the radical mastectomy sunscreen wars - acms · pdf filethe radical mastectomy sunscreen wars:...

Allegheny County MediCAl SoCiety

BulletinMAy 2017

The rise and fall ofthe radical mastectomy

Sunscreen wars: What to tell your patient

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Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate

Care is Your Business, Change is OursThe 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.

BulletinMAy 2017 / Vol. 107 No. 5


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Business • Employment • Estates and Trusts • Health Care Litigation • Oil and Gas • Public Finance • Real Estate

Care is Your Business, Change is OursThe 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.

ArticlesOpinion Departments

Materia Medica .................... 188Nebivolol/valsartan (Byvalson®) for the treatment of hypertensionArdis M. Copenhaver, MS, PharmD Nathan Lamberton, PharmD

Legal Report ....................... 190Regulatory repeal and reform: A health care lawyer’s wish listBeth Anne Jackson, Esq.

Practice Management ........ 194What your employees crave more than money or perksJoe Mull, MEd

Special Report .................... 196Home sweet (and healthy) homeMichelle Naccarati-ChapkisDeborah Gentile, MD

Special Report .................... 200JHF approves $300K grant to boost senior exercise and recreation options Jewish Healthcare Foundation

Special Report .................... 201Quality Insights offers free tools to reduce opioid misuse, increase annual wellness visit utilization

Editorial ............................... 166RulesDeval (Reshma) Paranjpe, MD, FACS

Editorial ............................... 168Lions and tigers and self-pay patients: Oh my!Charles Horton, MD

Perspective ......................... 170Why is breast density important? Its effect on breast cancer risk and screening mammographyDanielle Sharek, MD

Perspective ......................... 174Two roads traveled: 60-year history of the struggle to re-establish diversity in medical practice in the United StatesWilliam Simmons, MD

Perspective ......................... 176The rise and fall of the radical mastectomyKristen Ann Ehrenberger, MD, PhD

Perspective ......................... 178Sunscreen wars: What to tell your patientNicole F. Vélez, MD

Perspective ......................... 180Total human eye transplantation: Looking toward the futureIan A. Rosner, BSKia M. Washington, MD

Society News ...................... 182• Pennsylvania Geriatrics Society – Western Division• Pittsburgh Ophthalmology Society

ACMS Alliance News ......... 187

Classifieds .......................... 199

On the cover

White Water Rafting, Nantahala River, N.C.

Mark E. Thompson, MD

Dr. Thompson specializes in cardiology.

2017 ACMS Bulletin Photo Contest: See Page 202

ACMS ALLIANCEPresident

Kathleen ReshmiFirst Vice President

Patty BarnettSecond Vice President

Joyce Orr Recording Secretary

Justina Purpura Corresponding Secretary

Doris DelseroneTreasurer

Josephine MartinezAssistant Treasurer

Sandra Da Costa

2017 Executive Committee

and Board of Directors

PresidentDavid J. DeitrickPresident-electRobert C. CiccoVice President

Adele L. TowersSecretary

William K. JohnjulioTreasurer

Patricia L. BononiBoard Chair

Lawrence R. John

DIRECTORS 2017

Peter G. EllisTodd M. HertzbergBarbara A. KevishDavid A. LoganJan W. Madison

Matthew B. StrakaAngela M. Stupi

2018David L. Blinn

William F. Coppula Kevin O. Garrett

Raymond E. Pontzer John P. Williams

2019Thomas P. Campbell Michael B. Gaffney

Keith T. Kanel Jason L. Lamb

Maria J. Sunseri

PEER REVIEW BOARD2017

Donald B. MiddletonRalph Schmeltz

2018 Sharon L. Goldstein Bruce A. MacLeod

2019Robert W. Bragdon

John A. Straka

PAMED DISTRICT TRUSTEEAmelia A. Paré

COMMITTEESAwards

Donald B. MiddletonBylaws

Adele L. TowersFinance

David J. DeitrickGala

Patricia L. BononiAdele L. Towers

Nominating Matthew B. Straka

Primary CareLawrence R. John

COPYRIGHT 2017:ALLEGHENY COUNTY MEDICAL SOCIETYPOSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212.

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EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 713 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address.

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ISSN: 0098-3772Leadership and Advocacy for Patients and Physicians

Affiliated with Pennsylvania Medical Society and American Medical Association

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Bulletin Medical Editor

Deval (Reshma) Paranjpe([email protected])

Associate EditorsCharles Horton

([email protected])Robert H. Howland

([email protected]) John Kokales

[email protected] Miller

([email protected])Amelia A. Paré

([email protected])Gregory B. Patrick

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([email protected])Brahma N. Sharma

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Managing EditorMeagan K. Sable

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Editorial

166 www.acms.org

RulesDeval (Reshma) PaRanjPe, mD, FaCsMedical editor

1. Be nice.2. Tell the truth.3. No hitting, biting, or swearing.4. No name-calling.5. Don’t steal.6. Ask permission.7. Share. 8. Respect other people’s things.9. Say please and thank you.10. Raise your hand to speak and

wait your turn.11. Don’t shout.12. Make up and forgive each other.13. Communicate, but don’t talk

behind each others’ backs.14. Don’t eat too much sugar.15. Remember to nap.These were the basic rules of kin-

dergarten. Perhaps I’m missing a few. What seems like a necessary primer to avoid a gaggle of 5- and 6-year-olds from descending into chaos is actually a deceptively simple guide to adult life as well.

How many arguments, calamities, divorces and outright tragedies could be prevented by heeding these rules ... can you imagine if people actually followed them after the age of 10? The world would be a kinder place and would run so much more efficiently.

Rule 1: Be Nice. Trolls on the Internet would no longer exist. No more ridiculous celebrity feuds on Twitter and

SnapFace and FaceChat and InstaTwit and TwitGram. Political debates would be based on issues and not personal attacks.

Rule 2: Tell the truth. Seventy-five percent of court cases would no longer exist and would no longer clog the judicial system. We would actually know the truth about world politics and people’s motives. Spin would disap-pear from media.

Rule 3: No hitting, biting or swear-ing. Boxing, football and hockey injuries would be nonexistent. Most bad standup comedians would be out of work. Violent crime would disappear.

Rule 4: No name calling. The talking heads on every media outlet would probably explode.

Rule 5: Don’t steal. What an import-ant rule. Covers so very much.

Rule 6: Ask permission. Copyright suits would disappear. Rapes and as-saults would stop. Neighbors would not have to build walls to keep each other out and would respect each others’ boundaries.

Rule 7: Share. This doesn’t mean socialism. But charitable giving would rise. People would think about “us” rather than “me me me;” “there but for the grace of God go I” rather than “I’m a special snowflake and deserve special treatment above all others.” It’s

impossible to feel entitled and easy to feel magnanimous (not to mention the life of the party) if you bring in candy for everyone in class on Valentine’s Day and Halloween.

Rule 8: Respect other people’s prop-erty. Intellectual, physical, financial and spiritual. People would have respect for each other’s contributions, ideas, bodies and creations. No one would force their beliefs or person on anyone else.

Rule 9: Say please and thank you. Amazing what a little politeness can accomplish.

Rule 10: Raise your hand to speak and wait your turn.

Rule 11: Don’t shout.Taken together, these two rules

alone would make every major TV news channel watchable, nay, bearable again.

Rule 12: Make up and forgive each other. Democrats and Republicans would bridge the political divide and work together. Say what you will about lawyers, but they alone can fight each other all morning like pit bulls and then go out for a friendly lunch together af-terward. I think we can learn something from everyone, even them.

Rule 13: Communicate, but don’t talk behind each other’s backs. In the age of oversharing on social media, the concept of embarrassment and “would you like to share that with the rest of

Editorial

167ACMS Bulletin / May 2017

the class?” has been sadly lost. Don’t post anything you wouldn’t want your grandmother to see. Everything can end up as evidence in court.

Rule 14: Don’t eat too much sugar. Not only will it wind you up, but it also may be the new designated root of all health evils. Who knew that your kindergarten teacher was on to something?

Rule 15: Remember to nap. There really should be naptime for adults, complete with blankets, lights off. Ted-dy bear optional. It’s a metaphor for slowing down, resting an overactive mind and body, and resetting ourselves.

Wishing you a simple and lovely month.

Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at [email protected].

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 MarcocelliChadwick Martin Bailey, January 2016

Nondiscrimination Statement UPMC Health Plan1 complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

1UPMC Health Plan is the marketing name used to refer to the following companies, which are licensed to issue individual and group health insurance products or which provide third party administration services for group health plans: UPMC Health Network Inc., UPMC Health Options Inc., UPMC Health Coverage Inc., UPMC Health Plan Inc., UPMC Health Benefits Inc., UPMC for You Inc., and/or UPMC Benefit Management Services Inc.

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ObamaCare is the talk of the town, along with its potential reforms

or repeal. In the Pittsburgh market, the Big Two duke it out for control of hospitals and areas as the VA works to strengthen itself. And amidst this battle of the mighty, a curious phenomenon from the past is starting to reappear: patients who pay for their own care, of-ten as part of a system called Christian cost sharing.

Christian cost sharing is not insur-ance, but it works much like insurance did several decades ago. Consider how your car insurance works: It pays if you cause an accident, it might (de-pending on the policy) pay if a tree falls on your parked car, but you wouldn’t present your insurance card to pay for an oil change or a tank of gas. The insurance is there for large, unpredict-able events – and so it is with Christian cost sharing.

It works like this: Patients get the medical care they need, negotiate for a self-pay discount, then “share” their need through a service that divides it among an appropriate number of the subscribers. Members then reimburse each other directly. As a Christian ministry, cost sharing excludes services that conflict with a Biblical lifestyle, such as abortion. As a practical matter,

it also excludes small bills – Samaritan, one of the leading cost-sharing minis-tries, sets the bar at $300.

Why do patients choose it? Apart from concerns about insurance pre-miums funding procedures to which they object, patients also cite cost as a selling point for cost sharing. The ministries are run as nonprofits (and the kind of nonprofits that don’t own corporate jets), paperwork is minimal and executive salaries are modest. In addition, patients are free to get care wherever they please: There are no networks, nor other anti-competitive behavior.

What’s in it for you as the doctor? Plenty. If you’re tired of sending bills off to insurers for the pittance they’ve agreed by contract to pay, only to hear back in a month or two that they’re challenging even that, patients who pay promptly – with actual money! – will be a welcome surprise. Likewise, there is no pre-certification or other hassles designed to prevent you from doing what you feel is best for your patients.

What can you do to help self-pay patients? A few simple steps make life easier both for you and for them. First, decide on a reasonable discount for them. In light of the discounts insurers get, 50 and 75 percent are common discounts. (Again, unlike insurers, these patients pay promptly and with-

out bureaucratic hassles.) Second, re-member that patients who are self-pay for you are almost certainly self-pay for the rest of their services. This means labs and studies! Giving such patients a prescription for the studies you’d like, and asking them whether they’d like to shop online for a better price, may help them save substantially compared to drawing the lab work in the office and sending it yourself. (If you do that, the lab will happily bill your patient the full list price for the tests, when five minutes on Google could have saved hundreds of dollars. Ouch!) They’ll still have their lab work done at Quest or LabCorp – it’s just the lab equivalent of using a pharmacy discount card, but it has to happen before the lab work itself. Hint: Most online lab discounters have a bundle named “comprehensive wellness package,” or something along those lines. It’s generally a CBC, chem-7, LFTs, lipid panel and sometimes a TSH or HbA1c, and it usually goes for under $100.

How do these patients handle pre-scriptions? As with the lab world, online tools have helped self-pay patients minimize the pain of rising prices. GoodRx and Blink Health let patients quickly – even at the point of care, if they have smartphones – tell which pharmacies offer the best prices on a given drug, and obtain discounts. The difference can be remarkable: For a

168 www.acms.org

Editorial

Lions and tigers and self-pay patients: Oh my!ChaRles hoRton, mDassociate editor


few drugs I entered at GoodRx out of curiosity, discounts from the pharmacy’s cash price sometimes exceeded 80 percent.

Full disclosure: I should not be using the pronoun “they,” but “we:” My family and I have been self-pay since the beginning of this year. A series of adventures with insurers, all of which bore a distressing resemblance to a game of three-card monte, culminated in an independent provider refusing to care for us – even for cash! – be-cause the practice had signed a contract with an insurer forbidding them to care for patients with our particular flavor of that insurer’s product. It was the proverbial last straw: The freedom of self-pay has been, indeed, just what the doctor ordered.

Dr. Horton specializes in anesthesiology and is asso-ciate editor of the ACMS Bulletin. He can be reached at [email protected].

Editorial

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.

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Michael L. Gomber, MBAMore than 30 years meeting physicians’ needs 412.580.7900 Fax: 724.223.0959E-mail: [email protected]

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PerspectivePerspectivePerspective

Why is breast density important? Its effect on breast cancer risk and

screening mammographyDanielle shaRek, mD

Breast density has become an important topic in breast imaging

literature, due to advances in research about its effects on a woman’s risk of developing breast cancer. This has led to increased awareness of the implica-tions of breast density among the rest of the medical community and the gen-eral public. Laws are now in effect in 31 states (including Pennsylvania) that require radiologists to notify patients regarding their mammographic breast density (a).

Breast density refers to the relative amount of epithelial and stromal tissue (fibroglandular elements) compared to the amount of fatty tissue seen at mammography. Denser breasts have less fat and more fibroglandular com-ponents. The Breast Imaging Reporting and Data System (BI-RADS) lexicon uses four categories to classify breast density: fatty, scattered fibroglandular, heterogeneously dense and extremely dense (b). Each woman’s breast has a unique combination of fatty and fibroglandular tissue, and all categories are considered normal. Approximately 10 percent of women have breasts that are almost entirely fatty; 40 percent have scattered areas of fibroglandular tissue; 40 percent have heteroge-neously dense breasts; and 10 percent have extremely dense breasts (c,d). The term “dense breasts” includes

all women who have either hetero-geneously dense or extremely dense breasts (d).

Breast density is determined by the interpreting radiologist based on a woman’s mammogram. Multiple studies have shown considerable inter- and intra-observer variability in the subjective classification of breast density (e,f,g). For this reason, auto-mated methods of determining breast density have been developed, includ-ing three-dimensional (3D) volumetric quantitative programs, which have improved reproducibility (h,i). It is im-portant to note that a woman’s breast density does not remain constant over time (j,k). Breast density decreases with increased BMI and decreases with age. Other factors such as hormone replacement therapy, weight changes and tamoxifen therapy can affect densi-ty. Such changes may cause a woman to be assigned a different breast densi-ty category year to year.

Breast density affects breast cancer screening in two main ways. First, increased density has a masking effect on the detection of cancers (l). This refers to limited cancer visibility mammographically because cancers, which are radiopaque (white), are more difficult to detect in a background of dense radiopaque (white) tissue than in a background of fatty radiolucent

(gray) tissue. Additionally, dense breast tissue is an independent risk factor for the development of breast cancer (m,n). Compared with fatty breasts, dense breasts contain more epithelial and stromal elements. Most cancers are known to arise from epithelial cells. Studies have shown that dense breasts may significantly increase the risk for breast cancer. Women with dense breast tissue have a two-fold increased risk of developing primary breast cancer. Women with extremely dense breast tissue have up to a five-fold in-creased risk when compared to women with fatty breast tissue (o).

Given that increased breast density can increase a woman’s risk for breast cancer, a woman with dense breasts and her referring physicians should be aware of supplemental screening options. It is important to note, how-ever, that supplemental screening should not replace mammography, as mammography is the only imag-ing modality proven to reduce breast cancer mortality. 3D mammography (tomosynthesis) is recommended in all women to increase cancer detection, mostly by decreasing the masking effect upon breast cancer (p). Addi-tionally, supplemental screening for a woman with a high risk for breast cancer development (women with a BRCA gene mutation and their untest-



ed first-degree relatives; women with a history of chest irradiation between the ages of 10–30; and women with a 20 percent or greater lifetime risk of breast cancer) should include annual screening MRI (q).

However, supplemental screening in an intermediate- to average-risk woman with dense breast tissue is not as clearly defined. Ultrasound has been suggested specifically for women with dense breasts, as large studies have shown increased cancer detection with ultrasound, even after tomosynthesis (r). In dense tissue, ultrasound has been shown to detect another two to four cancers per 1,000

women screened that were not seen mammographically (s,t). The American College of Radiology and the Society of Breast Imaging have stated that in women with dense breasts (with an intermediate risk of breast cancer), supplemental screening with ultra-sound is an option to increase cancer detection. MRI in addition to mam-mography detects the most additional cancers in women of all densities, but is fraught with a high false-positive rate and is very expensive. Therefore, MRI is not routinely recommended in intermediate- to average-risk women with dense breasts.

As breast density legislation is

becoming widespread, women are becoming increasingly aware of their breast density. This awareness allows physicians a greater opportunity to dis-cuss density and supplemental screen-ing options with their patients, including the risks and benefits of supplemental screening. It is crucial that physicians educate patients so that women are empowered to make decisions that optimize the benefits that breast cancer screening provides.

Currently, Weinstein Imaging As-sociates (WIA) is participating in two different studies involving patients with dense breasts. One study, referred to

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as DBTUST (Dense Breast Tomosyn-thesis / Ultrasound Screening Trial) is being performed in conjunction with the University of Pittsburgh Medical Center. This study will evaluate the role of whole breast ultrasound as a supplement to to-mosynthesis for detecting breast cancer in the screening population of women with dense breasts. The other study being performed at WIA is sponsored by Delphinus Medical Technologies (DMT).

DMT has manufactured a whole breast ultrasound system that uses sound and water technology to obtain a 3D recon-structed image of a woman’s breast tissue. The goal of this technology is to assist radiologists in detecting more breast cancers than traditional ultra-sound for women with dense breasts, which is the most challenging group for mammographic screening.

Dr. Sharek received fellowship train-

ing in women’s imaging at UPMC Ma-gee-Womens Hospital. She currently is employed as a radiologist at Weinstein Imaging Associates, a private practice women’s imaging group. She can be reached at [email protected].

From Page 171

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.

Referencesa. DenseBreast-Info, Inc. Legislation and

Regulations for Dense Breast. http://dense-breast-info.org/legislation.aspx. Revised April 7, 2017. Accessed April 7, 2017.

b. D’Orsi CJ, Mendelson EB, Morris EA, et al. Breast Imaging Reporting and Data System: ACR BI-RADS. 5th ed. Reston, Va: American College of Radiology, 2012.

c. Kerlikowske K, Zhu W, Hubbard RA, et al. Outcomes of screening mammography by frequency, breast density, and post-menopausal hormone therapy. JAMA Intern Med 2013;173(9):807–816.

d. Lee CI, Bassett LW, Leh-man CD. Breast density legislation and opportunities for patient-centered outcomes research. Radiology 2012;264(3):632–636.

e. Vachon CM, Kushi LH, Cerhan JR, Kuni CC, Sellers TA. Association of diet and mammographic breast density in the Minne-sota breast cancer family cohort. Cancer Ep-idemiol Biomarkers Prev 2000;9(2):151–160

f. Carney PA, Miglioretti DL, Yankas-kas BC, et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003;138(3):168–17

g. Bae MS, Moon WK, Chang JM, et al. Breast cancer detected with screening US: reasons for nondetection at mammogra-phy. Radiology 2014;270(2):369–377

h. Boyd NF, Guo H, Martin LJ, et

al. Mammographic density and the risk and detection of breast cancer. N Engl J Med 2007;356(3):227–236

i. McCormack VA, dos Santos Sil-va I. Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis. Cancer Epidemiol Biomark-ers Prev 2006;15(6):1159–1169

j. McCormack, Valerie A., and Isabel dos Santos Silva. “Breast density and parenchy-mal patterns as markers of breast cancer risk: a meta-analysis.” Cancer Epidemiology and Prevention Biomarkers 15.6 (2006): 1159-1169.

k. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammog-raphy with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet On-col 2013;14(7):583–589

l. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57(2):75–89

m. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008;299(18):2151–2163

n. Berg WA, Blume JD, Adams AM, et al. Reasons women at elevated risk of breast cancer refuse breast MR imaging screening: ACRIN 6666. Radiology 2010;254(1):79–87

o. AS Tagliafico, M Cal-abrese, G Mariscotti, etal: Adjunct screen-ing with tomosynthesis or ultrasound in mammography-negative dense breasts (ASTOUND): Interim report of a prospective comparative trial J Clin Oncol 34:1882–1888,2016

p. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammog-raphy with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet On-col 2013;14(7):583–589

q. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57(2):75–89

r. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008;299(18):2151–2163

s. Berg WA, Blume JD, Adams AM, et al. Reasons women at elevated risk of breast cancer refuse breast MR imaging screening: ACRIN 6666. Radiology 2010;254(1):79–87

t. AS Tagliafico, M Cal-abrese, G Mariscotti, etal: Adjunct screen-ing with tomosynthesis or ultrasound in mammography-negative dense breasts (ASTOUND): Interim report of a prospective comparative trial J Clin Oncol 34:1882–1888,2016

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Two roads traveled: 60-year history of the struggle to re-establish diversity in medical practice in the United States

William simmons, mD


Medical education in the United States was shaped by the Flexner

Report of 1910. In the late 19th century, freedom from slavery and freedom from oppression started to flourish around the same time. With the enact-ment of the 13th, 14th and 15th Amend-ments to the Constitution, between 1865 and 1870, slavery was outlawed, blacks were given citizenship and black men were allowed to vote. During the Reconstruction Era that followed, blacks and women quickly became physicians, lawyers and business owners in large numbers. In 1870, Hiram Revels of Mississippi became the first black senator with 16 blacks in Congress and 600 in state legislatures. In 1920, the 19th Amendment allowed women the right to vote.

The rapid growth of proprietary and University-based medical training facilities without educational stan-dards prompted the American Medical Association (AMA), working with the Carnegie Foundation, to hire a pro-fessional educator, Abraham Flexner, to evaluate the hundreds of medical training facilities in North America. Female and black doctors had a sig-nificant presence in parts of the United States. Since there was resistance to admission of women and blacks into the established schools of medicine, they created their own school. Flex-

ner’s report, using Johns Hopkins as the gold standard, became the criteria for most foundations to distribute funds to medical schools. As an unintended consequence, five of the six women’s medical schools closed and five of the seven historically black medical colleges closed, along with hundreds of freestanding proprietary schools.

As a result, from 1910 to 1970, 93 percent of all medical students were men and 97 percent were non-Hispanic whites. Of the remaining 3 percent, all but a few were enrolled in the two re-maining predominantly black schools, Howard University in Washington, D.C., and Meharry Medical School in Nashville, Tenn.

By 1970, the Association of Ameri-can Medical Colleges (AAMC) strongly encouraged recruitment and enrollment of minority students through the new Affirmative Action Policy discussed in the 1961 Executive Order #10925. Around the same time, Executive Or-der #11375, which added anti-discrim-ination rules against sex to the 1965 Executive Order #11246, known as the Civil Rights Act, prohibited discrimina-tion based on race, color, religion, or national origin. While minority enroll-ment had early gains, increasing from 3 to 8 percent nationwide because of Affirmative Action Policies, women were supported by Women’s Equity

Action League (WEAL) and National Organization for Women (NOW) by pressuring government agencies to undertake their enforcement obliga-tions and suing state governments and institutions of higher learning known to limit or refuse to admit women. Discrimination in higher education was so emphasized by these groups that congress highlighted it in a landmark legislation of 1972 called the Education Amendment, or Title IX. “No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of or be subject-ed to discrimination under any edu-cational program or activity receiving Federal Financial Assistance.”

In 1974, the early gains seen with Affirmative Action started to be rolled back by a series of reverse discrimi-nation legal challenges decided by the Supreme Court. The first was Allan Bakke against the University of Cal-ifornia at the Davis School of Medi-cine. Although minorities were widely underrepresented, leading to the need for the Federal Comprehensive Health Manpower Training Act of 1971 and the 1965 Executive Order #11246 as a legal remedy (Affirmative Action), the court decided that a properly devised admissions policy involving competi-tive considerations of race and ethnic origin would be prudent. Quotas were



deemed unconstitutional. Multiple other challenges to Affirma-

tive Action came from several states and further weakened Affirmative Action (Executive Order #11246). In Texas, Hopwood v. Texas, the Fifth District Court of Appeals ruled that the civil rights of four white applicants had been violated by the University of Texas School of Law admission policy. The court stated that race could not be used as a factor. This became binding in all public higher education institutions in Texas, Louisiana and Mississippi, which is the jurisdiction of the Fifth District Court of Appeals. The Eleventh Circuit Court ruled that the University of Georgia’s admis-sion policy was unconstitutional. The Board of Regents of the University of California prohibited the use of race, religion, sex, color, ethnicity or national origin. Finally, President Clinton’s 1995 comprehensive review on Affirmative Action eliminated any programs that: 1) created a quota; 2) had a prefer-ence for unqualified individuals; or 3) created reverse discrimination. After those guidelines in 1997, Proposition 209 in California banned all forms of Affirmative Action. The 1998 “Initiative 200” in Washington State abolished state Affirmative Action. In 2000, the “One Florida” initiative banned race as a factor in college admissions.

In 2003, the Supreme Court heard two cases from Michigan. It upheld

(5-4) a University of Michigan Law School case that confirmed that race could be used among other things as a factor in the law school selection process. However, it defeated (3-6) the Affirmative Action plan of the University of Michigan undergraduate school that gave extra points to minorities to give them an advantage during the admis-sions process.

While Affirmative Action went down with multiple defeats, the 1972 Title IX Education Amendment, which states, “No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of or be subjected to discrimination under any education program or activity receiving Federal Financial Assistance,” was never challenged and is something women had been fight-ing to get for 200 years. The suffrage movement women of note from the 1800s and early 1900s often were abolitionists as well. The admission of primarily white women in institutions of higher learning skyrocketed. AAMC reports that in certain medical schools, the number of white women were equal or higher than white men. The Wall Street Journal’s Oct. 29, 2015, article: “The Good and the Bad Statistics on Women in Medicine,” states that a third of all practicing physicians are women; they account for 60 percent of the pe-diatricians, 51 percent of the obstetri-cians/gynecologists, 60 percent of the

trainees in dermatology and 38 percent of the trainees in general surgery. Even two-thirds of the black applicants to medical school are women.

The road to true diversity in medi-cine is still a long one, but the accom-plishments of women are laudable and should not be overlooked. The effort of women was grassroots, persistent from the bottom up. This creates an unshakeable foundation for lasting success. Blacks were on a grassroots trail, but the intervention of Affirmative Action as a top down intervention, un-sustained by true legislation, derailed genuine progress and its failure has left us years behind. The lesson from this comparison is that the only road to true progress is the grassroots efforts that we create for ourselves. In the immortal words of the musician James Brown, “I don’t want nobody to give me nothing, open up the door and I’ll get it myself.”

Dr. Simmons is associate professor, University of Pittsburgh School of Med-icine, UPMC Department of Anesthesi-ology. He can be reached at [email protected].



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The rise and fall of the radical mastectomy

kRisten ann ehRenbeRgeR, mD, PhD

In 1950, Dr. Owen Wangensteen declared, “The Halsted operation for

cancer of the breast is outmoded: It is not radical enough; it is an incomplete operation for cancer of the breast in patients exhibiting axillary metas-tases.”1 By “Halsted operation,” he meant radical mastectomy to remove the breast, the ipsilateral pectoralis major and minor muscles, and the axillary lymph nodes; it was a one-step procedure that combined biopsy with treatment.

The next year, Dr. George Pack at Memorial Sloane Kettering opined, “One may justifiably and ruthlessly remove multiple organs if the patient thereby is given a reasonable prospect of a cure or a shorter life worth living. The purpose of the surgeon to divorce the patient from his [sic] cancer ap-pears to be limited solely by the ability of the human remnant to survive.”2 In the immediate post-World War II period when Americans put great faith in science, technology and medicine, general surgeons tried to cure breast cancer with the knife.

By the 1970s, however, both statis-ticians and feminists excoriated them for the “mutilation” of their patients. Finding it hard to believe that surgeons acted with intentional malice, I picked up clinician-historian Barron Lerner’s “The Breast Cancer Wars” to answer

the question: Why did the one-step radical mastectomy remain so popular for so long?

To understand Halsted’s operation, you have to know how he understood breast cancer. Wilhelm Stewart Halst-ed (1852-1922) was one of America’s greatest surgeons. He is probably most famous for asking a company to devel-op rubber surgical gloves for the nurse he later married. He is most infamous for becoming addicted to cocaine and later morphine. Nevertheless, Halsted had impeccable surgical technique, im-proved intestinal suturing and inguinal hernia repair, and reportedly conduct-ed the first cholecystectomy on his mother, at 2 a.m. on her kitchen table. He pioneered the surgical residency at Johns Hopkins as a dual training program in both surgery and research.

Based on the clinical and patho-logical-anatomy studies he had done, Halsted understood breast cancer as a local disease that spread contiguously and centrifugally, first as a mass, then through the lymph nodes. The tumors he treated often were several centime-ters across and sometimes ulcerated, so it made sense to remove the whole breast en bloc for the widest possible margins. Knowing axillary metastases often heralded poor prognosis, he performed a thorough lymph node dissection. By World War I, “the Halst-

ed operation” was the leading breast cancer treatment in North America and Europe.

By the mid-20th century, diagno-sis of breast cancers had improved with public education, but mortality remained stubbornly the same. So Wangensteen, Pack and others devel-oped the “extended” or “super-radical” mastectomy, which also excised part of the rib cage, the internal mammary lymph nodes and sometimes the supra-clavicular lymph nodes, with or without the clavicle. The height of surgical bravado was reached in some cases with the additional amputation of the entire upper extremity. Dr. Cushmann Haagenson at Columbia-Presbyterian Hospital explained in 1950, “Every single carcinoma cell must be removed if cure is to be achieved, and a thor-oughly radical operation offers the best chance of accomplishing this.”3

Surgeons who performed su-per-radical mastectomies operated as if surgery were the only tool modern medicine had to treat breast cancer, but at least three other therapeutic modalities were available: radiation, hormone therapy and chemotherapy. Moreover, increasingly sophisticated biostatistics suggested that some breast tumors could grow large without malignant transformation, while many cancers had already spread through



the blood before they could be diag-nosed by palpation or even the new imaging technique of mammography. The tumors that surgeons saw in the 1970s were smaller than the ones Halsted treated. Some women with breast cancer did not want to live (or die) with the weakness, sunken chest, lymphedema and lopsided silhouette a radical mastectomy caused. And they increasingly demanded an active role in treatment after biopsy and before surgery. By 1974, modified radical mastectomy leaving the pecto-ralis muscle(s) had become the most commonly performed breast cancer surgery, and by 1985, University of Pittsburgh surgeon Bernard Fisher’s clinical trials had definitively ruled that radiation with either lumpectomy or simple mastectomy for stage I and II tumors had roughly similar recurrence rates with no increase in mortality.

While mid-century surgeons were trying to offer their patients the best care possible, they continued to recommend and perform the one-step Halsted operation longer than both science and society wanted them to. Because they trained the next generation that “bigger is better” and ostracized colleagues who

operated differently, many more wom-en over the last century-plus endured extensive surgery for breast cancer than would ever have died of it. There was implicit misogyny in the way some of them described the aging female breast as a “nonvital and functionless gland” and characterized breast reconstruction as shallow and materialistic, as if a woman could not want to survive breast cancer and be a sexual being at the same time.4 Because they believed this procedure developed by such a skillful surgeon was the only way to prevent metastasis, they were slow to accept the idea of randomized controlled trials of what was sure, in their minds, to be an inferior therapy. Perhaps the greatest flaw was the assumption that there was one, best, surgical treatment for breast cancer, and that all their patients shared their values.

I think Lerner’s most insightful observation is that when it comes to our health, Americans then and now are risk adverse. Collectively, we prefer to overtreat than undertreat. One-step, radical mastectomy as the treatment for breast cancer simultaneously succeeded and failed as one-size-fits-all therapy. It was too much for small

tumors and too little for metastases. That “many breast cancer patients were treated aggressively to potentially cure the few” in the middle of the 20th century is still true of breast cancer treatment today.5

For further reading:• Keith Wailoo, How Cancer

Crossed the Color Line (Oxford Univer-sity Press, 2011).

• Robert A. Aronowitz, Unnatural History: Breast Cancer and American Society (Cambridge University Press, 2007).

• Mary K. DeShazer, Fractured Borders: Reading Women’s Cancer Lit-erature (University of Michigan Press, 2005).

• James S. Olson, Bathsheba’s Breast: Women, Cancer, and History (Johns Hopkins Press, 2002).

Dr. Ehrenberger is an internal med-icine-pediatrics resident. She can be reached at [email protected].



References1. As quoted in Barron H. Lerner,

The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twenti-eth-Century America (New York: Oxford University Press, 2001), 69.

2. As quoted in Lerner, 76.3. Lerner, 82.4. Lerner, 895. Lerner, 82. See also Otis W.

Brawley, “Accepting the Existence of Breast Cancer Overdiagnosis,” Annals of Internal Medicine 166 (10 Jan. 2017):364-365..

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178 www.acms.org


Sunscreen wars: What to tell your patient

Although seemingly innocuous, sunscreen has been the target of

several controversies in the media in recent years. Among the most visible was a campaign by Lululemon which included yoga bags with the following message: “Sunscreen absorbed into the skin may be worse for you than sunshine.”1 These concerns are based primarily around (1) the potential hormonal effects of oxybenzone, one of the active ingredients in many sun-screens, (2) the safety of nanoparticles, used to deliver physical sunscreen in a more appealing (less greasy) formula-tion and (3) the fear that use may lower vitamin D levels. Last year, Consumer Reports released their sunscreen review stating that half of sunscreens did not meet their SPF claims.2 As the warm weather approaches, what will you tell your patients when they ask if it is safe and efficacious to apply sun-screen?

Here’s what we know1. Skin cancer is the most common

cancer in the United States. One in every five Americans will develop skin cancer in their lifetime. An estimated 87,110 new cases of invasive mela-noma will be diagnosed in the United States in 2017, and an estimated 9,730 people will die.3 Melanoma is the most common cancer among young adult

women. When detected early, five-year survival is 98 percent, but when lymph nodes are involved, five-year survival drops to 62 percent. Unprotected sun exposure is the main risk factor for skin cancer. Up to 86 percent of melanomas can be attributed to ultraviolet (UV) radiation.4 On average, a person’s risk for melanoma doubles if he or she has had more than five sunburns.

2. Sunscreen reduces the risk of skin cancer, including melanoma.5,6 In a large randomized controlled trial with 14 years follow up, half as many mel-anomas developed in the group that used daily sunscreen vs. discretionary sunscreen.5 Sunscreen also reduces the risk of sunburn and photoaging. Chemical sunscreens contain active ingredients that absorb the sun’s UV rays (e.g., oxybenzone, avobenzone), while physical sunscreens (also known as mineral sunscreens) contain active ingredients that block the sun’s rays (e.g., zinc oxide, titanium dioxide). The FDA has several safety and effective-ness regulations in place that govern sunscreen, including safety data on its ingredients. In fact, some argue that the FDA standards for approving new sunscreen ingredients are too rigid, preventing use of potentially superior products already available in Europe. When compared to shade (i.e., beach umbrella) alone, sunscreen was sig-

nificantly more effective at preventing against sunburn.7

3. Oxybenzone is an organic UV filter that has been used in the United States since the 1970s. In an in vivo study of rats that ingested oxybenzone, estrogenic and antiandrogenic effects were observed. Researchers estimated that it would take 277 years of daily application of sunscreen with 6 percent oxybenzone to attain the same level in humans.8

4. In recent years, micro- and nano-sized zinc oxide and titanium di-oxide particles have been generated to provide the benefit of a physical barrier without the unappealing thickness of the original product. Several studies to date have shown that these nanoparti-cles are confined to the straum corne-um after topical application, even in skin where barrier function is altered. The normal turnover of the stratum cor-neum also naturally prevents accumu-lation of these particles.8 While more studies need to be done, experts agree that the risk of skin cancer outweighs concern for potential absorption of nanoparticles.

5. Vitamin D is essential for bone health. Dietary and supplemental intake is the preferred method of maintaining normal serum levels. The Institute of Medicine Recommended Di-etary Allowance of the vitamin is based

niCole F. vélez, mD



on no or minimal sunlight.9 Additionally, studies have shown that normal usage of daily sunscreen did not result in vitamin D deficiency.10 This is because sunscreen does not block all UVB rays and most people do not apply sufficient sunscreen.

6. Patients must be educated on how to use sunscreen. Studies have shown that most consumers do not understand the sunscreen labels and fail to use sunscreen appropriately (i.e., do not apply enough). As a result, the real world SPF may not be the same as the laboratory SPF. When choosing a sunscreen, I tell my patients to look

for (1) broad spectrum coverage which protects against both UVA and UVB rays; (2) a Sun Protection Factor (SPF) of 30 or greater; (3) water resistance for up to 40 or 80 minutes. No sun-screen is waterproof, and most labels now reflect this. Sunscreen should be applied 30 minutes prior to exposure and should be reapplied every two hours. Beyond that, I tell my patients that the best sunscreen is the one that they will wear everyday, so they should choose a consistency and price point they feel comfortable with. As Consum-er Reports has shown, price does not correlate with quality or efficacy.

One final plug – daily use of sun-screen for just one year was associated with improved skin clarity and texture and reversal of existing photoaging.11

Dr. Vélez is a dermatologist and Mohs surgeon with Allegheny Health Network and clinical assistant profes-sor at Temple University. She can be reached at [email protected].



References1. “Don’t believe the anti-sunscreen warning

on Lululemon’s bag.” Business Insider. http://www.businessinsider.com/anti-sunscreen-warn-ing-on-lululemons-bag-2014-7. 9 July 2014.

2. “Sunscreen Buying Guide.” Consumer Reports. http://www.consumerreports.org/cro/sunscreens/buying-guide

3. “Cancer Facts and Figures 2017.” American Cancer Society. https://old.cancer.org/acs/groups/content/@editorial/docu-ments/document/acspc-048738.pdf

4. Parkin DM, Mesher D, Sasieni P. Cancers attributable to solar (ultraviolet) radiation exposure in the UK in 2010. Br J

Cancer 2011; 105:S66-S69.5. Bigby M, Kim CC. A prospective

randomized controlled trial indicates that sunscreen use reduced the risk of developing melanoma. Arch Dermatol 2011;147(7):853-3.

6. Ghiasvand R, Weiderpass E, Green AC et. al. Sunscreen use and subsequent melanoma risk: a population-based cohort study. J Clin Oncol 2016;34:3976-3983.

7. Ou-Yang H, Jiang Li, Meyer K, et al. Sun protection by beach umbrella vs sunscreen with a high sun protection factor: a randomized clinical trial. JAMA Dermatol 2017;153(3):304-308.

8. Jansen R, Osterwalder U, Wang SQ

et al. Photoprotection Part II Sunscreen: Development, efficacy, and controversies. J Am Acad Dermatol 2013;69:867.e1-14.

9. Institure of Medicine. 2011 Dietary Ref-erence Intakes for Calcium and Vitamin D. Wash-ington, DC: The National Academies Press.

10. Norval M,Wulf HC. Does chronic sunscreen use reduce vitamin D produc-tion to insufficient levels? Br J Dermatol 2009;161:732-6.

11. Randhawa M, Wang S, Leyden JJ. Daily use of a facial broad spectrum sun-screen over one-year significantly improves clinical evaluation of photoaging. Dermatol Surg 2016;42:1354-1361.

Help your patients talk to you about their BMI

Allegheny County Medical Society is offering free posters explaining body mass index (BMI) and showing a colorful, easy-to-read BMI chart. The posters can be used in your office to help you talk about weight loss and management with your patients.

To order a quantity of posters, call the society office at 412-321-5030.You can view or download a smaller version online at www.acms.org.

Allegheny County Medical Society

Nearly 39 million people worldwide suffer from blindness, primarily due

to age-related disease, other degener-ative disease, ocular trauma, or ocular tumors. The problem lies in the perma-nent nature of these maladies. Unfortu-nately, the majority of irreversible vision loss or blindness results from damage sustained by the optic nerve – the ca-ble that connects the eyes to the brain. Regeneration of the central nervous system (CNS), of which the optic nerve is a part, largely has been thought to be impossible.

When faced with an irreversible problem, a groundbreaking paradigm shift is key in reversing the irreversible. We believe whole eye transplantation could be that paradigm shift for many of those suffering from blindness, whether it’s due to degenerative dis-ease or ocular trauma in the military.

While a radical concept, eye trans-plantation is not a new idea. Rather, it can be traced back to 1885, when Dr. Chibret unsuccessfully attempted to transplant a rabbit eye into a young blind girl so she could see again. How-ever, in 1977, the advisory council for the National Eye Institute (NEI) con-cluded that, “at present, any effort to transplant a mammalian eye is doomed to failure …”

While previously seen as a shot in the dark, our team of researchers and collaborators believe functional whole eye transplantation to be a challeng-ing, yet attainable, goal. Among the

many difficulties of transplanting an eye is the varied types of tissues that must be preserved in the procedure. The advances made in the similarly challenging hand transplantation and research in face transplantation, pio-neered at the University of Pittsburgh, have set the stage for forging ahead in the field of eye transplantation and vision restoration.

Actualization of total human eye allotransplantation (THEA), otherwise known as whole eye transplantation (WET), would be the single most important jump in vision restoration research. Functional whole eye trans-plantation involves replacing the entire visual system – including all parts of the eye, the muscles to the eye and the optic nerve. A major stumbling block in the past has been establishing an an-imal model for whole eye transplanta-tion. Without an animal model, clinical trials and translation to humans would never get off the ground.

At this point, our team has estab-

lished the world’s first orthotopic whole eye transplant model in rats. What this means is that our surgeons have successively (and continue to repro-duce) transplanted one rat’s eye and surrounding tissue into another rat. The surrounding tissue heals and, along with the eye itself, receives adequate blood flow for survival. As our focus has been establishing a feasible sur-gical model, we have not yet achieved vision restoration in the transplanted eye because we have not yet em-ployed regenerative therapies for optic nerve regeneration.

Looking to the future, our next step is to work with our collaborators in order to achieve visual restoration through optic nerve preservation and regeneration. Plans to implement neu-roprotective and regenerative therapies in our working model already are in place. We have formed a strong col-laboration across multiple disciplines, institutions and countries working together using collective expertise in plastic surgery, ophthalmology, ocu-loplastics, neurosurgery and immu-nology to drive this ambitious project forward step by step to the ultimate goal of giving people around the world a second chance at sight.

This project has been generously supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award No. W81XWH-14-1-0421, The VA Pittsburgh Healthcare System, The Louis J. Fox Center for Vision

180 www.acms.org


Total human eye transplantation: Looking toward the future

kia m. Washington, mD

ian a. RosneR, bs



Restoration of UPMC, The Eye and Ear Foundation, Pittsburgh, Pa., and finally, an unrestricted grant from Research to Prevent Blindness, New York, N.Y.

Mr. Rosner is Dr. Washington’s lab manager and research tech-nician within the Vascularized Composite Allotransplantation (VCA) laboratory in the Department of Plastic Surgery at the University of Pittsburgh. He can be reached at [email protected].

Dr. Washington is assistant professor in the Department of Plastic Surgery at the University of Pittsburgh with secondary ap-pointments in the departments of Orthopaedic Surgery and Oph-thalmology and is section chief of Plastic Surgery, VA Pittsburgh Healthcare System. She can be reached at [email protected].

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.

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Quantities of cards are available at no cost, for distribution within Allegheny County, by contacting the Allegheny County Medical Society at (412) 321-5030.

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PerspectivePerspectiveSociety News

25th Annual Clinical Update in Geriatric Medicine conference

More than 350 geriatrics profession-als from all disciplines, including physi-cians, nurses, pharmacists, physician assistants, social workers, long-term care and managed care providers, and health care administrators participated in the 25th Annual Clinical Update in Geriatric Medicine conference held at the Pittsburgh Marriott City Center Hotel April 6-9. The course attracted registrants from numerous states, in-cluding California, North Carolina, New York and Washington.

Previously awarded the American Geriatrics Society Achievement Award for Excellence in a CME program, this conference continues to be a well-re-spected resource to educate health care professionals involved in the di-rect care of older persons by providing evidence-based solutions for common medical problems that afflict older adults daily and for which rapidly evolv-ing research (much done in Pittsburgh) is revealing new approaches that are feasible for the real world.

Under the leadership of course directors Shuja Hassan, MD, Judith S. Black, MD, MHA, and Neil M. Resnick, MD, the course is a premier education-al event in the region, while attracting prominent international and national lecturers and nationally renowned local faculty. Sharon Inouye, MD, MPH; Becky Brott Powers, MD; Deborah W. Robin, MD, MHCM; Stephanie Studenski, MD, MPH; and Michael Yao, MD, CMD, comprised this year’s exceptional guest faculty.

Nearly 40 state-of-the-art sessions taught by highly regarded clinician-ed-ucators and researchers were offered

during the three-day event. Each lec-ture, symposium and breakout session provided participants evidence-based “pearls for practice” designed to be im-mediately incorporated into the realities of daily practice.

Theresa Brown, BSN, RN, clinical nurse and author of the New York Times bestselling book, “The Shift: One Nurse, Twelve Hours, Four Pa-tients’ Lives” served as guest speaker for the dinner symposium. Ms. Brown presented “Only Connect: The Com-mingling of Care and Story at the End of Life,” to an audience of more than 100 guests.

The conference is jointly sponsored by the Pennsylvania Geriatrics Society – Western Division; UPMC/University of Pittsburgh Aging Institute; and Uni-versity of Pittsburgh School of Nursing,

in partnership with the University of Pittsburgh School of Medicine Center for Continuing Education in the Health Sciences.

Pittsburgh site of 15th annual HELP conference

The 15th annual National Hospital Elder Life Program (HELP) confer-ence was held in conjunction with the Clinical Update conference April 6-8. This two-day international conference educated HELP teams with strategies for delirium prevention, and insights to learn to use HELP to improve hospital-wide care of the elderly, and creating a climate of change.

Expert clinicians and seasoned members of the HELP sites shared evidence-based information and their

NadiNe PoPovich / acMSFrom left are Clinical Update in Geriatric Medicine Course Director Neil Res-nick, MD; symposium speaker Theresa Brown, BSN, RN; President and HELP Course Co-Director Fred Rubin, MD; and Course Directors Judith Black, MD, MHA, and Shuja Hassan, MD.


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clinical insights on selected topics regarding the influence of HELP, delirium updates and the larger policy implications of care for the elderly. The conference attracted registrants rep-resenting numerous states, including international participants from Canada and Thailand.

Serving as course directors were Fred Rubin, MD, chair, Department of Medicine, UPMC Shadyside; professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Sharon Inouye, MD, MPH, professor of Medicine, Beth Israel Deaconess Med-ical Center, Harvard Medical School; Milton and Shirley F. Levy Family

Chair; director, Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Mass.; and Sarah Dowal, LICSW, MPH, project director I, Aging Brain Center, Hebrew SeniorLife, Institute for Aging Research, Boston, Mass.

This innovative model program, designed by Dr. Inouye, improves the hospital experience for older patients by helping them maintain their cog-nitive and functional abilities; maxi-mizing independence at discharge; assisting with the transition to the home; and preventing unplanned readmission.

Through HELP, the hospital be-comes a place where older patients

can feel secure as they participate in their course of treatment and maintain some control over their own recupera-tion. Hospitals around the world have implemented the program, and HELP has received extensive coverage in medical journals and mainstream media.

For more information on HELP and delirium, or to learn how to become a HELP site, visit www.hospitalelderlife-program.org.

Geriatrics Society recognizes 2017 award recipients

The Pennsylvania Geriatrics Society – Western Division recognized the 2017 recipient of the David C. Martin

From Page 182

NadiNe PoPovich / acMSFrom left are 2017 HELP conference Course Directors Fred Rubin, MD, and Sharon Inouye, MD, MPH.

NadiNe PoPovich / acMSFrom left are Lifetime Achievement Award recipient Vincent M. Balestrino, MD; President Fred Rubin, MD; Awards Chair Rollin Wright, MD, MS, MPH; Physician Award recipient Debra K. Weiner, MD, FACP; Healthcare Profes-sional Award recipient Pamela E. Toto, PhD, OTR/L, BCG, FAOTA; and Secre-tary /Treasurer Judith S. Black, MD, MHA.



Award, Ms. Rebecca Abay, a third-year medical student attending the Univer-sity of Pittsburgh School of Medicine. Ms. Abay, who was unable to attend the presentation, received an honorari-um to defray the expenses of attending the 2017 Annual Scientific Meeting of the American Geriatrics Society conference, where her abstract, “Bone Microarchitecture is Preserved in Men with Prostate Cancer on Androgen Deprivation Therapy,” was selected for the Presidential Poster presentation. Abstracts receiving the highest scores through the peer review process are included in the Presidential Poster Session.

The award was named after David C. Martin, MD, who established the first geriatrics fellowship in Pittsburgh. The goal of this prestigious award is to en-courage and prepare future physicians in the field of geriatric medicine.

Since its inception, the Society is proud to have awarded more than $80,000 to area medical students inter-ested in the field of geriatric medicine.

Additionally, the 2017 Geriatrics Teacher of the Year Award presentation was held prior to the dinner symposium of the 25th Annual Clinical in Geriat-ric Medicine. Debra K. Weiner, MD, FACP; Pamela E. Toto, PhD, OTR/L, BCG, FAOTA; and Vincent M. Balestri-no, MD, were honored with a special recognition for their dedication and commitment to geriatrics education.

Rollin Wright, MD, MS, MPH, awards chair, and Fred Rubin, MD, president, shared the podium to high-light the achievements and significant contributions each awardee has made to the education and training of learn-ers in geriatrics and to the progress of geriatrics across the health profes-

sions. More than 100 attendees were on hand for the plaque presentation. Dr. Weiner and Dr. Toto received the Physician and Healthcare Professional Award, respectively, and Dr. Balestrino was honored with the Lifetime Achieve-ment Award.

A call for nominations for the 2018 Geriatrics Teacher of the Year award will begin in September 2017. Award eligibility, criteria and details on the nomination process will be available on the society website in August (www.pagswd.org).

Controversies in Geriatric Medicine scheduled for June 22

The Pennsylvania Geriatrics Soci-ety – Western Division is hosting the 3rd annual Controversies in Geriatric Medicine program June 22 at the Her-berman Conference Center, Pittsburgh, beginning at 6 p.m. with registration and networking, followed by dinner and program at 7 p.m. Internists, family practitioners, geriatricians, nurse prac-titioners, physician assistants, pharma-cists and other health care profession-als who provide care to older adults will find the program to be a beneficial resource.

“Who Might Benefit from TAVR for Aortic Stenosis?” presents the case of a 91-year-old woman with critical aortic stenosis who is now becoming symp-tomatic. She has mild cognitive and functional impairments and is largely homebound, but enjoys her life and her family and is interested in continuing her present status. Although she would be a candidate for traditional surgical replacement of her aortic valve, would she be a candidate for a transaortic valve replacement (TAVR)? Leading the panel discussion are two cardiolo-

gists with significant experience in this area.

Rachel Jantea, MD, geriatric medicine fellow, Division of Geriatric Medicine, University of Pittsburgh, will present this interesting case with Fred Rubin, MD, chief, Division of Medi-cine, UPMC Shadyside, professor of Medicine and vice chair, Department of Medicine, University of Pittsburgh School of Medicine, serving as moder-ator. Panel presenters for the evening include: Daniel Forman, MD, chair, Geriatric Cardiology Section, UPMC; professor of Medicine, Division of Geri-atric Medicine, University of Pittsburgh School of Medicine; physician scien-tist, Pittsburgh GRECC, VAPHS; and John Schindler, MD, FACC, FSCAI, cardiologist, UPMC Heart and Vascular Institute; assistant professor of Medi-cine, University of Pittsburgh School of Medicine.

The program is complimentary for members of the Society (registration is required). Non-members are welcome at a nominal fee of $35. Registration is being accepted at http://june2017pags.eventbrite.com.

The society is a regional affiliate of the American Geriatrics Society and is dedicated to promoting geriatric edu-cation to all health care professionals interested in improving the health and well-being of all older persons. This program is one of many that serve to enhance the suite of existing educa-tional programs offered by the Society. To inquire about becoming a member or additional program details, please contact Nadine Popovich at [email protected] or (412) 321-5030, or visit the society website at www.pagswd.org.


186 www.acms.org


Pittsburgh Ophthalmology Society installs new officers

Sharon L. Taylor, MD, was installed as president of the Pittsburgh Ophthal-mology Society (POS) at the society’s annual meeting held March 17 at the Pittsburgh Marriott City Center. Dr. Taylor, who served as president-elect since 2015, is the second woman in its history to hold the position as president of the local society. She will serve a two-year term.

Dr. Taylor has been an active mem-ber of the POS since 1990. She served as program director for the society’s Annual Meeting for Ophthalmic Per-sonnel from 2009 to 2015. She is a founding member of the Thorpe Circle, which was established in 2014 to help offset the costs associated with the annual meeting so the Society could continue to invite the best and brightest lecturers in the field of ophthalmology to the Pittsburgh area.

Dr. Taylor earned her medical de-gree from Albany Medical College. She moved to Pittsburgh in 1989 where she completed a transitional year internship followed by ophthalmology residency at St. Francis Medical Center. She joined

North Park Ophthal-mology, an indepen-dent comprehensive ophthalmology prac-tice in McCandless Township, in 1993 and has been in full-time practice ever since.

Board certified by the American Board of Ophthalmology, Dr. Taylor participates in the board’s Mainte-nance of Certificate program. She also has been actively involved in the medical staff at UPMC Passavant Hospital throughout her career, serving in various positions including OR committee chair, division chief and department chair. She was the medical director of Surgical Ser-vices from 2008 to 2014 and is current-ly physician advisor for Surgical Quality at the hospital.

Dr. Taylor began serving on the board of the Pennsylvania Academy of Ophthalmology in 2016 as an alternate councilor to the American Academy of Ophthalmology (AAO). She recently attended the AAO Advocacy Day and

Mid-Year Forum Council meetings in Washington, D.C.

David G. Buerger, MD, FACS, was elected to serve as president-elect of the POS at the annual meeting. Dr. Buerger earned his medical degree from Washington University School of Medicine, St. Louis, Mo., where he served as class president for four years. He completed a transitional in-ternship at Mercy Hospital before being selected to attend Wills Eye Hospital in Philadelphia for his ophthalmology residency. Following his year as chief resident, he completed a fellowship in Ophthalmic Plastic Surgery with Jo-seph Flanagan, MD, chief, Oculoplastic Surgery at Wills Eye Hospital.

Dr. Buerger returned to Pittsburgh in 1996 to practice as a physician and surgeon with Pittsburgh Oculoplas-tic Associates. He serves as clinical instructor, Ophthalmology and Ocu-loplastic Surgery, University of Pitts-burgh School of Medicine.

He is a fellow of the American Society of Ophthalmic Plastic and Re-constructive Surgery and the American Academy of Ophthalmology and is a diplomate of the American Board of Ophthalmology.

Dr. Taylor

Dr. Buerger

If you have an interesting hobby and would like to be interviewed for a Profile column, email [email protected], or call (412) 321-5030.

What do you do in your spare time?We’d love to hear about it!

Alliance News

PAMED Alliance meeting heldThe Pennsylvania Medical Society

(PAMED) Alliance Spring Meeting was important for information sharing and networking; it also was very successful as an educational event reminding and enlightening attendees on vociferous, influential women contributing signifi-cantly to human history!

Allegheny County Medical Society Alliance, via Sandra Da Costa, our regional representative to PAMED Alli-ance, has supported the Spring Meet-ing in Harrisburg with a contribution to the PAMED Alliance scholarship fund known as AMES – Alliance Medical Education Scholarship.

2018 Board and Delegate NominationsA Candidate for the ACMS Board of Directors:• Represents physicians on issues impacting the practice of medicine and makes policy decisions for the medical society.• Meets four times per year, special meetings as needed.

[Please print name] I am interested in the Board of Directors (Phone)

A Candidate for the ACMS Delegation to the PAMED:• Represents physicians of Allegheny County in creating statewide policy on issues impacting physicians, patients and the practice of medicine. • Meets as necessary prior to attending House of Delegates in October in Hershey, PA.

(Please print name) I am interested in the ACMS Delegation (Phone)

I would like to recommend the following individual(s) [Please print]

for Board Delegate

Please FAX completed form to (412) 321-5323 by Friday, June 23.

for Board Delegate

Thank you for your membership in the Allegheny County Medical Society

Please make your medical society stronger by encouraging your colleagues to become members of

the ACMS. For information, call the membership department at (412) 321-5030, ext. 101,

or email [email protected].

Affiliated with Pennsylvania Medical Society and American Medical Association

188 www.acms.org

Materia Medica

aRDis m. CoPenhaveR, ms, PhaRmD nathan lambeRton, PhaRmD

Nebivolol/valsartan (Byvalson®) is a combination of a beta-adrenergic

blocker/nitric oxide-producer and an angiotensin II receptor blocker (ARB). This product is the first to combine a beta-blocker/nitric oxide-producer and ARB for the treatment of hypertension.1

Previous combination medications for the treatment of hypertension have been limited, without options of a com-bined angiotensin-converting enzyme inhibitor (ACE-I)/ARB and beta-blocker.

SafetyPatients taking nebivolol/valsartan

may experience changes in renal func-tion including acute renal failure due to the valsartan component of the med-ication. Periodic monitoring of renal function is necessary in these patients. In the development of acute renal failure, withholding or discontinuing therapy in patients should be consid-ered. In the setting of mild (CrCl 60 to 90 ml/min) or moderate (CrCl 30 to 60 mL/min) renal impairment, no dosage adjustment is required. The valsartan component safety and effectiveness has not been established in patients with severe renal impairment.1

No dosage adjustment is required for patients with mild hepatic impair-ment; however, nebivolol/valsartan is

not recommended as initial treatment with moderate hepatic impairment. The recommended starting dose of nebiv-olol in this population is 2.5 mg once daily, which is a lower dose of nebiv-olol than contained in the fixed dose combination. Nebivolol/valsartan is not recommended for patients with severe hepatic impairment.1

Nebivolol/valsartan is contraindicat-ed in the following conditions: severe bradycardia, first degree heart block, patients with cardiogenic shock, acute decompensated heart failure, sick sinus syndrome, severe hepatic impair-ment (Child-Pugh B or greater) and a history of hypersensitivity reaction to any component. Do not co-administer aliskiren with nebivolol/valsartan in patients with diabetes due to increased risk of hyperkalemia, renal impairment and hypotension.1

The combination of nebivolol/valsartan can cause fetal harm when administered to a pregnant woman. The use of the single pill during the second and third trimester of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. The estimated risk of major birth defects and miscarriages in clinical pregnancies is between 2 to 4 percent and 15 to 20 percent for nebivolol and valsartan, re-spectively. When pregnancy is detected, the recommendation is to discontinue nebivolol/valsartan as soon as possible.1

Nebivolol/valsartan contains an ARB and is not recommended for use

in patients with a history of angioede-ma related to previous ACE inhibitor or ARB therapy.1 Although this side effect is infrequent (clinical trials report an incidence < 1 percent), it can be a life-threatening reaction.2

TolerabilitySide effects such as hypotension

may occur in patients receiving nebivo-lol/valsartan. To avoid risk of symptom-atic hypotension, ensure that patients do not experience further volume or salt-depletion from other agents (e.g., high dose diuretics).1 In addition, it is important to educate patients regarding orthostatic hypotension and to exercise caution when going from lying to sitting and/or sitting to standing.1

The valsartan component carries a risk of hyperkalemia, especially in the setting of reduced renal function. In patients receiving the nebivolol/valsar-tan, a greater than 20 percent increase in serum potassium was observed in 4.4 percent of patients compared with 2.9 percent of placebo patients. Holding or discontinuing the medication may be required in the setting of hyperkalemia.1

Avoid abruptly discontinuing nebiv-olol/valsartan in patients with coronary artery disease due to the nebivolol component. Severe exacerbation of angina, myocardial infarction and ven-tricular arrhythmias have been reported in patients following the abrupt discon-tinuation of beta-blocker therapy.

If a patient experiences symptoms

Nebivolol/valsartan (Byvalson®) for the treatment of hypertension


Materia Medica

of hypotension, bradycardia, acute renal injury, or uncontrolled hyperkale-mia, the recommendation is to discon-tinue nebivolol/valsartan and continue nebivolol monotherapy. This is a result of the combination tablet not being able to be split based on the manufacturer, and reduced doses are not available. In the setting of reduced renal function, nebivolol requires renal dose adjust-ments based on creatinine clearance. If nebivolol monotherapy is suspended due to hypotension or bradycardia, the recommendation is to taper over one to two weeks (nebivolol monotherapy tablet can be split) in patients with a history of coronary artery disease or ischemic symptoms to avoid ischemic symptoms or events. If angina wors-ens, restart nebivolol promptly for a temporary period, and restart taper at a slower schedule.1

EffectivenessIn a double-blind, placebo-con-

trolled, parallel-group, eight-week study of 4,161 patients with Stage 1 or 2 hy-pertension, patients were randomized to one of eight treatment groups, in-cluding: three fixed-dose combinations (FDC) of nebivolol/valsartan (5 mg/80 mg once daily, 5 mg/160 mg once daily, 10 mg/160 mg once daily), nebivolol monotherapy (5 mg or 20 mg once dai-ly), or valsartan monotherapy (80 mg or 160 mg daily) or placebo. During weeks five to eight of treatment, all doses were doubled and the results were reported based on the final dose. At week eight, the doubled dose of FDC 20 mg/320 mg once daily showed a statistically significant greater reduction in diastolic blood pressure from baseline compared with monotherapy of nebivolol 40 mg (SMD – least square mean difference)

-1.2 mmHg, 95 percent CI -2.3 to -0.01; p = 0.03) and monotherapy valsartan 320 mg (SMD -4.4 mmHg, 95 percent CI -5.4 to -3.3; p < 0.0001). All other comparisons also were statistically significant (all p < 0.01). The difference between monotherapy and FDC were found to be statistically significantly different in lowering diastolic and sys-tolic blood pressure. However, the use of both monotherapies compared with FDC (no comparison reported) may not show the same clinical difference considering nebivolol doses greater than 10 mg were not used in the FDCs.3 Overall, nebivolol/valsartan demon-strates a reduction in systolic and diastolic blood pressure in the treatment of hypertension.

PriceA 30-day supply of Byvalson (avail-

able in 5 mg nebivolol/ 80 mg valsartan per tablet) costs $131.52 for 30 tablets. No other FDA-approved combination medications for the treatment of hy-pertension include a beta-blocker and ACE-I/ARB for cost comparison.1

SimplicityThe only available fixed dose com-

bination strength of nebivolol/valsartan is 5 mg/80 mg. Nebivolol/valsartan may be substituted for its individual com-ponents in patients already receiving 5 mg nebivolol and 80 mg valsartan. Initially, and in patients not adequate-ly controlled on nebivolol up to and including 10 mg and valsartan 80 mg, the recommended starting dose is nebivolol/valsartan 5 mg/80 mg once daily. However, increasing the dose of nebivolol/valsartan does not result in any further meaningful reduction in blood pressure. The maximum hyper-

tensive effects are typically attained within two to four weeks with optimal medication adherence.1

Bottom lineNebivolol/valsartan is a new med-

ication combining a beta-blocker/nitric oxide-producer and ARB for the treatment of hypertension in patients who are poorly controlled on individual agents. This combination tablet will reduce pill burden for patients requiring both medications. In prescribing nebiv-olol/valsartan, evaluate the individual components for their FDA-approved indications, the limited dose titration available and the benefit of reduced pill burden prior to recommending and prescribing the FDC.

At the time of authorship, Ardis Copenhaver was a PGY1 pharmacy practice resident at UPMC St. Margaret and can still be reached at [email protected]. Nathan Lamberton is a PGY2 Family Medicine – Ambulatory Care pharmacy resident at UPMC St Margaret and can be reached at [email protected]. Heather Sakely, PharmD, BCPS, provided editing and mentoring for this article and can be reached at [email protected].

References1. Nebivolol/Valsartan (Byvalson ®)

[package insert]. California: Allergan USA Inc; 2016.

2. Knecht SE, Dunn SP, and Macaulay TE. Angioedema Related to Angiotensin Inhibitors. Journal of Pharmacy Practice. 2014: 27 (5): 461-65.

3. Gile TD, Weber MA, Basile J et al. Ef-ficacy and safety of nebivolol and valsartan as fixed-dose combination in hypertension: a randomized, multicentre study. Lancet. 2014; 383 (9932): 1889-89.

190 www.acms.org

Legal Report

While “repeal and replacement” of the Affordable Care Act (ACA)

seems unlikely anytime soon, Presi-dent Trump has signed two executive orders with potentially significant effects on health care regulation. The first executive order, issued Jan. 30, 2017, mandated that for every one new regulation, two existing regulations be identified for repeal. The executive order further capped the costs of new regulations for the fiscal year 2017 (already in progress) at “zero.” The second executive order, dated Feb. 24, 2017, required the appointment of a Regulatory Reform Officer in each agency within 60 days. The Regulatory Reform Officer will lead the Regulatory Reform Task Force, which is charged with reviewing existing regulations and making recommendations to the respective agency heads regarding repeal, replacement or modification. The task forces are, at a minimum, to identify regulations that:

i. eliminate jobs, or inhibit job cre-ation;

ii. are outdated, unnecessary, or ineffective;

iii. impose costs that exceed bene-fits;

iv. create a serious inconsistency or otherwise interfere with regulatory reform initiatives and policies;

v. are inconsistent with the require-

ments of section 515 of the Treasury and General Government Appropria-tions Act … that rely in whole or in part on data, information, or methods that are not publicly available or that are insufficiently transparent to meet the standard for reproducibility; or

vi. derive from or implement Ex-ecutive Orders or other presidential directives that have been subsequently rescinded or substantially modified.

Regardless of how one feels about Trump’s presidency, these executive orders present a potentially tremen-dous opportunity for stakeholders to provide input to these Regulatory Reform Task Forces. For health care, I would start with the following:

EMRs: Long a source of frustra-tion for physicians, electronic medical records (EMRs) often seem to have created more problems than they have solved: erecting barriers between physicians and their patients; impos-ing significant costs (both in terms of acquisition and productivity); increasing risk of unintended disclosure of pa-tient information; requiring significant investment (and liability) with respect to cybersecurity; creating an unachievably high standard for physician practices not large enough to have their own IT departments; and, especially for hospi-talized patients, producing an overload of often meaningless information. I

propose that the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS):

• Omit many of the documentation requirements for EMRs (why must a patient be asked about smoking at every visit?).

• Delay implementation of more requirements until the technology is commercially available (e.g., interoper-ability).

• Remove the penalty for not having EMRs for small, independent provid-ers and providers within five years of retirement.

• End goal: Make EMRs work to enhance health care, not just to create “big data.”

HIPAA: The Health Insurance Por-tability and Accountability Act (HIPAA) of 1996 sought to standardize and make more efficient health care trans-actions such as claims, enrollment, disenrollment, etc. by requiring that they be performed electronically. The privacy and security provisions grew out of a need to balance this enormous electronic interchange of information with the public’s demands for priva-cy protections. HHS responded with regulations that micro-manage a duty physicians already had to protect the confidentiality of patient information. I propose that HHS:

Regulatory repeal and reform: A health care lawyer’s wish list

beth anne jaCkson, esq.


Legal Report

• Eliminate the requirement to disseminate a privacy notice describ-ing the physician’s particular privacy practices; rather, HHS should issue a standard notice about how physicians and other providers may use protected health information, and give providers the option of specifying privacy practic-es that they do not participate in (e.g., fundraising).

• Eliminate the requirement for the patient to acknowledge receipt of the privacy notice in writing.

• Because business associates are now directly subject to HIPAA, omit the requirement for business associate agreements.

• Remove barriers (the threat of penalties) that keep providers from using their professional judgment regarding communicating with patients’ families and caregivers.

• With respect to security, make more standards “addressable” for smaller practices and provide addition-al guidance and approved vendors for such items as security software.

Stark: The physician anti self-re-ferral statute – formerly known as the “Stark Law” – prohibits physicians from referring (the mere writing of an order

constitutes a “referral”) to entities for certain designated health care services when the physician has a financial relationship with the entity unless an exception applies. The Stark Law is a strict liability statute, meaning that no intent to perform an act that violates the law is required. The penalties are draconian: Services furnished by any party to the prohibited referral may not be billed to Medicare (and if they have been billed, they must be refunded) and civil monetary penalties of up to $15,000 per service may be imposed. Figuring out how the rules apply to seemingly simple situations can involve multiple experienced attorneys parsing the regulations and the preamble to each set of final rules – literally hun-dreds of pages. The Anti-Kickback Statute can keep most of the problem-atic arrangements at bay. Ideally, the Stark Law itself would be repealed. In the absence of legislative action, I propose that HHS:

• Create one very broad exception to the prohibition: If the ownership or compensation relationship is fair market value and commercially reason-able, then it does not violate the Stark Law.

• “Fair market value” means that the compensation is not only fair market value in the ordinary sense of the term, but also not tied to the volume or value of referrals or other business generat-ed between the parties.

Medicare Advantage Plans/Monthly Exclusion Checks: Medi-care Advantage Plans (MA Plans) are required to ensure that the physicians with whom they contract are not ex-cluded from the Medicare program, nor are any of their respective employees or contractors. Accordingly, MA Plans typically require that physician prac-tices run three checks on employees, vendors and contractors at the time of hire and monthly thereafter: Medicare/OIG exclusion; Medicheck (Pennsylva-nia Medicaid exclusion); and System Awards Management (federal procure-ment debarment) exclusion at sam.gov. Depending on the number of employ-ees, independent contractors and ven-dors, this can be a very time-consum-ing, and therefore expensive, process. The Office of Inspector General (OIG) also suggests, but does not require, that the exclusion status of all persons be checked monthly (likely because the


JACKSON

BETHANNE

Esq. LLC

4050 Washington RoadSuite 3NMcMurray, PA 15317

724 [email protected]

Serving the legal needs of health care practitioners and facilities

• Regulatory - Stark, Anti-Kickback, HIPAA, EMTALA

• Compliance training and policies

• Physician-hospital contracts

• Employment contracts

• Joint ventures and other business transactions

• Operational issues and policies

192 www.acms.org

OIG exclusion list is updated monthly). I propose that: • The status of employees and independent contractors

should only have to be checked at the time of hire and yearly thereafter, unless there is reason to believe that the individual may have been excluded (e.g., conviction for controlled substances felony).

• For providers enrolled in Medicare, CMS should inform the employer or other entity to which billing privileges are assigned since Medicare has this information.

• For vendors, physicians should be able to rely on repre-sentations and warranties in vendor contracts.

Section 1557 of the ACA: Section 1557 of the ACA requires physicians and other providers to post notices in English and in the top 15 non-English languages spoken in their state regarding the prohibition of discrimination in health care services and, further, to put shorter non-discrim-ination statements in these languages on each “significant communication” like brochures and post cards. Moreover, it extends the requirements to provide translators – at the physician’s expense – for persons with limited English proficiency. Providing such a translator can cost more than the practice can bill for the service. Certainly, individuals with limited English proficiency need health care, but why is it the responsibility of the physician to pay for it without reimburse-ment? I propose that:

• The provision of medical translation services should be a compensable service – paid at cost as a pass-through expense – for physicians.

• Alternatively, the insurance companies or the govern-ment could provide the medical translation services directly. This makes sense as individual physician practices are not necessarily in a position to evaluate the qualification of companies and individuals providing such services.

• Eliminate the requirement of placing non-discrimination statements in 15 non-English languages, along with the provider’s phone number: It is utterly meaningless when no one at the practice speaks the language.

Physician practices are forced to spend too much time, energy and money on compliance, often at their patients’ ex-pense. The collective regulatory burden has led to physician burnout and early retirement, exhausted and overworked employees and patients who deal with the back of a screen instead of a person. While the government obviously needs to ensure that fraudulent or medically unnecessary claims

Legal Report

From Page 191 are not paid, it needs to eliminate regulations that do not directly protect public funds or promote the health, safety and welfare of its citizens. The proposals set forth above are just the beginning. What health care or other regula-tions would you propose for elimination? Let me know at [email protected].

DISCLAIMER: This article is for informational purpos-es 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 the sole member of Beth Anne Jack-son, Esq. LLC, a law firm that serves the legal needs of health care practitioners and facilities in western and central Pennsylvania. She may be reached at (724) 941-1902 or [email protected]. Her website is: www.jacksonhealthlaw.com. Follow her on Twitter @bajhealth-law1.

Physician Compensationand

Practice EvaluationsIncluding Billing Audits

For information, contact John Fenner

3 Penn Center West

Pittsburgh, PA 15276412-788-8007

[email protected]

Specializing in hoSpital and phySician

conSulting Since 1991 with officeS in:ohio • pennSylvania • virginia

Dr. Ayoub is a board-certified rheumatologist with many years of experience caring for patients with rheumatic diseases. He has particular expertise in treating rheumatoid arthritis, osteoarthritis, gout, osteoporosis, lupus, polymyalgia rheumatic, vasculitis, Lyme disease, tendonitis, bursitis, and other inflammatory diseases.

He is a graduate of Bucknell University. He earned his medical degree at Temple University School of Medicine, in Philadelphia, Pa., where he graduated with the Alpha Omega Alpha Medical Honor Society. He completed his residency in internal medicine and served as the chief resident at the Geisinger Medical Center in Danville, Pa. Dr. Ayoub went on to complete his rheumatology fellowship at Geisinger in 1983.

As always, new patients are welcome. Most major insurance plans are accepted.

Welcoming William T. Ayoub, MD, FACP, FACRRheumatology

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Call to make an appointment or visit AHN.org.

194 www.acms.org

Practice Management

Pop quiz: If you were to ask your employees what attributes are most

important when considering whether to take a job with a different organization, what would they rate highest?

If you said money or a pay increase of some kind, you would be wrong. In fact, compensation doesn’t even make the top three.

Gallup recently released the third it-eration of their comprehensive employ-ee engagement report titled, “The State of the American Workplace Report.” In it, they share research that employees place highest priority on doing work that aligns with their talents.

In order, employees place the great-est importance on a role and organiza-tion that offer them:

1. The ability to do what they do best

2. Greater work-life balance and better personal well-being

3. Greater stability and job security4. A significant increase in income5. The opportunity to work for a com-

pany with a great brand or reputation[Source: The State of the Ameri-

can Workplace Report (2016 Report), Clifton. (2017) Gallup]

As a leader, you must ask yourself then, if this is true, what else is true? For starters, it means that your most talented employees are more likely to leave if they aren’t getting a chance to

use their strengths on the job. Also true is that workers expect and seek out more balance between work and non-work hours than ever before.

In other words, if you aren’t active-ly holding conversations about your employees’ strengths, aren’t collabo-rating with them to put those strengths to use with greater frequency, and aren’t making sure the workload and/or schedule for each person is reason-able from week to week, then you are driving talent away, perhaps without even knowing it.

For decades, leaders have contin-ued to fall into the trap of believing that what employees crave most is more money. What employees truly desire, it turns out, is getting to do work that aligns with their interests, talents, skills and strengths. The most effective bosses spend time taking an inventory

of these areas with individual employ-ees, then tailoring their work experienc-es and roles as much as possible in response.

Want to retain your best talent? Want to reward your superstar work-ers? Then start exploring the unique gifts they bring to the workplace and engineer ways for them to use these gifts more often. While you’re at it, evaluate their level of work-life balance and look for ways to customize their workload, schedule, or responsibilities for better personal well-being.

Joe Mull, MEd, is a leadership trainer and keynote speaker. He works with healthcare organizations that want their practice leaders to engage, inspire, and succeed. To learn more or bring Joe to your site, visit www.joemull.com.

What your employees crave more than money or perks

joe mull, meD

In order, employees place the greatest importance on a role and organization that offer them:

1. The ability to do what they do best2. Greater work-life balance and better personal well-being3. Greater stability and job security4. A significant increase in income5. The opportunity to work for a company with a great brand or

reputation[Source: The State of the American Workplace Report (2016 Report), Clifton. (2017) Gallup]

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196 www.acms.org

Special Report

IntroductionIn the words of a Native American

midwife, Katsi Cook, a women’s body is the first environment. With the cele-bration of Mother’s Day this month, this is a time to address ways in which families can create a healthy home environment.

From the first prenatal visit, cli-nicians address many topics with their patients to ensure a safe and healthy pregnancy for both mom and the growing fetus, such as adhering to a healthy, well-balanced diet; main-taining daily exercise; and eliminating smoking/vaping, alcohol use and drug use.

One area of focus that perhaps does not get as much attention is avoiding toxic chemicals in and around the home. In 2015, the American College of Obstetricians and Gynecolo-gists (ACOG) provided the opinion that, “The scientific evidence over the last 15 years shows that exposure to toxic environmental agents before concep-tion and during pregnancy can have significant and long-lasting effects on reproductive health.”

When a new baby is about to arrive, expectant parents begin to prepare a safe environment for their new addi-

tion. The latest and greatest technolo-gy and gadgets are added to the baby registry. Oftentimes, a spare room gets transformed into a nursery. With these new experiences comes an opportunity to consider how the home environment may impact the growing fetus’ develop-ment, as well as that of the other family members.

How to reduce environmental exposures in the home

According to the Environmental Protection Agency (EPA), we spend approximately 90 percent of our time indoors. We should strive to make the built environment, including our homes, as healthy – and toxic-free – as possible. There are many items in and around the home that may con-tribute to poor indoor air quality. Some may be obvious, such as using a wood stove; however, others are less appar-ent.

For example, families should reduce their exposure to pesticides and fungicides in and around the home by practicing integrated pest management (IPM), which focuses on prevention rather than treatment. According to the World Health Organization (WHO), spraying pesticides in the home results

in increased risks to children because of higher concentrations near the floor and persistence in carpets and soft toys. Pesticides have been shown to be very allergenic, lead to central nervous system (CNS) toxicity at high levels of exposure and act as neuro-toxicants and neurodevelopmental toxicants.

Home furnishings and children’s products that contain foam (such as car seats, Boppy pillows and mat-tresses) often are treated with flame retardants, which do not chemically bond with the foam and are detected in household dust. These chemicals have been shown to impair neuro-development, impact reproductive systems and harm motor skill develop-ment in children.

Parents usually decide to paint the nursery before the baby arrives and do not realize that certain paints release volatile organic compounds (VOCs), which reduce indoor air quality. VOCs can have a greater health impact on children than adults. Acute exposure can lead to headache, dizziness, loss of coordination, nausea, visual disorders and allergic reactions, including asthma and rhinitis. Chronic exposure can dam-age the liver, kidneys, blood system and

Home sweet (and healthy) home

miChelle naCCaRati- ChaPkis

DeboRah gentile, mD


Special Report

central nervous system. These chemi-cals can linger in nurseries for months after the room is painted.

Because of trade secret and propri-ety protections, manufacturers are not required to disclose ingredients in their cleaning products. Studies have shown many of these ingredients can trigger allergy and asthma symptoms. Rather than petroleum-based cleaning prod-ucts, seek plant-based ones.

There are no legal standards for language on personal care product and cosmetic labels. Words such as natu-ral, organic, or eco-friendly are mere-ly marketing terms. Therefore, read the product labels and avoid products that contain fragrance, parabens, phthalates and triclosan.

As defined by The Endocrine So-ciety, endocrine disrupting chemicals (EDCs) are substances in our environ-ment, food and consumer products that interfere with hormone biosynthesis, metabolism, or action resulting in a de-viation from normal homeostatic control or reproduction. EDCs can be found in pesticides, fungicides, plastics (such as Bisphenol-A or BPA and phthalates) and personal care products. These chemicals also can be found in industri-al chemicals banned long ago, but per-sist in our environment today, including

polychlorinated biphenyls (PCBs) often found in the ballasts of fluorescent light fixtures, oil-based paint, floor finish and caulking used around windows.

ConclusionDuring this month of May, as we

celebrate mothers, as well as Asthma and Allergy Awareness month, let’s do all we can to ensure our homes are as safe and healthy as possible for grow-ing families. Share these simple steps to inform and educate your patients:

1. Test the home for lead and ra-don (the second-leading cause of lung cancer), and install smoke and carbon monoxide detectors.

2. Seal leaky windows and roofs, increase ventilation and dehumidify air to prevent mold growth.

3. Leave shoes at the door to en-sure pollutants remain outside.

4. Wet mop, dust frequently (micro-fiber cloths are useful), use a HEPA vacuum and change furnace filters often.

5. Seal cracks in the foundation, keep counters clear and cover trash cans to avoid pests.

6. Use glass containers and paper products to heat food in the microwave (avoid plastics; studies have shown the chemicals such as phthalates can leach into food).

7. Select natural flooring and use low and no VOC paints, adhesives and glues during home renovation projects.

8. Purchase household items containing foam that are free of flame retardants (117-2013 on the tag).

9. Choose natural cleaning products such as vinegar, baking soda, hydro-gen peroxide and lemon juice.

10. Avoid asthma triggers such as scented paraffin candles, incense, air fresheners (including sprays and plug-ins) and scented laundry products.

Ms. Naccarati-Chapkis is exec-utive director, Women for a Healthy Environment. She can be reached at [email protected].

Dr. Gentile is director of Clinical Research, Adult and Pediatric Allergy and Asthma, A Division of the Pediatric Allliance, adjunct professor of Phar-macy, Duquesne University School of Pharmacy. She can be reached at [email protected].

Reference1. https://www.ncbi.nlm.nih.gov/pmc/

articles/PMC2726844/ Endocrine-Disrupting Chemicals: An Endocrine Society Scientific Statement


Leadership and Advocacy for Patients and Physicians

Responding to an

Industry in Transition

Fox Rothschild’s Health Law Practice reflects an intimate knowledge of the special needs, circumstances and sensitivities of physicians in the constantly changing world of health care. With significant experience and a comprehensive, proactive approach to issues, we successfully meet the challenges faced by health care providers in this competitive, highly regulated environment.

After all, we’re not your ordinary health care attorneys.

BNY Mellon Center | 500 Grant Street, Suite 2500 | Pittsburgh, PA 15219 | 412.391.1334 | www.foxrothschild.com

Seth I. Corbin 412.394.5530

[email protected]

Edward J. Kabala 412.394.5599

[email protected]

William H. Maruca 412.394.5575

[email protected]

William L. Stang 412.394.5522

[email protected]

Michael G. Wiethorn 412.394.5537

[email protected]

Visit our HIPAA Blog: hipaahealthlaw.foxrothschild.com and our Physician Law Blog: physicianlaw.foxrothschild.com

Who Do You Know?Who you know may help the future of medicine.Are you friends with a state legislator? Your Congressman? If so, PAMED wants to know.

As part of our grassroots action team, we seek members who know elected leaders and are willing to talk to them about issues?

Visit www.pamedsoc.org/gotnames and complete the online form to join the team today or email Larry Light at [email protected].

777 East Park DriveHarrisburg, PA 17105(800) 228 7823

2017 Award NominationsHealthy Children, Healthy Communities, Healthy Future

Community Awards

Benjamin Rush Individual AwardRecognizes an individual who is not a physician and who devotes time, skills or resources to assisting others and contributes to the advancement of healthcare.

Benjamin Rush Community Organization AwardRecognizes a company, institution, organization or agency that is successfully addressing a community health issue.

Executive Leadership AwardRecognizes an individual who has demonstrated exemplary leadership and advocacy for physicians. Over a sustained time, the recipient shall have displayed administrative guidance and support to physicians to improve their ability to improve the lives and health of the people of our community.

Physician Awards

Nathaniel Bedford Primary Care AwardRecognizes a primary care physician for exemplary, compassionate, comprehensive and dedicated care of patients.

Ralph C. Wilde Leadership AwardRecognizes a physician who demonstrates exceptional skill in clinical care of patients and dedication to the ideals of the medical profession as a teacher or profession leader.

Physician Volunteer AwardRecognizes a physician for charitable, clinical, educational or community service activities, domestically or internationally, as a volunteer.

Richard E. Deitrick Humanity in Medicine AwardHonors a physician who has improved the lives of patients by caring for them with integrity, honesty, and respect for their human dignity, and is a role model for other physicians.

• You may nominate more than one individual or organization.• Individuals may not be practicing healthcare professionals. • Organizations may not be hospitals or care facilities.

• You may nominate more than one ACMS member.

Name:

Nominee Information:

Address:

City, State, Zip:

Name:

Submitted by:

Address:

City, State, Zip:

Phone:

Email:

I would like to nominate (please print):

Benjamin Rush Individual Award Benjamin Rush Community Organization AwardExecutive Leadership AwardPhysician Volunteer Award Nathaniel Bedford Primary Care AwardRalph C. Wilde Leadership AwardRichard E. Deitrick Humanity in Medicine Award

for the:

Please attach a letter explaining why you are nominating this individual or group. You may include a brief history of the individual or organization, letters of support, or up to 5 pages of supporting information. Please use one form for each nomination.

Nominations must be received by Wednesday,

July 19, 2017.

Nominations can be submitted online at:www.acms.org/awards

Awards will be presented at the ACMS Foundation Celebration of Excellence Gala Saturday, February 24, 2018.

200 www.acms.org

Special Report

jeWish healthCaRe FounDation

Since its establishment in 1990, the Jewish Healthcare Foundation

(JHF) has demonstrated a commitment to the physical, psychological and social well-being of seniors, as well as their caregivers. In 2016, the Founda-tion launched its Senior Connections initiative, which aims to strengthen a suite of service opportunities for older adults, including transportation and housing, exercise and recreation, geri-atric-friendly health care, nutrition and caregiver supports.

To advance the goals of Senior Connections, JHF recently approved a two-year, $300,000 grant to in-crease opportunities for local seniors to meaningfully engage in a variety of exercise and recreation programs throughout all four seasons. The exercise and recreation initiatives are the result of a community-wide charrette, or planning event, that JHF convened in summer 2016 with more than 100 individuals representing health providers, foundations, environ-mental and recreational groups, aging organizations, insurers, community service providers and activist groups. The Foundation will convene future charrettes focused on other compo-nents of Senior Connections, translat-ing the ideas uncovered and partner-ships formed during those events into various in-person and virtual program-

ming to enhance health and quality of life for older adults.

The multi-faceted approach to help seniors engage in exercise and recre-ation will include:

• Launching a pilot project to allow seniors of varied abilities to engage in health-focused, guided outings in South Park and Frick Park. The pro-grams in both parks will be designed to appeal to older adults with a wide range of fitness levels and interests. Venture Outdoors and Pittsburgh Parks Conservancy are the lead partners in developing programming for the pilot project. JHF also has partnered with AARP to recruit park ambassadors, who will help raise awareness of exercise and recreation opportunities and accompany seniors on such outings.

• Developing a mobile-friendly, senior-friendly application that uses maps, text and images to highlight curated walks, events and other attractions focused on a senior audience of varied abilities. The application can be used directly by seniors, as well as by health care and social service providers. The Allegheny County Parks Foundation and GreenInfo Network will develop the application. These materials also will be available in print.

• Engaging members of the medi-cal community to hold guided walking tours with seniors and their families. Physicians, nurses, physical and oc-

cupational therapists, and many other types of health care professionals will be recruited to lead the walking tours in conjunction with a Venture Outdoors staff member. The Allegheny County Medical Society (ACMS) and UPMC Rehabilitation Services will assist with recruitment efforts.

• Developing online exercise and recreation programming that seniors can use to stay active during the winter and during inclement weather, and if they are unable to attend in-person ac-tivities. The online programming will be housed on JHF’s soon-to-be-launched Virtual Senior Academy, a platform which connects community-dwelling seniors to interactive online classes and a peer network.

• Creating communications mate-rials that emphasize the importance of exercise and recreation on the health and well-being of older adults. JHF will partner with the Allegheny County Health Department (ACHD) and its Live Well Allegheny campaign to develop the senior-focused health messaging.

JHF will serve as the convener for all Senior Connections recreation and exercise activities and also will estab-lish an advisory board of local experts to guide the initiative.

If you are interested in becoming involved in the Senior Connections initiative, please contact JHF Chief Op-erating Officer/Chief Financial Officer Nancy Zionts at [email protected].

JHF approves $300K grant to boost senior exercise and recreation options


Special Report

The use of prescription opioid anal-gesics has increased dramatically

in the United States over the past two decades. There has been a corre-sponding increase in fatal drug over-doses, with deaths reaching an all-time high in 2014.

As part of the Reducing Opioid Misuse and Diversion project, Quality Insights’ team will:

• Engage patients and families by providing educational materials in physician offices;

• Provide tools and resources on prescribers’ use of Prescription Drug Monitoring Program (PDMP) databases;

• Promote the adoption of CDC Guidelines for Prescribing Opioids for Chronic Pain; and

• Serve as a convener at the state level for partners and stakeholders to promote and adopt strategies to reduce opioid misuse and diversion.

Nearly 90 percent of Medicare

beneficiaries visit a physician at least once a year. Yet the Centers for Dis-ease Control and Prevention (CDC) has reported that only 33 percent of women and 40 percent of men aged 65 and over receive their recommended age-specific preventive services.

As part of the Increasing Annual Wellness Visit Utilization project, Quali-ty Insights’ team will:

• Provide education and tools to help physician practices eliminate bar-riers that prevent patients from utilizing preventive health services;

• Examine office workflow to deter-mine areas where preventive services can be incorporated into daily routine; and

• Develop individualized practi-tioner reports to analyze the number of patients who receive preventive services and determine opportunities for improvement.

Participants in Quality Insights

initiatives receive tips, tools, resources and up-to-the-minute information. If you would like to partner with Quality Insights today for a healthier tomorrow, contact Biddy Smith at [email protected] or call (800) 642-8686.

About Quality InsightsAs the Quality Innovation Net-

work-Quality Improvement Organiza-tion (QIN-QIO) for Delaware, Louisi-ana, New Jersey, Pennsylvania and West Virginia, Quality Insights is com-mitted to collaborating with providers and the community on the Centers for Medicare & Medicaid Services’ goals of better health, smarter spending and healthier people. Our data-driven qual-ity initiatives improve patient safety, reduce harm and improve clinical care locally and across the network. To learn more about Quality Insights’ health care quality improvement initiatives, visit www.qualityinsights-qin.org.

Quality Insights offers free tools to reduce opioid misuse, increase annual wellness visit utilization

Per-Classifieds

FOR SALE: Steinway Baby Grand Model S Piano, 1997. Black satin finish. $25,000. Please call if seriously interested, 412-901-9014.

For advertising information, email Bulletin Managing

Editor Meagan Sable at [email protected].

Moving? Be sure to let us know ....

We can update our system to better serve you! When your patients call, we will know where to send them. Call (412) 321-5030 to update your information.

2017 ACMS Bulletin Photo Contest

The 2017 Photo Contest will be held completely online. Please note instructions for participation below:

1. Email your VERTICAL jpg photos with a resolution of 300 dpi or higher to [email protected]. Photos should be 8”W x 10”H but can be resized if the resolution is high enough.

2. You must be an ACMS member physician to submit photos. Voting will take place on the ACMS website, www.acms.org.

3. Include the name of the photo (please keep file names short) as well as your name, specialty, address and phone number in the email.

4. You will receive verification that your photo has been received and is eligible to be entered in the contest.

a) Horizontal photos will not be considered. b) Photos with low resolution will not be considered.c) Panoramic shots or photos featuring specifically identifiable individuals/

relatives will not be considered.5. The deadline for submission is Friday, September 1, 2017. Voting will open after

this date.6. Participants are permitted to submit three photos but are limited to two winning

entries.7. Voting will close Friday, October 6, 2017. Voters should vote for 12 photos.8. Winners will be announced on the ACMS website, in the Bulletin and via email.

The 1st-place winner’s photo will appear on the January 2018 cover; the remaining winning photos will appear on Bulletin covers throughout the year.

9. Please continue to check the ACMS website and future issues of the Bulletin for further updates and reminders.

10. If you have any questions, please call Bulletin Managing Editor Meagan Sable at (412) 321-5030, ext. 105, or email [email protected].

Please share with a colleague!APPLICATION FOR MEMBERSHIP

Full Name(please print):

Last First Middle

Office:

Area Code & Phone Number

Home:


E-Mail: Office Fax:


Sex: Date of Birth:

Primary Specialty: Secondary Specialty

License: PA No.: Date Issued:

Present Type of Practice: Employed by Hospital/Health System Employed by Physician(s) Employed by Industry or Government Owner of Physician Practice Independent Contractor Other (Specify) ______________________ Practice Name: Employment Status: Practicing full-time Practicing part-time Retired from practice Currently not in practice Other (Specify) ______________________

tes: Present Hospital Appointments: Dates:

Within the last 5 years, have you been convicted of a felony crime? Yes No. If yes, please provide full

information. Within the last 5 years, has your license to practice medicine in any jurisdiction been

limited, suspended or revoked? Yes No. If yes, please provide full

information. Within the last 5 years, have you been the subject of any disciplinary action by any

medical organization or hospital staff? Yes No. If yes, please provide full

information. If elected to membership, I agree to conduct myself professionally and personally according to the principles of medical ethics and to be governed by the Constitution and Bylaws of the Allegheny County Medical Society and the Pennsylvania Medical Society. I hereby release, and hold harmless from any liability or loss, the Allegheny County Medical Society, the Pennsylvania Medical Society, their officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the above named organizations, or to their authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership. I also authorize the above named organizations, in the consideration of my application, to make inquiry of any of my references and institutions by which I have been employed or extended privileges, as to my qualifications. I further authorize any of the above persons or institutions to forward any and all information their records may contain and agree to hold them harmless for any actions by me for their acts. Date: Signature:

Preferred Method of Contact: Mail: _____ (Office or Home) E-mail: _____ Fax: _____

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