ACMS Bulletin - September 2022

Neurosurgical expertise for patients.

Matthew Shepard, MD

Neurosurgeon

Locations: AHN Neurosurgery — Allegheny General Hospital St. Clair Hospital

Specialties : Removal of cancerous and benign tumors of the brain, skull, and spine

Neuro-oncologic procedures such as Gamma Knife radiosurgery, awake craniotomies and laser interstitial thermotherapy

Corrective surgery for Chiari malformation, stenosis, herniated disks, radiculopathy, and myelopathy

Opinion Departments

Editorial

• Swinging for the Fences Deval (Reshma) Paranjpe, MD, MBA, FACS

Associate Editorial

• It’s even more complicated

Andrea G. Witlin, DO, PhD

Editorial

• Boo the Ref; Kill the Ump.

Richard H. Daffner, MD, FACR

Perspective

• Physicians (and others) as Collateral Damage in Today’s Political Wars

Bruce L. Wilder, MD MPH JD

Perspective

• Healthcare for Immigrants: The Visiting Nurse Service of Pittsburgh’s Irene Kaufmann Settlement

Corey Schultz

Perspective

• Braving Through the Transitions

Anthony L Kovatch, M.D.

Society News

• Pittsburgh Ophthalmology Society Announces 2022-2023 Monthly and Annual Meetings Dates

Society News .........................24

• Pittsburgh Ophthalmology Society welcomes Sandra F. Sieminski, MD

Society News

• Greater Pittsburgh Diabetes Club set to host Fall Program

2022 ACMS Meeting and Activity Schedule......................7

Articles

Legal Summary

• Breaking Free: How to Opt Out of Medicare (and Other Payors) William H. Maruca, Esquire

Nomination Report

Putting Self-care into Health care .............................34

Robert Cicco, MD

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 B. Madison Raymond J. Pan

PEER REVIEW BOARD

2022

Niravkumar Barot

Kimberly A. Hennon

2023

Lauren C. Rossman

Angela M. Stupi

2024

Marilyn Daroski

David J. Levenson

PAMED DISTRICT TRUSTEE

G. Alan Yeasted

COMMITTEES

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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Swinging for the Fences

Deval (Reshma) PaRanjPe, mD, mBa, FaCs

September and October are months forever associated with returning to school for most of us. The slow cooling of the earth and the crispness in the air conjure up memories of school supplies, book reports, lockers clanging, and seeing how your friends changed over the summer. Suddenly, it’s time to buckle down and get serious about studies and work. New subjects, new projects, and new tests await.

The advent of autumn—the reminder of change and season of sobriety-brings both excitement and anxiety for many people. During school each autumn meant you were one year older, and expected to be one year wiser, one year better. But were you really? You couldn’t really tell by looking at yourself—not really-- so you looked at your friends and classmates to see what they had become, and if you were keeping pace.

My friends who have children mark the passage of time by their offspring’s milestones. Grace is born, Grace is 5 and comes up to here. Now she is in grade school. Now she is in braces. Now she is in high school, and suddenly Grace, who was a toddler last week, is learning to drive. Now she is going to prom, and college, and grad school, and now married, and having a Grace or two of her own. “We don’t feel old, but we must be old, because Grace is in grad

school now.” I mark the passage of time by their children too, of course, but it’s more startling for me because I see their children in flashes, years apart. The changes are tremendous.

My friends who have no children all have a sort of solidarity. We are by all accounts grown-up, mature and responsible members of society but we are also eternally children ourselves. We have no frame of reference.

So what’s a good benchmark? I recently had the good fortune to attend our Pittsburgh Symphony’s stunning opening night concert. Joshua Bell, our country’s foremost violinist, played the Tchaikovsky Violin Concerto. If you’ve never heard Joshua Bell’s performances, I urge you to listen to his albums and better yet see him in concert at any opportunity you may have. His performances are breathtaking in their technique, passion and delicacy. If you’ve never heard the Tchaikovsky Violin Concerto, it is a beloved and sweeping romantic piece imbued with a whirlwind breadth of emotions and plenty of opportunities for virtuoso showmanship . So this was the trifecta: an incomparable artist playing one of the most beautiful pieces of music ever written on an exquisite Stradivarius.

I’ve heard Joshua Bell play this piece three times ten years apart. The very first time was nearly twenty years ago during my fellowship in Minneapolis. I had become friends with a Minnesota Orchestra violinist who lived in my apartment building, which was practically across the street from Orchestra Hall. He urged me to go to this concert, but hadn’t a ticket he could give me. The obstacles were many: I was on call that Saturday and the concert was sure to be a sell-out. The lady at the box office told me there was only one ticket remaining, but it was a princely $100 and I was on a fellow’s meager salary in 2003. She urged me to take it, and hinted that the seat would be well worth the price. My co-fellow kindly covered my call for three hours, and I splurged on the ticket.

When I arrived at the concert hall, I could scarcely believe my luck. “I will remember this all my life” was the only thought in my dazed brain as I took my seat—and I have. The seat was front row center, about five feet directly in front of Joshua Bell and his magnificent violin. The concert was practically a personal serenade. I was in heaven. That night I also learned the value of splurging on experiences like this---even if alone--I was walking on air for weeks

while slogging through clinic with the music constantly in my head.

It occurred to me as I watched Josh Bell on stage this third time (again on call, again my partner kindly covering) that I was marking the passage of time through his performance of the Tchaikovsky Violin Concerto. I’ve heard him play it when he was 36, then 46, now 54. I must add that the man does not age; this may, like his talent, also be a God-given gift. (Or—much less likely-he is hiding a painting in his attic.) The first time he played it, his performance was flawless. I remember thinking that he took himself so seriously. He played with technical brilliance and restrained passion; his handsome face was set grimly in determination. He was delivering everything expected of a world-class artist, but he seemed self-conscious.

The second time I saw him play this piece was at Heinz Hall about 10 years ago. He still took himself quite seriously, but now there was an element of drama in his performance. His features softened, and his thick mop of brown hair flopped about a bit in the throes of playing. He had moved beyond

technical perfection; he began to take some liberties with his interpretation, and the piece was all the better for it.

This time, gentle reader, Joshua Bell swung for the fences. Face completely elastic, interpreting the music just as well as his violin. Hair frenzied and clearly the last thing on his mind. Collared shirt ditched for a dark Nehru jacket to conceal the sweat of a passionate performance under stage lights. And the music! This time, his interpretation had humor as well as pathos, delicacy as well as passion. He coaxed his violin into doing things I’d never heard before, things I didn’t know anyone was capable of doing. He was having fun, and had lost all of his past self-consciousness. This concerto is well known for tugging at your heartstrings; this time I laughed as well as cried. Josh Bell showed the audience every facet of Tchaikovsky’s glittering diamond. “This,” I thought, “is what mature genius sounds like. This….is true mastery, and I’ve been lucky enough to see his evolution to this point.”

After the concert, when by some miracle I met him and blurted out that I’d seen him play this piece thrice in twenty years, Joshua Bell laughed and wryly

pointed out: “You know, I DO play other things.”

We as physicians and surgeons also go through an evolution of sorts over time. We aim for technical perfection in our early career and take ourselves very seriously. We start to relax and explore the range of our abilities as the years progress. And in the prime of our career, if we get to the point where we are relaxed, confident and practiced enough that we know ourselves well, express ourselves fully and have fun with our work---swing for the fences---that must be mastery.

The audience (myself included) gave Joshua Bell a standing ovation after the first movement. This is a faux pas in the music world; one is meant to applaud only at the end. But Pittsburgh, a town already famous for its standing ovations, is renowned for this faux pas and the musicians chuckle and tolerate it appreciatively. Pittsburghers, in true salt of the earth fashion, know brilliance when they see it, and know that life is too short not to be effusive with praise.

Think of your own evolution, let go, have fun, see the humor in life, and be effusive with your praise as the season of being serious descends upon us. Swing for the fences, my friends.

Editorial

2022 ACMS Meeting & Activity Schedule

By Committee

House of Delegates

ACMS Foundation Board

Peter Ellis, MD, Chair

Finance Committee

Keith T. Kanel, MD, Chair

October 21-23

October 25

November 15

MPHC (Management Professionals in November 16 Health Care) at the Westin Convention Full Day Conference Center Downtown

Board of Directors

Patricia L. Bononi, MD, Chair

December 6

Meetings begin at 6:00PM. If you are interested in attending any of the meetings, please contact Melanie Mayer at mmayer@acms.org.

It’s even more complicated

How “Dobbs”(1) has upended health care for ALL women

anDRea G. Witlin, DO, PhD

Several years ago, I authored an article for this journal concerning “elective” abortion entitled “It’s complicated”. I never imagined that just 3 short years later, “Roe” would be invalidated and the specialty that I loved would be endangered. For the first time since my “forced” retirement (secondary to my numerous medical issues), I am thankful that I am no longer practicing Maternal Fetal Medicine (MFM)

Furthermore, I am grateful that I no longer live or practice in ground zero – Texas.

I never performed “elective” abortions. But I never had any qualms about participating in “terminations” related to maternal medical complications of pregnancy, fetal anomalies, or any combinations thereof. That said, I never had any issues with colleagues performing truly elective abortions, women who choose to terminate their pregnancy “just because”, or any combination or technique prior to fetal viability.

The notion of practicing obstetrics with a vigilante on one shoulder and a prosecutor looking over the other is abhorrent. The ever present fear of criminal prosecution is unconscionable. I never feared malpractice claims assuming I practiced according to the standard of care. Unfortunately, that standard of care is now tenuous. It’s

no longer written by experts in the field based upon medical research. It’s been upended by 5 or 6 supreme court justices(1) championed by their personal religious views. I’m not criticizing their personal beliefs. But I don’t believe that their personal beliefs should apply to the nuanced practice of medicine any more than mine should.

MFM is a challenging yet rewarding specialty. Life and death decisions must be made in a heartbeat. Consultations are long and complicated. There is no black and white, only infinite shades of grey. Nevertheless, I flourished in its stressful milieu. I’m constantly asked years after my forced retirement if I miss it. I always answered – YES… until now.

My practice included counseling for prenatal diagnosis and the potential need for pregnancy termination, selective reduction for higher order multifetal pregnancies, “indicated” termination for lethal fetal anomalies, and early delivery for those women with medical complications… to name a few. I counseled all of my patients alike, including those that I knew were deeply religious and would never accept those choices. I respected their decisions and they respected my counseling. I never worried about criminal prosecution. I even recall chatting with the local priest about

3 cases of anencephaly I had just admitted for termination.

Let’s fast forward to the current conundrum. The “abortion debate” and associated statistics are tainted by potentially confusing obstetric terms and definitions. Various naturally occurring and/or medical complications of pregnancy have the word, abortion, in their proper medical name. Other times, the term “abortion” is used to refer to medically indicated early delivery by either induction of labor or cesarean delivery. Women suffering early pregnancy loss may be tainted by association with elective abortion and thus have their necessary and potentially life-saving care jeopardized. Below are some definitions and examples.

• Spontaneous abortion otherwise known as miscarriage. Associated with onset of spotting, various amounts of bleeding including hemorrhage which continues until “products of conception” are removed from the uterus.

• Missed abortion refers to the “death” of the embryo/fetus without an attempt at natural passage of the products of conception.

• Induced abortion refers to voluntary termination and removal of a potentially viable gestation.

• Ectopic pregnancy occurs when a fertilized egg implants and grows outside of the uterine cavity. Such a pregnancy is not viable and must be treated either medically (with methotrexate) or via surgical removal.

According to the CDC slightly more than 620,000 legal induced abortions were reported in 2019.(2) The Guttmacher Institute states that 25% of women will have an abortion by the end of their childbearing years.(3)

Truly “elective” first trimester abortions have garnered the most attention. I won’t quarrel with the private reasons why a woman (or couple) chooses a first trimester elective termination. The ethical debate encompassing elective abortions and when life begins can be entrusted to a sociology, philosophy, or religion class. Underprivileged women and women of color seeking early elective abortions are most predominantly affected by the recent “Dobbs” decision. Women with means can travel to “safe” states or countries. That said, the consideration to fine or prosecute these women, their surrogates or docs is beyond abhorrent to me. Even though I didn’t perform elective abortions, I strongly believe that right shouldn’t be infringed upon. This leads me to a pet peeve, i.e., the lay pro-abortion press and even ACOG portraying these elective abortions as “Essential Health Care” for women.(4) I’m guessing that this can be a “turnoff” for others, i.e., those who would

never consider abortion personally, but understand why prohibition is not the best alternative. I believe that this singular focus detracts from those “other”, non-elective categories mentioned above that affect upwards of 30% of all pregnancies. In so doing, the chilling effect that this new Supreme Court ruling will have on all obstetric and medical care heretofore is discounted.

Methods of pregnancy termination are dependent upon the gestational age of the fetus and the operator skill. Medication abortion (up to 70 days of gestation) includes a combination of mifepristone (a selective progesterone receptor modulator) and misoprostol (a prostaglandin E1 analogue that causes cervical softening and uterine contractions).(5) Second-trimester abortion can be either surgical (D&E) or medical.(6) There are diminishing numbers of skilled providers for midtrimester surgical terminations which presents an issue for training of future OBG residents and corresponding certification of OBG residency programs. Similarly, programs in states with strict abortions restrictions may have difficulty recruiting residents and subsequent graduates for practice opportunities.

Personally, I take issue with referring to indicated medical terminations as abortions. I assume (without proof) that when “pro-life” advocates refer to late term abortions, they are referring to medically or obstetrically indicated deliveries during the late second or third trimester of pregnancy. Examples include but are not limited to lethal and severe fetal anomalies, maternal and/ or fetal infection, severe preeclampsia, HELLP syndrome, placental abruption,

maternal heart disease, or maternal malignancy requiring emergent therapy.

Non-obstetric related issues that potentially place the patient and her physician in jeopardy include genetic counseling and perinatal testing, IVF and related assisted reproductive technologies, and contraception (especially IUDs and the morning after pill).

For those non-OBG practitioners that think they’re safe from Dobbs or the Texas style vigilantes, think again. Oncologists may have the greatest conundrum. Therapeutic choices for new onset malignancy during pregnancy has always been difficult at best and dependent upon the gestational age at diagnosis. First trimester abortion or early third trimester delivery followed by aggressive therapies (chemo, radiation or surgery) are common. Granted there have always been women who decline treatment until the natural end of gestation. But you can bet there is a vigilante lurking in the wings who will be anxious to report you or harass your patient.

Medical disorders during pregnancy that require treatment with teratogenic drugs have been a longstanding conundrum for practitioners and their patients. The proliferation of new biologic agents to treat autoimmune rheumatologic, GI, or neurologic diseases add a new trepidation. Confounding the issue are those drugs, e.g., methotrexate and misoprostol used for rheumatologic or GI diseases but are now identified as abortifacients and thus blacklisted. Pharmacists may refuse to fill those prescriptions in

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reproductive age women for nefarious reasons and thus endanger the care of those women.

Burnout, early retirement, recruitment and retention of physicians have been mounting issues for years. Add to that list the latest potential for criminal penalties and associated escalating malpractice risks for docs. Think twice when you think this new ruling(1) is someone else’s problem.

References:

1. Supreme Court of the United States. Dobbs, State Health Officer of the Mississippi Department of Health, et al. v. Jackson Women’s Health Organization et al., No. 19-1391. Accessed August 15, 2022. https://www.supremecourt.gov/ opinions/21pdf/19-1392_6j37.pdf.

2. Center for Disease Control and Prevention. Available at https:/ www.cdc.gov/https://www.cdc. gov/reproductivehealth/data_ stats/. Accessed August 15, 2022.

3. Guttmacher Institute. United States Abortion. Accessed August 15, 2022.

4. American College of Obstetricians and Gynecologists. Abortion is essential health care. Accessed August 15, 2022. https://www.acog.org/advocacy/ abortion-is-essential

5. Medication abortion up to 70 days of gestation. ACOG Practice Bulletin No. 225. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;136:e31-47.

6. Second-Trimester Abortion. ACOG Practice Bulletin No. 135.

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Both are in excellent condition, low usage, price negotiable.

Call or text 412-716-3164 for details or demo.

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.

“Boo the Ref; Kill the Ump”

RiChaRD h. DaFFneR, mD, FaCR

Apoliceman’s lot is not a happy one”

Sirs William S. Gilbert and Arthur Sullivan

The Pirates of Penzance,1879

The coach was angry. His hockey team was playing poorly, and they were losing by three goals. I was one of the referees for that game and I was standing on the blue line that ended at the visitor’s bench. The coach shouted, “You guys are horse s—t!”

I immediately raised my arm and when his team gained possession of the puck, I blew my whistle, turned to the coach, and signaled an unsportsmanlike conduct penalty on him.

“I wasn’t talking to you, a—hole!” he snarled.

“OK, coach, now you’ve got yourself a misconduct penalty,” I replied.

“What are you going to do, throw me out?”

“Just say the “Magic Word.”

“F--- you!”

And with that, I ejected him from the game for gross misconduct. It was not the first ejection he had experienced, nor would it be his last. He was wellknown for verbally abusing his teenage players and game officials all the time. The parents loved him because his teams won. Unfortunately, he died at

an early age after suffering a massive heart attack during a game.

Gilbert and Sullivan’s operettas satirized the snobs and phonies in British society and elsewhere. More times than not their lyrics had a ring of truth to them. Throughout the world, most people fear and detest the police until they need them. As with any profession, there are bad apples. Most law enforcement members are dedicated public servants. Societies, whether on the federal, state, or local levels make laws that are intended to protect the citizens of that polity. The police are there to enforce those laws. Similarly, all sports have rules governing how the games should be played to ensure the safety of the athletes as well as the enjoyment of the spectators. The referees and umpires are there to enforce those

rules. Unfortunately, those officials become the targets of fan verbal and occasionally, physical abuse.

An article in the New York Times this past Spring highlighted a shortage of referees and umpires in youth sports caused by unruly behavior and a toxic environment created by parents, coaches, and the players themselves1.

I have had first-hand experience (as illustrated above) with this problem, having served as an on-ice hockey official for twelve years. While the experience gave me an additional perspective on the game I love (having played, coached, officiated, and watched the game), it also made me aware of the “dark side” of amateur sports. There is an attitude of “win at any cost” on the parts of coaches and parents. In some cases, parents of talented youth have hopes that

their children will be awarded athletic scholarships at (prestigious) colleges, and perhaps go on to the US Olympic team or even professional sports teams. The reality of this last goal is that all the major league sports teams have limited roster sizes (Major League Baseball 26, NFL 53, NBA 15, and NHL 23) reserved for the best of the best. This is illustrated in the 1994 documentary Hoop Dreams.

So, why does one become a sports official? Years ago, Larry Kielkopf, a teammate of mine in Louisville, and a fellow hockey official wrote an article on the subject in Louisville Magazine. He said that being a sports official gives an individual the opportunity to be a participant in the game he or she loves without having all the necessary skills to play at a competitive level. Most officials say they are not in it for the money, since most older ones have full time jobs and officiate in the evenings and on weekends.

Unfortunately, as Edwardo Medina reported1, officials of all ages and backgrounds are confronted with churlish and abusive behavior from the fans that has worsened over the years. Parents, having spent considerable time and money on youth sports come to games with professionallevel expectations and feel as though they have the right to berate the officials, particularly if they’re young1 Referees report being punched by parents, coaches, and players, have been followed to their cars, and struck by objects thrown from the stands. I remember being warned before taking the ice at a game in Johnstown to make sure my helmet was securely

fastened because there was a little old lady who would hit the officials on the head with her umbrella as we exited from our dressing room onto the ice –before the game started.

On the ice (or field) officials have penalties they can impose for rule violations. In many cases the severity of the penalty is up to the discretion of the official. For example, in amateur hockey, fighting is discouraged by imposing an immediate game misconduct (expulsion from the game) and a one game suspension. Players are aware of this, and as a result keep their gloves on during a scuffle (which usually results in a two-minute penalty for “roughing”). To keep things further under control, I added my own interpretation of what constituted fighting: one swing with a gloved hand was “roughing”; two or more swings (with or without gloves) were fighting. I explained this to the coaches before the start of every game.

Do officials make mistakes?

Absolutely. Hockey and basketball are fast games and officials must keep their heads on a swivel. Even so, our field of view is limited to what is in front of us at the time. The spectator in the stands has a wider field of view allowing them to see much more than the official on the ice or on the field. Referees are aware of this and try their best. In the ideal game, officiating doesn’t affect the outcome. One vociferous coach berated me after a game, “You guys cost us the game!” (His team lost 6-1). I growled back at him, “Right coach. We scored five goals.” Interestingly, he was the same coach I ejected from the game after the escalating series of bad language

ended in him dropping an “F-bomb” mentioned at the first part of this Editorial. My officiating partner and I also had the rink personnel throw out a drunken fan (at a Sunday morning game) who was shouting obscenities throughout the game when he had the poor judgment to combine the “F-bomb” with a racial slur in one sentence.

Fortunately, I have had only one instance where it was necessary to eject a player for gross misconduct (making an obscene gesture). Most players exhibit good sportsmanship and play within the boundaries of the rules, despite the poor examples set by their coaches and/or parents.

Many spectators think they know the rules better than the officials. One hockey rule that many spectators don’t understand regards the lines on the rink (blue lines, center red line, and goal lines). The rules state that if the puck is lying on one of the lines, it is considered to be still in the zone from which it came. For example, a puck lying halfway over the goal line is not a goal. The puck must be completely across the goal line with white ice showing between it and the red line. During one game I was officiating, there was a pile-up in front of the goal with the puck sitting ¾ of the way across the goal line. The goalie eventually saw the puck and covered it with his glove. I blew the whistle to stop play and immediately put my hand over the goalie’s glove. I said to the goalie, “Open your hand slowly, son.” He did and the puck had not moved. I signaled “no goal” and went to the benches to tell the coaches, who had no argument. Immediately, a woman

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in the stands went ballistic and started calling me every foul name in the book (including some I hadn’t heard before). She thought her son had scored a goal. Immediately after the game she confronted me as I was on my way to the dressing room.

“You’re blind as a bat,” she said. “Anybody could see that was a goal. You’re a disgrace to the profession. Anyone can do a better reffing job than you!”

“Do you think you can do a better job?” I asked.

“Yes,” she replied.

I took off my sweater and handed it to her with my whistle. “Good,” I said. “Go get your skates. You can officiate the next game.” She stormed off.

The Covid-19 pandemic resulted in most non-professional sports

being cancelled. With better testing, vaccinations, and now medications (PaxlovidTM) to treat Covid-19, amateur sports returned. Unfortunately, as Medina reported, an estimated 50,000 referees in all sports (20%) quit1. When interviewed, most cited the reasons listed above as influencing their decisions to not return.

We are living in an era of extreme political polarization, perhaps unseen since just before the Civil War. This polarization has angered people and brought out the worst of uncivil behavior, sometimes involving firearms. People are frustrated and take out their anger verbally at sporting events, as road rage, and all too often, by committing a mass shooting. So, it is no wonder that sports officials, long the targets of fan’s frustrations, are experiencing unprecedented

harassment. Only this time, they are saying, “Enough is enough. I quit.” A policeman’s lot is indeed not a happy one.

Reference:

1. Medina E. Bad Behavior Drove a Referee Shortage. Covid Made it Worse. NY Times Apr 21, 2022.

Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine. He was an ice hockey official for 12 years.

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.

Time to Update Your Information!

Time to Update Your Information!

It’s time for group practices to update their information so that we are able to bill appropriately for the upcoming membership dues cycle. Don’t miss our updates and practice administrator meeting!

It’s time for group practices to update their information so that we are able to bill appropriately for the upcoming membership dues cycle. Don’t miss our updates and practice administrator meeting!

Complete this simple three-step process:

Complete this simple three-step process:

1 Visit www.pamedsoc.org/verify to review your group’s information.

1 Visit www.pamedsoc.org/verify to review your group’s information.

2 Log in to the PAMED website with your username and password. If you do not yet have a PAMED website account, you will first need to create

2 Log in to the PAMED website with your username and password. If you do not yet have a PAMED website account, you will first need to create an account.

3 Review your group’s information.

3 Review your group’s information.

If updates are needed: Click the RED BUTTON that says, “Click here to Update your group information.”

If updates are needed: Click the RED BUTTON that says, “Click here to Update your group information.”

Note: If you are the practice administrator for more than one group and need to update more than one group’s information, please look for the ADD button on the Update Form.

Note: If you are the practice administrator for more than one group and need to update more than one group’s information, please look for the ADD button on the Update Form.

If your group’s information is current: Click the GREEN BUTTON that says, “Click here to verify your information is correct.”

If your group’s information is current: Click the GREEN BUTTON that says, “Click here to verify your information is correct.”

Questions? Contact knowledgecenter@pamedsoc.org or call 800-228-7823.

Questions? Contact knowledgecenter@pamedsoc.org or call 800-228-7823.

Physicians (and others) as Collateral Damage in Today’s Political Wars

BRuCe l. WilDeR, mD mPh jD

Much has been written about the increasing political divide in our country, and how it has spilled over into legislatures—or vice versa. But not enough attention has been paid as to how much that phenomenon has adversely affected the professional lives, and inevitably the personal lives of health care professionals and of the patients we serve.

Howard Rosenthal1, a recently deceased native of Pittsburgh, and former professor of Political Science at Carnegie Mellon University devoted much of his career to the phenomenon of political polarization, including the links between its increase and the increase in economic inequality over the past few years. And it appears that the problem will only continue and probably get worse until we can develop a system for a more equitable distribution of wealth.

Abortion

I recently heard a very convincing argument (at least from a perfectionist view of the Constitution, and leaving aside the idea that the Constitution is not perfect and never was) that Roe v. Wade was correctly overturned, from Akhil Amar, a widely respected Yale Law School professor who describes himself as a Democrat and pro-choice.

In the most recent issue of the Bulletin, Attorney Mary Beth Jackson details the dilemmas posed for physicians following the Dobbs decision, that might seem further compounded after the well-meaning Executive Orders that attempt to provide some protection for patients—something that the Supreme Court and Professor Amar appear to have given little thought to. In the long run, I think Amar is right that the decision in Dobbs will force us to more energetically exercise the democratic process, as imperfect as it is, but is it worth all that trouble under a Constitution that is probably indelibly flawed insofar as its ability to embody the ideals of a government that derives its powers from the consent of the governed, as expressed in the Declaration of Independence?

Getting back to the real world, as reported in The Daily Beast, “South Carolina State Rep. Neal Collins told an emotional story about the real-life fallout of the ‘Fetal Heartbeat Bill’ he had supported, which prevented a 19-year-old whose water broke at 15 weeks from terminating a pregnancy that was not viable. She was sent home from the hospital with a greater than 50 percent chance of losing her uterus, he said, and a 10 percent

chance of developing sepsis and dying. 3” The Louisiana law has already sown fear and confusion among doctors, hospitals and especially their patients, who have to make what is already a difficult, if not agonizing, decision about abortion even moreso.

As one letter writer to the New York Times put it, “OB-GYNs are now conflicted between offering a woman the care that is in her best interest versus withholding that care for fear of prosecution or loss of license.”5

Gender

London’s Tavistock Centre, a child gender identity clinic, was recently closed amid allegations of misconduct, but the demand for access to treatment of youngsters with gender identity issues has not gone away, and in fact is increasing.6

Science has come too far for us to go back to the comfortable (for many of us) idea that a male is a male and a female is a female, from fertilization to death, end of story. It was not so long ago that Dr. John Money advocated for gender-defining surgery on neonates with ambiguous genitalia, an idea that has, thankfully, fallen out of practice. At that time, there was not the highly politicized environment that

Perspective

exists today; and evolving standards of medical practice and credible allegations of misconduct by Money, not some grandstanding politicians, were the deciding factors in the discontinuation of this practice.

But now we have issues of puberty-blocking hormones, and “gender-confirming” surgery in minors, important issues of parental consent and professional ethics to be sure, being co-opted by politicians who don’t really understand the complex nature of the conditions that give rise to these recommendations, and who do not face anxious parents and often suicidal children in the clinical setting.

Quite recently, the political gender wars have come to Pittsburgh’s UPMC Children’s Hospital.7

It could be worse. We have seen an opinion8 by the Texas Attorney General (currently under investigation for other possible crimes and by the Texas Bar Association for possible professional misconduct)9 that seeks to have certain treatment of gender disorders in children classified as child abuse, thereby triggering reporting requirements, and thereby posing an agonizing and difficult dilemma physicians and their patients.

Guns

A 2011 Florida law that barred physicians from asking their patients about guns in the home was blocked by a federal judge shortly after it went into effect, but the matter was tortuously litigated for several years (the infamous “Docs vs. Glocks”10 case) until the statute was finally ruled

unconstitutional by the U.S. Court of Appeals for the 11th Circuit in 2017.11

Folks in Congress are sometimes easy targets for those with means, such as the NRA. Consider the longstanding ban of federal funding of research into gun violence – something enacted in 1996, and only recently repealed; and it was not easy.12

Vaccines

The history of the anti-vaccination movement is just about as old as vaccination itself,13 but it was given new life by a 1998 article in Lancet, despite its having been retracted in 2010.14 Its proponents have found a new battleground since the onset of the COVID-19 pandemic, and not a few politicians have become embroiled in it.

I don’t think anyone can reasonably disagree that the FDA-approved Pfizer and Moderna vaccines have significantly reduced the morbidity and mortality of COVID-19, and equally important, the need for hospitalization. Unfortunately, not only the misinformed, but the health care providers who risk their own lives from infection and are at increased risk for “burn-out” and other stress-related difficulties have to bear much of the brunt of misguided actions of antivaxxers and their supporters in the legislatures.

Conclusion

I am not saying that physicians always get it right the first time, but I am saying that when they eventually do, it is usually not because of legislative intervention. And I contend that legislative intervention can in fact misdirect or stifle attempts at progress, as demonstrated by the ban on federal

funding of research on gun violence referred to above.

I am not advocating that physicians initiate discussions about political issues with their patients—in fact I am opposed to it, since patients are a captive audience. However, I feel strongly that physicians should (and should be able to, without government interference) ask questions, and answer questions their patients ask, that are related to their health and that of their families, including preventive care.

So, one way to address the collateral damage I am talking about is for organized medicine to enhance their efforts to develop policies and make their concerns known to legislators—in other words, to make even more “good trouble.” To paraphrase the words of one writer (“But the intrusion of America’s culture wars into the clinical consulting room is almost certainly not at an end.”15), the intrusion of America’s political wars into the health care setting may be just beginning.

Perspective

References

1. Sam Roberts, Howard Rosenthal, 83, Professor Who Quantified Partisanship in Congress, New York Times, 8/25/22, https:// www.nytimes.com/2022/08/25/us/ politics/howard-rosenthal-dead. html

2. Louis Menand, American democracy was never designed to be democratic, The New Yorker, August 15, 2022, https://www.newyorker. com/magazine/2022/08/22/ american-democracy-was-neverdesigned-to-be-democratic-ericholder-our-unfinished-march-nickseabrook-one-person-one-votejacob-grumbach-laboratoriesagainst-democracy

3. Dan Ladden-Hall, Lawmaker Tearily Explains Teen Almost Lost Uterus Because of Abortion Law He Voted For, Daily Beast, 8/17/2022, https://www. thedailybeast.com/neal-collinssouth-carolina-pol-emotionalafter-teen-almost-loses-uterusdue-to-abortion-law-he-voted-for

4. Ava Sasani and Emily Cochrane, Doctors Finding Abortion Bans Hard to Decode, New York Times, 8/20/22, https://www.nytimes. com/2022/08/19/us/politics/ louisiana-abortion-law.html

5. Harold M. Bruck, Letter, The New York Times, p. A19, 8/26/22

6. Jasmine Andersson and Andre Rhoden-Paul, NHS to close Tavistock child gender identity clinic, BBC News, 7/28/22,

https://www.bbc.com/news/uk62335665

7. Hannah Webster, Critics attack UPMC Children’s over transgender care, Pittsburgh Post-Gazette, 8/28/22, https:// www.post-gazette.com/ news/health/2022/08/27/ upmc-children-transgendercare-pittsburgh-lgbtq-alt-rightthreats-hospital-patientspuberty-social-medical/ stories/202208250133

8. Opinion No. KP-0401, Available at https:// texasattorneygeneral.gov/sites/ default/files/global/KP-0401.pdf

9. Steve Benen, Texas AG Ken Paxton accused of breaking law (yes, again), MSNBC Maddowblog, https://www. msnbc.com/rachel-maddowshow/maddowblog/texas-ag-kenpaxton-accused-breaking-lawyes-again-n1287595

10. Paul S. Applebaum, M.D., “Docs vs. Glocks” and the Regulation of Physicians’ Speech, Psychiatric Services 2017;68:647 (July 2017) https:// ps.psychiatryonline.org/doi/ pdf/10.1176/appi.ps.68701

11. Rebecca Hersher, Court Strikes Down Florida law Barring Doctors From Discussing Guns With Patients, NPR The TwoWay, 2/17/17 https://www. npr.org/sections/thetwoway/2017/02/17/515764335/ court-strikes-down-florida-law-

barring-doctors-from-discussingguns-with-patient

12. Eliot Marshall, Obama Lifts Ban on Funding Gun Violence Research, 1/16/13, https://www. science.org/content/article/ obama-lifts-ban-funding-gunviolence-research; Christine Jamieson, Gun violence research:

13. History of the federal funding freeze, American Psychological Association, February, 2013; Rachel Roubein and McKenzie Beard, Now the government is funding gun violence research, but it’s years behind, Washington Post, 5/26/2022, https://www.apa.org/science/ about/psa/2013/02/gun-violence ; https://www.washingtonpost. com/politics/2022/05/26/ now-government-is-fundinggun-violence-research-ityears-behind/ History of Anti-Vaccination Movements, https://historyofvaccines.org/ vaccines-101/misconceptionsabout-vaccines/history-antivaccination-movements

14. Laura Eggertson. Lancet Retracts 12-year-old article linking autism to MMR vaccines, CMAJ, 2010;182(4):E199, https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2831678/

15. See note 10 supra (Applebaum)

Healthcare for Immigrants:

The Visiting Nurse Service of Pittsburgh’s Irene Kaufmann Settlement

Thank you to Kristen Ann Ehrenberger, MD PhD for sharing this article.

You surely have heard of the Montefiore and Kaufmann buildings standing side-by-side on Fifth Avenue in Oakland. What you may not know is that these names are reminders of the long history of Jewish healthcare in Pittsburgh. Montefiore Hospital was founded in 1908 to give Jewish physicians employment taking care of patients of any creed who needed them. The Kaufmann family endowed a number of medical facilities in the city, including the Emma Kaufmann Clinic (1897-1911), the Liliane S. Kaufmann Clinic (opened in 1935), and the Liliane S. Kaufmann School of Nursing (building dedicated in 1953). An institution named for Emma’s niece and Liliane’s cousin, the Irene Kaufmann Settlement, provided healthcare to immigrants in Pittsburgh and so much more.

In 1895, Rabbi Lippman Mayer of Rodef Shalom Congregation founded the Columbian Council School for Jewish immigrant children.1 The Columbian School gradually expanded its reach beyond religion classes, and beyond the Jewish community, as it came to serve immigrants of all backgrounds. Symbolic of this

change, Henry Kaufmann, co-owner of the successful department store in Pittsburgh, donated $190,000 in 1911 to rename the school in honor of his late daughter Irene Kaufmann, who died in 1907 of accidental poisoning at the age of 19.2 According to one of its early annual reports, the mission of the Irene Kaufmann Settlement was “the advancement of the civic, intellectual, and social welfare of the surrounding community.”3 During the rededication ceremony, headworker, Elizabeth E. Neufeld, emphasized the creation of a sense of community in saying, “to make this the real home of our neighborhood and for our neighborhood, it has to be made so by our neighborhood.”4

One of the ways that the IKS (pronounced “ikes”) served the community was through the implementation of health and wellness measures, such as well-baby clinics, a “milk well” (like a soda fountain but with cow’s milk), and cooking classes. One of the most prominent initiatives was the Visiting Nurse Service. Anna B. Heldman (1873-1940) was instrumental to the nursing services provided by the settlement from 1902 until her death.5 Known as “the Angel of the Hill [District],” “Heldy” and the other nurses held open hours in the dispensary,

where the people of the neighborhood could receive medical advice (including referrals to specialized clinics or the hospital), have wounds dressed, or fill prescriptions.6 The Visiting Nurse Service also made house calls: 100,138 visits to 16,093 patients in its first six years alone (1902-1907).7 The nurses cared for community members “irrespective of color, creed, race or nationality.”

8

Heldman detailed many of her experiences as a visiting nurse in the Hill District in an unpublished manuscript called “The Neighbor’s Tales.”9 One account that especially stands out is that of Mollie, whom Heldman met when Mollie was just nine years old. Mollie’s background is unknown, although most IKS clients were Russian Jews or Black Pittsburghers. Called to re-dress Mollie’s mother’s wounds after a recent operation in the hospital, Heldman described the family’s dismal living conditions, where Mollie worked for her father to strip tobacco leaves. Mollie became pregnant at 18, but her father refused to accept his grandchild. Heldman helped the young mother find a place to stay while she nursed the girl for a month and then helped place her in an orphanage until she found a couple in Homestead to adopt the

CORey sChultz

baby. Heldman kept in contact with Mollie, and she even visited Mollie after she later gave birth to twins.10 This story demonstrates how Anna Heldman, nurse of the Irene Kaufmann Settlement, impacted members of the community she served.

The influence of Anna Heldman and the IKS endure. The Settlement building was renamed the Anna B. Heldman Community Center in 1957. IKS merged with the Young Men’s & Women’s Hebrew Association (YM&WHA) to become the Y-IKS in 1960. Four years later, it moved to Squirrel Hill and is now known as the Jewish Community Centers (JCC) of Greater Pittsburgh. The city-wide nurse service cared for Pittsburghers until the year 2000. Today, the Hill House Association stands at the intersection of Centre Avenue and Heldman Street (name changed in 1939) and serves a predominantly Black population. From language classes to healthy meals to childcare, IKS workers built long-lasting connections with community members, such as the case with Anna Heldman and Mollie. Jewish organizations like the Irene Kaufmann Settlement and Montefiore Hospital were imperative to creating opportunities for immigrants to access healthcare in Pittsburgh. We can still see to this day, as the Kaufmann and Montefiore buildings stand side-by-side on Fifth Avenue, a constant reminder of the role they played.

Numerous groups tend to the health of immigrants and refugees in Pittsburgh today. Salud Para Niños, the Latino Community Center, and Casa San José (through the Sisters of St. Joseph of Baden) work closely

with the Spanish-speaking population of the area, while the Squirrel Hill Health Center, the Birmingham Free Clinic, and the Free Clinic at Braddock (founded by the Muslim Council of America Foundation) provide direct care in multiple languages and with cultural humility. The Allegheny Health Network Center for Inclusion Health disseminates best practices in their clinics and hospitals, including translation tools and trained doulas from similar backgrounds. Immigrant Services And Connections (led by Jewish Family and Community Services and funded by the Allegheny County Department of Human Services) and Hello Neighbor both coordinate healthcare and other needs through a consortium of nonprofit organizations. The variety of helpers reflects not just the diversity of New Americans in southwestern Pennsylvania but also on-going opportunities to get involved. Please visit their websites to find out how you can help.

Biography: Corey Schultz is a 2022 graduate of the University of Pittsburgh, with degrees in History and Neuroscience. This is an excerpt from his Bachelor of Philosophy thesis. He will spend the next year doing health education and community outreach at an FQHC in Philadelphia through Americorps and then pursue an MD PhD in History of Medicine with plans to go into primary care. Bulletin Associate Editor Kristen Ann Ehrenberger, MD PhD (History), serves as one of his mentors. He can be reached at cks21@pitt.edu.

References:

1. University of Pittsburgh Library System, “History of the Irene Kaufmann Settlement.”

2. “1911: Irene Kaufmann Settlement House,” A Tradition of Giving, Rauh Jewish Archives, accessed October 6, 2021, http://www.jewishhistoryhhc.org/ timeline.aspx#074c4a29-1921-4827-8b4d3b9d1fb46da1.

3. Irene Kaufmann Settlement, 19151916 Annual Report (Pittsburgh: Irene Kaufmann Settlement, 1916), 3.

4. Irene Kaufmann Settlement, “Program of Exercises for Irene Kaufmann Settlement Dedication in 1911,” Records of the Jewish Community Center of Greater Pittsburgh, 1902-2005, MSS #389 box 4 folder 13, Rauh Jewish Archives at the Heinz History Center, Pittsburgh, PA.

5. “Biography of Anna Barbara Heldman,” Literary and Cultural Heritage Maps of PA – Biographies, Pennsylvania Center for the Book, accessed June 14, 2021. https:// pabook.libraries.psu.edu/literary-culturalheritage-map-pa/bios/Heldman__Anna.

6. “Head President’s Report Irene Kaufmann Settlement,” The Jewish Criterion, November 5, 1915, 8, Carnegie Mellon University Digital Collections.

7. Irene Kaufmann Settlement, 1916-1917 Year Book (Pittsburgh: Irene Kaufmann Settlement, 1917), 29.

8. Ibid., 29.

9. Anna B. Heldman, “The Neighbors’ Tales,” Archives of Industrial Society Assorted Manuscripts Collection, Archives & Special Collections, AIS. Assorted. MSS Box 2 Folder 23, page 133, University of Pittsburgh Library System, Pittsburgh, PA.

10. Ibid., 91-97.

Perspective

Braving Through the Transitions

anthOny l KOvatCh, m.D.

What else is life but a series of preludes to that unknown song, the first and solemn note of which is sounded by Death…So when the trumpet sounds the alarm and calls him to arms, no matter what struggle calls him to its ranks, he may recover in battle the full consciousness of himself and the entire possession of his powers.

Les Préludes (“The Beginnings”) was first conceived as an overture to Hungarian composer/pianist Franz Liszt’s symphonic poem, Les quatre élémens (“The Four Elements”). As the 1856 composition developed, it was given a new title, inspired by an Ode from Nouvelles méditations poétiques by the French poet, Alphonse de Lamartine (summarized above).

Since my retirement this past March, I have had to convince myself that, in spite of the claim by the Existentialists that our lives are lived forward but understood backwards, I must develop the courage to “flash forward through the preludes” and understand life forwards. Therefore, I have become preoccupied with “stages.”

Liszt’s groundbreaking composition has four stages: love, storm, bucolic calm, battle and victory. Ironically, sociologists have described four stages or phases (or “preludes”) of the retirement that in the present day and age can embrace about one third of a health-conscious human being’s life span:

1. Vacation phase, focused on newlyexperienced relaxation and freedom. Lasting about one year, this stage transitions unexpectantly into….

These loses can contribute to physical decline, cognitive decline (especially memory loss), and depression.

3. A rebound search for meaning in life and ways to contribute through trial and error, and, if successfully negotiated, will produce…

4. Reinvention of the self and rewiring of the psyche. The long-term result is inner peace and a rededication to the service of others.

Sociologists have also concluded that focusing on these psychological transitions throughout retirement is far more crucial to our overall happiness than the preparatory recommendations of financial advisors. In an enlightening and amusing podcast that formed the construct for the above four phases, life coach Dr. Riley Moynes summarizes the process as “Squeezing All the Juice Out of Retirement.”

Franz Liszt was a prodigy and virtuoso on the piano; this was attributed to his massive hand-span. As with his contemporary Sergei Rachmaninov, the speculation now is that the outlying hand size was part of an underlying Marfan’s syndrome.

2. Phase of loss, dominated by boredom, fear, and anxiety. This stage is highlighted by the absence of integral parts of the workplace experience:

• routines, even the painstaking ones

• relationships, even the difficult ones --sense of identity --sense of purpose --sense of power or control

In order to reverse our sense of loss, some of us pediatricians sustain our relationships with our longtime patients and their parents by participating with them at community events, especially of the athletic variety. I recently discovered a personally uplifting association between the phases of retirement and the four components of a triathlon (TRI).

Yes, a triathlon actually has four preludes leading to the finish line! Although the triathlon (from the Greek) is classified as a “contest of three,” I contend that the “transitions” from swimming to biking and then from biking to running are an integral part of the contest (just like the transitions between the periods of our life). However, unlike life and retirement, the triathlon is a relatively new-kid-onthe-block when it comes to physical challenges and spectated athletic events.(1)

The first TRI took place in 1974 at Mission Bay, California. You can now find a TRI almost every summer and fall weekend in the greater Pittsburgh area. The Youth Triathlon is still a sport in its infancy, and only the bravest of kids attempt one.(2)

Running can make you tired but swimming requires far more energy and stamina; however, biking can be outright dangerous, even to experienced riders. (I’ve witnessed a “wipe-out” at just about every adult TRI I have attended.)

However, transitions must be respected; a matter of precious seconds can be critical in the competition among the elite. For very sub par participants like the author, the transitions are the only element of the race that can “level the playing field”; they have become my favorite parts of the race—when me and the “old yellow bike” that I have depended upon for every TRI can rest together in relative peace apart from the madding crowd.

Romancing the bike: this faithful “old yellow bike” has served me so well over the years that I hang my finisher’s medal on it after I cross the finish line!

Another salubrious prerequisite to participation in TRIs for which I am grateful in my transition from full-time pediatrician to the full-time retirement life is the urgency of tuning up my aging body for the challenge. The mind might be the “first thing to go” but loss of muscle mass and tone (sarcopenia) inevitably follows. Furthermore, of the five pillars documented by neurosurgeon and CNN medical correspondent Sanjay Gupta in his textbook for the layman “Keep Sharp”, to be necessary for the preservation of memory and overall cognitive functioning---healthy diet, exercise, rest and sleep, intellectual challenge, and social connectivity—regular exercise is paramount.

A large-scale landmark study published in 2015 in the Journal of the American Medical Association(3) showed that longevity and mental fitness were directly related to the cumulative duration of aerobic exercise (even walking) over time, rather than the intensity. The more aerobic activity the better is the rule of thumb, but the minimum requirement is at least 20

minutes per day for 5 days per week. This amounts to a drop of water in a swimming pool for a determined triathlete in training. Simply put, the more we exercise, the more juice we squeeze out of our retirement!

As a pediatrician for 4 decades, another cherished part of TRIs and road races over the years has been the emergence of the children and grandchildren of my peers as solid competition for their elders. This is not at all out of disrespect, but because of the inevitable chain of events: exposure to an adult who values exercise and competition fosters the same in the offspring. Imitation remains the highest form of admiration— whether for an older sibling, a parent, a grandparent, a spouse, or any loved one. In the future, the young will be compelled to reciprocate.

…And teach your parents well

Their children’s hell will slowly go by And feed them on your dreams

The ones they pick, the one you’ll know by

Don’t you ever ask them why?

If they told you, you would cry

So you look at them and sigh And know they love you.

—“Teach Your Children” by Crosby, Stills, Nash, and Young (1970)---written by Graham Nash

From Page 21

Medical research confirms this association. A systematic metaanalysis published in the International Journal of Behavioral Nutrition and Physical Activity as recently as May, 2020 (4) showed that the clear majority of studies observed a positive relationship between parent and child physical activity regardless of the age of the child, the genders of the parentchild dyad, and the type of physical activity. A classic case in point:

volunteer this information; you have to dig it up from their husbands, the grandparents, or even the babysitter!

Preteen Ellis absolutely “loves” TRIs in spite of a history of severe asthma; he competes with a beaming smile on his face, even on the rocky pavement during the crucial transition from swimming to biking.

I knew from his days as an obstreperous toddler that Ellis would be a fierce competitor, and I was not surprised to learn after the event that the boy’s mother was an Olympic ultra-triathlete who still regularly competes in long-distance swimming. She endorses my mother-child dyad hypothesis:

“Yes, parents tend to encourage activities that are familiar to them. The unknown activities seem harder to navigate. Plus, parents show the most enthusiasm for the activities they themselves did.”

Little Mae (on the far right ) will be joining her 3 older experienced siblings in the races as soon as she can mount a bike—then she will be the second member of the third generation of lady triathletes in the nuclear family to sport the coveted medal!

My contention from anecdotal experience alone is that children whose mothers were elite athletes wind up as the most superior of athletes themselves. Here is the rub: The reflection of a mother’s athletic prowess is never self-evident when they interact with the pediatrician. Furthermore, these unique prototypes are so humble that that they never

The reemergence of races is a reflection of civilization’s “control” over the COVID-19 pandemic. However, we all know that we are only in the “transition” phase of the race back to normalcy. May all the lessons we learned along the way propel us soberly into the future—aware that we have not yet crossed and may never completely cross the finish line.

I think this off-hand rhetorical comment by the late iconic baseball broadcaster Vin Scully (whose illustrious career included a 67 year “transition” with the Dodgers) says it all:

“Andre Dawson has a bruised knee and is listed as day to day. [pause] Aren’t we all.”

Interestingly, Scully reassured his “friends” (he refused to use the term “fans” because it is short for “fanatics”) in his farewell address to baseball at the age of 88:

“There’s that old saying: squeeze the juice out of life before life squeezes the juice out of you. I will try to squeeze the remaining juice out of life.”

The indefatigable Scully kept squeezing the juice until the age of 94. I will remember him as the patron saint and the “Mister Rogers” of my “transistor radio generation” of baseball junkies.

From my own thinking, I might add: What is life but a series of preludes---a series of transitions through which we all must brave---all leading to that one final act we call the FINISH LINE?

References:

1. http://www.thepediablog.com/2022/08/04/ out-of-the-old-black-bag-28/

“The TRI’s the Thing: Connecting the Generations

2. http://www.thepediablog.com/2013/08/19/ a-showcase-of-courage/ “A Showcase of Courage”

3. Thijs M. H. Eijsvogels, PhD1; Paul D. Thompson, MD2: “Exercise is Medicine: At Any Dose?” JAMA November 10, 2015

4. Loretta DiPietro, et al: “Advancing the global physical activity agenda: recommendations for future research by the 2020 WHO physical activity and sedentary behavior guidelines development group” International Journal of Behavioral Nutrition and Physical Activity Volume 17: 143 (2020)

The author wishes to thank Dr. Ned Ketyer, editor of the Pediablog, for his permission to publish this expanded version of the original article.

Pittsburgh Ophthalmology Society Announces 2022-2023 Monthly and Annual Meetings Dates

Marshall Stafford, MD, President of the Pittsburgh Ophthalmology Society (POS), is pleased to announce the 2022-2023 POS Monthly Meeting Series and Annual Meeting dates. A total of six meetings are scheduled, beginning in September, and concluding with the Annual meeting in March 2023.

The POS will host the monthly meetings as in person meetings in the Ohio Room at the Rivers Casino (777 Casino Dr, Pgh, PA 15212)*. The venue is centrally located on the North Side and offers free parking. Valet parking is also available for a small fee.

The ballroom, located on the 2nd level is a non-smoking facility and provides ample social distancing space.

*The November 3 program will be the only meeting held at the Babb Insurance Building (850 Ridge Ave, Pgh, PA 15212). More details will be provided on the November meeting notice and registration site.

Registration begins at 4:00 pm with the first lecture to commence at 4:30 pm. The agenda includes a Resident Case Presentation. This year’s secondyear Resident presenters from the University of Pittsburgh Eye Center include: Sonny Caplash, MD; Timothy

Chen, MD; Jonathan Peterson, MD; Matthew Sommers, MD; and Bushra Usmani, MD.

Members will receive registration information, including the link to register, 1-month prior from the date of each meeting. Registration is required (no walk-ins, please) and will be handled online only.

At the time of print, guest faculty for all meetings are in the process of being confirmed. Please visit the POS website www.pghoph.org periodically for updates on guest faculty and presentation details, as well as registration information.

Society News

The Allegheny County Medical Society is pleased to welcome Melanie ‘Mel’ Mayer to the team as of August 5, 2022.

Mel joins ACMS as the Administrative and Marketing Assistant. In this role, Mel provides administrative and exec utive support, assists with governance, and handles the administration of the ACMS marketing initiatives, including our newly revamped e-newsletter.

Before joining the team at the ACMS, Mel worked in various man agement and marketing roles in the boutique fitness industry. Her most recent role was with Orange Theory Fitness Wexford where she managed the member database, did administra tive work, dealt with customer service issues, and helped plan member ap preciation events. Mel is a graduate of Penn State with a Bachelor of Science.

When she’s not working, Mel enjoys spending time with her husband, her three children and their dog. In her free time, she loves to work out or read.

Mel can be reached at mmayer@ acms.org or 412-321-5030 x100.

Pittsburgh Ophthalmology Society welcomes Sandra F. Sieminski, MD

The Pittsburgh Ophthalmology Society (POS), opened their 2022-2023 meeting season on September 8 and welcomed Sara F. Siemsinki, MD Vice Chair of Clinical Affairs; Associate Professor, Director of Glaucoma, Ira G. Ross Eye Institute; Department of Ophthalmology Jacobs School of Medicine & Biomedical Sciences, University at Buffalo/State University of New York (SUNY).

The Allegheny Room at the Rivers provided a scenic and spacious atmosphere, with over 60 registrants attending the first meeting of the season. The POS would like to thank Alcon for sponsoring the meeting. They would also like to thank Ian Conner, MD, PhD for inviting Dr. Sieminski.

Dr. Sieminski presented two lectures, What’s New in MIGS and The Trab is not Dead. Each lecture was well received with an active question and answer session.

Timothy Chen, MD, Resident at the University of Pittsburgh Eye Center, presented an interesting case for commentary by Dr. Sieminski.

The POS will not meet in October due to the American Academy of Ophthalmology (AAO) Meeting. The next meeting is scheduled for November 3, 2022. Note – The November meeting will be held at the Babb Insurance Building (Ballroom). The building is located at 850 Ridge Ave, Pittsburgh, PA 15212 (on the North Shore of the Pittsburgh). Directions will be included in the registration email.

l to r: A. Ahmed, MD; J. Swogger, MD; J. Polat, MD; A. Williams, MD, I. Conner, MD (Board Member); S. Sieminski, MD (Guest Speaker); T. Shazly, MD; K. Lauer, MD; and M. Stafford, MD (President).

Greater Pittsburgh Diabetes Club set to host Fall Program

The Greater Pittsburgh Diabetes Club (GPDC) will host their annual fall program, Tuesday, October 25th. The in-person event will be held in the Babb Insurance Bldg., 850 Ridge Ave, Pittsburgh, PA. The event will begin at 6:00 p.m. with the popular Vendor Showcase. Following a brief welcome, the dinner and program will begin at 7:05 pm. The meeting is open to members of the Diabetes Club and non-members (guest fee will apply).

The GPDC is pleased to welcome guest speaker Joseph Aloi, MD, Section Chief for Endocrinology and Metabolism, Wake Forest Baptist Health, Winston Salem, NC. He will present Integrating Diabetes Technology with Inpatient Care. Thank you to the following companies who provided support for the program: AstraZeneca, Bayer, BoehringerIngelheim, Corcept Therapeutics, Dexcom, Novo Nordisk, Inc., Tandem

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.

For more information, and to register for the program, please visit www.pghdiabetesclub.org. Registration begins September 1 with a fee of $15 for members and a guest fee of $40.00 (which includes 1 year of membership in the GPDC). Questions can be directed to Nadine Popovich, administrator by email to: npopovich@ acms.org or to (412) 321-5030.

Joseph Aloi, MD

Pfanstiel,

Legal Summary

Breaking Free: How to Opt Out of Medicare (and Other Payors)

William h. maRuCa, esquiRe

Most physicians, unlike most other professionals, are beholden to two masters: their patients and their patients’ insurance carriers or other payors. Increasing interference with medical decision-making by third party payors has led some physicians to cut ties with Medicare and other insurers and deal directly with their patients. While such freedom may sound tempting, there are a number of steps that a physician must take in order to effectively declare your independence.

Medicare OptOut

The Balanced Budget Act of 1997 permits a physician to opt out of Medicare and enter into “private contracts” with their Medicare beneficiary patients, but only if the physician agrees to opt out of Medicare entirely for two years for all covered items and services furnished to Medicare beneficiaries. Under a private contract, the patient agrees to pay the physician without regard to any Medicare charge or payment limits and agrees not to submit those bills to Medicare. For many specialties, opting out of Medicare may not be practical, but for those whose patients have the resources to pay directly or who have relatively low Medicare numbers in

their payor mix, this concept may be viable.

The first step is to complete and submit an opt-out affidavit. The affidavit remains in effect for two years and is automatically renewed every two years. (The original program required biennial renewals) The opt-out election may be cancelled at the end of any two-year period by giving 30 days’ written notice. Pennsylvania’s Medicare Administrative Contractor (MAC), Novitas Solutions, has posted a form for this affidavit at https://www. novitas-solutions.com/webcenter/ content/conn/UCM_Repository/uuid/ dDocName:00008290. You should send this affidavit by certified mail and retain proof of delivery. If you routinely send Medicare claims to multiple MACs, i.e., if you practice near a state border, you need to notify all such MACs.

By signing the affidavit, the physician agrees:

• To provide services to Medicare beneficiaries only through qualifying private contracts for services that, but for their provision under a private contract, would have been Medicarecovered services, except for certain emergency or urgent care services.

• Not to submit a claim to Medicare for any service furnished to a Medicare beneficiary during the opt-out period or to permit anyone else to submit such a claim, except for certain emergency or urgent care services.

• Not to receive direct or indirect Medicare payment for services furnished to Medicare beneficiaries with whom the physician has privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under Medicare Advantage.

• Not to require any patient to enter into a private contract as a condition of providing urgent care or emergency services.

A physician that has opted out of the Medicare program is not required to complete a separate application to order or refer items/services for beneficiaries to other Medicare providers such as prescriptions, diagnostic tests or specialist care.

Legal Summary

There is a box that can be checked on the Novitas affidavit which reads “Do you wish to order & refer?” In most situations you should check “Yes.”

Each Medicare beneficiary treated by a physician who has opted out must sign a private contract before the physician charges the patient for a Medicare-covered service. The contract must meet certain criteria set forth in the Balanced Budget Act, including:

• Print sufficiently large to ensure that the beneficiary is able to read the contract.

• Disclosure of whether the provider has been excluded from Medicare.

• Acknowledgement that Medicare limits do not apply to the private contract charges.

• Patient’s agreement not to submit a claim to Medicare or to ask the physician or practitioner to submit a claim to Medicare.

• Patient’s acknowledgement that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

• Patient’s acknowledgement that they enter into this contract with the knowledge that he or she has the right to obtain Medicarecovered items and services from physicians and practitioners who have not opted-out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.

• Disclosure of the expected or known effective date and the expected or known expiration date of the current 2-year opt-out period.

• Patient’s acknowledgement that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

• Signature by the patient or legal representative and by the physician.

• May not be entered into by the patient during a time when the patient requires emergency care services or urgent care services.

Additionally, the physician must provide a copy to the patient before items or services are furnished to the patient under the terms of the contract; must keep a copy for the duration of the current 2-year opt-out period; and must make a copy available to CMS upon request.

CMS instructions still indicate that a new private contract must be entered into with each patient for each 2-year opt-out period, but this requirement is currently under challenge by the American Association of Physicians and Surgeons now that annual renewals are no longer required. Unless this rule is changed, you should calendar the two-year anniversary of each patient’s private contract and have it resigned every two years.

Note that both the private contracts and the physician’s opt-out are null and void for the remainder of the opt-out period if the physician fails to remain in compliance with the applicable conditions during the opt-out period. Therefore, you need to implement procedures to ensure that no claims are submitted to Medicare while under an opt-out affidavit and to make sure each patient signs the private contract and renews it in a timely manner.

Also note that the opt-out and private contracting rules only apply to services that would otherwise be covered by Medicare. You can charge patients whatever you see fit for services that are clearly noncovered services, such as cosmetic surgery. If the services are not covered for reasons such as medical necessity, you can charge the patient directly provided the patient has signed an Advanced Beneficiary Notice.

Legal Summary

Private Insurance

Opting out of Medicare does not prevent you from continuing to accept private insurance, other than Medicare Advantage or Medigap plans. However, if you decide you no longer want to accept a particular private plan, or any plan for that matter, you need to review your participation agreement with each plan. Most plans include a provision for termination that requires 60 – 90 days’ advance written notice. You should also give your patients plenty of advance notice when you are withdrawing from participation and advise them in writing before a visit that you are no longer accepting their insurance and that they will be expected to pay your fees in full.

Unlike opting out of Medicare, when you terminate participation with a private insurance plan you do not need to compel your patients to promise not to submit your bills to that plan, but the patient may not be reimbursed to the same degree (or at all) if you are nonparticipating. Also, even if you are not paid directly by a particular plan, your claims may still be audited by that plan if the patient submits your bills and is reimbursed directly. You may have additional defenses to such audits if you do not have a direct contract with the plan.

Next Steps:

Freeing yourself from the shackles of third-party payor participation with all its red tape and second-guessing of your professional decisions may allow you to focus on patient care, but it is not a decision you should make without plenty of preparation. Take the time to sound out your patients, particularly Medicare-eligible patients if you’re planning to opt out of Medicare and be prepared to ramp up your billing and collection processes or to require payment at the time of service.

William H. Maruca, Esquire is a healthcare partner in the Pittsburgh office of the national law firm Fox Rothschild LLP and can be reached at 412.394.5575 or wmaruca@ foxrothschild.com

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NOVEMBER 16

MPHC 2022, a premier educational event for medical practice administrators and their office personnel, provides a robust engagement opportunity to discuss the challenges facing medicine and to leave with innovative strategies to improve practices!

Conference Highlights include:

KEYNOTE SPEAKER

 Conference Kickoff and Closing Keynote: by Jordan Corcoran, CEO & Creator: ListenLucy.org Don’t miss this timely presentation on mental health in the workplace. Jordan candidly discusses her battle with mental illness in a relatable, honest, and informal way. Attendees will come away with self care and coping techniques to share with staff.

 Legislative and Regulatory Update: presented by a Pennsylvania Medical Society Advocacy team staff member, you’ll receive exclusive insight following the 2022 mid term elections.

 Idea Exchange! Connect with your colleagues to share professional experiences and solutions to your most challenging professional issues.

 Coding Session: *AAPC CEUs available: 1.0 CEU available for session. This session will help you to understand the high level changes for EM code sets in 2023, split/shared visits with mid-levels documentation rules for 2023, and current landscape of telehealth.

 Payor Help Support Desk: an exclusive opportunity to meet with insurance payors to discuss your practice's pain points. Time slots must be reserved and open only to MPHC 2022 attendees.

Presented by:

Nominating Committee Report for Officers and Delegates September 2022

The Nominating Committee met on August 31, 2022 and is pleased to recommend the following candidates for election to office in 2023 Elections will take place the first week of November

President elect Raymond E. Pontzer, MD (Automatically becomes president 2024)

Secretary Keith T. Kanel, MD

Treasurer William F. Coppula, MD

Directors (Five to be elected)

Anuradha Anand, MD Michael M. Aziz, MD Amber R. Elway, MD Stephen N. Fisher, MD Mark A. Goodman, MD Micah A. Jacobs, MD Ezz Eldin Moukamal, MD Elizabeth Ungerman, MD G. Alan Yeasted, MD Alexander Yu, MD

Other Directors currently serving but not up for election this year:

Term Expires in 2023

Term Expires in 2024

Douglas F. Clough, MD Matthew B. Straka, MD, President 2023 Bruce A. MacLeod, MD

Peter G. Ellis, MD, will Chair 2023 Steven Evans, MD

Kirsten D. Lin, MD

Jan B. Madison, MD Adele L. Towers, MD Raymond J. Pan, MD OPEN OPEN

Amelia A. Paré, MD

Nominating Committee Report for Officers and Delegates September 2022

The Nominating Committee met on August 31, 2022 and is pleased to recommend the following candidates for election to office in 2023. Elections will take place the first week of November.

President-elect Raymond E. Pontzer, MD (Automatically becomes president 2024)

Secretary Keith T. Kanel, MD

Treasurer William F. Coppula, MD

Directors (Five to be elected)

Anuradha Anand, MD

Michael M. Aziz, MD Amber R. Elway, MD Stephen N. Fisher, MD Mark A. Goodman, MD Micah A. Jacobs, MD Ezz Eldin Moukamal, MD Elizabeth Ungerman, MD G. Alan Yeasted, MD Alexander Yu, MD

Other Directors currently serving but not up for election this year:

Term Expires in 2023

Term Expires in 2024

Peter G. Ellis, MD, will Chair 2023

Steven Evans, MD

Douglas F. Clough, MD Matthew B. Straka, MD, President 2023 Bruce A. MacLeod, MD

Kirsten D. Lin, MD Amelia A. Paré, MD

Jan B. Madison, MD Adele L. Towers, MD

Raymond J. Pan, MD OPEN OPEN

“ACMS Launches New Blog: ACMS Insights”

Sara C. Hussey, ACMS Executive Director

As the health care profession continues to change, it only stands to reason that the Allegheny County Medical Society finds itself at a crucial turning point. We are up against generational and environmental shifts and the reality is: professional associations are different than they were 50 years ago. We are working hard to redefine what ACMS membership should be. It requires respecting the 165-year history of the organization while finding new ways to engage younger physicians with busy lives, families, and outside interests. Our biggest challenge at ACMS is creating programming and engagement

opportunities that you, as a member, will find valuable enough to give the ACMS even a single hour of your time. We recognize that it’s our job to make membership worth your while.

Part of our engagement is going to be connecting with our members more intentionally in the digital space. That includes the launch of our new blog: ACMS Insights (www.acms. org/acmsinsights). Don’t worry! You will still receive your monthly ACMS Bulletin in the mail, but you’ll also see increased visibility through blog posts, e-newsletters, and the ACMS social media channels.

We want to invite you, our

ACMS members, to be part of the conversation. Our blog and social media channels are there for you to engage with. We will be looking for guest bloggers and we are asking for you to share your programs or publications so that we can promote them on our social media platforms. We also look forward to spotlighting our members in our e-newsletters and providing more opportunities for peerto-peer connection.

Please reach out to us at the ACMS to continue the conversation. I can be reached at shussey@acms.org or you can reach anyone on the ACMS team by emailing acms@acms.org.

“Putting Self-Care in Health care”

Sara C. Hussey, MBA, CAE – ACMS Executive Director

When I started in my role as the Executive Director of the Allegheny County Medical Society in March of this year, I had a general awareness of the pressure, stress, and mental strain that was put on health care workers. But as I started to dig deeper and began speaking to ACMS members, I quickly learned much more about what their lives have looked like over the last few years. It was clear that there was a lot more going on behind the scenes than most could even imagine.

For many healthcare workers, specifically physicians, the stress and anxiety, coupled with long days, endless paperwork, and a continued campaign of distrust of the medical profession, is leading to a tremendous

increase in physician mental health conditions. The pandemic has affected the mental health of healthcare workers nationwide, with more than 50% of public health workers reporting symptoms of at least one mental health condition, such as anxiety, depression, and increased levels of post-traumatic stress disorder (PTSD).

During the month of September, we acknowledged Physician Suicide Awareness Day (September 17) by sharing some of the staggering and heartbreaking statistics around physician suicide and the stress medical professionals are facing.

But the month of September also saw the launch of the ACMS’s “Putting Self-Care in Health care” campaign.

This social media campaign was aimed at offering everyday solutions to help combat physician burnout. Each day the ACMS shared a new discount, service, or event on our social media pages, all with the intention of providing ways for physicians to take time away from their work, spend time with their families, or just take a single day for some self-care. We had many local Pittsburgh businesses step-up to offer some amazing giveaways, as well. Many of these discounts and services are ongoing and not just limited to September. Be sure to check out the full list of discounts at www.acms.org/ selfcareinhealthcare or you can visit any of our social media channels.

Our message to all healthcare workers is that, here at the ACMS, we see you, we appreciate you, and we THANK YOU for all that you have done and all that you continue to do. We hope you will take some time for yourself this month.

Be sure to follow our social media pages to catch all the exciting partnerships, discounts, and giveaways for healthcare workers throughout the month of September:

Facebook – Twitter – Instagram LinkedIn – acms.org

long as the humor, in this case name- beings.

OUR SYSTEM or YOUR SYSTEM?

to

• Physician Billing Services for All Specialties

We would use OUR billing system or YOUR billing system based on YOUR preference.

• Credentialing Services for All Specialties

• Accounts Receivable Follow-Up for Practice Support

We would work your accounts on your system to maximize cash flow.

NEW Billing Client Example: A new client (a 6-physician family medicine group) liked their EHR, so the group asked us to bill using their billing system. Besides the benefit of keeping their EHR, the group is now experiencing greater efficiency and stability in their office by eliminating problems caused by biller turnover, vacations, diversion, and other time off.

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

Three Penn Center West Pittsburgh, PA 15276 fennercorp.com