ACMS Bulletin October 2023

Bulletin Allegheny County Medical Society

October 2023

Value of Membership I’m a Proud Member of ACMS. Here’s Why. ACMS Member Benefits

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Allegheny County Medical Society

Bulletin October 2023 / Vol. 113 No. 10

Opinion

Departments

Articles

Value of Membership...............5 • Sara Hussey, ACMS Executive

ACMS Gift A Member............21 Materia Medica ......................16

Director

ACMS Member Benefits.......23

Editorial ..................................6 • I’m a Proud Member of ACMS.

ACMS Meet the Team...........24

Here’s Why. Deval (Reshma) Paranjpe, MD, MBA, FACS

Editorial ..................................8 • The Others Andrea G. Witlin, DO, PhD

Perspective............................11 • And Worry About It Later

ACMS Foundation..................26

• Medication Safety Spotlight: Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2) Christopher L. Biser and Linda M. Nicolaus, BS, PharmD

Legal Summary....................19 • Post-COVID Practice Check-Up Beth Anne Jackson

Renew Your ACMS Membership............................28

Anthony L. Kovatch, MD

Perspective............................14 • Is There a Doctor in the House?

And Who Is the Patient?

Bruce Wilder MD, MPH, JD

On the cover

Lunar Eclipse Mark E. Thompson, MD Mark E. Thompson MD specializes in Cardiology

Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2023 Executive Committee and Board of Directors President Matthew B. Straka, MD

PAMED DISTRICT TRUSTEE

Douglas F. Clough

G. Alan Yeasted, MD

Richard H. Daffner (rhdaffner@netscape.net)

COMMITTEES

Kristen M. Ehrenberger (kricket_04@yahoo.com)

President-elect Raymond E. Pontzer, MD

Bylaws Keith .T. Kanel, MD

Secretary Keith T. Kanel, MD

Finance William Coppula, MD

Treasurer William Coppula, MD Board Chair Peter G. Ellis, MD

Nominating Raymond E. Pontzer, MD

DIRECTORS Term Expires 2023 Michael M. Aziz, MD Micah A. Jacobs, MD Bruce A. MacLeod, MD Amelia A. Paré, MD Adele L. Towers, MD Term Expires 2024 Douglas F. Clough, MD Kirsten D. Lin, MD Jan B. Madison, MD Raymond J. Pan, MD G. Alan Yeasted, MD Term Expires 2025 Anuradha Anand, MD Amber Elway, DO Mark Goodman, MD Elizabeth Ungerman, MD Alexander Yu, MD

Anthony L. Kovatch (kovatcha42@gmail.com) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Andrea G. Witlin (agwmfm@gmail.com)

ADMINISTRATIVE STAFF Executive Director Sara Hussey (shussey@acms.org) Vice President - Member and Association Services Nadine M. Popovich (npopovich@acms.org)

Administrative & Marketing Assistant Melanie Mayer (mmayer@acms.org) Part-Time Controller Elizabeth Yurkovich (eyurkovich@acms.org)

Manager - Member and Association Services Eileen Taylor (etaylor@acms.org) ACMS ALLIANCE Co-Presidents

Corresponding Secretary

Patty Barnett

Doris Delserone

Barbara Wible Treasurer Recording Secretary

Sandra Da Costa

Justina Purpura Assistant Treasurer Liz Blume

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

EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323.

USPS #072920. PUBLISHER: Allegheny County Medical Society at above address.

The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws.

The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication.

Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted.

The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board.

Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted.

Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products.

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COPYRIGHT 2023: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212.

ISSN: 0098-3772

Meet the Team & Get in Touch

Meet Your ACMS Support Team! Please feel free to contact any of the team members below.

Members can also reach out to acms@acms.org for general questions and someone on our team will get back to you as soon as possible.

The Value of Membership Sara Hussey, ACMS Executive Director

M

embership is not a one-size-fits-all situation. Every individual views their participation in their professional association through a different lens. And, although I wish it weren’t the case, joining a membership organization doesn’t appeal to everyone. Life is busy. In addition to your busy careers as physicians, you also have families, friends, hobbies, pets, etc. I recognize that ACMS’s biggest competitor is one hour of your spare time. My goal, as Executive Director of ACMS, is to ensure that everything we do at the medical society is designed with the intention of never wasting a moment of your time.

One thing that my team and I, as association management professionals, understand is that we can’t be all things to all people. However, we are working on creating more programming and benefits for ACMS members at various stages of their membership journey. We hosted our Night at the Pirates Game to provide a place for our members to enjoy networking alongside a night of family fun. We launched a Women in Healthcare Committee to offer an opportunity for our female physicians to connect, learn, and grow. We put our physician leaders in front of legislators so that we can continue to bridge the gap between healthcare and Harrisburg. In between all of that, we have introduced some free CME opportunities, smaller networking events, and new approaches to social media and content creation.

As we approach the 2023 House of Delegates meeting (Oct. 27 – 28), I would be remiss if I didn’t remind our membership of the value of strength in numbers. As an individual, you may feel you have relatively little power to effect change. However, membership in an organization of like-minded professionals can help you not only advocate for the issues that matter to you but also see major results. Even if you aren’t an elected delegate, you have a voice in who you elect to our Delegation to represent YOU. You will receive your election ballots at the end of October, and I encourage you to vote with intention as you select your representatives for 2024.

Our work is never done. Each year, we will reinvent the wheel because we understand that things change for our members on an ongoing basis. As you read through this month’s edition of the ACMS Bulletin, I hope you will take note of the focus on membership that we’ve placed on this edition. We aim to showcase some of the great things we are doing here at your county medical society.

It’s time to renew your dues for 2024, and we hope you will continue to support our organization. Association membership can provide you with fulfilling relationships, professional networking, leadership opportunities, leads for career advancement, and easy access to recommendations, resources, and advice on a wealth of business or patient care topics. It could even lead to new patient referrals from fellow members and help you make a difference in the future of your industry.

My door is always open. I encourage you to reach out to me or any member of the ACMS Staff or Executive Committee to share your thoughts, ideas, concerns, or just to say hello and introduce yourself. We look forward to another busy, exciting, and meaningful year in 2024.

ACMS Bulletin / October 2023

5

Editorial

I’m a Proud Member of ACMS. Here’s Why. Deval (Reshma) Paranjpe, MD, MBA, FACS I joined the Allegheny County Medical Society when I started practice in Pittsburgh—wet behind the ears, straight out of fellowship and under the age of 30. Why did I join? I wanted a sense of community and belonging, mentorship from collegial older physicians, networking, discounts on insurance and other benefits, and a way to help my colleagues and patients via the power of organized medicine. I had been the state chair of my state’s AMA medical student section, but like most residents and fellows didn’t have the time to be active while in training.

I found all these benefits and more—including strong and enduring friendships with people I never would have met had I not joined ACMS. To our current members looking for talking points as to why someone should join the ACMS, here are some of my “why’s”. It is all of the above, plus a revamped, relevant, high energy ACMS that is committed to engaging with physicians no matter what the career stage, needs or interests may be.

Our members look like you and come from a broad range of specialties, practice settings, and demographics. We are engaged with the community and care deeply about our patients.

We care about and show up for each other in a world where it is easy to feel isolated and alone as a physician. We represent the voices of Allegheny County physicians and patients at the state and national levels. We care about each other.you. Come join us.

Networking, Socializing and Friendship Networking is an integral function of the ACMS. We provide opportunities for you to meet other physcians and engage with each

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other in multiple ways. These networking connections can lead to professional development, mentorship, curbside consults, and referrals.

Social connections lead to friendships across rivers and health systems. If a resident or physician has just moved to Pittsburgh and has yet to make many social connections, the ACMS is the perfect place to find a new circle of friends and colleagues. Meet your colleagues from the other side of the river or from across the county. Share and compare experiences; is the grass really greener? We all live in artificial professional bubbles—let’s burst them with glee and meet each other in happy and low stress settings.

ACMS events include networking socials like the ACMS Honors at the Heinz History Center and the Distinguished Award Event in November 2024, family friendly events like the ACMS Night at the Pirates Game, and many others throughout the year. The Women in Healthcare Committee Launched in Summer 2023; planned events in 2024 include a networking/speed mentoring-event, a potential half day conference with leadership training, and other quarterly events to provide guidance and support to female physicians in Allegheny County.

Physician Advocacy and Representation

CME

Self-care

ACMS offers live interactive CME programs including mandated reporter and opioid training CME courses which fulfill license requirements without spending endless hours clicking on a computer screen. ACMS affiliation with PAMED (our state medical society) allows for even more CME opportunities.

Need support and resources for yourself personally and professionally? We want to know what you need so we can help provide it or direct you to it. We have to look out for each other.

Physician advocacy and representation is at the heart of what we do. We advocate for our members at the local, state and national levels, working to ensure that healthcare policies and regulations align with the best interests of physicians and patients. ACMS has the largest active physician representation at the PAMED House of Delegates, which employs lobbyists at the state level as the AMA (national level organization) employs lobbyists at the national level to make sure physician voices are heard on legislation and regulations.

Our strong relationship with local law firms allows us to provide our members with updates onlaws and regulations. The ACMS team is also tapped into the legislative teams at both PAMED and the AMA, with frequent updates and communication regarding policy at both a state andnational level.

Are you frustrated with problems that shouldn’t exist in your daily practice of medicine? Organized medicine works and it can help fix those problems you see at work every day. There’s no better way to effect change in our field.

www.acms.org

Editorial We all preach social connection, physical and mental health care to our patients, but who’s looking out for us? This is a need that ACMS aims to fill. In 2023, the ACMS was awarded a $10,000 grant to create a physician wellness program. This program, set to launch in late 2024, will provide members with a safe place to seek mental health support.

Additionally, the ACMS is a proud supporter of the National Physician Suicide Awareness Day campaign. The entire month of September has been dedicated to raising awareness about the epidemic of physiciansuicide and to improving physician mental health.

We’ve offered direct links to confidential mental health resources during the pandemic and before, and also provide member discounts for dental, life, disability and malpractice insurance among other benefits.

Community Outreach and Grants ACMS is involved in community outreach and charitable activities. We aim to improve the health of the community and re-establish the image and relevance of physicians as integral to the everyday life and social fabric of our communities.

Want to make a difference on a grass-roots level in your community? ACMS can help with that. We’ve made direct impacts on community health including sourcing and distributing infant formula to local agencies and N95 masks to physicians during the pandemic.

Have ideas for public health initiatives?

Come aboard and benefit from the collective resources and members of the ACMS to help your community.

Know a worthy community organization deserving of support? The ACMS Foundation awards over $250K in grant dollars each year to non-profits in Allegheny County. Grant awardees also gain exposure to the physician community; these relationships encourage volunteer work, board engagement and publicity in the community at large.

ACMS maintains relationships with Allegheny County healthcare organizations, hospitals and clinics through its members to address common challenges, share resources, and enhance healthcare delivery in our region.

The Bulletin Lastly, there’s this humble Bulletin. The ACMS Bulletin is a monthly publication with over a century of storied history that provides peer to peer information on issues directly

relevant to physicians. It’s a relaxing piece of mail about medicine that you can look forward to reading each month. The Bulletin features helpful and relevant financial, legal, and pharmacological articles written by experts in the field for ACMS members. Specialty society events are also spotlighted as well as ACMS member events and benefits. All members are invited to submit articles for publication, and our editorial board provides insightful perspectives on medicine and beyond. The cover photo is one of 12 winners of the annual member photography competition. ACMS also has an online Blog, ACMS Insights, and a bi-weekly newsletter called ACMS Snapshots as well as a social media presence for your convenience.

We all went to medical school to help people. Let’s help each other as we fulfill that calling.

The ACMS is a gentle and lively place where you will find fellowship, support and advocacy.

Tell your colleagues to come join us, and if you have not renewed your membership, I encourage you to renew TODAY. The water’s fine. And we have cookies.

Allegheny County Blood Lead Testing Survey Blood lead testing is mandatory for children in Allegheny County. Lead testing can easily be incorporated as part of a well-child visit for all children in Allegheny County at 9- or 12-month exams and again at the 24-month exam. We are conducting a survey on child lead testing and provider knowledge of Allegheny County Health Department services regarding lead, such as home lead risk assessments. We want to gain a better understanding of the provider-side of lead testing, as well as to share information on the services that the health department can provide.

Please take the time to take our survey regarding pediatric blood lead testing, and please feel free to share the link with other healthcare providers: https://alleghenycounty.az1.qualtrics.com/jfe/form/SV_cuXlAzI5zxbwrRA

ACMS Bulletin / October 2023

(or here’s a QR code)

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Editorial

The Others How Support Staff Can Make or Break Patient Experience Andrea G. Witlin, DO, PhD

P

hysicians typically opine that they are the most important member of their respective patient’s health care team. This impression appears to be supported by the quantity and focus of the questions on the Press-Gainey surveys. I’m typically complementary vis a vis my docs. Queries and my responses relating to support staff and the overall team interactions appear to be glossed over on many of the surveys. But as I reminisce over my numerous experiences as a patient, many times it’s “the others” who impacted my day to day care the most.

Who are the others you ask? Simply put, they are the support staff – the receptionists and central appointment phone bank operators, the aides and nurses, the pharmacists and RX plan personnel, the lab techs and IV nurses, the parking lot attendants and transport personnel to acknowledge a few. We all know that the receptionists can make or break a practice. But they are among the lowest paid and least respected (other than perhaps cleaning staff) in the health care “food” chain. How often do physicians observe how their receptionist greets and interacts with their patients?

How often do physicians observe the aesthetics of and the interactions in the waiting rooms? A pleasant, welcoming 8

greeting puts me at ease as opposed to a gruff utterance, “last name” or worse yet, no greeting at all while being directed to sign in on a narrow line with a dirty, small pencil (or pen) when the receptionist is not visually busy and there are no other patients waiting. A dirty waiting room with a correspondingly ill kept restroom is a further turnoff. In recent years, having a working Wi-Fi connection is a must, especially for long delays.

As in real estate, location, location, location is everything. Is the office conveniently located? Is there a fee for parking? How difficult is the parking garage to navigate? How far is the walk from the parking area to the office? As a patient with orthopedic and cardiopulmonary limitations, I’ve been amazed at the answers to my accessibility questions and concerns.

The typical response to my query regarding the distance that I will need to walk is “not far”. When I try to drill down, “about a block” is another typical response. Yes, some places have valets and escort services. But some waits for the valet or transport can be lengthy and uncomfortable. In the past six months, I’ve had a provider, nurse manager, x-ray tech, and front office manager personally transport me to my car by wheelchair as the “standard” transport was either unavailable or an

indeterminate wait. I recall and value those experiences more than my visits with the associated physicians.

Another impediment to accessing care are the central appointment phone bank operators. Let’s be real – some of the prompts are beyond annoying before even be able to speak with a real person. The voice recognition software never seems to understand my requests. Before long, I find myself screaming at the errant interpretations of my voice. Far too often I get transferred to the wrong person or service and need to start over. There are also the times that I’m confident that I dialed the direct office number and nonetheless still get transferred to central appointments.

On many of those occasions, I know in advance that central appointments are unable to schedule the particular nuanced appointment or procedure that I need, but the attendant insists on trying anyway and resists transferring me to the specific office staff. One of my worst experiences recently was the attendant freelancing and entering the wrong diagnosis code despite my detailed instructions to the contrary. This was all unbeknownst to me as I was in sole possession of the “correct” printed order (from a different health care system). When I arrived for my appointment, the receptionist www.acms.org

Editorial never asked for my printed orders.

As a result, she admonished me that I wouldn’t be allowed to receive care unless I signed an unnecessary Medicare ABN form. Furthermore, she refused to allow me to speak to a supervisor, the technician or any other personnel. It took hours to track down the source of the error. It took far longer to recover from the subsequent aggravation and to reschedule my procedure. I have now mentally added to my to do list to double check that codes entered into the computer match reality.

While I’m on the subject of instructions…I have trouble containing my laughter when I’m told, “to wear comfortable shoes for my imaging appointment”??? Invariably I’m most amazed when the imaging appointment is for a condition that has limited my mobility, e.g., MRI for lower body orthopedic issue or CT of my lungs.

The operator is so intent on reading their requisite list of instructions that all common sense and compassion have vanished.

Another pet peeve revolves around imaginary Medicare rules. Yes, I know Medicare can be a pain. Yes, at times some of the rules are rigid and annoying. But none of us need to manufacture any extra rules. One of my favorite “new rules” is asking for mine and my husband’s retirement date. This is NOT a Medicare requirement – I’ve queried Medicare on multiple occasions. It’s information for Social Security eligibility, not Medicare.

Moreover, if it’s a “mandatory requirement” at ALL visits, it should be queried at ALL visits, at ALL health systems. It’s not. Furthermore, how

many seniors and elderly patients actually remember those dates? To add insult to injury, the incorrect dates populate my patient portal regardless of how many times, I re-enter the correct date.

I guess I’ve picked on the front office staff enough. Next is the process of being “roomed”. Recently, I commented about being disrespected by “young” assistants calling me “Andrea” and acting like I was a stereotypical older patient. So, a supervisor changed my EMR profile to reflect my preferred manner of being addressed as “Dr. Witlin”. It couldn’t be clearer in my record. Yet, at least half the time, I’m still called Andrea.

It’s getting better, but for years, the typical “weigh” station never had a place to sit down to take off shoes, hang jackets etc. I have custom shoes, braces, and orthotics that at any time add 3-5 pounds of weight (5% of my body weight). I’m amazed at how many assistants or nurses both question my rendition and/or refuse to deduct the extra weight. On the one hand, I shouldn’t care because I weigh myself daily. But on the other hand, I have medication dosages calculated based upon weight and diseases where specific weight gain/loss are followed by my physicians. If my weight is important enough to obtain, it should be done correctly.

I’ve published many peer-reviewed manuscripts, book chapters, and articles about blood pressure. So, I’m especially keen on technique, timing, and position of obtaining blood pressure readings. Normal blood pressure increases with activity.

Invariably (over 95% of the time), the

aide checks my BP immediately after my exhausting walk from the waiting room to exam room. Add to that any BP elevation as a result of aggravation from the aforementioned experiences and/or certain clinics or pre-procedure readings that are “triggers” for me.

Recently, I’ve taken to joking that “they didn’t aggravate me enough” because my BP was still “normal”! I realize that everyone is rushed and stressed and thus incorrect technique to measure BP is pervasive. But…it should be measured correctly. And the cuff itself should be cleaned before/after use! I even had one nurse accidentally drop the cuff on the floor and immediately thereafter place the cuff on my arm!

Proper hygiene is an ongoing issue.

My husband calls me the germ freak, but many of these examples are just common sense. Not cleaning the pulse ox. Not wearing gloves when starting my IV or purposely ripping the index finger of their glove. Donning gloves and then touching “dirty” surfaces, e.g., chair, mask. The aide or nurse grabbing my mask to pull it off instead of asking my assistance.

Wiping my arm with alcohol for blood draw or IV and then re-touching area with unsterile glove or bare hand.

Not wearing gloves (when standard practice dictates gloves), not washing hands (yes this really does happen).

I’m wearing down just recounting these experiences. This brings me to a gem from this past week. I was a patient at a “new” independent office.

I filled out the requisite history and demographic forms in advance. As per my usual practice, I added my typed, complete history and medication list.

Continued on Page 10

ACMS Bulletin / October 2023

9

Editorial From Page 9

The aide was visibly annoyed with me.

She was simultaneously incredulous that the list was so long, so complete, and actually correct. The thought of scanning the paper, leaving the details to later, and/or letting the physician

figure it out apparently never occurred to her. I was on the verge of walking out. I blurted out, “I can probably simplify this in 3-4 minutes with the doc”. I should have added “if you think your job is rough transcribing my history, just imagine living with these issues”! Fortunately, at least for now, the physician encounter was beneficial.

I can add more examples. But I’ll stop for now. Back to the Press-Ganey forms…I’m not sure that anyone really pays attention to them other than to post anonymous positive comments and give multiple stars. I have left my name and contact information on many occasions (associated with both good and bad reviews). I’ve yet to be contacted. It’s rare to find comment cards and boxes anymore.

Strategic Planning When joining or leaving a health system.

For information contact John Fenner Cell: 412-638-1846 Email: fenner@fennercorp.com

I’ve recently found it difficult to get through to administrative personnel to give comments both good and bad. I haven’t decided if people no longer care or are too busy to bother (I hope not). We’re told that we’re on a recorded line during many phone encounters – it sounds like a threat.

So many times, I respond “I sure hope this is recorded and that someone is listening”.

The “others” can make or break our collective experience(s). Stories like mine are repeated many times over and fill the comment boards on NextDoor and the like. Years ago, I was told, “you get more bees with honey”. A little extra honey would help us all.

Three Penn Center West Pittsburgh, PA 15276 fennercorp.com Specializing in Hospital and Physician Consulting and Billing Since 1991

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www.acms.org

Perspective

“…..And Worry About It Later”

Anthony L. Kovatch, MD “Let everything happen to you Beauty and terror Just keep going No feeling is final” —Rainer Maria Rilke (1875-1926), idiosyncratic Austrian poet and novelist, whose work is viewed by critics and scholars alike as possessing undertones of mysticism, exploring themes of subjective experience and disbelief Musical Accompaniment: “Bridge Over Troubled Water”

by Simon and Garfunkel— released in 1970, the year that Gary Gramc was born.

When I crossed the bridge over the waters of the three rivers and viewed the skyline of downtown Pittsburgh for the first time in early July of 1981—-knowing nothing of life, love, loss, true happiness, or even the art of pediatrics—I bargained with myself that I would return to the beaches

ACMS Bulletin / October 2023

and glamor of the East Coast after tolerating two years of hard work and loneliness as a fellow in pediatric infectious diseases in what at the time seemed a foreign land. I was unaware in the somber mood of that evening dusk that I would soon encounter two fellow travelers at the Children’s Hospital who would become the heroes of my life.

The first and more predictable individual would be my future wife Mary with whom I crossed paths “one enchanted evening” in the bacteriology laboratory; it turned out that she had been assigned to identify the bacteria in cultures of middle ear pus obtained in a research study. The bacteria in question—at that time called Branhamella catarrhalis (but subject to change when its popularity among Infectious Disease gurus skyrocketed)—was discovered by our department to be a bigger player in resistant ear infections than previously appreciated. It was love at first sight for me, we had a whirlwind affair, and I was overwhelmed with the notion of a rapid proposal.

However, despite knowing nothing of life, love, and loss, I had been cursed with a profound first-hand awareness of family suffering, discord, and worry beyond my control. When I was 9 years young, my dear mother— my greatest agent of affection and trust—embarked at the age of 42 on the inexorable course of psychological and physical deterioration characteristic of Huntington’s Disease.

Presenting primarily with psychiatric aberrations, the genetic condition— presenting at a later age or mercifully

denied in previous generations—took years to be diagnosed. The genetics bred true, affecting 6 of the 12 living siblings in the well-to-do Italian family of professionals; “Mommy” was the proband and the genetics were intentionally hidden from her 2 sons.

Our father, who would eventually collapse under the extraordinary weight of “the slings and arrows of outrageous fortune” caused by a simple loss of the coin toss at his loving wife’s conception, did his best to kindly deceive us of the heavy burden of this knowledge on our own lives by claiming that the disease mercifully “skips a generation”! But we and our cousins were not that gullible, and the specter of this unrelenting disease hung mercilessly over all of us until we reached senescence. As a fledgling physician who possessed both first- and second-hand knowledge of this psychological brutality, fear was my copilot: Fear of bridges, of crossing water, I might have died A thousand times already with one Swerve of the wheel.

— from “The Mind, It Strays in the Dark”

by Noah M. Raizman, MD, MFA —JAMA 330:12. Page 1195 This overarching knowledge provided the kind of conundrum I chose to ignore until my future wife revealed to me that a milder but similar degenerative condition—also of autosomal dominant inheritance— existed in her family of 12 siblings; Continued on Page 12

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Perspective From Page 11

I needed an affirmation that the best option was blind courage and acceptance of the consequences of love. However, that would come later. I still needed to impress Mary that I truly was, as defined by the Wizard of Oz, a “good deed doer.”

It was winter and, after 6 months of having crossed the bridge, I had become a budding Penguins fan.

As a fellow, I was charged with a study to determine whether antibiotic prophylaxis would be effective and safe in preventing infections in immunosuppressed children on anticancer chemotherapy. One of my patients was a young adolescent boy who required an amputation of his lower leg as a cure for a malignant bone tumor; the unfortunate boy was very stout-hearted---he was an elite ice hockey player.

Across the hallway in the oncology ward of the Children’s Hospital of generations gone by was a younger boy named Gary who had the most serious form of acute leukemia but was universally smiling and happy, so much so that he called me “Gilligan.”

Forty-one years later I learned from Gary’s mother, Phyllis, that he had honored me with this moniker because I had amused him during his times of suffering; he was not an elite athlete, but he did play street hockey and lived in the charming little town of Spring Garden.

To upgrade the spirits of these unfortunate boys, but mainly (in retrospect) to upgrade my romantic standing with Mary, I boldly called up the Penguins promotional office and requested a visit from a first-year

Penguins hockey star Paul Gardner, patient Gary, and his older brother David performing a “hat trick” on the Oncology ward at Children’s Hospital in May of 1982. The author was not absent; he was probably taking this photograph to preserve the memory.

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player eager to make a reputation for himself and impress the management.

The employee to whom I made the request might have envisioned that I was the Chairman of the Department of Pediatrics. Within a few days, I escorted Paul Gardner from the parking garage to the Oncology floor.

Paul was an experienced center from Canada who was no stranger to the National Hockey League and was making his second of 4 years with the Penguins the highest scoring (39 goals) of a long career as a player and coach. His career statistics included an identical 201 goals and 201 assists--as well as 207 minutes in the penalty box; he was a well-rounded player, indeed!

However, I am convinced that the powers-that-be assigned Paul to Gary’s case with the main objective of making the young boy’s mother one of the heroes of my unsettled life. Phyllis and I became close enough friends and I admired her courage under suffering to such a degree that I confided in her before I proposed to Mary. I was posing the same hackneyed but timehonored question to anyone who would listen (including the entire hospital maintenance crew): What advice would you give me about getting married?

I had cornered Phyllis as she was taking a coffee break in the snack shop/ gift shop at the hospital in the mid-afternoon. I remember that she looked tired and distracted and had probably been up all night with Gary.

“What can you tell me, Mrs. Gramc (as I called her in those days)?

www.acms.org

Perspective Phyllis chuckled but responded with total conviction (although she was unaware of my conundrum): “Get married….and worry about it later.”

And so, I did.

I would cross the bridge and get married within a few short weeks after I took Phyllis’s advice seriously to heart. I would remember the advice after each of my 4 children and 3 grandchildren was born. I would dig the advice out of the recesses of my mind whenever I had a pivotal decision to make about love or loss----in my own life and in the lives of the thousands of families I wound encounter over 40 years of pediatric practice.

Gary would go into remission from his leukemia after receiving a bone marrow transplant from his sister Carol. After many years of remission and fulfilling employment, he would pass away from an unpredictable complication of his disease. Ironically, I would care for Carol’s four children (especially her 3 boys who were elite wrestlers and football players) in my practice. Over the years, I would offer them counsel about life, love, and loss--always concluding with: “Get married

and worry about it later.” Over the long years, I came to eminently understand that this advice was the distillation of such profound commentary that only the saints, poets, and writers can adequately put it into words: “The depth of the love of parents for their children cannot be measured.

It is like no other relationship. It exceeds concern for life itself. The love of a parent for a child is continuous and transcends heartbreak and disappointment.”

of the life-changing advice she gave to “Gilligan” that day in the snack shop.

Anyway, we agreed to relive that moment. I asked her as I departed if it was OK that I write this story.

“Write anything that you want!” she chuckled.

“And worry about it later!”

I bemusedly replied.

And so, I did.

— James E Faust (1920-2007), American religious leader, lawyer, and politician Recently, I visited Phyllis in the assisted living facility where she hangs out surrounded by all the warm memories of Gary and her recently deceased husband “Umps.”

I reminded her that, although she still looked incredibly young, she was the “longest running show on Broadway”: the longest running mother with whom I had interacted and admired in my years of professional practice. After 41 years, she claims to have no memory

Time it was And what a time it was It was a time of innocence A time of confidences

Three elite athletes and admirable young men: the nephews.

“Gilligan” is convinced that Uncle Gary has been the hero of their young lives!

ACMS Bulletin / October 2023

Long ago, it must be I have a photograph Preserve your memories They’re all that’s left you — from “Bookends”

by Simon and Garfunkel 13

Perspective

Is There a Doctor in the House? And Who Is the Patient?

Bruce Wilder MD, MPH, JD Like most of us, I have more than once happened to be in a place where some medical emergency occurred. That includes in a restaurant, in an airport terminal, and on an airplane in flight.

On one occasion, we were about an hour into a transatlantic flight (not yet over the ocean) when a young man had a grandmal seizure. I made sure he had an adequate airway until the seizure stopped, and later found that he had a history ofseizures, but for some reason he had stopped taking his medication a few days earlier. As it happened, the “emergency”medical kit had no anticonvulsants. So I was asked whether the plane should make an emergency landing. The possibility of another seizure, or worse, the possibility of status epilepticus halfway across the Atlantic Ocean, even though remote, led me to recommend an emergency landing. So, in addition to my unexpected doctor-patient relationship, I also had a planeload of travelers who would be affected (such as missed connections), which made the decision much more difficult. And in making that decision I had to share information with the flight crew and ground control that was obtained in the setting of the doctor-patient relationship.

14

On another, about 45 minutes into a flight from Los Angeles to Pittsburgh, I saw a middle-aged woman having epigastric and retrosternal pain. I was able to get a history and do an examination with her stretched across three seats with the armrests down, and with only a stethoscope, but felt confident that this was not cardiac in origin, and probably related to peptic ulcer disease.

I was invited into the cockpit to speak with ground control and advised that an emergency landing was not necessary (in this case the decision was a little easier because the entire flight was over land, and an emergency landing could still have been done if something changed). Later, the airline sent me a letter of thanks and even told me that my diagnosis had been correct.

In both cases, thankfully, neither of the individuals was a public figure, and I did not have to deal with explaining anything in a public forum.

So I was intrigued by what transpired after Senate Majority Leader Mitch McConnell had a couple of episodes (like what my grandmother used to call “spells”) while speaking in public. There was a lot of speculation about what had caused these episodes, including that of physicians, some of whom were neurologists. In a September 5, 2023 letter1 to his patient, made public by Senator McConnell, Dr. Brain Monahan, the Office of the Attending Physician (O.A.P.) advised that there was no evidence of seizure disorder, stroke, TIA, or movement disorder, and that no changes in “treatment protocol” were recommended. It was less than satisfying in that no diagnosis or even possible diagnosis was given, except that it was later reported that Dr. Monahan “suggested” the cause may have been

dehydration—a diagnosis that was strongly criticized by Senator Rand Paul, himself a physician (although not a neurologist), going so far as to call it “misinformation”.2 Dr. Arthur Caplan, a highly respected medical ethicist at N.Y.U. Langone, compared the position of Dr. Monaghan to that of an athletic team physician (or perhaps other situations, like that of a company doctor), with dual loyalties.3 The O.A.P. originally came about in 1928 when the need for having a physician readily available to treat medical emergencies in members of Congress was recognized4. Its duties have expanded significantly since then, not only as the primary care physician for many members of Congress and the Supreme Court, but as a public health physician as well, with another set of loyalties and obligations – again not relevant in the McConnell case.5 I suggest that the first ethical obligation of the O.A.P. as treating physician (as it would be with any treating physician) is to the patient to

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Perspective keep confidential information acquired in the setting of the doctor-patient relationship. It is possible, of course, that some disclosure (say, if there is a risk of imminent danger to others) may be ethically required, or otherwise required by law.6 That said, it is not acceptable for a physician to release information that they know to be false or unsubstantiated in light of facts they know to be true. What information is divulged to the public should be decided by the individual themself; the physician must not allow themself to be placed in the position of revealing confidential information or inaccurate information. In other words, the patient must bear the political

consequences of what information they authorize to be released – or not release.

Even if the patient is lying about their diagnosis, I believe the physician has no ethical obligation to publicly correct the record, unless, of course, the lie endangers others.

So, in the end, perhaps the Attending Physician can and should escape politics.

What do you think?

Dr. Wilder is a past member of the American Bar Association Special Committee on Bioethics and theLaw, and of the Ethics Committee of the American Society for Reproductive Medicine.

References 1 Cark Hulse, McConnell Releases New Health Assurances From the Capitol’s Physician, NEW YORK TIMES, 9/5/23, available at https://www. nytimes.com/2023/09/05/us/politics/mcconnellhealth-capitol-physician-letter.html 2 Kayla Guo, At the Capitol, Even the Attending Physician Can’t Escape Politics, New York Times, 9/16/23 (print), also available at https:// www.nytimes.com/2023/09/15/us/politics/brianmonahan-capitol-attending-physician.html 3 Ibid.

4 Ibid.

5 http://wikileaks.se/leak/crs/RS20305.pdf 6 Bearing in mind the oft-quoted adage that “the law is what you must do, and ethics is what you ought to do”, and that sometimes there may be a real conflict for the physician (although such does not appear to be the case here).

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15

Materia Medica Medication Safety Spotlight: Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2) Christopher L. Biser and Linda M. Nicolaus, BS, PharmD Diabetic ketoacidosis (DKA) is a potentially life-threatening complication that can occur in patients with both type 1 and type 2 diabetes mellitus. Patients with DKA typically present with elevated blood glucose levels (>250 mg/dL), severe metabolic acidosis (pH<7.3, serum bicarbonate <18 mEq/L), increased serum ketones and dehydration.1 In a small percentage of cases, however, patients may present with the other clinical and metabolic indicators of DKA, but without significantly elevated blood glucose levels, and up to 7% of all reported DKA cases occur in patients with a blood glucose level of <250 mg/dL.2 This clinical presentation is termed normoglycemic or euglycemic DKA. The lack of significantly elevated blood glucose levels may lead clinical suspicion away from the consideration of diabetes mellitus as the cause of a patient’s symptoms, which can delay the diagnosis and treatment of euglycemic DKA and worsen patient outcomes.3 SGLT2s are commonly used for the treatment of type 2 diabetes, and occasionally off-label for type 1 diabetes, and the overall use of these agents is likely to increase based on recent and pending studies that show cardiovascular benefit from these agents in some patient populations. These agents are generally considered to be safe and effective options for the management of diabetes mellitus; however, the development of DKA continues to be a known risk for diabetic patients. A 2017 review of reports from the U.S. Food and Drug Administration Adverse Event Reporting

16

System identified more than 2,500 reports of DKA in patients that were concomitantly receiving SGLT2-mediated.4 It is estimated the fatality rate for all DKA patients is 0.4%, but this rate may be as high as 1.54% for patients concomitantly receiving an SGLT2 inhibitor.2 SGLT2 Inhibitor Mechanism of Action Glucose from the blood is normally filtered into the urine by the renal glomeruli; approximately 180 grams of glucose are filtered from the blood of a healthy human daily.5 Under normal conditions, most of this glucose is reabsorbed.

SGLT2, located in the early segment of the proximal tubule of the kidney, is responsible for almost 97% of glucose reabsorption into the bloodstream from the urine.6 In a person who experiences hyperglycemia, SGLT2 expression can be upregulated, further increasing the portion of glucose reabsorbed into the body.

This is a maladaptive change that can expose a person to the complications of further hyperglycemia.7 The dominance of SGLT2 in the reabsorption of glucose makes it an optimal target for medications intended to lower blood glucose levels. Inhibition of SGLT2 decreases renal glucose uptake leaving glucose in the urine for removal from the body. This mechanism offers a unique method to lower blood glucose levels to further glycemic control.

Numerous trials have studied the utility of SGLT2 inhibitors in the management of diabetes. In the EMPA REG MONO trial, the currently marketed 25 mg strength of empagliflozin was shown to reduce hemoglobin

A1C by 0.78% at 24 weeks compared to a 0.08% increase in A1C in participants treated with a placebo comparator.8 The reduction was achieved without an increase in hypoglycemia; ketoacidosis was not mentioned in the report.

A similar Phase 3 trial studied dapagliflozin as monotherapy for type 2 diabetes management, finding that dapagliflozin at the maximum dose of 10 mg currently marketed reduced hemoglobin A1C by 0.89% and fasting blood glucose by 28.8 mg/dL at 24 weeks.9 Aside from type 2 diabetes, SGLT2 inhibitors have shown benefit in heart failure and chronic kidney disease. A meta-analysis of five large trials studying dapagliflozin, empagliflozin, or sotagliflozin in patients with heart failure found that SGLT2 inhibitors reduced risks of cardiovascular death, heart failure hospitalizations, first hospitalization for heart failure, and death from any cause.10 DKA was described in some trials included in the metaanalysis without distinction as to whether these were cases of euglycemic DKA. A second meta-analysis of 27 studies in a total of 7363 participants also found that SGLT2 inhibitors reduced the risk of cardiovascular death as well as slowed annual eGFR decline in CKD.11 Proposed Mechanisms of Euglycemic DKA Euglycemic DKA is a complex complication of SGLT2 inhibitor therapy that was not researched in the major clinical trials that initially studied the efficacy and safety of these medications. Recent attention to the complication has spurred various publications to describe possible mechanisms that can lead to euglycemic DKA.

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Materia Medica Part of the mechanism behind euglycemic DKA has been tied to the metabolic changes that SGLT2 inhibitors cause through the induction of glycosuria. A 2014 study investigated the metabolic effects of empagliflozin on obese individuals with controlled type 2 diabetes.12 Before giving empagliflozin, the investigators found that the participants with diabetes had severely impaired insulin sensitivity compared to historical controls without diabetes. The participants with diabetes also exhibited a rise in GLP-1 (glucagon-like peptide 1), a decrease in their free fatty acid levels, and a typical rise in insulin levels in response to a carbohydratecontaining meal.

After being given a single dose of empagliflozin 25 mg, the investigators observed significant glycosuria even within three hours of a carbohydrate load.12 The investigators observed that along with glucose reductions in the blood of the participants, there was also a decrease in insulin levels and insulin secretion compared to baseline levels without empagliflozin. Increased glucagon levels were observed, and tissue glucose utilization was reduced. An increase in endogenous glucose production and GLP-1 levels were also observed compared to baseline. The previously observed decrease in free fatty acids after a meal was not as pronounced after taking empagliflozin. In a chronic study involving four weeks of empagliflozin therapy, tissue glucose utilization was further decreased beyond what was observed in the acute study. Free fatty acid suppression after a meal was still impaired compared to baseline at the end of the chronic study. The decreased insulin levels, increased glucagon levels, and increased levels of free fatty acids promote the oxidation of free fatty acids as an alternative source of energy.

This process creates ketone bodies that can cause the metabolic acidosis that characterizes DKA.13 In addition to the above metabolic changes, it has also been observed that enhanced glucose excretion in the urine can lead to the

ACMS Bulletin / October 2023

reabsorption of the ketone bodies that play a role in DKA.14 Animal studies have shown that nonselective SGLT inhibitors promote the reabsorption of acetoacetate. It has been proposed that this reabsorption of negatively charged ketone bodies is driven by a decrease in SGLT2 inhibitor sodium reabsorption into the renal tubule.15 The reabsorption of betahydroxybutyrate, a ketone body that plays a prominent role in euglycemic DKA symptoms and diagnosis, was not investigated in these animal studies, but the reabsorption is feasible as both beta-hydroxybutyrate and acetoacetone can be reabsorbed via sodium monocarboxylate transporter-1 (SLC5A8) in the renal tubules.

The metabolic changes described above do not cause euglycemic DKA in most patients taking SGLT2 inhibitors.2 These changes, when combined with a potential for ketone body reabsorption via the renal tubules, could create an additive rise in ketone bodies that leads to ketoacidosis. Because glycosuria continues throughout these processes, serum glucose levels may not appear elevated during the evaluation of a patient.

Risk Factors Many patients on SGLT2 therapy that develop euglycemic DKA do so during the first 2 months of therapy, and the condition typically develops in conjunction with a precipitating factor.2 Precipitating factors can include discontinuation or dose reduction of insulin, surgery, viral or bacterial infection, decrease in caloric intake or dehydration, which can be precipitated by vomiting or excessive ethanol intake.2 Gastroparesis, ingestion of substances such as alcohol or cocaine, pancreatitis, pregnancy, and renal or hepatic disease have all been associated with euglycemic DKA.13 Another factor that produces ketosis in humans is adherence to a ketogenic or very low carbohydrate diet. A ketogenic diet reduces glucose intake, and the body shifts to producing a surplus of acetyl-CoA as an

alternative source of energy.16 The upregulation of acetyl-CoA results in increased levels of beta-hydroxybutyrate, acetoacetate, and acetone, the ketone bodies that lead to ketosis.

This does not pose a significant risk to most individuals following a ketogenic diet, but those on an SGLT2 inhibitor are already predisposed to increased levels of free fatty acid lipolysis and ketone body reabsorption.12-15 This combination could put patients at a compounded risk of euglycemic DKA. Presentation Patients with euglycemic DKA related to SGLT2 use commonly present with non-specific symptoms such as nausea, vomiting and abdominal pain.2 Less common symptoms include altered mental status, tachypnea, malaise and diarrhea.17 Laboratory parameters identified by one systematic review specific to patients receiving SGLT2 inhibitors included blood glucose levels of 68-500 (average 265.6) mg/dL, carbon dioxide levels of 5.2313.67 (average 9.45) mEq/L, anion gap of 16.3-26.9 (average 21.6) mEq/L and pH of 6.9-7.2 (average 7.05).17 Since blood glucose monitoring is the mainstay of outpatient diabetes management, it is likely that patients themselves will not identify euglycemic DKA as a diabetes-related illness if their blood glucose levels are not markedly elevated, which can delay presentation to a health care provider.

When patients do present to a healthcare provider, their non-specific complaints may appear to be unrelated to their diabetes, potentially delaying accurate diagnosis.

Since DKA is a severe and potentially lifethreatening condition that requires emergency medical care and hospital admission in most cases, it is important that euglycemic DKA be considered in the differential diagnosis for patients with diabetes who present with the above non-specific symptoms.

Continued on Page 18

17

Materia Medica From Page 17

Conclusion

Management

Euglycemic DKA is a severe potential adverse event that can be related to SGLT2 therapy.

The risk of missed or delayed identification and treatment of euglycemic DKA presents a very real patient safety concern that can lead to suboptimal patient outcomes. With the increase in SGLT2 prescribing that we are likely to see in the future, it is imperative that physicians be aware of the risk of euglycemic DKA and the appropriate management strategies so that treatment is not delayed.

Euglycemic DKA should be managed similarly to hyperglycemic DKA, with the goals of restoring volume and correcting the metabolic abnormalities. Fluid replacement should be initiated immediately, with isotonic saline as the usual choice.2 Potassium may be added to the IV fluid if hypokalemia is present. Following the initial volume repletion, insulin infusion at a rate of 0.02-0.05 units/kg/hour should be administered along with fluids that contain dextrose with a blood glucose goal of 150200 mg/dL. Administration of dextrose along with insulin is crucial to avoid hypoglycemia, and patients must be closely monitored throughout the course of therapy. Treatment should continue until resolution of metabolic abnormalities is achieved, which one source defined as having two of the following criteria: serum bicarbonate level ≥15 mmol/L, anion gap ≤12 mmol/L and pH≥7.3.2 In certain situations, it may be appropriate to consider a temporary hold in SGLT2 inhibitor therapy to reduce the risk of euglycemic DKA. As precipitating factors for euglycemic DKA include dehydration or reduced calorie intake, providers caring for athletes may consider holding SGLT2 inhibitors 24 hours prior to a major event.13 Holding SGLT2 inhibitor therapy 3 days before surgical procedures as well as at the onset of an acute illness (infection, cardiovascular event, etc.) may reduce the risk of euglycemic DKA.18 The SGLT2 inhibitor would be restarted after the potentially precipitating event has passed. Patients should also be educated to report to their physician the development of any precipitating factor, such as acute illness or upcoming surgery.

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8. Roden M, Weng J, Eilbracht J, et al. Empagliflozin monotherapy with sitagliptin as an active comparator in patients with type 2 diabetes: a randomized, double-blind, placebo-controlled, phase 3 trial. Lancet Diabetes Endocrinol. 2013;1(3):208-219.

9. Ferrannini E, Ramos SJ, Salsali A, et al. Dapagliflozin monotherapy in type 2 diabetic patients with inadequate glycemic control by diet and exercise: a randomized, double-blind, placebo-controlled, phase 3 trial. Diabetes Care. 2010;33(10):2217-2224.

10. Vaduganathan M, Docherty KF, Claggett BL, et al.

SGLT-2 inhibitors in patients with heart failure: a comprehensive meta-analysis of five randomised controlled trials. Lancet. 2022;400(10354):757-767.

Mr. Biser is a Doctor of Pharmacy candidate at the University of Pittsburgh School of Pharmacy. Dr. Nicolaus is a Clinical Pharmacy Specialist in Medication Safety at the University of Pittsburgh Medical Center Passavant Hospital. She can be reached at nicolauslm@upmc.edu or (412) 748-7818.

11. Toyama T, Neuen BL, Jun M, et al. Effect of SGLT2 inhibitors on cardiovascular, renal, and safety outcomes in patients with type 2 diabetes mellitus and chronic kidney disease: a systematic review and meta-analysis.

References:

13. Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: etiologies, evaluation, and management. Am J Emerg Med. 2021;44:157-160.

1. W esterberg DP. Diabetic Ketoacidosis: Evaluation and Treatment. Am Fam Physician 2013;87(5):337-346.

12. Ferrannini E, Muscelli E, Frascerra S, et al. Metabolic response to sodium-glucose cotransporter 2 inhibition in type 2 diabetic patients. J Clin Invest.

2014;124(2):499-508.

2. D iaz-Ramos A, Eilbert W, Marquez D. Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-1 inhibitor use: a case report and review of the literature. Int J Emerg Med. 2019;12(1):27.

14. Somagutta MR, Agadi K, Hange N, et al. Euglycemic diabetic ketoacidosis and sodium-glucose cotransporter-2 inhibitors: a focused review of pathophysiology, risk factors, and triggers. Cureus.

2021;13(3):e13665.

3. N asa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: A missed diagnosis.

World J Diabetes 2021; 12(5): 514-523.

15. Taylor SI, Blau JE, Rother KI. SGLT2 inhibitors may predispose to ketoacidosis. J Clin Endocrinol Metab.

2015;100(8):2849-2852.

4. F adini GP, Bonora BM, Avogaro A. SGLT2 inhibitors and diabetic ketoacidosis: data from the FDA adverse event reporting system. Diabetologia. 2017;60:1385–9.

16. Paoli A. Ketogenic diet for obesity: friend or foe? Int J Environ Res Public Health. 2014;11(2):2092-2107.

5. V allon V, Platt KA, Cunard R, et al. SGLT2 mediates glucose reabsorption in the early proximal tubule. J Am Soc Nephrol. 2011;22(1):104-112.

6. R ieg T, Vallon V. Development of SGLT1 and SGLT2 inhibitors. Diabetologia. 2018;61(10):2079-2086.

7. D eFronzo RA, Davidson JA, Del Prato S. The role of the kidneys in glucose homeostasis: a new path towards normalizing glycaemia. Diabetes Obes Metab. 2012;14(1):5-14.

17. Burke KR, Schumacher CA, Harpe SE. SGLT2 inhibitors: a systematic review of diabetic ketoacidosis and related risk factors in the primary literature. Pharmacotherapy. 2017;37:187–94.

18. Goldenberg RM, Berard LD, Cheng AYY, et al.

SGLT2 inhibitor-associated diabetic ketoacidosis: clinical review and recommendations for prevention

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Legal Summary Post-COVID Practice Check-Up

By Beth Anne Jackson

Many group practices, liked their patients, avoided tending to everyday legal matters during the COVID public health emergency.

The results, predictably, approximate those of patients who deferred medical care – problems can be detected that could have been avoided with prompt attention. It is time to face the music and conduct your practice’s post-COVID check-up.

Stark compliance.

Significant changes to the Stark Law regulations occurred during COVID, and new rules regarding distribution of profits from designated health services (DHS) went into effect on January 1, 2022. Significantly, the revised rule prohibits segregating DHS profits by service line, a practice that was not uncommon in multi-specialty group practices.

Failure to appropriately distribute DHS profits affects whether a group qualifies as a “group practice,” which is necessary to utilize the “inoffice ancillary services” exception to provide and bill for DHS in your office. Determining Stark compliance also entails examining other aspects of your group’s characteristics.

Given the draconian consequences of a Stark violation, a thorough review of your group practice’s Stark compliance is always recommended, especially if the issue has not been addressed in several years.

Medicare provider enrollment issues.

Medicare rules require all providers to update their enrollment information. Did one of your partners retire during or after COVID? Any managing employees? Changes in ownership (including a change in an authorized or delegated official), a change in practice location, and any final adverse legal actions (felony or suspension of a federal or state license) must be reported within 30 days of the change. All other changes must be reported within 90 days of the change. If the group

ACMS Bulletin / October 2023

is also a DMEPOS supplier all changes to information on that enrollment must be reported within 30 days of the change. Practices should review their enrollment information on PECOS and correct any outdated information, because Medicare can revoke billing privileges for failure to do so if they detect an issue first.

HIPAA. The Office of Civil Rights (OCR), which administers and enforces HIPAA, and the Federal Trade Commission (FTC) have raised important issues regarding security risks inherent in the use of online technologies. In a joint letter issued in July 2023, OCR and FTC warned hospitals and telehealth providers about the privacy, security, and legal risks of using online tracking technologies in their websites and mobile apps. Technologies like Meta/Facebook pixels and Google Analytics can track a user’s online activities and may disclose Protected Health Information (PHI), as defined by HIPAA, or personal health information protected under the FTC Act and the FTC’s Health Breach Notification Rule.

Providers using tracking technologies need to examine whether PHI or personal health information is being shared in a manner that violates these laws. Further, with the increasing occurrence of ransomware attacks, OCR has counseled providers on the implementation of multi-factor authentication and training staff on phishing attacks as essential to preventing such attacks. A review of your HIPAA security compliance, including the tracking technology issue, and the performance of an annual security risk assessment are essential.

Employment Practices. COVID changed a myriad of employment practices, some of which may need to be changed again with the end of the PHE. In addition, legal changes, such as the calculation of overtime for salaried, nonexempt employees that went into effect

in Pennsylvania in August of 2022, should be reflected in your employee handbook.

Corporate matters.

Like many norms, corporate formalities may have been set aside during the pandemic.

Practices should review corporate actions and take steps to document approval by their governing body. At the very least, a written consent in lieu of an annual meeting – if one was not held –to approve all physician hires, significant purchases and other transactions should be drafted, signed, and maintained for each year.

Compliance with federal regulations is essential. If a practice knows or should have known that it received Medicare or Medicaid funds to which it was not entitled, failure to repay such overpayments may result in False Claims Act liability, which may result in the payment of treble damages. Reviewing these and other issues now can identify opportunities to detect non-compliance, correct your course, and minimize potential penalties that may be imposed. Further, ensuring proper documentation of operational and corporate issues can be an important risk mitigation measure.

DISCLAIMER: This article is for informational purposes only and does not constitute legal advice. You should contact your attorney to obtain advice with respect to your specific issue or problem.

Ms. Jackson is a Principal in the Health Care Practice Group of Post & Schell, P.C., which serves healthcare providers nationally. She is licensed in Pennsylvania and Texas and maintains an office in downtown Pittsburgh.

She may be reached at 412/506-6356 or bjackson@postschell.com. Her firm’s website is www.postschell.com.

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The ACMS is Proud to Serve as the Association Management Team for the following Specialty Organizations: Editorial Dr. Daffner, associate editor of the calling, American is meant in a benign fashion, adjacent lumbar vertebra, explaining College of it Allegheny County Chandler is considered harmless. her pain. My resident, from Georgia, ACMS Bulletin, isGrant a retired radiologist Surgeons Southwestern However, in today’s politically upon seeing the findings said, in his who practiced at Allegheny General Immunization Coalition Glaucoma Society Pennsylvania Chapter divisive atmosphere, it is best to use deep southern drawl, “Fellahs, there’s Hospital for more than 30 years. humor only when you truly know a lesson here. Crocks daah (die), He is emeritus clinical professor of your audience. As a good example, I too.” Unfortunately for the patient, CT Radiology at Temple University School remember the not so “good old days,” scanning and ultrasound exams had of Medicine and is the author of nine when it was expected that a speaker not been developed. The important textbooks. He can be reached at at a conference or a refresher course lesson is that for most patients with a bulletin@acms.org.

Pennsylvania tell jokes. Many ofThe the “old diagnosis of psychosomatic illness, the wouldGeriatric Greater Pittsburgh Pittsburgh The ACMS Alliance The opinion expressed in this column is that of the timers” were very colorful characters. symptoms are real, and in fact a small Society Diabetes Club Ophthalmology Society writer and does not necessarily reflect the opinion Today, fortunately, speakers are number of these patients indeed Western have Division of the Editorial Board, the Bulletin, or the Allegheny County Medical Society. business-like and jokes are tacitly real abnormalities accounting for their forbidden, since they are bound to symptoms.

References offend someone. Finally, we should Sigmund Freud’s view of humor 1. Shem S. The House of God. Richard was that it was a conscious expression always remember that no matter how Marek Publishers 1978.

2. Freud S, (Strachey J, Trans.). Jokes and unpleasant some of our patients are of thoughts that society usually their relation to the unconscious New York: W. 2 to us, they are still our fellow human suppressed or was forbidden. As W. Norton, 1960 (Original work published 1905). beings. long as the humor, in this case name-

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Allegheny County Medical Society is proud to offer you access to the My Benefit Advisor (MBA) program as your solution for employee benefits and health insurance.

ACMS Members received exclusive pricing as part of this group benefit.

OneDigital is a full service insurance and payroll service provider.

As a member of ACMS, you will receive preferred pricing as well as access to a state of the art benefits and payroll administration software system.

A well-designed website is no longer a viable strategy for medical practices. We bring all practices the comprehensive patient acquisition tools previously only available to health systems in a single inexpensive platform.

ACMS Bulletin / October 2023

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Meet the Team & Get in Touch Meet Your ACMS Support Team! Please feel free to contact any of the team members below.

Members can also reach out to acms@acms.org for general questions and someone on our team will get back to you as soon as possible.

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www.acms.org

“Back to Basics” Jenny Bender, MPH, BSN, RN, CIC

Did you know that our county has an immunization coalition? The Allegheny County Immunization Coalition (ACIC) was founded to educate our county’s public to have increased awareness of recommended immunizations, supporting professional immunization education, and sharing best practices in immunization promotion and education. We also work with our members and their organizations to advance policy issues related to childhood, adolescent, and adult immunizations. ACIC desires to attract and retain members from diverse organizations who are committed to achieving the coalition’s mission.

Our members include physicians, nurses, pharmacists, teachers, human services staff, public health professionals, and community members. We believe we can accomplish more together.

ACIC’s vaccine champions have been working collaboratively and proactively to enhance vaccination rates among children, adolescents, and adults in Western Pennsylvania. Their concerted efforts have brought together various partners from across the state, operating in diverse settings, to augment public awareness, sharpen the focus on healthcare providers, and engage communities

ACMS Bulletin / October 2023

in immunization initiatives. As a result, there has been a marked increase in vaccination rates, which will contribute to improved public health outcomes in the region.

One of the ways that ACIC educates its members and the public is through our annual conference – this year, the eighteenth annual ACIC conference will be held on November 8, 2023, at the Doubletree Hotel in Monroeville, PA. There is a wonderful lineup of speakers that will address important vaccine-related topics like disinformation, influenza, polio, RSV, PA SIIS, and HPV. ACIC would love to see you at the conference if you are interested in promoting immunization in our county. You can register here. At the conference, you will have an opportunity to become a member of the coalition – membership is entirely free to you and will benefit you by offering free educational activities, networking opportunities, and access to all the current immunization schedules and information. You can also add to your resume by serving on our board or any of our numerous comittees, or by volunteering at some of the immunization promotion events we do throughout the year.

We look forward to seeing you at this year’s conference, and even if you can’t attend, we hope that you will considering joining our coalition and helping us in our efforts to immunize Allegheny County!

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ACMS Foundation | 850 Ridge Avenue | Pittsburgh, PA 15212

ACMS Foundation Bylaws Change At the June 13, 2023 ACMS Foundation Board Meeting, the Foundation Board of Trustees approved a Bylaws revision that would add TWO (2) additional Community Board Members to the ACMS Foundation Board of Trustees, for a total of Four (4) Community Board Members, starting with the 2024 Year (Jan. 1, 2024). The suggested Bylaws changes below will be presented at the September 12, 2023, ACMS Board Meeting. The changes will be printed in the September and October ACMS Bulletin for comments by membership. Final changes and approval will be made at the December 5, 2023, Board Meeting.

ARTICLE IX Trustees and Officers 1.

Trustees

The Trustees shall be nine (9) eleven (11) in number consisting of five (5) members representing the Allegheny County Medical Society: the President, President-Elect, Secretary and the Treasurer; the most recent past president of the Allegheny County Medical Society, two (2) four (4) community members who are not physicians, one (1) member who shall have previously served as a physician Trustee and who shall serve as Secretary of this Foundation; and one (1) member who shall have previously served as a physician Trustee and who shall serve as Treasurer of this Foundation. All members shall have an equal vote.

2.

Election

A.

The two four (4) community members shall be elected, in alternate years, for a two-year term on nomination by the Board of Directors of the Allegheny County Medical Society. These members may be elected for two successive terms and shall take office January first following their election.

B.

The five (5) members who serve representing the Allegheny County Medical Society, shall serve for a term of one year, beginning January first, and their terms of office shall coincide with the terms of the Allegheny County Medical Society office held.

C.

The Secretary shall be elected by this Board of Trustees for a term of two years and may serve two successive terms.

D.

The Treasurer shall be elected by this Board of Trustees for a term of two years and may serve two successive terms.

3.

Organization

E.

Meetings of the Trustees shall be held at least twice a year at the call of the presiding officer. Five Six members present shall constitute a quorum with full power to act.

The ACMS Foundation Bylaws can be found on the website at: www.acms.org/acms-foundation/about-the-foundation/ Comments on these changes can be submitted to: ACMS Executive Director Sara Hussey at shussey@acms.org

Respectfully Submitted, 2023 Bylaws Committee Keith T. Kanel, MD (Chair), Peter G. Ellis, MD & Raymond E. Pontzer, MD

To learn more about the ACMS Foundation visit: acms.org/acmsfoundation 30

www.acms.org

ACMS Foundation | 850 Ridge Avenue | Pittsburgh, PA 15212

The ACMS Foundation

ACMS Foundation History Founded in 1960, the Allegheny County Medical Society Foundation has extended the reach of physicians into the community. Many of the remarkable medical achievements are undergirded by a network of organizations supported over the years by the ACMS Foundation’s charitable grants, with the common goal of improving the health and wellbeing of Allegheny County residents.

A diverse range of organizations throughout the county trace their growth in part to the generosity of the Foundation’s community grant making.

Scan this QR Code to Donate via Qgiv or visit acms.org/acms-foundation/donate/

Qgiv allows donors to setup monthly donations.

Consider setting up a recurring donation!

To learn more about the ACMS Foundation visit: acms.org/acmsfoundation

ACMS Bulletin / October 2023

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850 Ridge Avenue, Pittsburgh, PA 15212

ALLEGHENY COUNTY MEDICAL SOCIETY — 2023 MEETING SCHEDULE ALL MEETINGS BEGIN AT 6:00 PM Upcoming Events E xecutive Committee* No upcoming events Tuesday Evenings—2nd Tuesday at the start of each new quarter.

Finance Committee Tuesday Evenings

Board of Directors* Tuesday Evenings

Complete through 2023

November 14, 2023

December 5, 2023

RENEW YOUR ACMS MEMBERSHIP

Committees

TODAY

Dates to be announced

Delegation April, June, August, October Nominating May, August The Allegheny County Medical Society

(ACMS) membership provides advocacy and ACMS Foundation October 24—Grant Proposal Review local support for physicians.

PAMED BOARD RENEW PAMED HOUSEMEMBERSHIP OF DELEGATES / HERSHEY YOUR August 3 October 27-28, 2023 October 26-27, 2024 AMA HOUSE OF DELEGATES More InformationNovember : AMA Interim Meeting 11-14 National Harbor, MD www.acms.org 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) SCAN23—Thanksgiving QR CODE Day February 20—President’s Day (Monday) November (Thursday) May 29—Memorial Day (Monday) November 24—Thanksgiving TO RENEW NOW Friday (Friday) June 19—Juneteenth Day (Monday) December 25—Christmas (Monday) July 4—Independence Day (Tuesday)