Allegheny County Medical Society. Bulletin. July National Practitioner Data Bank changes Legislative update ACHD: Plan for a Healthier Allegheny

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1 Allegheny County Medical Society Bulletin July 2015 National Practitioner Data Bank changes Legislative update ACHD: Plan for a Healthier Allegheny

2 Care is Your Business, Change is Ours The healthcare environment is changing. Physicians must focus on providing the highest quality care with intense competition for their time. Medical practices face increased challenges tied to changes to regulation, insurance protocols, cost-management and revenue management. Houston Harbaugh has over 30 years of experience in helping physicians and medical practices manage change through contract negotiations with hospitals and payors; contract management; advocacy and new practice start-up counsel. We have provided critical support in practice mergers and acquisitions. And we have provided sound advocacy on issues ranging from HIPAA compliance to medical staff and peer review matters. Every challenge a medical practice can face, we have seen. We have helped practices of all size and structure meet these challenges. And we know what is ahead. hh-law.com Business Employment Estates and Trusts Health Care Litigation Oil and Gas Public Finance Real Estate

3 Allegheny County Medical Society Bulletin July 2015 / Vol. 105 No. 7 Articles Materia Medica Role of combination oxycodone and naloxone in abuse and opioid-induced constipation Ashley M. Higbea, PharmD, BCPS Nicole J. Payette, PharmD Legal Report National Practitioner Data Bank changes that may affect you William H. Maruca, Esq. Practice Management Feedback v. coaching v. mentoring: What s the difference? Joe Mull, MEd Special Report Advocate, communicate, collaborate: Get the skills you need at PAMED s Annual Education Conference Susan Wigger, Pennsylvania Medical Society Special Report Allegheny County Health Department: Providing the Plan for a Healthier Allegheny Karen Hacker, MD, MPH Special Report RHLC hosting free training at ACMS Articles Special Report CMS and AMA answer ICD-10 FAQs Perspectives Editorial Medical license requirements Deval (Reshma) Paranjpe, MD, FACS Editorial Facebook and the origin of the influencing machine Robert H. Howland, MD Perspective Perspectives on life Amy J. DiPlacido, MD Perspective Making a difference Lakshmi Madduru, MD Perspective Trauma talks (talk trauma) Judith A. Cohen, MD Perspective Caveat emptor Matthew R. Quigley, MD What Are You Reading? Martha D. John, MD Departments Society News ACMSF offers medical student scholarship Award established in ACMS members names Pennsylvania Primary Care Career Fair scheduled ACMS to host HIPAA, OSHA, OIG program ICD-10-CM program slated at ACMS Controversies in Geriatric Medicine hosted by PAGS-WD 2016 Clinical Update in Geriatric Medicine date set 14th International HELP conference scheduled Practice Managers meet at ACMS ACMS Alliance News In Memoriam Michael Krak, MD Activities & Accolades Legislative Update Announcement On the cover Freedom by Kimberly Hennon, MD Dr. Hennon specializes in emergency medicine.

4 2015 Executive Committee and Board of Directors President John P. Williams President-elect Lawrence R. John Vice President David J. Deitrick Secretary Robert C. Cicco Treasurer Adele L. Towers Board Chair Kevin O. Garrett DIRECTORS 2015 Vijay K. Bahl Patricia L. Bononi M. Sabina Daroski Sharon L. Goldstein Todd M. Hertzberg William K. Johnjulio Karl R. Olsen 2016 David L. Blinn Robert W. Bragdon Thomas B. Campbell Douglas F. Clough Jason J. Lamb 2017 Peter G. Ellis David A. Logan Jan W. Madison Matthew B. Straka Angela M. Stupi PEER REVIEW BOARD 2015 Paul W. Dishart G. Alan Yeasted 2016 John G. Guehl Rajiv R. Varma 2017 Donald B. Middleton Ralph Schmeltz Affiliated with Pennsylvania Medical Society and American Medical Association PAMED DISTRICT TRUSTEE John F. Delaney Jr. COMMITTEES Awards Donald B. Middleton Bylaws David J. Deitrick Communications Amelia A. Paré Finance Karl R. Olsen Gala Patricia Bononi Adele L. Towers Nominating Rajiv R. Varma Primary Care Lawrence R. John ADMINISTRATIVE STAFF Executive Director John G. Krah Assistant to the Director Dorothy S. Hostovich Bookkeeper Susan L. Brown Communications Bulletin Managing Editor Meagan K. Welling Assistant Executive Director, Membership/Information Services James D. Ireland Manager Dianne K. Meister Field Representative Nadine M. Popovich Bulletin Medical Editor Deval (Reshma) Paranjpe Associate Editors Michael Best Charles Horton, MD Robert H. Howland Timothy Lesaca Scott Miller Amelia A. Paré Gregory B. Patrick Brahma N. Sharma Managing Editor Meagan K. Welling ACMS ALLIANCE President Kathleen Reshmi First Vice President Patty Barnett Second Vice President Joyce Orr Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Josephine Martinez Assistant Treasurer Sandra Da Costa Leadership and Advocacy for Patients and Physicians EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212; (412) ; fax (412) USPS # PUBLISHER: Allegheny County Medical Society at above address. 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. Subscriptions: $30 nonprofit organizations; $40 ACMS advertisers; $50 others. Single copy, $5. Advertising rates and information sent upon request by calling (412) or online at COPYRIGHT 2015: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER Send address changes to: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA ISSN:

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6 Editorial Medical license requirements The Pennsylvania State Board of Medicine is charged with protecting the welfare of the citizens of Pennsylvania via regulating the practice of medicine. The Board regulates the practice of medicine through the licensure, registration and certification of members of the medical profession in the Commonwealth of Pennsylvania. The Board regulates medical doctors; physician assistants; radiology technicians; respiratory therapists; nurse-midwives; acupuncturists; practitioners of oriental medicine; perfusionists; behavioral specialists; and athletic trainers. It also periodically reviews institutions. The Board also has authority to take disciplinary or corrective action against individuals it regulates. It is comprised of physicians, public members and an allied health member who are all appointed by the governor and confirmed by the state legislature. What does the Board do? Cases on the monthly meeting agenda include determination of disciplinary action against licensees including probation, suspension and revocation of licenses, administration of fines, penalties and public reprimands, and disciplinary review of probation violations. Reciprocal discipline based on discipline or fines levied upon the licensee by other state medical boards also is addressed. The Board also reviews applications for initial and temporary licenses by applicants who may have a history of malpractice actions; it also reviews applications for full or licenses by endorsement/institutional licenses for well-qualified candidates who have Deval (Reshma) Paranjpe, MD, FACS extraordinary educational circumstances. The Board also may review single cases of negligence brought as complaints against practitioners/standard of care complaint cases. You may know that the Board exists, and exacts of you certain Continuing Medical Education (CME) requirements for renewal of licensure, but do you know what is required of you to avoid getting in trouble beyond using your common sense? Every physician should go online (website provided below) and read the rules by which we are expected to abide. The most significant change of late is the additional CME requirement. As of January 2015, per Act 31 of 2014, you must complete two (2) hours of Board-approved continuing education in child abuse recognition and reporting requirements renewal or reactivation of a license. Details and a list of Board-approved providers can be found at Some of these courses are online and some are in person; in either case, verification of completion must be sent electronically and directly from the course provider, and this can take up to seven days. It is therefore vital that you complete this training well in advance of your renewal deadline since (unlike most other CME) you are not in direct control of submitting your child abuse CME completion certificate to the Board, which normally processes online renewals within 24 hours. You must complete the two-hour child abuse CME requirement even if you are active/retired status and only treating your immediate family. The only way you can avoid this requirement is to be a new applicant, a trainee, or on inactive status. In addition, you will need to complete the standard 100 credit hours of AMA PRA Category 1 or 2 activities (20 of which must be Category 1, and 12 of which must be related to patient safety or risk management) per biennial cycle. Where can you find the rest of the rules to which we are expected to adhere? The regulations pertaining to the practice of medicine in Pennsylvania can be found at the following website: Pages/Board-Laws-and-Regulations. aspx#.vzr5oudi6ym A printed handbook delineating these laws and rules is available on request from the Board administrative office. The regulations review, among other important topics: The 2002 Mcare Act mandatory physician self-reporting requirements which obligate physicians to self-report to the Board within 60 days of the occurrence of any of the following: notice of a civil malpractice lawsuit, notice of a disciplinary action by another jurisdiction, any controlled substance conviction, and any arrests 278 Bulletin / July 2015

7 Editorial for criminal offenses such as homicide, assault, sexual offenses and controlled substance violations. Failure to do so exposes the physician to a civil penalty of $1,000 per offense. Basic definitions and information regarding the practice of medicine General license, certification and registration Practice by and through business entities Medical disciplinary process and procedures Minimum standards of practice (general) which covers record-keeping, etc. Minimum standards of practice with regard to child abuse, including: Definitions of child abuse Mandated reporting requirements for suspected child abuse Photographs, medical tests and X-rays of child subject to report Mandated reporting requirement of suspected death as result of child abuse Immunity from liability for reporting suspected abuse Confidentiality waived reporting suspected child abuse supersedes other obligations Penalties for noncompliance with reporting guidelines Sexual misconduct definitions regarding patient-physician sexual relationships While it may have been some time since you have reviewed these, or in the case that you have never had occasion to do so, there is no time like the present. This is a quick read which can answer most questions and save you unnecessary headaches. *Dr. Paranjpe is currently serving a four-year term on the State Board of Medicine. Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_ paranjpe@hotmail.com. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society. Ruby Marcocelli Bulletin / July

8 Executive Editorial Committee Facebook and the origin of the influencing machine Robert H. Howland, MD For those of you who are fans of horse racing, this year brought forth the excitement of the first Triple Crown champion in 37 years. Watching these races reminded me of Secretariat, one of the greatest thoroughbreds in racing history. After Secretariat s death, the veterinarian who performed a necropsy described his heart as massive, estimated at more than twice the weight of an average horse, but perfectly healthy It was just this huge engine. Secretariat and his huge engine of a heart had won the 1973 Triple Crown, winning the Belmont Stakes by an astounding 31 lengths. During the running of the Belmont, the television announcer said of Secretariat: He is moving like a tremendous machine! Secretariat died 70 years after Sir Barton won the first Triple Crown in 1919, the same year Sir Godfrey Hounsfield was born and Victor Tausk died. Hounsfield was an electrical engineer who first researched guided weapon systems and radar and then helped design the first commercial all-transistor computer in England. He later shared a Nobel Prize for the development of X-ray computer assisted tomography, a technology that allows us to peer into the brain though not necessarily the mind. Tausk was a judge and journalist who later received medical training and became a psychoanalyst. He is best known for writing a now classic paper, On the Origin of the Influencing Machine in Schizophrenia, published the year he died. Tausk wrote that the influencing machine was a machine of mystical nature, which may consist of boxes, cranks, levers, wheels, buttons, wires, batteries and the like, but whose construction is very obscure and largely unimaginable to the patient. All the discoveries of mankind, he said, are regarded as inadequate to explain the marvelous powers of this machine, by which patients may feel themselves persecuted. The influencing machine, sometimes described as a magic lantern or cinematograph, makes patients see pictures that are flat images, like on a windowpane, and not three-dimensional. It produces and removes thoughts and feelings by means of waves or rays or mysterious forces that the patient s knowledge of physics is inadequate to explain. In this way, Tausk said the influencing machine often is called a suggestion-apparatus. It also creates motor phenomena in the body as well as strange, indescribable sensations, either by means of suggestion or by air-currents, electricity, magnetism, or X-rays. Though the influencing machine The patient who is subject to the influencing machine cannot distinguish feelings, thoughts, sensations and memories that have been caused by this external influence from those that result from their own personal experience. serves to persecute the patient and is believed operated by enemies, Tausk noted that the manipulation of the apparatus is obscure to the patient, who rarely has a clear idea of its operation. The patient who is subject to the influencing machine cannot distinguish feelings, thoughts, sensations and memories that have been caused by this external influence from those that result from their own personal experience. In his paper, Tausk proposes that patients may unconsciously create the concept of an influencing machine as an outward manifestation of confusion about the separation of one s own thoughts from the experiences of the world outside themselves. The patient, he says, cannot or does not make this distinction. The great Secretariat was foaled in Caroline County, Va., more than three decades before Facebook, the largest social networking service in the world, 280 Bulletin / July 2015

9 Executive Editorial Committee was created in Cambridge, Mass. Facebook is a powerful social engine within a tremendous machine, the computer, whose construction is obscure and largely unimaginable to users. In a paper published in the journal Nature in 2012, a Facebook data scientist and his colleagues reported the results from a randomized controlled trial of political mobilization messages delivered to 61 million Facebook users during the 2010 U.S. congressional elections. In this experiment, the news feeds of Facebook users were changed subtly and without their knowledge. The researchers manipulated the news feeds to show which of their friends had already voted. One group received an informational-tailored voting message, whereas another group received a socially tailored voting message. The investigators tracked users behavior online and offline, using publicly available voter records to understand who actually went to vote and whether voting depended on their friends behavior. According to the authors, the results showed that the messages directly influenced political self-expression, information seeking and real-world voting behavior of millions of people. The messages not only influenced the users who received them but also the users friends, and friends of friends. The effect of social transmission on real-world voting was greater than the direct effect of the messages themselves, and nearly all the transmission occurred between close friends who were more likely to have a face-to-face relationship. Micah Sifry, in an article published in the magazine Mother Jones last year, described two similar voter manipulation experiments that were conducted by Facebook during the 2012 elections. Bulletin / July 2015 Both experiments apparently demonstrated that manipulating news feeds led to measurable behavior changes, but complete details of the study findings have not been published. Also last year, the findings from another Facebook study were published in the Proceedings of the National Academy of Sciences. In this experiment, Facebook manipulated the emotional content of the news feeds of nearly 700,000 users without their knowledge, and they examined how the emotions of the friends of users affected one another. The investigators demonstrated that emotional states can be transferred to others via emotional contagion, leading people to experience the same emotions without their awareness. This study also provided experimental evidence that emotional contagion can occur without direct interaction between people (exposure to a friend expressing an emotion is sufficient) and in the complete absence of nonverbal cues. Facebook s mission is to give people the power to share and make the world more open and connected. Tausk described the case of Miss Natalija A., who believed that a rejected male suitor was trying, by means of suggestion, to bring about a friendship between his sister-in-law, Natalija s mother, and Natalija herself to make her accept him. When suggestion failed, the suitor subjected her to the influence of the machine. Not only she herself, Natalija told Tausk, but also her mother, her physicians, her friends, all those who had her welfare at heart, came under the influence of this diabolical apparatus. Can Facebook as well be a potentially diabolical apparatus? Whether the Facebook studies were unethical, having been conducted without users explicit knowledge and consent, has been debated in the research community and in the media. What is most concerning, however, is not merely the ethics of these experiments, but rather that it is possible for those who control the function of Facebook to be able to manipulate the feelings and behaviors of millions of users. Today s version of a suggestion-apparatus or an influencing machine may be Facebook, and perhaps other social media apps, viewed on the flat, windowpane-like screens of smartphones. Further reading Bond RM, Fariss CJ, Jones JJ, et al. A 61-million-person experiment in social influence and political mobilization. Nature. 2012;489: Kramer ADI, Guillory JE, Hancock JT. Experimental evidence of massive-scale emotional contagion through social networks. Proceedings of the National Academy of Sciences. 2014;111(24): Tausk V, Feigenbaum D. On the Origin of the Influencing Machine in Schizophrenia. The Journal of Psychotherapy Practice and Research. 1992;1(2): Sifry ML. Facebook wants you to vote on Tuesday. Here s how it messed with your feed in Mother Jones. October 31, Dr. Howland is a psychiatrist and associate editor of the ACMS Bulletin. He can be reached at howlandrh@ upmc.edu. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society. 281

10 Perspective Perspectives on life One of my best friends from college recently contacted me for the first time in more than a decade. He has been teaching science and health in Alaska, and now he is working as the principal of a small high school. I have thought of him now and then over the years, remembering our inside jokes and the good times we had in Duquesne University s physics department. Since the day his name popped up in my inbox, we have been ing back and forth like no time has passed, discussing our families, our jobs and our favorite books, just like old times. He still uses the exact same address from years ago. Why didn t I try to him sooner? This friend contacted me a couple of weeks after a person established care in my office as a new patient. He had presented to the emergency room because of shortness of breath and weight gain, but said that overall he had been feeling fine. Almost two weeks in the hospital and many, many tests later, his discharge diagnosis was sobering. Widely metastatic cancer, primary site unknown. He and his family had many questions about his symptoms, the options for treatment and his prognosis. They were shocked, but grateful, to learn that he was at the end of his life. He was growing more and more tired with everyday tasks. His appetite was gone. Just getting to the Amy J. DiPlacido, MD bathroom was becoming an ordeal. I asked him what he wanted to do with his remaining time. I want to stay home, he said, with the hint of a smile. He died under hospice care less than three weeks later. My friend s recent s and this patient s death have given me pause. The truth is that I face issues like these every day, but for whatever reason, this particular friend, and this particular patient, have stood out to me. What would I do if faced with a finite prognosis? I can only guess, but would I spend more time with family? Take that trip around the world? Contact the rest of my long lost friends, like the one in Alaska? Would I eat chocolate for every meal? It didn t take much longer for me to realize the true bottom line for me in all of this. As health care providers, many of us give people bad news on a regular basis. It shouldn t matter if I know my own expiration date or not. Life is short. Do I need to have a critical illness with a grim prognosis to live my life to the fullest? The answer should be no. I can honestly say that I have a renewed outlook on life. If I don t love what I m doing each and every day, then why do it? I should make more of an effort to prioritize late morning brunch with my husband. I should eat Thai food with Brian, have Game Night with Angie and walk the dogs with my father every chance I get. I should laugh more, and cry more, and take more time just for me. I should make the most of each week, each day and each minute that I can. I will remember to be grateful for my health and the health of my loved ones. If every book I read is my new favorite, and every movie I see is the best one yet, then I m probably not reading or seeing enough of them. I will take the good with the bad, and remember that tomorrow is not guaranteed to anyone. And I will eat chocolate. Dr. DiPlacido specializes in family medicine and geriatrics at Renaissance Family Practice, Millvale, and Geriatric Care Center in Pittsburgh. She can be reached at diplacidoaj@upmc.edu. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society. Allegheny County Medical Society Leadership and Advocacy for Patients and Physicians 282 Bulletin / July 2015

11 Perspective Making a difference Medicine is an art and a science. Maintaining perfect harmony between both is challenging, but it is needed today more than ever. There are high expectations to be met in clinical and administrative perspectives, along with the business aspect of medicine which cannot be ignored. Inheriting the challenges of traditional medicine while meeting the demands of modern medicine is what physicians face today. Being one with the community you serve while satisfying the quality measures and financial incentives is but one piece of the puzzle. Expertise in coding and billing processes is a skill that is almost essential to survive whatever the specialty of medicine you practice. Technological skills with electronic health records (EHRs) are crucial in our lives technological advances bring perks with challenges. Interestingly, the scientific method still remains the fascinating aspect of medicine despite all else, the most satisfying aspect being the returning patient content with care. Our nonagenarians living independently at home in spite of scarce support systems are inspiring. Some of them are not only independent with their activities but also offer significant support to their families, living quite productively. Most elderly who come to the office for chronic care report myalgia; it is not uncommon that this is nonspecific. Muscle weakness below a certain threshold affects functional ability and mobility, which puts the elderly at increased risk of falling and fractures. Bulletin / July 2015 Lakshmi Madduru, MD Considering differential diagnoses to be polymyalgia rheumatica (PMR), symptoms such as depression, common in the elderly, complicate the diagnosis and treatment. In PMR, myalgia can be accompanied by depression, fatigue, malaise and sleep disorders. An erythrocyte sedimentation rate (esr) of more than 50 mm/hr delineates the diagnosis. Another causative factor perceived for myalgia are statins. These are being questioned more often than not; patients are hesitant to continue them despite reassurance. A literature review found that reports of muscle problems during statin clinical trials are extremely rare. The FDA Medwatch Reporting System lists 3,339 cases of statin-associated rhabdomyolysis reported between January 1, 1990, and March 31, Cerivastatin was the most commonly implicated statin. Few data are available regarding the frequency of less-serious events such as muscle pain and weakness, which may affect 1 percent to 5 percent of patients. The risk of rhabdomyolysis and other adverse effects with statin use can be exacerbated by several factors, including compromised hepatic and renal function, hypothyroidism, diabetes and concomitant medications. Recent evidence suggests that statins reduce the production of small regulatory proteins that are important for myocyte maintenance. Muscle weakness due to vitamin D deficiency is predominantly of the proximal muscle groups and is manifested by a feeling of heaviness in the legs, tiring easily and difficulty in mounting stairs and rising from a chair; the deficiency is reversible with supplementation. Muscle atrophy particularly of type II fibers has been described histopathologically in certain cases. Muscle as a target site for vitamin D metabolites Birge and Haddad in the mid-1970s were the first to show that 25(OH)D3 directly influences muscle phosphate metabolism in the diaphragms of vitamin D deficient rats. Since then, several studies have shown that vitamin D metabolites affect muscle cell metabolism through various pathways. 3 Vitamin D metabolites have been found to affect muscle metabolism in three ways: 1) by mediating gene transcription; 2) through rapid pathways not involving DNA synthesis; and 3) by the allelic variant of the vitamin D receptor (VDR). Both in animal models and in humans, a VDR has been found in skeletal muscle cells that specifically binds 1,25(OH)D3. 4,5 After transportation to the nucleus, this ligand receptor interaction is modulated by various transcription factors and biochemical processes, resulting in a final transcription complex. In cultured myoblasts, Continued on Page

12 Perspective From Page 283 this genomic pathway was found to influence muscle cell calcium uptake, phosphate transport across the muscle cell membrane, and phospholipid metabolism and to mediate cell proliferation and subsequently differentiation into mature muscle fibers. Vitamin D supplementation induces rapid changes in calcium metabolism of the muscle cell that cannot be explained by a slow genetic pathway. Evidence indicates that 1,25(OH)D3, possibly through a vitamin D membrane receptor, 7 acts directly on the muscle cell membrane. On 1,25(OH)D3 binding, several interacting second-messenger pathways were activated in the muscle cell, resulting in enhanced calcium uptake (within minutes), both through voltage-dependent calcium channels and calcium release activated calcium channels. Finally, muscle strength appears to be influenced by the genotype of the VDR in the muscle cell. With the use of specific restriction endonucleases, several VDR polymorphisms have been determined. In nonobese, elderly women, a 23 percent difference in quadriceps strength and a 7 percent difference in grip strength between the two homozygote types of a restriction site were found. 6 Epidemiological studies suggest that vitamin D insufficiency is related to a number of other disorders frequently observed among the elderly, such as breast, prostate and colon cancers, type 2 diabetes, and cardiovascular disorders including hypertension. 1 Vitamin D supplementation by reducing myalgias may have been a causal factor in reducing systolic blood pressure in some patients. Vitamin D supplementation in vitamin D deficient, elderly people improved muscle strength, walking distance and functional ability and resulted in a reduction in falls and nonvertebral fractures. Given the realities of variable adherence to clinician recommendations and the wide safety margin of vitamin D supplements, the recommendation is for vitamin D supplementation of at least 1,000 IU (average daily supplement) to reduce falls and fractures. Exceptions to this are patients with advanced renal failure and sarcoidosis. 2 Dr. Madduru specializes in family practice and geriatrics. She is board certified in family medicine from the American Board of Family Medicine. She completed her Geriatric Fellowship at the University of Pittsburgh Medical Center. Most recently, Dr. Madduru served as a family physician at Folcroft Family Practice, Philadelphia, and is currently working in Pittsburgh. She can be reached at bulletin@acms.org. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society. References 1.Vitamin D and the elderly. Clin Endocrinol (Oxf) Mar;62(3): Mosekilde L1. 2. Recommendations Abstracted from the American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults JAGS 62: , Vitamin D deficiency, muscle function, and falls in elderly people Hennie CJP Janssen, Monique M Samson, and Harald JJ Verhaar Am J Clin Nutr 2002;75: Bischoff HA, Borchers M, Gudat F, et al. In situ detection of 1,25-dihydroxyvitamin D3 receptor in human skeletal muscle tissue. Histochem J 2001;33: Costa EM, Blau HM, Feldman D. 1,25-Dihydroxyvitamin D3 receptors and hormonal responses in cloned human skeletal muscle cells. Endocrinology 1986;119: Quadriceps and grip strength are related to vitamin D receptor genotype in elderly nonobese women. Geusens P, Vandevyver C, Vanhoof J, Cassiman J-J, Boonen S, Raus J. J Bone Miner Res 1997;12: Identification of a membrane receptor for 1,25-dihydroxyvitamin D3 which mediates rapid activation of protein kinase C. J Bone Miner Res 1998;13: Nemere I, Dormanen MC, Hammond MW, Okamura WH, Norman AW J Biol Chem 1994;269: Looking for answers to your questions about government benefits and services? USA.gov has you covered. It s your official source for government information. USA.gov 1 (800) FED-INFO 284 Bulletin / July 2015

13 q Allegheny County MediCAl SoCiety Leadership and Advocacy for Patients and Physicians ACMS selects vendors for quality and value. Contact our Endorsed Vendors for special pricing. Banking, Financial and Leasing Services Medical Banking, Office VISA/MC Service PNC Bank Brian Wozniak, Real Estate Services Helen Lynch, Coldwell Banker Your Neighborhood Realtor (cell) , ext. 319 (office) com Group Insurance Programs Medical, Disability, Property and Casualty USI Affinity Bob Cagna, Professional Liability Insurance NORCAL Mutual Laurie Bush, , ext. 5558; com Medical and Surgical Supplies Allegheny Medcare Michael Gomber, com Life Insurance Malachy Whalen & Co. Malachy Whalen, What does ACMS membership do for me? Printing Services and Professional Announcements Service for New Associates, Offices and Address Changes Allegheny County Medical Society Susan Brown, Auto and Home Insurance Liberty Mutual Walter E. Jackson IV, , ext ; com Member Resources BMI Charts, Healthy Lifestyle Posters, Where-to-Turn cards Allegheny County Medical Society Bulletin / July

14 Perspective Trauma talks (talk trauma) Judith A. Cohen, MD Nell was angry. She had a long history of fighting and non-compliance with adult rules. She was missing school due to serious asthma attacks, and repeated running away threatened to disrupt her latest foster placement. A new case worker brought her for an evaluation but upon learning that we were the Center for Traumatic Stress, Nell wanted to leave, saying, No one ever talked about trauma before, why do you care now? Nell had a right to be mad. We professionals had let her down. She had been in foster care and counseling for eight of her 13 years and was on seven medications for ADHD, bipolar disorder and asthma, but no professional had asked her about past traumas or how these might be related to her problems, nor had any professional provided trauma-focused treatment. We should have. Nell had experienced sexual abuse, neglect, domestic violence and her mother s overdose death in her birth parents home and then was sexually and physically abused in foster care. Her behavioral and emotional regulation problems were predictable responses to learning that adults who should have kept her safe would instead abuse her. When understood through this trauma lens, her symptoms were more consistent with a diagnosis of complex Posttraumatic Stress Disorder (PTSD) than bipolar disorder or ADHD. As such, recommended first-line treatment for Nell was an evidence-base trauma treatment such as Trauma-Focused Cognitive Behavioral Therapy ( tfcbt.org) or others available through the SAMHSA-funded National Child Traumatic Stress Network ( org). Nell is not alone. Two-thirds of U.S. children experience at least one trauma before adulthood, and a third are multiply traumatized. Virtually every youth in foster care and most in the juvenile justice system have experienced trauma. Yet most children in these systems do not receive systematic trauma assessments, let alone evidence-based trauma treatment that could address the impact of these traumas and preempt or reverse the long-term negative outcomes. This is not only tragic for individuals; it s also bad public health policy and bad economics. A recent study indicated that the lifetime costs of child maltreatment exceeded $123 billion, with health care costs alone exceeding $25 billion. 1 Specifically, we now know that without effective treatment, trauma is associated with significantly higher rates of mental health problems like PTSD, depression, substance abuse and suicide in adulthood. Especially relevant to physicians, the Adverse Childhood Experiences (ACE) Study shows that child abuse, domestic violence and other childhood adversities are major risk factors for the leading causes of illness and death in the United States ( The higher an individual s ACE score (i.e., the greater number of early childhood traumas and adversities using the simple ACE self-report scale), Two-thirds of U.S. children experience at least one trauma before adulthood, and a third are multiply traumatized. the greater that individual s risk is for developing many common illnesses during adulthood. The hypothesized mechanisms are dysregulation of HPA axis, neurochemistry, and autonomic nervous system leading to an array of biological sequelae, including impaired immune functioning. No matter what your specialty, many of your patients have past trauma that may be contributing to significantly poorer health outcomes. Effective trauma treatment is available across the lifespan, and growing evidence suggests that such treatment not only resolves psychological symptoms but also has the potential to reverse negative neurobiological trauma impacts. 2 But like Nell, it s likely that no one has asked these patients about their trauma experiences. If we don t ask, they won t tell, because of shame, stigma, or not understanding the connection between their current problems and what happened in the past. When we recognize trauma s impact on diverse medical and mental health problems, we will do a better job of intervening to prevent its further progression. Talk about trauma with your patients. Have them complete the ACE screen and learn what the score means ( 286 Bulletin / July 2015

15 Perspective shots/2015/03/02/ /take-theace-quiz-and-learn-what-it-does-anddoesnt-mean). Because ACES focuses on family trauma, also ask about exposure to school bullying, community violence or disasters. If integrated care is available in your practice, refer those with past trauma or adversities to your mental health provider, particularly those with multiple traumas. If not, encourage these patients to seek an evaluation from therapists who provide evidence-based treatment such as TF-CBT for children and adolescents, or Cognitive Processing Therapy, Prolonged Exposure, or Eye Movement Desensitization and Reprocessing (EMDR) for adults. Nell and her foster mother reluctantly agreed to participate in TF-CBT. It took time and effort, but five months later, Nell s behavior and mood had dramatically improved. All but one psychiatric medication had been discontinued and she was attending school regularly, only using her Albuterol inhaler on a PRN basis. Instead of terminating her placement, her foster mother was planning to adopt her. Talking about trauma can be the first step toward significantly improving your patients health outcomes. Dr. Cohen is a professor of psychiatry with Allegheny Health Network. She can be reached at jcohen1@wpahs.org. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society. References 1. Fang, X, Brown, DS, Florence, CS & Mercy, JA (2012). The economic burden of child maltreatment in the United States and the implications for prevention. Child Abuse & Neglect, 36, Thomaes, K, Dorrepaal, E, Draijer, N, Jansma, EP, Veltman, DJ, & van Balkom, AJ (2014). Can pharmacological and psychological treatment change brain structure and function in PTSD? A systematic review. Journal of Psychiatric Research, 50, Our multi-million-dollar, state-of-the-art healthcare facility. Every day, we provide healthcare to more families in their homes than just about anyone. Whether you re recovering from surgery, disabled or just need a little help to maintain your independence, our trained, experienced caregivers will come to your house and take care of you. On a part-time, full-time or live-in basis. We re Interim HealthCare, and we provide healthcare for the people you love. Give us a call S Braddock Ave. Pittsburgh, PA (412) Bulletin / July Fox Chase Lane, Upper St. Clair Allegheny County South Hills of Pittsburgh Stately brick masterpiece with marble entry, curved staircase, Great Room with two-story wall of windows. Gourmet kitchen, first-floor home office and library. Designed and built by Thomas Builders, it offers 5 bedrooms and 5 full and 2 half baths, including an elegant master suite with gas fireplace and adjacent sitting room. The expansive and elegantly appointed lower level features a game room, guest space, full bath and kitchen, and fitness area! Professionally landscaped grounds and tree-lined yard. Award-winning Upper St. Clair School District with IB and AP programs. Near country club, recreation center, and I-79 for convenient commute. Call for a private tour. $995,000. Mary Eve Kearns (cell) x239 (office) MEKearns@HowardHanna.com MEKearns.HowardHanna.com 287

16 Perspective Caveat emptor While growing up in Brooklyn in the early 1960s, my mother would often take me to the A&S department store to shop for children s clothing. There, a legion of women would attend to us (male salespeople were found only in jewelry and men s clothing at the time). As I got older, my mother explained that although these salespeople were likely inherently nice people, their motivation at work was more straightforward and mercenary they worked on commission. Whereas this provided hustle when it came to the women attending to us, it also significantly colored our interaction in regard to how large the sale might be. This was especially so, as the base salary for these ladies was quite low in comparison to what they made on the commission. Their method of compensation, however, was transparent to all parties, buyer and seller alike. I was reminded of this recently last fall when I was presented with a take it or leave it contract at one of Pittsburgh s large health care organizations. As is now common in the industry, my contract stipulated a modest base with the balance of my compensation predicated on the generation of Relative Value Units (RVUs). I work in a procedure-based specialty. I make decisions regarding the advisability of surgery based upon history, clinical findings and radiographic studies. To say that there is a lot of discretion and art to determining whether a procedure is appropriate in a particular patient is hardly an exaggeration. In addition, with the sensitivity of Matthew R. Quigley, MD modern diagnostics, virtually everyone over the age of 20 has some abnormal finding, begging the question as to whether surgery is indicated. As a college student, I was fascinated with Plato s solution of the Philosopher King as the best method of leading the populace. He realized that the only way to prevent the corrupting influence of money and power was to shield the leader from them. Likewise, as my high school theology instructor told us, The Lord s Prayer says lead us not into temptation. It doesn t say Oh Lord, help me resist temptation. The Lord knew better. I would like to imagine that all the surgeons in Pittsburgh are a modern version of the Philosopher Physician, but experience has told me otherwise. My office used to be filled with folks who had big expensive back operations (or several) elsewhere and were no better. Review of their story and films often led to the fundamental question of why the procedure was done in the first place, or as my son would say, What were they thinking? I don t wish to impugn the motives of these other surgeons. I imagine that they did not consciously evaluate the patient with a car payment or tuition bill in mind. I m sure at some level they thought they were helping these people. But I wonder, would they have made the same decision if their productivity bonus was not on the line? Beyond that, as a student of human nature, I don t know what I would do if placed in the same situation. I hope that I could put the mercenary part of decision aside, but I just didn t know. So I left town and found a different place and financial model. Finally, although I have used the analogy of the salesman s commission to drive home the point of what our profession has been reduced to, there is something fundamentally different in our interaction with a patient compared to a department store clerk. My mother, the buyer, was well aware of the financial incentives inherent in the situation at the children s clothing department at A&S. I suspect that our patients are not. Most come to us assuming we primarily have their best health interests in mind, not that we are trying to maximize our fiduciary benefit. I trust most have no idea how we are compensated or how much of our compensation is predicated upon the hustle. I often find myself explaining to patients convinced they need an unindicated surgery, that I make lots more money if I were to operate as opposed to sending them on to therapy or pain clinic. Mute in all this are the health care systems and hospitals. Despite driving most procedural specialists into heavily weighted RVU-based contracts, this information is not passed on to their insured. On some level, wouldn t such a disclosure simply be fair? Just as all the nonprofit organizations can be com- 288 Bulletin / July 2015

17 Perspective pared based upon the percent of donations that are used for the charity s cause as opposed to overhead, shouldn t the patient be informed of what percent of their surgeon s compensation is based upon productivity and RVU targets? This would simply make the surgical decision-making progress analogous to my mother s trip to the A&S. I imagine this is not information systems and hospitals would willingly share. I imagine they don t want their insured to know how skewed toward productivity their physician s compensation is. Likely such knowledge would lead to a public outcry against the practice. And then, my friends, perhaps we can all get off the treadmill. Dr. Quigley practiced neurosurgery in Pittsburgh for nearly three decades. He currently is the chief of Neuroscience and Neurosurgery at the Guthrie Clinic in Sayre, Pa. Recruiting is hard work. We can help. Practice Opportunities in Pennsylvania at connects Physicians, Physician Assistants & Nurse Practitioners with Pennsylvania healthcare employers. Private practice memberships begin at $500. POP is a part of Medical Opportunities serving the Great Lakes Region since The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society Community awards Benjamin Rush Individual Award Recognizes an individual who is not a practicing health care professional, who devotes time, skills or resources to assisting others and contributes to the advancement of others. Benjamin Rush Community Organization Award Recognizes a company, institution, organization or agency that is successfully addressing a public health issue. Physician Awards Nathaniel Bedford Primary Care Award Recognizes a primary care physician for exemplary, compassionate, comprehensive and dedicated care of their patients. Ralph C. Wilde Leadership Award Recognizes a physician who demonstrates exceptional skill in their clinical care of patients and dedication to the ideals of the medical profession as a teacher or profession leader. Physician Volunteer Award Recognizes a physician who demonstrates exceptional skill in their clinical care of patients and dedication to the ideals of the medical profession as a teacher or profession leader. Richard E. Deitrick Humanity in Medicine Award Honors a physician who has improved the lives of patients by caring for them with integrity, honesty, and respect of their human dignity, and serves as a role model for other physicians. Nominations must be received by Monday, August 17, Nomination forms available at For more information, call (412) Bulletin / July

18 Welcoming Mary Beth Malay, MD Breast Surgeon Dr. Malay is a breast surgeon with extensive experience in breast care and surgery for patients with breast cancer and those with high risk for breast cancer or breast disease. She joins the physicians of Allegheny Health Network s Division of Breast Surgical Oncology. She received her medical degree from the Medical College of Pennsylvania and completed her general surgery residency at Allegheny General Hospital. She is certified by the American Board of Surgery and is a fellow in the American College of Surgeons. Dr. Malay holds professional memberships with the Pennsylvania Medical Society, the Allegheny County Medical Society and the American Society of Breast Surgeons. She has authored and co-authored several medical articles and has lectured to medical audiences at conferences locally and regionally. Dr. Malay is welcoming patients at her new office location. For an appointment, please call AHN Breast Surgeons Wexford Health + Wellness Pavilion Perry Highway Wexford, PA DOCTORS ( ) AHN.ORG As always, new patients are welcome. Most major insurances are accepted. 290 Bulletin / July 2015

19 The New World of Health Care is complicated. Are You Prepared? Allegheny County Medical Society members: The new world of Health Care ushered in by the Patient Protection and Affordable Care Act (ACA) has created uncertainty and confusion for most people. There are new regulations and requirements. Individual and employer mandates. Penalties for not purchasing coverage. On Exchange and Off Exchange access. As an Allegheny County Medical Society member, you have help. Talk to USI Affinity, the ACMS s endorsed insurance broker and partner. Our benefits specialists are experts in Health Care Reform. We can help you choose a health plan that provides the best coverage and value while ensuring you will be in compliance with complex new IRS and Department of Labor regulations. We ll also provide you the kind of world class service and support you need to make sure you get the most out of your health care benefits after you buy. You can also check out the NEW Allegheny County Medical Society Insurance Exchange, a convenient and secure online portal where you can find competitively priced insurance coverage for all your needs, including a wide variety of medical and dental plans. To learn more, contact USI Affinity today! Call , or visit the ACMS Insurance Exchange at Bulletin / July

20 Society News ACMS Foundation offers medical student scholarship The Allegheny County Medical Society Foundation is offering a $4,000 scholarship to a qualified medical student. Applications will be accepted from July 1 to September 30, Eligibility for scholarship applicants: Applicant must be a Pennsylvania resident from Allegheny County. Applicant must be a Pennsylvania resident for at least 12 months prior to registering as a medical student. Applicant must be enrolled full time in a fully accredited Pennsylvania medical school. Applicant must be enrolled or entering his/her third or fourth year of medical school. Applicant must submit: A completed scholarship application form. Two reference letters, from persons other than family members, documenting the applicant s integrity, interpersonal skills, and potential as a future physician. Note: One reference letter must be from either a medical school professor or a physician. A letter, on school letterhead, from the applicant s medical school verifying that he/she is enrolled full time as a third- or fourth-year medical student at that institution. A typed, one-page essay addressing the following: How do you hope to be involved in your community beyond clinical care of patients? In what ways would you hope to demonstrate leadership as a physician in your community? Application materials must be postmarked by September 30, Applicants will be notified of the committee s decision in December Students can download an application and review eligibility requirements at SFS/Scholarships/Allegheny.aspx. Application materials should be mailed to: ACMS Scholarship, c/o The Foundation, 777 East Park Drive, P.O. Box 8820, Harrisburg, PA For more information, call (717) or (717) , Fax: (717) , or studentservices-foundation@pamedsoc.org. The website is org. Award established in ACMS members names The children of Lawrence R. John, MD, ACMS president-elect, and Martha D. John, MD, have established an award, The Lawrence R. John, MD, ( 77) and Martha D. John ( 78) Award in Primary Care, to be gifted yearly to a graduating student from Case Western University School of Medicine. The John Family Children will gift a minimum of $1,000 to a graduating student entering the field of primary care, namely pediatrics or family medicine. Pennsylvania Primary Care Career Fair scheduled A 2015 Pennsylvania Primary Care Career Fair will be held in Pittsburgh Friday, September 11, from 5 to 8 p.m. at the Wyndham Pittsburgh University Center, 100 Lytton Avenue. Free food and free parking are available; attendees will be able to meet and network with practitioners working in primary care. Spouses, partners and children are welcome. To sign up, visit career-fairs/. For more information, contact Judd Mellinger-Blouch, director of the Pennsylvania Primary Care Career Center, at judd@pachc.org or (717) , ext ACMS to host HIPAA, OSHA, OIG program The Allegheny County Medical Society (ACMS) will host Checklist Review for HIPAA, OSHA, and OIG from 8 a.m. to noon Thursday, August 13, at the ACMS Mr. Suchocki building. The presenter will be Joe Suchocki, president of Eagle Associates Inc., a nationally recognized speaker and compliance consultant for medical practices. The program will provide updates on the following: OSHA: How up-to-date is your practice for major safety requirements? HIPAA: A review of Privacy, Breach Notification, and Security Rules will provide a quick status check for compliance with current requirements. OIG: Participants will be guided through steps or actions published by OIG to meet OIG requirements. The cost to attend the program is $125 for ACMS members and staff and $160 for non-members. To register, visit com. For more information, call Nadine Popovich at (412) , ext ICD-10-CM program slated at ACMS ICD-10-CM Made Easy will be held from 8:30 to 11 a.m. Thursday, August 20, at the ACMS building. The program will be presented by Linda Benner, CPC, CPMA, CASCC, COB- GC, AHIMA-Approved ICD-10-CM/ 292 Bulletin / July 2015