ACMS Bulletin June 2022 by TEAM

Bulletin Allegheny County Medical Society

June 2022

President’s Update Teenage Einstein’s Take Center Stage

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Allegheny County Medical Society

Bulletin June 2022 / Vol. 112 No. 6

Opinion President’s Message ..............5 • Update by Peter Ellis Editorial ....................................6 • Traditions to Keep

Departments

Articles

Society News .........................16 Materia Medica .......................26 • American College of Surgeons SWPA Chapter Most Interesting Cases

Deval (Reshma) Paranjpe, MD, MBA, FACS

ACMS Bylaws ........................18

Stage Anthony L. Kovatch, MD

• Sara Hussey, MBA, CAE – ACMS Executive Director

• Paxlovid: The First Authorized Oral Antiviral for COVID-19 Treatment in Non-Hospitalized Patients Elizabeth Posney, Pharm.D., PGY-1 Pharmacy Resident Ambulatory Care, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA

Allegheny County Editorial ....................................8 Medical Society Foundation • Teenage Einstein’s Take Center Tackles Formula Shortage.....34 Legal Summary .....................30 Editorial ..................................10 2022 ACMS Meeting and • Medical Historic Vignette: The Activity Schedule....................35 “Pornographic” Anatomy Book Richard H. Daffner, M.D., FACR

• Pregnancy-Related Protections for New Physicians Jeremy V. Farrell, Esquire Rebecca A. Moran, Esquire Tucker Arensberg, P.C.

Edtitorial Index ......................32

Perspective ............................14 • History of Nutrition

Election Form 2023 ...............36

Kristen Ann Ehrenberger, MD PhD

On the cover

Sunset

Nina Verghis, MD Dr. Verghis specializes in General Surgery

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 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 Board Chair Patricia L. Bononi DIRECTORS 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 Nominating Chair Raymond E. Pontzer

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) Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF

ACMS ALLIANCE

Executive Director Sara Hussey (shussey@acms.org)

Co-Presidents Patty Barnett Barbara Wible

Governance Administrator Dorothy Hostovich (dhostovich@acms.org) Vice President - Member and Association Services Nadine M. Popovich (npopovich@acms.org) Eileen Taylor Manager - Member and Association Services (etaylor@acms.org) Director of Publications Cindy Warren (cwarren@pamedsoc.org)

Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Sandra Da Costa Assistant Treasurers Liz Blume Kate Fitting

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

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Advertising rates and information available by calling (412) 321-5030 or online at www.acms.org. COPYRIGHT 2022: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212. ISSN: 0098-3772

Update

Happenings at your ACMS An update from your president, Peter Ellis, MD

t has been quite an eventful year for the ACMS. This brief article is intended to bring all of you up to speed with your organization and to give you an understanding of the vision for serving the physicians of Allegheny County. As most of you know, Jeremy Bonfini (prior CEO) left our organization for an opportunity with the Medical Association of Georgia in August of last year. His departure was preceded by the departure of Jim Ireland and followed by the departure of several of our more recent hires. The Executive Committee immediately convened a search committee for a new Executive Director and hired a temporary interim Executive Director. I am happy to report that, after an exhaustive search and interview process, (facilitated by the search firm, Non-Profit Talent), the search committee was able to recruit our new Executive Director, Sara Hussey. Sara has extensive experience with membership organizations, having spent 12 years with the Pennsylvania Institute of CPAs working as Vice President of member experience. She brings unparalleled experience, knowledge, enthusiasm, and energy into the ACMS. We are more than delighted to welcome her into the ACMS fold. Hopefully all of you will have the ability to interact with Sara in the coming year. Her start date was mid-March and already we are moving in a positive direction. ACMS Bulletin / June 2022

I would like to put in a special thanks to longtime ACMS staff member Dottie Hostovich for her support during this transition period. Dottie had retired from the ACMS last year but was willing to come back to help in our time of need. She intends to re-retire in August after she has helped with onboarding new employees at the Society. Best wishes to Dottie for a well-deserved second career in the retired world! I am pleased to announce that Nadine Popovich (a member of the ACMS team for 26 years) has accepted the position of Vice President of Member and Association Services. In this role, she will continue to supervise our specialty physician associations but will also be the administrative spearhead of Member Services. In July we will welcome a new employee, Eileen Taylor. Eileen most recently served as the Program Coordinator for the University of Pittsburgh Geriatric Medicine division. She will work with Nadine in Association Management and Member services. We also welcome summer intern Abby Casario, a Penn State University undergrad who is looking to broaden her experience in social media and digital marketing. You can expect to see a more active social media presence over the coming months! The last several months have seen us preparing our team to be nimble in reacting to the needs of today’s physician. Your Board, at its May

meeting, approved guidance to our executive team and administration to develop and put into place programs for our members that will meaningfully enhance their ability to serve the populace of Allegheny County. This will entail extensive volunteer committee work and administrative leadership but will result in a Society that is relevant to today’s physician needs, both employed and independent. Already, many of you may have seen in the news the ACMS and ACMS Foundation were able to provide desperately needed baby formula to the mothers and infants of Allegheny County. Also, in this month’s Bulletin, you will see efforts underway by the bylaws committee to revamp our by-laws to streamline our operations. We welcome and encourage member feedback on the proposed bylaws changes. To continue to be a successful organization, we ask you to be engaged in our group efforts. Please consider volunteering for a committee, talking to colleagues, or running for office. You will see summaries of services available to you as well as opportunities to get involved in the coming months. We are excited to serve YOU, our member and customer, as best we can through services, advocacy, and education. Thank you, Peter Ellis, MD President of Board ACMS 5

Editorial

Traditions to Keep Deval (Reshma) Paranjpe, MD, MBA, FACS

he pandemic isn’t quite over, but the media coverage has ebbed. Most people are either vaccinated or have been infected once or multiple times. Some people have long COVID-19.

We may not be entering “the after” yet, but it seems that we are entering “the aftermath”. What lessons have we learned, and what traditions will we keep because of what we’ve just lived through? I remember learning second-hand lessons as a child through wary adults who had lived through Watergate and Vietnam: question everything. Don’t blindly trust politicians or the media. These same lessons have echoed through the pandemic, along with a few new corollaries which will no doubt be explored in business and public health graduate schools for decades to come. The best interests of the economy don’t always align with the best interests of public health, health care workers, and individual patients. The best economic interest of an individual may not be aligned with the best health interest of that individual. Government institutions, including the CDC, are more vulnerable to political influence than we thought or 6

hoped. In many ways these have been rude but necessary awakenings to snap us all out of complacency. The children who came of intellectual age in these few years will in turn carry these lessons into their adulthood. But think about the positive side. What good traditions arose from these few years that we can carry forward? One small, beautiful, powerful tradition that arose from this pandemic is the friends and family check-in. At first, friends and family checked in on each other regularly to ascertain: “Are you sick? Are you well? Are you alive? Are you vaccinated?” Now, the checkins may grow a little sparser and less intense, but no less loving. We don’t take good health or recovery for granted anymore. We don’t take each other for granted anymore. Another tradition to carry forwardRediscovering and strengthening old bonds. Many of us reconnected with old friends from high school, college, medical school, and training during quarantine. We suddenly discovered that we have a long-neglected network of trusted physicians in various specialties at our disposal from medical school and residency/fellowship. We trust them clinically because we remember who wasn’t a slacker and who had the best scores and who was the good egg who’d go the extra mile.

We trust them personally as friends because we remember who was there when we needed someone to lean on and ask for help. Many stories of reconnection with old friends have emerged—from 2 am curbsides and impromptu zoom reunions - to sharing vital new medical knowledge from different areas of the country and tips on how to stay safe and protect our patients, our families and ourselves. Then there’s the tradition of Random Acts of Kindness. The pandemic has taken a toll on everyone’s mental health, and some people have made a point of lifting each other up. I have a friend who started sending me the most beautiful little gifts during the pandemic in the form of texting me music out of the blue in the middle of the workweek or weekend. Sometimes as a hello, sometimes as a thank you, sometimes just as an expression of joy, always as a desire to share something beautiful in the middle of a humdrum day. I never realized in all these years how much we had in common in terms of our musical taste. Sometimes we’ll have entire conversations which consist of: “have you heard this artist yet? You need to!”, “this is my favorite cover of Leonard Cohen’s Hallelujah,” and snippets of everything from bluegrass to opera to doo-wop to jazz. www.acms.org

Editorial

You don’t need much to spread joy, just the desire to lift someone else up and pay it forward. The pandemic tradition of cooking fun and delicious meals at home instead of dining out will serve us well during the forecasted recession ahead. The pandemic tradition of working remotely may stay in place longer than expected due to unprecedented gas prices. Many of us, having lived through the extraordinary sight of bare store shelves, have resolved to keep an ongoing reserve supply of stuff in our basements. Never again will we be caught without laundry detergent, canned goods, paper towels, or toilet paper. Our grandparents may have had the Depression-era mentality of saving and/or mending everything. We will adopt the pandemic mentality of hoarding and always being prepared for sudden disaster and scarcity. We are shaped by the hardships we have lived through, and though we may not realize it yet, our grandchildren’s generation may laugh at us and our compulsive toilet-paper hoarding decades from now. What else have we learned? We’ve learned that human nature hasn’t changed much over thousands of ACMS Bulletin / June 2022

years. A few semiconductors, some cryptocurrency and electric razors are all that separate modern man from long-ago ancestors in history books. Pride, greed, stubbornness, lack of consideration and care for our fellow man, avarice: all of these very human faults were on remarkable display in the past few years. The thin veneer of civilization that makes our society palatable showed considerable cracks and chips. We’ve learned that “Love Thy Neighbor as Thyself” makes such great sense as a societal maxim. And yet, how few people adhere to it! We’ve learned that some evil and societal ills go underground during times of crisis. School shootings disappeared only because school was closed. Mass shootings only disappeared because of curfews and quarantines. Stress and strain accelerated domestic violence and child abuse and drug abuse, and quarantine made these horrors invisible. Given the motive, means and opportunity, evil will act. It’s impractical to have purely virtual school and neverending curfew and quarantine, so the opportunity will always exist. But what will we do about reducing the motive and the means of these heinous crimes in the future? We’ve learned that all the scientific and societal progress of the last few hundreds of years can be undone

with the ravings of a few highly vocal uneducated people who engage in magical thinking and challenge common sense public health measures. We’ve learned that even within the scientific and medical communities there are varying degrees of buy-in, resistance, fear, politics, and intellectual curiosity. No more do I wonder: “how could the Salem witch hunts have happened? How could McCarthy get away with his anti-communist hysteria? How could the Inquisition have happened?” The seeds of hysteria, magical thinking, and rejection of the scientific method were to be seen everywhere around us. For heaven’s sake, people were actually drinking bleach. No more will I declare blithely “this could never happen today.” There is a reason why the survivors and witnesses of the Holocaust and other genocides have adopted the slogan “Never again.” It’s because they recognize that the flaws of the human race make such an awful thing possible at any time. We haven’t evolved past our collective, faulty, uncouth, tribal human nature, nor are we likely do so in the future without concerted and continual effort. And yet, there are better angels all around us and among us. These souls have demonstrated the best of human nature in the worst of circumstances and are beacons to the rest of us trying to do our best. They live the creed we all should strive to follow: Love Thy Neighbor as Thyself. What a wonderful tradition to keep.

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.

Editorial

Teenage Einsteins Take Center Stage Anthony L Kovatch, MD

earn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”

“

—Albert Einstein

I must admit that I was well over my head. Having been invited by the Allegheny County Medical Society to be a judge at the annual Pittsburgh Regional Science and Engineering Fair powered by the Carnegie Science Center, I was overwhelmed by the depth of scientific inquiry, the mastery of experimental design, and the brilliance of presentation displayed by the participating high school students of the Tri-State area. March 23, 2022 will be the day I learned that this new generation of scientists are poised to brighten the future for our planet. Fortunately, I was assigned to the Division of Medicine, Health and Microbiology, where I had at least a superficial level of expertise; the other two divisions---Engineering and Robotics and Physics and Astronomy ----required judges of a college professor background. We ACMS physicians evaluated and compared the merits of approximately 50 poster sessions; for myself the experience was a flashback to my earlier days in academic medicine where we “ran the gauntlet,” evaluating with a fine tooth comb research on the cutting edge 8

of our subspecialty. With a clipboard in hand and an unbiased mind, we scrutinized the clarity of the scientific method and the impact of the results and conclusions of the studies so elaborately presented. The students were professorial in discussing the motivations behind their projects. Many focused on topics that were germane to the current generation of teenagers or to millennials in general: treatment of acne vulgaris, the effects of playing X-box on quality of sleep, the addictive potential of energy drinks, the effects of athleticism on lung capacity, the relative dangers of the various artificial flavorings added to vaping products. The titles of the exhibits were creative and the layouts of the posters were monumental.

It became evident to me that some of the researchers had an ax to grind and were pursuing areas that were close to their hearts to benefit a loved one or to improve a personal area of disability. Prevention of infection was a recurring topic vis a vis the current COVID-19 pandemic, especially the efficacy of facemasks. Prevention of the progression of adolescent acne and dental caries were a recurring theme and were approached from the perspective of the specialists who treat these conditions on the front lines. One solo researcher who had a sibling with a gastrostomy tube compared how different food groups affect the breakdown of the silicone lining of the tube bulb over time. The diversity of the topics was matched by the diversity of the presenters, who represented just about every high school in the Tri-State area. I felt that the second floor of the Science Center was bursting with pride, not to mention intellectual fervor.

These exhibits escaped nobody’s attention!

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Editorial

Teamwork rules!

The future of the world’s scientific inquiry was on display

Some of the students were advancing the progress of complex projects of college mentors and had access to higher level technology. The graphs and statistical applications imitated those employed in the most prestigious medical journals. Moreover, when interrogated about the materials and methods employed in their projects, the junior investigators appeared to be their own fiercest critics. All the poster sessions included a panel of references and the very best even included an itemized list of acknowledgements (which I felt compelled to praise): “We all stand on the shoulders of giants.” There were no arguments to the contrary; humility continues to be a virtue of the gifted. However, it is my conviction that to a man, the students demonstrated a professionalism and scientific acumen well beyond their years. Although only a handful were awarded scholarships, all were winners in the minds of the judges and other observers. ACMS Bulletin / June 2022

When my brain stopped spinning, I remembered the sarcastic song from the movie “Bye, Bye Birdie” and the lines: Why can’t they be like we were--perfect in every way? What’s the matter with kids today?!” I think this generation will change our world for the better---in every way! “One generation passeth away, and another generation cometh; but the earth abideth forever… The sun also ariseth, and the sun goeth down, and hasteth to the place where he arose…” —Ecclesiastes 1:5 (King James version)

Editorial

Medical Historic Vignette: The “Pornographic” Anatomy Book Richard H. Daffner, M.D., F.A.C.R.

ross Anatomy was the bane of most first-year medical students, who, like me had a “classic” medical education. In those days we dissected an entire cadaver and were required to memorize hundreds of unconnected facts on each part of the human body, including the embryology, the names of each organ, muscle, blood vessel, and nerve. In addition, in the case of muscles, we had to learn its points of origin and insertion, innervation, blood supply, and function. Some of it made sense, when once a week, we would have a class with a radiologist who would show us x-rays that correlated with that week’s dissections. In truth, most of us would learn our anatomy on our clinical rotations as well as in our residencies. At my school (then SUNY at Buffalo, now Jacobs School of Medicine of the University at Buffalo) the highlight (or lowlight) of each week was the dreaded Saturday morning “recital” conference with the Chairman of Anatomy, Dr. Oliver P. Jones (“OP”). Dr. Jones took sadistic delight in grilling the students on the week’s dissections. It was a no-win situation, since he would continue the oral exam until the student was unable to answer, and the next victim was called upon. The upper classmen stoked our fear by warning us of the coming ordeal. I remember

that first conference when “OP” called on the first student, who immediately fainted. “Well, what are you looking at,” he growled at the student seated beside the woozy victim. “Get up!” I quickly learned that the whole exercise was a game for “OP” to entertain his staff and that we shouldn’t worry about looking stupid, because we all would be humiliated by the end of each conference. The standard textbook, of course, was Gray’s Anatomy. The original book, published in 1858, was the work of English physicians Dr. Henry Gray (Fig. 1), illustrated by his colleague Dr. Henry Vandyke Carter (Fig. 2) 1. The book was far more comprehensive than others at the time, and quickly became a best seller. The first American edition was published in Philadelphia in 1859 by Blanchard & Lea. I used the 27th American edition2 in 1963. That edition, and several subsequent editions used many of Dr. Carters illustrations. The current (42nd) edition3 is a multiauthored text and is lavishly illustrated with original color artwork as well as state-of-the-art X-ray, CT, MR, and ultrasound images. Owners may also download an eBook version that has additional material. Ruth Richardson, in “A Historical Introduction to Gray’s Anatomy” notes: “Neither Gray nor Carter … would have conceived that

years after their deaths their book would not only be a household name but regarded as a work of such pre-eminent importance … alongside the Bible and Shakespeare.”

(Fig 1) Henry Gray, FRS (1827 – 1861)

(Fig 2) Henry Vandyke Carter, MD (1831 – 1897)

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Editorial Over the decades, medical schools revised their curricula, introducing more clinical correlation at the expense of the basic sciences. In many schools, students no longer dissect a cadaver but learn their anatomy from fixed preparations such as the Visible Human Project run by the US National Library of Medicine as well as many other electronic resources. In 1966, the Duke University School of Medicine radically changed its curriculum, which affected the Department of Anatomy more than any other basic sciences department4. The time allotted to teaching gross, microscopic, and neuroanatomy was reduced by 50%. Several attempts by the faculty to present a useful course in gross anatomy failed, and resulted in most of the faculty, including the chairman, Dr. R. Frederick Becker to leave. Paradoxically, Duke Medical Center is world-renowned for their surgical programs. I remember one Duke medical student who rotated on radiology while I was on faculty emphatically insisting that the esophagus went through the foramen magnum! “That’s why it’s so big,” he said with confidence. While this controversy was brewing, Dr. Becker and two colleagues – James Wilson, MD, PhD, of the Department of Pathology and John Gehweiler, MD, of the Department of Radiology - were already collaborating on a new anatomy textbook, with the goal of producing a work with clinical emphasis4, appropriately titled The Anatomical Basis of Medical Practice5 (Fig 3).The book was organized by body regions and each chapter followed the sequence of clinical examination from the surface to the ACMS Bulletin / June 2022

limbs. Woven throughout the book was correlative embryology. A heavy emphasis was placed on radiology and clinical correlations4. The authors’ dedication clearly spelled out their goals: “This book is dedicated to YOU: You may be a medical student beginning anatomy in your first year; You may be taking an in-depth elective course in anatomy in a later year in the curriculum; Or You may be reviewing anatomy in a residency training program. Perhaps even You, the continuing student out in practice might find reading it a refreshing experience”5.

(Fig 3) The Anatomical Basis of Medical Practice

With these noble goals in mind, what possibly could have gone wrong? Early in the book, however, several unusual sections appeared. The authors initially considered that in presenting surface anatomy, they should use photographs of gardenvariety men and women (like 99% of patients) who would never win a beauty contest. Instead, they used nude female “pin-up” models. They wrote in the Preface, “The student will see the ordinary specimen every day, only on rare occasions will

the attractive, well-tuned specimen appear before him for consultation. He should be prepared for this pleasant shock. For the growing ranks of female medics, we included the body beautiful of a robust, healthy male5” (Dr. Becker’s son). Interestingly, the walls of Becker’s office, however, were plastered with Playboy centerfolds, that he used in teaching surface anatomy for his anatomy classes. Co-author Dr. Wilson was an acquaintance of photographer Peter Gowland, who was internationally famous for his work with female models. Wilson, Becker and Gehweiler selected around twenty of Gowland’s photographs which were used to illustrate surface anatomy. Most of the pictures are stylized and posed. There are no photographs showing the pubic region, and the illustrations in the book of pelvic reproductive organs are black and white drawings. In contrast, the male model is posed in a nonsuggestive manner and the photographs are cropped to show only the anatomic areas of interest, whereas the female photographs are full body “pin-up girl” poses4. (Sorry, discretion will not allow an example to be shown) Overall, there were fewer than twenty of the female poses, and by today’s standards, all are tame. Interestingly, nobody commented on the single “pornographic” illustration, Figure 10-50 which compares the analogs of male and female genitalia. The illustration shows a midsagittal section of the organs in a couple in copulo. Continued on Page 12

Editorial From Page 11

The book became a best seller when it was published in 1971. However, the nascent feminist movement quickly began protesting the sexist nature of the book, especially after the cover story in an issue of The New Physician entitled “The New Anatomy” appeared complete with a centerfold ala Playboy. The fight was led by the late Dr. Estelle Ramey, a Georgetown University endocrinologist and staunch feminist whose medical expertise and rapier tongue earned her the moniker as the “Mort Sahl of the women’s movement.” As presidentelect of the Association for Women in Science, she led a campaign against the publisher, Williams & Wilkins, that made national headlines. The company withdrew the book after Ramey and others threatened a boycott. Today, used copies of the book are available for purchase for upwards of $1,000. From a historical perspective it is important to consider how different societal and professional attitudes were fifty years ago. Civil Rights issues and protests over the Vietnam War emboldened feminists to demand equality as well. I graduated medical school in 1967. My graduating class of 100 had only seven women. Today, women make up 54% of medical school classes. I remember that it was common at that time for women applicants for radiology residencies to be asked if they planned to become pregnant during their training. At professional meetings, it was common for speakers to tell jokes, many of which were not only off-color, but also included topics that are offensive.

The three co-authors of The Anatomical Basis of Medical Practice could be compared to the pranksters on truTV’s Impractical Jokers for their perverse sense of humor (amply on display in the Preface). Fortunately, times have changed. I recall an exchange I had while interviewing a woman resident applicant many years ago. When I was finished discussing our program and answering the usual questions, I asked her if she had any more questions for me. She replied, “How come you didn’t ask me if I planned to become pregnant during my residency.” “It’s none of my business. Besides, we’re not allowed to ask that,” I answered. “But what if I do? I don’t want to be exposed to radiation.” “In our program we don’t depend on the residents to get the work done. There are enough rotations where you wouldn’t be exposed to fluoroscopy,” I replied. Times had, indeed changed. When the controversy over the racy pictures is put aside, the book otherwise fulfilled the author’s goals of providing anatomical correlation that can relate to medical and surgical practice. I frequently referred to my copy of the book as a welcome alternative to my copy of Gray’s Anatomy that sat on my bookshelf throughout my residency as well as in my many years of practice.

References: 1. Gray H, Carter HV. Anatomy: Descriptive and Surgical. London, John W. Parker and Son, 1858 2. Goss CM, editor. Gray’s Anatomy of the Human Body, 27th ed. Philadelphia, Lea & Febiger, 1959. 3. Sandring S, editor. Gray’s Anatomy: The anatomical Basis of Clinical Practice 42nd ed. London, Elsevier Churchill Livingstone, 2020. 4. Halperin H. The pornographic anatomy book. The curious tale of The Anatomical Basis of Medical Practice. Acad Med 2009; 84:278 – 283. 5. Becker RF, Wilson JW, Gehweiler JA. The Anatomical Basis of Medical Practice. Baltimore, Williams & Wilkins, 1971. 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. He is also an amateur historian.

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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suppressed or was forbidden. As long as the humor, in this case name-

to us, they are still our fellow human beings.

W. Norton, 1960 (Original work published 1905).

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Perspective Perspective

History of Nutrition in Medical Training Kristen Ann Ehrenberger, MD PhD

ere you required to take a class on nutrition in medical school? Was an elective even an option? How many morning reports, noon conferences, or journal clubs in residency were dedicated to perioperative hydration? Have you been offered continuing medical education on the physiology of weight gain and loss? The “triple burden” of undernutrition, overnutrition, and micronutrient deficiencies underlie significant morbidity and mortality around the world today, and many patients trust their doctors to give them dietary advice, yet few physicians feel qualified to give it. Laments about the poor state of nutrition training fill the medical education literature, going back at least to the late 1950s, when Edward High (1919-1986) at Meharry in Nashville surveyed 66 of the 80 medical schools then in operation. Mid-century angst may reflect the vacuum created when dieticians coalesced as a (largely female and undervalued) profession. Assuming it had been present in curricula earlier, the subject may have been dropped for mostly male medical and surgical trainees destined for increasingly refined and technical (sub)specialties rather than for general practice. Alternatively, the decline in interest may only appear to have 14

started in the post-war period as an artifact of what has been digitized and indexed; if and when I have the time to search older publications, I would not be surprised to find William Osler or his teachers’ teachers complaining that there are not enough lectures devoted to dietetics. Is there nothing new under the sun? Whenever its nadir, medical training in nutrition may have peaked in the 1980s, when total parenteral nutrition (TPN) was all the rage. Stanley J. Dudrick (1935-2020) had developed this method for intravenously nourishing beagle puppies while a surgical resident at the University of Pennsylvania in the 1960s. The first infant to be fed by vein was a girl born in July 1967 with near-total small bowel atresia; remarkably, she survived for 22 months. For about 15 years, TPN was a panacea, until clinicians realized that the risks of infection, thrombosis, and liver injury might outweigh the benefits in patients who could tolerate enteral feeds. Support for physiciannutritionists waned such that, a decade ago, the average number of hours of undergraduate medical nutrition instruction was 19, and fewer than 20% of North American medical schools required a course on nutrition, much less the 25-30 contact hours recommended by the United States

Committee on Nutrition in Medical Education in 1985. Since then, the pendulum seems to be swinging back in the other direction. Public discussion of the “obesity epidemic” has increased, and clubs or electives in “culinary medicine” have popped up in many medical schools. Unfortunately, first-year students’ interest in the subject tends to wane by graduation, crowded out by sexier topics like point of care ultrasound (POCUS) if not reinforced by clinical preceptors.1 My own effort to remedy this situation locally is an elective for medical students at the University of Pittsburgh called “Medical Nutrition: Past & Present Theories & Practice.” The syllabus reflects my dual training in the history of medicine and in healthcare across the lifespan, with one week each devoted to general (adult) dietary principles, pediatric nutrition, obesity, and surgical or artificial nutrition. I piloted the course in January with 17 fourth-year medical students. We met every day for 2 hours over Zoom to discuss a historical article on why diabetes used to be coded as “a Jewish disease,” listen to a dietician guest lecture on medically supervised weight loss, or practice calculating tube feeds and TPN. The students had three research projects: one to prepare www.acms.org

Perspective Perspective a meal from a non-grocery store, one to evaluate the evidence behind a fad diet, and one to present on a topic of their choice, such as the effect of BMI on the outcomes of laparoscopic gynecological procedures, or the unbearable whiteness of contemporary nutrition advice from the perspective of a Muslim Ethiopian-American student. One hundred percent of the students later reported that the course had improved both their clinical skills and their historical knowledge of nutrition, yet only fifty percent thought such a class should be required. Thirty eight percent thought that some of the lessons could be incorporated into the existing curriculum and the rest offered as an elective, but they and the twelve percent who answered “no” to requiring it worried about losing time for career exploration through electives, the dampening effect a mandate would have on enthusiasm, and that nutrition is not relevant to all their classmates. While it is true that a future pathologist or radiologist may not give patients dietary advice, studies have shown that exposure to nutrition content improves medical students’ own knowledge and behaviors. With so much smoke, you might expect to find some fire. However, the fact that articles continue to be written about insufficient training in nutrition demonstrates the continuing mismatch between what is and what could be taught. This despite the fact that in the 1990s, the National Heart Lung and Blood Institute (NHLBI) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) dispersed 5-year grants to 21 medical schools to develop a Nutrition Curriculum Guide for Training ACMS Bulletin / June 2022

Physicians. At the same time, the National Institutes of Health paid University of North Carolina to develop a standardized Nutrition in Medicine syllabus for undergraduate medical education; around 2010, they added modules for graduate and continuing medical education called Nutritional Education for Practicing Physicians. Although these are all freely available online, medical schools continue to ignore the recommendations for nutrition training or—like I did—reinvent the wheel if they do offer this content. When I revise the syllabus over the summer, I will make sure it covers what the guidelines suggest while not sacrificing what makes this course unique: the inclusion of historical perspectives. When students wondered why current patient handouts about the benefits of a low-sodium diet specifically target “African-Americans/ blacks [sic],” we discussed the “slavery hypertension hypothesis,” which has no basis in science or historical fact. If a new parent resists the pediatrician’s feeding advice, it may be helpful to recall that professional and advertising agencies only positioned doctors as child-rearing experts 100 years ago; experienced grandmothers and aunties have been keeping babies alive for millennia. And the obesity epidemic was largely born out of the 1998 re-definition of a “normal” body mass index from 27-28kg/m2, a descriptive value reflecting US statistical averages by sex, to <25 kg/m2, a prescriptive value in line with World Health Organization standards. Finally, if you would like a book-length description of how American dietary practices came to carry so much personal weight and public stigma, I highly

recommend Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (UNC Press, 2013), by Helen Zoe Veit. Kristen Ann Ehrenberger is a MedPeds physician who directs the Progressive Evaluation and Referral Center (PERC) at UPMC and serves as secretary of the C.F. Reynolds Medical History Society.

1 Kelly M. Adams, W. Scott Butsch, Martin Kohlmeier, “The State of Nutrition Education at US Medical Schools,” Journal of Biomedical Education vol. 2015 (2015): [7 pages]. 2 Committee on Nutrition in Medical Education, Nutrition Education in U.S. Medical Schools (Washington, DC: National Academies Press, 1985). 3 Curriculum Committee of the Nutrition Academic Award Program, “Nutrition curriculum guide for training physician practice behavior skills and attitudes across the curriculum,” (2002): https://www.nhlbi.nih.gov/ sites/default/files/media/docs/ NAA%20Nutrition%20Curriculum%20 Guide.pdf. 4 Nutrition in Medicine can be found at http://www.nutritioninmedicine.org (copyright 2014).

Society News American College of Surgeons—SWPA Chapter Most Interesting Cases

On Tuesday, May 31, the Southwestern Pennsylvania Chapter of the American College of Surgeons (ACS-SWPA) hosted the “Most Interesting Case” Presentations as an in-person meeting. Monterey Bay Fish Grotto, with its stellar views of Pittsburgh, was the perfect setting for members of the ACS-SWPA and their guests to reconnect and socialize. The annual program hosts interesting case presentations by surgical residents from area training programs. Eight cases were submitted and the top five were selected for discussion at

the event. Resident presenters included: Cody Woodhouse, MD, Allegheny Health Network, Neurosciences Institute, Department of Neurosurgery. Nathan Esplin, MD, Allegheny Heath Network, Department of Neurosurgery presented the following on behalf of Dr. Woodhouse “Case of Expectorated Screw Following Anterior Cervical Discectomy and Fusion”; Jonathan Nakata, MD, UPMC Mercy, Department of General Surgery presented, “Cardiac Tamponade From Embolization of a Fractured Inferior Vena Cava Filter”; Kimberly Howell, DO, Conemaugh Memorial Medical Center, Department of General Surgery, presented “Portal Mesenteric Thrombosis Following Routine Laparoscopic Surgery”; Renee Davis, DO, UPMC Mercy, Department of General Surgery, presented “Congenital Peritoneal Encapsulation, Volvulus, SMV Thrombosis, and HIT”; and

Zachary Spigel, MD, MPH, Allegheny Health Network, Department of General Surgery. Dr. Spigel’s presentation “Primary Biliopancreatic Limb Gallstone Causing Gallstone Ileus After Roux-en-Y Gastric ByPass” was presented by Johan Van Wyk, DO. H. Kenneth Williams, MD, FACS, Chapter President, and Richard Fortunato, DO, FACS, Program Chair, served as moderators and judges for the evening’s event. Renee Davis, DO received 1st place for her most interesting case; 2nd place was awarded to Cody Woodhouse, MD and 3rd place was awarded to Jonathan Nakata, MD. The ACS-SWPA Chapter looks forward to hosting a fall program. Members are asked to contact Eileen Taylor, Chapter Administrator by email to etaylor@acms.org for questions regarding their member status.

Richard Fortunato, DO, FACS, Program Chair (left) and H. Kenneth Williams, MD, FACS. Chapter President (far right) with resident presenters Nathan Esplin, MD; Jonathan Nakata, MD; Kimberly Howell, DO; Renee Davis, DO; and Johan Van Wyk, DO; 16

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Society News

Physicians interested in joining the Chapter may also contact Ms. Taylor or visit the ACS-SWPA website at https://acs-swpa.org/.

Award recipients (l. to r.) Jonathan Nakata, MD (3rd place); Nathan Esplin, MD (presenting on behalf of Cody Woodhouse, MD - 2nd place) and Renee Davis, DO (1st place).

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. ACMS Bulletin / June 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.

ACMS Bylaws BULLETIN NOTICE RECOMMENDATION OF CHANGES BYLAWS COMMITTEE

The Executive Committee had charged the Bylaws Committee to review certain items within the Bylaws and correct outdated language. These items were reviewed by the Bylaws Committee on May 3, 2022, and recommended for approval at the Board of Directors meeting on May 10, 2022. Bylaws changes must be read at two consecutive Board of Director meetings and published in the ACMS Bulletin before final approval. The Bylaws Committee recommends the following updates and changes to the ACMS Bylaws: 1. Update language:  Remove “ex-officio members of all committees with right to vote.”  Remove line “Treasurer to present to the Board of Directors a monthly report of receipts and expenditures, be bonded in such sums as shall be directed by the Board of Directors.”  Change Chief Executive Officer to Executive Director.  Remove “all officers are ex-officio members of all committees with the right to vote.”  Remove “The President may also appoint, subject to the approval of the Board of Directors, a Director representing Medical Students and a Director representing Residents with right to vote.” 2. Officer / Committee Appointments  Treasurer will chair Finance Committee, with right to vote.  Secretary will chair ByLaws Committee, with right to vote.  President Elect will chair Nominating Committee, with right to vote.  Eliminate the Vice President office.  Secretary to assume President Elect if vacant position.  If vacancy for Secretary or Treasurer, President could appoint replacement.  Medical student and Residents are welcome to attend Board meetings as non-voting members. 3. Revise Peer Review Board  Change the Peer Review Board to consist of the three immediate past presidents, the most recent to chair. If any of the three immediate past presidents are not available, the succession line of previous past presidents will be contacted until the Peer Review Board consists of three members. 

When a complaint is received at the Society office, it is the discretion of the Secretary to determine if it requires referral to the Peer Review Board.  Any questions regarding the above-noted changes can be directed to the Bylaws Committee through the Society office. [dhostovich@acms.org  412-321-5030].

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ACMS Bylaws LINE NUMBER REFERRENCED IN BYLAWS 256

Eliminate Vice President – see Line 394

258

Students and Residents should not be voting members of the board. See line 440.

278

Peer Review – see Line 632.

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Secretary to assume President elect if vacant position. . If a vacancy for Secretary or Treasurer, the President can appoint a successor.

378

Remove line “ex officio member of all committees with the right to vote” for all officers.

387

President Elect to chair Nominating Committee.

394

Eliminate Vice President position.

413

Secretary shall chair Bylaws Committee.

422

Remove “Treasurer to present to the Board of Directors a monthly report of receipts and expenditures, be bonded in such sums as shall be directed by the Board of Directors.”

424

Treasurer shall chair the Finance Committee.

440

Resident & Students – remove as voting members of the Board. They are invited to participate.

511

Change Chief Executive Officer to Executive Director.

636

Update Peer Review. The Peer Review to consist of the three immediate past presidents, most recent to chair. • If any of the three immediate past presidents are not available, the succession line of previous past presidents will be contacted until the Peer Review Board consists of three members. • When a complaint is received at the Society office, it is the discretion of the Secretary to determine if it requires referral to the Peer Review Board.

663

See Attached Redlined Bylaws Red Line = Deletions ADDITIONS/NEW LANGUAGE

ACMS Bulletin / June 2022

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ACMS BYLAWS

(https://www.acms.org/bylaws) Recorded in the office for the recording of deeds, etc., in and for said County on the 26th day of April 1919, in charter Book, Vol. 67, page 701. Witness my hand and seal of said office the day and year aforesaid. SAMUEL D. FOSTER, Recorder ARTICLE I NAME Section 1.

The name of this organization shall be Allegheny County Medical Society.

Section2. This society shall have all of the powers usual and incident to organizations of like character which are permitted by the laws and customs of the Commonwealth of Pennsylvania and necessary or appropriate to the fulfillment of its purpose. ARTICLE II PURPOSES The purposes of this Society shall be to extend medical knowledge and advance medical science; to elevate the standard of medical practice; to promote friendly interactions among physicians; to uphold the ethics and dignity of the medical profession; and may unite with similar societies of other counties to form the Pennsylvania Medical Society; to enlighten and direct public opinion in regard to the problems of public health, and any other problems relating to the practice of medicine so that the profession shall become more useful to the public in the prevention and management of disease and in prolonging and adding comfort to life. ARTICLE III MEMBERSHIP Section 1.

Rights and Privileges of Membership including Voting Rights

Members of this Society shall have all the rights and privileges of membership except as otherwise provided in these Bylaws. No member of this Society of any class shall have any direct vote in the affairs of this Society except as to such matters, if any, where such vote is required by the laws of the Commonwealth of Pennsylvania. Section 2.

Admission to Membership

To be a member of this Society an individual must be a physician, in training to be a physician, or a student in an accredited school of medicine or osteopathic medicine. The term, physician, means a person who has received formal and recognized training in the art and science of medicine and is qualified to acquire an unlimited license to practice medicine and surgery in the Commonwealth of Pennsylvania. Section 3. 1.

Membership Categories

Active Member: A. Full Active: Persons who hold the degree of Doctor of Medicine or Osteopathy or the equivalent from a recognized accredited medical school, and who hold or are eligible to hold an unrestricted license to practice

Applications by Transfer

A physician applying for membership as a transferee from any other county medical society shall contact either the member’s original component society, the component society into whose jurisdiction the member moves, or the State Society with all pertinent information. The procedure for election to membership shall be the same as set forth in these bylaws. Annual dues shall be prorated making due allowance for dues previously paid by the transferee during the fiscal year. 2.

Fees and Dues A. Dues for each category of membership shall be designated each year by the Board of Directors upon recommendation of the Finance Committee as stated in Article IV, Section 2. B.

A member admitted by transfer shall not be subject to a membership fee and shall pay no annual dues for the current year provided that he or she has paid the dues to his or her previous society for the current year.

A member admitted by transfer from another Pennsylvania County shall be subject to all special assessments that are in effect at the time of his or her admission to membership in this Society.

Section 7. Choice of Membership A physician residing in a community immediately adjacent to Allegheny County may choose to apply for membership in the Allegheny County Medical Society when it is more convenient for the member to attend meetings and take an active part in this Society than in the medical society of their home county. ARTICLE IV FEES, DUES AND ASSESSMENTS Section 1.

Fiscal Year

The fiscal year of this Society shall begin January 1 and end December 31. Section 2.

Annual Dues

Money for the purposes of the Society shall be raised by annual assessment payable by each member. Prior to the end of the fiscal year and upon recommendation of the Finance Committee, the Board of Directors shall approve the amount of dues for each category of membership for the following year. Notice of dues payable January 1 of the next year shall be mailed to the address of record before November 15 of the current year. Section 3.

New Membership

The dues for the current year of new members shall be pro-rated on a monthly basis for the current fiscal year. Section 4.

Special Assessments

Special assessments may be made by the membership at a Business Meeting of the Society provided that previous notice of the proposal has been published in the BULLETIN of the Allegheny County Medical Society for two successive issues prior to the meeting. The assessment and the amount of the assessment for each class of membership shall be determined by a majority of the Active members of the Society in good standing present at the meeting. This assessment shall be uniform within each category of membership.

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medicine and surgery in Pennsylvania, are eligible for active membership in this Society. Upon admission to membership, such members shall have the right to vote and hold office in this Society.

Residents and fellows serving in residency or fellowship programs approved by this Society are eligible for active membership in this Society. Upon admission to membership, such members shall have the right to vote and hold office in this Society.

Medical students enrolled in a medical school approved by this Society are eligible for active membership in this Society. Such students are entitled to all rights and privileges of membership. Medical Students may not vote or hold office except for the member appointed to the Board of Directors.

Associate Member A. A physician not engaged in active practice may be an affiliate member of this Society and remain as such providing the individual is one of the following: (1) a physician who is a member of a national medical society of a foreign country; (2) an American physician who is engaged in missionary or philanthropic labors who may or may not have an unlimited license to practice medicine and surgery in the Commonwealth of Pennsylvania; (3) a fulltime teacher of medicine or of the arts and sciences allied to medicine who does not have a license to practice medicine and surgery in the Commonwealth of Pennsylvania; (4) a physician who is engaged in research or administrative medicine in Pennsylvania who does not have an unlimited license to practice medicine and surgery in the Commonwealth of Pennsylvania; (5) a physician who is retired from active practice (6) a physician who resides in a state other than Pennsylvania and concurrently maintains active membership in another state medical society.

Supporter Member Any physician who is engaged in professional activities related to the active practice of medicine, but who is not engaged in active practice within Allegheny County. A supporter member may not vote or hold office. A supporter member may serve as a member of any workgroup or committee.

Retired Member An Emeritus member shall be an Active member who has been a member of this Society. A member in this status shall not be engaged in the practice of medicine. They may vote, hold office and serve on any committee.

Other Member Categories The Board of Directors may designate other categories of membership which shall not have the right to vote or hold office.

Section 4.

Procedure for Application and Election to Membership

Application for membership shall be made to the Secretary of the Society. The applicant shall return to the Secretary the properly executed application form and the required dues. Applications shall be reviewed pursuant to guidelines of the Society to determine whether the applicant meets the qualifications for membership. Section 5.

Rejection of Application

The Secretary shall immediately return the entrance fee and dues to any candidate who has not been accepted for membership. An applicant who has been rejected may not have his or her name presented again within twelve months. Section 6.

Section 5.

Transfer of Membership to the Allegheny County Medical Society

Notification of Delinquency

A member whose annual dues are not paid prior to the date determined by the Board of Directors shall be delinquent and shall not be in good standing in this Society. No delinquent member shall be entitled to exercise any of the rights and privileges of membership in this Society during the period of delinquency. Notice shall be sent to each delinquent member promptly noting the delinquency and the date upon which membership will be terminated unless membership dues are paid. Section 6.

Reinstatement After Suspension

A member suspended for nonpayment of dues may be reinstated after payment of the dues for the current year. The member shall be notified that his or her rights and privileges begin as of the date of reinstatement but are not retroactive to January 1. A member who has been suspended for cause other than nonpayment of dues shall be required to continue the payment of annual dues and assessments without any reduction whatsoever during the period of suspension. Section 7.

Reinstatement of a Terminated Membership

A member whose membership has been terminated for nonpayment of dues may be reinstated before the end of the fiscal year after payment of the member’s dues. A member whose membership has been terminated for nonpayment of dues and who has not sought reinstatement during the fiscal year in which his or her membership was terminated, may make formal application for membership as in Article III, Section 4. Section 8.

Inability to Pay

In the event a member of this Society is unable to pay dues and/or assessments, the Executive Committee of the Board of Directors is empowered to act upon a petition presented directly or through associates for the omissions of dues. The name of the member shall not be made known to the Society membership. Application for omission or reduction of dues is effective for one year only but may be renewed if warranted. During the year, the member is entitled to all the rights and privileges of the individual’s class of membership in the Allegheny County Medical Society. Section 9.

No Refund of Dues or Assessments

In the event of termination of membership for any cause except transfer, there will be no refund of dues or assessments. ARTICLE V TENURE OF MEMBERSHIP Section 1.

Security of Membership

A member shall retain their membership as long as they comply with the provisions of the Charter and Bylaws of the Society. Section 2.

Resignation

Resignation from membership must be presented by the Secretary for action by the Board of Directors. Section 3.

Transfer of Residence

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A. A member who no longer resides or practices in Allegheny County automatically terminates his or her membership in the Allegheny County Medical Society as of the date he or she no longer qualifies for membership. B.

A member in good standing who moves to another county in Pennsylvania shall have his or her membership transferred to the component society into whose jurisdiction he or she moves in accordance with the bylaws of the Pennsylvania Medical Society.

A member moving to another state may receive upon request a letter of recommendation.

Section 4.

Failure to Pay Dues

A member who has failed to pay his or her dues by April 1 of the current year shall automatically have his or her membership terminated as of the date he or she no longer qualify for membership. His or her record shall bear the notation “membership terminated for non-payment of dues” and the Pennsylvania Medical Society shall be so notified. Section 5.

Reinstatement

A former member of the Society may be reinstated. 1.

A member whose membership has been terminated for non-payment of dues may apply for reinstatement as provided in Article III.

A member who transfers back to Allegheny County from another component society may apply for reinstatement as provided in Article III, Section 6.

A member desiring readmission to the Society after resignation may apply for new membership as provided in Article III.

A member who has been expelled due to the revocation of such member’s license may apply for readmission to membership as a new member as described in Article III, Section 4, upon reinstatement of such member’s license. ARTICLE VI

OFFICERS AND DELEGATES Section 1.

Numbers of Officers and Delegates

The officers of this Society shall be a President, a President-Elect, a Vice President, a Secretary, a Treasurer and a Board of fifteen Directors elected by the membership-at-large. The President may also appoint, subject to the approval of the Board of Directors, a Director representing Medical Students and a Director representing Residents. Delegates and Alternate Delegates to the Pennsylvania Medical Society shall be elected in the proportion as dictated by Pennsylvania Medical Society Bylaws. The officers shall assume their duties on January 1 of the year following election. Section 2.

Term of Office

The President, President-Elect, Vice President, Secretary and Treasurer shall be elected to serve for one year. The President, President-Elect and Vice President shall not be eligible to serve for two consecutive terms. The Secretary and Treasurer are eligible to serve for no more than three consecutive terms. Members of the Board of Directors at-large shall be elected for a term of three years. Five Directors shall be elected each year. No Director may serve more than two consecutive full terms.

A Nominating Committee of five to seven members, appointed by the President and confirmed by the Board of Directors, will present a slate of candidates by September 1. The Committee may nominate more than the required number of candidates. Additional nominations of candidates may be made in writing prior to October 1. Nominations made in writing shall contain the written permission of the nominees. Section 4.

Publication of Nominations

All nominations for Officers and Delegates shall be made prior to October 1 and shall be distributed to the members of the Allegheny County Medical Society prior to the distribution of the ballots. Section 5.

Manner of Elections

The voting shall be by secret ballot. Voting may be conducted by mail or electronic means. The polls will close at 12:00 p.m. ten days after balloting begins or the next regular business day.

Mark the ballot for the designated number of Officers and Delegates in each category. A vote may be made for a candidate for any office whose name does not appear on the official ballot by writing his or her name in the appropriate space.

The results of the election shall be reported to the President and to the Secretary. The candidate receiving the plurality of votes shall fill the office. The Delegates and Alternate Delegates shall be listed in order of the votes received. Delegates and Alternate Delegates shall be elected as shall be necessary to complete the full number of Delegates to which the Society is entitled. Those candidates receiving the highest number of votes shall be considered elected until all places are filled. In the event of an increase in the number of authorized Delegates, the President shall appoint such additional Delegates as may be required. The appointments shall be made first from the list of candidates unsuccessful in the preceding election in order of the number of votes received. Additional appointments shall then be made from the list of Alternate Delegates in the order of the votes received. The list of the Alternate Delegates shall then be supplemented by appointment from the Society at-large. In the event of a reduction in the number of authorized Delegates, the appropriate number of Delegates shall be removed from the list of those elected beginning with the Delegate who received the smallest number of votes and continuing in order until the proper number of Delegates has been secured. The list of Alternate Delegates shall be reduced in a comparable manner.

No member may cast more than one vote for any candidate for any elective office.

Resolution of a tie vote – In the event of a tie between candidates for election to any office, the Board of Directors shall select the candidate to fill the office.

Publication of election results – The results of the election shall be published in the first issue of the BULLETIN of the Allegheny County Medical Society following the election. ARTICLE VIII

DUTIES OF EXECUTIVE OFFICERS Section 1.

President

The President shall: preside at the meetings of the Society; shall perform such other duties as parliamentary usage and these Bylaws require. The President shall be a member of the Board of Directors with the right to vote and an ex-officio member of all committees with the right to vote. The President shall appoint all committees of the Society as provided in these ByLaws. In the absence of the Treasurer, the President shall be empowered to sign duly authorized warrants dispensing funds.

ACMS Bulletin / June 2022

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Delegates to the Pennsylvania Medical Society shall be elected for a term of two years; approximately one-half of the required number of Delegates shall be elected each year. They are not eligible to serve more than three consecutive terms. Alternate Delegates are elected for a term of one year. Unlimited one-year terms. Members of the Peer Review Board shall be elected for a term of three years. They are not eligible to serve two consecutive terms. Section 3.

Vacancy in Office

If an office becomes vacant for any reason, the unexpired term shall be filled as described below: 1.

President – in the event of a vacancy, the President-Elect shall assume the office of President for the unexpired term.

President-Elect – In the event of a vacancy, the Vice President SECRETARY shall assume the office of President-Elect for the unexpired term.

Vice President – In the event of a vacancy, nominations for this office shall be made at a special meeting called for that purpose. Election shall be by mail as described in Article VIII, Section 6.

Secretary or Treasurer – In the event of a vacancy in either office, the Board of Directors, shall elect a successor who shall complete the unexpired term. PRESIDENT CAN APPOINT A REPLACEMENT. This individual may be a candidate for office at the next annual election.

Board of Directors – In the event of a vacancy on the Board of Directors, the vacancy shall be filled by the member receiving the next highest number of votes for the office of Director in the most recent annual election.

Other Offices – In the event of a vacancy in any of the other offices, the Board of Directors shall elect a member to fill the unexpired term of the officer. A member so elected may be a candidate for a full term of this office at the next annual election. In the event of a vacancy among the Delegates to the Pennsylvania Medical Society, the President shall fill the vacancy from the list of Alternates with the member receiving the next highest number of votes in the last election. ARTICLE VII

NOMINATIONS AND ELECTIONS Section 1.

Time of Election

The regular election of Officers and Delegates shall be held the first week in November of each year. Section 2.

Officers and Delegates to be Elected

At each annual election the following Officers and Delegates shall be elected: (1) President-Elect (2) Vice President (3) Secretary (4) Treasurer (5) Five members of the Board of Directors (6) Two members of the Peer Review Board (7) One-half of required number of Delegates to the Pennsylvania Medical Society and one Alternate for every two Delegates Section 3.

Section 2.

Nominations of Candidates for Officers and Delegates

President-Elect

The President-Elect shall: become familiar with all the activities of the Society; shall be a member of the Board of Directors with the right to vote; shall be a member ex-officio of all committees with the right to vote. THE PRESIDENT ELECT SHALL CHAIR THE NOMINATING COMMITTEE WITH THE RIGHT TO VOTE. Each year the President-Elect shall appoint all Chairpersons and members of the standing committees of the Society described in Article XV effective January 1 of the ensuing year. In the temporary absence of the President, the President-Elect shall preside and function in the place of the President. Section 3.

Vice President

The Vice President shall: preside and function as the President in the temporary absence of both the President and the President-Elect; shall be a member of the Board of Directors with the right to vote; shall be a member ex-officio of all committees with the right to vote. Section 4.

Secretary

The Secretary shall: shall be a member of the Board of Directors with the right to vote; shall be a member ex-officio of all committees with the right to vote. be responsible for the minutes of the proceedings at this Society; act as Clerk of the Board of Directors; have charge of all papers belonging to this Society except those pertaining to the Treasurer, the Peer Review Board, or to special committees; promptly notify all officers and newly elected members of their election, and the chairperson and members of standing and special committees of their appointments and the names of their associates and of the resolution under which the committee was appointed; forward credentials to members elected as Delegates to the Pennsylvania Medical Society; certify the Delegates to the meeting of the Pennsylvania Medical Society; forward to the Secretary of the Pennsylvania Medical Society a list of the officers of this Society and a notice of any changes in its membership and, from time to time, of any amendments to the ByLaws that may have been made during the year; send to the Secretary of the Pennsylvania Medical Society the names of the Delegates and Alternate Delegates elected; conduct the correspondence of this Society and perform such other duties pertaining to this office as may from time to time be required; issue the call for all Business Meetings of this Society and for all special meetings at the direction of the President; record the death of a member; perform such other duties as designated by the President, with the approval of the Board of Directors. THE SECRETARY SHALL CHAIR THE BYLAWS COMMITTEE WITH THE RIGHT TO VOTE. Section 5.

Treasurer

The Treasurer shall: shall be a member of the Board of Directors with the right to vote; shall be a member ex-officio of all committees with the right to vote. be apprised of all the monies belonging to this Society and deposit such funds in the name of the Society in banks or trust companies designated by the Board of Directors; disburse the same for payment of any legitimate bills authorized in the budget as approved by the Board of Directors, or other lawful debts of the Society as requested by the Finance Committee; present to the Board of Directors a monthly report of receipts and expenditures; be bonded in such sums as shall be directed by the Board of Directors, the premium to be paid by this Society. THE TREASURER SHALL BE THE CHAIR OF THE FINANCE COMMITTEE WITH THE RIGHT TO VOTE. Section 6.

Chair of the Board of Directors

The Chair of the Board of Directors presides at the meetings of the Board of Directors. The chair does not have the right to vote except in the event of a deadlock decision. ARTICLE IX BOARD OF DIRECTORS Section 1.

Composition

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The Board of Directors shall consist of the President, President-Elect, the immediate Past President, Vice President, Treasurer, Secretary, fifteen Directors elected by the Society at-large, a Director representing Medical Students, a Director representing Residents. RESIDENT AND STUDENT REPRESENTATIVES MAY BE INVITED TO ATTEND THE BOARD OF DIRECTORS MEETINGS, WITHOUT THE RIGHT TO VOTE. Section 2.

Organization

The Immediate Past President shall: assume the position of Chair of the Board of Directors at its January meeting. In the absence of the Immediate Past President, the President shall serve as Chair of the Board. The President-Elect shall serve as Parliamentarian of the Board of Directors. The Secretary of the Society shall serve as Clerk of the Board of Directors and shall keep its record including a register of attendance at its meetings. Section 3.

Meetings

The Board of Directors shall meet at least four times each year and as necessary. Special meetings of the Board of Directors may be called by the President at any time or upon written request of the majority of the Board. The notice convening a special meeting must state the purpose of the meeting; other matters may be considered only by unanimous vote. Section 4.

Duties

A. The Board of Directors shall have charge of the general business of the Society and shall have full authority to act upon all matters within the jurisdiction of the Society, except as otherwise provided in these ByLaws. B.

Any member of the Board of Directors or of the standing committees of the Board not attending three consecutive meetings without due cause shall automatically forfeit the office or committee appointment and the vacancy shall be filled by the Board of Directors to serve until the next regular election.

The Board of Directors shall have the authority to declare any office vacant if: a member fails to accept the office; neglects to perform the duties of the office; or the office becomes vacant. A successor shall be appointed by the Board of Directors to serve until the next annual election, except as provided elsewhere in these ByLaws.

D. The Board of Directors shall receive and approve or disapprove recommendations for action by the Peer Review Board. It shall implement such decisions forthwith. E.

The Board of Directors shall elect, suspend, terminate membership and reinstate members of the Society in accordance with the provisions of these ByLaws.

Section 5.

Quorum

Fifty percent plus one of the voting members of the Board of Directors shall constitute a quorum. Section 6.

BULLETIN of the Allegheny County Medical Society

The Board shall provide for and supervise the publication of the BULLETIN of the Allegheny County Medical Society. The Board shall determine the editorial policy and supervise the contents of the publication. A. Medical Editor (1) The Board of Directors shall appoint the medical editor for a term of three years upon the recommendation of the Executive Committee. This appointment shall be subject to yearly confirmation at the January meeting of the Board of Directors.

(2) The Medical Editor shall recommend Associate Editors to the Board of Directors for appointment for a term of two years. There shall be a total of eight Associate Editors, four to be appointed each year by the Board of Directors. An Associate Editor may serve three consecutive terms. B.

Editorial Board

The Medical Editor and the Associate Editors shall constitute the Editorial Board and shall be responsible to the Board of Directors for the editorial policy of the BULLETIN of the Allegheny County Medical Society. The Medical Editor shall serve as Chair of the Editorial Board. C.

Official Notices

The proceedings of this Society, and those of the Board of Directors, after approval by the Board for publication, shall be published as soon as practicable in the BULLETIN of the Allegheny County Medical Society. Authorized notices of this Society shall be official when published therein. Any paper, communication, or transaction may be published in whole, or in part, excepting official notices and proposals to amend the ByLaws which must be published in full. Section 7.

Office of the Society

The Board of Directors shall provide an office for the Society and shall employ an Executive Director / Chief Executive Officer. Section 8.

Executive Director / Chief Executive Officer

The Executive Director / Chief Executive Officer shall: be in charge of the administrative staff, including appropriate personnel to staff the Society’s publications, and subject to the limitations of the appropriations authorized by the Board; have full authority to engage administrative personnel, to assign their duties and to adjust their salaries with such job classifications and salary scales as may be approved by the Board of Directors. The Executive Committee shall specify and supervise the duties of the Executive Director / Chief Executive Officer. The Executive Director / Chief Executive Officer shall make monthly reports to the Executive Committee which shall be submitted to the Board of Directors as part of the report of the Executive Committee. Section 9.

Standing Committees of the Board

The Board of Directors shall have the following Standing Committees: The Executive Committee shall consist of the President, President-Elect, Immediate Past President, Vice President, Secretary and Treasurer. The function of the Committee shall be to regulate the work in the Executive Office of the Society, to the end that the wishes of the Board of Directors are carried out and that the work of the standing and special committees is facilitated. It shall also be a duty of this THE EXECUTIVE Committee to recognize and permanently record the services of the chair and members of all committees from year to year. A. The Finance Committee shall consist of the Executive Committee and three Directors appointed by the President and confirmed by the Board of Directors. It shall have supervision of the funds of the Society. It shall prepare an annual budget and submit it for the Board of Directors no later than November 1, including the recommended amount of dues for each category of membership for the next fiscal year. It shall authorize the payment of bills of an emergency nature and shall recommend the investment of Society funds when requested to do so by the Board of Directors. This Committee shall audit annually the accounts of all the Officers and committees that receive or disburse funds of this Society and shall be authorized to employ a professional accountant for assistance in such audit. B.

The ByLaws Committee shall consist of the Vice President SECRETARY and two other members of the Board appointed by the President and confirmed by the Board of Directors. All recommendations for changes in the ByLaws submitted by Officers or members of the Society shall be referred to this Committee for study and recommendation

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to the Board of Directors. It shall be the duty of this Committee to re-examine the ByLaws as necessary and to recommend to the Board of Directors such revisions as may be indicated. C

The Nominating Committee shall be appointed as described in Article VIII, Section 3.

Section 10.

Special Committees of the Board

The Board of Directors shall have the authority to constitute such special committees as may be required to accomplish the purposes of the Society. A. The Chair and members of such committees shall be appointed from the membership at-large by the President. B.

All special committees shall be terminated as of December 31 each year. The Board of Directors at its last meeting of the fiscal year shall reinstate or discontinue the individual special committees in accordance with the current needs of the Society.

A special committee may have a budget as shall be determined annually by the Board of Directors.

The Chair of a committee which is entitled to a budget shall certify all charges made against the budget before payment is made. No expenses beyond the limit of the allotted budget may be incurred without specific authorization of the Board of Directors. The Chair of a committee which is entitled to a budget shall submit a request for an annual budget to the Chair of the Finance Committee on or before September 1 of each year. Sufficient detail must be provided to permit adequate analysis for the request for funds. The Chair of each special committee shall submit to the Board of Directors for its last meeting of the fiscal year a written report summarizing the activities of the committee during the year and recommendation for the continuation or dissolution of the committee. Section 11.

Expenditures

A. All motions for expenditures of the monies of this Society shall originate in the Board 0f Directors. B.

The Board of Directors shall designate the amounts of the honoraria for the Medical Editor of the BULLETIN of the Allegheny County Medical Society and the salary of the Executive Director / Chief Executive Officer.

The Board of Directors shall adopt an annual budget prepared by the Finance Committee showing the proposed allotment of funds in the various categories of authorized expenditures.

D. Special appropriations may be authorized in accordance with specific resolutions of the Board of Directors. E.

No expenditure may be made in excess of the amount specified for that purpose by the Board of Directors.

Section 12.

Liability of Board Members and Officers

A board member or officer of the Society shall not be personally liable for money damages as such for any action taken or failure to take action as a director or officer unless the member’s or officer’s action constitutes self-dealing, willful misconduct or recklessness, or unless liability is imposed pursuant to criminal statute or for payment of taxes. The Board of Directors may provide for indemnification of Board members and officers to the extent allowed by law. ARTICLE X DELEGATION TO THE PENNSYLVANIA MEDICAL SOCIETY Section 1.

Composition and Election

The Delegation of the Allegheny County Medical Society to the Pennsylvania Medical Society shall consist of the number of Delegates and/or Alternates appropriate for the number of Active members in the Allegheny County Medical Society. The Delegates shall be elected for a term of two years, one half of the number being elected each year. The elected Delegates shall take office as of January of the year following their election. Section 2.

Organization

The Delegation shall elect its own Chair and Vice Chair annually. The Delegation shall have the right, subject to the limitations of these bylaws, to adopt reasonable rules and regulations except that the majority may not rule that unit voting must be followed. Section 3.

Meetings

Meetings of the Allegheny County Delegation shall be held each year at the call of the Chair of the Delegation of the Allegheny County Medical Society or upon request by five members of the Delegation. Section 4.

Duties

The Delegation to the Pennsylvania Medical Society has the responsibility of representing the members of the Allegheny County Medical Society to the House of Delegates of the Pennsylvania Medical Society. It shall have the further duty of presenting to the House of Delegates the resolution(s) presented to it by the Board of Directors of the Allegheny County Medical Society. Section 5.

Report

The Chair of the Delegation shall submit a report in writing to the Board of Directors following the Annual meeting. This report shall summarize the important actions of the Delegation at the Annual Meeting of the Pennsylvania Medical Society. ARTICLE XI PEER REVIEW BOARD Section 1.

Composition and Election

The Peer Review Board shall consist of six members, two to be elected annually for a term of three years THREE OF THE IMMEDIATE PAST PRESIDENTS, THE MOST RECENT TO CHAIR. IF ANY OF THE THREE IMMEDIAE PAST PRESIDENTS ARE NOT AVAILABLE, THE SUCCESSION LINE OF PREVIOUS PAST PRESIDENTS WILL BE CONTACTED UNTIL THE PEER REVIEW BOARD CONSISTS OF THREE MEMBERS.

The members of the Peer Review Board are not eligible to serve more than one term.

No member of the Peer Review Board shall be a member of the Board of Directors of the Allegheny County Medical Society.

Section 2. Organization 1. Each member shall serve as Chair for six months in the last year of his or her term. 2.

The Peer Review Board shall have the right, subject to the limitations of these ByLaws, to adopt reasonable rules and regulations.

It shall have access to legal counsel.

Section 3.

Meetings

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Meetings of the Peer Review Board shall be held at the discretion of the Chair. Section 4.

Duties

The Peer Review Board shall assist in the settlement of disputes between members of the Allegheny County Medical Society.

WHEN A DISPUTE IS RECEIVED AT THE SOCIETY OFFICE, IT IS THE DISCRETION OF THE SECRETARY TO DETERMINE IF IT REQUIRES REFERRAL TO THE PEER REVIEW BOARD.

The Peer Review Board shall investigate written allegations of ethical violations or unprofessional conduct on the part of a member of the Allegheny County Medical Society made by a physician or physicians.

The Peer Review Board shall investigate written allegations made by a physician or physicians that a member of the Allegheny County Medical Society has acted in a manner which discredits the members of the society.

It shall have the duty, at its discretion, to investigate general professional conditions and all matters pertaining to the relations of physicians to one another and to the public and to make such recommendations to the Board of Directors as it deems necessary.

It shall review all applications for reinstatement of membership described in Article IV, Section 7, and make appropriate recommendations to the Board of Directors.

It shall have jurisdiction on all questions of medical ethics and of interpretation of the bylaws of this Society.

It shall investigate all disputed elections. It shall consider and report to the Board of Directors upon any matter referred to it in writing by the Board of Directors or by a petition signed by ten Active members of the Society.

Section 5.

Authority

The Peer Review Board is authorized to recommend that disciplinary action be taken by the Board of Directors.

The Peer Review Board is authorized to summon any member of the Society to appear before it and, having been summoned and failing to appear, such member shall be held in contempt and shall be reported to the Society with the recommendation that the member be reprimanded, suspended or expelled.

Section 6.

Decisions

Decisions and recommendations of the Peer Review Board shall be made to the Board of Directors for consideration and action at the next Board meeting. Implementation procedures shall start within thirty days of the action of the Board of Directors. Section 7.

Responsibility of the Society

The Society shall assume all responsibility for the actions of the Peer Review Board. Section 8.

Records

The records of the Peer Review Board shall remain in the custody of the Society. They shall be retained for three years and then destroyed. Section 9.

Annual Report

The Chair shall submit an annual report to the Board of Directors. The Board of Directors shall determine the publication of this report.

ARTICLE XII CHARGES AND DISCIPLINE Section 1.

Causes for Disciplinary Action

The following causes may be considered sufficient for the initiation of disciplinary action against a member of the Society. (1) Conviction for a statutory offense against the State or Federal Government; (2) Revocation of license to practice medicine; (3) Violations of the bylaws of this Society; (4) Violations of the Principles of Medical Ethics of the American Medical Association; (5) Conduct or actions which tend to bring discredit on the membership of the Allegheny County Medical Society, including ethical violations and unprofessional conduct as determined by the Peer Review Board; (6) Failure by a member to notify the Society of a change in the status of such member license to practice medicine. Section 2. Jurisdiction The Allegheny County Medical Society holds primary jurisdiction in all matters pertaining to the discipline of a member. The Pennsylvania Medical Society may assume jurisdiction, in accordance with its bylaws, with the consent of the Board of Directors of the Allegheny County Medical Society. The American Medical Association may assume jurisdiction if the accused member is also a member of the American Medical Association, in accordance with its bylaws, with the consent of the Board of Directors of the Allegheny County Medical Society. Section 3.

General Rules for All Disciplinary Proceedings

All disciplinary proceedings against a member shall be ordered by the Board of Directors after investigation and recommendation by the Peer Review Board. The charge or charges upon which the proceeding is based shall be in writing and in sufficient detail to enable the member to properly defend the charges A written copy of the charge or charges shall be sent to the member concerned by certified mail, to the address which appears on the Society records, at least thirty days prior to the date of a hearing. The date and place of the hearing shall be set forth thereon. All rules and regulations shall apply equally to all classes of membership. Section 4.

Conduct of a Hearing

(1) All hearings on disciplinary matters shall be conducted before the Board of Directors in a meeting especially convened for the purpose, which is composed of the President, President-Elect, Vice President, Secretary, Treasurer, Immediate Past President, and voting members of the Board of Directors. The members of the Peer Review Board shall be requested to attend but shall not have the right to vote. Voting members are the named officers and members of the Board of Directors. (2) The Chair of the Board of Directors shall serve as the presiding officer with the right to vote in case of an indecisive vote. (3) The Secretary of the Society shall make a record of the hearing. (4) The presence of a majority of the members of the Board of Directors shall constitute a valid meeting. (5) Presentation of the charges shall be made by the Chair of the Peer Review Board or a representative who is also a member of the Peer Review Board.

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(6) The defense may be made by one or two Active members of the Society who have been selected by the defendant. (7) A hearing may be conducted in the event of the voluntary absence of the defendant. In this event, the defense presented by the defendant’s chosen or assigned colleagues, as described in Section 6, shall be considered adequate. (8) The hearing shall be open to all Active members of the Society. No other persons except designated employees of the Allegheny County Medical Society may be present. (9) Members who are not specifically designated by the Peer Review Board or by the defense shall be granted the privilege of the floor only at the discretion of the presiding officer and only for the purpose of presenting pertinent facts not otherwise available. (10) The Board of Directors shall not be bound by the rules of evidence used in courts and may receive such oral or written evidence as in their judgment will best and most fairly present the relevant facts. (11) A majority vote of the members of the Board of Directors present shall be necessary for a conviction. (12) In the event of a conviction, a two-thirds vote of the members of the Committee present shall determine the penalty. Section 5.

Penalties

In the event of a conviction the penalty may be (1) reprimand, (2) suspension, or (3) expulsion. ‘Reprimand’ shall he interpreted to mean an admonishment to the accused to change the member’s conduct in order that the member may not bring unfavorable criticism upon the medical profession or the individual. ‘Suspension’ shall be interpreted to mean to cause a temporary loss of all rights and privileges of membership. Said suspension shall not be deemed to affect the continuity of membership of said member for purposes of the member becoming other than an Active member. Dues are payable during a suspension. ‘Expulsion’ shall be interpreted to mean an involuntary termination of membership. Section 6. 1.

Effective Date of Decisions

The decision of the Board of Directors shall be sent by the Secretary to the member concerned in writing by certified mail within forty-eight hours of the meeting. The penalty imposed shall be that penalty recommended by the Board of Directors following disciplinary proceedings in accordance with this Article, except that any member whose license to practice medicine is suspended or revoked by the Pennsylvania State Board of Medicine shall be automatically expelled from membership in the Society unless such suspension or revocation is being appealed. If such suspension or revocation is being appealed, such member shall be automatically suspended from membership in the Society until all appeals have been exhausted. Upon a final appellate decision affirming the suspension or revocation of a member’s license to practice medicine, such member shall be automatically expelled from membership in the Society. Upon a final appellate decision reinstating such a member’s license, such member shall be automatically reinstated as a member in good standing of the Society.

(2)

In the absence of an appeal, the effective date of the decision shall be thirty days after the date of notification of the member by certified mail as in Paragraph 1.

(3) In the event of an appeal from the decision of the Board of Directors, the effective date shall be determined by the Board of Directors of the Society after the disposition of the appeal or the expiration of the appeal period. (4) When the effective date of a disciplinary action has been determined, the Secretary shall notify the member concerned, and the Secretary of the Pennsylvania Medical Society. Section 7.

Appeals

(1) A defendant shall have the right of appeal from the decision of the Board of Directors to the Pennsylvania Medical Society within thirty days of his or her notification. (2) In the event that the defendant is also a member of the American Medical Association, an appeal from the Judicial Council of the Pennsylvania Medical Society to the Judicial Council of the American Medical Association may be made as described in the bylaws of the Pennsylvania Medical Society and the ByLaws of the American Medical Association. Section 8.

Reinstatement

A member who has been suspended may apply for reinstatement as provided in Article IV, Section 7. A member who has been expelled may apply for an initial membership as provided in Article IV, Section 7, after the expiration of two years. ARTICLE XIII MEETINGS Section 1.

Business Meetings

Regular Business Meetings of the Society shall be held when convened by the Board of Directors. Section 2.

Annual Installation of Officers

Officers shall assume office January 1 of each year. Section 3.

Special Meetings

A Special Meeting of the Society may be called by the President, as directed by the Board of Directors, or upon the written request of fifty Active members. Notice of the meeting shall be provided to all members prior to the meeting, or by electronic communication. The notice shall state the purpose of the meeting. Other matters may be considered at a Special Meeting only by the unanimous consent of those members present. Section 4.

Quorum

Fifty Active members present shall constitute a quorum for a Business or Special Meeting. In the absence of a quorum, a special meeting of the Board of Directors shall be convened forthwith. This meeting of the Board of Directors shall have the authority to transact all the specified business of the Society including the nominations and elections required by the bylaws of the Society. Matters transacted at this special meeting of the Board of Directors shall be regarded as approved by the membership of the Society. For this special meeting of the Board of Directors, 75 percent of the members of the Board of Directors shall constitute a quorum. Section 5.

Vote by Mail

When a matter is, in the opinion of the Board of Directors, of sufficient gravity, the Board of Directors may authorize a poll of the membership by mail or electronic ballot as permitted by Pennsylvania law to confirm or reject the decision of the Board of Directors. A recorded negative vote of 51 percent of the membership entitled to vote (regardless of the number of votes cast) shall be required to reject a decision of the Board of Directors. Ballots must be returned within two weeks. A vote may be authorized by the Board of Directors upon a written petition signed by fifty Active members. ARTICLE XIV

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STANDING AND OTHER COMMITTEES Section 1.

Standing Committees

Standing Committees shall be: Executive, Finance, Nominating and Bylaws. Number The President, with the approval of the Board of Directors, shall create ad hoc committees for a term of one year. The Board of Directors may also instruct the President to appoint specific committees. Section 2.

Appointment

Appointments to a Committee shall be for a term of one year. The President, President-Elect, Vice President, Secretary and Treasurer of the Allegheny County Medical Society are exofficio members of all Standing Committees with the right to vote. Section 3.

Organization

The Chair and members of each committee shall be appointed yearly by the President-Elect as described in Article IX, Section 2. The committee shall make its own rules provided that these rules are not in conflict with the ByLaws of the Society. Section 4.

Finances

A Committee may have a budget as will be determined annually by the Board of Directors. No expenses beyond the limit of the allotted budget may be incurred without the specific authorization of the Board of Directors. Section 5.

Meetings

A committee shall meet at the call of the Chair. The presence of a majority of the members of a committee shall constitute a quorum. A report of these meetings shall be submitted to the Board of Directors when action is required. Section 6.

Reports

The Chair of each Committee shall submit a written report to the Board of Directors as necessary, or upon request of the Board. ARTICLE XV MISCELLANEOUS Section 1.

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The most recent version of Robert’s Rules of Order, shall determine all points of order not provided for in these bylaws.

===================================== These changes were read for the first time at The May 10, 2022 Board of Directors Meeting

APPROVED AND ACCEPTED ACMS Board of Directors September 10, 2019 APPROVED AND ACCEPTED ACMS Board of Directors September 11, 2018 APPROVED AND ACCEPTED: ACMS Board of Directors December 5, 2017 APPROVED AND ACCEPTED: ACMS Board of Directors September 20, 2005  2021 Allegheny County Medical Society 850 Ridge Avenue Pittsburgh, PA 15212 412-321-5030  acms@acms.org 

Notices

The term “notice” as used in these bylaws shall mean a communication written, printed, or published in the BULLETIN of the Allegheny County Medical Society which is sent to the last recorded address of a member. Section 2.

Seal

The seal of this Society shall contain the following: In the center a Caduceus surrounded by a circle containing the words. “Organized 1865 Incorporated January 30th 1892” and an outside circle containing the words: “Allegheny County Medical Society, Pennsylvania.” Section 3.

Execution of Documents

The President shall execute on behalf of the Society under its seal any bond, deeds, mortgages, or other contracts approved by the Board of Directors or the membership at a regular or special Business meeting. Section 4.

Amendments to Bylaws

A proposal to amend any Portion, Section or Article of the bylaws may be initiated by a petition submitted to the Secretary in writing and signed by twenty-five (25) Active members or by action of the Board of Directors. The proposal shall be referred to the Bylaws Committee for examination and recommendation to the Board of Directors. If approved by the Board of Directors, the proposal shall be published in full together with the names of the proposers in the BULLETIN of the Allegheny County Medical Society which immediately precedes the Business Meeting at which the amendment is to be considered. Section 6.

Supercedence

All bylaws previously adopted are hereby repealed and any rules, standing resolutions or decisions of the Chair previously rendered, which may in any manner interfere with the intent and purpose of the ByLaws or are inconsistent therewith, are hereby repealed and declared to be invalid. Section 7.

Affiliations

The Board of Directors is authorized to affiliate by acquiring membership and paying required dues in local, state or national organizations, which in the opinion of the Board of Directors, will help in the promotion of the purposes of this Society as described in Article II. The Board of Directors is authorized to engage jointly with other organizations in enterprises, which in the opinion of the Board of Directors, will help promote the purposes of this Society as described in Article II. Section 8.

Legal Counsel

The Board of Directors is authorized to appoint legal counsel and may pay such counsel an annual retainer fee. The counsel shall consider all matters formally referred to them by the Board of Directors, the Executive Committee, and the Peer Review Board. Section 9.

Right to Petition

Members of the Allegheny County Medical Society shall have the right to petition the Board of Directors on any matters dealing with the operation of the County Society. A petition shall be in writing, addressed to the Secretary of the Society and signed by one or more Active members of the Society. It shall state clearly and succinctly the matter for consideration. This petition shall be considered at the next regular meeting of the Board of Directors at which time the petitioner is entitled to a personal appearance on behalf of the petition. At the discretion of the Board of Directors, such a petition may be presented at the next regular Business Meeting of the Society. Section 10.

Right to Receive and Administer Special Funds

The Board of Directors is authorized to accept in the name of the Allegheny County Medical Society specific funds and bequests consistent with purposes of this Society and to administer such funds in accordance with the terms set forth. Section 11.

Honorary Members of Committees

The Board of Directors is authorized to appoint non-members of the Allegheny County Medical Society to Honorary membership on special committees when it is deemed in the best interest of the Society. Section 12.

Rule of Order

www.acms.org

IN-PERSON TRAINING SATURDAY,

AUGUST

9:00 am to 12:30 pm Babb Insurance Bldg 850 Ridge Ave Pittsburgh PA 15212

HOW, WHEN & WHY TO REPORT: Mandated Reporter Training for Professionals (Mandated Act 31 Child Abuse Training)

The in-person training program is open to ACMS members and non-members. This 3-hour program meets the requirements for licensure and license renewal. The presenter will be Jacqueline Wilson, PhD, CEO of Three Rivers Adoption Council

Cost is $25 for ACMS members; $50 for non-members with advance registration required for all participants. Registration Includes: ✓ Breakfast & Break Refreshments ✓ Free Parking

Questions? Contact Nadine Popovich at npopovich@acms.org or to 412.321.5030.

Materia Medica

Paxlovid: The First Authorized Oral Antiviral for COVID-19 Treatment in Non-Hospitalized Patients Elizabeth Posney, Pharm.D., PGY-1 Pharmacy Resident - Ambulatory Care, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA Pfizer’s anti-COVID medication, Paxlovid (nirmatrelvir/ritonavir), is the newest tool in the healthcare provider’s toolkit to treat COVID-19 in nonhospitalized patients. It was authorized for emergency use by the FDA in December of 2021, and the COVID-19 treatment guidelines have recently been updated to include Paxlovid as the most preferred agent to use for COVID-19 treatment in the outpatient setting.1 Given the expanded access of this medication and still-rising numbers of COVID-19 cases, it is important for practitioners to stay updated on Paxlovid safety and efficacy data.

Figure 1. COVID-19 Treatment Guidelines: therapeutic management of non-hospitalized adults with COVID-191

How it works Pfizer took a novel approach to fighting the virus—instead of targeting the spike protein of SARS-CoV-2 like other COVID-19 treatments, this medication targets an intra-cellular protease that drives viral replication. Paxlovid is sold as two separate antiviral medications, nirmatrelvir and ritonavir, that are packaged together in a dose card blister pack. Patients take three oral tablets twice daily for 5 days: two tablets of nirmatrelvir 150 mg with one tablet of ritonavir 100 mg. Nirmatrelvir works by blocking the actions of SARS-CoV-2-3 26

chymotrypsin-like cysteine protease Mpro (3CL protease), which is an enzyme used for viral replication at the proteolysis stage, before viral RNA replication takes place (Figure 2). This enzyme was targeted because there is a low likelihood of off-target activity, and there are no recognized human analogues.2 Additionally, there is thought to be less mutation in this site compared to spike protein sites on the virus, which means there is a higher likelihood that efficacy can be maintained across variants.

The purpose of the ritonavir component is not to provide additional antiviral activity; instead, it is used to block the elimination of nirmatrelvir so that anti-viral activity is maintained. Ritonavir is a strong CYP3A4 inhibitor and allows for nirmatrelvir concentrations to be maintained at 5-6 times the concentration needed to block viral replication of SARS-CoV-2.2 In terms of pharmacokinetics, the medication is cleared hepatically by CYP3A4 (major) and CYP2D6 (minor) and has an elimination half-life of about 6 hours.3 www.acms.org

Materia Medica Who can access Paxlovid, and where:

Figure 2. Nirmatrelvir mechanism of action: inhibition of viral 3CL protease, so that functional, smaller viral proteins cannot be produced.4

Dosing5 This medication should be taken within 5 days of symptom onset. After initiating treatment, if hospitalization is required, completion of a 5-day course can be considered at the provider’s discretion. Patients are to complete a total of 5 days of nirmatrelvir 300 mg with ritonavir 100 mg, taken together twice daily. No dose adjustment is needed for patients with estimated glomerular filtration rate (eGFR) of at least 60 mL/minute, but the dose should be lowered to nirmatrelvir 150 mg and ritonavir 100 mg twice daily in those with eGFR 30 to 59 mL/ minute. Use is contraindicated if eGFR is less than 30 mL/minute. No dose adjustment is necessary in mild to moderate hepatic impairment, but use is not recommended in severe hepatic impairment.

Paxlovid is currently under EUAapproval for use in patients age 12 and up, weighing at least 88 lbs, and meeting at least one of the following high-risk criteria: history of cancer, chronic liver, kidney, lung, or cardiovascular conditions (including hyperlipidemia and hypertension), sickle cell disease, cystic fibrosis, dementia or other neurological conditions, diabetes, disabilities, HIV, mood disorders such as depression or schizophrenia, transplant, substance use disorders, tuberculosis, immunocompromised status, age at least 65 years, or BMI >25 kg/m2.6 Additionally, patients need to be within

5 days of symptom onset and have a positive COVID test in order to qualify for treatment with Paxlovid. National supplies of Paxlovid began to increase in March 2022 (Figure 3), and President Biden recently announced the national Test-toTreat Initiative to make it easier for higher-risk patients to quickly access oral antiviral treatments.7 There are currently about 2,200 Test to Treat sites in pharmacies and other clinical settings, where patients can get a COVID test, visit with a doctor, and obtain free Paxlovid all in one visit. The Federal government is working to expand access to these sites and include telehealth options.7 Patients can also obtain Paxlovid from any local pharmacy with a prescription from their healthcare provider.

Figure 3. Pfizer report of Paxlovid usage February through April 20228

ACMS Bulletin / June 2022

Materia Medica How well does it work? Clinical trials testing the efficacy and safety of Paxlovid are called the EPIC trials--Evaluation of Protease Inhibition for COVID-19 in high-risk patients (EPIC-HR) and standard risk patients (EPIC-SR). EPIC-HR was published in the New England Journal of Medicine in April 2022, and EPIC SR has yet to be published, although Pfizer announced interim results of EPIC-SR in December 2021. In the high-risk trial, patients were included if they tested positive to COVID-19, were unvaccinated, and had at least one symptom of COVID-19. Patients also had to meet at least one of the specified high-risk criteria. For the standard-risk study, patients were included if they were unvaccinated with a low risk of hospitalization or death or vaccinated with at least one risk factor for progressing to severe illness.

EPIC-HR showed that Paxlovid was effective in preventing COVID-related hospitalization and death. For patients who started treatment within 3 days of symptom onset, there was a relative risk reduction of 88.9% of COVID-19related hospitalization or death from any cause by day 28 (5 of 697 in the nirmatrelvir group vs. 44 of 682 in the placebo group, p<0.0001, Figure 2).9 Nine deaths were reported in the placebo group vs. no deaths in the treatment group. Among patients who started treatment within 5 days of symptom onset, relative risk reduction was 87.8%. Viral load was also significantly reduced by 10-fold at day 5 (p<0.0001) when treatment was initiated within 5 days of symptom onset.

Pfizer revealed interim results of EPIC-SR with 80% of their target patient population in December of last year. They reported that there was a 70% relative risk reduction of COVID-19 related hospitalizations or death from any cause in the Paxlovid group vs. placebo group. However, the secondary endpoint of self-reported, sustained alleviation of all symptoms for four consecutive days, was not met.10 Interestingly, Pfizer recently stopped enrolling anyone who received a vaccine or booster in the past year, which suggests that those patients may not be benefitting from Paxlovid treatment. In regard to efficacy against different variants, Pfizer has announced that invitro data showed that the medication was just as effective against Omicron as it was against earlier variants. This is based on data from three laboratory studies.10

Is it safe?

Figure 4. EPIC-HR primary outcome results9

In clinical trials, the most commonly reported side effects of Paxlovid included poor taste (5.6%), diarrhea (3.1%), fibrin d-dimer increase (1.9%), alanine aminotransferase increase (1.5%), headache (1.4%), creatinine clearance decrease (1.4%), nausea (1.4%), and vomiting (1.1%)—all were grade 1-2 in severity and resolved after the treatment course was finished.9 There were fewer grade 3 to 4 events in the treatment group compared to the placebo group. There was a similar overall adverse event incidence in the Paxlovid and placebo groups (22.6% vs. 23.9%, respectively). www.acms.org

Materia Medica After the clinical trial results were released, there have been reports of rebound symptoms several days after patients complete the 5-day treatment regimen. FDA and Pfizer have stated that 1-2% of patients in the original study experienced increased viral levels around 10 days post-treatment, which was about the same among people taking placebo, so the FDA concluded that there is not enough evidence at this time to say that this is related to drug treatment.10 COVID-19 guidelines were updated on May 13, 2022 to acknowledge these reports of viral rebound, but that frequency and clinical implications are unknown.1 Contraindications to Paxlovid in the package labeling include history of hypersensitivity to drug ingredients and co-administration with strong CYP3A4 inhibitors/inducers. Precautions and warnings include hepatotoxicity, HIV drug resistance, and hypersensitivity reactions, which have occurred postclinical trials.3 Drug-drug interactions are one of the biggest barriers to prescribing this medication. Several cardiovascular medications, including digoxin, simvastatin, lovastatin, ranolazine, and amiodarone cannot be used concurrently with Paxlovid, as well as some birth control medications, anti-convulsants, and anticoagulants. Providers should refer to medication labeling for a complete list of drug interactions before prescribing Paxlovid.3 Patients should be counseled on these potential drug interactions and should be aware that they must let their doctor know if they have recently started new medications prior to taking Paxlovid.

ACMS Bulletin / June 2022

Currently, there is no human data regarding safety and efficacy in patients who are pregnant and lactating.

Still to come…. One of the biggest critiques against Paxlovid is that we do not yet know how effective the medication is in patients who are vaccinated. Results from the EPIC-SR trial are expected to be released in the Fall of 2022, which will include a study population that is more representative of the current overall population in the United States. Furthermore, Pfizer has begun phase 2/3 trials of Paxlovid safety and efficacy in children and teens ages 6-17. Studies directly comparing Paxlovid efficacy with that of alternative antiviral medications such as remdesivir and Merck’s molnupiravir are also underway, as well as studies focusing on efficacy of Paxlovid against new variants.

References: 1. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available at https://www. covid19treatmentguidelines.nih.gov/. Accessed 5.17.22 2. Hammond J, Leister Tebbe H, Gardner A, et al. Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with COVID-19. N Engl J Med 2022; 386:1397-1408. 3. Paxlovid Fact Sheet for Healthcare Providers: EUA for Paxlovid. https://www. fda.gov/media/155050/download. Accessed 5.18.22. 4. Doyle K. Nimatrelvir’s mechanism of action. Promega Connections. Posted January 24, 2022. https://www.promegaconnections. com/covid-19-antiviral-therapies-what-arethe-new-drugs-and-how-do-they-work/. Accessed 5.18.22.

5. Lexicomp. Nirmatrelvir and Ritonavir (Lexi-Drugs). Wolter’s Kluwar. Updated May 25, 2022. Accessed 5.26.22. 6. Medical Conditions. Centers for Disease Control and Prevention. Updated May 2, 2022. https://www.cdc.gov/coronavirus/2019ncov/need-extra-precautions/people-withmedical-conditions.html. Accessed 5.17.22 7. Fact Sheet: Biden administration increases access to COVID-19 treatments and boosts patient and provider awareness. Whitehouse.gov. https:// www.whitehouse.gov/briefing-room/ statements-releases/2022/04/26/fact-sheetbiden-administration-increases-access-tocovid-19-treatments-and-boosts-patient-andprovider-awareness/. Accessed 5.18.22. 8. Pfizer First Quarter 2022 Earnings Teleconference. Pfizer. Posted May 3, 2022. https://s28.q4cdn.com/781576035/files/ doc_financials/2022/q1/Q1-2022-EarningsCharts-FINAL-(1).pdf. Accessed 5.18.22. 9. Hammond J, Leister Tebbe H, Gardner A, et al. Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with COVID-19. N Engl J Med 2022; 386:1397-1408. 10. Press release: Pfizer announces additional phase 2/3 study results. Pfizer. Posted December 14, 2021. https://www.pfizer. com/news/press-release/press-releasedetail/pfizer-announces-additional-phase23-study-results. Accessed 5.18.22.

Dr. Posney is a PGY-1 Ambulatory Care Pharmacy Resident at Allegheny General Hospital. For any questions concerning this article, please contact Elizabeth Posney, Pharm.D., at the Allegheny Health Network, Allegheny General Hospital, Center for Pharmaceutical Care, Pittsburgh, PA. (412) 359-3192 or email elizabeth.posney@ahn.org

Legal Summary

Pregnancy-Related Protections for New Physicians Jeremy Farrell & Rebecca Moran Tucker Arensburg PC Finishing residency, interviewing, and committing to their first full-time position is an exciting time for most physicians. But a lot can happen in the year between when the interviews and the job start—including pregnancy. Physicians who become pregnant during this time often wonder about their rights and obligations and how pregnancy could impact negotiations or the start of their careers. If the physician is pregnant during the interview process, must she disclose that information? If she signs her contract and subsequently becomes pregnant with a need to take leave at the beginning of her employment, can she be terminated? Will she be entitled to leave or other benefits? This article summarizes key legal protections and highlights things that a physician should consider while trying to navigate this situation. The primary issue is that family leave policies vary greatly from one employer to the next, and the jobprotected leave that is provided by the employer or by law often is not triggered until the employee reaches a particular length of service. Unfortunately, the standard jobprotected leave laws do not provide much help to physicians who find 30

themselves in this situation. There is the Family and Medical Leave Act (FMLA), which among other things, provides 12 weeks of unpaid leave to care for a newborn child. But employees aren’t eligible to take FMLA leave until they work at a job for more than 12 months. There are also some instances where the Americans with Disabilities Act (ADA) could require employers to grant unpaid leaves of absences to employees. But a normal pregnancy and childbirth (one free of complications) do not qualify as disabilities under the ADA, meaning that employers are generally not under a duty to reasonably accommodate them. That doesn’t mean that individuals who find themselves in this situation are without legal protection. Those who are pregnant or intend to become pregnant are among the people protected against pregnancy discrimination at work by a federal law called the Pregnancy Discrimination Act (PDA). The PDA prohibits a broad range of discriminatory conduct based on an individual’s pregnancy, including refusing to hire an applicant. That means, in general, a job offer shouldn’t be pulled just because an applicant is or becomes pregnant. By extension, that means applicants are under no legal obligation to

disclose their pregnancy to current or prospective employers. In fact, the Equal Employment Opportunity Commission (EEOC), the federal agency that enforces the PDA, recommends that employers not ask about pregnancy during the interview process. Beyond that, the full extent of the PDA’s protections is a bit murky, in that the statute doesn’t clearly address the accommodations that employers may be required to make for pregnant employees or applicants.The PDA’s general rule is that companies must treat pregnant women the same way they treat other employees with a similar ability or inability to work. The EEOC’s regulations provide that if an employee cannot perform functions of her job for reasons relating to pregnancy, the employer must treat that employee in the same way it treats others who are temporarily disabled and unable to work. This could include providing leave without pay, modified job tasks, or alternative assignments. While the precise contours of the PDA haven’t been clearly drawn, the EEOC has taken up the case on behalf of pregnant job applicants who the agency felt had wrongfully had their job offers rescinded because they were pregnant. For example, in a 2019 case it brought against Scribe-X

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Legal Summary Northwest, a medical documentation service provider, the EEOC alleged that Scribe-X unlawfully pulled an offer from a pregnant applicant. The EEOC’s investigation revealed that the applicant applied for a position online, was given an offer, and then completed all pre-hiring screens. Several months later, she told the company she was pregnant. The next week, the CEO rescinded her offer, telling the applicant that she should have disclosed her pregnancy during the interview. The EEOC sued Scribe-X, and the parties ultimately agreed to settle. The terms required that Scribe-X pay $80,000 and provide various other forms of compliance-related relief. In announcing the settlement, the EEOC stated that “rejecting a qualified applicant because of pregnancy is a form of sex discrimination” that violates the PDA. A couple months later, the EEOC announced another settlement of similar claims against Matrix Medical, a nationwide healthcare company headquartered in Scottsdale, which alleged that Matrix also unlawfully rescinded a job offer for a credentialing manager position within a week of finding out the applicant was pregnant. The settlement required that Matrix pay $150,000 to the applicant, write a letter of apology, and make various changes to its internal leave and nondiscrimination policies. Based on the above, physicians who are pregnant or who are likely to become pregnant are well-advised to consider the implications of this during the contract negotiation process. This includes learning as much as possible about the employer’s leave policies, negotiating for additional general ACMS Bulletin / June 2022

paid time off, negotiating salary to offset loss of compensation during unpaid leave, and understanding the contractual parameters under which the employer can otherwise terminate the employment agreement (i.e. for convenience or for a disability lasting a certain number of days). For a physician who becomes pregnant after the agreement has been signed, the main consideration is when to disclose that information. Technically, there is no obligation to disclose the pregnancy to your prospective employer but there can be advantages to doing so, bearing in mind the PDA’s protections discussed above. This may prompt a dialogue between employer and employee about how best to move forward, which could include moving back the first day of employment or modified duties for a certain period of time. Given the various considerations at play, individuals who find themselves in this situation are encouraged to consult with their attorney to explore their rights and the options available to them. 1

Note: The PDA applies to employers who have more than 15 employees. Depending on your jurisdiction, state laws may offer additional protections.

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

Editorial Index Perspective A ACMS Alliance News: 2021 Holiday Party and Dinner..................................No. 2, Page 18 Activities & Accolades Adam Barsouk—Winner of ACMS Scholarship………….......….No.1, Page 29 C.F. Reynolds Medical History Society..…...........................No. 1, Page 31 2022 Cover Page winners ……..…………................….No. 2, Page 28 ACMS Announces New Executive Director……No. 3, Page 26 Doctor’s Day Winners from ACMS………………..…...…No. 4, Page 15 PAGSWD David Martin Awardee…………............…No. 5, Page 18 B Bylaws C D E Editorial: Winter Nourishment Deval (Reshma) Paranjpe, MD, MBA, FACS…….......................…..No. 1, Page 5 Diversity Richard H. Daffner, MD, FACR ..............................................No. 1, Page 8 A “professional patient’s” journey to burnout Andrea G. Witlin, DO, PhD..No. 1, Page 10 Take That, Pharma Bros Deval (Reshma) Paranjpe, MD,MBA, FACS……….........................No. 2, Page 5 Experience Counts Richard H. Daffner, MD, FACR……………….........…..No. 2, Page 8 Love Thy Neighbor Deval (Reshma) Paranjpe, MD, MBA, FACS…………….....…No. 3, Page 5 Osher Richard H. Daffner, MD, FACR…………………...........No. 3, Page 8 Move it or lose it: Promoting wellness and exercise in senior adults Terence W. Starz, MD……..No. 3, Page 11 Spring Nourishment Deval (Reshma) Paranjpe, MD, MBA, FACS……..…….......…No. 4, Page 5

Poultice Richard H. Daffner, MD, FACR………...............………No. 4, Page 8 Bringing Home Baby Marta Kolthoff, MD……..….No. 4, Page 10 Doomed from Birth: The Ida May Fuller Story Joseph Paviglianiti, MD……No. 4, Page 12 May Adventures Deval (Reshma) Paranjpe, MD, MBA, FACS……..…............…No.5, Page 5 Appropriateness Richard H. Daffner, MD, FACR ..............................................No. 5, Page 8 Title Coming... Deval (Reshma) Paranjpe, MD, MBA, FACS……..………....…No.5, Page 6 Teenage Einstein’s Take Center Stage Anthony L. Kovatch, MD ..............................................No. 6, Page 8 Medical Historic Vignette: The “Pornographic” Anatomy Book Richard H. Daffner, M.D., FACR…………….............…No. 6, Page 10 F G Grass Roots Support: Pittsburgh Cure Sarcoma Mark Goodman, MD….........No 3. Page 21 H I In Memoriam: J K L Legal Summary: What Physicians Need to Know About The No Surprises Act Edward J. Cyran, Sarah M. Rozek and William H. Maruca……..…..No. 1, Page 26 COVID-19 and Disciplinary Actions against Physicians: Medical Boards or State Legislature? Beth Anne Jackson..…....…No. 2, Page 24 Employment Contract Issues For New (and maybe old) Physicians Michael A. Cassidy, Esquire... ...........................................No. 3, Page 22 The Future of Telemedicine William H. Maruca, Esquire ............................................No. 4, Page 25

Disclosure of Mental Health Records: Traps for Psychiatrists and Other Providers Beth Anne Jackson……..….No. 5, Page 22 Pregnancy-Related Protections for New Physicians Jeremy V. Farrell, Esquire, Rebecca A. Moran, Esquire, Tucker Arensberg, P.C….....No. 6, Page 30 M Materia Medica: The Ejection Fraction May Be Preserved but Treatment is Evolving:Analysis of |New Data Surrounding Heart Failure with a Preserved Ejection Fraction Thomas Greco, Megan Obeid, Rebecca Schoen…......…….No.1, Page 20 Finerenone (Kerendia®) Arianna Sprando, PharmD and Alicia Faggioli, PharmD, BCPS……….......................No. 2, Page 20 Breaking Down the Cost Barrier: Helping Patients Afford Their Medications Melanie Riggio, Pharm.D…..No 3, Page 18 Abemaciclib: Escalating adjuvant endocrine therapy for high-risk early-stage breast cancer Karen M. Fancher, PharmD, BCOP……...........................No. 4, Page 23 Vericiguat (Verquvo®) Lauren Sittard, PharmD and William Beathard, PharmD, BCPS………..................…..No. 5, Page 20 Paxlovid: The First Authorized Oral Antiviral for COVID-19 Treatment in Non-Hospitalized Patients Elizabeth Posney, Pharm.D.. ............................................No. 6, Page 26 N O P Perspective: Are All Happy Families Alike? Anthony L. Kovatch, MD…..No. 1, Page 13 Online Physician Reviews Timothy Lesaca, MD…....… No. 2, Page 11 What is the future of cybersecurity in health care? Ransomware, patient safety, and the protection of physician-patient communications. Bruce Wilder, MD…….....….No 3, Page 13

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Editorial Index Perspective Serving the Underserved Michael G. Lamb, MD……..No. 3, Page 15 Running Boston Backwards Anthony L. Kovatch, MD…..No. 4, Page 16 Neighbors Helping Neighbors: How Communities of Practice Drive Change Jessica Carlson, Hannah Hamlin, and Anthony DiGioia. MD….......No. 5, Page 14 To Be, Or Not To Be… Maria Sunseri, MD FAASM………………........…No.5, Page 11 History of Nutrition Kristen Ann Ehrenberger, MD PhD…………........................No 6. Page 14 President’s Message….......…No 6, Page 5 Q R Reportable Diseases ...................No. 2, Page 26; No.5, Page 24

S Society News .... 30th Annual Virtual Clinical Update in Geriatric Medicine…………..No.1, Page 16 Pittsburgh Ophthalmology Society 57th Annual Meeting ............................................No. 1, Page 18 30th Annual Virtual Clinical Update in Geriatric Medicine………….No. 2, Page 14 Pittsburgh Ophthalmology Society 57th Annual Meeting ............................................No. 2. Page 16 Pittsburgh Ophthalmology Society welcomes David Crandall, M.D ............................................No. 3, Page 17 Pittsburgh Ophthalmology Society hosts 57th Annual Meeting ............................................No. 4, Page 20 42nd Annual Meeting for Ophthalmic Personnel….....No. 4, Page 21 Greater Pittsburgh Diabetes Club set to host Spring Program .............................................No.4, Page 21

Pennsylvania Geriatrics Society— Western Division hosts Virtual Conference..........................No. 4, Page 22 2023 Election Nomination....No. 5, Page 19 American College of Surgeons -SWPA Chapter Most Interesting Cases .............................................No. 6, Page 16 Special Report: It’s Been A While... Since 2013 Joan M. Keil, PhD, CHPS ............................................No. 1, Page 24 T U V W X Y Z

Advertising Index Perspective

2022 Bulletin Advertising Index: January-July Accounting Billing/Claims/Collections

Fenner Corporation……………………….…(412) 788-8007

Charity

Pittsburgh Cure Sarcoma Run: https://pghcuresarcoma.org/runwalk/

Clinical

Allegheny Health Network ......................... (724) 933-1445

Legal

Tucker Arensberg PC.................................. (412) 566-1212

Real Estate

Berkshire Hathaway: Julie Wolff Rost ..........(412) 521-5500 Berkshire Hathaway: Deb Arrisher……….....(412) 367-8028

The Bulletin depends on its advertisers. Be sure to tell them you saw their ad here. ACMS Bulletin / June 2022

Allegheny County Medical Society Foundation Tackles Formula Shortage Sara Hussey, MBA, CAE – ACMS Executive Director The shortage of baby formula that began almost five months ago is expected to drag on into the summer. Parents in Allegheny County are feeling the impact of this shortage, finding mostly empty shelves in the formula aisle of every grocery store and pharmacy. In May, the ACMS Foundation was able to step-in to provide some much needed relief. Through a series of connections, the ACMS was able to work with a medical supply company that had access to Enfamil formula through one of their FDA distributors. The distributor was only selling the formula by the pallet in an effort to get the formula to places that could make an immediate and direct impact. The ACMS Foundation board approved the purchase of 1200 containers of Enfamil formula that would be dispersed to 4

local organizations who would get it in to the hands of those in most need. On Friday, May 27, the formula was distributed to the local organizations. The bulk of the order went to the Allegheny County Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and Beverly’s Birthdays, a Pittsburgh nonprofit that serves families in need. Smaller distributions went to the Lemieux Children’s Home and Every Child Inc. The mission of the ACMS Foundation is “Advancing Wellness by confronting Social Determinants and Health Disparities.” Alongside the mission of the foundation, the formula shortage and public health crisis around it, made this formula procurement an easy “yes” for ACMS officers and Foundation Board members. They

were also incredibly responsive to the fast-moving initiative, and they stepped up to volunteer to help with distribution. It is a real testament to the connection that physicians have to this community and their awareness of how impactful this donation of formula would be to the local organizations. As a mother to a seven-month-old, I can’t help but feel that the timing of my new role as Executive Director of the ACMS is somewhat serendipitous. I know, firsthand, what it’s been like to walk into a grocery store and see absolutely no formula on the shelves. Alongside my job running the association, I’m also CEO and Executive Director of my household, which includes my 6-year-old daughter Bellamy and my 7-month-old son Bowen. This formula shortage is incredibly personal to me. I

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felt such a connection to the issue, and I understood the urgency of what was happening. I still feel the impact of worrying about having enough food for my infant, but I also recognize how lucky I am to have family and friends who are always looking out for formula for me. The donation of this formula into the community gives access to those who might not have otherwise been able to find it elsewhere. As the Executive Director of the ACMS, I am proud of the work that this foundation did. And as a mom of an infant, I am grateful to this organization for their support. The ACMS Foundation is the 501 (c) 3 charitable arm of the Allegheny County Medical Society. The Foundation believes that all people have the inherent capacity to effect change in their lives and in their communities. The Foundation will support programs that respect and value individuals and their collaborative work to improve healthcare in our community. If you would like to donate to the Allegheny County Medical Society Foundation to help support future programs, please email Sara Hussey (shussey@acms. org) or send your donation to: ACMS Foundation, 850 Ridge Avenue, Pittsburgh, PA 15212.

2022 ACMS Meeting & Activity Schedule By Committee Finance Committee

Keith T. Kanel, MD, Chair November 15

August 30

Patricia L. Bononi, MD, Chair December 6

September 13

Board of Directors

Delegation

Deborah Gentile, MD, Chair August 31 Bruce A. MacLeod, MD, Vice Chair House of Delegates October 21-22 MPHC (Management Professionals in November 16 Health Care) at the Westin Convention Center Downtown Meetings begin at 6:00PM. If you are interested in attending any of the meeting, please contact Mrs. Hostovich at 412.321.5030.

ACMS Bulletin / June 2022

ELECTION 2023 The Allegheny County Medical Society is looking for motivated individuals interested in joining our leadership team to develop our Society to meet the future needs of our members and community. ACMS is now seeking candidates for the 2023 ACMS Board of Directors and ACMS Delegates to the Pennsylvania Medical Society and invite your nominations. If you want to make a difference and are interested in participating in ACMS leadership, send in your nomination. If you would like to recommend a colleague, please e-mail [dhostovich@acms.org] or fax this memo back to 412321-5323. Get involved – send in your nominations today. If you have any questions, please contact the Society at 412-321-5030; our staff is eager to assist you. Sincerely,

Mark A. Goodman, MD Mark A. Goodman, MD Secretary

Nominations for 2023 Election [Please Print] I would like to recommend ___________________________________________________________for ________ Board of Directors

________ Delegate.

I am interested in being a candidate for the ACMS: Board of Directors _______ ♦ ♦ ♦

Delegate to the PAMED Society _______

Represents physicians on issues impacting the practice of medicine and makes policy decisions for the Society. Meets four times per year, special meetings as needed. Three-year term: 2023-25. Eligible for reelection.

♦ ♦ ♦

Represents the physicians of Allegheny County in creating statewide policy on issues impacting physicians, patients and the practice of medicine. Meets as necessary prior to attending the House of Delegates in October in Hershey, PA. Two-year term: 2023-24. Eligible for re-election.

Name _______________________________ Phone ________________ Email _____________________________ [Please Print] Please enclose a copy of your CV. Fax the completed form to 412-321-5323 by Monday, July 15, 2022. Thank you.

ACMS Bulletin June 2022

Articles inside

2022 ACMS Meeting and Activity Schedule

Legal Summary

Editorial

Materia Medica

Allegheny County Medical Society Foundation Tackles Formula Shortage

Editorial

Perspective

Society News

President’s Message