ACMS Bulletin November 2022

Psychological Safety in Health care Thanksgiving 1976*

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 Adele L. Towers 2024

Douglas F. Clough Kirsten D. Lin Jan W. 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

Bylaws

Raymond E. Pontzer

Finance

Keith T. Kanel

Membership

Matthew B. Straka

Nominating Raymond E. Pontzer

Bulletin

Medical Editor

Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com)

Associate Editors

Douglas F. Clough (dclough@acms.org)

Richard H. Daffner (rdaffner@acms.org)

Kristen M. Ehrenberger (kehrenberger@acms.org)

Anthony L. Kovatch (mkovatch@comcast.net)

Joseph C. Paviglianiti (jcpmd@pedstrab.com)

Andrea G. Witlin (agwmfm@gmail.com)

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Giving Thanks

Deval (Reshma) PaRanjPe, mD, mBa, FaCs

This year, like the past few years, has been full of unexpected changes, laughter, stress, tears, and love. We now face a triple whammy winter of COVID-19, RSV and influenza. While we have entered a new and slightly better phase in the pandemic, the country is probably starting a slow slide into recession. Inflation is everpresent, and the Great Resignation is starting to look like the Great Remorse as employment is becoming harder to find for job seekers. War in Ukraine,

economic instability in the rest of the world, and a somewhat surreal political landscape in our own country are our new realities.

Gratitude is an unexpected antidote to so many negative states of mind: fear, sadness, anger, malaise, and depression among them. This is a lesson taught early that we seem to forget as we grow older, and it populates every children’s story and great movie. The reminder to be grateful for what you

have is the crux of the classic parental exhortation to “finish your supper, because there are children starving in Africa.”

The song “My Favorite Things” from the film The Sound of Music is, in effect, an exercise in gratitude; Maria declares “When the dog bites, when the bee stings, when I’m feeling sad….I simply remember my favorite things, and then I don’t feel so bad.”

Feeling better and stronger can be as simple as remembering that good things and good people exist. Remembering that good times exist and will return is similarly therapeutic; life is cyclical, as are weather patterns, politics, and the economy. Living on the East Coast makes you grateful for good weather when you remember the cold and the snows past and future; in the depths of winter, there are days when only the memory of summer and the promise of spring keeps you going. But there are also winter days so stunningly beautiful that you are glad you bear witness to sunlight sparkling on frosted branches and the pale pink light. Resilience is built on both hope and gratitude

Sharing your troubles with a friend can be therapeutic and can also remind you to be grateful. I have a dear friend

From Page 5

who reminds me at the close of every mutual decompression session: “but our problems are nothing; we could be in Ukraine right now.” Perspective itself is a gift. Here are things I am grateful for this year: 1.The love and existence of family and good friends

The mercy of God/the universe

The chance to see another sunrise each day

Health and the chance to improve it

Kindness and righteousness in the hearts of strangers

Second chances

Food, clothing, working utilities and a roof over my head

Peacetime for our country

The laughter of children

The commitment, kindness, and conscientiousness of colleagues

I’m grateful for each and every one of you who read this Bulletin and this column and wish you every best wish for good health and much joy during the holiday season.

Selected Reportable Disease/Condition*

REPORTABLE DISEASES 2022: Q1-Q3

Allegheny County Health Department

Selected Reportable Diseases/Conditions

January to September** 2020 2021 2022

AMEBIASIS 4 3 3

ANAPLASMOSIS 12 17 30

BABESIOSIS 0 1 0

BOTULISM INFANT 1 1 0

CAMPYLOBACTERIOSIS 81 84 84 CANDIDA AURIS*** 0 0 2

CARBAPENEMASE-PRODUCING CARBAPENEM-RESISTANT ENTEROBACTERALES*** 6 10 17

COVID-19 12,180 62,942 115,970

CRYPTOSPORIDIOSIS 11 16 21

DENGUE FEVER 0 1 0

GIARDIASIS 42 44 46

GUILLAIN-BARRE SYNDROME 1 3 1

HAEMOPHILUS INFLUENZAE 13 3 9

HEPATITIS A 4 0 1

HEPATITIS B ACUTE 5 0 1

HEPATITIS B CHRONIC 35 50 22

HEPATITIS C PAST/PRESENT 780 730 700

LEGIONELLOSIS 44 51 34

LISTERIOSIS 1 5 1

MALARIA 0 5 3 MEASLES 0 0 0 MONKEYPOX 0 0 68 MUMPS 1 0 1

NEISSERIA MENINGITIDIS 0 0 1

PERTUSSIS 23 3 1 SALMONELLOSIS 71 81 90 SHIGELLOSIS 10 9 17

SHIGATOXIN-PRODUCING E COLI 1 24 13

STREPTOCOCCAL DISEASE INVASIVE, GROUP A 24 14 31 STREPTOCOCCUS PNEUMONIAE INVASIVE 23 8 26

TOXOPLASMOSIS 0 1 0

TUBERCULOSIS 10 13 7

TYPHOID FEVER 0 1 0

VARICELLA 6 4 9

WEST NILE VIRUS 0 0 0

ZIKA VIRUS 0 0 0

* Case classifications reflect definitions utilized by CDC Morbidity and Mortality Weekly Report.

** These counts do not reflect official case counts, as current year numbers are not yet finalized Inaccuracies in working case counts may be due to reporting/investigation lag.

***Newly reportable in 2022.

NOTE: Disease reports may be filed electronically via PA-NEDSS. To register for PA-NEDSS, go to https://www.nedss.state.pa.us/NEDSS To report outbreaks or diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243.

For more complete surveillance information, see ACHD’s 10-year summary of reportable diseases: https://www.alleghenycounty.us/Health-De partment/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Epidemiology-Reports-and-Resources.aspx.

Psychological Safety in Health care

“Institutions are where the human heart either gets welcomed or thwarted or broken.”

—Parker Palmer.1

RosemaRy hanRahan, mD, mPh, PCC

During a recent webinar on psychological safety hosted by of the Center for Creative Leadership, the facilitator invited us to reflect on two situations from our past when we participated as a member of a professional team. We were asked to think about a time when we experienced a powerful connection between team members, and conversely, we were asked to recall a time when we experienced discouraging disconnection.2

For most of us, the latter scenario came to mind more easily. After all, as psychologist Rick Hanson, Senior Fellow of UC Berkeley’s Greater Good Science Center, and New York Times best-selling author reminds us, our brains are like Velcro for the bad and Teflon for the good.3

My reflection jettisoned me back 35 years to my first year and first day of internal medicine residency. Fresh with considerable knowledge, ample enthusiasm, and a fair amount of anxiety, I listened as our senior resident told us about “complication rounds.” These rounds, conducted three times a week, were a chance for ward teams, attending physicians, and faculty members to come together and discuss patient care situations with undesirable outcomes.

Complication rounds were meant to be opportunities to learn together without assigning blame or evoking shame so that we all would all become better physicians—first year and senior residents, fellows and attending physicians. We also received a free lunch.

Although these encounters occasionally went as forecasted, more often they morphed into a blame and shame scenario, at times ending with tears either in the conference room or after in solitude.

In the ensuing months, I first noticed that the residents stopped eating the free lunch, as did I--nothing could get past the lump in my throat and the knot in my stomach. Then I noticed, firstyear residents stopped volunteering cases for discussion. Finally, unless we absolutely had to be there, we stopped coming. Not only was it painful to be on the receiving end of the harsh scrutiny, it was also incredibly painful to watch others in the hot seat.

Reflecting back, with the clarity of time and experience, I now know that physical and psychological safety are essential for learning and personal fulfillment. I also acknowledge that what I needed then (and now) in times of distress, was the support of my colleagues, who I knew to be extraordinarily kind and compassionate.

I’d like to think that the incredible advances medicine has made in those 35 years since my residency include a more humane approach to human error. As a physician who has faced the personal and professional impacts of medical error, and as a professional coach who works with individuals in a variety of high-stress health care environments, I can attest that we are not there yet.

However, based on considerable experience and knowledge from other industries, we are beginning to recognize the critical need for psychological safety in health care for health care professionals. We are beginning to have the “Totally Honest, Totally Kind” (THTK) conversations we need to have so that we can consistently integrate psychological safety into our health care leadership discussions and team interactions.2

What is psychological safety?

Dr. Amy C. Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, is a widely recognized expert in psychological safety and the author of The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation and Growth.4

As defined by Dr. Edmondson, and elaborated on by the American Medical Association, “Psychological safety is a climate of trust and respect in which people are comfortable expressing and being themselves, and share the belief that teammates will not embarrass, reject, or punish a colleague for speaking up.”4,5,6

Speaking up may sound like asking for help or balanced feedback or saying I don’t know, or I made a mistake. At times, speaking up means feeling safe enough to share half-formed and messy ideas, or voicing problems without solutions in tow.

It also helpful to consider what psychological safety is not. It is not freedom from conflict or messy conversations. Nor is it seeking consensus. It is not a guarantee that others will agree or be persuaded by one’s ideas. Most definitely, psychological safety is not immunity from the consequences of mistakes, nor is it a safe haven for repeated poor performance. Psychological safety comes from a belief that while failure is not the desired outcome, it is an option that doesn’t require shaming an individual or ending a career.

This important topic has garnered attention in almost every industry. An often cited initiative is Google’s Project Aristotle of 2012. In their quest to build a perfect team, Google found that intelligence (IQ points) and resources (money) can’t compensate for what a team lacks in psychological safety. In fact, the company concluded that psychological safety was the single most important factor in explaining high performance.4,7

When psychological safety is high, people take more ownership and

put forth more discretionary effort. Learning and problem-solving occur at greater velocity. When it’s low, people don’t move through the fear. Instead, they tend to shut down, self-censor, and focus their energy toward risk management, pain avoidance, and self-preservation.7

Some barriers to psychological safety rest at the individual level and are fundamental to our basic human need for safety. Both consciously and unconsciously, we all want to manage our image to look smart and capable to others.

In health care, culturally based and “institutionalized” barriers are common, including a culture that is drawn to tradition, undervalues dissent, highly values perfectionism and is highly litigious.

Clearly, psychological safety is complex and difficult to establish. It is also fragile and easily lost. Psychological safety is influenced by individual-level factors, organizational climate, and leadership. However, it primarily lives and breathes as a team-level phenomenon.8

Why is psychological safety important in health care?

High-quality health care delivery is innately iterative and highly dependent on interprofessional teams. These teams must work together in complex, highly technical, and rapidly changing environments. Stakes are high, and uncertainty and ambiguity rumble with facts and data on a frequent basis. Yet a hierarchy of authority and power exists, and some would argue it is necessary at times. Grit and even ego are amazing qualities that often manifest as strengths; however,

when overutilized, these strengths can become derailers, fostering a fixed rather than growth mindset. A growth mindset embraces challenge as opportunities to learn and innovate. Psychology safety can help individuals and teams shift from fixed to growth mindsets.5

In health care, we are fortunate to have many of the brightest minds, kindest hearts, and most expert hands in the world. The culture of an organization, and the day-to-day teams are the “institutions” that can welcome, thwart, or break hearts and minds.

In her work with health care teams, Dr. Edmondson found that when psychological safety was present, mistakes were reported more often, but earlier. Silence leads to harm that could have been prevented. When employees don’t have the freedom to speak up, organization’s lose mindshare and early awareness of risks.4

Burnout is at the forefront of many conversations today. As forces join to support health care workers in staying well, we know that peer support is an important intervention in preventing burnout and other manifestations of clinician distress. Psychological safety is foundational in establishing peer support programs.5

What is the role of leadership in establishing psychological safety?

The topic of psychological safety frequently comes up in both team and leadership coaching. If psychological safety lives and breathes at the team level, what is the role of the leader in establishing psychological safety? Edmondson offers one tip for creating psychological safety: it starts with the leader.4

Fostering psychological safety necessitates the awareness and dismantling of barriers and establishment of new norms within teams and organizations. The leader’s most important role—above that of creating a vision and setting strategy— is to cultivate an environment of trust and respect. A leader also serves as the link between individuals, teams, and other influencers and decision makers.7

Psychological safety is not binary, something teams either have or don’t. Though, to some extent, it can be measured. A number of short Likert scale-type surveys are available to assess psychological safety within teams. Most are adapted from a seven-question survey developed by Edmondson. The survey questions examine individual safety, team respect, and team learning.4,9

Shifting the culture of blame and shame that still exists in many health care environments and tapping into the wisdom and gifts of highly skilled and caring teams will take time-and tolerance for discomfort and imperfection.

Nevertheless, small, consistent steps in the right direction will get us far. I find it helpful for myself and with coaching clients to approach desired change from the inside out, sometimes described as “being and doing.” I offer a few suggestions in this direction:

1. Become aware of your own mindset and behaviors: Be aware of your derailers. These can be difficult to sort out alone. Consider asking for assistance from a trusted colleague or professional coach. Assessments such as the Hogan Development Survey can be helpful.10

2. Model the behavior you want to see from others: Actively listen to what is being said and not said. Invite dissent by asking openended questions: “What are we missing here?” or “What’s another viewpoint?” Acknowledge and thank people when they speak up. Stay curious and engage in co-discovery as a team when complex problems arise or mistakes occur. Be THTK without excusing repeated poor performance.

3. Be willing to show vulnerability: Admit you don’t know the answer, that you need help and/or that you have made a mistake.

4. Make it easy to ask for help and offer input: Not everyone will speak out in a large group, especially introverts who may need time to process. Create different forums for input-reach out by email or schedule one-on-one meetings. Establish norms that encourage the sharing of imperfectly formed ideas, as well as problems (especially complex ones) that may not yet have solutions.

5. Pay attention and be intentional about how mistakes are handled: When a mistake is made, especially when significant harm occurs, we are at our most vulnerable. We must always keep our patients at the center of our caring and focus. Yet, we can also support each other and avoid blame and shame. In doing so, we can learn and thrive with hearts and minds that are welcomed and opened.

We are rapidly, albeit unevenly, gaining awareness about what psychological safety is and is not. We are beginning to realize what it means to integrate the mindset and behaviors necessary for psychological safety into a profession that thrives with talented and compassionate individuals and high-functioning teams.

I encourage us to reflect on what it looks like, and means to be a powerfully connected team and ask ourselves--what will I stop, start, or continue to do to foster psychological safety?

References

1. Intrator, S. E., ed. (2005). Living the questions: Essays inspired by the work and life of Parker J. Palmer. Jossey–Bass.

2. Altman, D. (2022). How leaders & leadership collectives can increase psychological safety. https://www. ccl.org/webinars/how-leaders-andleadership-collectives-can-increasepsychological-safety-at-work/

3. Bergeisen, M. (2010). The neuroscience of happiness. https://greatergood.berkeley.edu/ article/item/the_neuroscience_of_ happiness

4. Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.

5. American Medical Association (AMA). (2020). Jo Shapiro, MD, explorespeer support implementation during a crisis. https://www.ama-assn.org/practicemanagement/sustainability/joshapiro-md-explores-peer-supportimplementation during-crisis

6. Center for Creative Leadership. (2022). What is psychological safety at work? https://www.ccl.org/articles/ leadingeffectively-articles/what-ispsychological-safety-at-work/

7. Clark, T. R. (2020). The four stages of psychological safety. Porchlight. https://www.porchlightbooks. com/blog/changethis/2020/ the-four-stages-of-psychologicalsafety#:~:text=Psychological%20 safety%20is%20a%20 condition,or%20punished%20in%20 some%20way

8. O’Donovan, R., Aoife De Brún, A., & McAuliffe, E. (2021). Healthcare professionals experience of psychological safety, voice, and silence. Frontiers in Psychology, 12, 1–16. doi.org/10.3389/ fpsyg.2021.626689

9. Psychological Safety. (2020). Measuring psychological safety. https://psychsafety.co.uk/measurepsychological-safety/#:~:text=By%20 regularly%20measuring%20the%20 degree,for%20developing%20 and%20maintaining%20it

10. Hogan. (2022). Hogan development survey. https:// www.hoganassessments.com/ assessment/hogan-developmentsurvey/

About the Author

Rosemary Hanrahan, MD, MPH, PCC: After three decades of practice in Anatomic and Clinical Pathology, Rosemary transitioned to executive leadership and academic coaching for individuals in the health care and non-profit sectors. She also supports and encourages medical laboratory excellence as a part-time field representative with The Joint Commission. Rosemary can be contacted at beyondwordswellnessresources@ gmail.com.

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

Thanksgiving 1976*

RiChaRD h. DaFFneR, mD, FaCR

ost people attribute the annual Thanksgiving holiday tradition in the United States to the Pilgrims who settled in Massachusetts in 1620. However, the celebration is documented to have begun a year earlier, in what is now Virginia. It began as a day of giving thanks to God for the blessings of the harvest and for having survived the triumphs and disappointments of preceding year. For most of us, it is a day of (over)eating and watching football. Thanksgiving 1976 changed my perspective on the holiday forever and I remember the details as if it happened yesterday.

In October 1976, I was working at the VA Hospital in Durham, N.C. Earlier that fall I had joined an adult soccer league. In my first game, I jumped to “head” the ball, and when I landed, I hyperextended my left knee and tore my ACL. I was fortunate to have a conservative orthopedic surgeon who urged me to try to avoid surgery and to see how I did with vigorous rehabilitation. In 1976, there were about a dozen surgical procedures for ACL repairs, none of which worked very well. (This was long before the late Dr. Freddie Fu developed his unique repair.) And so, once the swelling and pain had subsided, I dutifully went to physical therapy at the hospital every day at lunchtime

to strengthen the muscles around my injured knee.

The U.S. involvement in Vietnam ended March 29, 1973. That war had killed 58,220 Americans and had wounded another 153,303 (not to mention an estimated two million Vietnamese dead and wounded). In 1976, the VA population of patients had many young former servicemen (and a few women) who were still dealing with the aftermaths of injuries suffered in Vietnam. The war injuries tended to be more common in lower limbs due to land mines and booby traps the enemy was using. Statistics showed that more GIs were surviving battle trauma thanks to air evacuation as well as advances in surgical and medical care. Unfortunately, bullet wounds to the head or torso from an AK-47 the enemy used were usually fatal.

The Physical Therapy Department at the hospital scheduled patients in regular time slots. And every day when I came during the noon lunch hour there were the same three patients. We talked briefly about our injuries, and they told me about what combat was like. I, too, was a veteran; having been in the Air Force during the Vietnam era, but I had the good fortune to have served my entire tour of duty in the United States.

The youngest of the three veterans, in his early 20s, had stepped on a land mine which miraculously (my judgment) had taken off only the front half of his left foot. Unfortunately, the wound hadn’t healed properly, resulting in him eventually undergoing an amputation at the ankle. He was getting used to a new prosthesis. The second man was slightly older and had suffered trauma to both legs, also from a land mine, which necessitated below-the-knee amputations. He, too, was adjusting to using new leg prostheses. The third man, a prototypical “hard boiled” sergeant (complete with cigar clamped between his teeth – at the time, the VA allowed smoking on the premises and even sold cigarettes at a discount in the PX in the basement), had been in a bunker that had taken a direct hit from a rocket-propelled grenade. He lost his right arm just below the shoulder, as well as both legs above the knees.

As the days progressed in November, the talk in physical therapy turned to the upcoming holidays, beginning with Thanksgiving. All three of the ex-GIs would be going home on leave for the holidays. The two men with the more significant amputations were excited about spending the holidays with their families. The youngest, however, was really depressed over his lost foot

and was clearly not in the mood for giving thanks. I, too, was certainly not happy with my injury, which paled in comparison to what these three men had lost.

The youngest veteran started a conversation in which he wondered why his two buddies had anything to be thankful for. “Look at us,” he said. “We’re cripples for life.”

“Well,” said the double amputee. “It could have been worse. Look at poor Sarge here. I’m thankful I still have most of my legs and both arms.”

“I’m thankful, too,” said the sergeant.

“For what?” asked the younger man. “You’ve lost both legs and an arm.”

The old veteran looked at the young man and with tears in his eyes said, “You know I told you how I was wounded. What I didn’t tell you, son, was that the day I lost my arm and both legs I was with three other men from my squad. Of the four of us, I am the only one who will be celebrating Thanksgiving this year.”

The silence that followed was deafening. After hearing that story, I no longer felt so bad about my injured knee. I realized then that it is sometimes better to look at the glass

being half full rather than half empty. Things could always be worse. Forty-six years have passed since I met those three GIs. Every year as Thanksgiving comes around, I think about those three men and realize how grateful I am for having been able to share the experience with them. And I give thanks that despite my injury, I was still able to play hockey for another ten years (with a knee brace). And when I think about those men, I know that for too many people throughout the world things are, in fact, worse.

* A shorter version of this piece, entitled “Three GIs” was originally published as a First-Person column in the Pittsburgh Post-Gazette, November 21, 2009.

Dr.Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine and is the author of 9 textbooks.

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Counterpoint: Two Patients, Two Persons

By ChRistina a. CiRuCCi, mD, FaCoG

In Dr. Witlin’s editorial, “It’s even more complicated,” she expresses concern with the Dobbs’ decision. I respect the years of experience in high-risk pregnancy management that Dr. Witlin brings as a maternal fetal medicine specialist. I agree that there has been confusion and conflation of terminology since the Dobbs decision. Missed abortion and spontaneous abortion are medical terms referring to miscarriage and must not be confused with elective or induced abortion. Similarly, treatment of ectopic pregnancy is not abortion. There was never any confusion about this prior to Dobbs, and there should not be now. I would like to offer a different perspective on the rest of the editorial.

Supreme Court Motives - Dr. Witlin states that the standard of care has “been upended by 5 or 6 supreme court justices championed by their personal religious views.” It is unclear on what basis she draws this conclusion. This statement assumes motive and bias. As stated by the majority opinion in Dobbs, “The critical question is whether the Constitution, properly understood, confers a right to obtain an abortion.” 1 In their lengthy opinion, the majority explains that the right to abortion is not a constitutional right, and thus they returned that decision to the people. “Abortion presents a profound moral question. The Constitution does not prohibit the citizens of each State from regulating or prohibiting abortion. Roe and Casey arrogated that authority. We now overrule those decisions and return that authority to the people and their elected representatives.” 1

The decision was made on legal grounds. The Justices stated, “Our opinion is not based on any view about if and when prenatal life is entitled to any of the rights enjoyed after birth. The dissent, by contrast, would impose on the people particular theory about when the rights of personhood begin. According to the dissent, the Constitution requires the States to regard a fetus as lacking even the most basic human right—to live—at least until an arbitrary point in a pregnancy has passed. Nothing in the Constitution or in our Nation’s legal traditions authorizes the Court to adopt that “’theory of life.’”1

The Dobbs decision was not about whether abortion is right or wrong but about whether there is a constitutional right to it. The Supreme Court concluded there is not. Assuming that the Supreme Court Justices had motives other than properly interpreting the Constitution is unjustifiable.

Life and Personhood– Dr. Witlin states that the “ethical debate encompassing elective abortions and when life begins can be entrusted to a sociology, philosophy, or religion class.” In the past, abortion advocates have denied that a pre-born baby is a human, but that is no longer the crux of the abortion debate. Basic embryology teaches that a genetically distinct human being is formed at conception. Virtually all professional bioethicists agree that life begins at conception.

2 Due to advances in scientific understanding, the abortion argument is no longer whether the pre-born baby is a life but whether the pre-born baby is a person deserving the same rights

as those who live outside the womb. We know that life begins at conception, and most arguments for abortion now are instead based on the personhood theory.2 Humans are typically afforded the rights of personhood after birth, but not always before birth. Yet, we would not find poverty, rape, disability, terminal condition, or unwantedness to permit a mother to kill her toddler. There is no scientific evidence of a transformation from non-person to person between conception and birth. I find no rationale why a tiny human life should be denied the rights of personhood prior to being born.

Late-term abortions - Admitting she has no proof, Dr. Witlin states that she assumes that when pro-life advocates speak of late-term abortions, they are referring to medically or obstetrical indicated deliveries during the late second or third trimester and provides a long list of very different conditions. Late-term abortions are not limited to maternal medical and obstetrical conditions; this is not what most prolife advocates call late-term abortions, as Dr. Witlin assumes. Most late-term abortions are elective, done on healthy women with healthy fetuses, and for the same reasons given by women who have first-trimester abortions.3 As noted in the Dobbs majority decision, “only six countries besides the United States permit[ted] non-therapeutic or elective abortion-on-demand after the twentieth week of gestation.” 1 These countries are China, North Korea, Vietnam, the Netherlands, Singapore, and Canada.

Early delivery is not abortion – I agree that there are certain conditions,

such as HELLP and chorioamnionitis, in which early delivery may be necessary to save the mother’s life. If nothing is done, both mother and baby may die. Early delivery is not abortion. When the mother and her baby must be separated prematurely, neonatal resuscitation is appropriate at viability and beyond, and comfort care and perinatal hospice are appropriate prior to viability. Delivering a baby early to save a life is not abortion.

Abortion for fetal anomalies – In her editorial, Dr. Witlin takes issue with referring to “medically indicated terminations” for fetal anomalies as abortions. I propose that killing a baby for a fetal anomaly is neither indicated nor compassionate. Although a baby may live only minutes, hours, or days, the baby’s life is still of value. Parents of such babies have found perinatal hospice helpful in managing their grief and spending precious moments with their child. In perinatal hospice, the baby is delivered, and the parents are given time with their child before death. Disability and medical conditions should never be reasons to end a life. Dismembering a baby or withholding comfort care is not a treatment for a lethal fetal anomaly.

Women of Color - I would agree with Dr. Witlin that underprivileged women and women of color are most affected by Dobbs, but probably in the opposite way that she speaks. The sad truth is that abortion disproportionately kills black babies. The abortion rate is higher in black women (21.2 abortions per 1000 women) than in White (6.3 per 1000), Hispanic (10.9 per 1000), or other races (11.9 per 1000). 4 The latest CDC Abortion Surveillance Report states that 38.4% of reported abortions were in Black women, 4 yet the population percentage is only 13.6%.5

Curtis Hill, who served as the 43rd attorney general of Indiana and is black, said, “We can only speculate about what these innocent little black children could have become had they been given the chance to continue their lives. But we as a nation have failed miserably to properly affirm their value in the eyes of God.” 6 The abortion movement was founded on eugenics. Margaret Sanger, the founder of Planned Parenthood, said, “colored people are like weeds and need to be exterminated. We don’t want the word to get out…” 7 Let us not pretend that abortion benefits women of color or their babies.

Criminalization - Dr. Witlin states, “But you can bet there is a vigilante in the wings who will be anxious to report you or harass your patient.” As an obstetrician who is pro-life, I have no desire to report a physician or harass a patient. I want to provide the best care for my patients, both the mother and her baby. I have no desire for criminal penalties for doctors or women, and I do not know anyone who does. The motivation of my pro-life colleagues is to prevent the killing of a pre-born child. We see the unborn as a person with the same rights as all people. There will always be the rogue outsider on both sides of any debate, but looking to report a physician or harass a patient is not the motivation of anyone I know. It is best not to assume intent and motives.

As a board-certified obstetrician/ gynecologist, I have two lives to care for: the mother and her baby. We must treat both lives with dignity and respect. If we cannot save both lives, we must do what we can to save one. Sometimes maternal conditions require early delivery. Some fetal anomalies are life-limiting. Comfort care and perinatal hospice are better than abortion. Abortion is not the cure.

I appreciate that Dr. Witlin and I can have different views on abortion and appreciate that Dr. Witlin took the time to express her views. The Dobbs decision was based on a legal interpretation of the Constitution, and there is no justification for assuming bias or wrong motives of those in our highest court. I believe that personhood begins at conception, that lethal anomalies and disabilities do not justify killing, and that abortion disproportionately harms women of color and their babies. If we treat both of our patients with the care and respect they deserve as human persons, then we will always do the right thing. I agree that abortion is not essential healthcare. It is not healthcare at all.

1. Supreme Court of the United States. Dobbs, States Health Office of the Mississippi Department of Health, et al, v. Jackson Women’s Health Organization et al. In: Supreme Court of the United States, editor. 19-13922022. p. 1, 38-39, 78-79.

2. Pearcey NR. Love Thy Body: Answering Hard Questions about Life and Sexuality. Baker Books; 2018:24-25.

3. Studnicki J. Late-Term Abortion and Medical Necessity: A Failure of Science. Health Serv Res Manag Epidemiol. Jan-Dec 2019;6:2333392819841781. doi:10.1177/2333392819841781

4. Kortsmit K, Mandel MG, Reeves JA, et al. Abortion Surveillance - United States, 2019. MMWR Surveill Summ. Nov 26 2021;70(9):1-29. doi:10.15585/mmwr.ss7009a1

5United States Census Bureau. Quick Facts. Accessed August 5, 2022. https://www.census. gov/quickfacts/fact/table/US/RHI725221

6. Hill C. Black lives matter — including those of unborn babies. The Washington Examiner. July 2. https://www.washingtonexaminer.com/opinion/opeds/black-lives-matter-including-those-of-unbornbabies. Accessed October 10, 2022

7. King A, Tolbert LV. Life at all Costs: An Anthology of Voices from 21st Century Black Prolife Leaders. Xlibris Corporation; 2012.

Return to Camelot

anthony l. KovatCh, mD

It was long overdue. Even as an in-law, or perhaps because I was an in-law whose role in the Lyons Family “dynasty” was often from the outsidelooking-in, I sensed a weakening of the glue adhering the generations together since the grand matriarch Mary Irene (a facsimile of the late Queen Elizabeth II with a rivaling sense of humor) passed away in 2018. No better time for an inaugural Lyons Family reunion than in the dog days of the summer of 2022. Aware that any reunion can morph into an awkward, contentious affair, I highly promoted the event and promised to report on it for posterity, but left the details to family members acknowledged for their skill and experience in planning such celebrations, ie, the womenfolk.

For my own selfish reasons, I was concerned that the generations comprising Mary and Jack Lyons’ grandchildren and great grandchildren would be strangers to each other as their 12 children left their own backyards in Pittsburgh seeking fortune and happiness in distant localities. I know that I was sensitized to this unintentional disintegration of family ties having witnessed it first hand with my mother’s large 13-child

Italian Bonacci family, whose members moved out of the little village of Treskow in Northeastern Pennsylvania to leave the anthracite coal mines and seek the American dream elsewhere in the mid 20th century.

“You are very blessed if your children stay and raise your grandchildren in the Steel City,” I told the parents in my practice. “They will be so happy (and I will be too) that you can bring them when necessary to the pediatrician’s office. I will be green with envy!”

So those who were able to sacrifice the weekend made the trek. My grandchildren Miles and Mary who live in Virginia arrived the day before the event and turned our house on its head with excitement. Being 7 ½ and 6 years old, they competed relentlessly for their grandparents’ attention. Exhausted, I bemoaned the rhetorical questions presented in the accusatory song from “Bye, Bye, Birdie,” criticizing the parenting skills of my own children: “Why can’t they be like we were--perfect in every way? What’s the matter with kids (and parents) today?!”

Before turning in for a good night of recuperative sleep before the reunion, we watched old videos of my own four offspring at various ages “doing their thing” under our “supervision.”

I was appalled as I witnessed full documentation of my ineptitude as a disciplinarian; the antics of my own children far outshadowed those of my grandchildren. I then recalled MY father’s tales to my relatives describing how my brother and I “destroyed” the old apartment we lived in before we moved to a house in the suburbs; Miles and Mary are pikers compared to their grandfather. As the old admonition goes: “The more things change, the more they remain the same.”

With this new perspective, I approached the reunion the following afternoon with great humility and apprehension about the validity of my remote memory! Furthermore, was it not this pediatrician who insisted on referring to this current generation of millennial parents as “Generation A”---awesome, amazing, awakened, aware, attached----because of their superior child-rearing skills compared to us baby boomers?

Somehow, I had it stuck in my aging, romanticizing mind that the reunion would be a return to a time in my life that might be referred to as “Camelot.” We remember Camelot as that mythical time and place in the 12th Century AD that featured the citadel of King Arthur and the noble Knights of the Round Table--- symbolizing an atmosphere of idyllic bravery and happiness, where goodness reigned supreme. In the context of my own family, Camelot embodied the wonder years of raising babies and innocent, frolicking little children and contentious but aspiring teenagers---all at the same time. Little did they know!

I later realized that my subconscious hidden agenda was to gain personal redemption for the years as a young professional when I was compelled by ambition and selfishness to “steal” (the term used by pediatrician/ poet William Carlos

Williams) quality time from my devoted wife and young children. I believe that I vicariously experienced his personal guilt by reading his memoirs and that reversed my misguided emphasis on reputation germane to the medical profession; I implicitly trusted the wisdom of Williams because he practiced in Rutherford, NJ---across the Passaic River from where I grew up in Clifton---and he also graduated from Penn (across the Delaware River in Philly).

Although the great grandchildren reluctantly engaged each other and posed for pictures together, I was surprised that most of them gravitated to the activities of us elders; Miles was preoccupied with proving to his uncles that he was a formidable opponent in chess. Mary stole the spotlight by crushing the adults in jenga, a sport I had never even heard of. However, some of the more astute individuals

reported hearing the laughter of matriarch Mary Irene among the adjacent grove of North Park trees; I suspect it was nervous laughter due to frustration on her part because, dining alfresco, there was no need for the activities she most enjoyed performing at parties: washing and drying the dishes!

As the family members were dispersing, I dwelt on the legacy into which I had been adopted 40 years hence and, even moreso, to the interview of the American press with first lady Jacqueline Kennedy following JFK’s untimely assassination in 1963. It was “Jackie” who first attached the term “Camelot” to the two years of the Kennedy presidency with its grandeur, glamor, and unrivaled idealism. That short epoch in time embodied qualities reminiscent of the romanticized Camelot of Arthur, Guinevere, and Lancelot: youth, fashion, charisma, legendary bravery. This sentiment of Jackie helped to dispel the national stigma surrounding the tragedies that beset America’s first family: the curse of the Kennedys.

I think that every human life is fraught with unforeseen danger and that all families have their intrinsic “curse,” whether it be destruction by their own or by outside hands, genetic maladies caused simply by “losing the coin toss” at conception, fame or fortune that is unable to be reconciled, or even spiritual desertion or unavoidable loneliness. A genetic neurological disorder affected 50 percent of the 12 children who survived childhood in the well-to-do Bonacci family and had repercussions for the families of all 12 offspring. How crucial and sustaining it is to cherish those

The Great Grandchildren---the offspring of Generation A---displaying varying degrees of enthusiasm for the reunion.

memories created in those times of happiness and freedom from want and anxiety that seem so rare---rather than at the reunion surrounding a funeral.

Historians have spilt much ink comparing the Kennedys to another American family immersed in fame and grief—the Hemingways. “We were, sort of, the other American family that had this horrible curse!” admitted nominated actress Mariel Hemingway, the granddaughter of iconic author Ernest Hemingway. The curse involved multigenerational mental illness and substance abuse, primarily alcoholism.

As a diffident, anxious collegiate, I had great reverence for Ernest Hemingway as an author and championed the theme that served as the underpinning of his celebrated fiction: Courage is grace under pressure. I wrote a thesis glorifying his huge body of work. I got an “A.” (too bad I managed only a “C’ in physical chemistry)

In recent years historical treatises (like the Ken Burns documentary series) have shed light on the brilliant author’s troubled life: the chaotic upbringing, his narcissistic personality, the four troubled marriages, his physician father’s violent suicide, his lifelong battle with depression culminating in his taking of his own life with the shot of a handgun to the head at the age of only 61. His untimely demise occurred shorty after he won the Nobel Prize for one of his most-cherished stories, “The Old Man and the Sea.” In retrospect, there were repeated foreshadowings of “Papa” Hemingway’s preoccupation with violent death in his fiction; it was reported that he once told star actress

and friend Ava Gardner, “I spend a hell of a lot of time killing animals and fish so I won’t kill myself.”

It is believed that a distant ancestor of the Bonacci family, Fibonacci (“son of Bonacci”), founder of the Fibonacci sequence, was considered to be “the most talented Western mathematician of the Middle Ages.” Both granddaughters of Ernest--Margaux and Mariel---were talented actresses and were famous. After her sister’s suicide, Mariel became a public spokeswoman for the ravages fraught by mental health disorders:

“I think we live in a world where creativity is defined by how much pain you go through, and that’s a misinterpretation of artistry… I think if my grandfather were around today, he would go, ‘Wow, I didn’t have to suffer.’”

Why? Hemingway! Like most things in medicine, it was multifactorial!

Ironically, Hemingway would later refer to the father who taught him how to hunt and fish, and who shielded him in part from the recriminations of his overbearing mother, as a “coward.”

He would not be alive to comment in later years when his youngest and only brother Leicester (also a writer) died of a self-inflicted gunshot wound nor when his sister Ursula died by intentional drug overdose---as did Margaux Hemingway, the daughter of his oldest son Jack (fondly nicknamed “Bumby”). Of the 8 members of Ernest’s nuclear family, 4 succumbed to suicide; although not a genetic disorder with a Mendelian mode of autosomal dominant inheritance (like Huntington’s Disease---the curse of the Bonacci family), suicide behaved like one in this relationship.

Perhaps, the premonition of a premature death is not acquired solely by what one witnesses during their lifetime, especially their childhood. Perhaps, the premonition is also inherent in our DNA. Regardless of the truth, I think it is incumbent on us to be proactive in the matter rather than fatalistic, as was “Papa” Hemingway:

“The world breaks everyone and afterward many are strong at the broken places. But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these you can be sure it will kill you too but there will be no special hurry.” ----from “A Farewell to Arms,” thought by some to be his greatest novel

It is improbable that Death thinks like the Army Corps of Engineers, whose motto is

“The Difficult We Do Immediately. The Impossible Takes a Little Longer!” However, it has occurred to me as a senior citizen that it is critical not to

Perspective

Emily is waiting at the graveyard with her loving relatives expecting to join them in the afterlife; the audience is made to believe that she will soon die in childbirth (she does not) and is awakened to the fact that every tick of the clock is truly Camelot:

“But, just for a moment now we’re all together. Mama, just for a moment we’re happy. Let’s look at one another.

I can’t. I can’t go on. It goes so fast. We don’t have time to look at one another. I didn’t realize. All that was going on in life, and we never noticed. Take me back – up the hill –to my grave.

procrastinate when it comes to warm, tender memory formation. It is time now for this writer to return to the inaugural Lyons Family reunion before tangential thinking takes me deeper into the darkness of the human condition.

A recent study published in the Journal of the American Medical Society (9/6/22) confirmed what practitioners already strongly suspected: there is a correlation between genetics and suicide attempts across the life span; this allows stratification of risk in order to focus more selectively on mediation. We must all be strong advocates for formal group education of mental health issues in the school systems, starting as early as the later elementary school years. Indeed, however, the prevention of psychological trauma needs to start in the cradle. Perhaps, the family reunion can be a periodic rededication to this global initiative (as well as to reversing climate change).

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)

It all boils down to appreciating the “small change”---the simplistic everyday memories that comprise the fabric of our earthly lives. Let us fondly remember Emily’s searing monologue at the conclusion of Thorton Wilder’s sentimental, existential play “Our Town.”

But first: Wait! One more look. Good-by, Good-by, world… Oh, earth, you’re too wonderful for anybody to realize you.

Do any human beings ever realize life while they live it? – every, every minute?”

The stage manager answers without emotion: “No. The saints and poets, maybe they do some.”

“Don’t let it be forgot, that once there was a spot, for one brief, shining moment that was known as Camelot.”

—closing lines from the song “Camelot” by Lerner and Loewe

The author wishes to acknowledge Dr Ned Ketyer for his editing of the original article published in the Pediablog.

Top Pharma’s Paradigm Shift

RoBeRt s. Whitman, mD

Many things never change! Our Earth continues to lean 23.5 degrees tilted on its axis toward the sun, creating our seasons. Professional sporting events recur annually on a specific schedule. Love, marriage, procreation, birth, developmental milestones as well as illness and death, follow a defined sequence throughout our lifetime. Of course, occasional variations will result, and changes will occur for a variety of unexpected reasons.

However, significant changes have occurred in many areas over the past decade including politics, finance, technology, design, and medicine. among the industries whose presentation has been most significantly modified is that of the top pharmaceutical companies worldwide. Those include companies located in the U.S. Here, they produce the largest number of advanced tested and approved effective therapies for an astronomical number of illnesses and diseases. Their Research and Development divisions are increasingly effective in producing a seemingly endless supply of medications for a wide range of diseases.

Paradigm shifts everywhere are the result of when the usual way of accomplishing something is replaced by a new and different method. That method is quantitative once the method is identified, measured, and understood.

Having engaged that premise, it has become evident that pharma companies have become very aggressive advertisers using television. Multiple channels in the U.S., and elsewhere are utilized by these companies to hawk their products to consumers.

Until recent years, there was a prescribed way that new pharmaceuticals were introduced. A representative from a pharmaceutical company would meet with the physician to introduce, present, and promote what was new.

In recent years, TV advertisement has become the method of choice. This provides an immediate, general, and wide-reaching exposure to millions of people. Pharma now recognizes that this type of advertising is the most immediate and impactful method to introduce and market all new medications.

Currently, the total advertising expenses to the top pharma companies in the U.S. exceeds more than $6.5 billion dollars annually. This is exclusive of the funds needed for scientists to develop, test, and submit to the FDA to allow its use. Apparently, there has been a paradigm shift in advertising from pharma companies, and they are increasing their revenue.

There are many costs associated to produce these advertisements in a slick, efficient manner. There are surveys, demographers, psychologists, marketing experts, writers, video and film experts, artists, actors, musicians, and editors, etc. Production costs and airtime costs are part of the process, too.

The choosing of the best times to put these advertisements on the air is essential. There must be careful consideration as to the target audience and when best to capture their attention. Day time audiences may include children, their caretakers, and retirees. Prime time presentation targets the 18–49 year-olds. Evening news and generally popular shows draw yet another large, diverse group.

Advertising costs related to time slots are very impactful. Prime time in the U.S., such as during the Super Bowl, could cost upwards of $100,000. More typically, a 60 second time slot is chosen to present a product (which seemingly is affordable considering how many we are bombarded with every day). Perhaps if pharma would reduce the expense and frequency of these annoying repetitions, patients would benefit greatly by a reduction in prescription pricing!

Interestingly, while practicing Internal Medicine for over forty years, these advertisements never sparked a conversation with a patient who viewed any of these commercials. Perhaps the warnings about drug interactions and frightening side effects scared them off from wanting to know more!

One further observation: new drug names are selected in an altogether alternate vernacular. Most are pronounced in three syllables that are likely chosen to provide attention because odd numbers are more effective in capturing visual interest. And, by frequently adding the last ten letters of the alphabet to new drug naming provides a most unique identity.

Thank you for your membership in the Allegheny County Medical Society

Aparna

Malcolm P. Berger, MD Neurology Oakmont Moon

Aparna Balichetty, MD Family Physician Schenley Park, PIttsburgh

David J. Levenson MD Nephrology

Red Leaves #1

Mark E. Thompson, MD Cardiologist Pileated Woodpecker

John Hyland, MD Radiation Oncologist Singing Canyon

Mark E. Thompson, MD Cardiologist Lunar Eclipse 2022

John Hyland, MD Radiation Oncologist Sanibel Sunrise Louis A. DiToppa, DO, FAAFP Family Practice Thunderbirds, Memorial Day Indy 500

Adam Tobias, MD Emergency Medicine Aspen Grove, Near Vail, Colorado

Alexanndra Kreps, MD Psychiatry Beautiful Evening in Pittsburgh

Balichetty, MD Family Physician North Park, Pittsburgh

JANUARY

MAY

Society News

American College of Surgeons – Southwestern Pennsylvania Chapter Resident Surgical Jeopardy

On Wednesday, November 9, the SWPA Chapter of the American College of Surgeons hosted a Resident Surgical Jeopardy 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 network, socialize, and compete in a hilariously fun game show and knowledge-based competition.

The Surgical Jeopardy welcomed medical students and residents from Allegheny Health Network, Conemaugh Health System, Drexel University, UPMC Mercy, and UPMC Presbyterian. After cocktails and dinner, the event

provided surgical residents the opportunity to compete in a game show to vie for the top prize of $500 in cash. Ari Reichstein, MD of Allegheny Health Network, and Program Committee Chair of the ACS-SWPA chapter, was the perfect game show host. UPMC Mercy: Renee Davis, DO, Hannah Medeck, MD, David Orozco, MD and Peter Zak, MD, ended the evening as the winners of Jeopardy and the $500 grand prize.

SWPA Chapter Members, Marc Brozovich, MD, Hiram Gonzalez-Ortiz, MD, and Harry Null, MD served as moderators and judges for the evening’s event.

The ACS-SWPA Chapter looks forward to hosting their Most Interesting Cases event in May, as well as new programming such as Debates & Dilemmas and Journal Club in 2023. Members will be notified by email with details of events. Members are asked to contact Eileen Taylor, chapter administrator by email to etaylor@ acms.org for questions regarding their member status. Physicians interested in joining the society may also contact Ms. Taylor or visit the ACS-SWPA website at https://acs-swpa.org/

Jeopardy Winners, UPMC Mercy: Renee Davis, DO, Hannah Medeck, MD, David Orozco, MD and Peter Zak, MD.

Winning Team from UPMC Mercy with Richard Fortunato, DO, FACS, Chapter President, Ari Reichstein, MD, Chapter Program Committee Chair, Hiram Gonzalez-Ortiz, MD, Chapter Member and Harry Null, MD, Chapter Member.

POS Meets December 1 Society News

November 3 Pittsburgh Ophthalmology Society Monthly Meeting Featuring Ann Shue, MD

The November 3 POS monthly meeting attracted a large crowd as they welcomed Ann Shue, MD, Clinical Assistant Professor, Ophthalmology; Clinical Assistant Professor, Pediatrics, Stanford Health Care, Stanford Medicine Children’s Health, Stanford, CA. Thank you to the following sponsors who supported the program, PNC Bank, Sight Sciences, Inc., Sun Ophthalmics and to Ian Conner, MD, PhD who invited Dr. Shue.

Dr. Shue presented two interesting lectures The World of Childhood Glau coma and Where Glaucoma, Pediatric Ophthalmology and Strabismus Meet. Both lectures stimulated an interesting discussion and conversation.

Bushra Usmani, MD Resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary by Dr. Shue.

The POS returns to the Rivers Casino ballroom on December 1st and welcomes Sunil Srivastava, MD, Fellowship Director, Vitreo-Retinal Fellowships, Cleveland Clinic Cole Eye Institute, Cleveland, OH. Thank you to Jared Knickelbein, MD, PhD for inviting Dr. Srivastava and to the following co-sponsors of the program: BioTissue, DORC, and Genentech.

Dr. Srivastava is both a Senior Achievement Award recipient from the American Academy of Ophthalmology and a Senior Honor Award from American Society of Retinal Specialists.

He has received multiple Cleveland Clinic Innovations Awards for his work in novel imaging analysis. Dr. Srivas tava has co-authored over 140 publica tions in peer-reviewed journals and has delivered over 200 lectures at national and international conferences. His cur rent interest includes the use of novel imaging in uveitis and retinal diseases, the development imaging outcome measures in uveitis and intraoperative imaging in vireo-retinal surgery.

Contact Nadine Popovich, administrator, to confirm the status of your membership, registration, or to inquire about an upcoming program. She can be reached by email: npopovich@acms. org or by phone: 412.321.5030 x110.

l to r: I. Conner, MD, PhD; A. Shue, MD (Guest Faculty); J. Swogger, MD; L. To, MD. M. Stafford, MD (President, POS); A. Williams, MD

Aloi, MD

The in-person event was held in the Babb Insurance Building, beginning at 6:00 pm with the popular Vendor Showcase. The Exhibitors in attendance included Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Corcept, Dexcom, VGo, Lilly, Novo Nordisk, Tandem Diabetes Care and Xeris.

Guests then commenced for dinner and a talk given by guest speaker Joseph Aloi, MD, Section Chief for Endocrinology and Metabolism, Wake Forest Baptist Health, Winston Salem, NC. He presented a program titled: Integrating Diabetes Technology with Inpatient Care.

Dr. Aloi is the current Chair of the American Diabetes Technology Interest Group at the American Diabetes Association. He is very involved with trials examining the continuous glucose monitors, inpatient glucose management software and is well published in this field. Dr. Aloi is an active investigator and is focused on bringing technology to help improve the care of persons with diabetes. He is a moderator for many national and international diabetes meetings and serves on the Carolinas Society of Endocrinology Board of Directors.

Planning for the 2022 Spring meeting will begin in January. Members will receive notification by email once plans are finalized. Information is also available on the GPDC website.

The Greater Pittsburgh Diabetes Club (GPDC) hosted their annual fall program, Tuesday, October 25th.

Joseph

2022 PAMED HOUSE OF DELEGATES–OVERVIEW

For the past two years the PAMED House of Delegates (HOD) was conducted via virtual assistance. With the easing of COVID restrictions, the 2022 HOD was a hybrid version. As it has been several years since the delegation met in Hershey, PAMED held an in-person meeting October 2122 in Hershey, with an option for virtual participation.

The PAMED technical and IT teams set out early to arrange for information to be readily available on-line. Beginning in May, PAMED prepared interactive capabilities on HOD 101 Basics, training, resolutions, reports, questions and discussions. The Speaker and Vice Speaker of

the House, Drs. John Pagan and Todd Hertzberg, provided video instructions on what to expect at the House, Parliamentary procedures, how reference committees will perform, how to do electronic voting, and even how to participate in the socials by virtual means. The PAMED team was well prepared for the House of Delegates and covered all areas of concern. We applaud PAMED, its staff and leadership for an excellent production. The week leading up to the House had dedicated virtual specialty section meetings for the Early Career Physicians Section, Women Physicians Section, Medical Students Section, International Medical Graduates

Section, and Resident and Fellows Section. The PAMPAC and PAMED Socials were held Friday evening, providing an opportunity for delegates to meet and greet in an easy setting and on-line.

Special thanks to all our ACMS delegates, in-person and virtual, for their time and engagement in the ACMS caucus and the PAMED committees. The goal is better physicians and a better medical community—we are grateful for your efforts.

Chairing the 2022 ACMS Delegation was Deborah Gentile, MD; and Vice Chair, Bruce A. MacLeod, MD; Delegation Secretary, Mark A. Goodman, MD.

ACMS DELEGATION: PHYSICIAN / RESIDENT / STUDENT DELEGATES

Weston F. Bettner, MD

Richard B. Hoffmaster, MD

Donald Bourne, MS Michael S. Hu, MD (R)

Coleen A. Carignan, MD

Brittany Chamberlain, MS

Douglas F. Clough, MD

William F. Coppula, MD

David J. Deitrick, DO

Amber R. Elway, DO

Micah A. Jacobs, MD

Keith T. Kanel, MD

Jan W. Madison, MD

Michael M. McDowell, MD (R)

Jeni Morrison, MS

Barbara A. Nightingale, MD

Abigail A. Palmer, DO (R)

Cynthia Pathmathasan, MD (R)

Joseph C. Paviglianiti, MD

Amjab Quabbani, MD (R)

Keerthana Samanthapudi, MS

Nadia A. Sundlass, MD

Adele L. Towers, MD

Rajiv R. Varma, MD

ALTERNATES

Vint R. Blackburn, MD

Patricia L. Dalby, MD

Lawrence R. John, MD

MD; (R) Resident; (S) Student

Marilyn R. Daroski, MD

Richard A. Fortunato, MD

Anthony L. Kovatch, MD

Alexander Yu, MD

Friday evening was HOD homecoming. Friends and colleagues from across the state gathered for food, fun and endless conversation. PAMPAC held a special gathering for its members; PAMED hosted a social for all. Again, special thanks to the PAMED staff for making these events so warm and welcoming. ACMS had its own gathering while our delegates arrived throughout the evening.

Physicians/Residents/Students had a great time at the Fire and Grain grill. ACMS welcomed visitors from Philadelphia County Medical Society, Mark Austerberry, Executive Director, and Lynn Lucas-Fehm, MD, candidate for vice president.

The House of Delegates was called to order on Saturday at 9:00 am by John Pagan, MD, Speaker of the House. Dr. Pagan gave an overview of the agenda and House procedures. Business of the House began cautiously as PAMED IT tested the in-person/virtual participation and feedback. It all worked nicely. Elections were held during the lunch break; some results are noted below. The afternoon portion went a little longer than anticipated, but most everyone was home in time to watch the Pittsburgh Penguins win over the Columbus Bluejackets (6 – 3)!

www.pamedsoc.org/HOD

To all our delegates, we cannot express enough our thanks for your time, patience and participation at the House of Delegates. You once again helped the Society set standards and goals for physicians of Pennsylvania and better health care for our communities. Your dedication is greatly appreciated.

Deborah Gentile, MD, Chair

Bruce A. MacLeod, MD, Vice Chair

Mark A. Goodman, MD, Secretary

Results of the PAMED elections are as follows: Elected for 2023:

F. Wilson Jackson, MD, 173rd PAMED President 2023

Lynn Lucas-Fehm, MD, JD, Vice President (Philadelphia)

ACMS congratulates our physicians:

Todd M. Hertzberg, MD, elected Speaker of the House 2023

David J. Deitrick, DO, elected to Judicial Council

Bruce A. MacLeod, MD, AMA Representative, re-elected

John P. Williams, MD, AMA Representative, re-elected

ACMS representatives currently serving on the PAMED Board of Trustees:

Amelia A. Paré, MD, At Large Trustee

John P. Williams, MD, Hospital Based Trustee

G. Alan Yeasted, MD, 13th District Trustee

For additional Information regarding the House of Delegates, elections and all the resolutions that were addressed at the 2022 HOD, please visit the PAMED website for updates

Tio learn more about the HOD overview and other topics at the ACMS Blog: ACMS Insights

Click here or scan the QR code.

2022

ACMS Blog HOD Overview

Evinacumab-dgnb (EvkeezaTM)

josePh RizKalla, PhaRmD alexanDRia tayloR, PhaRmD, BCPs

Background

Evinacumab-dgnb (EvkeezaTM) is an injectable, fully human monoclonal antibody recently approved in February 2021 as adjunct to other low-density lipoprotein (LDL) lowering agents to treat homozygous familial hypercholesterolemia (HoFH) in patients 12 years old or older.1 HoFH is a rare disease that affects approximately 1 in 300,000 people, causing high LDL levels and an increased risk of early atherosclerotic disease.2 Patients often require multiple treatment modalities including statin medications, nonstatin medications such as ezetimibe or lomitapide, or PCSK9 inhibitors sometimes with inadequate LDLlowering response.3 Evinacumab-dgnb is the first medication on the market to inhibit angiopoietin-like 3 (ANGPTL3). ANGPTL3 is part of the regulation pathway of lipid metabolism. By blocking ANGPTL3, there is enhanced clearance of very low-density lipoprotein which then reduces LDL levels independent of LDL receptors.4 This is particularly useful in patients with mutations in LDL receptors which can occur in up to 79 percent of familial hypercholesterolemia cases.5 Evinacumab-dgnb is dosed 15 mg/kg as IV infusion every 4 weeks.

Safety

Evinacumab-dgnb is contraindicated only in patients with a history of serious hypersensitivity reactions to the medication or any of the excipients as anaphylaxis has been reported with administration.1 The manufacturer does not make any recommendations for dose adjustments in patients who have renal or hepatic impairment. Patients with mild to moderate renal impairment had concentrations that were like patients with normal renal function.1 In phase 1 studies, evinacumab-dgnb led to an increase in liver enzymes compared to placebo, however, this did not lead to any treatment discontinuations or serious adverse events.6 In animal studies involving subcutaneous administration of evinacumab-dgnb, it was found to cause fetal malformations. As such, it is recommended for patients who could become pregnant to use appropriate contraception when taking evinacumab-dgnb and for the 5 months following the last treatment.1 The risks of birth defects or miscarriages are not known while taking this medication and any potential exposures by a pregnant patient should be reported to the manufacturer.

Tolerability

Evinacumab-dgnb is a relatively well-tolerated medication.1 Common adverse events that occurred more frequently in evinacumab-dgnb compared to placebo included nasopharyngitis (16 percent), influenza-like illness (7 percent), dizziness (6 percent), rhinorrhea (5 percent), nausea (5 percent), pain in extremity (4 percent), asthenia (4 percent), and anaphylaxis (1 percent).1 In a pooled analysis of two randomized, double-blind, placebo-controlled trials, only two patients required discontinuation of the medication due to adverse events out of a total of 81 patients.1 Only one of these discontinuations was deemed to be related to the medication. The reaction was an anaphylactic-like reaction with dizziness, chest pressure, and shortness of breath among other symptoms. During the infusion of evinacumab-dgnb, there were mild to moderate decreases in diastolic blood pressure and increases in heart rate, but these incidents resolved after the infusion had finished. Infusion site reactions were also noted such as pruritus, pyrexia, muscular weakness, nausea, and nasal congestion which occurred more frequently than placebo (7 percent vs. 4 percent respectively), but no statistical comparisons were done.1 If a patient develops any signs of adverse reactions during the infusion, it is recommended to slow, interrupt, or discontinue the infusion based on patient response.

Materia Medica

Efficacy

In a double-blind, placebo-controlled phase two trial, 272 patients with refractory hypercholesterolemia and an average BMI between 28 and 30 kg/ m2 were randomized to receive various weight-based doses of evinacumabdgnb or placebo to determine optimal treatment dose.7 The lowest leastsquares mean difference in LDL reduction between the different doses and placebo was -24.2 percent (95 percent CI -42.6 to -5.7) when a 5 mg/ kg IV dose was used for 16 weeks. When comparing a 15 mg/kg IV dose to placebo, the difference was more profound at an LDL reduction of 50.5 percent (95 percent CI -68.4 to -32.6).7 In a subsequent phase 3 randomized, placebo-controlled, parallel-group trial, evinacumab-dgnb was found to be highly efficacious. A total of 65 patients with an LDL of 70 mg/dL or greater were randomized to receive either evinacumab-dgnb 15 mg/kg or placebo for 24 weeks. To be enrolled in the trial, patients had to have a confirmed diagnosis of HoFH through genetic testing or a clinical diagnosis defined as an untreated LDL of 500 mg/dL or greater with either both parents having an untreated total cholesterol greater than 250 mg/dL or the presence xanthoma before 10 years of age. At the end of the trial period, the group taking evinacumab-dgnb had 47.1 percent decrease in LDL compared to a 1.9 percent increase in LDL in the placebo group resulting in a leastsquares mean difference of -49 percent (95 percent -65.0 to -33.1).2 This study also showed the potential triglyceride lowering effects of evinacumab-

dgnb as participants taking the trial medication had a decrease of 55 percent compared to only a decrease of 4.6 percent in the placebo group with a least-squares mean difference of -50.4 percent (95 percent CI -65.6 to -35.2).2 No published clinical trials have looked at the effect evinacumab-dgnb has on reducing atherosclerotic cardiovascular events or mortality in patients. The European Society of Cardiology and European Atherosclerosis Society Guidelines for the Management of Dyslipidemias mention evinacumab-dgnb as a potential lipid-lowering option under investigation, but do not list a place in therapy.8 There is currently no mention of this medication in North American Guidelines.

Price

The average wholesale price of EvkeezaTM is $5,625 per milliliter. It is available in a 345 milligram/2.3 milliliter vial or a 1200 milligram/8 milliliter vial thereby making the price $12,937.50 and $45,000 per vial respectively. Assuming a patient weight of 80 kg, the monthly cost for the medication would be $45,000 and the yearly cost would be $540,000. Regeneron, the manufacturer of evinacumab-dgnb offers two patient assistance programs, one program with benefits of up to $25,000 per year for patients who have private insurance, and another program for patients who are uninsured or have an annual gross household income that is less than 500 percent of the Federal Poverty Level.9

Simplicity

Evinacumab-dgnb is dosed as 15 mg/kg IV infusion every 4 weeks using the patient’s actual body weight. As such, this medication must be prepared in a sterile compounding hood using aseptic technique. The final prepared solution should be administered immediately after dilution but may be stored in a refrigerator for 24 hours or at room temperature for up to 6 hours. It is administered over 60 minutes through an IV line that contains a 0.2 to 5-micron filter. If a dose of medication is missed, the next dose should be administered as soon as possible, and the 4-week interval should be adjusted to account for the new infusion date.1 Evinacumab-dgnb is only indicated as adjunct therapy, therefore patients must also be taking other medications that lower LDL-C such as statins or PCSK9 inhibitors. The levels of statin medications and evinacumabdgnb were not altered when taken concomitantly. Evinacumab-dgnb levels were also not altered when patients were taking non-statin medications or PCSK9 inhibitors.1

Bottom-line

Evinacumab-dgnb is a safe and effective option to help lower LDL in patients with HoFH already taking other LDL lowering medications. Due to its novel mechanism of action, this medication may help refractory cases of HoFH achieve goal LDL levels who were otherwise unable to do so. Patients should be counseled on the increased risk of nasopharyngitis when starting this medication and the potential for anaphylaxis.

Materia Medica

From Page 23

Joseph Rizkalla, PharmD is a PGY1 Pharmacy Resident at UPMC St. Margaret and can be reached rizkallajs@upmc.edu.

Alexandria Taylor, PharmD, BCPS is a PGY2 Ambulatory Care Pharmacy Resident at UPMC St. Margaret and can be reached at tayloram9@upmc.edu.

Heather Sakely, PharmD, BCPS, BCGP, the Director of Geriatric Pharmacotherapy and Director of the PGY2 Geriatric Pharmacy Residency, served as editor and mentor for this work and can be reached at sakelyh@upmc.edu.

References:

1. EvkeezaTM (evinacumab) [prescribing information]. Tarrytown, NY: Regeneron Pharmaceuticals Inc; February 2021

2. Raal FJ, Rosenson RS, Reeskamp LF, Hovingh GK, Kastelein JJP, Rubba P, Ali S, Banerjee P, Chan KC, Gipe DA, Khilla N, Pordy R, Weinreich DM, Yancopoulos GD, Zhang Y, Gaudet D; ELIPSE HoFH Investigators. Evinacumab for Homozygous Familial Hypercholesterolemia. N Engl J Med. 2020 Aug 20;383(8):711-720.

3. Blom DJ, Cuchel M, Ager M, Phillips H. Target achievement and cardiovascular event rates with Lomitapide in homozygous Familial Hypercholesterolaemia. Orphanet J Rare Dis. 2018 Jun 20;13(1):96.

4. Adam RC, Mintah IJ, AlexaBraun CA, et al. Angiopoietin-like protein 3 governs LDL-cholesterol levels through endothelial lipasedependent VLDL clearance. J Lipid Res. 2020;61(9):1271-1286.

5. Henderson R, O’Kane M, McGilligan V, Watterson S. The genetics and screening of familial hypercholesterolaemia. J Biomed Sci. 2016 Apr 16;23:39.

6. Ahmad Z, Banerjee P, Hamon S, et al. Inhibition of AngiopoietinLike Protein 3 With a Monoclonal Antibody Reduces Triglycerides in Hypertriglyceridemia. Circulation. 2019;140(6):470-486.

7. Rosenson RS, Burgess LJ, Ebenbichler CF, Baum SJ, Stroes ESG, Ali S, Khilla N, Hamlin R, Pordy R, Dong Y, Son V, Gaudet D. Evinacumab in Patients with Refractory Hypercholesterolemia. N Engl J Med. 2020 Dec 10;383(24):2307-2319.

8. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020 Jan 1;41(1):111-188.

9. The Patient Support Program for EvkeezaTM. Regeneron. May 2021. Accessed October 11th, 2021. https:// www.evkeeza.com/patient-support

ALLEGENY COUNTY MEDICAL SOCIETY ALLIANCE Holiday Party

December 3, 2022 South Hills Country Club

Greetings!

This affair is presented for our members requesting a daytime event.

Accordingly, this affair is scheduled for 11:30 AM and will begin witha brief meet and greet period – followed by lunch.

Yes, we are anticipating entertainment at this event!

The planned menu will include: Harvest Salad with a ranch or balsamic dressing on the side, Chicken Cordon Bleu or Baked White fish, greenbean almondine, cheese tortellini in herb butter –and a sweet dessert.

Alliance members are receiving invitations—as well as ACMS Officers. Of course, ACMS mem bers (chauffer’s), are welcome !

Submitted: Barbara Wible, Co-Pres. ACMS Alliance

PS: Patty Barnett, Co-Pres. ACMS Alliance, invitations & entertainment

ALLEGHENY COUNTY MEDICAL SOCIETY—2022 -2023 MEETING SCHEDULE

ALL MEETINGS BEGIN AT 6:00 PM

Upcoming Events

December 3 – Mandated Report CME Training (in-person) | Babb Bldg. 9:30am – 1:00pm

Executive Committee*

Tuesday Evenings – 2nd Tuesday at the start of each new quarter.

January 10, 2023

April 11, 2023

July 11, 2023 October 10, 2023

Finance Committee Tuesday Evenings

January 24, 2023 April 25, 2023 August 29, 2023 November 14, 2023

Committees Dates to be announced

Delegation April, June, August, October

Nominating May, August

ACMS Foundation

PAMED BOARD

Board of Directors* Tuesday Evenings

December 6, 2022

February 2023 TBD May 9, 2023

September 12, 2023 December 5, 2023

March 14 – Planning Meeting/Special Grants June 20 – Prep for Grant Proposals October 24 – Grant Proposal Review

PAMED HOUSE OF DELEGATES / HERSHEY

May 4 October 27-28, 2023

August 3 October 26-27, 2024

AMA HOUSE OF DELEGATES

June 10-14 Chicago, IL

AMA Interim Meeting November 11-14 National Harbor, MD AMA Annual Meeting June 2024 Chicago, IL

ACMS HOLIDAYS – OFFICE CLOSED

January 2 – New Year’s Day (Monday) September 4 – Labor Day (Monday)

January 16 – Martin Luther King (Monday) November 10 – Veteran’s Day (Friday)

February 20 – President’s Day (Monday) November 23 – Thanksgiving Day (Thursday)

May 29 – Memorial Day (Monday) November 24 – Thanksgiving Friday (Friday)

June 19 – Juneteenth Day (Monday) December 25 – Christmas (Monday)

July 4 – Independence Day (Tuesday)

Legal Summary

The Basic Anatomy Of A Government Investigation and How Providers Can Be Proactive

Health care providers are increasingly facing criminal prosecution for fraud-related crimes. Providers should be prepared to navigate the treacherous waters of a government investigation. A lack of preparation or adequate response to a government investigation may expose a provider to incarceration, significant financial penalties and exclusion from federal, state, and other insurance programs. Accordingly, providers must understand the process of government investigations and take a pro-active approach to prepare for any potential investigation.

Most health care fraud charges relate to a provider making a false statement in order to induce reimbursement by a government benefits program such as Medicare or Tricare for a service that is not entitled to payment under Program rules. The most commonly prosecuted misstatements include: the medical necessity of a service; that the billing submission is not related to violations of Program rules such as the antikickback provisions; that the service was performed when, in fact, it was not; upcoding, etc. In general, these

prosecutions involve a substantial pattern of conduct and can implicate staggering loss amounts.

In order to obtain a conviction for health care fraud, the government must prove that the provider intended to mislead the benefits program through the false statement. Intent is usually the most difficult element for the government to prove. Testimony by alleged “co-conspirators” or former employees who know the provider’s practice and who hear the provider’s conversations are the most common and compelling evidence in these cases. A provider’s most trusted employees can accordingly become essential witnesses in a health care fraud prosecution.

A government investigation can be sparked in different ways. A competitor, disgruntled employee or patient might contact law enforcement. An unusual pattern in billing submissions can alert the benefit administrator to misconduct, or a cooperating witness to a separate investigation might provide information as part of their assistance to law enforcement. Regardless of how it commences, once the government receives information about a

possible violation of law, a full-blown investigation can be commenced that might lead to a criminal prosecution and/or a potentially costly civil lawsuit under the False Claims Act.

Once a federal investigation has been initiated, agents are assigned to investigate. These agents may come from different government agencies such as the Federal Bureau of Investigation (FBI), the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Centers for Medicare & Medicaid Services (CMS), Drug Enforcement Administration (DEA), Defense Criminal Investigative Service (DCIS), Federal Deposit Insurance Corporation Office of the Inspector General (FDIC-OIG), Internal Revenue Service (IRS) or another agency. These agencies often coordinate their efforts.

A provider will most often learn that he or she is under investigation when his or her employee advises that agents approached them after hours asking questions about the provider’s practice. This surprise approach is designed to obtain as much information as possible from a nervous and

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Legal Summary

off-guard witness. If the employee is not properly prepared, they will be intimidated and agree to talk to the agents without understanding that t hey are not legally required to do so and might, in fact, be also incriminating themselves.

Providers should take some control of the investigation

There are ways that a provider can protect themselves and their practices prior to the commencement of any investigation. The first and most important step is for providers to seek the advice of attorneys with experience in government investigations to prevent any unintentional missteps and to avoid any perception by the government that they are attempting to obstruct justice or tamper with potential witnesses. Below are four key events that require a plan of action by providers and their employees:

1. Government approaches a provider’s employee: Employees should be trained in the normal course of business on how to respond if government agents approach them inquiring about the provider’s practice. Employees should be informed about their rights and given guidance as to their options. An employee has a right to speak to a government agent if he or she knowingly and willingly chooses to do so. An employee also has a right to decline to speak to an agent. For instance, if agents approach an employee, and the employee willingly chooses not to speak with the agent, the employee can decline and politely ask for the agents’

business card. The employee can also tell the agent that an attorney will call them as soon as possible. The employee should notify the provider about the encounter and the provider should immediately contact an attorney who has experience in government prosecutions.

Some agencies have a right to access a provider’s books and records and can demand to inspect those items on the spot. Having access to the records does not mean that the employees must agree to be interviewed, however. Employees should receive proactive guidance related to how the office should proceed under such circumstances. This will alleviate the employee’s anxieties and provide them with a proper plan of action that might avoid unwanted disclosures.

2. Search Warrants: A search warrant is a document signed by a judge after determining that there is probable cause to believe that a crime was committed, and that evidence of such crime is located at a target location. It allows the government to enter and search the target location without permission by the owner/lessor to look for and seize the evidence of the enunciated crime during specific times and dates. The execution of a search warrant can be frightening. Usually, a search warrant squad descends on a practice with no advanced warning carrying badges, guns, and bullet proof vests. This surprise tactic is designed to prevent destruction of evidence by the provider, to secure the target

location, and to intimidate. Such an event can cause tremendous disruption in the workplace and rattle employees and patients. Employees should be informed in advance as to what a search warrant is, what the government might do while executing a search warrant, and the employees’ roles and rights during such an occurrence. Additionally, the office should have a plan in place that designates an employee to act as a point person upon the execution of a search warrant. That employee should be given guidance about the steps that should be taken, including:

a. Accepting the search warrant and reviewing it to make sure all pages are included;

b. Immediately notifying the provider and the practice’s attorney and sending each a copy of the warrant;

c. Reading the warrant carefully to make sure that the search takes place in the location and at the times authorized in the warrant and that the items seized are those also specifically authorized in the warrant.

d. Asking the agents to wait until the provider’s attorney is called but if the agents refuse, the employee should not do anything that is perceived to obstruct the search.

Execution of search warrants are chaotic and frightening. A full explanation of how the government conducts search warrants and a plan

Legal Summary

of action for the employees will turn a chaotic situation into one where the provider and employees will feel more in control.

3. Subpoenas: A subpoena is a court document ordering the recipient to appear in court or before a grand jury to testify. A subpoena duces tecum is a court document ordering the recipient to produce specified documents to the Grand Jury or at trial. At times, a subpoena orders both the production of specified documents and the attendance at a court or grand jury proceeding. When being served with a subpoena, an employee should immediately provide the subpoena to the provider who should in turn immediately contact their attorney to plan a response. There are multiple basis to object to subpoenas that are drafted poorly, including over-breadth and/ or vagueness. Additionally, certain documents can be withheld from production, including those protected by the

attorney-client privilege. All of this must be explored with an attorney.

4.Civil Investigative Demand (“CID”): A CID is an administrative subpoena issued by a government agency, such as the U.S. Department of Health and Human Services Office of Inspector General, demanding the provider to produce certain documents. The government issues CIDs when investigating a civil matter and before a civil complaint is filed. Although an investigation may start as a civil matter, it can turn into a criminal case. Therefore, receipt of a CID should be taken seriously and responded to carefully.

Navigating a government investigation is very complex and full of potential traps. Most health care providers and their employees have had no prior contact with criminal investigators. They also believe they have done nothing wrong and have nothing to hide. Without proper preparation, they often hand the government key evidence that can

result in a criminal prosecution and conviction. Likewise, inadequate preparation with knowledgeable counsel may cause a provider and his or her employees to take actions that could subject them to additional charges such as making false statements, tampering with witnesses and/or obstruction of justice. Providers are thus exposed to staggering financial liability, exclusion from practice and federal programs and decades of incarceration when ill-prepared. Because of the potentially dire consequences inherent in a government investigation, providers and their employees should be prepared to respond to a government investigation properly and under the guidance of a qualified attorney.

DISCLAIMER: This article is for information only and should not be considered legal advice. To obtain legal advice on this matter, please contact an attorney experienced in this area of law.

Lourdes Sanchez Ridge is a partner and co-Practice Group Leader of the Government Enforcement, Compliance, & White-Collar Litigation Group at Pietragallo Gordon Alfano Bosick & Raspanti LLP. She is licensed in Pennsylvania, Washington, D.C. and Florida. Tama Kudman is also a partner at Pietragallo Gordon Alfano Bosick & Raspanti LLP and a Practice Group Leader of the Florida Government Enforcement, Compliance, & White-Collar Litigation Group. She is licensed to practice law in Florida. Their bio can be found at https://www.pietragallo.com/lawyers

PA 15212

2021-2022 ACMS Foundation Impact

Angels’ Place, Inc.

Beverly’s Birthdays

Blind & Vision Rehabilitation Services of Pittsburgh

Blood Science Foundation

Catholic Charities Free Health Care Center

Church Union

Community Partners in Asthma Care

Faith United Methodist Church

Family House

Family Medicine Education Consortium

Footbridge for Families

Jeremiah’s Place

Strong Women, Strong Girls

The Children’s Home and Lemieux Family Center

The Ronald McDonald House Charities

The Samaritan Counseling Center of Western PA

Abiding Missions

Angels’ Place, Inc.

Beverly’s Birthdays

Blind & Vision Rehabilitation Services of Pittsburgh

Family House

Footbridge for Families

Homeless Children’s Education Fund

Jeremiah’s Place

Light of Life Ministries, Inc.

North Hills Affordable Housing HEARTH

Roots of Faith Faith United Methodist Church

Storehouse for Teachers The Education Partnership

Strong Women, Strong Girls

The Ronald McDonald House Charities

The Samaritan Counseling Center of Western PA

United Methodist Church Union

MISSION

Founded in 1960, the Allegheny County Medical Society Foundation has extended the reach of physicians into the community through grant giving to local organizations.

The mission of the Foundation is: A Advancing Wellness by confronting Social Determinants and Health Disparities This mission works to fulfill an overall vision of a healthy and safe Allegheny County.

Throughout the ups and downs of the past few years, the Foundation’s work has become even more important in supporting local non profit organizations.

The desire to give back to the community is an inherent trait of those who become physicians. In past year ’s the ACMS has hosted an annual gala to help raise funds to support the Foundation. Due to COVID 19, just like many other organizations, the ACMS had to forego the in person gathering. While we look forward to hosting a Foundation fundraising event in the near future, the work of the Foundation continues on. Please consider how you can personally help support the Foundation and, in turn, continue to support a healthy region.

Contact the ACMS team to learn more about how your organization can help support the ACMS Foundation.

As physicians, you know that it takes a village to keep the community healthy and safe. As we approach the holiday season and you are considering ways to give back, please consider a donation to the Allegheny County Medical Society Foundation.

Your donation will help the Foundation fund local non profits in future grant cycles, and will help further the mission of the ACMS Foundation.

Donations can be mailed to: ACMS Foundation 850 Ridge Avenue Pittsburgh, PA 15212

Scan this QR Code to Donate via Qgiv:

2022 Washington and Jefferson College Alumni Award Given

Marcela Böhm-Vélez, M.D., FACR, FSRU, FAIUM was honored as the 2022 Washington and Jefferson College Alumni Award for Achievement recipient Saturday, October 1, 2022.

Dr. Marcela Böhm-Vélez is a radiologist and the President of Weinstein Imaging Associates, a private practice dedicated to Women’s Imaging with three offices in Pittsburgh, Pennsylvania. She graduated from Washington & Jefferson College (W&J) with a dual major in Pre-Med and Chemistry in 1975, and was a member of the 2nd graduating class of women at W&J..

Her mother, Dr. Delia E. Böhm, was one of the first women professors at W&J, and more recently, her daughter

Carolina Vélez co-developed and taught a course in the Conflict & Resolution Concentration at the College, with Professor Easton. Dr. Böhm-Vélez’s areas of expertise include breast imaging, gynecological, obstetrical, interventional, and vascular ultrasound. She has organized seminars and lectured extensively at national and international conferences. She was co-editor of a foundational text on what has become a mainstay pelvic imaging technique, known as “Transvaginal Ultrasound,” published several chapters, and numerous scientific papers used as reference materials in current medical practice.

She has been an active participant in the ultrasound and mammography accreditation process for the American College of Radiology (ACR), co-writer of the Breast Ultrasound section of the BI-RADS® Atlas 5th Edition and involved in multiple research projects.

Dr. Böhm-Vélez holds a position as Adjunct Professor of Radiology at the University of Pittsburgh, is a Diplomate of the American Board of Radiology, and a Fellow of the ACR, Society of Radiologists in Ultrasound (SRU), and of the American Institute of Ultrasound in Medicine. She is an active member of the ACR (member of the Fellowship Committee), SRU, Pennsylvania Radiological Society (PRS) committees chairing the Breast Imaging Committee and serving as President of the PRS, and on the Board for the International Society of Densitometry.

She was the Honored Radiologist for the PRS in 2014 and delivered the 2021 PRS Gold Medallion Honored Lecture 2021.

For the past six years, she has been on the Board of WQED and during the pandemic served on the Community Emergency Response Fund Committee for the Latino Community Center.

She believes her most significant accomplishments are personal. Her successful 41-year marriage with Rafael I. Vélez, M.D., a graduate from Hahnemann Medical School and practicing anesthesiologist, and their three children (Nicole, a Mohs surgeon in Pittsburgh, Carolina, a lawyer who works for Microsoft as an Executive Engagement

Lead, and Andres the Chief Operating Officer for Octane), and their four healthy grandchildren.

Dr. Marcela Böhm-Vélez with President of Washington and Jefferson College, Dr. Knapp.

Editorial Editorial

adjacent lumbar vertebra, explaining her pain. My resident, from Georgia, upon seeing the findings said, in his deep southern drawl, “Fellahs, there’s a lesson here. Crocks daah (die), too.” Unfortunately for the patient, CT scanning and ultrasound exams had not been developed. The important lesson is that for most patients with a diagnosis of psychosomatic illness, the symptoms are real, and in fact a small number of these patients indeed have real abnormalities accounting for their symptoms.

Sigmund Freud’s view of humor was that it was a conscious expression of thoughts that society usually suppressed or was forbidden.2 As long as the humor, in this case name-

calling, is meant in a benign fashion, it is considered harmless.

However, in today’s politically divisive atmosphere, it is best to use humor only when you truly know your audience. As a good example, I remember the not so “good old days,” when it was expected that a speaker at a conference or a refresher course would tell jokes. Many of the “old timers” were very colorful characters. Today, fortunately, speakers are business-like and jokes are tacitly forbidden, since they are bound to offend someone. Finally, we should always remember that no matter how unpleasant some of our patients are to us, they are still our fellow human beings.

Dr. Daffner, associate editor of the ACMS Bulletin, is a retired radiologist who practiced at Allegheny General Hospital for more than 30 years. He is emeritus clinical professor of Radiology at Temple University School of Medicine and is the author of nine textbooks. He can be reached at bulletin@acms.org.

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

References

1. Shem S. The House of God. Richard Marek Publishers 1978.

2. Freud S, (Strachey J, Trans.). Jokes and their relation to the unconscious New York: W. W. Norton, 1960 (Original work published 1905).

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Contact Ruby Marcocelli, Vice President at 412-788-8007 or rmarcocelli@fennercorp.com

Three Penn Center West Pittsburgh, PA 15276 fennercorp.com

Thank you for your membership in the Allegheny County Medical Society

The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.

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