growth plates in his leg were moving and nothing could be done in the short term. Matt would have to wait three or four years before he could have surgery. There would be no soccer for Matt for a long time. The news was a crushing blow. “Soccer was everything to me,” Matt says. “All I wanted was to play on that team. I went home and sobbed.” His parents knew what was at stake for their son. They managed to get an appointment for Matt with Dr. Fu. Matt recalls that event with vivid clarity. “We went to the UPMC Sports Facility, and just walking in there was amazing. There

were big photographs of famous athletes who had been treated by Dr. Fu. He explained that a fracture on my kneecap had caused a bone chip. He told me, ‘I’ll just remove the chipped bone, we’ll get you to PT to restore your muscles and you’ll be back to playing in three months. You can run.’ He made it simple and easy.” Matt’s surgery was a success, he had no further knee problems and he went on to play competitive soccer for years. After playing for Mt. Lebanon, he went on to Division 1 Soccer at the University of Pittsburgh. In 2008-2009, he played for the Pittsburgh Riverhounds. Matt credits Dr. Fu for changing his life. “Dr. Fu had a profound influence on me. The trajectory of my life would have been so different if not for him. Sports were my life and he understood that. I was so fortunate that I was able to see him. Dr. Fu gave me back my future and restored my hope.” Matt is 35 now and still plays soccer. His passion for sports led him to create a non-profit soccer organization to teach children the benefits of sports. “Sports create a positive environment for learning teamwork, respect, discipline and making friends. I love soccer for the creativity and teamwork; soccer is the world’s game; it connects people across cultures. Soccer has meant everything to me, and I am forever grateful to Dr. Fu for restoring my dream.” Dr. Fu was the David Silver Professor, Division of Sports Medicine, distinguished service professor, and chair, Department of Orthopedic Surgery, University of Pittsburgh School of Medicine; head team physician, Department of Athletics; professor of physical therapy, School of Health and Continued on page 298

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In Memoriam Perspective From page 297 ––––––––––––––––––– Rehab Sciences; professor of health and physical activity, School of Education; and professor of mechanical engineering, Swanson School of Engineering, University of Pittsburgh. His research interests focused on clinical outcomes following sports-related injuries, as well as orthopedic bioengineering. He pioneered numerous innovative arthroscopic surgical techniques to treat injuries to the knee and shoulder and has performed extensive knee joint research in biomechanics, in vivo kinematics, comparative anatomy, and stem cell and regenerative medicine involving the knee. He published over 600 peer-reviewed articles, 173 book chapters and 30 major textbooks on the management of sports injuries. Dr. Fu was recently awarded the John G. Krah Executive Leadership Award from the Allegheny County Medical Society Foundation. This award recognizes an individual who has demonstrated exemplary leadership and advocacy for

physicians. Dr. Fu was nominated for this award by Mark A. Goodman, MD, who credits Dr. Fu’s superlative leadership as orthopedic department chair for advancing orthopedic surgery and transforming sports medicine in Pittsburgh. “Dr. Fu founded the Department of Sports Medicine in 1986, and his leadership and clinical innovation have brought international attention to Pittsburgh,” Dr. Goodman states. “Thanks to his pioneering leadership, Pittsburgh has become a world leader in sports medicine and concussion care.” In 2018, in recognition of his outstanding contributions to the advancement of sports medicine, the UPMC sports medicine facility was renamed in his honor, becoming the Freddie Fu Sports Medicine Center of the UPMC Rooney Sports Complex. An ardent proponent and supporter of diversity in medicine, Dr. Fu developed one of the most ethnically and gender-diverse academic and clinical departments in the country. He had an

Wherre to turn… Dome estic Abuse Pallm Cards Availab ble at ACMS Where--to-Turn cards give importa ant information and phone numbers n for victims of do omestic violence. The cards arre the size of a business card and are discreet enough to carry in a wallet or purse. 06 DW &DOO $&0 for more m information. 298

enormous impact on the entire western Pennsylvania region as a deeply devoted and enthusiastic community ambassador, actively serving on the boards of numerous non-profit organizations and life-enriching initiatives for more than 30 years. A native of Hong Kong, Dr. Fu was a 1974 graduate of Dartmouth University. He attended the University of Pittsburgh School of Medicine. He completed his residency in orthopedic surgery and a fellowship in orthopedic surgery at UPMC. Dr. Fu was a leader in the Chinese American community in Pittsburgh; with his wife Hilda, he served as the parade Grand Marshall for the annual New Year’s Parade. He also supported the work of Luminati, the non-profit that Hilda founded, that provides activities to inspire innovation and community engagement among young people. Ms. Kennedy is a communications consultant for ACMS. She can be reached at nkennedy@acms.org.

ACMS members: We want to hear your opinions on important topics affecting health care. Email acms@acms.org to learn more about submitting a Perspective column to the Bulletin.

Materia Medica Perspective

Management of Endocrine Therapy Adverse Eﬀects in Breast Cancer Survivors: A New Guideline SAM ARONSON, PHARMD CANDIDATE AND KAREN M. FANCHER, PHARMD, BCOP ormone-receptor positive breast cancer makes up between 70 and 80 percent of all breast cancer cases.1 The long-term management of breast cancers, specifically hormone-receptor positive breast cancer, has improved dramatically in recent history. The use of estrogen-regulating therapy has contributed to some of these impressive improvements. There are five agents that are recommended for the prevention of recurrence in hormone receptor-positive breast cancer. The first agent is tamoxifen (Nolvadex®, Sotamox®), which is a selective estrogen receptor modulator and is the most well-established adjuvant endocrine therapy. It is the preferred agent in pre-menopausal women as it has some estrogen-like effects and will not induce menopause. 2 Three of the other agents are aromatase inhibitors, and include anastrozole, letrozole, and exemestane. All these agents will block the synthesis of estrogen entirely. Anastrozole (Arimidex®) and letrozole (Femara®) are non-steroidal aromatase inhibitors and are preferred on most insurance formularies. Exemestane (Aromasin®) is a steroidal aromatase inhibitor and is generally reserved for patients non-responsive to both tamoxifen and the non-steroidal aromatase inhibitors.2,3 The final agent is fulvestrant

(Faslodex®), which is an estrogen receptor antagonist that also leads to the downregulation of estrogen receptors.2 It is the most aggressive of the adjuvant endocrine therapies and has the most adverse effects. Each of these agents is recommended to be used for 5-10 years after the completion of surgery, chemotherapy and/or radiation to prevent recurrence of hormone-receptor positive breast cancer.3 On April 20, 2021, Lancet Oncology published a new guideline titled “Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer” regarding the management of adverse effects caused by these hormonal therapies.4 All these agents share a similar adverse effect profile, and patients may be dealing with those adverse effects for 5-10 years. This article will serve to review and summarize the adverse effects caused by adjuvant endocrine therapy and how to manage them based on the guidelines.

Hot flashes The first major adverse effect that these patients face are hot flashes. Both pharmacological and non-pharmacological management of this adverse effect has been studied. The most well-studied agent is

venlafaxine (Effexor®). Based on several randomized controlled trials which studied women who have breast cancer and were experiencing hot flashes, venlafaxine has been shown to reduce hot flashes by up to 60%.4-6 Doses ranging from 37.5 to 150 mg daily have been studied, and while the higher doses tend to be more effective, they are also associated with higher incidence rates of xerostomia, decreased appetite, nausea, and constipation.4,7 Other selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) have also been studied and have shown positive results, but none as extensively as venlafaxine. Fluoxetine (Prozac®) and paroxetine (Paxil®) are SSRIs that are strong CYP2D6 inhibitors, and sertraline (Zoloft®) is a moderate CYP2D6 inhibitor, and all three of these agents could potentially decrease the bioavailability, and subsequently the efficacy of tamoxifen, which should be considered in our patients.4,8,9 Gabapentin and pregabalin (Neurontin® and Lyrica®, respectively) also have some data behind them for treating hot flashes and have similar efficacy rates to venlafaxine. In trials that compared these agents to venlafaxine, patients preferred venlafaxine due to the more tolerable adverse effect profile.4,10 Clonidine (Catapres®) was also studied Continued on page 300

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Materia Medica Perspective From page 299 ––––––––––––––––––– in the reduction of hot flashes, but was found to be inferior to venlafaxine, and thus is not recommended as a first line agent in their management.4,6 One placebo-controlled trial studied oxybutynin (Ditropan®) and found that oxybutynin was superior to placebo in the management of hot flashes. Notably, this trial did not evaluate cognitive impairment, which could be a critical adverse effect in elderly patients.4,11 There has not been a formal study assessing the safety of hormonal pharmacologic agents such as megestrol and medroxyprogesterone (Megace® and Provera®, respectively) in the treatment of patients experiencing hot flashes because of their hormonal therapy to prevent breast cancer. It is possible that these agents may be efficacious in reducing hot flashes but could simultaneously increase the risk for breast cancer recurrence.4,12 Please refer to Table 1 for a summary of these pharmacological agents and their efficacy. A variety of non-pharmacological strategies have been studied to reduce hot flashes in breast cancer survivors. The first of these strategies is weight control. Two cohort studies found that weight gain was independently associated with an increased risk of developing hot flashes in patients taking tamoxifen or an aromatase inhibitor.4 This is also supported by the National Comprehensive Cancer Network (NCCN) Survivorship guidelines, which encourages all patients to eat healthful foods and to have 150 minutes of physical activity a week.13 Another option that was studied was a stellate ganglion block procedure, which is a procedure involving an injection of a local 300

anesthetic to block sympathetic nerves on either side of the voice box in the neck.14 Multiple trials have shown this therapy to be efficacious, however it is much more invasive than other modes of therapy and does not offer any increased effect, so pharmacological therapy and other non-pharmacological management is preferred.4 The final method of non-pharmacological management that was studied is cognitive behavioral therapy (CBT). The MENOS 1 trial compared the standard of care to the standard of care plus cognitive behavioral therapy and found that the intervention group had a significant benefit after 26 weeks, but that there were no differences between the groups at 9 weeks or 26 weeks.4 Table 2 summarizes the benefits of non-pharmacological and alternative therapies. There are also a few trials that analyzed the efficacy of complementary and alternative medicine tactics. A recent randomized trial found that acupuncture had a lasting effect on hot flash frequency four months after completion of the treatment, which did not occur in the comparator group of gabapentin therapy. Acupuncture should be considered whenever available, as there is also data showing it can reduce cancer-related fatigue and joint pain.4 One randomized trial found that hypnosis can have a positive effect in hot flash reduction as well as anxiety, depression, and sleep compared with a control group.4 Hypnosis has potential to be a useful intervention, however its limited availability prevents it from having widespread inclusion in survivorship care. Supplements and magnet therapy were studied and found to have no benefit compared to placebo.4 Lastly,

yoga and relaxation training can help reduce hot flashes in breast cancer survivors, but there is no concrete recommendation on their implementation.4 Please refer to Table 2 for a summary of the efficacy of alternative medicine tactics.

Sexual dysfunction Another prominent side effect due to hormonal therapy is sexual dysfunction. This typically manifests as vaginal dryness or painful intercourse, and psychosocial effects such as decreased libido, changes in self-esteem or body image, and barriers to intimacy.4 There are a variety of both pharmacological and non-pharmacological methods available to treat these symptoms. The first pharmacological intervention is localized estrogen therapy such as an intravaginal estradiol tablet, estradiol based vaginal creams, or any other topical formulation that would be administered vaginally. All these therapies have some level of systemic estradiol absorption, but there is currently no evidence on how this absorption affects the risk of breast cancers.4 Another therapy was ospemifene (Osphena®), which is another SERM that treats painful intercourse associated with menopause.15 Preclinical studies suggest that this agent might block estrogen activity in breast cells, but there is no data supporting the safety of its use in breast cancer patients.4,16 Until there is more concrete data surrounding the safety of systemic hormonal therapy, local estrogen therapy and non-hormonal modalities of therapy will remain the first line choice for treatment of sexual www.acms.org

Materia Medica Perspective dysfunction.4 There was a small, randomized, controlled trial that suggested a 4% aqueous lidocaine compress applied to the vulvar vestibule prior to penetration can effectively improve dyspareunia in breast cancer survivors taking endocrine therapy.17 Additionally, multiple trials support the use of vaginal lubricants to treat genitourinary symptoms in breast cancer survivors taking endocrine therapy. Lubricants are widely available and generally affordable, and as such are considered the first line option for breast cancer survivors reporting sexual dysfunction and vaginal symptoms.4 A summary of pharmacological therapy in sexual dysfunction is presented in Table Multiple studies have shown a benefit of cognitive behavioral therapy in improving symptoms of sexual dysfunction. One 24-week trial showed that patients reported improvements in overall sexual function, sexual desire, arousal, and vaginal lubrication, as well as improvements in sexual pleasure, discomfort, and sexual distress.4 Several other studies have looked at other modes of CBT including a telephone counseling intervention, an in-person six -week sexual life reframing program, and fourhour group intervention followed by a telephone call one month later. All methods of CBT were shown to have a positive effect on female sexual health, and as such cognitive behavioral therapy is highly encouraged for all breast cancer survivors dealing with sexual dysfunction; dedicated and experienced counselling should be available to these patients.4 There have been several trials that have a shown a positive effect of vaginal laser therapy ACMS Bulletin / October 2021

for sexual dysfunction symptoms, however, there have not been any randomized trials nor has there been any long-term safety analyses regarding its use. As a result of this lack of data and its high cost, this treatment option is not broadly recommended.4 Refer to Table 2 for a summary of non-pharmacological and alternative medicine in the management of sexual dysfunction.

Weight gain Many breast cancer survivors deal with weight gain as an adverse effect of anti-hormonal therapy, which can lead to serious comorbidities, fatigue, and poorer overall quality of life. Weight gain could also potentially affect the efficacy of anti-estrogen therapy, as an increase an adipose tissue could lead to the production of more estrogen.4 Further, the NCCN Survivorship guidelines recommend that patients strive to achieve and maintain a normal weight as well as sustain metabolic health.13 Multiple randomized controlled trails have shown that weight loss is possible in this patient population.4 The most efficient methods for weight loss are multifactorial, and include regular physical exercise, a healthy diet, and cognitive behavioral therapy.4 All forms of interventions (both in person and remote) have shown to be superior to standard medical care, and there are currently ongoing studies investigating mobile tracking tools to help patients manage their diet and training. Currently, weight loss is recommended in all overweight or obese breast cancer survivors taking endocrine therapy and maintaining a normal weight should be encouraged in all breast cancer survivors.4

Musculoskeletal pain Many breast cancer survivors taking endocrine therapy suffer from musculoskeletal pain including arthralgia, myalgia, arthritis, and tendonitis. This typically occurs in patients taking an aromatase inhibitor, as its effect on estrogen levels is much more pronounced. Multiple trials have shown that the first option is to switch to a different aromatase inhibitor, as it allows the patient to continue therapy.4 The ATOLL study evaluated the switch from anastrozole to letrozole and found that 72% of patients were able to continue therapy for at least six months.18 Unfortunately, 74% of patients continued to have musculoskeletal pain despite the switch. The pharmacologic therapy of choice is duloxetine (Cymbalta®).4 In one randomized trial, a 12 week treatment with duloxetine showed that patients in the treatment group had a pain score 0.82 points lower than patients in the placebo arm of the study.4,19 It is worth noting that these patients also reported further quality of life improvements, likely due to duloxetine being effective as an anti-depressant and having potential benefits in the treatment of hot flashes.4 One randomized trial suggested high dose vitamin D having benefit, but other trials reported negative results.4 A few other agents have been studied, but no conclusive data has been found to support use of them. Refer to Table 1 for a summary of the use of pharmacological agents in the treatment of musculoskeletal pain. Non-pharmacologic management of musculoskeletal pain is limited, but it was found through the HOPE trial that 150 minutes per week of aerobic exercise decreased joint pain scores by 29%.20 Continued on page 302

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Materia Medica From page 301 ––––––––––––––––––– This is in line with the physical activity recommendations in the NCCN Survivorship guidelines.13 Other studies have considered the potential efficacy of acupuncture, yoga, and omega-3 supplementation in the treatment of musculoskeletal pain in this population, and all three therapies were found to have no significant effect on the symptoms of musculoskeletal pain.4 Further studies into the use of yoga are warranted, as the study by Peppone et al. determined that the use of the YOCAS yoga regimen showed greater reductions in musculoskeletal pain, muscle aches, and total physical discomfort.21 However, the primary endpoint was sleep quality, and specific questionnaires to assess musculoskeletal pain were not used.4 Refer to Table 2 for a summary of alternative medicine use in management of musculoskeletal pain.

Fatigue The final side effect that breast cancer survivors taking endocrine therapy typically experience is fatigue. There are no current pharmacological recommendations for the treatment of fatigue, but there are a variety of non-pharmacological and alternative medicine options. Several randomized trials have shown physical exercise has a positive effect on reducing fatigue scores and improving quality of life.4 Various types of exercise are effective, but aerobic exercise and muscle strength training are the most supported. Physical exercise should be recommended for all breast cancer survivors receiving endocrine therapy having fatigue.4 The CHANGE study 302

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Materia Medica found that internet-based cognitive behavioral therapy resulted in significantly less fatigue and self-rated improvement from patients.20 While this is not enough data to broadly recommend cognitive behavioral therapy to all patients, further studies are warranted. A randomized trial found that an 8-week course of acupuncture showed a significant improvement in fatigue, anxiety, and depression during the 12-week intervention, which is consistent with the growing body of literature supporting the use of acupuncture for the treatment of a variety of symptoms in breast cancer survivors receiving endocrine therapy.4 Several pilot studies have found that yoga and mindfulness have shown improvements in fatigue. Compared with usual care, a 12-week yoga and meditation intervention were found to improve menopausal symptoms, fatigue scores, and overall quality of life immediately following the intervention and at three-month follow up.4 Patients should be encouraged to use these intervention modalities if they are available to them.

Recommendations for clinical practice Breast cancer survivors taking endocrine therapy may experience a myriad of adverse effects that can dramatically lower their quality of life if not managed properly. There are a variety of options available for the majority of the symptoms, and a multidisciplinary and dedicated team of healthcare professionals should strive to make the most effective interventions for these patients.

ACMS Bulletin / October 2021

Mr. Aronson is a Doctor of Pharmacy candidate at Duquesne University School of Pharmacy. Dr. Fancher is an associate professor of pharmacy practice at Duquesne University School of Pharmacy. She

REFERENCES 1. The Who, What, Where, When and Sometimes, Why. Susan G. Komen. Available at https://www.komen.org/breast-cancer/diagnosis/fact ors-that-affect-prognosis/tumor-characteristics/. Accessed September 2, 2021. 2. Lexicomp Online. Waltham, MA: UpToDate, Inc.; July 30, 2021. Available at https://online.lexi.com. Accessed September 2, 2021. 3. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Breast Cancer v.7.2021. Available at www.nccn.org . Accessed September 2, 2021. 4. Franzoi MA, Agostinetto E, Perachino M, et al. Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer. Lancet Oncol. 2021;22(7):e303-e313. 5. Boekhout AH, Vincent AD, Dalesio OB, et al. Management of hot flashes in patients who have breast cancer with venlafaxine and clonidine: a randomized, double-blind, placebo-controlled trial. J Clin Oncol. 2011;29(29):3862-3868. 6. Loibl S, Schwedler K, von Minckwitz G, Strohmeier R, Mehta KM, Kaufmann M. Venlafaxine is superior to clonidine as treatment of hot flashes in breast cancer patients--a double-blind, randomized study. Ann Oncol. 2007;18(4):689-693. 7. Carpenter JS, Storniolo AM, Johns S, et al. Randomized, double-blind, placebo-controlled crossover trials of venlafaxine for hot flashes after breast cancer. Oncologist. 2007;12(1):124-135. 8. Goetz MP, Suman VJ, Nakamura Y, Kiyotani K, Jordan VC, Ingle JN. Tamoxifen metabolism and breast cancer recurrence: a question unanswered by CYPTAM. J Clin Oncol. 2019;37(22):1982-1983. 9. Sanchez-Spitman A, Dezentje V, Swen J, et al. Tamoxifen pharmacogenetics and metabolism: results from the prospective CYPTAM study. J Clin Oncol. 2019;37(8):636-646. 10. Bordeleau L, Pritchard KI, Loprinzi CL, et al. Multicenter, randomized, cross-over clinical trial of venlafaxine versus gabapentin for the management of hot flashes in breast cancer survivors. J Clin Oncol. 2010;28(35):5147-5152. 11. Leon-Ferre RA, Novotny PJ, Wolfe EG, et al. Oxybutynin vs placebo for hot flashes in women with or without breast cancer: a randomized, double-blind

also serves as a clinical pharmacy specialist in oncology at the University of Pittsburgh Medical Center at Passavant Hospital. She can be reached at fancherk@duq.edu or (412) 396-5485.

clinical trial (ACCRU SC-1603). JNCI Cancer Spectr. 2020;4(1):pkz088. 12. Holmberg L, Anderson H, Steering H, et al. HABITS (hormonal replacement therapy after breast cancer--is it safe?), a randomised comparison: trial stopped. Lancet. 2004;363(9407):453-455. 13. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Survivorship v.3.2021. Available at www.nccn.org . Accessed September 2, 2021. 14. Stellate Ganglion Blocks. University of Maryland Medical System. Available at https://www.umms.org/rehab/health-services/pain-m anagement/treatments/stellate-ganglion-blocks. Accessed September 2, 2021. 15. Portman DJ, Bachmann GA, Simon JA, et al. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Menopause. 2013;20(6):623-630. 16. Wurz GT, Soe LH, DeGregorio MW. Ospemifene, vulvovaginal atrophy, and breast cancer. Maturitas. 2013;74(3):220-225. 17. Goetsch MF, Lim JY, Caughey AB. A practical solution for dyspareunia in breast cancer survivors: a randomized controlled trial. J Clin Oncol. 2015;33(30):3394-3400. 18. Briot K, Tubiana-Hulin M, Bastit L, Kloos I, Roux C. Effect of a switch of aromatase inhibitors on musculoskeletal symptoms in postmenopausal women with hormone-receptor-positive breast cancer: the ATOLL (articular tolerance of letrozole) study. Breast Cancer Res Treat. 2010;120(1):127-134. 19. Henry NL, Unger JM, Schott AF, et al. Randomized, multicenter, placebo-controlled clinical trial of duloxetine versus placebo for aromatase inhibitor-associated arthralgias in early-stage breast cancer: SWOG S1202. J Clin Oncol. 2018;36(4):326-332. 20. Irwin ML, Cartmel B, Gross CP, et al. Randomized exercise trial of aromatase inhibitor-induced arthralgia in breast cancer survivors. J Clin Oncol. 2015;33(10):1104-1111. 21. Peppone LJ, Janelsins MC, Kamen C, et al. The effect of YOCAS(c)(R) yoga for musculoskeletal symptoms among breast cancer survivors on hormonal therapy. Breast Cancer Res Treat. 2015;150(3):597-604.

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Legal Report Perspective

A big win for Peer Review Protection in PA WILLIAM H. MARUCA, ESQUIRE he Pennsylvania Supreme Court unanimously reversed its own prior narrow interpretation of the Peer Review Protection Act (PRPA) in an opinion published on August 17, 2021. The court has now broadened the category of documents that are protected under the PRPA to include materials that were generated outside a formal “peer review committee” so long as they represent peer review activities. Malpractice defense counsel are welcoming this about-face and are calling it a return to normal. In Leadbitter v. Keystone Anesthesia Consultants, et.al., the plaintiff in a malpractice suit alleged a hospital's credentialing and privileging process was inadequate, and that the hospital knew or should have known that a surgeon lacked the expertise to be authorized to perform the surgery in question, resulting in the patient’s permanent disability. The plaintiff demanded the hospital produce the surgeon’s entire credentialing and privileging file. The hospital produced a version of the record which redacted certain opinions about the surgeon’s competence, and specifically withheld OPPE (Ongoing Professional Practice Evaluation) Summary Report; a Professional Peer Review Reference and Competency Evaluation, which

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contained evaluations prepared by other physicians of the surgeon’s performance; and three documents described as "National Data Bank Practitioner Query Response," based on queries submitted to the National Practitioner Data Bank, claiming that these documents were privileged under the PPRA. The plaintiff filed a motion to compel the production of the withheld documents, and the trial court agreed, citing the 2018 case of Reginelli v. Boggs. In Reginelli, the Pennsylvania Supreme Court held 4-3 that the “performance file” of an emergency medicine physician was ineligible for peer review privilege protection because PRPA evidentiary protection is restricted to a narrow class of entities using a peer review committee for a narrow class of specified activities. On appeal, the Superior Court sided with the plaintiff and ordered the release of the materials based on the Reginelli precedent, which they understood as holding that only documents of a formal "review committee" enjoyed the statutory protection, and not documents kept by a "review organization" such as a credentials committee. Upon appeal to the state Supreme Court, the hospital argued that denying confidentiality to peer-review materials based solely on a committee's label as a

credentials committee misunderstands how such bodies operate, and fails to protect the confidentiality of peer-review materials as intended when the PRPA was enacted. The hospital noted that candid assessments of a physician’s capabilities could be chilled if peer-level reviewers knew their evaluations might be disclosed during litigation, which was a key factor in the legislature’s decision to protect such assessments from discovery when passing the PPRA in 1974. In Leadbitter, the Pennsylvania Supreme Court held that any hospital committee that engages in peer review activities can be considered a "review committee" under the PRPA, and its documents are protected from discovery. The majority opinion noted that in Reginelli, the court did not purport to analyze review for delineated hospital privileges, thereby ducking the question of whether to totally overturn the prior decision. “Privileging is distinct from credentialing as it involves giving the physician permission to treat patients at the hospital, and not merely to exercise political rights in relation to staff and committee meetings.” The assessment of a physician’s experience, capabilities, and competence inherently involve peer review regardless of whether the committee that performs them is named www.acms.org

Legal Report Perspective the "credentials committee" and regardless of whether the same committee also does credentialing review. A credentials committee may perform peer review in addition to verifying academic degrees, board certifications, and licensure status. The state Supreme Court sent the case back to the trial court and directed the judge to review the redacted and withheld information to determine if they constitute peer review materials as defined in the PRPA. Turning to the National Practitioner Data Bank documents sought by the plaintiff, the court cited the federal Health Care Quality Improvement Act (HCQIA) protected NPDB query responses from discovery as well as reports made to the NPDB. This is a logical conclusion, as it would make little sense to protect incoming reports but permit Data Bank reports sent to hospitals and other querying entities to be subpoenaed. In a concurring opinion, Justice David Wecht agreed with the outcome

and cited his own dissent in Reginelli, but took issue with the contortions the majority opinion undertook to distinguish its holding in Leadbitter instead of overturning it directly. He contends that the PRPA clearly protects the actions of any hospital body that undertakes peer review activities, no matter how it is labelled or what other duties it performs. Peer review activities, including credentialing and privileging, rely on confidentiality to encourage open, honest and sometimes uncomfortable dialogue about physicians’ competence. Peer review protection laws have been praised for breaking a perceived wall of silence that discouraged physicians from speaking ill of each other prior to the advent of such laws in the 1970s. For the past three years, the Reginelli rule has muddied the protection of many common forms of peer review and evaluation outside formal peer review committees. Physicians who had grown hesitant to participate in such candid assessments for fear of liability to

themselves, their colleagues and their institutions can take comfort in the relatively expedited reversal of what a majority of the court may have concluded was an ill-considered, overly-formalistic analysis. Pennsylvania physicians are once again free to speak their minds about their peers’ capabilities without worrying that their words will be forcibly revealed in the context of litigation. After all, the objective of the peer review system is to improve the quality of patient care and remove unqualified or negligent practitioners, not to cover up mistakes or protect careless physicians. It is the confidentiality of the peer review process that allows the free and open discussion of qualifications that allows and supports such candor. William H. Maruca, Esquire is a healthcare partner with the national law firm Fox Rothschild LLP in the Pittsburgh Office. He can be reached at wmaruca@foxrothschild.com (412) 394-5575.

Thank you for yoour membership in the t Allegheny Couunty Medical Societty The ACMS Membership Com mmittee appreciates your support. Your membership strengthens the society and helps protect our patients. Pl Please make k your medical di l society i t stronger t g by b encouraging gi g your colleagues ll g tto bbecome mem mbers of the ACMS. For information, call the membership department at (412) 321-5030, ext. 10 09, ACMS Bulletin / October 2021

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Special Report Perspective

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Allegheny County Medical Society BULLETIN, October 2021

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