Transactions THE NEWSLETTER OF THE PHILADELPHIA PSYCHIATRIC SOCIETY / SPRING 2021
In Memoriam / Holly Valerio, MD It is with great sadness that we share the news of the passing of our beloved colleague, friend, and mentor Dr. Lawrence “Larry” Real. Dr. Real made a lasting impression on pretty much everyone who crossed his path, imparting kindness, wisdom, and always humor. His impact on Philadelphia psychiatry is hard to capture in words. It can certainly be felt in the admiration and gratitude of his many former students, mentees, and colleagues. Dr. Real has inspired so many of us to be better leaders and clinicians, to take time to care for each other and ourselves, and to enjoy life. He was exceptional in his advocacy for and empowerment of his patients and their families, in his dedication to forwarding the recovery movement in Philadelphia and beyond, and in his ability to instill hope and caring in our world of community psychiatry. He was a source of light in this world and has changed it immensely for the better.
Society, the 2013 Exemplary Psychiatrist Award from NAMI Pennsylvania, the 2012 Bell of Hope Award from the Mental Health Association of SE PA, and the 2011 “Righteous Person” award from the TIKVAH/ Advocates for the Jewish Mentally Ill, an organization which he co-founded. He was a charter member of the Pennsylvania Psychiatric Leadership Council and a Distinguished Life Fellow of the APA.
Dr. Real was a colleague, friend, and mentor to many within the Pennsylvania Psychiatric Society. He was a past president of the Pennsylvania Psychiatric Society (2001-2002) and the Philadelphia Psychiatric Society (1992-1993). He remained very active in the Philadelphia chapter serving on committees and offering support any way he could. Dr. Real was the Medical Director at Horizon House in Philadelphia where he was loved by staff, colleagues, and participants alike. He served as the Co-Director of the Fellowship in Public Psychiatry at the University of Pennsylvania. He was also the Chief Medical Officer for the City of Philadelphia’s Department of Behavioral Health & Intellectual disAbility Services from 2015 to 2018.
I first met Larry in 1997 when I was working as a Mental Health worker in Belmont Hospital of which he was a Medical Director and I have fond memories of those times.
Dr. Real’s accomplishments included the 2017 Paul J. Fink Leadership Award from the Philadelphia Psychiatric
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COVID Pandemic Families
A celebration of Dr. Real’s life will be held in the fall when everyone can gather safely. Contributions in Larry’s memory may be made to Horizon House or World Café Live’s education programs. Words of Remembrance for Dr. Real from Members So very sorry to hear the news; I knew him as an amazing and talented medical student! —Barbara A Schindler MD That is sad news. Especially for those of us who had not witnessed Larry’s struggles in the past few months it seems so sudden. He sure was one of the most distinguished and brightest people in our field and will be remembered by many.
My sincerest condolences to the family. — Ilia Nikhinson, MD PPS President It truly is a loss to all! What an upbeat and amazingly skilled, empathetic, and engaged person! I remember how he supported equal opportunity for women clinicians, always giving us the time and mentoring we cherished. For the Women’s Committee, he provided a great networking capability, helping us secure excellent speakers (who all admired and appreciated Larry and seemed willing to do anything he needed!) His sense of humor and timing was well honed and often changed the tone of a discussion in a positive way. —Ellen Conroy, DO
COS Poster Winners
New Members
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Have You Heard? Marina Goldman, MD, FAPA Philadelphia continues to face the worst urban opioid crisis in the country. Many of our city’s residents require treatment for concurrent substance-related and psychiatric disorders. Unfortunately, despite increasing demand for addiction services, there is a shortage of specialists in many clinical settings. To help address this crisis, this June and July, Sidney Kimmel Medical College at Thomas Jefferson University/TJUH Department of Psychiatry and Human Behavior is welcoming fellows to their new Addiction Psychiatry Fellowship. This is a one -year ACGME-accredited fellowship program in Addiction Psychiatry that is running concurrently with the one-year ACGME-accredited fellowship program in Addiction Medicine. The Addiction Psychiatry and Addiction Medicine fellows will be training together in a variety of clinical settings, including Belmont Behavioral Hospital. The fellowship program will be working to form
partnerships with communities and organizations to help develop and implement integrated addiction psychiatry programs that are specifically designed to meet the needs of marginalized populations. Our community partners include: Pathways to Housing PA and Project Home-Health Services. The fellowship has off-cycle positions and is open to board eligible psychiatrists or psychiatry residents in the final year of a four year, ACGME-accredited residency program in General Psychiatry, and accepts candidates with J-1 or HB-1 visas. For more information about the Addiction Psychiatry Fellowship at Thomas Jefferson University, please contact annalee.locke@jefferson.edu
IN MEMORIAM Always on our minds, forever in our hearts.
Harinder K. Bansal, MD, LFAPA
Lawrence A. Real, MD, DLFAPA
Faith Bustard Midwood, MD, DLFAPA
Marc H. Zisselman, MD, DLFAPA
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Training in Psychoanalytic Psychotherapy Mark Moore, PhD Psychoanalytic Center of Philadelphia From 2014 until last June, I had the good fortune and pleasure of being the director of the Psychoanalytic Center of Philadelphia’s (PCOP) Adult Psychotherapy Program. At that time, at least half the student body was made up of psychiatry residents. Typical classes were 10-12 students who met every Tuesday from 6-9pm over 30 weeks. In 2015, PCOP changed the format of the program from two to three years; with the first year being a Foundation year and providing students a certificate if they ended at that one-year point. Students who continued for the remaining two years would deepen their immersion in clinical theory and be required to being regular supervision and personal therapy. This greater flexibility brought about an immediate increase in the number of students, and in the past two years the incoming class size has grown so much that we now teach two cohorts at a time. The number of psychiatry residents has also increased as we developed closer relationships with local residency programs.
Many residents remain deeply interested in the practice of talk therapy, and specifically psychoanalytic psychotherapy as it offers an emphasis on the mind and subjective experience that can often get lost in the necessary teaching of psychophysiology, biochemistry, and medications. Residents are well-equipped to think in terms of DSM diagnoses and appropriate medication regimens, but they often struggle to sit with ease as their patients describe past traumas and inner torments; or to understand why a patient refuses to accept their recommendations; or to know how to respond to anger, disappointment or uncertainty. Many are also distrustful or uncomfortable with their own personal response to a patient and do not recognize it as important clinical information. I believe that the success and popularity of PCOP’s program with psychiatry residents is due to how it expands their understanding of their patient’s experience, and their own self-understanding. It deepens their curiosity about the human condition and fires their passion for their work. I am optimistic that, as our program grows, we will continue to serve the needs of residents and provide a supportive community to help them to develop their professional identity. Should you, or a resident you know, be interested in our program we can be found at pcph. memberclicks.net.
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COVID Pandemic Families: Major Challenges and Resources Niharika Padala, MS3 Rama Rao Gogineni, MD For over a year, a microbe has changed the shape of civilization from the way we greet one another to shaking the financial horns of the bull market. According to Johns Hopkins’ COVID map as of April 2021, the US accounts for over 31 million cases and is in the lead on a global scale. These are not just 31 million individuals, but 31 million friends and families of these people. During an age when mental health awareness is on the rise, the pandemic unmasked and further brewed psychiatric illnesses in the US population. COVID-19 not only affected mental health on a molecular level but on a socioecological level as well. Inequities in the healthcare system and the degree of damage it can cause to whole communities became apparent. We write today to shed light on the ways COVID-19 has affected family units and ways mental health providers may help them. Pandemic Effects on Families: n I ncreased time together as families became a doubleedged sword. Families now have more access and time to discover new hobbies, talents, likes, and dislikes of each other. Opportunities for personal development and self-care grew. While it was expected that divorce rates may go up, polling described by Stanley and Markman (2020) showed that the majority of couples reported no change in the level of relationship satisfaction (Lebow). nO n the other end, NORC surveys reported that intimate partner violence has risen while reporting it to authorities has decreased. Compared to previous years, there is increased depression, anxiety, irritability, loss of temper, and loss of companionship, all of which stress interpersonal relationships (Lebow). Increased exposure to perpetrators and reduced opportunities for escape have become problematic for victims of domestic violence—partners and children alike (Fegert). nW hile virtual schooling initially seemed like a welcome snow day off from school, it quickly revealed many vital aspects of childcare. For students dreading going to school because of bullying or other reasons, homeschooling is a relief. However, with more extended access to time online, there may be an increase in the sexual exploitation of children. There is already a reported increase in child pornography since the past year (Fegert). Decreased services for special needs
children or children with disabilities have broken their routine. This change in routines, unstable mode of schooling, long hours in one setting, lack of social support from relatives, teachers, and friends alike have contributed to an increase in mental health crises, including depression, and anxiety, suicidal ideation in child and adolescent populations (Fegert). nR estricted social support and leisure outlets to send children to due to social distance protocols placed a high burden of childcare and maintenance on full-time working parents. Factors such as fear of death, grief from the loss of family members due to COVID, financial disturbances, job insecurities, added childcare and education responsibilities, lack of coping skills, lack of time and access for their mental illness or substance use needs, along with lack of privacy have all increased pressure on parents. All these stressors have been significant contributors to the rising incidence of child abuse. In addition, child protective services and similar organizations have been disrupted and limited, placing families—particularly those with vulnerable children—at higher risk for harm (Fegert). nP eople of color have been affected out of proportion to their population size, as evidenced by a single statistic by CDC’s 2020 data: despite making up only 13% of the total US population, the Black population accounts for 30% of the COVID-19 cases (SAMHSA). nA rise in xenophobia, intolerance, and systemic racism was seen not just on a local level but on a political level (Lebow), leading to increased hate crimes, murders, and civil unrest, which all naturally lead to a rise in mental health crisis stemming from fear and anxiety. nF amilies of color are particularly at a higher risk for severe illness from COVID-19 because of comorbidities, including diabetes, hypertension, obesity, lack of insurance, and treatment/testing access. Lack of access is limited to COVID-19 related measures as well as general healthcare for their underlying medical needs, mental health needs, and substance-use treatment (SAMHSA).
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COVID Pandemic Families: Major Challenges and Resources Continued from page 4
nO ther factors also play a role in susceptibility to contracting the virus or developing health complications from it due to low socioeconomic status, crowded housing, or increased racial risk for incarceration disabling proper quarantine measures, and working in jobs in service industries that are in losses due to the pandemic and jobs without teleworking flexibility (SAMHSA). nA midst the chaos and confusion this virus has brought, there are also stories of heroic acts, measures of selflessness, a rising sense of camaraderie and community. Creativity in virtual gatherings provided opportunities for socializing that were previously closed off to select populations. Social distancing and wearing masks have become symbols of showing concern for loved ones and respect for neighbors. Recommendations and Resources: nA dvocate for increased number of mental healthcare providers and services. nT rain in and become more comfortable with techniques in providing telehealth care. Understand some populations of color, age, or low socioeconomic status may not have steady constant access to devices or internet allowing for telemedicine visits and work around that barrier. nU nderstand that spirituality and ethical beliefs can be powerful sources of coping strategies and resilience building. Become comfortable addressing them and utilizing them where appropriate.
nU tilize medical tele-interpreters for effective communication with patients with limited English proficiency and avoid putting that burden on the patients’ family. Medicaid even provides reimbursement in selective states. nS ee this special section by Jay L. Lebow for a collection of carefully selected papers on various aspects of family therapy during COVID-19: https:// onlinelibrary.wiley.com/doi/10.1111/famp.12590 nR ead Neurodevelopmental Disorders: Families during the COVID-19 for better understanding of and how to help families of children with ASD, ADHD, or other neurodevelopmental disorders. https://www.aacap.org/App_Themes/AACAP/Docs/ regional_organizations/EastPa_NJ_council/EPSNJNewsletter-Feb-2021.pdf#page=7 nW atch the Association of Family Psychiatrists “Family Therapy and Family Support in a Transformed World” virtual conference recording: https://www.familypsychiatrists.org/ nS ee the American Academy of Child And Adolescent Psychiatry’s comprehensive list of resources for families and clinicians: https://www.aacap.org/ coronavirus#telepsych REFERENCES “COVID-19 Map.” Johns Hopkins Coronavirus Resource Center, Johns Hopkins University & Medicine, 16 Apr. 2021, coronavirus.jhu.edu/ map.html.
nU se key community members and local faith-based leaders as first line communicators to bring awareness about resources, vaccinations, and COVID-19 spread prevention hygiene.
Fegert JM, Vitiello B, Plener PL, Clemens V. Challenges and burden of
nU se culturally sensitive resources such as: https:// blackdoctor.org/ for populations of color to help reduce distrust of the health system and increase access to care.
Adolesc Psychiatry Ment Health. 2020 May 12;14:20. doi: 10.1186/
n I ncrease cultural competency in the context of treating patients during the pandemic through workshops such as: https://pttcnetwork.org/centers/networkcoordinating-office/sdh-and-covid-discussion-series where recorded presentations specific to different communities can be found.
https://doi.org/10.1111/famp.12590
the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child s13034-020-00329-3. PMID: 32419840; PMCID: PMC7216870. Lebow J. L. (2020). COVID-19, Families, and Family Therapy: Shining Light into the Darkness. Family process, 59(3), 825–831.
OBHE. “Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S.” SAMHSA, 5 Jan. 2021.
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Later in Our Careers: A COS Breakout Session Mark Reber, MD Barbara Schindler, MD Nielufar Varjavand, MD At the Philadelphia Psychiatric Society’s Colloquium of Scholars in April 2021, Drs. Mark Reber, Barbara Schindler and Nielufar Varjavand, from Drexel University, Philadelphia, PA, led a break-out session entitled “Later in our Careers.” In this well-attended afternoon gathering, participants had the opportunity to discuss their specific concerns as they approach and enter the later parts of their career. For instance, we heard about the frustrations as well as joys of telemedicine, logistics of licensure change, and more commonly, issues relating to retirement. These included how best to prepare for retirement (questions of how to wind down a practice, concerns about who will care for patients and the personal challenges of losing patient relationships); alternatives to a complete retirement; and finding activities that promote one’s self-care, provide personal satisfaction and serve a social good. One of the potential barriers to retiring is the ongoing decline in the number of psychiatrists. Dr. Reber presented data that showed that this decline would continue through 2024, when the projected shortage would be 14,000 to 31,000 in the U.S.1 Data from Australia2 are similar. One new development, however, is the increase in psychiatric nurse practitioners and physician assistants, who presently account for 28% of the psychiatric workforce.3 Many participants had questions of licensure change upon retiring and whether one loses board certification if retiring a license. In her role as Program Director for the Drexel Physician Refresher/Reentry Program, Dr. Varjavand highlighted that if one retires their license and then chooses to return to active practice, the state board of medicine will likely ask for completion of a
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reentry program/assessment to assure the physician is up-to-date before return to practice.4 To continue practice, participants offered descriptions of their own experiences. These included continuing part-time clinical activity through locum tenens work and serving on Assertive Community Treatment (ACT) teams. Some favored a change of practice through increasing telemedicine visits. Meanwhile, for those who continue to practice, it was noted that one health system is asking for further testing that includes neurocognitive evaluations when credentialing their medical staff members over the age of 70.5 On the other hand, other participants advocated for leaving practice completely and enjoying retirement activities, such as regular exercise regimens, volunteering for COVID-19 outreach and other public health services, serving as museum docents and playing in music ensembles. Overall, though on video, the forty members had an engaging discussion where they learned from each other about options later in their careers. 1. S atiani, A. et al., Projected Workforce of Psychiatrists in the United States. 2018 Jun 1;69(6):710-713. doi: 10.1176/appi.ps.201700344. Epub 2018 Mar 15. 2. F letcher, S & Schofield D; Impact of generational change & retirement on Psychiatry to 2025. BMC Health Serv Res 7, 141 (2007). https://doi.org/10.1186/1472-6963-7-141 3. B eck, AJ et al. The Distribution of Advanced Practice Nurses Within the Psychiatric Workforce. Journal of the American Psychiatric Nurses Association. 2019. 4. G orman, Anna. “For Doctors Who Take a Break From Practice, Coming Back Can Be Tough” Physicians News Digest (June 16, 2015) 5. C ooney L, Balcesak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA. 2020;323(2):179-180. doi:10.1001/ jama.2019.18665
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The Colloquium of Scholars Committee congratulates the poster winners from this year’s Colloquium of Scholars. The poster judging was led by John O’Reardon, MD, who was assisted by (alphabetically) Claudia Baldassano, MD, and Laurel Weaver, MD. Click here to view the all of the winning abstracts. Original Research Posters: First Place Differences in Treatment Outcomes with Suboxone between Fentanyl Users and other Opiate Users Michael Roman, MD, Resident, University of Pennsylvania Second Place Prevalence of Trauma and the Use of Coping Mechanisms in Midlife Women in North Philadelphia Sarah Mooar, Medical Student, Temple University Third Place Demographics, Psychiatric Diagnoses and Concomitant Medications Use in Cannabis only, Opioid only and Combined Cannabis/Opioid Users: A Retrospective Analysis Christopher Yamada, Medical Student, Cooper University Case Report Posters: First Place Diagnostic Challenges in Atypical Psychiatric Manifestations of Behavioral Variant Frontotemporal Dementia Daniella Vasquez, Medical Student, Temple University
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Second Place A Little Dab Will Do: A Case of Cannabis Induced Psychosis Garrett Rossi, MD Resident, Cooper University Third Place Longing for Death in Early Treatment of Chronic Lymphocytic Leukemia: A Case Report Arianna Ghazanfar, Medical Student, Temple University The following awards were announced in conjunction with the Colloquium of Scholars meeting held on April 10, 2021. Psychodynamic Psychiatry Case Write-up Award (Co-sponsored by the Philadelphia Psychiatric Society and the Psychanalytic Center of Philadelphia. Organized by Kimberly Best, MD) Awardee: Tyler Fleming, DO (Resident, Department of Psychiatry, Einstein Medical Center) Cognitive Behavioral Therapy Scientific Paper or Case Formulation Award (Co-sponsored by the Philadelphia Psychiatric Society and the Academy of Cognitive Therapy. Organized by Donna Sudak, MD) Awardee: Sarita Metzger, MD (Resident, Department of Psychiatry, University of Pennsylvania) Family-Oriented Clinical Care Award (Co-sponsored by the Philadelphia Psychiatric Society and the Association of Family Psychiatrists. Organized by Ellen Berman, MD, and Rama Rao Gogineni, MD) Awardee: Nana A. Asabere, MD (Resident, Department of Psychiatry, University of Pennsylvania)
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Welcome to Our New Members January to April 2021 General Members Thomas A. Armistead, MD Jack Castro, MD Kimberly Downing, MD Vinu M. George, MD Adam L. Glushakow, MD Kevin G. Huang, MD Rayea Nafiz, MD Samantha Dyan Powell, MD William M. Singletary, MD Eliza N. Wilfred, MD Samantha Zwiebel, MD Distinguished Fellow Members John Lauriello, MD Luciano Lizzi, MD Natalia Ortiz, MD
Life Distinguished Fellow Member Roberta R. Ball, DO Members in Training Nana A. Asabere, MD Aaron Bloch, MD Catherine M. Boylan, MD Brijae Chavarria, MD Lauren Dubner, MD Julia E. Hannigan, MD Lea Hecht, MD Adam C. Holstein, DO Yunichel Joo, MD Ashby A. Mammen, MD Divya Patel, MD Michael W. Pelekanos, MD Emily P. Sudhakar, MD
Ilia Nikhinson, MD President
Rajnish Mago, MD, DFAPA Editor
Pietro Miazzo, MD Immediate Past President
Dawn Losiewicz Deputy Association Executive Administrative Office 400 Winding Creek Blvd. Mechanicsburg, PA 17050-1885 Toll free: (888) 723-2501 Toll free fax: (855) 918-3611 Email: philapsych@papsych.org Website: www.papsych.org
Holly J. Valerio, MD President Elect Wei Du, MD Vice President Christopher W. Tjoa, MD Treasurer Ellen D. Conroy, DO Secretary
Transactions, the newsletter of the Philadelphia Psychiatric Society is published two times per year, with Spring and Fall issues. Editor: Rajnish Mago, MD, DFAPA Staff Editor: Dawn Losiewicz Articles published in the newsletter may be published in other APA district branch newsletters without permission. Attribution is requested and appreciated. All other rights reserved. transactions welcomes comments and opinions from the membership. Address correspondence to: Newsletter Editor Philadelphia Psychiatric Society 400 Winding Creek Blvd. Mechanicsburg, PA 17050-1885 Copyright ©2021. Philadelphia Psychiatric Society.
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