ACMS Bulletin, January 2022

Bulletin Allegheny County Medical Society

January 2022

Diversity Are All Happy Families Alike?

—A Refutation of Tolstoy

Allegheny County Medical Society

Bulletin

January 2022 / Vol. 111 No. 1

Opinion

Departments

Articles

Editorial ....................................5 Society News .........................16 Materia Medica .......................20 • Winter Nourishment • 30th Annual Virtual Clinical Update • The Ejection Fraction May Be Deval (Reshma) Paranjpe, MD, FACS

in Geriatric Medicine

Editorial ....................................8 Society News .........................18 • Diversity • Pittsburgh Ophthalmology Society Richard H. Daffner, MD, FACR

57th Annual Meeting

Associate Editorial.................10 • A “professional patient’s” journey to burnout Andrea G. Witlin, DO, PhD

Perspective ............................13 • Are All Happy Families Alike?

On the cover River Lightning Malcolm Berger, MD Dr. Burger specializes in Neurology

Preserved but Treatment is Evolving: Analysis of New Data Surroundiing Heart Failure with a Preserved Ejection Fraction Thomas Greco Megan Obeid, Rebecca Schoen

Special Report .......................24 • It’s Been A While... Since 2013 Joan M. Keil, PhD, CHPS

Legal Report .........................26 • What Physicians Need to Know

About The No Surprises Act

by Edward J. Cyran, Sarah M. Rozek and William H. Maruca

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

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

2022 Executive Committee and Board of Directors President Peter G. Ellis President-elect Matthew B. Straka Vice President Raymond E. Pontzer Secretary Mark A. Goodman Treasurer Keith T. Kanel, MD Board Chair Patricia L. Bononi DIRECTORS Board Term Ends 2022 William F. Coppula Micah A. Jacobs G. Alan Yeasted Alexander Yu 2023 Steven Evans Bruce A. MacLeod Amelia A. Pare Maritsa Scoulous-Hanson Adele L. Towers 2024 Douglas F. Clough Kirsten D. Lin Jan B. Madison Raymond J. Pan

PEER REVIEW BOARD 2022 Niravkumar Barot Kimberly A. Hennon 2023 Lauren C. Rossman Angela M. Stupi 2024 Marilyn Daroski David J. Levenson

PAMED DISTRICT TRUSTEE G. Alan Yeasted COMMITTEES Awards Mark A. Goodman Bylaws Raymond E. Pontzer Finance Keith T. Kanel Membership Matthew B. Straka

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)

Nominating Raymond E. Pontzer

ACMS ALLIANCE

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

Co-Presidents Patty Barnett Barbara Wible

Association Manager Mary Ellen Muth memuth@acms.org Interim Executive Assistant Dottie Hostovich dhostovich@acms.org Director of Publications Cindy Warren bulletin@amcs.org

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.

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

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Editorial

Winter Nourishment Deval (Reshma) Paranjpe, MD, FACS

I

t’s a blustery January day as I write this, but it feels like Groundhog Day. There’s another COVID surge, and the case counts have doubled since Christmas week. Everyone is getting sick, likely with the Omicron variant.

One patient I just saw told me eight neighbors on her street had died of COVID in the last year, and she was just trying to survive.

We’ve passed the point of emotional limbo. We’ve passed the point of frustration. Intellectually everyone has accepted what is going on, nobody likes it, and everyone is crying inside.

We all just desperately need some good news.

Well, good news could be around the corner. If Omicron is more contagious and less severe (at least for the vaccinated), then the next variants might be even more so, and soon we could be looking at an endemic situation where COVID resembles the flu, or if we’re really lucky, the common cold.

With the FDA emergency use authorization and release of Pfizer’s Paxlovid and Merck’s molunupiravir, highly anticipated oral antiviral pills given to reduce the severity of COVID (think Tamiflu for influenza), the world is one step closer to the pandemic’s abatement. Although these drugs

are not yet widely available for home use, one day soon they will be. And if effective, life will slowly begin to return to normal. Hope is on the horizon.

In the meantime, dining out and dinner parties may not be the wisest thing to do during a highly contagious Omicron surge. Even if you are willing to risk eating out, many restaurants are temporarily closing as COVID is decimating their employees. But I’m going to give you a list of restaurants to look forward to as well as a list of cookbooks to try out at home to beat the winter doldrums. Save your dollars and deploy them on takeout, and on dine-in as soon as the surge is over.

Sure, there are the usual reliable powerhouses of Poulet Bleu, Morcilla, Piccolo Forno and Senti (all in Lawrenceville), Gaucho Parrilla Argentina (Downtown), Con Alma (Downtown and Shadyside), Eleven and DiAnoia’s (both in the Strip District), the revamped and sophisticated high-end Thai of Pusadee’s Garden (Lawrenceville), and Apteka (Bloomfield).

But also give these new openings a whirl in person when the calm returns, and inquire about takeout now: Travel the world via takeout cuisine, even if you can’t travel the world any other way right now:

Craving something you’ve never tried in Pittsburgh?

Afghan Kebab House (231 East Main Street, Carnegie) Founded by an Afghan journalist and teacher who fled his homeland with his family as refugees in 2015, this authentic restaurant serves far more than the namesake kebabs and will introduce you to flavorful dishes you have likely never experienced.

Need some sunshine and a tropical safari?

African Eats Cuisine (2032 Murray Avenue, Squirrel Hill) A family business founded by a Nigerian doctoral student and her sister and mother, this spot serves both the possibly familiar (spicy goat with plantains, jollof rice) and dishes farther afield (beef suya—thinly sliced steak with Nigerian peppers and orange seasoning). Check it out for a dose of sunshine and spice.

Dreaming of Italy?

Levia Trattoria (5336 Butler Street, Lawrenceville) In the site of the former hotspot Cure, you’ll find a beautiful replacement—an upscale but unpretentious Italian scratch kitchen Continued on Page 6

ACMS Bulletin / January 2022

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Editorial From Page 5

“like Grandma’s house” offering dishes like arancini, vitello tonnato, braised octopus, calamarata alla Genovese, a seafood-heavy linguini alla puttanesca, lemon ricotta ravioli and rigatoni with pork ragu. I’ll race you here when the plague lifts.

Dreaming of Italy, and….

Nashville? and can’t decide?

Doughbar (1831 East Carson Street, South Side) Check out the sourdough pizza, NY style pizza and a smorgasboard of specialty pizzas you won’t find anywhere else—case in point pizza with sugo (pork braised in tomato sauce) and house made Stracciatella cheese. Inexplicably, this pizza palace also serves scrumptious whole fried chickens. (I’m not complaining, and neither will the keto/ paleo January people in your life).

Looking for a cosmopolitan getaway—Las Vegas, NYC, SF, LA or Tokyo?

Gi-Jin (208 6th Street, Downtown) Feeling fancy? Check out Richard DeShantz’s new high end sushi place which offers a huge selection of sake, gin, Japanese whisky as well as a tempting selction of sushi, sashimi, hand rolls and other delights. Delicious, glamorous, and a great excuse to shed your pajamas and don some dapper togs again and indulge in a cocktail.

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Need an island getaway? Can’t decide? How about Hawaii AND Puerto Rico in one place?

Hapa & Secretos (1334 Fifth Avenue, Uptown) This is the special magic that happens when the owners of the Secretos di mi Abuela food truck and the Hapa Hawaiian Grill join forces to bring you a taste of paradise from both the East and West of Pittsburgh.

Fast-casual delights to help you dream of the tropics.

Finally, do you miss Bohemian Brunch?

The Nook (3811 Butler Street, Lawrenceville) Filling the considerable void left by Coca Café, The Nook offers a cozy, warm and comforting breakfast, brunch and lunch including seriously hearty omelets and burgers. Look for the extra drink menu including treats like floral teas, Nutella hot chocolate and boozy options from mimosas to Bloody Marys and espresso martinis.

If you’re not leaving the house in 16 degree weather for takeout, I don’t blame you.

Check out these cookbooks: Cookish: Throw It Together, by Christopher Kimball of Milk Street.

As much as I find this gentleman amusing, I have to admit that his cookbook is nothing short of genius.

Every recipe is healthy and will set off spectacular fireworks for your taste buds to enjoy. Best of all, the ingredients are readily available, and easy to quickly throw together in 30 minutes or less, as the title implies.

Even better, I can realistically see myself making each and every one of these gems, and each recipe leaves itself open to tinkering to please the individual palate.

The Food Lab: Better Home Cooking Through Science, by J. Kenji Lopez-Alt. A classic at this point, this 2015 cookbook is great if you’re a foodie and a food nerd—Lopez-Alt has done the experiments and research so you understand what you’re doing and why in the kitchen, so you needn’t fret when you try a new recipe. Here’s all the information to make you a better and more confident cook; great for beginners and seasoned cooks alike.

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Editorial Salt, Fat, Acid, Heat: Mastering the Elements of Good Cooking

by Samin Nosrat. Written by a younger Persian-American chef who has become the food darling of the pandemic, this James Beard Award-winning cookbook will help you become a better chef while learning fabulous recipes. Gorgeous illustrations and humor throughout.

Zero: A New Approach to Non-Alcoholic Drinks, by Grant Achatz. The chef behind the famous Chicago restaurant Alinea has come up with 100 beautiful non-alcoholic cocktail recipes that will allow you to have fantastic and noteworthy libations so beautiful that you’ll not miss the alcohol. The perfect cocktail book for the health-conscious, the post-holiday detoxer, and the gourmet.

Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support.

Your membership strengthens the society and helps protect our patients.

Remember: many other things in history have tried to crush the human spirit and failed. All we have to do is survive. Go forth and enjoy your life as safely as you can.

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

ACMS Bulletin / January 2022

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

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Editorial

Diversity Richard H. Daffner, MD, FACR

D

iversity is a word we frequently hear today, usually in the context of increasing representation of women or people of color and other minorities in American society.

However, the diversity I am writing about refers to the make-up of members of medical groups. Are the groups inbred, made up of individuals who trained at the same institution, or are they diverse, made up of individuals from different (training) backgrounds and experiences?

There are advantages and disadvantages to each.

Inbred departments are most often found in academic medical centers.

The advantages of inbreeding assure that all procedures and treatments follow the same protocols. In other words, everyone in the group is “on the same page.” From an economic standpoint this makes sense because everybody uses the same equipment and the same brands of instruments.

Southwest Airlines is a good example of this, in that they fly only one type of aircraft, the Boeing 737 (in its multiple versions). This means that all their pilots are certified to fly the same plane, all their mechanics service only one type of aircraft, and the company needs to only stock parts for that one type of aircraft. Other airlines, with a diverse fleet of aircraft have pilots and mechanics qualified for each type of 8

aircraft and, of necessity must stock spare parts for each.

Perhaps the biggest advantage of inbreeding is in the selection of new members to join the department from among their finishing trainees (residents and fellows). They are known quantities regarding work ethics and personalities. The finishing trainees also know the faculty, know what is expected of them, and most important, they know the “system.”

The disadvantages of inbreeding include a rigidity in thinking and actions and a lack of innovation in problem solving. The adage, “if your only tool is a hammer, everything looks like a nail,” is in play. The ancient Romans had a term for this, “mos maiorum,” the way we’ve always done things. Unfortunately, as a non-native of Pittsburgh, I have often encountered this attitude here, both within and outside of medical practice.

Inbreeding also encourages a degree of arrogance, in that the practitioners feel that they know better than anyone else. And sometimes, that attitude affects patient care. For example, one orthopedic surgeon I worked with in the past insisted on obtaining tomograms and CT scans for every fracture he treated because that was what was done at the medical center where he trained. (CT gives better information, allows multiplanar and 3-D

reconstructions, and results in lower radiation exposure to the patient).

Diverse departments, on the other hand, are, by definition, made up of individuals who have trained in different institutions. While there is uniformity from one training center to another regarding following established national guidelines, there are also minor variations in how some procedures are performed. For example, as a resident I learned how to perform knee arthrograms with the patient lying in the supine position. Kaye and Freiberger, in their definitive text Arthrography1 showed knee arthrograms being performed with the patient prone. I tried both methods and found the supine position to be more comfortable for the patient than the prone position. Several years later, while at a meeting, I asked the late Jeremy Kaye why he and Bob Frieberger used the prone position. I told him that I didn’t see any difference in the results. He told me that he and Bob learned arthrography using that position and reported it as such in their book.

When I joined the staff at Allegheny General Hospital in 1983, I was the eighth member of the radiology group.

What was interesting was that each member had trained in a different residency program. As the group grew (to now over 50 members) it inevitably included individuals who had trained www.acms.org

Editorial locally (at AHN and UPMC) as well as those from outside of Pittsburgh.

The diversity in the group allowed the residents to learn different techniques for performing (invasive) procedures.

For example, using knee arthrograms again, one of my two partners in the MSK section had trained at UPMC and the other at the late St. Francis. While the results of our knee arthrograms were the same, our techniques were slightly different. When I accompanied a resident doing an arthrogram, (s) he often asked whose method they should use. I told them that when they were with me, they were to use my technique; when they were with Drs. (Bob) Sciulli, or (Carmen) Latona, they were to use theirs; and when they were out on their own, they could choose whichever method worked best for them or use one of their own. In short, the residents were taught the wisdom of the adage, “there’s more than one way to skin a cat” (sorry cat lovers).

Occasionally, my partners adopted my techniques. When I first came to AGH all the radiologists took general call that often involved performing emergency angiography after hours.

Most angiograms use the femoral artery or femoral vein approach. I had been trained to do pulmonary arteriograms using the left brachial vein as my entry point whenever possible. The reason for this was that the catheter easily followed the contour of the vessels through the right atrium into the right ventricle and then into the pulmonary artery. I had learned from experience that accessing the pulmonary artery from the femoral vein necessitated making an abrupt left turn from the right atrium to enter the right ventricle and then the pulmonary ACMS Bulletin / January 2022

artery. My colleague, who performed angiography during regular duty hours, adopted my technique.

Another advantage of diversity is the sharing of opinions and ideas when confronted with difficult clinical situations or in departmental conferences. All departments are mandated to conduct some form of monthly Morbidity and Mortality conference to discuss less-thansatisfactory patient outcomes and/ or complications. In a non-diverse department, the discussion may be limited by the lack of outside experiences. In a diverse department, such as ours, staff members were asked to give their opinions on what would have been done in their former medical centers (“Well, Dr. Daffner, how would they have approached this issue at Duke?”).

The main disadvantage of diversity is the necessity to have each individual’s protocols listed in the department’s book of Standard Operating Procedures (SOP’s). Each of

our interventional radiologists had their favorite catheters and other equipment that had to be stocked. Fortunately, these did not break the budget. On the other hand, one of the orthopedic surgeons, whose subspecialty was joint replacement insisted on using a brand of implants, different from that used by his partners, because he had been trained at an institution that favored them and he was familiar with them. These were expensive, and he ultimately left when the hospital insisted that he use the same brands that the other joint surgeons were using. These other surgeons, who had all trained in different programs showed that they were adaptable to trying something different, so long as there was no compromise to patient care.

Diversity, as mentioned above, certainly has its advantages and disadvantages. Why do I favor diversity? Mainly because I believe in the old saw that “variety is the spice of life.”

Reference 1. Kaye JJ, Freiberger RH. Arthrography, New York, Appleton and Lange, 1979.

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.

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Editorial

A “professional patient’s” journey to burnout Andrea G. Witlin, DO, PhD Forty-two years ago, I was halfway through an exhausting, yet exhilarating 48-hour in-house shift near the end of my OBG internship. My department chief and I performed multiple deliveries and surgeries non-stop. We were both clearly dragging through morning ward rounds, commiserating with each other, our staff, and even our patients until one patient retorted: “You’re the fools who chose this.” That silenced us instantaneously. She was the one in a hospital bed. My chief laughed it off—burnout was never part of his lexicon. I “sucked it up” as I was invigorated from the experience.

Exhaustion be damned. Sleep would come later.

Over the years, I spent innumerable hours on my feet, missed countless holidays with family, meals were either forgotten or consisted of leftover snacks in breakrooms. I experienced the extremes of life—from the exhilaration of new parents to my oncology patients wasting away. I thought I understood the physical and mental exhaustion that accompanied my professional life.

Over the years, I observed my patients’ anguish and genuinely thought I comprehended. Occasionally, they informed me otherwise. I was blessed with great support staff who 10

aided in my understanding of my patients’ interpersonal relationships and tribulations. Through my early interest in oncology, I was well versed (or so I thought) in the 5 stages of death and dying.

Fast forward to my current life as a “professional patient”. Unbeknownst at the time, my journey began early in my career. I regarded my incipient unconnected, disjointed, intermittent symptoms with a combination of DENIAL and managed my ills with curbside consults. We weren’t allowed sick days during residency.

Whereas everyone else’s minor colds lasted 1-2 days, mine persisted for weeks to months at a time. Primary immunodeficiency (and my subsequent official diagnosis of CVID) wasn’t on anyone’s bingo card back then.

Over time, my DENIAL, surreptitious visits, lab tests, and treatments became harder to disguise.

I even paid out of pocket for additional health insurance so that my forays into “legitimate” medical care could remain concealed from my employer and colleagues. Occasional ANGER and BARGAINING crept in as I navigated more public manifestations of my unusual symptoms. Invariably, I was chronically physically exhausted from my insane schedule but yet refused to accept and acknowledge

my developing limitations. My friends and family didn’t grasp why I appeared like a zombie. My colleagues saw me motoring through but didn’t understand or oblige when I would occasionally beg for help. Worse yet, many of my treating docs never took my complaints seriously.

At some point, DEPRESSION (of sorts) entered the picture. My then PCP worked overtime struggling to convince me that I was indeed depressed. I was infuriated that my “medical” complaints were given short shrift. Severe fatigue was misinterpreted as depression.

Enteropathy and severe GERD with my accompanying weight loss was mistaken for depression. My joint pain was attributed to my long hours on my feet. My non-stop sinus infections were treated with antibiotics and so

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Editorial worked for a while...until the medication no longer worked, the complications accumulated, and more mysterious symptoms appeared. It was now crystal clear that my bouts of overwhelming fatigue and the accompanying new complications were easily confused with classic depression. Each time, my dour mood was alleviated by my newest medication. Unfortunately, each new episode increased my disease related restrictions exponentially.

I joked that my social life consists of my doctor’s visits, on. I recognized that no amount of PT/OT, pharmacy calls, and of counseling or antidepressants could cure my as yet undiagnosed underlying course those dreaded fights with insurance companies. diseases – CVID and incipient connective tissue disease despite the protestations of my PCP. So, I floated between DENIAL (maybe this wasn’t real), ANGER (I was being mistreated or more correctly untreated), BARGAINING – I kept searching for the mythical doc who would rescue me.

I was finally entering the ACCEPTANCE phase when I reticently uttered to my husband—I think I know what’s going on—“I have lupus”. He knew I was probably correct yet dissed me as had everyone else before. He could clearly see the deterioration I had sustained. Shortly thereafter, I was vindicated. ACCEPTANCE was overtaken by joy. I finally found a new rheumatologist who believed me and crafted the “receipts” to prove it. My long awaited appropriate immunosuppressive treatment would follow. My friends and family would finally believe me and be empathetic. I could return to the activities in life that I had left behind. Or so I thought. That ACMS Bulletin / January 2022

My motto became—I can feel like shit, but I don’t have to look like shit.

So, I dressed up for my visits. That backfired because “I looked too good to be sick.” Over time, it became clear that my providers, family and friends understood less and less about me and my daily trials and tribulations.

As a result, I reverted to my early days of coping, i.e., withholding information from those around me.

It wasn’t because I was trying to be surreptitious. I had become too complicated. Many of my providers spent extra time with me sorting out my many physical issues, reading my chart and writing notes at ungodly hours of the night. Several had actually developed a kinship of sorts and were worried that they had lost perspective on treating me or worse yet that their treatment might kill me. Some apparently had burned out on our relationship to the detriment of my care.

One day, I needed to arrive earlier than usual for a new immunosuppressive medication. But unbeknownst to me (or the scheduling gods), the infusion center waiting room was closed for a staff meeting and I was relegated to sitting on the floor in the lobby. By the time my infusion commenced, I was beyond miserable.

My displeasure was obviously palpable to all those around, yet no one asked why. Not even my regular nurse who seemingly “knew me!” However, added to my discharge papers was a card for their “therapist.” I was dumbfounded.

I protested “I’ve been sick for years, what is someone going to tell me now?” The retort from my nurse: “that’s my point, you’ve been sick for years and “now” need help coping.” I tossed the card and never confided in that nurse again. I added her to “my list” of those that didn’t get “it.” Medical care was becoming more difficult once again. I retreated into my shell to my “safe space.”

Fast forward several years as I was in limbo between burnout, frustration and a need for new solutions. I was referred to yet another super subspecialist. To be honest, I was irritated and burned out by these visits and was less than enthusiastic about the outcome of this latest venture.

I was bored and agitated as I was forced once again to recount years of nuanced history. About an hour in, the doc stopped, abruptly changed course and asked: “how does someone like you make it through a day”? I answered – with great difficulty. My mood changed abruptly – I was beaming with appreciation inside.

Occasionally, someone still “got it”

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Where to turn…

Domestic Abuse Palm Cards Available at ACMS Where-to-Turn cards give important information and phone numbers for victims of domestic violence.

The cards are the size of a business card and are discreet enough to carry in a wallet or purse.

Call ACMS at (412) 321-5030 for more information.

Letter to the Editor I was both intrigued and troubled by the quote from C. Henry Kempe, MD in Dr. Daffner’s excellent article, Medical historic vignette: Child abuse, which appeared in November’s Bulletin. Intrigued, because it wasn’t clear to me what principles Dr. Kempe found it necessary to forget in order to do what he thought was right, although presumably in order to bring attention to and/ or to take action against child abuse, a motive that few would question today.

Troubled, because, taken alone, that statement might encourage reckless and even dangerous behavior in those who have a misguided view of what is “right,” as we have dramatically witnessed in the American political arena over the past several months.

We have seen that when a group of people do something that they may fervently believe – against all the evidence and contrary to the views of respected commentators – is “right,” 12

and in doing so, cast aside well-settled principles, like acknowledging reasonably well-established facts, adherence to time-tested norms in government, and respect for courts of law, the very core of our democracy can be threatened to the point that it is in danger of extinction.

There are, of course, instances where doing the right thing may be in conflict with principles, the law, or well-established ethical norms. The history books are filled with such instances. But when confronted with such situations, it is incumbent on the actor to critically examine the principles they are willing to “forget” and before acting, to hold them up to the mirror of what they believe is “right,” and to consider what the long-term effects of abandoning those principles will be.

Our principles can and should evolve; not from rash acts, but from a critical analysis of whether those prin-

ciples should be changed, a process that often takes enormous courage and strength of character. In other words, we need to do more than just “forget about” our principles if we believe them to be in conflict with doing the “right” thing.

Bruce L. Wilder, MD, MPH, JD New Orleans 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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Perspective Perspective

Are All Happy Families Alike?

A Refutation of Tolstoy Anthony L. Kovatch, MD All happy families are alike; each unhappy family is unhappy in its own way.

---Leo Tolsoy, from “Anna Karenina” We are family I got all my sisters with me We are family Get up everybody and sing Living life is fun and we’ve just begun To get our share of this world’s delights (High) high hopes we have for the future And our goal’s in sight no, we don’t get depressed Here’s what we call our golden rule Have faith in you and the things you do You won’t go wrong, oh no This is our family jewel ----Sister Sledge.

This popular song rallied the Pittsburgh Pirates led by “Pops” (Willie Stargell) to the World Series championship in the late 1970s In my youthful days of ignorance, I believed that all families were intrinsically happy merely because they represented a group of human beings united by the ties of marriage, blood, or adoption. After I had been

sternly reminded by my struggling, long-suffering father during my high school years that our nuclear family was “different from other families” because of the exhausting care my neurologically deteriorating mother demanded from the rest of us, I declared to myself that by default ours was an unhappy family. I believed that all other families could only be happy ones and I would write enviously and vividly in later years about my loneliness on my rides back to Philadelphia on the night train leaving Newark, NJ station after spending the Thanksgiving holidays with my extended family during those “lost years” of college and medical school.

By that time, the members of my oncehappy nuclear happy had either died or retreated. I wrote: “As the train pulled out of lonely Newark station with the speed of a sloth, I could see below the level of the mounted tracks the small homes of the city-dwellers. In contrast to the bleak darkness of the autumn evening, I could easily see into the lighted family rooms of the homes—mothers and fathers and other adults laughing and watching television, children playing with siblings or pets, older folks hunkering down for the night by eating snacks. The artificial light but palpable

tenderness emanating from within the modest homes replaced my personal emptiness during the long dark ride back to ambiguity. I remember those intense feelings of loneliness with an ironic fondness today, as I am thankful that it has been many years---now that I have been husband and father of my own nuclear family---since I have been the one “on the outside looking in.”

Although this young medical student was completely unaware of it at the time, he was learning a fundamental tenet of the human condition: “Mostly it is the loss which teaches us about the worth of things.” ---Arthur Schopenhauer (1788-1860), German philosopher who opened the path for many, including Tolstoy himself.

One of the greatest, if not the greatest, commentator on human nature Lev Nikolayezevich Tolstoy (1828-1910) portrays in “Anna Karenina” the anatomy of a Russian family unhappy by choice alone. The carrying card of the aristocratic families in this novel is infidelity. Tolstoy and his wife Sophia had 13 children—8 of whom survived childhood---and history reports that their early married life was indeed happy. As their father’s fame and notoriety expanded, most of the children spent their lives either Continued on Page 14

ACMS Bulletin / January 2022

13

Perspective Perspective Editorial 399 ButlerorSt., Etna promoting denouncing his teachings.

For a culinary cross-country road Ultimately, many lead troubled lives trip, Tolstoy stop in this converted autowife service and eventually left his over station for a taste of roadside delights the details of his will. The Tolstoy family frombeen coastreferred to coasttofrom ChefofAnthony has as “one the Tripi.

Twenty draft beers and fun unhappiest in literary history.” cocktails to boot.

Borrowing from the master’s Adda Bazaar, 725believe Penn Ave., premise, sociologists that Downtown for a family to be happy several key The newest Coffee aspects must beofaAdda given, such&asTea House’s multiple cafes. Adda good health of alldowntown family members, is the term for the long Bengali tradition financial security, favorable luck, and of stimulating intellectual discourse with mutual affection.

This theory has been friends over tea and coffee.

Here’s your extrapolated to the realms of science chance to try thethink, art ofquite Adda,fallaciously! with a and industry---I selection of fine teas and coffees.

The “Anna Karenina principle” states Bakery inSquare delights: thatThree a deficiency any one of several AVP, Bakery Square, 6425 Penn factors dooms an endeavor to failure; Ave., East Liberty consequently, a successful endeavor is Fans of Big Burrito’s Alta Via pizza one for which every possible deficiency in Fox Chapel can or venture to Bakery has been avoided corrected.

Subject Square to try the casual California to this principle, a happy family is astyle Italianofcuisine of its cousin, AVP.and Enjoy result premeditated planning seasonal vegetable-forward dishes is forged by calculation rather than by as well as pizzas andlove. sandwiches for intangibles, such as lunch and dinner seven days a week.

Forty-plus years of pediatric practice täkō,me Bakery 6425 Penn compel to defySquare, this principle and Ave., East Liberty to repudiate the dogma of Tolstoy the downtown Richard thatLove “all happy families are alike.” I DeShantz jewel of a restaurant have witnessed the vicissitudes called of täkō, but can’t get of a reservation in the countless families all stripes over crowded space?

Come enjoy its vast three generations and I believe that Bakery Square complete all families who outpost, share some degreewith of 5000 square feet of space and both happiness, although vastly different, indoor andtooutdoor dining. simple also tend share several Galley – Bakery Square, 6425I will underpinnings. Per Sister Sledge, PenntoAve., Liberty refer themEast as their “jewels.”

Galley – Bakery Square is the

latest branch of the Galley restaurant incubator featuring theissame Jewel #1.concept, Financial stability not a formula as its sister sites Federal Galley prerequisite. on This the North Side and theupStrip District can be summed by the old location.

Four emerging chefs are conviction: “He who knows he has selectedistorich.” openHappy their own restaurant enough families find within the space, with 12-18 months to a way to transcend want and privation. win over an audience and establish their brand. #2.

YouExtravagance can try a little of Jewel is everything eschewed. from all four restaurants during the Little houses can make the happiest same meal – heaven for foodies. of homes. There is an overall unspoken Tupelo Honey, 100 West Station contentment with the ordained lifestyle.

Square Drive, South Side Crammed living quarters promote Craving fried green tomatoes, better connectivity. buttermilk biscuits, shrimp and grits and banana pudding – and oh yes, fried chicken and waffles? Tupelo Honey Café will open this fall in Station Square to remedy that, in style.

Con Alma Downtown, 613 Penn Ave., Downtown The new jewel of the Downtown Cultural District features insanely good Miami/Latin/Caribbean cuisine along with live jazz.

Gaucho Parrilla Argentina, 146 Sixth St., Downtown The resident jewel of the Downtown Cultural District dazzles with an incredible array of steaks and wood fired meats with a variety of sauces and accompaniments. Takeout and dine-in available.

Wild Child, 372 Butler St., Etna The brainchild of Chef Jamilka Borges, Wild Child emphasizes coastal and island cuisine and is sure to delight.

Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver

Chef Kevin Sousa’s new project will combine shop, bar and pizzeria Jewel #3.aAwine sense of wonder in the former Kullman’s Bakery space. regarding the “small stuff.”

Sustainable, biodynamic organic Author Shelley Alfano and Berad--wines from around the world will be “I mother of 6---sums it up in her blog: featuredthe along a down believe key with to finding joytoisearth, first and rustic menu.

Nonalcoholic wines and foremost taking time to see the wonder cocktails will be showcased. that is justalso outside your front door.

G’s On Liberty, 5104 Liberty Ave., Watch the sun rise in the morning…

Bloomfield smell the scent of flowers…I try to G’s turnsofformer Alexander’s instill some this wonder into myItalian kids Bistro a seasonal as theyinto grow up, try to scratch get themkitchen out to withas creative and great cocktails. see much food of God’s creation Coming in theI fall. as I am able. try to point out the finallyand … creativity we see all vastAnd diversity Chengdu Gourmet, McKnight around us every single day and how it Road, Ross Township all works harmoniously.

Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining menu. Something to look forward to in early 2022.

Enjoy, and be safe.

“

“

FromRear PageEnd 13 Gastropub & Garage,

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

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

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

ACMS Bulletin / August 2021 14

www.acms.org 223

Perspective Perspective I pray that my children might embrace a faith that is real and lasting and not dependent on their circumstances alone.”

Tolstoy himself was a firm believer in faith: “Only faith can give truth.”

I might add: Every single tick of the clock is a gift. Amen.

Jewel #4. Learn and practice the art of forgiveness.

The characters in “Anna Karenina” lack the capacity for forgiveness.

Rather they embrace the cynicism of Irish poet and playwright Oscar Wilde (1854-1900) “Children begin by loving their parents; after a time, they judge them; rarely, if ever, do they forgive them.”

It is debatable whether the capacity to forgive is learned or hereditary, but the burgeoning field of Epigenesis attempts to bridge the gap. This concept informs us that the stress and trauma of an individual affects the genetic core of his/her being and that these gene changes are passed down through the generations. This scientific fact—which we might consider to be the biochemical basis of “family karma”---awakens us to the lasting impact that living with emotional pain, especially the refusal to forgive even a legitimate wrong, will have upon future generations. More simply stated

by William Shakespeare in “Julius Caesar”: The evil men do lives after them; the good is often interred in their bones. The creed of a happy family must be: No wrongdoing is too serious to be forgiven---and time is of the essence!

ACMS Bulletin / January 2022

Jewel #5. Acceptance of suffering When I was informed as a teenager that our nuclear family was “different” and therefore, by default, unhappy, I was rescued from despair by the philosophy of Austrian Neurologist and holocaust-survivor Viktor Frankl. The crux of Frankl’s theory---embodied in his therapeutic approach to suffering--is that all human beings are motivated by a “search for meaning” in their lives and that the ability to endure suffering and hardship (even of monumental proportions) is a primary mechanism of survival. I believe that the happiest of families are those who bear the cross of caring for a sick member by intensifying the bonds of love among them.

As Pope Francis recently explained: “The family has always been the closest hospital” ---the site of mutual devotion, loyalty, and compassion. As another world leader the Dalai Lama

preaches in “The Art of Happiness”: “If you want OTHERS to be happy, practice compassion. If YOU want to be happy, practice compassion.”

I think it is impossible to recognize a truly happy family on the surface; this can only happen when we have walked repeatedly in their shoes. However, if I had to point out one discernible attribute from my experience, it would be this: The members of a happy family freely make fun of each other in public, but none of them ever take offense.

Still waters run deep. When it all boils down to the clear definition of happiness, I defer to the conclusion of Taoist philosopher Lao Tzu: “Those who know do not tell; those who tell do not know.”

Each happy family is different in its own way.

15

Society News

30th Annual Virtual Clinical Update in Geriatric Medicine–March 31 through April 1 The 30th Annual Clinical Update in Geriatric Medicine will be held virtually on March 31–April 1, 2022.

Presented by the Pennsylvania Geriatrics Society—Western Division (PAGS-WD), UPMC/University of Pittsburgh Aging Institute and the University of Pittsburgh School of Medicine Center for Continuing Education in Health Science, the conference provides an evidencebased approach to help clinicians take exceptional care of elderly patients. The virtual offering includes an outstanding agenda of lectures and panel discussions, including live question-and-answer sessions, vendor halls and opportunities to engage in conversations with speakers, exhibitors, and fellow attendees.

With the fastest-growing segment of the population comprised of individ¬uals more than 85 years of age, this conference is a premier educational resource for healthcare professionals involved in the direct care of older people. As the recipient of the American Geri¬atrics Society State Achievement Award for Innovative Educational Programming, the Clinical 16

Daniel Foreman, MD

Deirde O’Neill, MD, MSc,

Parag Goyal, MD, MSc

Lewis Lipsitz, MD

FRCPC

Mary Tinetti, MD

Update attracts prominent national and international lecturers and nationally renowned local faculty. Continuing Medical Education credits are available to participants.

Course Directors, Shuja Hassan, MD; Neil Resnick, MD; and Lyn Weinberg, MD, along with the planning committee, are delighted to welcome distinguished guest faculty Lewis Lipsitz, MD Professor of Medicine, Harvard Medical School; Chief Academic Officer and Irving and Edyth S. Usen and Family; Director of the Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life; Chief, Division of Gerontology, Beth Israel Deaconess Medical Center; and Editor-in-Chief, Journal of Gerontology www.acms.org

Society News

Medical Sciences. Dr. Lipsitz will present, Falls and Syncope— Red Flags.

Mary Tinetti, MD, the Gladys Philips Crofoot Professor of Medicine (Geriatrics), Epidemiology, and Public Health at Yale School of Medicine and Yale New Haven Health. Her current research and clinical focus are on clinical decision-making for older adults in the face of multiple health conditions, measuring the net benefit and harms of commonly used medications, and the importance of cross-disease universal health outcomes. Dr. Tinetti will present, Aligning Care with Patient’s Priorities.

ACMS Bulletin / January 2022

Back by popular demand, a Geriatric Cardiology Expert Panel will be part of the agenda. Featured faculty include Parag Goyal, MD, MSc, assistant professor, Weill Cornell Medicine, New York. Dr. Goyal has joint appointments in the Division of Cardiology as a heart failure cardiologist and in the Division of General Internal Medicine as a member of the Health Services Research core faculty. Daniel Forman, MD, Professor of Medicine, Division of Geriatric Medicine University of Pittsburgh School of Medicine; Chair, Geriatric Cardiology, UPMC, Director, Cardiac Rehabilitation VA Pittsburgh

Healthcare System. Deirde O’Neill, MD, MSc, FRCPC, Assistant Professor, Division of Cardiology, Department of Medicine University of Alberta, Alberta, Canada. All three physicians will participate in a live, rapid-fire ques¬tion-and-answer session.

To view the complete conference agenda and details on registration, please visit: https://dom.pitt.edu/ugm/.

Registration begins late January.

Mem¬bers of the PAGS-WD receive a discount when registering. To check on your membership status, please contact Mary Ellen Muth at memuth@acms.org

17

Society News

Pittsburgh Ophthalmology Society 57th Annual Meeting and Ophthalmic Personnel Meeting slated for March 11, 2022 The Pittsburgh Ophthalmology Society,

under the leadership of President Marshall W. Stafford, M.D. is pleased to announce the 57th Annual Meeting and the 42nd Meeting for Ophthalmic Personnel, scheduled for March 11, 2022, will be in-person events. Both meetings will take place at the Omni William Penn Hotel in Pittsburgh, PA. We look forward to offering an engaging and robust experience for attendees and exhibitors and are committed to providing a safe, productive, and welcoming environment in which to learn and gather.

Registration begins January 28 with POS members and ophthalmic personnel attendees receiving information by email and mail.

The Society is pleased to welcome Uday Devgan, M.D., FACS as the 41st annual Harvey E. Thorpe Lecturer.

Dr. Devgan is Clinical Professor of Ophthalmology, Jules Stein Eye Institute Clinical Professor Ophthalmology, Jules Stein Eye Institute at UCLA School of Medicine and Refractive and Cataract Surgeon at Devgan Eye Institute Los Angeles, CA. 18

Dr. Devgan is truly world renowned in the field of ocular surgery. He has taught surgery in 40 countries and writes teaching columns in eye surgery journals which are distributed worldwide. He has written more than 200 books, chapters, medical papers, and journal articles about techniques of cataract, lens, and LASIK surgery. These writings as well as his instructional surgical videos have helped thousands of ophthalmologists and their patients.

Participating distinguished guest faculty who confirmed include:

Chris Albanis, M.D.— Comprehensive Ophthalmology and Refractive Surgery, Chief Medical Officer, Ocular Partners, Inc; President, Arbor Centers for EyeCare; Clinical Associate, The University of Chicago; Chairperson, Advocate Christ Medical Center, Department of Ophthalmology Chicago, IL. She teaches residents at The University of Chicago as a Clinical Assistant in the Department of Ophthalmology and Visual Science.

Her pleasure in teaching extends to her colleagues, which has earned her several invitations to lecture on various ocular diseases nationally and internationally. She also serves as the Chair of Ophthalmology at Advocate Christ Medical Center. Dr. Albanis serves in many leadership roles with the Illinois Society of Eye Physicians and Surgeons and the American Academy of Ophthalmology, where she advocates for the needs of doctors and patients of Illinois.

Emily Chew, M.D.— Director of the Division of Epidemiology and Clinical Applications (DECA), at the National Eye Institute, the National Institutes of Health in Bethesda, Maryland. She is also the Chief of the Clinical Trials Branch. Dr. Chew is a medical retina specialist and has had extensive experience in designing and implementing clinical trials (of Phases 1, 2 and 3) at the NIH Clinical Center. Dr. Chew has a strong clinical and research interest in diabetic eye disease and age-related eye diseases. She has thoroughly worked on analyzing the data from the Early Treatment Diabetic Retinopathy Study (ETDRS) and she continues to manage and analyze data from the Age-Related Eye Disease Study (AREDS).

José Alain-Sahel, M.D— Distinguished Professor and Chairman; The Eye and Ear Endowed Chair Department of Ophthalmology; Director, UPMC Eye Center University of Pittsburgh School of Medicine Pittsburgh, PA. Dr. Sahel is a clinicianscientist conducting research on vision restoration focusing on cellular and molecular mechanisms underlying retinal degeneration, and development of treatments for currently untreatable retinal diseases. He co-authored over 660 peer-reviewed articles and 40 patents. Dr. Sahel is recipient of numerous awards including the Foundation Fighting Blindness (FFB) Trustee Award, Alcon Research Institute Award for Excellence in Vision Research, Grand Prix NRJNeurosciences-Institut de France, Foundation Fighting Blindness Llura Liggett Gund Award, CharpakDubousset Award, Médaille Grand www.acms.org

Society News Vermeil, Ville de Paris. He was elected to the: Academia Ophthalmologica Internationalis, Académie des Sciences-Institut de France, German National Academy of Sciences Leopoldina, National Academy of Technologies of France, Association of American Physicians and American Ophthalmology Society. Dr. Sahel is Honoris Causa doctorate of University of Geneva and held the Technological Innovation Chair at the Collège de France (2015-2016). He is a member of several Editorial Scientific Advisory Boards, including Science Translational Medicine.

Steven R. Sarkisian, Jr., M.D.—

42nd Annual Meeting for Ophthalmic Personnel The 42nd Annual Meeting for Ophthalmic Personnel, presented by the Pittsburgh Ophthalmology Society (POS), will run concurrently with the POS Annual Meeting Friday, March 11, 2022. Application to IJCAHPO has been submitted for attendees to earn a maximum of 7 credit hours.

Course directors Pamela Rath, M.D., Avni Vyas, M.D., and Zachary Koretz, M.D. have prepared an exceptional educational offering for Ophthalmic staff. Highlights of the course include presentations on

Neuro-Ophthalmology; Oculoplastics; Interpretation of Fundus/OCT Photos; MIPS; and Biomicroscopy, Angles and Pupils.

The conference provides exceptional educational opportunities for ophthalmic personnel in and around the region and continually attracts wellrespected local faculty, who present relevant and quality instruction through numerous breakout sessions.

On-line registration begins January 28, 2022, www.pghoph.org. Contact Nadine Popovich, administrator, for details and more information at npopovich@acms.org.

founder, and CEO of Oklahoma Eye Surgeons, PLLC. Dr. Sarkisian specializes in premium cataract surgery and glaucoma surgery, with a special interest in helping his patients be glasses-free and performing minimally invasive glaucoma surgery (MIGS). He implants premium lenses with cataract surgery and was the first in Oklahoma to implant the PanOptix trifocal lens.

This is the newest premium lens, and now for the first time, we can treat distance, intermediate, and near vision, as well as astigmatism, all at the same time. He was also the first surgeon in Oklahoma to perform the iStent, iStent Inject, the Xen Gel Stent, and canaloplasty. He was the first in the U.S. to use the OMNI device and the first in the world to use the TRAB360 and VISCO360 surgical systems, the predicate devices to the OMNI. For more information on the Annual meeting please visit the POS website at www.pghoph.org or contact Nadine Popovich, Administrator at npopovich@ acms.org or to 412.321.5030.

ACMS Bulletin / January 2022

Omni William Penn Hotel in Pittsburgh, PA

19

Materia Medica The Ejection Fraction May Be Preserved but Treatment is Evolving: Analysis of New Data Surrounding Heart Failure with a Preserved Ejection Fraction Authors: Thomas Greco, Megan Obeid, Rebecca Schoen Heart failure (HF) is becoming more common in the American population with the prevalence reaching close to 6 million people.1 Rates are rising in those aged 65-70 and in the African American population, where women are at an even higher risk for disability. Heart failure is the result of many cardiometabolic diseases.

Those diagnosed with hypertension, diabetes, hyperlipidemia, or those who smoke are at an increased risk of development. Heart failure has historically been classified by two phenotypes: heart failure with a reduced ejection fraction (HFrEF) and heart failure with a preserved ejection fraction (HFpEF). HFrEF is defined by a left ventricular ejection fraction <40%, whereas HFpEF is defined by a left ventricular ejection fraction ≥ 50%.2 More recently, these categories have been clarified to include a third phenotype defined as an ejection fraction from 40-49% called heart failure with a mildly reduced or midrange ejection fraction (HFmEF).

Several different medication classes have shown benefit in managing patient symptoms and improving mortality outcomes in HFrEF. Unfortunately, the treatments for those with an EF >40% are limited.

Pharmacological treatment for HFpEF is focused on adequate blood pressure 20

not statistically significant (hazard ratio [HR], 0.89. 95% CI 0.77-1.04).

Considering the secondary outcomes, patients treated with spironolactone had similar rates of death compared to placebo (9.3% versus 10.2%, HR 0.90, 95% CI 0.73-1.12) while heart failure hospitalization differed slightly (12.0% versus 14.2%, HR 0.83, 95% CI 0.69-0.99). Given this non-significant primary outcome, the authors of the TOPCAT trial concluded that adding spironolactone did not alter the time to first hospitalization or death for patients with HFpEF. Regional differences in the Review of Notable HFpEF Trials data have generated hypotheses that spironolactone could provide benefit for Assessment of the clinical trials some patients and a post-hoc analysis previously completed on HFpEF suggested reduced hospitalizations demonstrates the lack of guideline for an EF more indicative of HFmrEF. directed medical therapy (GDMT) for This analysis prompted the European HFpEF. A few trials or retrospective Society of Cardiology (ESC) to analyses have suggested potential consider Mineralocorticoid Receptor evidence for ACE inhibitors, ARBs, Antagonists in HFmrEF but as a IIb, C and Beta Blockers in HFmrEF, but ultimately, there is no clear, compelling level recommendation reflective of this case for use of a specific medication in conflicting evidence and spironolactone HFpEF, particularly when assessed as is not included in the ESC HFpEF treatment recommendations.2 a primary outcome.2 Spironolactone can be used for The TOPCAT (Spironolactone for Heart Failure with a Preserved Ejection management of hypertension as a second line antihypertensive agent in Fraction) trial completed in 2014 patients with HFpEF needing additional compared the use of spironolactone blood pressure control, particularly in versus placebo on cardiac outcomes resistant hypertension.7 in HFpEF.6 The primary outcome of this study was the composite of PARAGON-HF (Angiotensincardiovascular (CV) death, aborted Neprilysin Inhibition in Heart Failure cardiac arrest, or hospitalization. with Preserved Ejection Fraction), was Use of spironolactone resulted in a published in 2019 and compared the reduced primary outcome of 18.6% use of sacubitril/valsartan to the use of of patients as compared to 20.4% of valsartan alone in those with HFpEF, patients in the placebo arm but was

control. Diuretics have been used for symptom management, but no medication class has convincingly reduced morbidity and mortality.2 SGLT2 inhibitors, which have shown benefit in the management of patients with NYHA class II-IV HFrEF, have now been studied in patients with an EF > 40%.3-5 A discussion of recent notable trials for patients with an EF >40% including the new published data surrounding SGLT2 inhibitors, is provided in this review.

www.acms.org

Materia Medica patients with and without diabetes at an almost equal proportion. All patients had an ejection fraction of 40% or higher and approximately 1/3 of the patients had an EF of 40-50%, 50-60% and above 60% respectively. Over 80% of patients had NYHA functional class II HF and approximately 18% had NYHA functional class III HF. The primary outcome studied was the time to first event of the composite of CV death or first hospitalization for heart failure. The study’s results showed the primary outcome occurred in 13.8% of the empagliflozin arm and 17.1% of the placebo arm (HR, 0.79, 95% CI 0.69-0.90). As secondary outcomes, the individual components of this composite outcome were also assessed. In the empagliflozin group, 8.6% of patients were hospitalized for heart failure compared to the 11.8% of patients treated with placebo (HR, 0.71, 95% CI 0.60-0.83). There was not a statistically significant reduction in the secondary outcome of cardiovascular mortality between the two groups (7.3% versus 8.2%, HR, 0.91, 95% CI 0.76-1.09). These secondary results suggest that the primary outcome was driven primarily by a reduction in hospitalizations for heart failure.

The results of EMPEROR Preserved are similar to those seen in EMPEROR Reduced (Cardiovascular and Renal Outcomes Newest Evidence for SGLT2 with Empagliflozin in Heart Failure), Inhibitors suggesting that empagliflozin may play a potential role in the treatment The October 2021 publication of 4 EMPEROR Preserved (Empagliflozin in of both phenotypes of heart failure.

Heart Failure with a Preserved Ejection In the subgroup analysis all groups stratified by EF trended toward favoring Fraction) studied empagliflozin, an empagliflozin, but the largest benefit SGLT2 inhibitor, in the management was in an EF in the 40-50% while an of HFpEF regardless of a comorbid EF ≥60% did not indicate statistical diagnosis of Type 2 diabetes.3 significance.

EMPEROR Preserved enrolled specifically an EF > 45%.8 While sacubitril/valsartan is currently a first line agent for GDMT of HFrEF due to mortality benefit, this trial in patients with HFpEF did not indicate the same impact. For the primary outcome of CV death or hospitalization, 12.8 vs 14.6 events per 100 patient years occurred in the sacubitril/valsartan arm vs valsartan alone respectively (Relative risk [RR], 0.87, 95% CI 0.75-1.01). Out of 2407 Sacubitril/valsartan patients, there were 690 hospitalizations for heart failure compared to 797 hospitalizations occurring in the 2389 patients treated with valsartan (RR, 0.85, 95% CI 0.72-1.00). When analyzing the pre-specified subgroup based on EF, patients with an EF of 45-57% seemed to show a larger benefit than those with a higher EF. This analysis led to expanded labeling for sacubitril/valsartan: “to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure.

Benefits are most clearly evident in patients with left ventricular ejection fraction (LVEF) below normal.”9 With the non-significant primary outcome and stronger data for those with HFmrEF, the benefit is less well defined for HFpEF, particularly in those with a higher EF.

ACMS Bulletin / January 2022

In addition to patients with a high EF percentage, some caution is warranted when applying the findings of the EMPEROR Preserved data to non-white patients, patients with NYHA Class III/IV HF, and those with reduced eGFR. The population studied in EMPEROR Preserved skewed towards mainly white patients with NYHA Class II heart failure, potentially limiting the generalizability to those of a different ethnicity or classification of heart failure. EMPEROR Preserved also excluded anyone with an eGFR < 20 ml/min/1.73 m2. It is common to see a decline in eGFR in the first few weeks when patients are first started on an SGLT-2 inhibitor. However, SGLT2 inhibitors are thought to have overall renal protective benefits due to a slower rate of eGFR decline.10 There are some patient specific considerations when implementing an SGLT-2 inhibitor in heart failure.

Caution should be used in patients who are at higher risk of diabetic ketoacidosis since SGLT-2 inhibitors can cause euglycemic ketoacidosis, which does not present with the typical signs of diabetic ketoacidosis.11 Patients with type 1 diabetes are at a higher risk of diabetic ketoacidosis and they were excluded from EMPEROR Preserved.3,11 Empagliflozin can increase the risk of genital mycotic infections and urinary tract infections and has a black box warning for a rare but serious risk of necrotizing fasciitis of the perineum.11 If added to a patient’s regimen that already includes insulin or an insulin secretagogues like a sulfonylurea, the patient may need a dose reduction in these therapies to avoid hypoglycemia.

Other common adverse drug reactions for empagliflozin include nausea, Continued on Page 262

21

Materia Medica From Page 261

increased urination, increased thirst, and hypotension. Special care and monitoring should be in place if the patient is already on a diuretic, as this can increase the risk for dehydration. The diuretic may need a dose reduction or in some cases discontinued altogether. SGLT-2 inhibitors are generally more expensive for patients as they are brand only medications.

In addition to this latest data regarding empagliflozin, the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure) is underway.12 The DAPA-HF trial previously studied dapagliflozin in patients with HFrEF and suggested cardiovascular mortality and heart failure benefits.5 The DELIVER trial is designed similarly to EMPEROR Preserved and aims to study the effects of dapagliflozin in those with an EF >40%. The results of the DELIVER trial may clarify the data surrounding the use of different SGLT-2 inhibitors in the treatment of HFmrEF and HFpEF.

Conclusion Given the recent published data regarding the use of empagliflozin in HFpEF and the limited alternatives for clinically meaningful improvements in this disease state, the SGLT-2 inhibitor class of medications may be a helpful tool in the treatment of those with an EF > 40%. The benefit to these patients may be driven mostly by reduced HF hospitalizations based on the secondary outcomes.

Subgroup analysis of the trials with an SGLT2 inhibitor or ARNI could indicate 22

potential treatment differences between the HFpEF population with higher baseline EF percentages and the HFmrEF population. First line treatment of proper blood pressure control should be addressed before starting an SGLT-2 inhibitor for HFpEF, and the risk vs. benefit for each specific patient should be analyzed. Some patients may have additive benefits with an SGLT2 inhibitor based on previous trial data in Type 2 diabetes patients such as glycemic, cardiovascular or renal benefits.13 With limited treatment options in this patient population, benefit in a primary outcome for patients with an EF >40% is a notable development.

At the time of this writing in December 2021, Mr. Greco and Ms. Obeid are Doctor of Pharmacy candidates at Duquesne University School of Pharmacy with an anticipated completion of study in May of 2022. Dr. Schoen is an Assistant Professor in the Pharmacy Practice Division at Duquesne University School of Pharmacy. She serves as a clinical pharmacy specialist focused in primary care with the Allegheny Health Network. She can be reached at schoenr@duq.edu or (412) 396-2367.

References 1. Roger VL. Epidemiology of Heart Failure.

Circ Res. 2021;128(10):1421-1434. doi:10.1161/ circresaha.121.318172 2. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2021; 42(36): 3599- 3726. doi:10.1093/eurheartj/ ehab368

3. Anker SD, Butler J, Filippatos G, et al.

Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med. 2021;385(16):1451-1461. doi:10.1056/nejmoa2107038 4. P acker M, Anker SD, Butler J, et al.

Cardiovascular and renal outcomes with Empagliflozin in heart failure. N Engl J Med. 2020;383(15):1413-1424. doi:10.1056/ nejmoa2022190 5. M cMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019; 381:1995-2008.

6. P itt B, Pfeffer MA, Assmann SF, et al. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370(15):13831392. doi:10.1056/nejmoa1313731 7. W helton PK, Carey RM, Aronow WS, et al.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115. doi:10.1161/ HYP.0000000000000065 8. Solomon SD, McMurray JJV, Anand IS, et al.

Angiotensin–NEPRILYSIN inhibition in heart failure with preserved ejection fraction. N Engl J Med. 2019;381(17):1609-1620. doi:10.1056/ nejmoa1908655 9. S acubitril and Valsartan. Package Insert.

Novartis Pharmaceutical Company; 2021.10.

Meraz-Muñoz AY, Weinstein J, Wald R. EGFR decline after SGLT2 inhibitor initiation: The Tortoise and the Hare Reimagined. Kidney360. 2021;2(6):1042-1047. doi:10.34067/ kid.0001172021 11. Empagliflozin. Package Insert. Boehringer Ingelheim Pharmaceuticals; 2021.

12. S olomon SD, Boer RA, DeMets D, et al.

Dapagliflozin in heart failure with preserved and mildly reduced ejection fraction: Rationale and design of the deliver trial. Eur J Heart Fail. 2021. doi:10.1002/ejhf.2249 13. American Diabetes Association. Standards of Medical Care in Diabetes-2021. Diabetes Care 2021 Jan; 44(Supplement 1): S1-222. https://doi.org/10.2337/dc21-Sint.1

www.acms.org

st Liberty ery Square is the

Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver

opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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

ACMS Bulletin / January 2022

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23

Special Report

It’s Been A While…

Since 2013 Joan M Kiel, Ph.D, CHPS The world has changed, healthcare has changed, and now the Health Insurance Portability and Accountability Act, (HIPAA), will change. Spurred on by the quick flip to telemedicine during the pandemic, the onslaught of social media platforms, the deluge of healthcare hacking incidents, and smart phone apps, HIPAA is ‘catching up.’ What it means for you are new policies, new formage, and new training.

In January 2021, the Federal Government issued a Notice of Proposed Rulemaking to recommend changes to HIPAA and garner public comment. As of now, the feedback is being culled and changes are predicted for 2022 that will enhance privacy and security measures, but also allow individuals greater access to their patient health information (PHI).

Once the changes are made, covered entities would have 240 days to be in compliance.

In 1996, when HIPAA was first introduced, electronic health records were in their infancy and personal health applications were still on the drawing board. Fast forward a quarter century and the HIPAA changes will include definitions on the two (45CFR164.501). Covered entities will need to incorporate those definitions into their policies and operational processes.

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The pandemic made clear how access to one’s PHI or designating an individual to have access if the individual themselves could not have access is paramount. The proposed changes will address this. The proposed changes will add to and update 45CFR164.514 on individuals having access to PHI. As of now HIPAA allows individuals to view and get a copy of their PHI, but the proposed rule will allow the person to take notes, videos, and photographs of the record. Physician practices will need a policy as to the operational aspects of this and how staff will implement this in a private area of the office.

Timely access to PHI is a concern for individuals and thus the proposed rule will decrease the response time from 30 days to 15 days to answer a request for PHI. Physician practices will need to review their staffing and policies to assess how this stricter timeline can be met.

The new changes will encompass changes in how individuals are identified when requesting to access records. What is being proposed is that a covered entity cannot impose undue hardships on requiring a written request or a certain type of identification. Just as with many organizations, two factor authentication has become the norm and that is being discussed.

The fee structure charged for access to medical records is being examined. Here again, any barrier that prevents access to one’s records is being taken into consideration and physician practices will need to understand how this affects their finances and staffing. Given the changes from paper records in 1996 to more electronic health records in 2022, ramifications may not be devastatingly significant.

Since 2003, covered entities have had patients sign the Notice of Privacy Practices. Carefully crafted with language specified in the HIPAA law, this document outlines the rights of both the patient and the covered entity. Covered entities had to obtain verification of receipt and maintain that documentation for six years. The proposed changes would negate the need for the required signature and the Notice language would be updated.

Here, physician practices would need www.acms.org

Editorial Special Report

Rear End Gastropub & Garage, 399 Butler St., Etna to formulate a newcross-country Notice of Privacy For a culinary road Practices language trip, stop ingiven this the converted autospecified service in the 2013 and decide if station for aHIPAA taste ofRule roadside delights they recommend maintain the from would coast to coast fromtoChef Anthony signature in the event a patient later Tripi. Twenty draft beers and fun states thattothey cocktails boot.did not know the rights.

Bazaar, 725 Penn Ave., At Adda this time, covered Downtown entities should be aware The newest of Adda Coffee & Tea House’s multiple downtown cafes. that changes are coming inAdda is the term the long 2022 andforbegin to Bengali talk totradition of stimulating intellectual discourse with staff theirHere’s your friendsand overexamine tea and coffee. present issues. chance to operational try the art of Adda, with a selection of fine teas and coffees.

Three Bakery Square delights: AVP, Bakery Square, 6425 Penn Ave., East Liberty Fans of Big Burrito’s Alta Via pizza in Fox Chapel can venture to Bakery Square to try the casual California style Italian cuisine of its cousin, AVP. Enjoy seasonal vegetable-forward dishes as well as pizzas and sandwiches for lunch and dinner seven days a week. täkō, Bakery Square, 6425 Penn Ave., East Liberty Love the downtown Richard DeShantz jewel of a restaurant called täkō, but can’t get a reservation in the crowded space? Come enjoy its vast Bakery Square outpost, complete with 5000 square feet of space and both indoor and outdoor dining.

Galley – Bakery Square, 6425 Penn Ave., East Liberty Galley – Bakery Square is the

latest branch of the Galley restaurant incubator concept, featuring the same Whatas won’t change the needGalley for formula its sister sitesis Federal personnel designated as a Privacy on the North Side and the Strip District Director Security Director location. and Fouraemerging chefs areas well as ongoing training. covered selected to open their ownAll restaurant entities willspace, need with training as months the within the 12-18 to HIPAA law will have substantial win over an audience and establish their changes. brand. YouThe canpositives try a littleofofthe everything changes are that HIPAAduring will reflect from all four restaurants the the current healthcare and technology same meal – heaven for foodies. environments, and 100 remember, you Tupelo Honey, West Station have changed HIPAA Square Drive,with South Sidein 2013.

Craving fried green tomatoes, buttermilk biscuits, shrimp and grits and banana pudding – and oh yes, fried chicken and waffles? Tupelo Honey Café will open this fall in Station Square to remedy that, in style.

Con Alma Downtown, 613 Penn Ave., Downtown The new jewel of the Downtown Cultural District features insanely good Miami/Latin/Caribbean cuisine along with live jazz.

Gaucho Parrilla Argentina, 146 Sixth St., Downtown The resident jewel of the Downtown Cultural District dazzles with an incredible array of steaks and wood fired meats with a variety of sauces and accompaniments. Takeout and dine-in available.

Wild Child, 372 Butler St., Etna The brainchild of Chef Jamilka Borges, Wild Child emphasizes coastal and island cuisine and is sure to delight.

Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver

Chef Kevin Sousa’s new project will combine a wine shop, bar and pizzeria Federal Register, Proposed in the former Kullman’s Bakery space.

Modifications to the HIPAA Privacy Sustainable, biodynamic and organic Rule To Support, and Remove wines from around the world will be Barriers Coordinated Care featuredto, along with a down to and earth, Individual Engagement.

A Proposed rustic menu. Nonalcoholic wines and Rule by the Health Human cocktails also will beand showcased.

Services 01/21/2021.

G’s OnDepartment.

Liberty, 5104 Liberty Ave., https://www.federalregister.gov/ Bloomfield documents/2021/01/21/2020-27157/ G’s turns former Alexander’s Italian proposed-modifications-to-the-hipaaBistro into a seasonal scratch kitchen privacy-rule-to-support-and-removewith creative food and cocktails. barriers-to-coordinated-care Coming in the fall.

And finally …

Chengdu Gourmet, McKnight Road, Ross Township Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining menu. Something to look forward to in early 2022.

Enjoy, and be safe.

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

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

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

ACMS Bulletin / August 2021

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ACMS Bulletin / January 2022

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Legal Report

What Physicians Need to Know About the No Surprises Act

By Edward J. Cyran, Sarah M. Rozek, and William H. Maruca Edward J. Cyran

A new law enacted in late 2020 to protect consumers from unexpected medical bills took effect on January 1, 2022, and may require immediate action. The federal No Surprises Act is aimed at reducing “surprise bills” to patients in the context of services provided at hospitals and ambulatory surgical centers, and includes requirements for healthcare facilities as well as physicians providing services at such facilities.

Generally, a “surprise bill” is one that the patient receives for services from a provider who the patient was not aware was out-of-network with their insurer. Surprise bills often occur with emergency services or with nonemergency services received from nonparticipating providers at in-network facilities, such as out-of-network anesthesiologists at an in-network hospital.

The Act and its implementing regulations prohibit certain balance billing practices by out-of-network providers and mandate a set of disclosures with respect to health care services provided at hospitals and ambulatory surgical centers. The Act also contains notice requirements for health insurers and establishes an arbitration process for out-of-network services in this context.

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Sarah M. Rozek

William H. Maruca

For physicians, the key elements of the Act are the limitations on balance billing for emergency services; the notice and consent requirements for balance billing for out-of-network nonemergency services in an in-network facility; and the required good faith cost estimates that must be provided to uninsured or self-pay patients.

Physicians should also be familiar with the dispute resolution process which applies to payments for out-of-network claims subject to the Act’s limitations.

Three Interim Final Rules have been published in the Federal Register interpreting and implementing the Act using a process that bypasses the usual advance notice and comment requirements for federal regulations.

Accordingly, additional changes may be adopted in the future in response to health industry and consumer advocate comments and other input after the Act takes effect.

• Out-of-network charges for ancillary care (such as from an anesthesiologist or pathologist) at an in-network facility in all circumstances.

The Act prohibits: • Surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.

The Act mandates a plain-language consumer notice regarding: • T he restrictions on balance billing for such services under the Act.

• Out-of-network charges for surgeons and other non-ancillary professional services without advance notice to and consent of the patient.

•O ut-of-network cost-sharing for emergency services, and for non-emergency services in this context without the patient’s advance consent. Patient costsharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network provider, and any coinsurance or deductible must be based on in-network provider rates.

• Any state law balance billing protections that may apply.

www.acms.org

Legal Report • How to contact relevant state and federal agencies if a patient believes that the provider has violated any of the restrictions.

This notice must be given to the patient no later than the date and time on which the provider requests payment from the individual (including cost-sharing amounts). The notice must also be published on an easily searchable part of the provider’s website and prominently displayed on-site at the provider’s location where scheduling or questions about the cost of items or services occur. Sample notices are posted at www.cms.gov/ nosurprises.

Disclosure and Consent to Out-of-Network Rates The Act permits certain out-ofnetwork physicians to bill a patient and the patient’s insurance plan at the full out-of-network rate for services provided at an in-network facility, but only if the physician provides a separate disclosure to the patient and obtains the patient’s written consent at least 72-hours prior to their appointment. Otherwise, balance billing for that service is prohibited.

Such notice and consent requirements are met if the patient is provided written notice and consent 72 hours in advance of appointment, must include a good faith estimate of the costs of the services and a list of in-network providers at the facility and information regarding medical care management, such as prior authorization.

The disclosure and consent exception for out-of-network billing described above does not apply to ACMS Bulletin / January 2022

emergency medicine, anesthesiology, pathology, radiology, neonatology, diagnostic testing, or services provided by assistant surgeons, hospitalists and intensivists, which cannot be provided at higher out-of-network rates and for which a patient cannot be asked to give consent.

The Secretary of HHS may apply civil monetary penalties of up to $10,000 for failure to comply. Hardship exemptions or penalty waivers may be available for providers and facilities that did not knowingly violate the Act.

Good Faith Estimates The Act requires providers to give a good faith estimate of the expected charges for non-emergency services to any uninsured (or self-pay) patient within certain timeframes following the scheduling of that service.

The estimate must contain certain information as detailed by the Act. These estimates must generally be provided no later than 3 business days after scheduling the service if the appointment was made at least ten days in advance; not later than three business days after the patient requested an estimate, and if the service is scheduled at least three business days before the appointment date (but less than 10 business days), no later than one business day after the date of scheduling. Guidance and templates are posted at www.cms.gov/ nosurprises. The estimate must contain: • The patient’s name and date of birth; • A description of the primary item or service being furnished to the

patient (and if applicable, the date the primary item or service is scheduled); • An itemized list of items or services that are ‘reasonably expected’ to be furnished; • Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service; • The name, National Provider Identifier, and Tax Identification Number (TIN) of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished.; • A list of items or services that the provider or convening facility (the provider or facility that handles the scheduling of the service) anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service; • A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate; • A disclaimer that the information provided in the good faith estimate Continued on Page 28

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Legal Report From Page 27

is only an estimate and that actual items, services, or charges may differ from the good faith estimate; and • A disclaimer that informs the patient of their right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate; and • A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

The Act also requires providers to inform all uninsured (or self-pay) patients of the availability of a good faith estimate of expected charges in connection with scheduling a service or upon request. The notice must be prominently displayed on-site at the provider where scheduling or questions about the cost of items or services occur and published on an easily searchable part of the provider’s website.

Dispute resolution The Act establishes an arbitration process to determine the amount insurers must pay out-of-network providers in scenarios where the patient did not consent to being balance billed for a scheduled service. If an out-of-network provider is dissatisfied with a health plan’s 28

payment, it can initiate a 30-day negotiation period, after which the parties must submit their final offers to an arbitrator, who must select the most reasonable offer. This process uses “baseball-style” arbitration where the arbitrator may only pick between two proposed alternatives, and may not split the difference.

In making its determination, the arbitrator will consider a number of factors, including, but not limited to, the health plan’s historical median in-network rate for similar services in the geographic area and whether the parties have made good faith efforts to reach a network agreement within the last four years.

The American Medical Association (AMA) and the American Hospital Association (AHA), among others, filed suit in December 2021 to challenge a provision in the regulations that may result in underpayments to providers and impaired access to care. Specifically, they assert that the regulations create a presumption in favor of the commercial insurers’ median in-network rate during the independent dispute resolution process, which deprives the independent arbitrator of his or her discretion to consider all other factors such as whether a teaching hospital might have higher costs than average, the training and experience of a treating physician, or the complexity of the care that physicians provided.

This suit is still pending in the courts.

There is also a process to resolve disputes between certain patients and providers if bills exceed the required good faith estimate by more than $400.

A third-party arbitrator will review the good faith estimate, final bill, and other information submitted by the provider or facility. This process is available if the patient is uninsured or self-pay; received a good faith estimate from the provider or facility; received a bill within the last 120 calendar days, and the difference between the good faith estimate and the bill is at least $400.

Next Steps Hospital-based physicians, including emergency physicians, radiologists, anesthesiologists and pathologists, will need to ensure that no balance billing occurs for their services after January 1, 2022. Surgeons and other procedure-oriented physicians need to understand the notice and consent requirements when treating a patient in an in-network facility if the physician is not in the patient’s insurer’s network.

All physicians must be ready to provide good faith estimates to patients/ prospective patients who are uninsured or plan to self-pay – note that further guidance is anticipated regarding future good faith estimate requirements for patients using insurance. And all physicians whose out-of-network charges are capped under the Act should become familiar with the dispute resolution process to challenge underpayments from insurers.

Edward J. Cyran, Sarah M. Rozek and William H. Maruca are healthcare attorneys with the national firm Fox Rothschild, LLP and can be reached at ecyran@foxrothschild.com; srozek@foxrothschild.com and wmaruca@foxrothschild.com. www.acms.org

Adam Barsouk—Winner of ACMS Scholarship Congratulations to Adam Barsouk, who received a $4,000 award through the ACMS Foundation scholarship fund. Eligibility for the annual scholarship is for a third- or fourth-year Pennsylvania medical student from Allegheny County, U.S. citizenship, and full-time enrollment in a Pennsylvania medical school.

In response to the question, How do you hope to be involved in your community beyond clinical care of patients? In what ways would you hope to demonstrate leadership as a physician in your community? Barsouk said, “Between Pittsburgh, DuBois, State College, and now Philadelphia, I’ve never lived a day outside of Pennsylvania. My father, desperate for any opportunity to escape the Soviet Union’s anti-Semitism, ended up halfway across the world cleaning pipettes in a little-known lab at the University of Pittsburgh. Despite language and cultural barriers, my family has made a home here ever since.

Having lived, studied, and worked in both major cities and rural areas, I know PA is as diverse as it is wide. The steps I’ve learned to take with patients in Philadelphia, like asking for their preferred pronouns, would seem foreign to some of my neighbors in central PA. And yet, across disparate communities, we all share the same goal: innovative, accessible, and affordable healthcare.

I studied Health Policy and Administration at Penn State in 2018—a perfect time to analyze the benefits and shortcomings of the largest healthcare reform in decades, the Affordable Care Act. While Medicaid expansion helped support millions in the cities, recruitment for the program has been slower in the countryside. Similarly, between falling reimbursements and the financial impact of COVID-19, rural practices, and hospitals, as well as urban hospitals in underserved communities, like Hahnemann, have shut their doors. It may take decades for us to recover.

I’d always pictured my future as that of an academic oncologist, participating in cutting-edge clinical trials and treating patients at some big-name academic center. But after finally working with patients, I’ve realized that it’s exactly the opposite of those kinds of centers that are desperate for the next generation of doctors. I could have a much more meaningful impact treating patients, and perhaps building up a research and training program, at a less well-known community hospital in the city or the country—one that serves populations that can’t always access the care they deserve.

I’ve seen the city and the country become more socially divided than ever, with many points of contention, such as vaccination, access to abortion, and gun ownership, carrying immense public health ramifications. I witnessed these issues firsthand when 11 people were murdered in the attack on Tree of Life, my childhood synagogue mere blocks from my home. As physicians in the midst of chaos and suffering, we can’t afford to ‘stay in our lane,’ but we also can’t let our opinions supersede patient autonomy. Working in an underserved area would allow me not just to offer patients the latest in cancer care, but also to do my part in bridging our nation’s divide. I hope to call upon my background in medical communication to quell distrust in healthcare and media and explain everything from vaccinations to the latest immunotherapies in an accessible manner.

My family was fortunate to end up here, and I aspire to give back to the many communities across the state that graciously took us in.”

Additional information about the ACMS Scholarship Fund that is administered through the Pennsylvania Medical Society can be found at https://www.foundationpamedsoc.org/student-financial-services/scholarships/ acms-scholarship.

ACMS Bulletin / January 2022

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ACMS/FYI

Retired and Interested in Becoming a Physician Volunteer?

Are you retired or retiring and interested in applying as a physician volunteer? With a dogged persistence, Dr. Patricia Canfield uncovered and simplified the process for others, providing ACMS with a shortcut to the application. https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Nursing/Documents/Applications%20and%20Forms/Volunteer%20License%20Application.pdf According to PAMED, “Volunteer licenses are available to retiring health care practitioners or non-retired practitioners who are not required, because the practitioner is not otherwise practicing medicine or providing health care services in Pennsylvania, to maintain professional liability insurance under the Medical Care Availability and Reduction of Error (MCARE) Act. To qualify for a volunteer license, a physician must currently hold an active unrestricted license.”

To learn more about CME requirements, liability protection and other information, visit https://www.pamedsoc.org/list/articles/volunteer-medical-license-pennsylvania According to Dr. Canfield, “Once the application is completed, it must be mailed (versus submitted electronically).”

Thank you, Dr. Canfield and all physician volunteers!

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www.acms.org

C.F. Reynolds Medical History Society—FREE LECTURE

What is the Sound of Happiness?

Tuesday, February 22, 2022 6-7:15pm Eastern Time (US and Canada) “Negotiating Normalcy: Deafness Cures in American History” Jaipreet Virdi, PhD (History, University of Delaware)

This lecture is based on Dr. Virdi’s recent book Hearing Happiness: Deafness Cures in History (University of Chicago, 2020), in which she combines historical research with personal memoir. She is a specialist in the history of medicine, disability studies, and the history of technologies such as hearing aids.

Dr. Viridi will give the annual Reynolds Society Grand Rounds for the University of Pittsburgh Department of Medicine at noon on the same day; contact the University of Pittsburgh Department of Medicine if you are interested in joining that talk via Teams.

At 4pm on Tuesday, Dr. Virdi will join the University of Pittsburgh Science, Technology, and Society interest group for a book discussion on Zoom. If you would like to participate, please contact the Society at cfreynoldsmhs@gmail.com for the link. Plus, we will reimburse you for purchasing the book! https://urldefense.com/v3/__https:/ccac.zoom.us/j/93228738857?pwd=RDlsNTBGczk4UEVITXFyTzJBTkpYUT09__;!!NHLzug!ZQ5oKnm0S16h3S-TeejwdSDFs9gpbvXX5hMNT3Mb13IiAX_4gD_XmMrAFLctkUbRPtkB$

Retiring?

New Address?

ACMS Members:

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

Call (412) 321-5030 for more information.

ACMS Bulletin / January 2022

New Partner?

Congratulatory message?

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Congratulations to the Photographers whose work was selected for the 2022 year!

January River Lightning Malcom Berger

February Pittsburgh Sunrise Terenze Starz

March Tranquility, Cooks Forest Alexanndra Kreps

April Lake McDonald— Glacier Park David Sacco

May Waterfall Nina Verghis

June Sunset Nina Verghis

July Ohiopyle Elias Hilal

August IENHART Mark Thompson

September Tower of Voices at Flight 93 Memorial Robert Cicco

October City of Bridges Elias Hilal

November Perfection Terenze Starz

December Shenandoah Sunset Mark Thompson