BULLETIN - Allegheny County Medical Society

Transcription

BULLETIN
October 2009
Vol. 99 No. 10
of the Allegheny County Medical Society
ARTICLES
PERSPECTIVES
DEPARTMENTS
Materia Medica........................ 446
Miller Time ............................. 434
Society News ........................... 439
Pharmacogenomics: A New World of Drug
Therapy
Michael Isaac, PharmD
Thomas L. Rihn, PharmD
“I’m Not a Doctor. I Just Play One on TV”
Scott Miller, MD, MA
♦
♦
Editorial................................... 436
Community Notes ................... 441
Shift Work
Gregory B. Patrick, MD, FACP, FCCP
Activities & Accolades ............. 443
Feature ..................................... 452
The Israeli Health Care System
Carey Vinson, MD, MPM
Feature ..................................... 456
An Update on Post-Traumatic Stress Disorder
Barry W. Fisher, MD, DFAPA
Special Report.......................... 460
Updated Health Care Power of Attorney and
Living Will Form Now Available
Special Report.......................... 463
Jefferson Regional Medical Center: Highmark’s
Dean Ornish Program Reversing Heart Disease
Profile ...................................... 464
Stephen F. Conti, MD: Helping Pittsburghers
Put Their Best Foot Forward
Linda L. Smith
Special Report.......................... 467
Remodel Your Home Insurance Before
Remodeling Your Home
Ophthalmology society
ACMS Gala: Save the Date!
Continuing Education ............. 444
first green
Naturesis gold
Calendar .................................. 445
Her hardest hue
to hold
Her early leafs
a flower;
But only so an hour.
Then leaf subsides
to leaf.
So Eden sank to grief,
So dawn goes down
to day.
Nothing gold can stay.
Robert Frost
Looking Back in Time ............. 450
Legal Summary ........................ 451
Board of Directors ................... 468
Classifieds ................................ 470

Cover Art:
Cascading Fall Colors
by John M. Mikulla, MD
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Dr. Mikulla is an ophthalmologist.
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Bulletin
Medical Editor
Scott Miller
(millers8@upmc.edu)
Affiliated with Pennsylvania Medical Society and American Medical Association
2009
Executive Committee and
Board of Directors
President
Douglas F. Clough
President-elect
John F. Delaney Jr.
Vice President
Leo R. McCafferty
Secretary
Rajiv R. Varma
Treasurer
Amelia A. Paré
Board Chair
Adam J. Gordon
DIRECTORS
2009
Doris K. Cope
Lawrence R. John
Brian Miller
Deval M. Paranjpe
Daniel W. Pituch
Anthony Spinola
James E. Wilberger Jr.
John P. Williams
2010
Parvis Baghai
Christopher J. Daly
David J. Deitrick
Steven Evans
Jon A. Levy
2011
Melinda M. Campopiano
Kevin O. Garrett
Donald B. Middleton
Adriana M. Selvaggio
G. Alan Yeasted
PEER REVIEW BOARD
2009
Leo R. McCafferty
Mark A. Goodman
Russell J. Sacco
2010
Alan A. Axelson
Terence W. Starz
2011
Krishnan A. Gopal
William M. Swartz
PMS DISTRICT TRUSTEE
Paul W. Dishart
COMMITTEES
Bylaws
Leo R. McCafferty
Communications
Amelia A. Paré
Finance
G. Alan Yeasted
Membership
John F. Delaney Jr.
Nominating
John F. Delaney Jr.
Occupational Medicine
Joseph J. Schwerha
ADMINISTRATIVE STAFF
Executive Director
John G. Krah
(jkrah@acms.org)
Assistant to the Director
Dorothy S. Hostovich
(dhostovich@acms.org)
Bookkeeper
Susan L. Brown
(sbrown@acms.org)
Communications
Bulletin Managing Editor
Linda L. Smith
(lsmith@acms.org)
Assistant Executive Director,
Membership/Information
Services
James D. Ireland
(jireland@acms.org)
Association Administrators
Dianne K. Meister
(dmeister@acms.org)
Nadine M. Popovich
(npopovich@acms.org)
Associate Editors
Melinda M. Campopiano
(campopianomm@gmail.com)
Michael P. Chapman
(chapmanmp@upmc.edu)
Fredric Jarrett
(jarrettf@upmc.edu)
Deval Paranjpe
(reshma_paranjpe@hotmail.com)
Stuart G. Tauberg
(tlindsey@nb.net)
Adam Z. Tobias
(tobiasa@upmc.edu)
Frank Vertosick
(vertosick@acms.org)
Gary S. Weinstein
(garyweinsteinmd@aol.com)
Managing Editor
Linda L. Smith
(lsmith@acms.org)
Contributing Editors
(bulletin@acms.org)
Gregory B. Patrick
Heather A. Sakely
Carey T. Vinson
ACMS ALLIANCE
President
Patty Barnett
First Vice President
Lois Levy
Second Vice President
Ruhie Radfar
Recording Secretary
Sandie Colatrella
Corresponding Secretary
Doris Delserone
www.acms.org.
Leadership and Advocacy for Patients and Physicians
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.
The Bulletin of the Allegheny
County Medical Society welcomes
contributions from readers, physicians, medical students, members
of allied professions, spouses, etc.
Items may be letters, informal clinical reports, editorials, or articles.
Contributions are received with the
understanding that they are not under simultaneous consideration by
another publication.
Issued the third Saturday of each
month. Deadline for submission of
copy is the SECOND Wednesday
preceding publication date. Periodical postage paid at Pittsburgh, PA.
Bulletin of the Allegheny County
Medical Society reserves the right
to edit all reader contributions for
brevity, clarity, and length as well as
to reject any subject material submitted.
The opinions expressed in the
Editorials and other opinion
pieces are those of the writer and
do not necessarily reflect the official policy of the Allegheny
County Medical Society, the institution with which the author is
affiliated, or the opinion of the
Editorial Board. Advertisements
do not imply sponsorship by or
endorsement of the ACMS, except where noted.
Publisher reserves the right to exclude any advertisement which in
its opinion does not conform to the
standards of the publication. The
acceptance of advertising in this
publication in no way constitutes
approval or endorsement of products or services by the Allegheny
County Medical Society of any company or its products.
Subscriptions: $30 nonprofit organizations; $40 ACMS advertisers,
and $50 others. Single copy $5.
Advertising rates and information
sent upon request by calling (412)
321-5030. Visit www.acms.org.
COPYRIGHT 2009:
ALLEGHENY COUNTY MEDICAL
SOCIETY
POSTMASTERSend address
changes to: Bulletin of the
Allegheny County Medical
Society, 713 Ridge Avenue,
Pittsburgh, PA 15212.
ISSN: 0098-3772
MILLER TIME
“I’m Not A Doctor. I
Just Play One On TV”
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SCOTT MILLER, MD, MA
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don’t know about you, but I am
growing weary of yet another
season of television shows about the
lives of fictitous doctors and nurses.
This season alone brings us Mercy,
Trauma and Three Rivers, about the
personal and working lives of nurses,
emergency medical technicians and
transplant surgeons, respectively.
It’s not that these shows about
the medical profession are not
entertaining or well acted, or that
the stories aren’t compelling, or that
the emotional impact is not sincere.
It’s that, as an actual practicing
physician, my personal and working
life just can’t live up to the standards
to which these shows set the bar.
Take House. (Please…!) It’s about
a brilliant but handicapped diagnostician named Dr. House, who, with
a team of other somewhat dysfunctional, less-experienced physicians,
solves medical dilemmas too complex for the “average” doctor.
My oldest son is 15 and watches
the show regularly. In the beginning,
I thought this might be a good way
for him to learn about what his dad
does for a living, but since he is a
teenager and I am his father, he
doesn’t see me as Dr. House. Instead,
he wants to know if there is a Dr.
House at my hospital with whom I
consult when I am baffled by a
patient’s illness. And given how most
teenagers view their parents, he
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believes I am baffled on a regular
basis—at home and at work.
Of course, he doesn’t realize that,
in the real world of medicine, there
is actually no such thing as a “Dr.
House.” Which is actually a good
thing. Because, along with Dr.
House’s brilliance comes drug
addiction, loss of professional
integrity and a recent stay in a
mental institution—hard to emulate
that and keep your job. Although
from a telemedicine perspective, I can
envision that a stay in a mental
institution would leave Dr. House
with a whole new set of diagnostic
conundrums on which the bumbling
psychiatrists could benefit from his
assistance. I think in the long run,
however, this is not something a
physician wants to have on his or
her resume.
Further, I think that show
should really be titled House Calls,
given the amount of time he and his
team spend going to his patients’
homes to search for heavy metals,
molds, non-prescription drugs and
other unusual toxins that often serve
as the mysterious causes of his
patients’ illnesses. I don’t know
about you, but I generally get about
15-30 minutes of free time a day,
and I use it to eat lunch. I diagnose
better on a full stomach.
Another telemedicine standard
that I am unable to live up to is that
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of the “super physician.” These
physicians actually practice more
than one specialty at a time! The
internists on House are apparently
also trained to do both the complicated surgical procedures and all the
diagnostic testing their patients
need. The pediatricians on ER treat
adult psychiatric illness. And in one
particularly memorable episode of
Grey’s Anatomy, the new interns take
a dead patient to the morgue where,
as forensic pathologists, they perform his autopsy. In secret. Without
permission. That episode alone is
good for a week’s worth of discussions in a medical ethics class.
And no matter what the TV
show, doctors and nurses seem to do
little but have sex with one another
in every imaginable location, mostly
while they are at work! They have
sex in the call rooms, the operating
rooms and the patient rooms. In the
linen closet, the janitor’s closet and
the medication closet. The fact is,
most hospitals don’t even have all
these closets anymore—probably to
cut down on the amount of sex we
are having in the building. It’s
enough to make you think that the
patients are the ones who need to
wear the protective gowns, masks
and gloves.
Along these lines, I have to
remind you that the entire premise
of the first season of Grey’s Anatomy
Bulletin :: October 2009
MILLER TIME
was built around the storyline of a
brilliant senior staff neurosurgeon
who is having an ongoing sexual
relationship with one of his trainees
(Meredith Grey). Openly. In most of
the above-mentioned locations. I
guess studying Grey’s anatomy has
more than one meaning.
And just so nurses shouldn’t feel
left out, those of you with cable TV
and a “Showtime” subscription can
watch Nurse Jackie. She is an olderbut-weary, experienced-but-jaded
hospital nurse who also happens to
be addicted to opiate pain medications. Her personal life is a complete
mess; she is married with two
children and having an affair with
the hospital’s single and lonely
pharmacist for the sole purpose of
trading sex with him for the opiates
he can surreptitiously steal from the
hospital’s pharmacy.
Yet that’s not the worst part. In
the first few episodes, Jackie forges a
dead patient’s signature on an organ
donation card and discards a
patient’s lopped-off earlobe down
the toilet when she learns he has
been abusive to women. And not to
be outdone by this lack of professionalism is a newly graduated junior
physician who has a tendency to
fondle Jackie’s breasts when he is
under stress. I must have missed that
class in medical school.
I freely admit to watching these
medical shows long enough to allow
for the possibility that any one of
them might actually portray the
medical profession more realistically.
In that spirit, I watched the premiere
episode of Mercy last week. May
God have mercy on all of us if that is
anywhere near an accurate depiction
of how doctors, nurses, and patients
interact.
So it is with extreme pride and
satisfaction, that after all these years,
I can declare: “I am a REAL doctor,
and I don’t play one on TV…”
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Dr. Miller, a practicing internist, ethicist and
palliative care physician, is medical editor of
the Bulletin. He also serves as one of the
medical directors of Family Hospice in
Pittsburgh. He can be reached at
millers8@upmc.edu or (412) 572-8800.
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.
The West Penn Allegheny Health System
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October 2009 :: Bulletin
435
EDITORIAL
Shift Work
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GREGORY B. PATRICK, MD, FACP, FCCP
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grew up with doctors at the
patient’s bedside in the Sinclair
Lewis novel, Arrowsmith, and A.J.
Cronin’s The Citadel. I watched Drs.
James Kildare and Ben Casey on
television standing at the bedside.
Most of my professional training
occurred at the bedside. So I was
troubled by a conversation that I had
with a colleague (much younger
than I in both age and training) who
told me, “I’ll be by the bedside, but
only until the guy covering me
comes in. Then I’m outta here.” He
calls it “time-defined medical practice.” I called it shift work.
“It’s all about balance,” he says:
You Boomer Docs (Boomer Docs?)
don’t have a good balance between
work and home. You worked such
long hours during your training that
you don’t know any better. You’ve
spent so much time at work that you
don’t have a life. Your generation
lives to work, while my generation
works to live. We are redefining
professionalism. We work in teams.
We are committed to our patients—
but only during defined hours.
Regular hours and appropriate
income; that’s what’s important. In
fact, when we talk about choosing a
medical specialty offering good
hours, plus good income, we talk
about the ROAD to happiness:
436
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squeeze in time at the
Radiology, Ophthalbedside with all of the
mology, Anesthesiology
lectures, conferences,
and Dermatology. I
Im
documentation and
gotta have the free time;
outta
other requirements
there’s more to me than
here
needed to meet educamedicine.”
tion guidelines). My
This editorial is not
young colleague was
a tirade against the
simply reflecting the
younger generation.
opinions of his age.
Who can argue against
But medical shift
the need for a balance
work has consequences.
between work life and
Continuity of care will be further
home life? If “it takes a village” to
eroded. Already the doctor who sees
raise a child, why should physicians
the patient in the office is unlikely
not enjoy an active family life? My
medical training occurred during the to be the doctor who sees the patient
in the hospital. With more physitime depicted in Samuel Shem’s
cians taking care of each patient,
House of God—an era when every
communication during patient
third night on call meant that you
handoffs assumes even greater
still routinely worked 100 to 120
importance. One positive effect will
hours a week because you never
be to accelerate interest in electronic
signed out an unstable patient, no
matter how tired you were. I do not medical records in order to better
transfer data among practitioners.
regret the process; it was a rite of
Medical shift work will magnify the
passage that reflected its time and is
doctor shortage, especially among
part of my personal history. The
practitioners willing to come to the
intensity and the hours were grueling and “burn out” was not uncom- hospital. The sickest patients require
mon. In the interest of patient safety, the most care at the least convenient
hours. This will fuel the growing
today’s interns and residents are
shortage of critical care physicians.
legally required to work no more
than 80 hours a week. This has to be Large medical groups can promise
fewer nights on call. Recruiting
more humane (although, given the
replacements for Western
increasing complexity of medical
Pennsylvania’s solo and small group
practice, I wonder how they will
EDITORIAL
practices will prove even more
difficult, particularly as Boomer
Docs retire from community hospitals. Clock-watchers will not care
about unmet needs.
I told my young colleague that
Boomer Docs are equally interested
in achieving balance between work
and home. In fact, this struggle is
not limited to physicians. Many
people in many fields complain to
me about this lack of balance in
their lives. Seeking balance has been
an ongoing issue for most of my
adult life. The equilibrium point on
the work-home axis is a moving
target that varies internally with age
and the individual and externally
with time and circumstance. Paying
off student loans or college tuition
may push you in one direction at the
same time that caring for young
children or elderly parents is pushing
you in the opposite direction. I
wished him luck in his search for
balance.
I told my young colleague that
focusing on teams and the end of
the shift risks loss of accountability.
Which shift is responsible for
accomplishing the many tasks that
are necessary but not reimbursed,
such as talking to patient families
and completing work forms? You
cannot focus on the patient if you
are focused on the clock. Like most
relationships, the doctor-patient
relationship requires time. Caring
for people sometimes takes “as long
as it takes.” Patients can tell when
someone who is seeing them is really
watching the clock.
I told my young colleague: Do
not be afraid to fall in love with
Medicine. We physicians spend so
much time complaining about the
externals—payment, malpractice,
and so on—that we forget to mention that practicing Medicine is fun.
Medicine is one of the few professions where you can translate a
desire to help someone into positive
action and not infrequently see an
immediate result. When you evaluate a patient, make a diagnosis and
start treatment—and the magic
works and the patient gets better—
there is an emotional rush that
cannot be underestimated. It is a
privilege to be a physician. We are
invited to the bedside. We are
invited in to share in people’s lives.
We are invited in when people are
most frightened and needy. This is
not an invitation that should be
taken lightly. Focusing on when you
can leave the bedside insults this
invitation.
What I thought of later, and
what I wish that I had told my
young colleague, was that life is not
a zero sum game. Life is a series of
choices that you make and then
must live with. Nothing can replace
all of the meals, games, performances and family time that I have
missed because I was beside a
patient’s bed. However, I do not
regret my time spent at the bedside;
I am permitted to participate in the
mysteries of life. During the dark
nights of the soul, when I wonder
why I am here and whether I have
made a difference in this world, I
can reflect that there are people who
walk this earth because of what I
have done for them. I do not regret
my passion for Medicine. There is
much more to me than practicing
Medicine. But being a doctor is a
large part of who I am.
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Dr. Patrick, an internist who specializes in
pulmonary disease, serves as a contributing
editor for the ACMS Bulletin. He can be
reached at gpatrick@hvhs.org.
The opinion expressed in this column
is that of the writer and does not
necessarily reflect the opinion of the
Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
437
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438
SOCIETY NEWS
Drs. Bonnie An Henderson and Norman
Edelstein.
Ophthalmology society
Bonnie An Henderson, MD, served
as guest speaker for the September
17 meeting of the Pittsburgh Ophthalmology Society, talking on
innovative technology used to learn
and enhance surgical skills, as well as
surgical management of astigmatism.
Representing the Pennsylvania
Academy of Ophthalmology, John
Milliron also spoke to the physicians
regarding Pennsylvania House Bill
1188 and Senate Bill 846. Jack
Kennerdell, MD, outlined the need
for volunteers for the Catholic
Charities Free Health Care Center
and asked those interested to contact
him for information.
The society’s new president, Dr.
Norman Edelstein, took the opportunity to introduce new residents
from the UPMC Department of
Ophthalmology and new fellows
from both UPMC and Allegheny
General Hospital.
Dr. Edelstein was especially
pleased with the meeting’s record
attendance, as fellows and residents
came to hear Dr. Henderson (who
graciously changed her schedule so
the meeting didn’t conflict with the
Pittsburgh Steeler’s opening game).
Dr. Henderson, who is a partner
at Ophthalmic Consultants of
Boston and assistant clinical professor at Comprehensive Ophthalmology at the Massachusetts Eye and
Ear Infirmary, is an accomplished
surgeon, teacher and member of the
ophthalmologic community; her
research focuses on education, and
she is currently creating a virtual
mentor cataract surgery computer
program. Known for her gracious
personality and limitless energy, Dr.
Henderson is married with three
children and competes in
triathalons.
ACMS Gala: Save the Date!
The ACMS Foundation Gala is set
for January 30, 2010, at Heinz
Field, East Club Lounge, including a
reception, auction, dinner and
awards. Pittsburgh Proud is an
evening that will celebrate the many
reasons to be proud of the Pittsburgh region, including this year’s
Allegheny County Medical Society
award winners. Join us as we honor
those individuals and organizations
that have made significant contributions to the health care needs of the
Pittsburgh Community.
Fabulous auction items including luxury vacations, fine jewelry,
sports memorabilia and more will be
available to the highest bidder. All
proceeds from the gala will directly
benefit the ACMS Foundation
medical and nursing student scholarship fund.
This date falls on the weekend
between the NFL conference championship and Super Bowl game—so
no conflicts! For more information,
visit www.acmsgala.com.
If you are unable to attend, but
would like to support the scholarship fund, checks can be made
payable to the ACMS Foundation
and mailed to 713 Ridge Avenue,
Pittsburgh, PA 15212. More fun and
exciting details on the gala will be
revealed in the November Bulletin.
For more information call Nadine
Popovich at (412) 321-5030.
Got Something to Say?
If youre an ACMS member and would
like to write a Perspective, e-mail
Linda Smith at lsmith@acms.org. or
call (412) 321-5030, x105.
439
Announcing
our new location
UPMC Passavant–Cranberry is pleased to announce the
opening of our new location in Northpointe Center.
Joseph J. Colella, MD
Minimally Invasive Bariatric and General Surgery
Joseph J. Colella, MD, has joined UPMC Passavant–Cranberry and welcomes
patients in his Seven Fields office. Dr. Colella specializes in minimally invasive
bariatric and general surgery.
Dr. Colella is a graduate of the University of Pittsburgh School of Medicine and
completed his internship and residency at Allegheny General Hospital, Pittsburgh.
He is board-certified by the American Board of Surgery and specializes in
bariatric and upper gastrointestinal tract surgery.
Dr. Colella, who recently performed western Pennsylvania’s first robotic
bariatric surgery, is an assistant professor of surgery at the University
of Pittsburgh.
For more information or to schedule an appointment,
call 1-877-442-2990.
Northpointe Center
Suite 104
200 Northpointe Circle
Seven Fields, PA 16046
upmc.com
440
COMMUNITY NOTES
Nursing conference
The Pittsburgh Chapter of the
American Association of Legal Nurse
Consultants, in conjunction with the
Graduate Forensic Nursing Department of Duquesne University, is
presenting its biennial educational
conference on November 6 in the
Power Center Ballroom at Duquesne
University.
Scheduled from 7:30 a.m. to
3 p.m., the conference, Is Your
Nursing Unit a Crime Scene? seeks to
educate legal nurse consultants,
nursing and home administrators,
advanced nurse practitioners and
nursing students on the science of
forensics in nursing and its relationship to legal nurse consulting, and to
promote the awareness and value of
the profession throughout the legal
and health communities. Participants
will be awarded five nursing contact
hours by the Pittsburgh Chapter of
the AALNC. Members of AALNC
Chapters in Ohio and West Virginia
are invited to participate.
For more information, visit
www.aalncpittsburgh.org or call
(724) 864-2424.
Laureate Lecture series
As part of The University of Pittsburgh School of Medicine 2009
Laureate Lecture series, Gregory J.
Hannon, Ph.D., professor in the
Watson School of Biological Sciences, program chair for
bioinformatics/genetics, and a
Howard Hughes Medical Institute
investigator at Cold Spring Harbor
Laboratory, will present Conserved
Roles of Small RNAs in Genome
Defense on November 17. The
lecture, which begins at noon at
Scaife Hall, Auditorium 6, is free
and open to the public.
Community education
Children’s Hospital of Pittsburgh,
UPMC, is offering classes this fall
for children and adults throughout
the Greater Pittsburgh area. Registration for any of the classes is
required. Class topics include:
Alone at Home
Avoid Power Struggles with Your
Kids
Babysitting 101
CPR (Infant and Child)
Early Childhood Parenting Made
Fun
Happiest Baby on the Block
Parenting Doesn’t Have to be
Rocket Science
Taming Your Toddler
E-mail commed@chp.edu or call
(412) 692-7105 for more information or to register.
ADHD research
Pittsburgh’s Youth and Family
Research Program (University of
Pittsburgh Department of Psychiatry) is recruiting children, ages six to
12, with Attention Deficit Hyperactivity Disorder (ADHD) to participate in the Treatment of Severe
Childhood Aggression (TOSCA)
study. Following assessments, children will receive methylphenidate or
placebo while parents undergo
parenting training. Participants will
be compensated. Call (412) 2464661 or (412) 246-5651.
Autism research
The Center for Autism and Developmental Disorders at Western
Psychiatric Institute and Clinic of
UPMC is recruiting children, ages
six to 12, with autusm to participate
in a research study examining the
use of an investigational medication
to relieve symptoms associated with
autism. The study will require eight
visits (once every two weeks).
Evaluations, study visits and medication are provided free. Visit www.
autismresearchstudy.com or call
(888) 79-STUDY.
Contraception research
Clinical Trials Research Services,
LLC, is seeking healthy women, ages
18-45, for a transdermal contraception patch study evaluating cycle
control and blood pressure. Eligible
participants receive a physical exam,
gynecological exam, pap smear and
blood work at no cost. There are
eight visits and contraception is
provided for seven cycles. Parking is
free and $40 is paid per completed
study visit. Call (412) 363-1900 or
e-mail mcelanovic@ctrsllc.com.
Menopause research
Clinical Trials Research Services,
LLC, is seeking healthy female
participants, ages 40 to 64, who are
seeking treatment for the symptoms
of menopause. Study participation
lasts for 14½ months with eight
visits; qualified participants receive
medical evaluations, mammograms,
gynecological exams, bone density
scans (if elilgible) and study drug at
no cost. Parking is free and $650
will be paid for the completed study.
Call (412) 363-1900 for additional
information or e-mail cdutka@
ctrsllc.com.
ACMS Member Benefit #9
Credentialing-The Pennsylvania
Medical Society Keeping You Informed
This brief document explains the
credentialing process and gives helpful
tips and a checklist to facilitate a smooth
transition from training to active practice.
Available free at www.pamedsoc.org/store
441
Introducing our
newest doctor
UPMC Passavant–Cranberry is pleased to
welcome our newest doctor.
James P. Celebrezze Jr., MD
Colorectal Surgery
James P. Celebrezze Jr., MD has joined UPMC Passavant–Cranberry and welcomes
patients in his Seven Fields office.
Dr. Celebrezze specializes in minimally invasive surgeries for colon and rectal
cancer, advanced surgical techniques for inflammatory bowel disease and other
conditions of the colon, and colonoscopies and endoscopic treatment of polyps.
Dr. Celebrezze is board-certified in surgery and colon and rectal surgery. He is a
graduate of Northeastern Ohio Universities College of Medicine, and completed
his residency at Akron City Hospital and his fellowship in colon and rectal surgery
at the Cleveland Clinic Foundation. He is an assistant professor of surgery at the
University of Pittsburgh School of Medicine, and has been in practice in the
Pittsburgh area for nine years.
For more information or to schedule an appointment, call 1-877-684-7189.
Northpointe Center
Suite 104
200 Northpointe Circle
Seven Fields, PA 16046
upmc.com
442
ACTIVITIES &
ACCOLADES
The Pittsburgh Tribune-Review featured
Peter J. Jannetta, MD,
neurosurgery, as a
Newsmaker in September. Dr. Jannetta,
Dr. Jannetta
vice chairman of the
neurosurgery department at Allegheny General Hospital, is one of the
world’s leading neurosurgical pioneers.
Also, the World Federation of
Neurosurgical Societies recently
awarded Dr. Jannetta its Medal of
Honor in recognition of his contributions to the advancement of
medicine.
Headshots
Needed
Chandrappa S.
Reshmi, MD,
ophthalmology, was
an invited judge for
the European Society
of Cataract and
Dr. Reshmi
Refractive Surgeons
video festival held in Barcelona,
Spain, in September. He was the
only invited American judge out of
10 international judges.
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Send your Activities & Accolades items,
including a photo, to Linda Smith at ACMS,
713 Ridge Ave., Pittsburgh, PA 15212 or email lsmith@acms.org.
○
ACMS members! Please send a recent
headshot photo of yourself to be stored
in the medical society files. These photos
will be used to accompany Bulletin
articles.
Files in jpeg or tiff (.jpg; .tif) format can
be sent via e-mail to lsmith@acms.org.
Send hard copies to Linda Smith at
ACMS, 713 Ridge Avenue, Pittsburgh,
PA 15212. Please indicate whether or not
you would like them returned.
443
Bothered By...
Ankle Swelling
Red or Blue Veins
Night Cramping
Burning, Aching, Swelling or Inflammation
History of Vein Thrombosis (DVT)
Brown Skin Discoloration
Bursting Pain
Ulcerations
CONTINUING EDUCATION
26TH ANNUAL PITTSBURGH SCHIZOPHRENIA CONFERENCE—
October 28, 2009. Sponsor: Western Psychiatric Institute and
Clinic, et al. Pittsburgh Sheraton Station Square. For information, call (412) 802-6917 or visit www.wpic.pitt.edu/oerp.
REGIONAL MENTAL HEALTH TRAINING SERIES. Sept.-Dec. Sponsor:
UPMC Western Psychiatric Institute and Clinic, various
locations. For information, visit www.wpic.pitt.edu/oerp.
HIV/AIDS TRAININGS—many available. Sponsor: Pennsylvania/
MidAtlantic AIDS Education and Training Center, various
locations. For information, visit www.pamaaetc.org.
Mario T. Plaza-Ponte, MD
FACS, FASCRS, RVT, RPVI, Venous Circulation Specialist
DST ends November 1 at 2 a.m.
2550 Mosside Blvd., Suite 105, Monroeville • 412-373-9580
828 W. Main St., Suite 1, Mt. Pleasant • 724-542-4142
www.pittsburghveins.com
444
OCTOBER/NOVEMBER CALENDAR
October 20 is World Osteoporosis Day. November
is the month for the following national awareness
programs: American Diabetes, Alzheimers
Disease, Healthy Skin, Family Caregivers and
Hospice Palliative Care. (Source: U.S. Dept. of Health
and Human Services, www.healthfinder.gov/library/nho/).
Oct 19, 6 pm ......................... ACMS Editorial Board
Oct 19, 6 pm ......................... Pennsylvania Geriatrics Society, West. Div.
Oct 19, 6 pm ......................... Pittsburgh Urological Association
Capital Grille
Oct 20, 6 pm ......................... ACMS Executive Committee
Oct 23-24 ............................. House of Delegates, Hershey
Oct 28, 5:30 pm .................... Pittsburgh Pathology Society
Oct 29, 1-4 pm ..................... Pittsburgh Public Schools Administration
Nov 1, 2 a.m. ........................ Standard Time begins: Set clocks back
Nov 2, 5 pm .......................... Pittsburgh Obstetrical/Gynecological
Council
Nov 2, 6 pm .......................... Pittsburgh Obstetrical/Gynecological
Society
Nov 11, 8-9:30 am ................ Committee for Quality at End of Life
Nov 17, 6 pm ........................ ACMS Board of Directors
Nov 18, 11:30 am-3:30 pm ... Emergency Medical Services
Nov 19, 1-4 pm ..................... Pittsburgh Public Schools Administration
Nov 26-27 ............................. Thanksgiving Holiday: ACMS office closed
Jewel of the Sea a 2008 photo contest entry by Dr. Robert H.
Trivus, whose specialty is psychiatry.
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445
MATERIA MEDICA
Pharmacogenomics: A
New World of Drug
Therapy
MICHAEL ISAAC, PharmD
THOMAS L. RIHN, PharmD
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harmacogenomics is a science that examines the
genetic composition of a patient to determine the
variability in response to a pharmaceutical agent.
More than 1.4 million single-nucleotide polymorphisms
(SNPs) were identified when the human genome was
initially sequenced.1 Many of the SNPs were related to
genetic variability in terms of absorption, metabolism
and therapeutic effect of medications. Understanding
the genomics of a patient would ultimately determine
how a patient may or may not respond to a particular
drug, thus “personalizing medicine.”
The primary benefit of pharmacogenomics is in the
prevention of adverse drug reactions and improvement
in dosing.2 Genetic variations in the metabolism of a
drug may result in sub-therapeutic or toxic levels of the
drug. A patient who is a “rapid metabolizer” will metabolize the drug too quickly. This would result in the
patient needing a higher
dose to achieve therapeutic
results. Conversely,
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a patient who is a “slow metabolizer” will accumulate the
drug in the body, which may result in adverse events.
The dosage would have to be decreased to optimize
therapy. Pharmacogenomics would allow the physician
or pharmacist to identify “rapid or slow metabolizers”
and adjust the dose accordingly to attain therapeutic
levels.
In addition to improved dosing and decreased
adverse events, pharmacogenomics can be used to target
drug therapy and detect drug resistance in certain
viruses. Examples of drugs that need certain targets
within the body include trastuzumab (Herceptin) and
cetuximab (Erbitux) with the drug targets of Her2
receptor and epidermal growth factor receptor (EGFR),
respectively. In terms of viral drug resistance, a kit is
available to test resistance of the HIV virus.2
Other specific examples of the application of
pharmacogenomics in clinical
practice relate to the therapeu-
MATERIA MEDICA
tic use of warfarin, carbamazepine and phenytoin.
Warfarin (Coumadin), an oral anticoagulant, has a
narrow therapeutic window. Genetic differences from
patient to patient produce variability in terms of the
drug target and metabolism. The actual inter-patient
variability occurs in the vitamin K epoxide reductase
(VKORC1) and cytochrome P450 2C9 (CYP2C9)
genes.2 The VKORC1 gene is the warfarin target and the
CYP2C9 is the metabolizing enzyme in the liver.3
Genetic differences result in variable patient responses to
different dosages. Patients may experience an elevated
International Normalized Ratio (INR) if a certain
CYP2C9 allele is present. This could subject the patient
to an increased risk of bleeding because warfarin will
begin to accumulate in the body. Furthermore, if the
VKORC1 gene contains an SNP, a higher dose of
warfarin may be needed. Ultimately, if pharmacogenomic studies are performed on patients who are
prescribed warfarin, safer and more effective anticoagulation therapy will be provided to the patient.
A study was recently completed that estimated the
warfarin dose with clinical and pharmacogenetic data. A
pharmacogenetic algorithm assessed polymorphisms in
the VKORC1 and CYP2C9 genes, along with race, age,
height, weight, use of amiodarone and use of enzyme
inducers. The clinical algorithm employed current
clinical practice techniques. These algorithms were
developed and then used to calculate the warfarin dose
using data from patients (4,043 patients in the derivation group and 1,009 patients in the validation group)
who were therapeutically stable with an INR of 2 to 3.
The patients were grouped according to low-dose (<21
mg per week), intermediate-dose (>21 and <49 mg per
week), and high-dose (>49 mg per week). The pharmacogenetic algorithm produced results that were significantly better than the clinical algorithm. The most
beneficial results were noted in the low-dose and highdose groups where adverse effects could result if the dose
is not therapeutic. The limitations of the study were that
important factors such as smoking status or vitamin K
intake were not available, adverse events before the
patients were stable were unattainable, different sites
genotyped the alleles differently, and the population was
mainly elderly patients with an INR between 2 and 3.4
Additional clinical trials of genetic dose estimations in
warfarin patients are underway.
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continued on page 449
:
:
October 2009 Bulletin
447
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P RO F E S S I O N A L
448
I N S U R A N C E
S O L U T I O N S
MATERIA MEDICA
(from page 447)
pharmacogenomics include the anti-seizure agents,
carbamazepine and phenytoin. Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
have been reported with both of these drugs. These
reactions are very serious and even fatal in some cases.
New data has shown that patients from Asia have an
increased risk of SJS/TEN if a certain allele (HLAB*1502) is present.5 The HLA-B*1502 allele ranges
from 12-15.7% in Malay populations from Malaysia
and Singapore, 5.7-14.5% in Han Chinese in Taiwan,
Hong Kong, Malaysia and Singapore, 8.5-27.5% in
Thai and >10% in Vietnamese patients.5 The frequency
of the presence of this allele in patients from Sri Lanka,
Japan and Korea is very low.
Due to the high prevalence of HLA-B*1502 in the
Asian population, the FDA now recommends to test for
this allele if initiation of carbamazepine therapy is
indicated.5 If the patient tests positive, carbamazepine
should only be used if the benefits outweigh the risks.
Current data also demonstrates that this association is
linked with phenytoin/fosphenytoin.6 The reaction is
known to develop within 25 to 90 days of therapy, and
patients on therapy for more than three months have a
very low risk of SJS or TEN.5 Ultimately, pharmacogenomics may be a key component to improving patient
outcomes in antiepileptic treatment for Asian patients.
Future research is needed to further define this
association between the HLA-B*1502 allele in Asian
patients and SJS/TEN. Possible areas of interest include
the dosage of carbamazepine that results in this adverse
effect, the reason why the interactions generally take
about one to three months to occur, and the mechanism
as to how the HLA-B*1502 allele causes this reaction in
patients of Asian ancestry.5
The examples cited above illustrate the evolving
importance of pharmacogenomics in pharmaceutical
care. The incidence of adverse events will decrease and
therapeutic outcomes will be enhanced if medication
therapy can be tailored to patients’ genetic profiles.
Future studies will also further define the true benefits of
pharmacogenomics in terms of clinical and economic
outcomes with advances in this technology. In many
diseases, the application of pharmacogenomics will
result in the “personalization of medicine,” which will
greatly enhance the safe and effective use of medication.
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Dr. Isaac is clinical pharmacist with Excela Health System. Dr. Rihn is
associate professor of clinical pharmacy, Duquesne University School of
Pharmacy, and chief clinical officer, University Pharmacotherapy
Associates. He can be reached at (412) 396-1295.
REFERENCES
Evans WE, McLeod HL. Pharmacogenomics-drug disposition,
drug targets, and side effects. N Engl J Med 2003;348:538-549.
1
Food and Drug Administration. Safety Newsletter.
Pharmacogenomics and its role in drug safety. www.fda.gov/cder/
dsn/2008_winter/pharmacogenomics. Accessed March 19, 2009.
2
Phillips KA, Veenstra DL, Oren E, Lee JK, Sadee W. Potential
role of pharmacogenomics in reducing adverse drug reactions.
JAMA 2001; 286(18):2270-2279.
3
Estimation of warfarin dose with clinical and pharmacogenetic
data. N Engl J Med 2009; 360(8):753-764.
4
Lim KS, Kwan P, Tan CT. Association of HLA-B*1502 allele and
carbamazepine-induced severe adverse cutaneous drug reaction
among Asians, a review. Neurology Asia 2008; 13:15-21.
5
Food and Drug Administration. Information of Healthcare
Professionals. Phenytoin and Fosphenytoin sodium. www.fda.gov/
CDER/Drug/InfoSheets/HCP/phenytoin_fosphenytoinHCP.
Accessed March 19, 2009.
6
449
Looking Back in Time:
Golden Glimpses
Bulletin, Vol. 69, No. 14
September 27, 1980
In response to the Bulletins
invitation for comments on the
occasion of 50 years in
practice, John W. Leech, MD,
submitted a number of
impressions that were interesting. Dr. Leech served as a house
physician at Municipal Hospital (now Salk Hall at the
University of Pittsburgh) from 1932 to 1934 and
obtained extensive experience with the common
infectious diseases of the day. Some of his observations follow:
What I cant understand is why many of us did
not have one or many beta-hemolytic strep
infections, since we examined throats daily and
occasionally did mouth-to-mouth resuscitation on
dying patients.
Meningococcic meningitis was treated by daily
intrathecal antiserumwhich was first instituted
by Dr. Frank Hazlett, who preceded me (at
Muncipal Hospital).
Today, one cannot perceive or even dream that,
from 1944 to 1960, I would get up at 2 to 3 a.m.
drive ten or more miles, examine an infant or
child, do a myringotomy (occasionally under ethyl
chloride general anesthesia), give penicillin I.M.
and charge $7 to $10.
Does it
hurt
when I
push
here?
I am sorry for and only a little bit sympathetic with
the medical profession for its present charges.
When I hear that my neighbors have paid $200 to
$400 for an annual check-up, including a few lab
tests, I cringe and answer, Thats what I hear is
the going rate.
More and more doctors are reporting a feeling of
“pressure and discomfort” in their bottom lines.
Get some relief...
Call the Kell Group 412-381-5160.
I am only one of many who no longer use the
prefix, Doctor or degree, MD, except on rare
occasions. We are embarrassed to admit that we
are members of a profession that is charging
such inflated fees. I will concede that there has
been inflation, and that we all have been grossly
overcharged by other professions and tradesmen, but I feel that the MDs increases in fees
over the past 40 years have been excessive.
John W. Leech, MD
KELL GROUP, LLC
the
www.kellgroup.com
450
Medical billing and consulting
The Best Kept Secret
in Mens Clothing is
37 Years Old!
Legal Summary
Does Sexual Misconduct
Equal Medical Malpractice?
—Thierfelder v. Wolfert

Custom Made
at Ready-Made Prices
Suits from
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Shirts from
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In Thierfelder v. Wolfert1, the Pennsylvania Superior Court transformed sexual conduct prohibited under Board of Medicine regulations into a cause of action for medical malpractice. Prior to this
case, it was considered unethical, but not a breach of the duty of
carean element necessary for a negligence action to proceed
when a general practitioner engaged in a sexual relationship with a
patient. The new rule is that a physician, whether a psychiatrist or a
general practitioner, may be sued for medical malpractice if:
ALL SHOES
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the physician renders psychological care;
the physician has a sexual relationship with the patient during the
course of treatment; and
Two locations:
201 Penn Center Blvd.
300 Smithfield St.
Monroeville, PA
One Oxford Center
412-824-9565
Downtown Pittsburgh
412-391-9333
Background. A family physician treated a female patient for depression and anxiety. Both the patient and her husband confided in the
physician about their intimate relations for treatment purposes. After
the patient confessed her strong feelings towards her physician, they
became sexually involved for almost a year. The plaintiff ended the
relationship and then sued the physician for medical malpractice,
alleging that he had breached his duty of care to her and caused her
psychological harm.
Import: Liability with No Coverage. This ruling expands the tort
liability of a physician who enters into a consensual sexual relationship with a patient to whom he has rendered psychological care. The
conduct may subject the physician to both disciplinary action and
medical malpractice liability that will not be covered by insurance.
The Superior Courts imposition of this new duty of care runs counter
to extensive efforts by the Pennsylvania legislature and judicial
system to appropriately limit liability for medical malpractice to actual
malpractice.2
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QXUVLQJKRPHVDQGSHUVRQDOFDUHKRPHV
REFERENCES
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2009 PA Super 92 (May 19, 2009).
1
The Pennsylvania Supreme Court in defining malpractice for
insurance coverage purposes looks to whether the act that caused the
alleged harm is a medical skill associated with specialized training.
Physicians Ins. Co. v. Pistone, 726 A2d 339, 344 (Pa. 1999). In her
dissenting opinion, Justice Lally-Green cited this case as controlling;
Justices Orie Melvin and Shogan joined in the dissent.
2
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Johnston & Murphy,
Alden, Belvedere, Mezlan
Allen Edmonds and
Maury Shoes
MONTAJ HONG KONG
CUSTOM TAILORS
the relationship causes the patients emotional or psychological
symptoms to worsen.
Ms. Jackson is the sole member of Beth Anne
Jackson, Esq. LLC, a law firm that serves the
legal needs of health care practitioners and
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bjackson-law@verizon.net.
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451
FEATURE
The Israeli Health Care
System
CAREY VINSON, MD, MPM
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ith the health care reform debate raging in
this country, it is valuable to examine the
experiences of the health care systems of
other nations.
This past March and June, the Pittsburgh Jewish
Healthcare Foundation conducted two study mission
trips to the State of Israel to gain an understanding of
the Israeli health care system. I was invited to participate, along with Dr. Donald Fischer from Highmark,
Drs. Susan Greenspan and Neil Resnick from the
University of Pittsburgh and UPMC, Dr. Bernard
Bernacki from the UPMC Shadyside Hospital and Dr.
Keith Kanel from Carnegie Mellon University.
The Pittsburgh contingent went to Israel to learn
about Israel’s health care system and determine significant relevance to and important lessons for the U.S.
health care reform efforts. The trip was an opportunity
to determine how the Israeli integrated system operates.
Despite spending about half of what Americans spend
on health care, how has this small country—with its
population of 7 million—achieved better health outcomes than the U.S.?
We met with physicians and opinion leaders from
throughout the country: Prof. Avi Israeli, director
general of the Ministry of Health, responsible for what
medical services are provided to the country’s residents;
Dr. Bruce Rose, Prof. Gabi Bin Nun, Dr. Tuvia Horev
and Prof. Jack Habib from the Myers-JDC-Brookdale
452
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Institute, a center for applied social research for Israel
and the Jewish world community; Dr. David Chinitz,
a health care economist from the Hebrew University,
Hadassah School of Public Health; and physician leaders
from the Clalit Health Plan, the Maccabi Health Plan,
the Tarem-Tayelet Emergency Medical Centers and the
Soroka Medical Center in Beer Sheva.
Historical background
The health care system in Israel is based on a system
of voluntary health plans, originally called sick funds,
first established in the 1920s during British Mandatory
regime. After the establishment of the State of Israel in
1948, unions continued the system and, by the 1980s,
four sick funds, now called health plans, were covering
about 95 percent of the citizens. In 1995 the National
Health Insurance law was instituted, making membership in one of the health plans compulsory for all
citizens and establishing public funding of basic care by
means of a progressive health tax. Employers stopped
having a role in the provision or funding of health care
services.
According to Israeli government and World Health
Organization statistics, Israel’s population health statistics are superior to U.S. findings: lower infant mortality
and maternal mortality rates, higher immunization rates,
longer life expectancy and more physician contacts.
Israelis smoke more, but have much lower obesity rates.
FEATURE
Ministry of health
Every resident is entitled to health services according
to the National Health Insurance law. Revenue from a
health care tax on individuals and from the general fund
tax is collected for the Ministry of Finance, which
annually determines the percentage of collected taxes
that is allocated to the Ministry of Health for funding of
health care services.
In 2006 Israel spending on health care was 8 percent
of the GNP (U.S. spending was 16 percent.) and government funding accounted for 65 percent of all health
care expenditures.
The Ministry of Health is responsible for providing
perinatal care. The Ministry of Health directly operates
460 mother-and-child-care centers and funds 390
centers operated by municipalities or health plans. The
Ministry of Health owns 45 percent of the country’s 47
acute care hospitals. The Ministry of Health also funds
mental health care, nursing home care and the country’s
four medical schools.
With the approval of the Knesset (Israel’s legislature), the Ministry of Health establishes the health
services “basket” that the health plans must provide to
its insured members. The basket includes services in:
diagnosis, consultation and medical treatment,
medications,
medical services in work places,
hospitalization,
accessories and medical equipment,
rehabilitation.
The health plans sell supplemental insurance to its
insured members that pays for services not included in
the basket (e.g., dental, complementary and alternative
health services, extended nursing home care). Health
plans and independent companies sell private insurance
that pays providers for additional care (e.g., using nonhealth plan physicians, scheduling more convenient
appointments, getting elective surgery sooner). About 80
percent of Israeli residents have supplemental insurance
and about 30 percent have private insurance.
Are your medical records being audited
by Medicare or an insurance company?
YOU DON’T HAVE TO GO INTO AN AUDIT “BLINDLY.”
If you would like your medical records audited by an
outside expert before a payor audits them, or if you
need a second opinion regarding the results of a
recent audit, contact PMSCO Health Consulting
(PMSCO).
PMSCO’s experienced coders are certified through
the American Academy of Professional Coders, and
have performed hundreds of medical practice coding
audits.
PMSCO will work with you, or your legal counsel
through attorney-client privilege, to ensure the best
outcome possible in an audit situation.
Let PMSCO’s certified coders guide you by providing
expert advice, confirmatory audit service, and documentation and coding education.
Contact PMSCO by calling 1-888-294-4336, or by
visiting our website at www.consultPMSCO.com.
Contact Information: www.consultPMSCO.com 888.294.4336 experts@consultPMSCO.com
453
FEATURE
(from page 453)
Health plans
Residents must join one of four health plans: Clalit,
Maccabi, Leumit or Meuhedet. Clalit, the oldest health
plan started in 1911—and the largest, with 54 percent
of the covered lives—employs a closed panel of physicians and owns 30 percent of the hospitals. Maccabi,
Leumit and Meuhedet each contract with independent
physicians, along with the government and private
hospitals. The health plans have their insured members
pick a health plan-participating primary care physician.
The health plans perform most of the care coordination
between providers and the patients, but prior authorization is seldom used.
The health plans are paid a capitated rate by the
Ministry of Health. There is increased payment adjusted
for age over 60 years, but no increased capitation for
other health risks. The health plans pay the physicians a
salary or annual capitation. Except for the Clalit and its
owned hospitals, the health plans pay the hospitals a
negotiated annual amount that is adjusted at the end of
the fiscal year for the volume of patients treated.
Israeli residents may change health plans annually.
The average change rate is 1 percent per year. The health
plans’ leaders believe the low change rate reflects the
quality of the health plans, but my discussions with
patients indicated that they stayed with their health
plan, in part, to keep their PCPs.
Physicians
Physicians are employed by a health plan or a
hospital, either as a salaried employee or an independent
physician accepting patients through the National
Health Insurance. Most physicians work a set number of
hours per week (about 40 hours based on my conversations with physicians). Physicians can also work in the
private sector outside of their salaried position and be
paid out-of-pocket by the patient or through the
patient’s private insurance. The physicians belong to the
Israel Medical Association as a union, and the union
negotiates salaries with the Ministry of Health. The
negotiated salaries are paid by the health plans and
hospitals. (Physicians have, in the past, engaged in
nationwide strikes.) Israel has one of the highest physician per capita rates in the world at 3.7/1000; the U.S.
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454
FEATURE
ratio is 2.6/1000. There are almost as many primary care
physicians as there are specialists and, except for some
unique specialties such as transplant surgeons, primary
care physicians and specialists are paid about the same.
Physicians are among the highest paid professionals in
Israel, making three to 3.5 times the country’s mean
salary. Medical school training is combined with college
for a six-year degree. Tuition is subsidized by the government and is about $2,500 per year. Israeli postgraduate
training is one to two years longer than U.S. training, so
that total post-high school training is similar to the U.S.
Primary care physicians
PCPs work in the community and generally do not
have hospital privileges. Some of the health plans require
referrals from a PCP prior to a member seeing a specialist or having an elective admission to the hospital. Over
99 percent of the primary care physicians have an
electronic medical record supplied by the health plan.
The electronic health record has advanced functions,
including care reminders and patient registries. The
health plans monitor and report on the physicians on a
weekly to monthly basis. The health plans do not use
pay-for-performance. I was told physicians are expected
to see at least two to three patients an hour, but the
physicians normally see four to eight patients an hour.
PCPs use very few support or nursing staff; in many
cases, PCPs had no help.
Thank You
for your membership in
the Allegheny County
Medical Society
Hospitals
Compared to the U.S., the Israeli hospitals were
behind in the adoption of technology. Except for electronic documentation of a limited list of diagnoses and
medications, the admission note and the discharge note,
the hospitals were still using a paper system. The hospitals have earlier generation laboratory and radiology
equipment. The physical plants are older, and new
construction is restricted by the Ministry of Health’s
limited funding. There is minimal transition-of-care,
post-hospital discharge planning with the primary care
physician.
Lessons learned
Israel appears to have achieved a very high degree of
health care for its citizens, while spending less than other
developed nations and much less than the U.S. What
seems to make the difference are universal coverage,
primary care emphasis, primary care physician monitoring and constructive feedback by the health plans, and
all parties working within the confine of very strict
budgets. Israel may spend too little on some important
areas such as cancer treatments and geriatric care, but
patients and doctors are by-and-large satisfied with their
health care system.
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Dr. Vinson is vice president, Quality and Medical Performance
Management at Highmark Inc. He can be reached at
carey.vinsonmd@highmark.com.
The ACMS Membership Committee thanks you
for your support. Your membership strengthens
the society and helps protect our patients.
Please do your part to make your medical society
stronger by encouraging your colleagues to
become members of the ACMS.
Questions or Comments? Call the membership
department at 412-321-5030, ext. 110 or e-mail
membership@acms.org.
455
FEATURE
An Update on PostTraumatic Stress
Disorder
BARRY W. FISHER, MD, DFAPA
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ince the terror attacks on the World Trade Center
on 9/11/01, there has been an increase in interest
in the diagnosis and treatment of post-traumatic
stress disorder (PTSD). Devastating natural disasters,
wars, accidents and personal assaults are a few of the
traumas we have witnessed over the past 10 years.
Somewhere between 10 percent and 25 percent of
people exposed to such traumatic events will develop
ongoing difficulties meeting the criterion for PTSD.
The condition is more common in women, tends to
occur more commonly when interpersonal violence is
the stressor (rather than a natural disaster), and when
individuals may have other pre-existing emotional
vulnerabilities. Biological risk factors may be associated
with abnormalities of the adrenal-cortical axis and with
the normal stress response.
In order to receive a diagnosis of PTSD (according
to the Diagnostic and Statistical Manual of Mental
Disorders IV), one must have been exposed to, or witnessed, a potentially life threatening event and, at the
time of the exposure, have experienced intense fear. In
addition, he or she should have symptoms indicative of
re-experiencing of the trauma (nightmares, flashbacks,
intrusive memories, physiologic reactivity to reminders
of the trauma), avoidance of stimuli associated with the
trauma (often with general emotional withdrawal and
detachment), and hyper-arousal (exaggerated startle,
poor sleep, poor concentration and problems with anger
456
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control). A condition with similar symptoms developing
within a month of exposure to a traumatic event and
lasting between two days and four weeks is diagnosed as
an Acute Stress Disorder (ASD). ASD often progresses
to PTSD over time. In addition, there can be a delayed
onset to PTSD relative to the time of exposure to the
stressor.
The pathophysiology of PTSD involves abnormalities of the normal stress response. When individuals are
stressed, information regarding the stressful stimulus is
communicated to the limbic lobe, specifically the
amygdala. Projections from the amygdala cause the
sympathetic nervous system to be activated with an
increase in heart rate, BP, endogenous opiates and
glucagon, often described as the “fight or flight response.” In order to re-establish homeostasis, CRF is
released, which causes the release of ACTH and, subsequently, cortisol (the anti-stress hormone); through
negative feedback on the hypothalamus, pituitary gland,
hippocampus and amygdala, the pre-stressed levels of
catecholamines and cortisol are re-established. When
stressors are severe and recurrent, some individuals will
develop a more sluggish cortisol response to stress and
establish a new homeostatic set point with a higher
resting catecholamine level. High levels of cortisol can
be neurotoxic to hippocampal cells, so establishing a
new set point may actually help preserve memory and
may explain why patients with PTSD often have some
FEATURE
difficulty learning new nonTable 1. Psychophysiologic sxs
emotionally laden material.
The hippocampus is the
Exhaustion
Hyperventilation
Dizziness
locus of logical and non Muscle weakness
Urinary frequency
Blurry Vision
emotional memory, and
Difficulty swollowing
Perspiration
Tachacardia
projections from it to the
amygdala help to modulate
Abdominal pain
BP changes
Chest Pain
the stress response. Neuro Nausea/vomitting
Leucocytosis
Parathesias
transmitters that appear to
Irritable bowel sxs
Circadian changes
Tremor
help modulate the stress
Irregular breathing
Loss of libido
Bruxism
response are GABA and
Serotonin, while Glutamate
Breath holding
Memory difficulty
TMJ
appears to be the neurotrans Fibromyalgia
mitter involved in promoting
the stress response. PharmaTable 2. Psychotherapy Treatments
cologic strategies are currently
directed at influencing these
Exposure therapy—related imaginal exposure with listening to taped
neurotransmitter systems.
description of trauma at home
Brain imaging studies of
Cognitive therapy—most effective if combined with exposure tx
individuals who develop PTSD
EMDR
show reduced size and activation in
the hippocampus and increased size
Psychodynamic psychotherapy
and activity in the amygdala.
Debriefing as prevention (most studies do not support its efficacy)
Broca’s area appears to shut down
during flashbacks (dissociative reTable 3. Medications recommended in PTSD
experiencing of the trauma with
loss of orientation to the current
SSRIs for depression/anxiety
environment and lack of memory
Benzodiazpines for anxiety
for the periods of disorientation).
There is marked right hemispheric
Anticonvulsants for core PTSD sxs (re-experiencing, irritability, poor
lateralization of activation during
sleep)
recollection of traumatic memories.
These findings correlate with the
Prazosin, donidine-nightmares/hyper-arousal
increase in reactive, emotional
Atypical antipsychotics for anxiety, irritability, poor sleep
memory, as well as suggest a
physiologic explanation for the
Betablocker—to prevent development of PTSD
traumatized individual’s difficulty
Other antidepressants for anxiety, depression
remembering and discussing in a
logical manner his or her traumatic
etiology) Pierre Janet found that, with the use of hypnoexperiences.
sis, prior traumas could be remembered and physical
As might be expected, patients with PTSD may not
symptoms diminished. He found the following pheremember or be forthcoming regarding prior traumatic
nomenon common in his hysterical patients: disturevents. They may experience the traumatic memories as
bances of memory, avoidance of situations associated
physiologic symptoms that the body associates with the
with prior traumas and general hyper-arousal. As might
trauma rather than in narrative form. At the turn of the
be expected, patients with PTSD may present first to
19th century in his work treating patients who had
developed hysteria (what is now referred to as conversion their primary care doctor with a myriad of physical
disorder-physical symptoms without obvious biological
:
457
October 2009 : Bulletin
Does
ACMS
Membership
Doo FFor
What D
oes ACM
S Member
ship D
or Me?
ACMS members have exclusive access to vendors of physician
supplies and services at special rates. We screen all vendors for
quality and value, so you don’t have to.
Membership Group Insurance
Programs
Blue Cross/Blue Shield, Disability,
Property and Casualty
USI Affinity
Bob Cagna, 724.873.8150
Banking, Financial and
Leasing Services
Medical Banking, Office VISA/MC
Service
PNC Bank
Frank Van Horn, 724.853.0238
Medical Liability Insurance
PMSLIC
Marketing Department
Lisa Klinger, 717.802.9236
458
Medical Supplies
Allegheny Medcare
Michael Gomber, 412.580.7900
Medical Waste Removal
Medical Waste Recovery Inc.
Mike Musiak, 724.309.9261
Printing Services and
Professional Announcements
Records Management
Business Records Management
Inc. (BRM)
David Phillips, 412.321.0600
Auto and Home Insurance
Liberty Mutual
Angelo DiNardo, 412-859-6605,
ext. 51902
Member Resources
Service for New Associates, Offices
and Address Changes
BMI Charts, Where-to-Turn cards
Society
Susan Brown, 412.321.5030
Society
412.321.5030
Life, HIV Coverage
Malachy Whalen & Co.
Malachy Whalen, 412.281.4050
FEATURE
(from page 457)
Psychiatrists on Call
symptoms that are not easily explained. Table 1 (page
457) lists some of the common physical complaints
associated with PTSD.
Strategies for treatment include both psychotherapeutic and psychopharmacologic interventions. The
Federal Drug Administration has approved two serotonin re-uptake inhibitors as first-line agents in the treatment of PTSD, namely sertraline and paroxetine.
Recently the Institute of Medicine reviewed the clinical
research to date, both for medications and psychotherapies; while many treatments were reported as helpful,
they found that the only evidence-based treatment
effective for PTSD was exposure therapy. They argued
for more rigorous research to show unequivocally that
many of treatments used currently in PTSD could be
validated as effective. Tables 2 & 3 (page 457) list
various medications and psychotherapies currently used
to treat PTSD.
For the primary care physician who diagnoses PTSD
in his or her patient, many resources are available for
treatment. Referral to a psychologist or psychiatrist who
specializes in treating trauma is recommended for
patients who do not respond to initial treatment with an
SSRI. Expertise in complex pharmacotherapy and
specific trauma-based psychotherapies is often needed to
effectively treat this disorder. For veterans or active duty
soldiers, referral to clinics associated with the Veterans
Administration or Department of Defense is advised.
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Dr. Fisher is medical director of the PTSD/Behavioral Medicine Clinic
VA Pittsburgh Health Care System. He is clinical assistant professor at
the University of Pittsburgh School of Medicine and adjunct clinical
assistant professor at Drexel University College of Medicine, Allegheny
Campus. He can be reached at barry.fisher@va.gov or (412) 954-4319.
REFERENCES
Diagnostic and Statistical Manual of Mental Disorders 4th Edition,
DSM IV, APA Press, Washington DC, 1994.
Colleagues working together for optimal patient care
Through its Outreach Consultation Projects, the Pennsylvania
Psychiatric Society (PPS) is making available consultations for
primary care physiciansinternists, family medicine physicians and
pediatricians in Pennsylvaniawith board-certified psychiatrists
willing to informally talk with them, answer questions and provide
psychiatric advice on the patients they treat. Consultations are free.
Visit the Outreach Consultation Projects web page
(www.papsych.org/psychiatristsoncall.aspx) to find a list of
participating PPS members and their contact information. Choose
a psychiatric consultant by geographic area, subspecialty or area
of interest.
Call the psychiatrists office. Mention the Outreach Consultation
Project and request help. The psychiatrist will return your call
within 24 hours and will either talk with you immediately or set up a
time for a consultation that meets everyones schedule. If the
psychiatrist cannot provide help within the time frame you need,
simply refer back to the website listing for a second name.
The Pennsylvania Psychiatric Society volunteer will assist you by
sharing his or her knowledge and experience, but you make all
decisions regarding your patients diagnosis and treatment.
You can also access advice and guidance from a psychiatrist who
is expert in treating patients requiring specialized care such as
children, adolescents, geriatric adults or those with dual diagnoses.
Pennsylvania Psychiatric Society sponsors The Outreach Consultation Project, made possible by a generous grant from the American
Psychiatric Association, with additional funding from Wyeth Pharmaceuticals. For more information, call the PPS at (800) 422-2900.
ACMS Members
New Partner?
New Address?
Retiring?
Congratulatory Message?
Gorman J, ed., Fear and Anxiety: The Benefits of Translational
Research, APA Press, Washington DC, London, 2004.
Announce it here...
Treatment of Post-traumatic Stress Disorder: An Assessment of
the Evidence (Free Executive Summary), 2008 www.nap.edu/
catalog/11955.html
Professional announcement advertisements in
the Bulletin are available to ACMS members
at our lowest prices.
Van der Kolk B, McFarlane A, Weisaeth, L,eds. Traumatic Stress
The Effects of Overwhelming Experience on Mind, Body, and
Society, the Guilford Press, New York, London, 1996.
Yehuda R, Davidson J. Clinicians Manual on Post-traumatic
Stress Disorder, Science Press, London, 2000.
Contact Linda Smith at 412-321-5030
for more information.
459
SPECIAL REPORT
Updated Health Care Power of
Attorney and Living Will Form
Now Available
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he Allegheny County Bar Association (ACBA)
and the Allegheny County Medical Society
(ACMS) have set an example for the Commonwealth by providing the public with access to updated
health care documents.
The organizations, which first provided a free health
care power of attorney and living will form to the public
15 years ago, recently revised the document to comply
with new laws and to make it easier to understand. The
form, educational information, frequently asked questions and instructions on how to complete the document
are available on their respective websites (www.acba.org
and www.acms.org). On the ACBA site, the form is
under “Free Brochures” in the “For the Public” section.
“It was updated to reflect changes in the law concerning health care decision-making brought about by Act
169, which became effective in 2007 and provided a
substantial statutory framework for health care powers of
attorney that didn’t exist when we drafted the previously
endorsed form,” says Bob Wolf, a partner at Tener, Van
Kirk, Wolf & Moore who was instrumental in creating
the form. “The prior statute as it pertained to living wills
was triggered by permanent unconsciousness or a terminal condition. The new statute uses the words end-state
medical condition, which more broadly reflects the legislative intent and was not intended to convey any particular
timeframe for life expectancy, such as the six-month
period commonly thought to be conveyed by the words
terminal condition.”
Amending the original form was done with input
from the ACBA’s Elder Law Committee, the Health Law
Section, and the Probate and Trust Law Section, with
support from ACBA President Jay Blechman and final
460
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reprinted with permission from the Allegheny County Bar Association
approval from the association’s Board of Governors on
March 17, 2009. The revised form also required approval from the ACMS’s governing body.
“The changes to the form will impact the public
because it will now conform to the new law in Pennsylvania,” says William McCormick, immediate past chair
of the Health Law Section and senior vice president/
general counsel for Triad Isotopes Inc. in Orlando.
“The use of the term, end-stage medical condition, in
lieu of terminal condition is intended to expand the
scope of situations where a living will can be recognized
by health care providers.”
Mr. McCormick urged the Health Law Section to
approve the changes at its March meeting by emphasizing that 15 years is a long time for a health care document to be in place without revisions.
“The Allegheny County form is generally the most
accepted form in the commonwealth, so it made sense
that it be updated to comply with Act 169 because so
many citizens rely on it,” says Mr. McCormick.
Christine Kornosky, who chairs the Probate and
Trust Law Section, says this particular project was an
important part of her goal to provide service to ACBA
members and the public.
“This is why I asked our section council to approve
the form and to authorize Bob Wolf and me to seek the
approval of the Board of Governors to post this form
on the ACBA website,” she says. “I believe that the
other section chairs involved feel the same way, and this
is why they joined our efforts. I would like to thank
Bob for his hard work in creating this form and for his
help in obtaining the endorsement of both the ACBA
and the ACMS.”
SPECIAL REPORT
Virtually everyone needs them
(living wills) so they can express
their opinion about who should
speak for them on medical issues, if
they cannot speak for themselves.
Attorney Blechman says the changes make the form
more flexible and easier to read. “People need to have
the ability to make choices in the event of end-stage
medical conditions. A living will in a clear and easy-touse format will help members of the public in effectuating those very personal choices,” he says.
Mr. Wolf noted that everyone who is at least
18 years old should complete the form. It is estimated
that less than 20 percent of the people who currently
need the documents actually have them in place.
“Virtually everyone needs them so they can express
their opinion about who should speak for them on
medical issues if they cannot speak for themselves,” says
Mr. Wolf. “Interestingly, the most famous cases regarding these issues have involved young people under the
age of 30, who, as a result of a dramatic accident, ended
up in very difficult circumstances in an irreversible coma
or irreversible vegetative state.”
Mr. Wolf explained that the health care POA and
living will form provided by ACBA and ACMS has been
completely reviewed and substantially rewritten. The
form contains a HIPAA authorization to share medical
information with a designated agent. HIPAA regulations
did not exist when the original form was created.
“It reflects in a more neutral way the choice that
each individual has to direct either more aggressive or
less aggressive care under difficult circumstances. It
includes a section on organ donation to make sure this
issue is addressed in the person’s wishes,” he says. “Although the new form is ‘springing,’ or not effective
while the individual is able to understand, make or
communicate his or her choice regarding a health care
decision, it allows patients to ‘spring’ the power by
simply informing their doctor. This means that patients
stay in charge of their health care decisions as long as
they wish.”
The form maintains important information conOctober 2009 :: Bulletin
tained in the original document to make it clear that
any medical treatment necessary to reduce suffering
should be allowed, even if efforts to merely sustain life
or prolong the process of dying should not be undertaken. In regards to directing the withdrawal of care, the
form requires that there be “no realistic hope of significant recovery,” which inserts an important level of
thought and judgment into the living will form.
The high-quality legal and medical document can
be downloaded from the websites at no cost.
Mr. Wolf says a process enabling the public to
obtain pre-printed copies has not been established. One
possibility under consideration is to make the forms
available at local libraries. Details are also being worked
out regarding distribution of the forms to law firms that
want to provide them to their clients.
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Information for this Special Report was provided by the Allegheny
County Bar Association. The article first appeared in ACBA’s Lawyer’s
Journal, July 3, 2009. For more information, call (412) 261-6161.
461
Doctors and Patients. Preserve the Relationship.®
Free. Members-Only Information
From the Pennsylvania Medical Society
Of the thousands of calls and e-mails we receive from Members every year, many concern the
same issues and questions. So, we’ve developed a series of brief publications that address
these common Concerns. They’re free and available only to Members.
Regulations
Practice Management
Practice Guidelines for Physician Assistants
and Certified Registered Nurse Practitioners
A resource for physician practices to understand licensure, scope of practice, and reimbursement rules and
guidelines for these positions.
Policy and Procedural Manuals/Employee
Handbooks for Medical Practices
Use this brief publication to find out the basic information that should be included in a comprehensive
employee handbook for your practice.
Setting the Record Straight: What You Need to Know
About Medical Records
From Ownership rights to copying fees, “Setting the
Record Straight” will help you make sure you’re handling
these vital documents appropriately and legally.
Selecting Computer Hardware
and Software for Your Medical Practice
Use this short paper to help you with the process of
selecting a practice management system for your
medical practice.
Disease Reporting
Includes lists of reportable diseases, how and where to
report, confidentiality rules and penalties for failing to
report.
Setting Up a Practice—Areas to Consider
For physicians who are considering starting a practice.
With all there is to consider, you’ll probably miss
something without a checklist like this.
Reimbursement
Medical Liability
Act 6: A Crash Course in Auto Accident
Reimbursement
A concise run-down of the steps you need to take to get
appropriately reimbursed for care of patients injured in a
motor vehicle accident.
Arbitration of Medical Liability Claims
Focuses on private arbitration outside the judicial
system that takes place if the physician and patient
have a voluntary agreement to engage in arbitration.
Your Right to Timely Payment Under Act 68
Provides details of physician’s rights under the Quality and
Health Care Accountability & Protection Act, including
provisions for prompt payment of clean claims within 45
days.
Collection Protocols for the Medical Practice
Manage your accounts receivable and prevent them from
becoming delinquent. “Collection Protocols” includes tips
on managing accounts and also useful collection techniques.
Workers’ Compensation:
The Application for Fee Review Process
FAQs and sample forms for when you have trouble getting
paid for workers’ compensation health care services or
when an insurer is making you wait for payment.
462
Medical Professional Liability Insurance Options
Basic information and definitions for physicians considering new as well as traditional medical liability insurance options.
Lawsuit Protection Strategies
Designed to be an instructional tool for physicians so
that they can have a more informed discussion with
their legal and financial advisors.
Order any of these publications
by calling (800) 228-7823
or on the Pennsylvania Medical Society
Web site store, www.pamedsoc.org/store.
SPECIAL REPORT
Jefferson Regional Medical
Center: Highmark’s Dean Ornish
Program Reversing Heart Disease
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s everyone knows, heart attack and
stroke are the number-one killers of
both men and women in the United
States. Recommended lifestyle modification
has been the cornerstone of therapy for
years. Unfortunately, implementing these
lifestyle changes has been the Achilles heel in
the treatment of coronary artery disease.
Residents of Allegheny County are fortunate
to have Jefferson Regional Medical Center and The Dr.
Dean Ornish Program for Reversing Heart Disease. The
Dr. Dean Ornish program not only implements lifestyle
changes but has shown clear-cut, verifiable results in
reducing heart attacks and in preventing all types of
cardiovascular events. The program has improved the
quality of life for every one of the more than 200 participants since 2005.
“We are so pleased and proud of the work that the
Ornish team at Jefferson has done. Their commitment
to the program has benefited many individuals as the
outcomes continue to be consistently positive,” says
Anna Silberman, Highmark vice president of preventive
health services and clinical client relationships.”
Jefferson Regional Medical Center is the only facility
in Allegheny County to provide the Dean Ornish
Program. Patient outcomes have been phenomenal and
include average weight loss of 19.2 pounds per patient
and an average body mass index decrease of 2.8 points.
Blood pressures have declined from an average of 9.7
points systole and 5.4 points diastole. Total cholesterol
has decreased by an average of 17.7 points per patient.
The Dr. Dean Ornish Program for Reversing Heart
Disease combines unique dietary modification, stress
reduction with yoga and group support and cardiac
rehabilitation. The program encompasses a full multiOctober 2009 :: Bulletin
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disciplinary approach with support from the
Dean Ornish team of medical professionals,
including registered nurses, registered dietitians, exercise physiologists, stress management specialists and group support facilitators. Each professional provides both
individual and group instruction and
education to facilitate program success.
The Jefferson Regional Medical Center
Dean Ornish team is headed by Saul Silver, MD, medical director of the Dr. Dean Ornish Program. Dr. Silver
has been one of the program’s strongest proponents for
more than 15 years, and he strongly emphasizes the
program in his cardiovascular medical practice and his
management of patients with known coronary artery
disease or other risk factors for heart disease.
The program is successful because of the people
involved. From the team leader to the yoga instructor,
dietitians and exercise physiologists, the program has a
team that is fully dedicated to the wellness of its patients—patients who deserve to experience not only the
benefits of the program but the experience of these
wonderful, dedicated employees.
The demand for the Dean Ornish program has
driven expansion of services to locations in West Mifflin
and the Pittsburgh/Squirrel Hill area. The Dr. Dean
Ornish Program is a covered service by Highmark and,
most recently, the UPMC Health Plan.
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Information for this Special Report was provided by the Dr. Dean
Ornish Program, Ornish Advantage & Highmark Preventative
Programs, and The Heart Institute at Jefferson Regional Medical
Center. For additional information, visit www.jeffersonregional.com or
contact Beth Kramer, team leader, at (412) 653-1391. Referrals can be
made at (888) 866-4744.
463
PROFILE
Stephen F. Conti, MD:
Helping Pittsburghers
Put Their Best Foot
Forward
LINDA L. SMITH
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arlier this summer, the Pittsburgh Post-Gazette
presented Stephen F. Conti, MD, along with his
son Matthew and daughter Laura, with its
Jefferson Award, designed to honor Western
Pennsylvania’s “Community Champions”—everyday
citizens who encounter problems in their neighborhood
and create solutions to fix them. The Jefferson Awards
are part of a larger national program named for Thomas
Jefferson to honor individuals for their achievements
and contributions through public and community
service.
A local orthopedic surgeon and member of the
Allegheny County Medical Society, Dr. Conti, five years
ago, helped Matthew and Laura launch “Our Hearts to
Your Soles,” a non-profit organization that provides free
medical foot screening examinations and shoes to the
less fortunate people of the metropolitan Pittsburgh
area. At the time, Matthew and Laura were students in
the North Allegheny School District near Pittsburgh;
while volunteering for the summer at Allegheny General
Hospital, they saw first-hand the problems that can be
caused by improper footwear and decided to do something about the problem. Because other programs
provided clothing but not shoes to the needy, the kids
saw a great need for the organization.
Today the organization has grown into a large
national charity. Our Hearts to Your Soles is registered
with the Commonwealth of Pennsylvania, and virtually
100 percent of donations go directly to the people who
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need it the most. Visit www.heartstosoles.com for more
information.
Dr. Conti, congratulations on receiving the Pittsburgh Post
Gazette’s Jefferson Award for your work with “Our Hearts
to Your Soles,” a local group that provides footwear for the
needy. Can you tell our readers how that group came about?
Many years ago, I would collect shoes with Ted
Colaizzi, a local pedorthist, and then visit the Jubilee
Kitchen the day before Thanksgiving to give the shoes to
the poor who came there for a meal. Eventually that
stopped due to our difficulty getting good quality shoes
for that event. My kids remembered me telling them
stories of those days and, when they saw the problems at
the hospital, they decided to resurrect the activity. After
a few local events, Matthew and Laura continued growing the work of the charity until we now have volunteers
in 40 states. Our most recent event was last Thanksgiving when we were able to medically screen and give away
free socks and Red Wing shoes to the poor, more than
200 locally and 4,000 nationwide.
How did this activity go from local to nationwide?
Actually that’s what I most want people to know:
how a small idea can become a large national charity. We
began 15 years ago as indicated above with the Jubilee
Kitchen and the next year we went to the Light of Life
Ministries. Once my children became involved, my son
recruited a physician in Hershey and we had two sites
PROFILE
for the activity; eventually Matthew grew the activity to
10 more states, each with a single site. When he went off
to college, Laura continued the work, taking the total to
25 different states one year and 40 states the next. This
year, Our Hearts to Your Soles will provide foot screenings and new socks and shoes in 48 of the 50 states. My
job is professional networking, talking with physicians
about organizing branches of the charity in their areas.
Where does the money come from for the shoes?
The total cost to put on the event around the
country is $30,000 annually, which comes through
corporate sponsorships and donations from individuals
who hear about the charity and want to help. My wife
and I and our children work at raising
funds throughout the year. Hearts to Soles Top: Dr. Conti
(left) and Ted
also coordinates with a larger charity
Colaizzi check
organization out of Nashville called
for proper fit.
“Soles4Souls,” which solicits good quality
shoes from manufacturers and then serves
Bottom:
Volunteers in
as a distribution site. Right now, each of
Pittsburgh
the sites in our 48 states gets about 200
provided
foot
pairs of shoes for its annual event. Any
comfort for
shoes not distributed on that day are kept more than 200
at the site and given to needy individuals
needy on
throughout the year who come in needing Thanksgiving
Day 2008.
a new pair of shoes.
How many physicians locally (including
residents and medical students) do you
believe participate in the “Our Hearts
to Your Soles” program?
Our core group includes myself;
my fellow, Dr. Richard Owens; a few
orthopedic residents; Ted Colaizzi
from Colaizzi Pedorthis Center; and
Russ Reiger from Hanger Prosthetics
and Orthotics. We always have at
least one of the kids at the event,
depending on their school schedules,
and several other non-medical people
who volunteer to help us. I’ve spoken
with physicians from a number of
sites nationwide who have begun the
tradition of providing a special
dinner the day before Thanksgiving
for volunteers who give of their own
time on Thanksgiving Day.
Where will the local event be held this year?
Last year we worked with Catholic Charities (CC)
and had a tremendous event, serving more than 200
Pittsburghers. We plan to put the event on again this
year at CC’s Downtown Health Center the day before
Thanksgiving. I am hoping to make it more of a medical
fair so, in addition to having volunteers from Our
Hearts to Your Soles, we will also have volunteers from
Allegheny General Hospital there to perform routine
screenings that the poor may not have access to.
465
FEATURE (from page 465)
Pennsylvania Medical Societys
Institute for Good Medicine
Has the Pittsburgh Post-Gazette’s Jefferson Award helped
to promote the program?
I think the Jefferson Award has definitely brought
the charity some notoriety. It is really quite amazing how
many people I know or work with, or care for, who will
see an article about the charity and comment to me
about it. We are really the ultimate small business
charity. Over the years most all of our work has been
done out of our home, with the kids doing most of the
work and my wife and I overseeing them—mostly
arranging to get doctors in the different states to agree to
participate. Since all the money we take in goes to
getting the shoes to the poor, we have no money for
advertising; thus we rely on articles such as this to get
the word out and direct people to the website to donate.
When Peter S. Lund, MD, FACS, became president of the Pennsylvania Medical Society, he wanted to focus on the positives: positive
things that physicians are doing in their communities; positive
changes that patients can make to improve their health; and
positive relationships between physicians and patients.
Out of this came Pennsylvania Medical Societys Institute for Good
Medicine. With the completion of its inaugural year under its belt,
the institute has launched its website: www.goodmedicine.org.
The site focuses on professionalism within the practice of medicine,
providing information on opportunities for mentoring, volunteerism
and communications. A visit to the website can help you decide how
or where you should volunteer your precious time, including a
clearinghouse of volunteer experiences from physicians along with
their comments. The possibilities are endless, but for physicians,
volunteer service is especially important. The medical profession,
one of the most altruistic professions, has a specialvery powerfulniche in volunteer work.
How did the culture of volunteerism become rooted in your
family? Is it generational, or was this the first volunteer
activity for you all?
This is the first volunteer activity that I know of for
my family. It is now a routine part of my own family’s
culture since we have been doing this for many years
now. I think it is all a matter of perspective, and we are
all so thankful with our other successes that we just want
to give back to the community in some way; this is a
way to do it as a family.
In addition, the website (www.goodmedicine.org) provides educational opportunities, including past results from The Patient Poll, a
statewide research tool to better understand Pennsylvania patient
knowledge, perceptions and expectations on specific issues such as
organ donations and advance health care directives. Furthermore,
visitors to the website can review the latest medical research stories
through a special medical news feed.
While the website is geared towards medical students, residents
and practicing physicians of all ages, www.goodmedicine.org also
can help both high school and college students decide whether or
not to pursue a medical career.
The new website also helps patients by providing links to its
companion website at www.myfamilywellness.org and its health
tools, tests and stories.
Five years have passed since Matthew and Laura started
their footwear program. What are they up to now?
Matt is entering his junior year at the University of
Notre Dame and will spend the year studying at Oxford
University in England. Laura just graduated from North
Allegheny High School and is starting as a freshman at
Notre Dame.
Physicians and professional leaders seem to agree that
community participation is an important professional role
for physicians. In what way has your involvement with the
shoes for the needy program helped you to be a better
physician?
I don’t really think this program makes me a better
physician. I would like to think that I am a good person
and a good doctor, and that is why I volunteer. I know
that the 40 or more physicians around the country who
help us put on these programs are all good people to
start with, and that is exactly why they help.
466
The Institute for Good Medicine at the Pennsylvania Medical
Society strives to help patients and doctors by promoting healthy
practices. For the public, through The Patient Poll, the Institute
explores a variety of health issues to measure patient knowledge
and concerns to give them a voice in health care. For physicians
and medical students, the institute addresses issues related to
professionalism, including volunteerism and mentoring.
Thank you for your time, Dr. Conti. Is there anything else
you would like our readers to know?
Just that we all appreciate any kind of support
someone is willing to give, including prayers, well wishes
and donations. They can reach me at sconti@wpahs.org
or can visit our website at www.heartstosoles.com.
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Ms. Smith is managing editor of the ACMS Bulletin; she can be
reached at lsmith@acms.org or (412) 321-5030.
SPECIAL REPORT
Remodel Your Home Insurance
Before Remodeling Your Home
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omeowner spending on remodeling projects is
projected to increase by 44 percent between
2005 and 2015, according to a recent Harvard
University study. Yet, as you plan that kitchen upgrade
with new cabinetry, tile and appliances, remember
to also remodel your home insurance policy.
Your property insurance limits are
tied to your home’s replacement
cost—the amount needed to rebuild
your home with the same quality and
type of materials in the event of a total
loss—and not its market value. If you
live in a region currently experiencing
a cool real estate market, your home’s
market value may have diminished;
however, this does not mean the cost
to rebuild the home after a loss will
necessarily be less.
Many insurers have developed tools to help you
determine a proper replacement cost estimate and also
offer a low-cost endorsement (an amendment attached
to your insurance policy) that, in the event of a total
loss, offers additional coverage up to 120 percent of your
policy’s coverage amount.
Homeowners should review their home insurance
coverage on a yearly basis, and it is especially important
to do so before beginning any home improvement
project. Increasing your coverage before renovations
begin will protect you from the costs of repairing or
rebuilding damage to the new addition. Your home’s
replacement cost estimate should also reflect the price of
the building materials and labor associated with residential construction in your community. This, of course,
tends to fluctuate due to inflation and other factors, so
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be sure to ask your insurer if it offers inflation protection
coverage. This coverage, which automatically adjusts
your policy limits to keep pace with inflation, is usually
free.
Whether you are renovating that master bath,
bumping out a dormer or adding a three-season
porch, be sure a complete home insurance
review is on your checklist. However, adjusting
the coverage limits of your policy isn’t
limited only to major renovations. Any
special changes to your home might
make your protection inadequate,
such as finely crafted doors, moldings
and countertops, uniquely pitched or
vaulted ceilings or stained glass
windows.
Or, if a home improvement project isn’t in the near
future but you haven’t reviewed your home insurance
policy in the past year, call your insurance agent for a
professional consultation on your limits and endorsements, and to make sure that you are receiving all the
discounts available to you.
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Information in this article was provided by Liberty Mutual, Allegheny
County Medical Society’s endorsed vendor for automobile and home
insurance. For more information on this member benefit, call Angelo
DeNardo at (412) 859-6605, Ext. 51902, or visit
www.libertymutual.com/lm/acms.
REFERENCE
Foundations for Future Growth in the Remodeling Industry. Joint
Center for Housing Studies press release, Harvard University.
Feb. 8, 2007.
1
467
ACMS BOARD OF DIRECTORS
Dr. Adam J. Gordon, board chair,
called to order a meeting of the ACMS
Board of Directors at 6:10 p.m. on
June 9. Prior to call-to-order, board
members gathered for their annual
group photo.
the MCare unfunded liability.
Without legislative action, this will
begin in 2010. MCare limits will be
decreased and will be replaced with
mandated higher private limits. This
assessment will continue until all the
unfunded liability is paid off. Even
r. Gordon welcomed Mr.
new physicians, who never received
Angelo DiNardo, executive
MCare coverage, will be forced to
sales representative from Liberty
pay premiums to eliminate the
Mutual Group, an ACMS endorsed
unfunded liability, a significant
vendor, who reviewed auto and
barrier to retaining physicians and
homeowner insurance products
attracting new physicians to practice
offered to members at group rates.
in Pennsylvania. The governor has
presented a three-year transition
MCare phase-out
plan. Physicians could see an inDr. Ralph Schmeltz, vice presicrease of 20 percent to 35 percent in
dent of the Pennsylvania Medical
their liability insurance. By 2013
Society, detailed PMS activities
physicians will be required to cover
concerning the MCare phase-out,
$1 million in liability insurance
providing a brief history on the CAT through the primary market and
Fund (now MCare), the current
private carriers. PMS and HAP have
situation and legislative actions in
proposed a five-year transition plan.
the state budget. He says there is a
Dr. Schmeltz noted that premilack of understanding by many in
ums in Pennsylvania are higher than
the legislature regarding the MCare
surrounding states. With an average
fund. The $700 million accumulated age of 49 for physicians in Pennsylin the Healthcare Provider Retention vania, only 6 percent of physicians
account is very attractive to the state are under the age of 35; 20 percent
of Pennsylvania with respect to
of the physicians surveyed do not
meeting its budget deficit, reported
plan to practice medicine in Pennto be $3.2 million. Governor
sylvania in the next five years; and
Rendell wants to use the money to
only two out of five physicians who
expand health coverage for the
complete their training in Pennsylvauninsured, but has indicated support nia stay here to practice.
for using a portion of the surplus
Physicians are asked to contact
fund to pay for MCare’s unfunded
their legislators (see www.acms.
liability, phase-out MCare and move org) to express the need to eliminate
all coverage to the private market.
the MCare fund over five years using
PMS and HAP support phase-out of the existing funds to help physicians
the fund, but actuaries recommend
and hospitals to transition coverage.
approximately $400 million will be
The goal is to retire the fund by
needed, compared to the governor’s
supporting the PMS and HAP plan
allocation of $128 million.
to phase out MCare and minimize
Current law (Act 13 of 2002)
the additional cost to physicians and
sets the phase out of MCare in
hospitals.
motion. Physicians and health care
providers will be required to pay for
468
D
Finance Committee
Reporting for the ACMS Finance Committee, Leo McCafferty,
MD, reviewed the 2008 reserve
portfolios’ financial performance,
noting the use of three separate
portfolio managers and a Vanguard
index fund. All of the portfolios
experienced losses in 2008, reflecting
the recession and broad economic
decline. However, the combined
performance was better than the
overall indices. The Board of Directors made no changes to the current
investment strategy, and the Finance
Committee will monitor the funds
monthly.
Action items
The medical society will promote
an upcoming Gateway Medical
Society medical conference.
The medical society will work with
Highmark to offer ACMS leadership an on-line continuing medical education course on cultural
competency.
At the request of ACMS President
Douglas Clough, the board will
submit suggestions on how best to
recruit employed physicians and
inquire what it is that employed
physicians need from ACMS.
The board will invite A. J. Harper,
president, Hospital Council of
Western Pennsylvania (HCWP),
to present the group’s economic
impact study at a future board
meeting. HCWP is currently
working on a correction of the
Area Wage Index that determines
hospital base payments from
Medicare. Wages for the Pittsburgh/Western Pennsylvania area
are lower than most rural areas,
but it is believed that data reporting and collection do not accurately reflect prevailing costs in the
BOARD OF DIRECTORS
area. HCWP is contacting federal
legislators seeking legislative
support for an increase in the wage
index for the 32-county area.
The Board of Directors approved
ACMS Pension Plan amendments
as presented by legal counsel to
comply with federal requirements.
The board asked anyone interested
in being nominated for the
PMSCO Board of Trustees to
notify the medical society. Dr.
Marc Schneiderman will be
nominated for another term. Also,
anyone interested in serving on the
PMS Executive councils and
commissions should notify the
medical society.
Executive director’s report
ACMS Executive Director John
Krah introduced Ann Miller, a
health policy and administration
major at The Pennsylvania State
University, who will spend the
summer working as an intern for the
medical society. Other items noted
by Mr. Krah include:
Along with Dr. Clough, he will
continue to meet with area hospital medical staffs.
ACMS will participate at the
upcoming resident welcoming
sessions at University of Pittsburgh
Medical Center and West Penn
mini-summit on Health Care
Allegheny Health System.
Reform was well attended, and
The ACMS Finance Committee
plans are underway for a fall
will prepare the 2010 budget in
summit on models of care. He
September.
noted that the current health care
Highmark has recently completed
actions in Washington will affect
some management restructure.
the group’s future actions.
ACMS contacts Augusta Kariys
PMS Trustee Paul W. Dishart,
and Drs. Don Fischer and Carey
MD, reported that PMS continues
Vinson will continue with their
to work with the governor’s office
relationship with the medical
on the MCare issue, and that PMS
society, although their responsibiliis working on the Good Samaritan
ties have changed slightly.
insurance coverage issue for
The ACMS Gala Committee will
volunteer physicians. Denise
meet on June 17.
Zimmerman has been named
The ACMS Foundation will meet
executive vice president of the
on June 23 to review 12 grant
Pennsylvania Medical Society.
applications.
Amelia A. Paré, MD, reported that
Legislative contacts will be made
PAMPAC is preparing to support
to achieve changes to the SustainJane Orie Melvin for Pennsylvania
able Growth Rate (SGR) payment
Supreme Court justice in the
formula in Medicare.
upcoming election and that it is
reviewing all the candidates for
Other business
governor. She encouraged the
Dr. Gordon announced the Call
Board of Directors to participate
for Nominations for ACMS
in PAMPAC.
Office, stressing the importance of
new leadership and asking board
This is a summary report. A full report is
members to suggest colleagues
available by calling the ACMS office at (412)
who would be a strong voice for
321-5030. Board meetings are open to
the society and its members.
members. If you wish to attend, contact the
Dr. Lawrence John noted that the society to receive a schedule and meeting
work of the Primary Care Work
agenda. The next regular Board of Directors
meeting is Tuesday, November 17, 2009.
Group is ongoing. A May 14
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The Gloria Carroll Team
www.gloriacarrollteam.com
Prudential Preferred Realty
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(412) 367-8000 Ext. 242
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469
CLASSIFIEDS
HELP WANTED
PHYSICIAN WITH ACTIVE/
or can activate PA license, any
specialty, for two half days per
month. Malpractice insurance
provided. Ideal for retired physician. 412-734-1100.
RADIOLOGISTS AND CARDIOLOGIST for sono interpretation. Med Health Services, a
high-technology, outpatient facility providing access to blood lab
testing, all modalities of diagnostic sonography and nuclear cardiology studies, is seeking a cardiologist and radiologist to
interpret sonography studies. The
ideal candidate will hold medical
licenses in PA, OH and WV. Persons interested should contact
Josephine C. Oria at 412-3737900 ext. 116 or josephineoria@
mhs-pci.com, or Sandy Sturkie at
412-373-7900, ext. 143 or
ssturkie@mhs-pci.com.
FOR LEASE
Towers. Previously clinic of a psychiatrist. 412-302-1943. e-mail:
tnn275@gmail.com.
FOR SUBLEASE
MD OFFICE ON PENN AVE
directly across from Children’s
Hospital interested in subletting
two days per week. 724-9350400 Margie.
Call
(412) 321-5030
today and place
your ad here!
ALLEGHENY COUNTY
MEDICAL SOCIETY
Box Replies:
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ACMS/box number
713 Ridge Avenue
Pittsburgh PA 15212
700 SQ FT of PRIME DOWNTOWN office space at Gateway
The medical society appreciates
and depends on its advertisers.
Please remember to tell them
you saw their ad in the Bulletin.
EXERCISE
DEMOCRACYS
GREATEST
PRIVILEGE.
x
VOTE ON NOVEMBER 3!
Tuesday
Nov. 3
Free classified ad on the world wide web!
www.
acms.
org
470
Place a classified advertisement in the BULLETIN
and your ad will also appear on the Allegheny
County Medical Societys website for the duration
of the advertisement at NO ADDITIONAL COST. Check
out your ad at http://www.acms.org. For more
information, call Linda Smith at (412) 321-5030.
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Phone: 800 445-1212, ext. 5551 or 717 802-2365
E-mail: kelliott@pmslic.com
WWW.PMSLIC.COM
800 445-1212
Exclusively sponsored by the
ALLEGHENY COUNTY MEDICAL SOCIETY
471
Malachy Whalen & Co., Inc.
Visit www.malachy.com
(412) 281-4050
(800) 343-5382
FAX (412) 261-5955
Why should you call us for insurance????
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♦ Low Cost: NO HASSLE!
We have low-cost term insurance that are the same
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♦ Easy Application Process: NO HASSLE!
Malachy Whalen
mw@malachy.com
Just complete and e-mail a simple request form and
we’ll go shopping for you!
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clarkw@malachy.com
www.malachy.com
Your ACMS
“No Hassle”
Insurance Source
endorsed by
Peggy McNamee
peggymc@malachy.com
Allegheny County
Medical Society