chester county medicine 2015 winter

Heritage That We Cannot Ignore f e a t u r e d o n p a g e 1 4PROTECTING PATIentS

SODIUM RESTRICTION: A TIME-HONORED DOGMA OR AN EVIDENCE-BASED PURSUIT?

IN CHESTER COUNTY FROM ONE-SIZE-FITS-ALL HEALTHCARE

THE ART

of

Chester County

Winter 2015

tips for finding aChildren’s Mental Health

Clinician

Spend 10 jazz- and blues-filled days and nights in the Greater Reading area! Over 120 scheduled events, plus great shopping and dining in one area, make the 25th annual Boscov’s Berks Jazz Fest your perfect spring getaway.

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NEW YORK VOICES AND THE READING POPS ORCHESTRA • BILLY COBHAM ‘SPECTRUM 40’ BAND FEATURING DEAN BROWN, GARY HUSBAND, RIC FIERABRACCI • GERALD ALBRIGHT

GOSPEL ACCORDING TO JAZZ CELEBRATION: KIRK WHALUM, YOLANDA ADAMS, KEVIN WHALUM, JOHN STODDART AND THE DOXA GOSPEL ENSEMBLE • MARC ANTOINE • ALEX BUGNON

STRINGS ATTACHED FEATURING LARRY CORYELL, JIMMY BRUNO, VIC JURIS, JACK WILKINS, JOE COHN • PHILADELPHIA JAZZ ORCHESTRA DIRECTED BY TERELL STAFFORD

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JUNIOR BAND • ANDREW NEU WITH CAROL RIDDICK, DAVID P STEVENS • DANCE HALL DOCS FEATURING BRENT CARTER • THE UPTOWN BAND FEATURING ERICH CAWALLA & JENIFER KINDER

GREG HATZA & TIM PRICE ORGAN QUARTET • PAT TRAVERS BAND • CRAIG THATCHER BAND • THE ORIGINAL GROOVEMASTERS • REGGIE BROWN AND BUNCH A FUNK

THE ROYAL SCAM • DJANGOHOLICS ANONYMOUS: JOSH TAYLOR,CHRIS HESLOP, BILL NIXON, MICHAEL NIKOLIDAKIS, TREY LARUE • SAX SUMMIT: NATHAN BELLOTT, SETH EBERSOLE,

ANDY MOHLER, GREG WILSON • RANDY HANSEN • CELEBRATE SINATRA: LOU DOTTOLI AND THE SOUNDS OF SUNNYBROOK DANCE BAND • U.S. ARMY JAZZ AMBASSADORS AND MORE!*

* LINEUP AS OF 11/26/14. SUBJECT TO CHANGE

James Hunter

Six Dave Koz

Terell Stafford

Incognito

Wynton Marsalis

Yolanda Adams

Boney James

Brian Culbertson

Follow us on Twitter@berksjazzfest

April 10-19, 2015Reading, PA

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PROUD SPONSOR OF THE BOSCOV’S BERKS JAZZ FEST

Spend 10 jazz- and blues-filled days and nights in the Greater Reading area! Over 120 scheduled events, plus great shopping and dining in one area, make the 25th annual Boscov’s Berks Jazz Fest your perfect spring getaway.

For tickets, call Ticketmaster toll free at 1-800-745-3000 or visit www.ticketmaster.com to order online.

JAZZ AT LINCOLN CENTER ORCHESTRA WITH WYNTON MARSALIS • DAVE KOZ • INCOGNITO • BRIAN CULBERTSON • DIANNE REEVES • BONEY JAMES • PIECES OF A DREAM

MINDI ABAIR & THE BONESHAKERS WITH SWEETPEA ATKINSON • THE SOUL OF JAZZ FEATURING JEFFREY OSBORNE, NAJEE, MAYSA, NICK COLIONNE, GERALD VEASLEY, BRIAN SIMPSON

NEW YORK VOICES AND THE READING POPS ORCHESTRA • BILLY COBHAM ‘SPECTRUM 40’ BAND FEATURING DEAN BROWN, GARY HUSBAND, RIC FIERABRACCI • GERALD ALBRIGHT

GOSPEL ACCORDING TO JAZZ CELEBRATION: KIRK WHALUM, YOLANDA ADAMS, KEVIN WHALUM, JOHN STODDART AND THE DOXA GOSPEL ENSEMBLE • MARC ANTOINE • ALEX BUGNON

STRINGS ATTACHED FEATURING LARRY CORYELL, JIMMY BRUNO, VIC JURIS, JACK WILKINS, JOE COHN • PHILADELPHIA JAZZ ORCHESTRA DIRECTED BY TERELL STAFFORD

REMEMBERING JOE SAMPLE: BOBBY LYLE, WILTON FELDER, RAY PARKER JR., JEFF BRADSHAW, NICHOLAS SAMPLE, LIONEL CORDEW, LIZ HOGUE • BRIAN BROMBERG

NICK COLIONNE • JAZZ ATTACK: RICK BRAUN, PETER WHITE, EUGE GROOVE, ELLIOTT YAMIN • MARION MEADOWS • PAUL TAYLOR • JAZZ FUNK SOUL: CHUCK LOEB, JEFF LORBER,

EVERETTE HARP • FOURPLAY: BOB JAMES, NATHAN EAST, HARVEY MASON, CHUCK LOEB • KIND OF NEW: JASON MILES, INGRID JENSEN, RAY RODRIGUEZ, MIKE CLARK, JERRY

BROOKS PLUS SPECIAL GUESTS LIONEL LOUEKE, GARY BARTZ • PAT MARTINO TRIO WITH PAT BIANCHI, CARMEN INTORRE • LIVE AT THE FILLMORE: TRIBUTE TO THE ORIGINAL ALLMAN

BROTHERS • URBAN JAZZ COALITION • TOMMY KATONA & TEXAS FLOOD • FRANK VIGNOLA & VINNY RANIOLO • THE JOST PROJECT: TONY MICELI, PAUL JOST, KEVIN MACCONNELL,

ANWAR MARSHALL • ROYAL SOUTHERN BROTHERHOOD FEATURING DEVON ALLMAN, CYRILL NEVILLE, CHARLIE WOOTEN, YONRICO SCOTT, BART WALKER • JAMES HUNTER SIX • MIKEY

JUNIOR BAND • ANDREW NEU WITH CAROL RIDDICK, DAVID P STEVENS • DANCE HALL DOCS FEATURING BRENT CARTER • THE UPTOWN BAND FEATURING ERICH CAWALLA & JENIFER KINDER

GREG HATZA & TIM PRICE ORGAN QUARTET • PAT TRAVERS BAND • CRAIG THATCHER BAND • THE ORIGINAL GROOVEMASTERS • REGGIE BROWN AND BUNCH A FUNK

THE ROYAL SCAM • DJANGOHOLICS ANONYMOUS: JOSH TAYLOR,CHRIS HESLOP, BILL NIXON, MICHAEL NIKOLIDAKIS, TREY LARUE • SAX SUMMIT: NATHAN BELLOTT, SETH EBERSOLE,

ANDY MOHLER, GREG WILSON • RANDY HANSEN • CELEBRATE SINATRA: LOU DOTTOLI AND THE SOUNDS OF SUNNYBROOK DANCE BAND • U.S. ARMY JAZZ AMBASSADORS AND MORE!*

* LINEUP AS OF 11/26/14. SUBJECT TO CHANGE

James Hunter

Six Dave Koz

Terell Stafford

Incognito

Wynton Marsalis

Yolanda Adams

Boney James

Brian Culbertson

Follow us on Twitter@berksjazzfest

April 10-19, 2015Reading, PA

berksjazzfest.com

PROUD SPONSOR OF THE BOSCOV’S BERKS JAZZ FEST

Gateway Medical Associates, Chester County’s largest independent physician practice, has been serving our community since 1996. Gateway strives to provide the highest quality primary and specialty care with a focus on our patients’ wellbeing and health.

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Chester County Medicine is a publication of the Chester County

Medical Society (CCMS). The Chester County Medical Society’s mission

has evolved to represent and serve all physicians of Chester County and

their patients in order to preserve the doctor-patient relationship, maintain safe and quality care, advance the practice of medicine and enhance

the role of medicine and health care within the community, Chester

County and Pennsylvania.

The opinions expressed in these pages are those of the individual

authors and not necessarily those of the Chester County Medical Society. The ad material is for the information

and consideration of the reader. It does not necessarily represent an

endorsement or recommendation by the Chester County Medical Society.

Chester County Medicine ispublished by

Hoffmann Publishing Group, Inc.,Reading PA 19608

HoffmannPublishing.com For advertising information,

contact Karen Zach610.685.0914

[email protected]

2013-2016CCMS OFFICERS

PresidentWinslow W. Murdoch, MD

President-Elect

Mian A. Jan, MD, FACC

Vice PresidentBruce A. Colley, DO

Secretary

David E. Bobman, MD

TreasurerLiza P. Jodry, MD

Board Members

Mahmoud K. Effat, MD

Heidar K. Jahromi, MD

John P. Maher, MD

Charles P. McClure, MD

Susan B. Ward, MD

Chester County Medicine is published by Hoffmann Publishing Group, Inc. Reading, PA I HoffmannPublishing.com I 610.685.0914 I for advertising information: [email protected]

WINTER 2015Contents

w w w . c h e s t e r c m s . o r g

Features

Heritage That We Cannot Ignore

24 Tips for Finding a Children’s Mental Health Clinician

From Fly Fishing to the Operating Room

18

14

In Every Issue

8 The MOC Debate Hits Home10 Ensuring Better Health for Healthcare Professionals11 The Importance of Adding Fiber to Your Diet 12 JNC 8: Is a 150/90 BR Target Justified?22 In Appreciation of a Life: Discoverer of Lyme Disease Organism26 Lack of Exercise Is the Primary Link to Obesity28 CCMS Membership: Resources You Need

6 President’s Message20 The Art of Chester County 30 Membership News & Announcements

C H E S T E R C O U N T Y 6 M E D I C I N E


Patient-generated data (PGD) and information sharing is going through an epic transformation that is beginning to

impact the doctor-patient relationship. In the recent past, empowered patients were limited to health information provided by family and friends, and resources like the Merck Manual Home Edition. Biometric data was primarily limited to a home scale, thermometer, home blood pressure cuffs, and when appropriate, finger stick glucose meters. Today, not only is the amount of medical consumer information endless, for better or worse, via the Internet, but actual sharing of biometric data is going through a revolution. The “Quantified Self” movement is hot, as seen in the sale of Fitbit, Jawbone, and other devices during the 2014 holiday season. Pew Internet Research reports that 21% of all adults now use technology to track their own activities for exercise or fitness. Heart rhythm monitoring (AliveCor); ear exams via smartphone attachments; smart watches that can continuously monitor blood pressure or blood oxygen concentration; wearable sensors that continuously track blood glucose, physical activity, number of bites taken, sleep quantity and quality, cardiac output and stroke volume; and a wide array of routine lab data through smartphone device attachments are available now or on the immediate horizon. The Internet of Things envisions a world in which the physical world is becoming one big information system. Many of these technologic advancements, once FDA approved, are being marketed directly to the consumer. Their messages convey that by using their product to measure and share, the consumer’s doctor will be more able to actively monitor and advise care, contextualized by the

President’s Message

A NewBeginningperson’s real-world experiences and environment, thereby improving outcomes. Neither patients nor doctors have ever had such information before. For sure, that’s… empowering? Our connected, “on-demand” culture is rapidly evolving. The market is constantly adding

conveniences such as the Uber app to summon a car, online shopping with next day delivery almost anywhere, mobile banking, online socializing, and even ordering groceries for delivery at a convenient time for the customer. Expectations of immediate access and service on demand 24/7 are becoming the norm. Urgent care clinics, retail pharmacy, and department store clinics are springing up everywhere to meet the perceived need for convenient access for problems that patients self-triage as simple. Home telemedicine consultations with large hospital systems will also take a bite of this convenience apple. Care is increasingly being provided by anonymous “providers” who are not responsible for the long-term care of patients.

PGD: Addressing the Concern

Hopefully, some of this PDG, and the associated algorithms that are developed, will improve clinical outcomes and enhance care efficiency. Realistically, most have not been clinically evaluated in communities of patients, and with their direct to consumer marketing, will become problematic for those who provide longitudinal care for these patients. I think I am safe in saying that physicians are concerned about this PGD movement. Will the data be accurate or misleading? Reviewing PGD will add significant time to many patient interactions. By and large, we have no evidence


W I N T E R 2 0 1 5

that applying this new continuous PGD will lead to improved outcomes. In fact, it could lead to patient harm from overtreatment. There are inevitable unintended consequences, side effects, and known complications to many interventions. We would feel compelled to initiate treatment because “the machine that goes ping” shows actionable data that is not reflected in our current treatment guidelines or clinical experience. How will we deal with our patients filling electronic medical records with a torrent of data for guidance? Or will the computer algorithms built into these devices bombard us with false or unnecessary alarms as we have experienced with electronic prescribing? These are just some of the relevant questions that will need to be addressed by regulatory oversight, software programming, and collaboration with doctors, you know, the ones who take longitudinal ownership of the PGD, and partner with their patients within the medical community. We have an opportunity, while early in this development cycle, to become a part of the process. Alternatively, we can sit back and receive truckloads of PGD, not vetted for clinical decision making. Developers often begin by collaborating with teaching institutions. To expand to the larger population, most need the guidance

Murdoch

of those practicing in the community to make their creations a reality. If we, as organized practicing physicians, collaborate with the developers of these new technologies, and with patients who might need them, the quality of the data received will be more prescriptive and directly beneficial. In order to make a difference, practicing physicians need to expand their involvement in organized medicine. Opportunities are more likely to come through local and state organized medicine channels. Again I invite you to reach out, get involved, and be on the front of this emerging paradigm shift through participating in projects beyond your immediate scope of practice. I hope, if given the opportunity, you will help guide this evolving and exciting revolution for the betterment of our patients. These topics will soon become a major focus of organized medicine. I invite you to get involved early in this transformational process.

Winslow W. Murdoch, MD, practices family medicine in West Chester. He is president of the Chester County Medical Society. Contact Dr. Murdoch at [email protected].

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Chester County Hospital


the MoC debate Hits Home

Rarely does an issue simultaneously instill great passion and considerable angst for physicians at the level that we are seeing for the American

Board of Medical Specialties’ (ABMS’) Maintenance of Certification™ (MOC). Most physicians will concede that the expressed intent of MOC is appropriate: to ensure the patient community that physicians are continuing to assess and improve their knowledge and capabilities after graduate medical education (GME) training. It goes without saying that physicians are committed to lifelong learning and continuous improvement. However, this same group also contends that the current processes and practices in place across the various specialty boards are cumbersome, costly, and significantly cutting into their time with patients. Of the four components of MOC — (I) licensure and professional standing, (II) lifelong learning and assessment, (III) cognitive exam, and (IV) practice performance assessment — the exam and the practice performance assessment appear to be the areas of greatest concern. The exam component, in particular, has been under a great deal of scrutiny. Input we’ve received from Pennsylvania Medical Society (PAMED) members thus far indicates that it is viewed as an uncertain measure of a physician’s actual skill in his or her specialty and is punitive. Consequently, many fear that failing the exam will result in a loss of privileges at hospitals, insurance reimbursements, network participation, and possibly even employment. PAMED has formed a Task Force on Continuous Professional Education to examine MOC in its current form and the concerns circulating throughout the state and to seek input from Pennsylvania’s physicians. The goal: reshape MOC, in whatever future form it might take, into a process of continuous learning and improvement based on evidence-based guidelines, national standards, and best practices that is relevant to what a physician actually does within his or her practice of medicine and one that


Features

enhances, rather than impedes, the care of patients. Delegates at the 2014 House of Delegates meeting, held October 17-19 in Hershey, debated the merits of the task force’s initial recommendations, as well as other resolutions and reports related to MOC. One of the documents developed by the task force and adopted by the PAMED Board is a Maintenance of Certification Statement of Principles which outlines PAMED’s position on what MOC should be:

• PAMEDiscommittedtolifelonglearning,cognitive expertise, practice quality improvement, and adherence to the highest standards of medical practice. • PAMEDsupportsaprocessofcontinuouslearning and improvement based on evidence-based guidelines, national standards, and best practices, in combination with customized continuing education. • TheMOCprocessshouldbedesignedtoidentify performance gaps and unmet needs, providing direction and guidance for improvement in physician performance and delivery of care. • TheMOCprocessshouldbeevaluatedperiodically to measure physician satisfaction, knowledge uptake, and intent to maintain or change practice. • Boardcertificatesshouldhavelifetimestatus,with MOC used as a tool for continuous improvement. • TheMOCprogramshouldnotbeassociatedwith hospital privileges, insurance reimbursements, or network participation. • TheMOCprogramshouldnotberequiredfor Maintenance of Licensure (MOL). • Specialtyboards,whichdevelopMOCstandards, may approve curriculum, but should be independent from entities designing and delivering that curriculum, and should have no financial interest in the process.

BY LESLIE HOWELL


• Amajorityofspecialtyboardmemberswhoare involved with the MOC program should be actively practicing physicians directly engaged in patient care. • MOCactivitiesandmeasurementshouldbe relevant to real world clinical practice. • MOCprocessshouldnotbecostprohibitiveor present barriers to patient care.

The delegates also asked that several items be referred to the AMA:

• WorkwiththeABMStoeliminatepractice performance assessment modules as currently written from the requirements of MOC. • Developanddisseminateapublicstatement,with simultaneous direct notification to the American Board of Internal Medicine (ABIM) and other ABMS-sponsoring boards, that their current MOC program appears to be focused too heavily on enhancing ABIM revenues and fails to provide a meaningful, evidence-based, and accurate assessment of clinical skills. • Investigateand/orestablishalternativepathwaysfor MOC.

W I N T E R 2 0 1 5

• ReportbacktotheHouseofDelegatesatthe Annual AMA Meeting in June 2015.

The delegates also recommended that PAMED ask the AMA to revoke its support for MOC if no action is taken by the ABMS in working with the AMA to make MOC requirements less onerous. PAMED will continue to support efforts to create a reasonable and economical assessment process that provides physicians with the information necessary to improve the quality and efficiency of their practices. PAMED is pleased that on February 3, 2015, as a result of input from the Society and other stakeholder groups, the ABIM announced major changes to its MOC program. PAMED will work aggressively to ensure that the ABIM’s final product is consistent with our principles for continuous improvement and lifelong learning. For more information on PAMED’s Task Force on Continuous Professional Education or next steps on MOC, please email Scot Chadwick at [email protected] or call Scot at (717) 558-7814.

Leslie Howell is director of CME, training, and physician leadership programs for the Pennsylvania Medical Society.

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Howell


The Pennsylvania Physicians’ Health Programs (PHP), part of The Foundation of the Pennsylvania Medical Society,

helps individuals suffering from addiction or work-related stress. PHP monitors a variety of healthcare professionals (HCPs)—physicians, physician assistants, dentists, dental hygienists, expanded function dental assistants, and medical students, when necessary. The process of assisting HCPs might be broken down to evaluation, treatment, monitoring, and advocacy. The process of referral to PHP and evaluation is a step to ensuring better health for HCPs.

Professionals are referred to PHP through many sources. We receive referrals from spouses, friends, co-workers, and employers as well as self-referrals. There has been a recent increase in the number of referrals from the Board of Medicine caused by a history of driving under the influence (DUI). These referrals occur when the applicant checks a box on the application/renewal form indicating a history of a DUI. Alternatively, the HCP may be reported to the Board of Medicine by JNET. JNET is a web-based information sharing portal for agencies in the Commonwealth of Pennsylvania. This sharing of information regarding DUI arrests has led to an increase in referrals from the state to PHP. When the PHP receives a referral for a HCP with a possible problem, the HCP is referred to an independent

evaluator. The PHP staff obtains the appropriate releases so that we may report back to the referral source. Our case managers always strive to give the HCP a choice of evaluators that are suited to his or her individual circumstances. The evaluator will interview the HCP, perform drug tests, and obtain information from collateral sources. If no impairment is diagnosed, the PHP will notify the referral source and the individual referred of the outcome. When the referral comes from the State Board, the HCP’s license will be issued and no PHP monitoring will be required. If a substance abuse or psychiatric problem is defined, then the physician or HCP is given a choice of treatment centers suited to his or her problem. Depending on the complexity of the case, an evaluation may take anywhere from one to five days. Evaluations can be an expensive and time-consuming endeavor, but they are an essential step in assisting HCPs in need. The PHP prefers to work with evaluators and treatment centers with experience in dealing with HCPs. We have no affiliation with particular centers or financial conflicts of interest. Whenever possible, the PHP offers a choice of clinicians to support the HCP’s autonomy. For more information regarding the treatment process for HCPs with substance abuse and psychiatric diagnoses, email us at [email protected]. For counseling or referral service, call the Physicians’ Health Programs at 800-228-7823. PHP is a program of The Foundation of the Pennsylvania Medical Society that provides programs and services for individual physicians and others that improve the well-being of Pennsylvanians and sustain the future of medicine. Visit us at www.foundationpamedsoc.org.

Jon Shapiro, MD, is medical director of Pennsylvania Physicians’ Health Programs.

Ensuring Better Health for Healthcare Professionals


Features

BY JON SHAPIRO, MD


Many health problems can be prevented or treated by the addition of fiber to your regular diet and thereby “normalizing” bowel function. In certain

circumstances, people experiencing diarrhea and those with constipation can benefit from fiber as can those with “regular” bowel habits. The addition of fiber to the diet has been shown to lower serum cholesterol, decrease the cramps and pain associated with irritable bowel syndrome (or so-called “spastic colitis”), prevent the development of diverticulosis and diverticulitis, and perhaps, even prevent colon cancer. The addition of fiber to the diet can also decrease or prevent the development of anal fissures and decrease or prevent the development of symptoms from hemorrhoids and brim irritation. The proper amount of fiber in the digestive tract makes it easier for the intestines to function properly. As an indication of how fiber works, try this: place one finger from your left hand in the palm of your right hand and try to squeeze it as hard as you can. Now, place three fingers from your left hand in the palm of your right hand and squeeze. Notice how much easier it is to squeeze by adding more “bulk.” This shows how adding more fiber to your diet works for your intestines.

I recommend people get 30 – 40 grams of fiber each day. The amount of fiber required differs for each person, but the goal is to have soft, well-formed, somewhat bulky stools that are easy to pass. It is also important to consume enough fluid along with the fiber to create the proper stool consistency. If your stools are too hard, add fluid; if too loose, add fiber. There are many foods that are high in fiber per serving, such as beets, beans, peas, sweet potatoes, figs, blackberries, pears, raspberries, strawberries, whole grain breads, and bran cereals. If you find you have trouble adding high-fiber foods to your diet, I often recommend supplements like Benifiber, FiberCon, and Konsyl. Remember, your goal should be to always have “regular” bowel movements, so keep eating fiber to maximize its many health benefits.

A. Gerald Frost, MD, is a board-certified colon and rectal surgeon and a fellow of the American Society of Colon and Rectal Surgeons. He is a member of the medical staff at Phoenixville Hospital.

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Features

The Importance of Adding Fiber to Your Diet

BY A. GERALD FROSt, MD, FASCRS

Frost



Features

Epidemiological studies have demonstrated a strong, graded relationship between

increased blood pressure and risk of cardiovascular disease. The risk of these adverse events appears to begin at around 120/80 mmHg. Randomized clinical trials have failed to justify targeting BP goals to these low levels, particularly in the general population. In fact, the 2014 Evidence-based Guideline for the Management of High

Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) have recommended a BP target less than 150/90 for the general population over age 60.1 This stands in opposition to competing hypertension guidelines published in 2014 that set the target BP for the general population at less than 140/90. The recommendation by JNC 8 for a higher BP target within the general population has sparked considerable debate among the medical community. Is the higher BP target proposed by JNC 8 justified? The evidence for reducing BP less than 150/90 in individuals over age 60 within the general population is robust. Three studies (HYVET, Syst‐Eur, and SHEP) examined the cardiovascular (CV) benefit of reducing BP to less than 150/90 in people over age 60 within the general population.2,3,4 Cerebrovascular morbidity and/or mortality were the primary outcomes in each of these trials. HYVET and Syst‐Eur had systolic blood pressure goals of less than 150 mm Hg. The systolic blood pressure goal in SHEP ranged from 140-159 mmHg. In all three trials, cerebrovascular morbidity or mortality was significantly reduced when participants were treated with antihypertensive medications to a systolic blood pressure goal of less than 150 mmHg. In SHEP and Syst‐Eur, combined fatal and non‐fatal stroke were reduced by 36% (p=0.0003) and 42% (p=0.003), respectively. In fact, HYVET was stopped early

because of a 21% reduction in mortality in the treatment group. Conversely, the evidence that more aggressive BP reduction (below 140/90) will reduce CV events in individuals over age 60 is not impressive. Of the available studies, JNC 8 found only 2 studies to be of sufficient quality. JATOS compared SBP goal of less than 140 mmHg to a goal of 140-160 mmHg in adults age 65-85.5

VALISH compared a SBP of less than 140 to a goal of 140-149 in adults age 70-85.6 The primary outcomes were cardiovascular and renal events. In both studies, a lower BP target did not reduce CV and/or renal events. The panel did recognize the limitations of these studies. First, the studies were performed in Japan, which makes the applicability of the study results dubious. Second, the follow-up time of approximately 2 years in both studies may have been too short to detect meaningful changes in the outcomes. Although the decision was not unanimous, the panel majority ruled that the lack of benefit, rather than low level data, was responsible for the study outcomes. Consequently, the JNC 8 panel found no justification for a lower target BP beyond 150/90. Some have speculated that raising the BP target in the general population over age 60 will lead to less stringent BP control, and, ultimately, accelerate the rate of CV events in a high-risk population. Proponents of the new guideline feel that raising the BP target will reduce the risk of adverse drug events in a susceptible population without appreciable impact on cardiovascular disease (CVD) risk. An ongoing clinical trial may help establish the most appropriate BP target in this population. The SPRINT trial is a multi-centered, randomized trial that is currently underway. SPRINT will randomize about 9250 participants aged ≥ 55 years with SBP ≥130 mmHg and at least one additional CVD risk factor.7 The trial will compare the effects of randomization to a treatment program of an intensive SBP goal (less than 120) with randomization to a treatment program of a standard goal (less than 140).

JNC 8: Is a 150/90 BP Target Justified? BY MICHAEL R. LAttANZIO, DO


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Lattanzio

Currently, a target BP less than 150/90 in the general population over age 60 can be supported by sound clinical trial evidence. Conversely, the data to justify a target BP less than 140/90 within the general population over age 60 is more dubious. Hopefully, ongoing clinical trials will elucidate which BP target provides the greatest benefit in CV events within this population. Until that time, physicians should incorporate the latest body of scientific evidence into a therapeutic plan that suits each patient with close surveillance of treatment efficacy and safety. Clinical practice guidelines are not intended to be firm rules, and the clinical judgment of the physician remains pivotal in the treatment and eventual outcome of any blood pressure reduction strategy. References

1James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.2Beckett, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-1898.3Staessen JA, Fagard R, Thijs L, et al; The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350(9080):757-764.4SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265(24):3255-3264.5JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31(12):2115-2127.6Ogihara T, Saruta T, Rakugi H, et al; Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: Valsartan in Elderly Isolated Systolic Hypertension Study. Hypertension. 2010;56(2):196-202.7https://clinicaltrials.gov/ct2/show/NCT01206062Systolic Blood Pressure Intervention ttriaTrial (SPRINT) :https://clinicaltrials.gov/ct2/show/NCT01206062https://clinicaltrials.gov/ct2/show/

Michael R. Lattanzio, DO, is a clinical nephrologist and hypertension specialist with Clinical Renal Associates of Chester County.

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My introduction to the Chester County Historical Society (CCHS) occurred many years ago when I took my three

boys, Gibran, Kouresch, and Zarshawn, to the Society Museum. The kids were mesmerized by the pewter and clock exhibits, and I was fascinated by the manuscripts that told the history of Chester County. Later I learned about a gentleman by the name of Josiah Harlan, a Chester County Quaker whose life was portrayed in the 1888 novella by Rudyard Kipling and whose archives are preserved by the Chester County Historical Society. The Kipling book, titled The Man Who Would Be King, is based on the lives of Josiah Harlan and James Brook, an Englishman who became the first white rajah in Borneo. A partially fictionalized story depicted these two gentlemen traveling to Kafiristan, which straddles the area between Afghanistan and Pakistan, not too far from where I was born and spent my early life. Josiah Harlan was an adventurer who grew up in a Newlin Township farm with nine siblings. Josiah visited Pakistan and Afghanistan and became part of the highest echelon of their society when he was named the Prince of Ghor. The book was immortalized by the movie of the same name, made in 1975, with Sean Connery and Michael Caine playing the two adventurers. As I get older, I realize how important it is to preserve our heritage regardless of where we were born, remembering our history and the history of those that came before us by documenting their stories, their hardships, and their dreams. Our ancestors and those who were already indigenous to the area together make the

Heritage That We Cannot IgnoreBY MIAN A. JAN, MD


Features

“Trying to plan

for the future

without knowing

the past is like

trying to plant

cut flowers.”

— Daniel Boorstin


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United States the greatest country in the world. It is important to remember the brief history of the Chester County Historical Society. In 1893, Gilbert Cope, a Chester County historian, along with six men and four women established the initial charter of Chester County Historical Society. It is interesting to see that the society has always involved women in governance. At first the society meetings were held in a room in the West Chester Public Library on North Church Street. The society originally raised $95.49 from 46 persons who had paid the initiation fee and 34 of these who had paid their annual dues. Because of the small space available at the library, society meetings were moved to a room on the second floor, of what was then known as Normal School Library. At this time projects were created around the Native Americans and the early settlers. Under the leadership of Dr. Charles Philips, monthly meetings and annual banquets were held with a membership of 87 in 1907. After World War 1, in 1920, Dr. Philips died. Activities continued with The Honorable Frank Hause, a Chester County judge, chosen to lead the organization. The lack of space to house an exhibit and the ever-expanding collection continued to be a problem for the society as the years passed. In the 1930s a building committee looked at various options. Memorial Hall on High Street in uptown West Chester was bequeathed by Mrs. Uriah Painter and was rebuilt to become the future home of the historical society. The condition of the bequest was that the society could not occupy the building until after the death of the last member of the Grand Army of the Republic (GAR), who used the building (which happened in 1937). Isabel Darlington, chair of the Finance Committee, was instrumental in helping to raise the money needed. Memorial Hall officially opened on February 28, 1942. From 1937 to 1951 Dr. Francis Harvey Green served as president of the Chester County Historical Society. In May 1945 the society had 590 active members. The 1950s saw consistent growth in membership. In 1951 there were 902 members with an annual budget of $7520.00. Costs usually outweighed the funds collected. At one time the treasurer reported $196.00 in the general fund and 13 cents in petty cash. In 1960, under the leadership of Dr. James, a landmark step was taken to create a women’s organization, Mrs. Ball was designated in charge of this group. In the 1960s membership exceeded 1,000 individuals, making Memorial Hall now inadequate for exhibiting and storing the society’s holdings. Dr. James retired as president in 1967, and George Norman Highley, a banker, succeeded him as the president. Another important year for the society was 1974 when Barclay Rubincam was the subject of a popular exhibition and more importantly the society’s board approved the funds for the expansion of the facility. Congressman Ware served as chair of this funding committee. Roland Woodward, a native of Chester

Jan

Gilbert Cope

Dr. Francis Harvey Green

West Chester Public Library

West Chester Opera House

Ribbon Cutting

Memorial Hall



Features

County, was executive director of the Society. The society’s annual budget reached almost $500,000 in 1985-1986. There were several successful exhibitions during the 1980s; including the “Historic Signs” exhibit in 1985, “Silver” exhibit in 1986, “Pewter” exhibit in 1987, and “Quaker Clothing” exhibit in 1990. Also, in 1988 an important exhibit of nationally known Chester County native painter, Horace Pippin, was held. In 1992 a capital fund drive, with a goal of $4 million, was set. By mid-1994 the amount of $4.8 million was reached. The grand opening celebration occurred on April 29, 1995. The current historical society is 56,000 square feet with a dramatic 250-seat auditorium. The Chester County Historical Society has grown considerably under the robust leadership of President Rob Lukens and a volunteer board of trustees, led by Chairman George Zumbano. The organization is continuing old traditions but also

PLAn YOuR ViSiT

Who: Plan to immerse yourself in Chester County’s history by visting the Chester County Historical Society (CCHS).

Where: The History Center225 n. High StreetWest Chester, PA 19380-2658610.692.4800

When: Hours of operation are Wednesday – Saturday from 9:30 a.m. to 4:30 p.m.

What: The History Center houses CCHS’s museum, library and photo archives.

How: Learn more at CCHS’s website, www.chestercohistorical.org.

Barclay RubincamNorth New Street, West Chester

Collection of Drs. Amber and Mian Jan

Embroidered Globe

Mary Moore Heston


moving into the 21st century. Along with their mandate of preserving our heritage, the society is bridging cultures between those who came many generations ago with those who have arrived more recently from far flung areas like India, Pakistan, China, Eastern Europe, and the Middle East to this great country we live in. One needs to remember that it is our society, regardless of where one is from, and we are very interested in preserving heritage, regardless of race, sex, religion or ethnicity. Chester County Historical Society’s mission is guided by the tenets of relevance and sustainability and responsibility, to continue with the collections and exhibitions, but also the educational programs and outreach.

Mian A. Jan, MD, is a novice collector and an interventional cardiologist practicing in Chester County. He urges you to visit the Chester County Historical Society Museum and become a member.

Barclay RubincamWinter landscape with

covered bridgeCollection of Drs. Amber

and Mian Jan

Turks Head Tavern Sign

Chest of Drawers

Clocks

Jan

One of the great achievements of my surgical career came in the implementation of my procedure to repair iris defects.1 In the past, large iris defects

were considered to be more or less normal. Earlier techniques used these anomalies to remove cataracts through the pupil. As a refractive surgeon with an interest in optics, this particular defect always bothered me. Depth of field was effectively reduced because the pupil no longer constricted. It reminded me of a Nikon camera with an adjustable diaphragm that was half missing. When cataract surgery was done on eyes that required thick glasses or contacts to see, vision was improved with implantation of an intraocular lens. Terrible pupillary defects, however, were not addressed. I set about trying to repair them and found it very difficult. There was no safe and effective technique to repair these defects. Dr. Malcolm McCannel came up with a suture technique, which basically externalized the iris to sew it closed. This led to dialysis of the inferior iris, resulting in poor repairs. The solution to achieving an aesthetic iris repair was inspired by my interest in fly fishing. Under the tutelage of the late Ben Houser, MD, of Tamaqua, PA, a fantastic

From Fly Fishing to the Operating Room Reflections on Development of an

Iris Defect Repair Procedure


ophthalmologist, artist, woodworker and expert fly tier, I learned the art. This newly developed skill influenced me in creating a procedure that now bears my name. During a Wills Eye Hospital conference in Key West, I watched video of a cumbersome attempt to repair an iris defect. That day, I was out fishing for tarpon and had been tying some flies. It occurred to me that I could use the same “sliding knot” maneuver to develop a “closed eye” technique to repair irises. Thus the “Siepser Sliding Knot” was born. Immediately, a retinue of patients needing iris repairs presented. Many came from my senior associate, Dr. Edwin Tait, who had used sector iridectomies for years when he removed cataracts. I combined the placement of an intra-ocular lens with an iris repair and got spectacular results. These happy patients referred their friends to me. It was easy for them to spot the old “keyhole” pupil of people who had undergone cataract extractions before the Siepser Sliding Knot. Over the years, patients have traveled from all over the world to have me perform this technique. My operating suite has also welcomed many surgeons observing the procedure. Recently a lovely patient came from Missouri

BY StEVEN B. SIEPSER, MD, FACS


Features


with an entirely “blown” pupil, meaning the pupil was totally dilated and nonreactive. She found me via the Internet. I contacted her surgeon who kindly supplied photos, assisted me in her preparation, and agreed to do the follow up. A recent note from this patient describes the results:

I still get excited when I look into the mirror and see the green color of my iris. It was always difficult for me to look in the mirror and see a solid black eye looking back at me. The glare has been greatly reduced. For the first time in seven years I am able to go outside and not have to keep my eye closed. I am comfortable outside in the sun and can actually drive now without always having to wear really dark sunglasses. Also, my vision in that eye has improved. I am now able to see closeup book print, make out faces, and see details I couldn’t see before. My life has changed completely.

I wanted to teach this procedure but resistance to the idea of repairing iris defects stunned me. To this day I have colleagues who tell me these revisions are not needed. They operate on cataracts caused by trauma yet don’t repair any iris defects because they don’t know how. They say, defensively, that it isn’t needed. In 1996, I ran a course at the annual Wills Eye Conference in Philadelphia. Three people attended. Fast forward to 2012 when I headed up a course at the national American Society for Cataract and Refractive Surgery. Over 350 surgeons attended. It was very satisfying to see the interest but as a visionary, I have learned that time is needed for change to gain acceptance.

1 Steven B. Siepser, M.D., “The Closed Chamber Slipping Suture Technique for Iris Repair,” Annals of Ophthalmology (1994) 26:71-72

Steven B. Siepser, MD, FACS, is a practicing ophthalmologist in Chester County.

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Siepser

Ask a Physician:

If you have any medical questions for a physician member of the Chester County Medical Society, please submit an inquiry to [email protected] with “Ask a Physician” as the subject. Your question will be forwarded to a physician and may be featured with an answer in a future issue of the magazine.

150787 BF CC Medicine Ad.indd 1 1/22/15 11:02 AM


The Art of Chester County

BY BRUCE A. COLLEY, DO

Born and raised in Wayne, Lauren Acton initially trained at the Fashion Institute of Technology in New York City. Subsequently, she studied at the Pennsylvania Academy of Fine Art School for Advance Studies, and then received her master of

fine arts degree from Lesley College in Boston. Her genre is expressionistic (see winter barns) and impressionistic (see bridge). Lauren is accomplished in water colors, oil, and acrylic mediums. Her works have been shown extensively throughout Pennsylvania since 2007. Lauren continues to teach painting privately and at local art centers. Enjoy Lauren’s descriptions of her works. Anyone who has grown up in Chester County appreciates the barns that occupy the local landscape. They have been there for at least100 years, and many, 200 to 300 years. Each has its own personality, the sentinel of the neighborhood. We find over the years they become almost like friends, serene and reassuring as we drive past them each day. Lauren captures these peaceful icons in their winter dress using acrylic and oil. The Chesterbrook Bridge, rendered in the spring, reminds us that the winter environs will soon give way to glorious spring.

Bruce A. Colley, DO, is vice president of the Chester County Medical Society.

The Art of Chester County

(Above) “Chesterbrook Bridge, Chester County” is done in acrylic and is in Chesterbrook where I live. I have spruced it up a bit as it is a bit rusty but I have great memories of running over it with my young son.



“Paoli Barn, Chester County” is off of Route 252 down some back roads with many beautiful properties, a few of which are original 18th century main houses with barns. Some are preserved well and some need a little more help. I happen to prefer the more needy ones; there’s a spirit there that looks lived and worked in with plenty of stories to tell. This is another oil on a great property looking down to the brook.

“Lionville Barn, Chester County.” On my way to teach painting or fashion design at Art at 260 Park, an art center located near Marsh Creek Park, I drive past this barn in Lionville. This is painted in oil, my preferred medium. There are so many great barns out there. It can be hazardous when trying to photograph around cars and cows!

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Colley

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Dr. Wilhelm (Willy) Burgdorf was a man of many facets and skills—an entomologist, zoologist, bacteriologist, parasitologist, researcher, teacher, prolific author, and Swiss army soldier

for three years before coming to the United States. He passed away in mid-November in Hamilton, Montana, of complications of Parkinson’s disease at the age of 89. Dr. Burgdorf, while best known as an American scientist (he became a naturalized citizen in 1957), was born and educated in Basel, Switzerland. He took his undergraduate studies at the University of Basel and at the Swiss Tropical Institute in the same city. In 1951, on a U.S. Public Health Service fellowship, Dr. Burgdorf took a position as a research fellow at the Hamilton-based Rocky Mountain Laboratories of the U.S. National Institute of Allergy and Infectious Diseases. In 1957, he was admitted to staff as a medical entomologist, and proceeded to pursue his “destructive specialty of tick surgery,” the meticulous dissection of ticks to study the diseases they could spread. He was fascinated by the connections between animal and human diseases, particularly diseases spread by the bites of arthropod vectors, such as fleas, ticks, and mosquitoes. In 1982, in what he modestly admitted to be serendipitous, his earlier work on relapsing fever helped him to recognize the putative cause of the relatively newly described disease known as Lyme disease. He had had a discussion with Dr. Alan Steere, of Yale, whose research on cases of juvenile arthritis had described Lyme disease in the mid 1970s. Dr. Steere’s group had originally thought the cause was a tick-borne virus. However, while studying the Ixodes deer ticks, looking for the cause of an outbreak of spotted fever in New York, Burgdorf and a colleague came upon an unusual finding. As per Louis Pasteur’s aphorism (“Chance favors the prepared mind”), Dr. Burgdorf reported, “I recognized what I had seen a million times before.” They found spirochetes in one specific part of the ticks, the mid-gut. Until then, deer ticks had not been known to carry spirochetes, but testing proved him right, and the results were published in Science in 1982. Despite the many challenges and controversies in dealing with Lyme disease, Dr. Burgdorf ’s research was instrumental in advancing the efforts

In Appreciation of a Life w w w . c h e s t e r c m s . o r g

Features

Discoverer of

Lyme Disease Organism

Dr. Wilhelm (Willy) Burgdorf

BY JOHN P. MAHER, MD, MPH


at Lyme diagnosis and treatment which causes 20,000–30,000 cases per year in the U.S. alone. Ironically Dr. Burgdorf developed an eye infection from washing out the cages of lab rabbits that had been experimentally infected with the spirochetes. Within a few weeks, he developed “a typical bull’s-eye rash.” He was treated with antibiotics but, like many Lyme disease sufferers, he admitted he could not be sure it was beaten: “Who is there to prove,” he asked in 1991, “that I had it or that I did not have it? I just hope that it is gone and that one morning I do not wake up and find I cannot walk anymore. Where does the bug go? How does it behave? What causes the symptoms? How does it relate to the immune system? We don’t know. It’s still up in the air.”

While some critics feel this is a sign of anxiety, the CDC reminds us that 10-20% of patients treated with two to four weeks regimen of antibiotics will have lingering symptoms in what is now being called PTLD (post-treatment Lyme disease) syndrome. Dr. Burgdorf retired in 1986 after writing more than 225 scientific papers. He also received the prestigious Robert Koch gold medal for excellence in biomedical research and the Walter Reed medal of the American Society of Tropical Medicine and Hygiene. He was honored by having the organism named after him (Borrellia burgdorferi). He received many other honors in his lifetime including several honorary doctor of science degrees, and two honorary MD degrees (University of Bern, Switzerland, 1986; and the University of Marseilles, France, 1990).

John P. Maher, MD, MPH, is the former director of the Chester County Health Department and a long-time member of the Chester County Medical Society Board of Directors.

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Maher

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Three-year-old Sara comes in to my office, hiding behind her mother. She has been discharged from her third day care center for biting another child.

Since Sara’s baby brother was born a year ago, things have fallen apart for Sara and her parents who are mortified by her aggressive behavior. Kyle is a smart 11-year-old boy who has done poorly in school and now has begun fighting with and yelling at both his parents. His parents are in the process of separating. Nineteen-year-old Jen, an honor graduate from a superb private high school, barricaded herself in her room after her parents found out she failed all of her courses during her first semester at college. Alarmed at her bizarre behavior, her parents sought consultation. The Sandy Hook shooting, delinquency, increasing rates of suicide, and autistic spectrum disorder. Recently there have been loud alarms around children’s mental illness. Some might say that children’s well-being is the purview of parents and the family. The 40% of children living with divorce often are being less than adequately attended to in terms of their mental well-being as parents lose sight of their children in the divorce situation. Even in intact families, the home environment can be less than ideal, especially when parents are economically or emotionally stressed, or a child is out of control for no apparent reason. Pediatric Care

Pediatricians see these challenges every day. Most pediatricians are skilled and comfortable in the initial assessment. But what’s next? The difficulty with psychotherapy and mental health in general is that the basic research of the adult mind is difficult to do and does not yield the kind of data to which most scientists are accustomed. There are of course clinical trials supporting evidence-based therapies, but these trials do not begin to touch the variations encountered when dealing with the mind. When it comes to children’s mental health, however, there is good news. In the last 60 years, there has been an explosion of knowledge and understanding about

psychological development of the mind from infancy through adolescence. Consider the physical body in all of its manifestations from a newborn infant through all the ways and variations of growth to an adult body. The developing mind can be conceptualized in the same way. For example we know much about the mind of an infant, the ways it takes in the world, experiences itself and the world, how it organizes and protects itself psychologically. This functioning changes, grows, and develops in a predictable way with many variations, the same as the physical body. Within this complex abstract growth chart, one can trace various lines of development: affect regulation, the ability to relate to and communicate with others, self-esteem, sexuality and regulation of aggression, cognitive development, self-reflective thought, and the ability to tolerate frustration, loneliness, and the unknown. When these lines of development are synchronized and occur normative chronologically, the child is prepared to meet the normal developmental challenges. However, when the lines of development are not synchronized, for example when a child’s intellect far outpaces affect regulation, or when the environment presents challenges to the child for which he or she is not prepared, then mental well-being is disturbed and symptoms occur.

Finding a Mental Health Clinician

So where do you go when more is needed? Finding a well-trained mental health clinician in general, and a child mental health clinician in particular, is a challenge. Whereas for physicians, training has been standardized ever since the Flexner report in 1912, for mental health training, there is no such standardization of education. However, a few guidelines can be considered in looking for a mental health clinician. A bit of history will help put this in perspective. Psychotherapy, the talking cure, was first put forth by Sigmund Freud, a neurologist who established training guidelines that included didactics and mentoring, much as training residencies are in all of medicine. In addition, Freud specified that the student


Features

tips for finding a Children’s Mental Health Clinician

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had to subject himself to the psychotherapy process. The purpose of this was that the student experience his own mind and begin to work with the mind. This was part of training the mind since the mind itself is the instrument of the psychotherapy process. Of course much has happened since Sigmund Freud. In the literature there are over 400 kinds of psychotherapy. Cognitive behavior therapy (CBT) and dialectic behavior therapy are two of the more popular recent versions. All of these psychotherapies, of course, have been derived from Freud’s approach to the mind, that is, thoughts and feelings are worth understanding and valuable entities with which to work. In addition, these therapies, especially the more popular ones, with few exceptions, have taken a piece of the broader understanding of the mind, and based the “new” psychotherapy around a more limited scope of the mind in an effort to be more expedient. For example, CBT was originally written as a manual to help people to do a standard form of therapy without being completely trained as a psychoanalyst. Since mental health training is not standardized, one place to begin is to consider the clinician’s training. The basic didactic training for social workers is a two year masters, for clinical psychologists it is a two year masters or six or so years doctoral program, which usually includes a year or two of clinical practicums much the same way medical school includes the clinical years. For physicians, of course there is medical school. Then there is the post-graduate training: for social workers there is a year internship, for psychologists that work may extend to two years, for physicians, a psychiatry residency is four years. But for well-trained clinicians, it will be an additional 5 to 10 years of didactics, supervision, personal self-examination, and clinical experience before they will be reasonably prepared. For a child mental health clinician, add at least another five years. The only formalized training of this kind is psychoanalytic training through the American Psychoanalytic Association and its affiliates, and a handful of other world-renowned centers. However, even if this very expensive and time-consuming training is not done, there are various other certificate programs, mentors, and continuing education programs to support this kind of intensive training. Good clinicians will pursue this post-post graduate training because of pressure from a dizzying sense of uncertainty that is faced in a mental health clinical practice. Still, with all of this training, there is no guarantee of an excellent clinician any more than medical school and residency is a guarantee of an excellent physician. Without this training, clinicians will likely be able to address issues the way most parents raise their children. However, there is far more known about mental health assessment, and psychotherapy just as there is far more known about how to promote optimal psychological development than most parents know. That knowledge and skill is cumulative

over a professional lifetime. In fact, it is legend that a world famous Yale psychoanalyst, Hans Loewald, bemoaned as he was retiring in his late 80s, “Darn, just when I was beginning to get good.” So what of Sara, Kyle, and Jen? Hopefully they will find a well-seasoned child mental health clinician to assess them. For example, Sara may be suffering from the normative trauma of the birth of a younger sibling that might be alleviated with some parent guidance to help them recognize the strain that Sara experienced under these circumstances. Or Sara’s difficulty may be a manifestation of poor development in being able to relate to others and she may need more developmental support to nurture that growth. Kyle may have a learning disability and is likely experiencing adrenarchy or the early effects of puberty with increased levels of aggression from the normatively increased androgen levels along with decreased support from his parents because they are preoccupied with their dissolving marriage. Kyle and his family may respond to some parent guidance and/or perhaps an opportunity for Kyle to talk through his troubled thoughts. On the other hand, these strains coinciding in a vulnerable child may lead to a disorganization that could be the nidus for psychosis in early adolescence. Jen, on the other hand, is clearly failing at taking the next step in development and appears to be behaving in an uncharacteristic and irrational manner. She is clearly at risk and a thorough assessment of not only her present mental state, but also of the development of her mind from infancy, along with a thorough assessment of parental support throughout that development is called for in order to understand her present development, and determine how to support her and get her back on developmental track.

Theodore Fallon, Jr., MD, MPH, FAACAP, is chair of the Child and Adolescent Psychoanalytic Training Program at the Psychoanalytic Center of Philadelphia, associate clinical professor of the Department of Psychiatry and Department of Humanities and Community Medicine at Drexel College of Medicine, and author of Disordered Thought in Development: Chaos to Organization in the Moment.

W I N T E R 2 0 1 5

Fallon



Features

EXERCiSE iS KEY It’s always been understood that exercise is the basic building block of a healthy lifestyle. Combined with proper nutrition and a focus on emotional well-being, it is the cornerstone of any program seeking to positively impact lifestyle change. There is a plethora of recent literature to support the importance of these concepts – most specifically the extreme importance of exercise (or lack thereof) as the primary link to obesity. Data gathered as part of the Gallup-Healthways Well-Being Index from Jan.-Sept. 2012 revealed that for U.S. workers, exercising fewer than three days a week is more closely linked to obesity (Body Mass Index, or BMI, greater than 30) than any of 26 other behavioral or emotional factors. This analysis is based on interviews with over 139,000 American workers. Poor eating habits, insufficient money to buy food, not having a place to exercise, a history of depression, and lack of dental care are all linked to workers’ obesity. The analysis evaluated the relationship between workers’ obesity and each of 27 behavioral and emotional factors while controlling for age, ethnicity, race, marital status, gender, income, education, region, and religiosity. The findings of the study are consistent with Gallup’s previous research on factors most related to high or low BMI among U.S. adults. At least one in four U.S. workers is obese. Employers bear a tremendous financial burden as a result, including increased healthcare costs, higher absenteeism, and lower productivity. In 2008 the Centers for Disease Control and Prevention estimated that the healthcare costs for an obese individual were $1,429 higher than for those with a normal BMI. Gallup estimates that the annual cost for lost productivity due to obesity and associated conditions ranges from $160 million among agricultural workers to $24 billion among

professionals. Employers can improve productivity and cut healthcare costs by implementing interventions focused on the behaviors most closely linked to obesity. Clearly, exercise should be a focus. Incentivizing exercise and ensuring a safe place to exercise are key factors in any program designed to address this problem. It is important to remember that the population who most needs this intervention is the same population that is most at risk for injury or failure when starting an exercise program. It is vital to ensure that the workout environment is well supervised and safe – both physically and psychologically. The actual physical location of the facility is not critical. Excellent programming can be carried out at myriad locations. Corporate office exercise facilities, community centers, local school facilities, and certified fitness centers are all appropriate if the layout is safe and the oversight appropriate for the necessary basic introduction to exercise. The goal is to ensure success and, in the ideal setting, create an ongoing commitment to lifestyle change. It is important when dealing with this population to recognize that they are at higher risk for cardiac events or exacerbation of underlying disease states. Additionally they are frequently deconditioned and often unfamiliar with exercise equipment and programming. Employees with significant risk factors such as diabetes, hypertension, or heart disease should consider medical clearance prior to embarking on an exercise program. Novice exercisers, if unfamiliar with the equipment or regimens, should seek guidance from certified fitness professionals. This will help to ensure a safe and injury-free pathway to the desired goals. When designing an activity or exercise program for a novice exerciser, it is important to understand the common fears that they must overcome in order to even start on the path to a healthier lifestyle, such as a fear of

Lack of Exercise is the Primary Link to Obesity

Gallup Well-being Analysis (2012) finds inactivity more closely linked to being overweight than

26 other behavioral, emotional factorsBY GREGORY DEGNAN, MD

C H E S T E R C O U N T Y 26 M E D I C I N E C H E S T E R C O U N T Y 27 M E D I C I N E

W I N T E R 2 0 1 5

financial commitment, fear of looking foolish due to lack of knowledge, concerns about body image, and finally the fear of failure. In order to achieve success and truly modify behavior in the long-term, it is important to acknowledge and address all of these issues when designing an activity program. Strategies for success include encouraging the use of a workout partner who is in a similar circumstance, ensuring access to appropriate instruction in the use of equipment or in training procedures, and finally encouraging the use of a fitness professional for instruction and to help to define the ultimate goals and outline a clear pathway to achieve them.

FinAL WRAP...History shows that programs that introduce workers to a safe, non-intimidating, and guided exercise regimen maximize the chances for individual and organizational success. Why not make 2015 the year you take charge of your health and self-image?

Degnan

Gregory Degnan, MD, is medical director of ACAC Fitness & Wellness Centers.



Features

PAMED and Chester County Medical Society (CCMS) membership supports you and your community in many ways. Membership in both Societies provides an indispensable resource for information, continuing education, distance learning, professional contact, and networking.

PAMED offers practice management courses and refreshers on patient care. As leadership development is hard to find, PAMED presents webinars, online courses, conferences, and seminars for the benefit of its physician members. PAMED advocacy has an inside track on legislative and executive proposals on need-to-know issues so we can keep members like you fully informed.

CCMS works collaboratively with PAMED, but its focus is on the local Chester County community. Some specific benefits of membership in CCMS include:• AnopportunitytosignupforthePAMED“FindaPhysician”program to promote your practice• Representationwithlocallegislators• Anannualmeetingwhichprovidesyouwiththeopportunity to impact your Society’s activities and goals• Alegislativedinner,knownas“TheClamBake,”whereyoucanmeet with local legislators in an informal setting• AnautomaticsubscriptiontoChester County Medicine magazine, the Society’s new twist on its longtime quarterly publication, and• AccesstoDocBookMD®,anexclusiveHIPAA-securemessagingapplication for smart phone and tablet devices.

CCMS Membership: Resources You Need

Building

Better

Practices

and Stronger

Communities

One Member

at a Time

For additional information about becoming a PAMED and CCMS member, visit

http://www.pamedsoc.org/membership and click “Join PAMED,”

email [email protected], or call ( (717) 909-2684.

To renew your current membership, visit http://www.pamedsoc.org/membershipand click “Renew your membership.”

Membership is available only for physicians licensed to practice in Pennsylvania.

APPLICATION___________________________________ County Medical Society(You may choose to be a member of the county in which youeither live or work.)

777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820 717-558-7750 (Phone) 717-558-7840 (Fax)

Full Name (Print): ___________________________________________________________________________________Last First Middle

Home Address:________________________________________________________ _________________________Area Code & Phone Number

Office Address:________________________________________________________ _________________________Area Code & Phone Number

Email Address: ____________________________________________ Office Fax _________________________Area Code & Phone Number

For mailing, please use: Office Address Home Address Preferred Communication: Email Fax Mail

BIOGRAPHICAL DATAGender: Male Female Date of Birth: ____________ Spouseʼs Name:

EDUCATION INSTITUTION LOCATION DEGREE BEGIN DATE END DATEMedical -

FOR RESIDENCY & FELLOWSHIP, YOU MUST GIVE ACTUAL OR PROJECTED ENDING MONTH & YEARBEGIN DATE END DATE

Residency__________________________________________________________________ __________ -_________Fellowships_________________________________________________________________ __________ -_________License: PA No. Date Issued

PROFESSIONAL DATAPresent Type of Practice (Check Appropriately): Owner of Physician Practice Group Name ___________________________________________________ Employed by Hospital/Health System Employed by Physician(s) Group Name ___________________________________________________ Employed by Industry or Government Independent Contractor Other (specify) _________________________________________________

Specialty:

Within the last 5 years, have you been convicted of a felony crime or is your license to practice medicine actively suspended or revoked? If yes, please provide full information._________________________________________________________________________________________________________________________________________________________________________________

Yes No

DATE SIGNATURE

RETURN TO: Pennsylvania Medical SocietyATTENTION: Member Services

QUESTIONS? Call (800) 228-7823

FAX: 717-558-7840MAIL: 777 East Park Drive

PO Box 8820Harrisburg, PA 17105-8820


Frontline GroupsFrontline Groups with 100 percent membership in CCMS are the backbone of the society. We are thankful for their total commitment to CCMS. This list reflects the Frontline Groups as of April 13, 2014.

Members in the News

To publish photos ofnew CCMS member physicians, please submit digital copies to [email protected]

We would like your help in touting the accomplishments of Chester County physicians. If you receive an award or certification or have other good news and photos to share, please submit it to [email protected].

Pathologist Lisa Perez Jodry, MD, a member of the Chester County Medical Society Board of Directors, recently obtained a Certificate of Recognition for Multidisciplinary Breast Pathology from the College of American Pathologists (CAP) by completing CAP’s Advanced Practical Pathology Program

in Breast Pathology. Only 0.2 percent of pathologists in the United States has obtained this certificate.

Academic Urology-West Chester

Brandywine Gastroenterology Associates Ltd.

Cardiology Consultants of Philadelphia-Main Line

Cardiology Consultants of Philadelphia-Paoli

Cardiology Consultants of Philadelphia-West Chester

Chester County Eye Care Associates PC

Chester County Otolaryngology & Allergy Associates

Clinical Renal Associates-Exton

Devon Family Practice LLP

Gateway Endocrinology Associates

Gateway Family Practice Downingtown

Gateway Internal Medicine of West Chester

Gateway Medical Colonial Family Practice

Gateway Myers Squire & Limpert

Great Valley Medical Associates PC

Levin Luminais Chronister Eye Associates

Main Line Dermatology

Main Line Gastroenterology Associates

Medical Inpatient Care Associates

Paoli Hematology Oncology Associates PC

Plastic & Reconstructive Surgery of Chester County PC

Village Family Medicine

Wade Townend Pediatric Associates

West Chester GI Associates PC

Membership News & Announcements

Save the Datethe annual Chester County Medical Society

Clam Bake is an opportunity for the legislators and physicians of Chester County to discuss current medical policy issues and

enjoy a casual sumptuous dinner.

Join usfriday, September 11, 2015

6:00 pm - 9:00 pm

At the beautiful Radley Run Country Club Clubhouse Dining Room

https://www.radleyruncountryclub.com

Refreshments and hors d’oeuvres will be served on the patio at 6:00 pm, followed by a delicious

buffet of clams, filet mignon, shrimp, crab, tilapia, chicken, and fabulous desserts.

Mark your calendar now and watch for registration information soon.

Did you know that:• There is a direct correlation between hearing loss & diabetes• Researchers have found a link between age-related hearing loss and cognitive decline• Relationships, self-image, and social life greatly improve with hearing loss treatment• 90 percent of hearing losses can be effectively treated with hearing aids

HearingCare4u.com

Joan D’Alessandro, Au.D.Annette Peppard, Au.D.Kelly Flaherty, Au.D.

Paoli • 30 S Valley Rd, Ste 206

610.296.5857Pottstown • 1800 E High St, Ste 330

610.326.3044

At Advanced Hearing Care,we take a patient-focused and clinical approach to audiology and hearing loss.

The purpose of this educational activity is to provide education on recent advances in the field of cardiovascular medicine and how these impact the management of patients. The emphasis will be on evidence-based, best practice standards of care. It will focus on practical and clinical issues faced on a daily basis by the health care professional.

This activity has been designed for Primary Care Physicians, Interventional Cardiologists, Clinical Cardiologists, Cardiac Surgeons, Vascular Surgeons, Hospitalists, Emergency Medicine Specialists, Interventional Radiologists, Nurses, Technologists and other health care professionals who want to enhance their knowledge of current advances in the management of patients with heart and vascular disease.

For more information: 215-898-6400 or 215-898-8005 [email protected] • penncmeonline.com/node/48022

PerelmanSchool of MedicineUniversity of Pennsylvania

Continuing Medical Education

A C M E / C N E - C E R T I F I E D C O U R S E http://penncmeonline.com/node/48022

Friday, May 8, 2015The Desmond Hotel & Conference CenterOne Liberty BoulevardMalvern, PA 19355

Accreditation Physicians: Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Nurses: An approved provider of continuing nursing education by the PA State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.Designation of Credit Physicians: This live activity is designated for a maximum of 7.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses: The program will award 7.0 contact hours.

Current Advances inCardiovascular Care 2015

COURSE DIRECTORS Michael Acker, MDTimothy Boyek, MDMian Jan, MDNicholas Vaganos, MD

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