chester county medicine | spring 2016

Chester CountyThe Art of

Y O U R C O M M U N I T Y R E S O U R C E F O R W H A T ’ S H A P P E N I N G I N H E A L T H C A R E

SPRING 2016CHESTER COUNTYMedicineP u b l i s h e d b y P e n n s y l v a n i a ’ s F i r s t M e d i c a l S o c i e t y

Ryan Costello:A Man For All Seasons

The Clinic Launches “Girls In Medicine”

Program

by Mian A. Jan, MD

Skill.

Ravishankar Raman, M.B.B.S., F.R.C.S.Board Certified in Cardiac Surgery

Medical Director of Cardiothoracic Surgery, Brandywine Hospital

Assistant Professor of Clinical Surgery, Lewis Katz School of Medicine

at Temple University

Independent Member of the Medical Staff at Brandywine Hospital

Temple cardiothoracic surgeons now perform procedures at Brandywine Hospital.To provide patients with easier access to advanced heart and lung care, cardiothoracic surgeons from the Temple Heart & Vascular Institute are now performing surgery at Brandywine Hospital under the leadership of Medical Director of Cardiothoracic Surgery Ravishankar Raman.

Dr. Raman completed his fellowship training at Mayo Clinic and Hahnemann University Hospital, and his residency in the United Kingdom. He has performed thousands of open heart surgeries, including minimally invasive techniques.

Our program takes an integrated approach across medical disciplines and care settings to truly provide patient-centered care. And patients who require very complex procedures can easily access Temple University Hospital.

The surgical team performs a wide range of surgeries at Brandywine Hospital, including:

Myocardial revascularization • Beating heart surgery Total arterial revascularization • Surgery for valvular heart disease Surgical treatment for atrial fibrillation • Non-cardiac thoracic surgery, including VATS, lobectomy and lung surgery for thoracic oncology

Why have we taken this important step? We believe hospitals should work together for patients.

To speak with a clinical coordinator, call 610-383-8434.

201 Reeceville Road, Coatesville

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CHESTER COUNTYMedicine

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.

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contact Karen Zach610.685.0914

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2013-2016CCMS OFFICERS

PresidentWinslow W. Murdoch, MD

President-ElectMian A. Jan, MD, FACC

Vice PresidentBruce A. Colley, DO

SecretaryDavid E. Bobman, MD

TreasurerLiza P. Jodry, MD

Board MembersMahmoud K. Effat, MD

Heidar K. Jahromi, MD

John P. Maher, MD

Charles P. McClure, MD

David A. McKeighan

Executive Director Rosemary McNeal

Administrative Assistant CCMS Headquarters

(610) 827-1543

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Contents

Letters to the Editor: If you would like to respond to an item you read in Chester County Medicine, or suggest additional content, please submit a message to [email protected] with “Letter to the Editor” as the subject. Your message will be read and considered by the editor, and may appear in a future issue of the magazine.

In Every Issue6 President’s Message20 The Art of Chester County

Features14 Ryan Costello: A Man For All Seasons

24 Cardio-Renal Syndrome — A Complex, Difficult to Manage Condition

29 Community Volunteers in Medicine — A Medical and Dental Home for the Uninsured — How You Can Help?

S P R I N G 2 0 1 6

On the Cover: Warm Summer Day By Madalyn Morley Acrylic on canvas 18" x 24"A self-portrait from an unusual perspective capturing the energy and sunlight of the day.

HAVE YOUR PATIENTS HAD A QUALITY

COLONOSCOPY?

8


Program


18

20

Donald Berwick, a prior pediatrician from Boston and Alaska, as well as past CMS director, provided the keynote speech to

the Institute of Healthcare Improvement (IHI) conference in November, 2015. He notes that we are evolving into the third era in modern medicine. The first era was physician and acute disease centric, and involved large public health works. It lasted centuries. The second era, you know, the current one we are all trying to survive, arrived as academics started to question physician autonomy, scrutinized outcomes data, and questioned established treatments and procedures that offered little benefit, and sometimes true harm. “To Err Is Human” published in 1999 by the Institute of Medicine, with all its assumptions and inaccuracies, became the battle cry for this second era. Concomitantly, there has been an explosion of expensive new technology; pills and procedures. Thus, in the name of “patient safety, cost effectiveness, and standardization of practice,” an enormous and ever growing army of middlemen — the “Watchers” — has been assembled. Metrics measurers, third parties, Payers, data entry mandates for clinicians, mandatory MOC, hospital administrative process, utilization reviews, prior certification or authorization requirements for almost every clinical decision, and onerous bureaucratic oversight flourish. I would assume that all full time practicing clinicians would agree that the second era has run roughshod over common sense in the last 25 years. With a few notable exceptions, primarily in surgical services, it has had the opposite effect as intended. Costs have skyrocketed. Clinicians have lost the ability to spend time needed to improve standards of care and safety, as we are too busy complying with the Watchers mandates. The second era hijacked our focus, energy, and passion, thereby impeding our connection to our patients, and amongst our colleagues, in order to feed the Watchers. The powerful impact realized when healthcare is delivered in a trusting patient-physician relationship within a community of collaborative and empowered clinicians has been diluted to almost homeopathic proportions. As a result, if you haven’t noticed, doctors are increasingly participating in a painful transition, the “Micro Strike” en

The Third Erain Medicine

mass, doctor by doctor, practice by practice. This is exceedingly common for primary care front line physicians. We cease doing procedures that are required to be done in the hospital Emergency Department, as to avoid the requirement to be on the emergency room “on call” rotation (which may be continuous for days, even weeks, at a time for some underrepresented specialties). We relinquish all hospital and nursing home care to full time hospitalists or skilled facility staff physicians.

We stop doing high risk procedures like obstetrics or surgeries that require hospitalization that cannot be performed in an outpatient surgical center or our office. We shift our practice focus to providing services that are not covered by insurance, that are charged directly to the patient; Monthly administrative fees, Botox, medical weight management, pain management, functional or alternative medical treatments, nutraceutical sales, cosmetic skin and soft tissue procedures, “Machines that go Ping.” We reduce our management of core illness that we were trained to manage, but that take so much time and energy to document for the Watchers. We change our primary care or medical specialty offices to concierge, direct care, or fee for service practice models that care for a smaller number of patients, or do not participate with Medicare, Medicaid, or commercial insurers – the Watchers. We reduce or close our primary care offices, and instead work in urgent care centers where patients expect us to only deal with one issue per visit, and no chronic conditions are longitudinally managed. We opt for part time medical directorships at hospitals, insurance or pharmaceutical companies to supplement, and often make up the bulk of our income — become a Watcher. We avoid high risk, high care requiring individual patients, within ACOs or Clinically Integrated Networks to improve our “Watcher measured” utilization profile. Our medical students are opting for non-clinical careers in record numbers. Those that do practice are increasingly choosing specialties that are very narrow, or that limit or are lucrative enough to outsource the Watcher’s burdens.

6 C H E S T E R C O U N T Y M e d i c i n e | S P R I N G 2 0 1 6

w w w . C H E S T E R C M S . o r g

President’s Message

Clinicians are giving away/selling (?) their practices to large hospital systems, in order to function as an employee. We have false hope that the hospital system will be efficient at meeting the demands of the Watchers. We increasingly turn over our patients’ management to our CRNP and PA colleagues and function as their Watcher. Many are moving to another state or country to practice, looking for a more collaborative professional environment where our service is appreciated and reimbursed sustainably. Some are leaving medical careers to engage their dream legacy career if they have been financially blessed or frugal. Some are choosing early retirement when in the past they would have practiced into their late 70s. Others are choosing reasons to claim disability, as reflected in the meteoric rise in disability insurance premiums for physicians when, in the first era, it was exceedingly rare for a physician to claim disability. Suicide amongst physicians is at a rate now almost 3x that of the national average. The third era cannot come soon enough. It will continue to build on the now robust population-based outcomes and cost data, and increasingly incorporate artificial intelligence and personalized genomic data to best create care plans. But, importantly, the third era will again refocus on the patient-physician as well as the physician-physician/care team relationship. Empowered physicians working collaboratively to improve care, and save money. Patients in a trusting relationship with an empowered physician are more invested in their care and do better.

The cost of feeding the Watchers is unsustainable. Information technology may be on the cusp of creating incredible efficiencies in data collation and dissemination, and drastically reduce the cost of feeding the Watchers, but the cost of data input at the clinician’s level is unsustainable. Additionally, data is mounting from clinicians who are collaborating within their Micro Strike practices. Measured quality, utilization, and patient experiences in practices that focus on the relationship and not feeding the Watchers has no parallel. As the community of physicians, we will have to persevere the tail end of this second era, and through collaboration, create a culture of local and regional relationships to best advocate for our patients. Yes, that means more emails, call backs and updates. But these collaborations will improve our morale, and professional environment over time. Improving information systems will evolve to more efficiently share and disseminate updates on best practices. Yes clinical medicine will always be challenging work, and test the resilience of ourselves and our families, but there is a future in this third era that we are at the front lines of shaping. Let’s get started together. If you are not a member of the Chester County Medical Society and PAMED, you are missing a tremendous opportunity to have a hand in the creation of this third era.

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].

S P R I N G 2 0 1 6 | C H E S T E R C O U N T Y M E D I C I N E 7


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HAVE YOUR PATIENTS HAD A QUALITY

COLONOSCOPY?BY ASHISH CHAWLA, MD

8 C H E S T E R C O U N T Y M e d i c i n e | S P R I N G 2 0 1 6 S P R I N G 2 0 1 6 | C H E S T E R C O U N T Y M E D I C I N E 9


Three months ago, my wife got off the phone after speaking with her first cousin in England. She was devastated after hearing that her cousin, a 52-year-old Indian man, was diagnosed with stage 4 colon cancer with

liver metastasis. His mother died from stage 4 colon cancer, but her disease occurred in her late 70s (the cousin did not have family history of colon cancer by strict definition). Surprisingly, he had a colonoscopy 2.5 years ago and was told everything “looked good.” My wife immediately approached me and asked, “How did this happen? Does this happen in the United States? Isn’t he too young to develop stage 4 colon cancer? Why can’t we eliminate colon cancer?” I still do not have all of the answers to her questions, but let me share some data to better help understand the problem. Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States when men and women are combined; it affects both sexes equally. There are approximately 140,000 people in the U.S. who are diagnosed with CRC each year, and over 50,000 die from it annually. The cost of treating new cases of colon cancer is estimated at $14.4 billion annually. While these numbers are staggering, fortunately, the vast majority of CRC can be prevented by early detection and removal of adenomatous polyps (precancerous polyps) via a colonoscopy. Unfortunately, 1/3 of Americans between the ages of 50-75 years are still not getting screened for CRC as per the Centers for Disease Control.1 Despite this inadequate population screening, colonoscopy has decreased the incidence of colon cancer. Data from the American Cancer Society in 2013 demonstrate a 30% drop in incidence rates of CRC as a result of screening colonoscopy.2 However, other recent studies report that colonoscopy is less effective in preventing proximal or right sided colon cancer and its cancer related deaths.3,4 In fact, partially based on these studies, the Canadian Task Force for Preventative Health Care recommended against using colonoscopy as a screening test for CRC starting in 2016. Finally, there is also increasing incidence of interval CRC (colon cancers that occur after a previous colonoscopy and before

Continued on page 10



next screening or surveillance examination) in the United States. How do we reconcile these conflicting findings? Is colonoscopy truly beneficial? The answer to these questions is that a “quality” colonoscopy is beneficial and can reduce the incidence of all CRC (left, right and interval CRC).5 There is a large variation in the effectiveness of colonoscopies across the U.S. For example, four studies have suggested that gastroenterologists are more effective than surgeons at preventing CRC by colonoscopy.6,7,8,9 What factors drive a “quality” or highly efficacious colonoscopy? The American Society of Gastrointestinal Endoscopy (ASGE) has developed quality indicators for colonoscopy which have been adapted by CMS. These quality indicators have an evidence based impact on the reduction of CRC; can be reliably measured; and are useful to all customers (patients, physicians and payers).10 The efficacy of a colonoscopy is defined by these quality parameters: preparation of bowel; completeness of exam; duration of withdrawal time from cecum, and meticulous examination/technique to increase polyp detection rate (also known as Adenoma Detection Rate - ADR). It makes sense that a cleaner colon and a complete exam to the cecum would better help detect CRC. However, Adenoma Detection Rate or ADR is considered the single most important quality measure in a colonoscopy since CRC can only be prevented by complete removal of adenomas (precancerous polyps). The target ADR (identifying one or more adenomas and removing them) is 30% for men and 20% for women undergoing screening colonoscopy.10 To obtain national physician buy-in, these rates are set far below the true prevalence of adenomas as defined by autopsy studies. In fact, in multiple studies, physicians with higher polypectomy rates (ADRs) protected patients from right-sided and interval colon cancer better than physicians with low polypectomy rates (ADRs). A recent trial in Northern California looked at the association of ADRs and CRC in over 220,000 patients undergoing screening colonoscopies. This study showed:

• ADRs of the 136 gastroenterologists in the study ranged between 7.4% and 52.5%. • 1% increase in ADR lead to a 3% reduction in CRC incidence and a 5% reduction in cancer mortality.• Higher ADRs were associated with a reduced risk of both proximal and distal cancer in both men and women.11 • Higher withdrawal times (time of visualization of colon after reaching cecum) correlated with high ADRs.

Based on this new evidence, the ASGE task force recommends that all colonoscopists (gastroenterologists and surgeons) should have their ADR measured and the current ADR targets should NOT be considered a standard of care. Rather, they should be used as performance targets to exceed in order to achieve a quality colonoscopy.

One of the biggest hurdles in achieving high quality colonoscopies has been the paucity of data nationally on ADR by private and academic institutions. We, at West Chester Gastroenterology Group (WCGG), decided to share our data below regarding ADR, cecal intubation rate and recall rate. At WCGG, our ADR for men is 63% and for women is 43%; the cecal intubation rate is 99.5%, and 98.3% of recalls are done correctly.

1) Cecal intubation rate with photo documentation, i.e. How often do we make it to the end? a. Benchmark: >90% b. WCGG: 99.0%

2) Proper use of recommended intervals between colonoscopies performed for average-risk patients and for colon polyp surveillance. a. WCGG has a robust, blinded, quarterly evaluation of representative pathology for each physician to ensure proper surveillance. Our CMS QualityNet Data shows compliance in excess of 98%.

After reviewing this data, I explained to my wife that her cousin unfortunately developed interval colon cancer. Most likely, the polyp/carcinoma was either incompletely removed or missed as a flat lesion in the right colon. But why did he develop stage 4 cancer so early? Again, a recent study from the University of Michigan highlights the changing incidence of CRC. This study identified over 258,000 patients from 1998-2011 with CRC from the SEER (Surveillance, Epidemiology, and End Results) Database, a national database of cancer incidence. The study found almost 15% or 1 in 7 colon and rectal cancers are now diagnosed in patients younger than the age of 50. The average age of these patients was 42 and in comparison to the older cohort, they were 30% more likely to have positive lymph nodes and 50% more likely to have metastatic disease.12 While the USPTF has not changed any screening guidelines based on this early data, primary care physicians need to be aware of the changing incidence of colon cancer. Younger patients often present with bleeding and change in bowel habits to their PCP and often these symptoms are ascribed to hemorrhoids. Prior to jumping to this diagnosis, primary care physicians should perform a digital rectal exam and anoscopy and use their clinical judgement for referral to gastroenterology. I saved the hardest question for last. How can we eliminate CRC? While it may not be possible to eliminate CRC, it certainly has to be our goal in Chester County. I know that I do not have the answer to this question, but I summarized some of my thoughts and some measures that have worked nationally.



How to Eliminate Colon Cancer in Chester County

1. Teamwork. Primary care physicians cannot be expected to improve CRC screening measures alone. Every sub-speciality (medical, surgical, and hospitalists) in Chester County needs to get involved to remind patients about colon cancer screening. Each patient encounter offers us a chance to improve our patient’s health care — from an ENT visit to a gyn appointment. Studies demonstrate preventative screening does not just have to be broached by a primary care provider.

2. Use Ancillary staff to prime the pump. While MAs, nurses, nursing assistants, and pharmacists cannot order colonoscopies, they are an integral part of a healthcare team that often have more face to face time with our patients. They are more apt to learn about patient apprehensions and can assuage patient fears. Empowering our staff to aid with screening measures can improve quality and also impacts staff satisfaction. Keep an electronic tally of your patients that are referred for screening tests by your staff. With the help of your GI group, find patients that had high risk

polyps removed and cancer prevented. Celebrate the accomplishment of your employees and watch as prevention will become infectious.

3. Use the EMR to develop a dashboard. A quarterly dashboard of unscreened patients will help remind you who is at risk. A dashboard also helps you measure your modifications to improve screening.

4. Pick one measure to improve at a time. While improving other cancer screening, diabetes management and HTN are all critical for our patients, we cannot improve all of them at once. Trying to do this often overwhelms the provider and the patient, and eventually leads to failure. Colorectal cancer is a preventable illness and low hanging fruit — simple steps can help us reach our goals in Chester County. Use the knowledge from this exercise to address the next preventative measure in a timely fashion.

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5. Transparency of Adenoma Detection Rate. Not all colonoscopies are created equal. Colorectal cancer is NOT preventable if adenomatous polyps are not found and removed during colonoscopy. ADR is the critical measure of a quality colonoscopy. Small improvements in adenoma detection and removal make marked improvement in reducing interval colon cancer and mortality from all colorectal cancer. Insist on transparency of ADR from your endoscopy providers. As value based reimbursements are becoming the norm, it is critical for the primary to find a GI group who will share their data to ensure quality and fiscal success.

6. Insist on proper surveillance intervals after colonoscopy and polyp removal. Recent evidence from 4 surveys indicated that post-polypectomy surveillance colonoscopy in the United States is frequently performed at intervals that are shorter than those recommended in guidelines.13 Improper intervals lead to increased healthcare costs and to patient and PCP fatigue. Patients are also needlessly put at risk for unnecessary colonoscopies. Again, like the ADR, insist on data from your GI and Surgical groups to ensure proper surveillance.

7. Target high risk patients. Patients who have 3 or more adenomas, high grade polyps (dysplasia or villous features presents) or larger polyps > 1 cm in size, are at higher risk for CRC and need more aggressive follow up. Data suggest these patients are often under-screened even though they are the most likely to develop interval colon cancer. Find a GI champion who will target these patients and remind you when they do not come in.

8. Find out the complication rate of your endoscopy providers. Complications occur during screening colonoscopy: post polypectomy bleeding, perforation, infection and hospitalization due to cardio- pulmonary events. Minimizing complications while maximizing ADR should be the goal to any quality program.

9. Even though a colonoscopy is the best way to prevent colon cancer, other tests, such as Fecal DNA and FIT, can be effective in patients who refuse colonoscopy. The best screening test is a test the patient will do — doing nothing is not an option. However, you must be careful with the data that you get back. Patients who have a positive FIT or Fecal DNA test are at much higher risk for high grade polyps and less than 5% already have colon cancer. Therefore, these patients cannot be treated as average risk screening and require an immediate high quality colonoscopy. Remember, loss of follow-up of these patients is tremendous risk from health quality and legal liability standpoint.

10. Integrate and communicate. Gastroenterologists cannot work in silos, isolated from the primary care providers. Gastroenterologists need to team up with PCPs to improve: patient awareness of CRC, access towards a timely colonoscopy, and in developing a workflow when patients don’t show up.



Colon cancer is a preventable illness that has tremendous health care and social costs in our community. In order to eliminate colorectal cancer from Chester County, we need to change our current paradigm of screening. Let us start today!

1. CDC, Colorectal Cancer Screening Test Use — United States, 2012; Morb Mortal Wkly Rep. 2013;62:1-8.2. Siegel, R; DeSantis, C; Ahmedin, J. Colorectal cancer statistics, 2013-14. 2014,64(2):104-117.3. Lakoff J, Saskin R, et al. Risk of developing proximal versus distal colorectal cancer after a negative colonoscopy: a population- based study. Clin Gastroenterol Hepatol 2008;6:1117-21.4. Singh H, Nugent Z, Demers AA, et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology 2010;139:1128-37.5. Williams JE, Le TD, Faigel DO. Polypectomy rate as a quality measure for colonoscopy. Gastrointest Endosc 2011;73:498-506.6. Baxter N, Forbes DD, et al. Analysis of administrative data finds endoscopist quality measures associated with post-colonoscopy colorectal cancer. Gastroenterology 2011;140:65-72.7. Rabeneck L, Paszat LF, Saskin R. Endoscopist specialty is associated with incident colorectal cancer after a negative colonoscopy. Clin Gastroenterol Hepatol 2010;8:275

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8. Baxter NN, Barrett MJ, et al. Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. J Clin Oncol 2012;30: 2664-9.9. Ko CW, Green P, et al. Specialty differences in polyp detection, removal, and biopsy during colonoscopy. Am J Med 2010;123:528-35.10. Rex D, Quality Indicators For GI Endoscopic Procedures, Volume 81, Gastrointestinal Endoscopy, 2015; 1: 35-53.11. Corley D, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370: 1298-306.12. Abdelsattar Z et al. Colorectal cancer outcomes and treatment patterns in patients too young for average-risk screening. Cancer 2016;122-6:922-34.13. Mysliwiec PA, Brown ML, Klabunde CN, et al. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2008;141:264–71.

After completing his residency at Massachusetts General Hospital and his fellowship in gastroenterology at University of Pennsylvania, Dr. Chawla served as chief of GI in TPMG - Kaiser Permanente. Currently, he works as a practicing physician at West Chester Gastroenterology Group. You can contact him at [email protected].

Ryan Costello:A Man For All Seasons

BY MIAN JAN, MD

If memory serves me right it was early 2011 when my good friend Skip Brion introduced me at an event to a tall, elegant, dignified, well dressed young man. I think

at that time he was the Chester County Recorder of Deeds and he was running for the Board of Commissioners of Chester County. I have been practicing medicine for over 25 years and I’ve become a decent judge of character and right away I recognized a gem who would go places. We spoke for a few minutes but he paid attention to every word I said. Of course he was elected and then became Chairman of the Board of Commissioners in 2013. Over the years I have gotten to know him better and can safely call him my friend. As commissioner he had balanced and revised a five hundred million dollar annual budget and cut government spending; reduced the size of government but at the same time set a range of priorities and goals in many fields, putting health, the environment, public safety, transportation and future growth as his priorities. He was also interested in improved water quality and protecting open spaces in Chester County. Despite being a proponent of cutting government spending he did not pursue a reduction of services to the elderly and the needy. I remember receiving a call from him to see if he could come and seek my counsel on the Pocopson Home for the elderly. In my position as President of the Chester County Medical Society and as a physician on staff at the Pocopson Home I could give some insight. He cared and listened attentively without interrupting my take on the matter and agreed. Pocopson Home is a facility which is too vital for the citizens of Chester County and should not be closed. I was impressed by his candor and passion to



Congressman Ryan Costello

Dr. Mian Jan and Cong. Ryan Costello

do the best without bipartisan thoughts and cares only for his constituents. Not only that, a couple of days later I received a thank you note from him and that has been the trend whenever there is some minor service I have contributed; he has thanked me profusely. He also gave me his cell phone number and I can’t remember when he hasn’t taken time to answer my calls. In 2014 when the esteemed Jim Gerlach, after serving the citizens of Chester County for many years, called it a day we were sad for his departure but ecstatic when Ryan was elected to his position. In keeping with his great character he spoke to me and asked me if I could continue to advise him and counsel him. He never asked me for donations, only my limited ability to contribute. I never felt he was humoring me or had a condescending attitude. The moment you meet him you know he is one of the smartest people around but never for a moment does he make you feel like a lesser person. It’s the hallmark of a gentleman and he is a man of character. I ask myself, what can a middle - aged doctor give to a US congressman other than his prayers, goodwill and promise of keeping his constituents healthy? Despite his busy schedule he showed up when I asked him to come to events like the Medical Society clam bakes and Historical Society gatherings.




Congressman Ryan Costello, Dr. Mian Jan and Chairman of the CCHS Board of Trustees, George Zumbano, at an event at the Chester County Historical Society

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I recall I was at an event at West Chester University and he spent almost half an hour speaking to my son Zarshawn, giving him advice and the secrets to success in life. He invited Amber and I to his installation ceremony as a congressman in Washington, D.C. Unfortunately, we could not attend the event because we were out of the country. I have followed his career as a US congressman and the thing I find most impressive is his ability to put partisan politics aside and take a thoughtful approach to each vote based upon what is the best interest of our district and the constituents he represents. Some examples of bipartisan bills that he voted to support include:

• The Medicare Access and CHIP Reauthorization Act (H.R. 2): A bipartisan effort that permanently fixed the Medicare Sustainable Growth Rate formula – otherwise known as the “Doc Fix” – and made sure seniors have continued access to their physicians.

• The Every Student Succeeds Act (H.R. 5/S. 1177): Another bipartisan effort to replace No Child Left Behind and improve our public elementary and high schools by blocking the federal government from imposing standards, like Common Core, on our children.

• The 21st Century Cures Act (H.R. 6): A visionary effort to modernize health care innovation by improving and streamlining the FDA review process and supporting life-saving research at the National Institutes of Health.

In addition, he has also taken a leadership role on H.R. 3235, the Bringing Postpartum Depression Out of the Shadows Act of 2015, with Congresswoman Katherine Clark of Massachusetts, a Democrat. This bill improves access to postpartum depression screenings and treatment for new mothers. Unlike other health care legislation, H.R. 3235 doesn’t impose any new mandates; rather it opens up resources to states and organizations that want to improve existing postpartum screening and treatment efforts. Not only did he vote based on the welfare of the citizens, he was proactive when he felt there could be harm to our beloved country. Ryan along with ten other GOP house freshmen composed a letter to the Republican colleagues in September of 2015 urging them to pass a resolution to avert a government shutdown. Behind every successful man is a woman and Ryan is blessed to have Christine who is not only smart, beautiful and sophisticated but also politically savvy. God has also blessed them with a beautiful child, which completes their storybook perfect family.



Congressman Ryan Costello, Speaker Paul Ryan and Commissioner Terence Farrell

Congressman Ryan Costello, Christine Costello and Ryan Costello Jr.

There is a saying that politicians will build you a bridge when there is no river, but Ryan is truly a bridge builder across race, sex, age and generations. I was talking to him recently and we spoke about a true friend of doctors and health care professionals, Congressman Joe Pitts, who I believe is retiring. We will miss him greatly for he was a true icon and a champion of physicians and health care; we need someone to champion our cause. Ryan is very excited about health care; he has a great interest in health care and I believe he will be a great champion for the rights of doctors and patients who are under siege with increasing costs, diminishing returns and horrendous life styles after years of education and training. I strongly believe, in this time of gutter policies when even wives and families are not safe from vile politicians’ innuendoes, Ryan is a breath of fresh air; he is a modern man who believes in old Chester County values and is exactly what we need at the national level. I call him a man of all seasons and I am proud to be his constituent and friend.



Dr. Mian Jan is a cardiologist practicing in Chester County and is President-Elect of the Chester County Medical Society.



Program Since The Clinic, located in Phoenixville, opened its doors in 2002, it has been

providing comprehensive health care to the uninsured. We are committed to helping not only those who need healthcare but also those who seek to provide it. That is why we have created Girls in Medicine, the only program of its kind in Pennsylvania. Girls in Medicine connects high school girls interested in healthcare careers with hospitals, healthcare professionals, and mentors who can help them learn how to achieve their dreams.

T H E P R O G R A M

Girls in Medicine is a rigorous one-year enrichment program for highly motivated and talented high school girls interested in pre-medicine and healthcare careers. Accepted applicants will learn from top medical leaders in the area, study at Paoli and Phoenixville Hospital facilities, gain medical research and presentation skills,

achieve CPR/First Aid Certifications, receive volunteer and internship opportunities,

and obtain leadership experience as a Health Ambassador. Our goal with Girls in Medicine is

to help young women build their self-confidence to discover and realize their full potential for a career in

medicine.



. S P R E A D T H E W O R D

Because of the overwhelming response to the Girls in Medicine Program, a second week for new applicants has been added to fulfill the Summer Healthcare components of this year-long enrichment program. If you know a girl who might be interested in applying to the program, she should email Marrea Walker Smith, Director of Girls in Medicine, The Clinic at [email protected].

MAKE A DIFFERENCE Please confirm your interest in being a

mentor or speaker by emailing: David A McKeighan, Executive Director,

Chester County Medical Society at [email protected]

M E N TO R S N E E D E D

Each student will have a mentor to assist her in building self-confidence, provide an experience that she may not otherwise be able to obtain, and encourage her to pursue her dreams. If you are a physician or allied healthcare professional, you can be a Medical Practice Mentor, agreeing to have a student shadow you in the office. This provides the student with first-hand observation of medicine in action. There is a minimum requirement of one hour per month of your time for nine months. If you are a health care administrator, you can be a Supportive Mentor advising a student as she works on her Girls in Medicine Health Ambassador Project. You would answer questions and help a student analyze her project’s strengths and weaknesses. No research or writing on your part is necessary. It requires 30 minutes of your time by phone or 60 minutes at your place of employment per month. This small commitment will be time well spent, helping a young girl reach her dream of a career in medicine, where she may help thousands people throughout the course of her career. You will truly be paying it forward. As a mentor, you need several legal clearances that many health care professionals already have including: Pennsylvania State Police, Pennsylvania Child Abuse, and Federal clearances.

S P E A K E R S / P R E S E N TAT I O N S

We have a need for speakers who can provide information in your area of expertise so the students have an idea of the myriad of career opportunities available in medicine.

BY BRUCE A. COLLEY, DO

Good luck comes to those that listen, and such good luck came to me. After three or four readers of the Chester County Medical Society Journal communicated

to me that a great source of art talent matriculates in our local high schools and that perhaps I should look there for our next featured artist, I thought they may be onto something. My wife and I have, for the past 25 years, enjoyed attending many of our local high school musicals. We go to see them on those “gee, wouldn’t that be fun to do nights.” We’ve never been disappointed, and in fact are “blown away” by the talent of these local students, and routinely brought to tears in amazement. It would follow then that there must be a community of very talented fine art students in our local high schools. So I cast my rod and contacted a few county high school art departments. Then, is what seemed to be about ten seconds, I had a bite. Then amazement again when I stopped at Downingtown West High School to preview Madalyn’s art. I left with the same feeling I’ve had at the musicals — amazement, goose-bumps, what talent we have in “blind sight.” So let me introduce you to our featured artist, Madalyn Morley. Maddy’s mom, a self-taught artist, made sure that her daughter was surrounded by pencils, crayons, paper and clay; and it was from a very early age that Maddy knew she had a knack for making things with her hands, and that art would be part of her world. Another key motivation was a visit, as a youngster, to the Wharton Esherich Studio Museum ( Mr. Esherich, another creative Chester County polymath — if you have not visited the Wharton Esherich Studio do so soon!) left Maddy with a realization and appreciation for the relationship and unity among art forms and craft skills. Design, architecture, glass, metal, clay and wood working were revealed to her. A testament to her observation skills and exuberant curiosity. Curranty, Madalyn is a senior at Downingtown West High School. She has been an active participant in her school arts




On the Cover: Warm Summer Day Acrylic on canvas 18” x 24”A self-portrait from an unusual perspective capturing the energy and sunlight of the day.

Opposite Page: Springton Manor Acrylic on canvas 18" x 24"Landscape of Springton Manor farm in the summer en plein air with a focus on color and movement on the farm.


Hand Acrylic on canvas 18" x 24"Study of the hand and experimentation with color and brush stroke.



Strength Through Unity Acrylic on canvas 16"x 20"A self-portrait demonstrating extreme movement and the anatomy of the figure.

Still life with Pinecone Acrylic on paper 10" x 14"A mechanical and botanical still life contrasting the simple beauty of natural objects and the complexity of the mechanical man-made objects.

On My Mind Ink and acrylic on paper 13" x 16"The anatomical inner workings of the human head that portrays the relationship of the wonder of the human body with the beauty of the world around us.

community and has taken AP Studio Art the past two years. Last year she submitted work for a 3D Design portfolio while this year Maddy is working on a Drawing portfolio. One component of her portfolio involves creating work for a concentration or the exploration of a specific theme. This year her work focuses on the anatomy of the human body in relation to its environment. A propitious coincident for our medical journal. In addition to taking art classes, Madalyn is a member of the National Art Honor Society which promotes the arts through community service. She is a recent winner of the Downingtown West 2016 Senior Mantle award where she designed the class emblem for the robe worn by the class president at commencement. Along with her involvement in the arts, she is the captain of the school rugby team which recently traveled to Scotland to compete. After graduation, Maddy hopes to study either medicine or art at college. (I vote she does both, but mostly medicine — though I may be a little biased.) No matter what major Maddy chooses, she intends to continue to keep art as an important part of her life. Please take a minute to enjoy her inspired works.

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

The Science Behind Man Acrylic on paper 22" x 30"A reinterpretation if Michelangelo’s famous Creation of Man showing the anatomy and science behind the classic painting.



Opposite Page: Still life with PomegranateAcrylic on paper 10" x 12"A combination of unrelated objects which together create a sense of disorientation.

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Cardio-Renal SyndromeA Complex, Difficult to Manage Condition

BY MIAN A. JAN, M.D.AMBEREEN M. JAN, M.D.



Cardio-Renal Syndrome (“CRS”) is an umbrella term used to describe disorders of heart and kidney, whereby disorder in one

organ can induce dysfunction in the other. There is a complex bidirectional pathophysiological interaction between heart and kidney which involves physiological, biochemical and hormonal pathways. It has great importance because more than 50% of patients coming in with CHF have some sort of Cardio-Renal Syndrome.

DEFINITION There was no uniform definition of CRS until 2004 when The National Heart and Lung Institute defined CRS as a single entity in which therapy to relieve congestive symptoms of heart failure is limited by further worsening of renal function. However, a complex relationship exists between cardiac and kidney disease; kidney function declines in the presence of cardiac pathology and conversely CKD is considered an independent risk factor for developing cardiovascular disease.

The current universally accepted definition is: “Cardio-Renal syndromes are disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other.”

PATHOPHYSIOLOGY We will describe this when I go over Types of CRS; the principle is based on Guyton’s hemodynamic model, which illustrates the regulation of extracellular volume, cardiac output and mean arterial pressure through feedback mechanisms between the heart and kidney. Main pathways involved are: -Nitric oxide-reactive oxygen species imbalance, -Sympathetic nervous system activation, -Renin Angiotensin Activation and inflammation

When any of these connectors become deranged the others do too, leading to structural damage. This vicious cycle results in severe CRS.

Part 1



TYPES

There are five main types of CRS:

Figure 1

*Cardio-Renal Syndrome Type 1 (see figure 1) Definition: when acute cardiac dysfunction results in acute kidney injury.

This is fairly common and seen in 27% to 40% of patients hospitalized for acute decompensated CHF who also develop acute kidney injury. In The ESCAPE Trial, 70% of patients with cardiogenic shock also had acute kidney injury; most of these patients had acute anterior wall MI, mitral valve papillary muscle rupture or acute Aortic Regurgitation. Acute decompensation of chronic heart failure can also present as type 1 CRS. Even patients with preserved LV function can present with flash pulmonary edema in hypertensive emergencies and develop CRS. The pathophysiology is depicted in figure 1 and is caused by hemodynamically mediated damage mediated through oxidative stress and other mechanisms resulting in hypoxia and acute kidney injury.

Figure 2

*Cardio-Renal Syndrome Type 2 (see figure 2) Definition: when chronic heart disease causes chronic kidney disease. Continued on page 26



Acute kidney injury induced by Glomerulonephritis, Interstitial kidney disease and Obstructive kidney disease via volume expansion, RAAS and SNS activation via Reactive oxygen species and oxidative stress, cause acute pump failure, Arrythmias and ACS. Although data is limited because most studies exclude renal failure, the prognosis in such patients is not good. Patients with acute contrast nephropathy are twice more likely to suffer downstream cardiovascular events in the year following exposure.

Figure 5

*Cardio-Renal Syndrome Type 4 (see figure 5) Definition: CRS type 4 patients develop chronic cardiac disease secondary to chronic kidney disease.

The pathology is depicted in cardiac conditions like cardiomyopathy, chronic CHF, chronic CAD and valvular heart disease resulting in endothelial dysfunction, oxidative stress and accelerated atherosclerosis which results in kidney dysfunction and renal failure. Up to 63% of patients with chronic CHF have been shown to have type 2 CRS. In the ADHERE Registry, a large number of patients admitted with CHF also had mild to severe CKD:

Figure 3 (right)

Not only that, but high BUN was the number one predictor of in-house mortality.

*Cardio-Renal Syndrome Type 3 (see figure 4) Definition: acute kidney injury results in acute cardiac decompensation.

Figure 4



These are the patients with chronic kidney disease stage 1 through 5 who end up developing CRS type 4. Chronic CKD via anemia, uremia, fluid overload, inflammation, calcification and oxidative stress causes cardiac remodeling, LVH, CHF, valvular heart disease and coronary artery disease. Go, et. al, demonstrated graded increase in risk of cardiovascular events in follow ups of patients with CKD (see figure 6).

Figure 6 Figure 7

Figure 8

*Cardio-Renal Syndrome Type 5 (see figure 8) Definition: CRS type 5 is the co-development of cardiac and kidney disease secondary to systemic critical illness.

Hemodynamic changes with diffuse hypoperfusion and hypoxia, along with metabolic changes and immunological responses and cytokines, result in multi-organ failure. These are the patients admitted with overwhelming infections, trauma and exposure.

Mian A. Jan is an interventional cardiologist practicing in Chester County.Ambereen M. Jan is a nephrologist practicing in Chester County.

Cardiovascular mortality in 30-year-old dialysis patients is comparable to a 70-year-old patient in the general population (see figure 7).

COMMUNITY VOLUNTEERS IN MEDICINE A Medical and Dental Home

for the Uninsured How You Can Help?




Community Volunteers In Medicine (CVIM) was founded in 1998 as a non-profit, free clinic staffed primarily by volunteers to address the need for increased

access to high quality primary medical and dental care and free prescription medications for uninsured, vulnerable adults and children living in poverty — the working poor who have no place to turn for care. Studies at that time estimated that 6 to 9% of the county’s population was uninsured or underinsured. Aware of this strain on communities and healthcare systems, the Paoli Hospital Foundation and its Auxiliary set aside funds in 1996 to develop CVIM and our first patients were treated in 1998. Current census data estimates that 8% of the county’s more than 512,000 residents or 41,000 people are uninsured. Today, our clinic serves as the premier free medical and dental home for thousands of uninsured adults and children living in poverty and near poverty and whose gross income is at or below 300% of the federal poverty level and are not eligible for government programs. In 2014, our 16th year of serving our community, we were able to purchase our building and once again expand our physical plant, thus assuring a strong future for our programs and enhancing our ability to continue our commitment as the only totally free, comprehensive medical home serving uninsured. Since our founding, we have continued to effectively address the gap in the access to healthcare for the uninsured through collaborative relationships with hospitals, healthcare providers, community volunteers, and philanthropists. Our clinic’s growth and the impact we have had on the health of our community are a direct result of our ability to identify areas of need and to collaborate with appropriate partners to jointly address the urgent

health issues facing our shared community. Together with our partners we have served as a catalyst for change in the provision of free healthcare for the underserved — how it is delivered, kept cost effective, yet comprehensive and how the model can be replicated in other communities. Our Mission: CVIM provides compassionate primary medical and dental care and health education to people who lack access to insurance and who live or work in Chester County in order to support their goals to lead productive, healthy, and hopeful lives.

Our Vision: CVIM will continue to remain a nimble and relevant organization that will evolve with purpose to meet the primary healthcare needs of uninsured adults, children and seniors across the county and surrounding neighborhoods. We will continue to strengthen our successful programs and services that provide primary medical and dental care and free prescription medications, while developing additional ones in dental outreach, behavioral health, health education and prevention services to serve the identified unmet needs of marginalized populations in our region. Compelled by our conviction that all deserve access to vital healthcare services and powered by our partnerships with volunteer clinicians, healthcare providers and like-minded philanthropists, CVIM will expand our outreach and therefore our positive impact on the health of Chester County.



Our Accomplishments during Fiscal Year 2015:

• The CVIM team of 380 clinical and professional support volunteers treated 3,059 unduplicated patients during 31,819 patient visits during 50,866 hours of donated volunteer hours.

• The eligibility team screened 3,428 new and returning patients for eligibility.• CVIM Dentists and Hygienists cared for 2,099 patients during 5,541 visits, including the oral health of

close to 800 children living in poverty referred from local school districts

and through community outreach programs.• On average CVIM treated 50 unscheduled dental emergencies every month.• Through our Transitional Care program 206 uninsured patients discharged from ERs, hospitals and other institutions received continuity of care at CVIM.• With more than 47% of CVIM medical patients suffering with a chronic disease, we treated 948 patients during 5,293 visits in our Chronic Disease Management program.• CVIM provided 718 social service sessions, an 18% increase from FY2014.• A total of 444 GYN patients were seen in CVIM’s Women’s Clinic with 377 receiving a Pap test and 27 a Colposcopy; 242 received a preventative or follow-up mammogram.• CVIM patients received 1,339 referral visits to offsite clinical experts, community partners who provide services in their practices and/or medical facilities.• During more than 8,700 dispensary visits, patients received life-saving prescription medications valued at $2,280,857.

Who We Serve and Where We are Located

Chester County is the wealthiest county in the Commonwealth of Pennsylvania and the 24th wealthiest in our nation. Yet, there are pockets of poverty and near-poverty throughout the county. CVIM is based in West Chester near the center of the county in order to serve the uninsured from all zip codes in the county and is strategically located near the two major not-for-profit acute care hospital systems (Main Line Health and Chester County Hospital/Penn Medicine) where a disproportionate quantity of uninsured patients seek care in their emergency rooms. Our neighbors that are eligible for care at CVIM include those working hard at one or more low-paying jobs and making less than 300% of the Federal Poverty Level. They struggle with the daily demands of keeping a roof over their heads, food on the table and gas in the car so that they may get to their jobs. The percentage of households living at or below the Federal Poverty Level in our County is 7% and has not decreased over the past four years. It is reasonable to assume that the need for CVIM’s services will not diminish. We also serve those who have lost their jobs and healthcare benefits during economic downturns. Many have worked for years at better paying jobs, however, job loss and longer term unemployment coupled with subsequent health issues in their families has caused them to deplete their savings and they now turn to CVIM for healthcare services. A portion of our patients have been able to take advantage of the plans offered by the Affordable Care Act; however, many continue to be caught in the spiral of poverty. And, as with most free clinics, we continue to be challenged to educate the community, that even with the implementation of the ACA; CVIM continues to be a vital safety net provider of quality and free healthcare in our County. The majority of our patients fall through the “Coverage Gap” and remain uninsured. We have also experienced the return of patients who had been able to afford a Bronze Plan through an exchange and subsequently have incurred large debts due to unexpectedly high deductibles and co-pays. So as not to go further into debt many have opted to cancel their plans and return to CVIM for care. Albeit the Commonwealth of Pennsylvania expanded the state’s Medicaid program, that only covers people up to 138% of the Federal Poverty Level. Despite the expansion that has helped some families, there has been little



school. I can take my time with patients. I am surrounded by a skilled team of clinical and social support staff which works seamlessly together to provide holistic care to our patients. My fellow volunteers are dedicated, experienced, professional and kind. Interacting with students and residents allows me to teach, but also to continue what is the endless process of learning medicine. I come to CVIM weekly, and I can honestly say, it is the highlight of my week.”

We are in need of Physicians, Dentists, Physician Assistants, Nurse Practitioners,

Pharmacists, Dieticians, Physical Therapists, Dental Hygienists and English/Spanish

bilingual Medical Interpreters.

If you can volunteer at CVIM, please contact Marie Frey, Vice President of

Operations, at [email protected] or call 610.836.5990 ext. 106. www.cvim.org

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impact on dental and mental health insurance coverage. CVIM remains focused on people lacking insurance, while helping those newly eligible for insurance to transition to a high quality, culturally competent provider to the extent possible.

How do we get the job done?

Care is provided by more than 380 volunteer licensed healthcare professionals and support volunteers coordinated by a core staff of 17 full-time and 13 part-time employees. Our medical division is overseen by one paid physician who oversees 90 medical providers. Our dental department is served by three part-time dentists making up over 1 full-time employee with one serving as oversight for the department. For nearly two decades, CVIM has remained a beacon of hope and a premier provider of free and compassionate healthcare for people in Chester County lacking access to quality medical and dental services. Current census data estimates that 8% of the county’s more than 512,000 residents or 41,000 people are uninsured. The uninsured go without necessary healthcare, affecting their ability to work and to provide and care for themselves and their families. Children suffering from dental pain and neglect struggle in school and often regress socially. The uninsured seek care from already overburdened hospital emergency rooms for non-emergent problems as well as uncontrolled chronic diseases, thus exacerbating the financial and staffing issues facing our hospitals and creating unnecessarily higher health costs that must be absorbed by all of us. Frankly stated, helping the uninsured gain access to care is a path we should all consider because at any moment in our ever-changing, volatile economy we could be the person struggling to gain that access.

Sustainability

CVIM’s entire budget is supported by philanthropy, and through the generosity of a broad base of donors and prudent fiscal management, we have been able to continue to accept new patients and expand our programs.

A Physician Testimonial

Laura Offutt, MD, volunteer Internist, says it best. “I came to CVIM two years ago. When I tell people that I am a volunteer physician here, they often comment how nice that is of me. But truly, working at CVIM gives me many times over what contribution I make to CVIM. The quality of care is high, but equally important so is the compassion. The patients are people we meet over the course of our day-to-day lives: cooks, wait staff, school bus drivers, landscapers, house cleaners, home health aides, day care workers, mothers, and many, many other hard working people who through no fault of their own do not have health insurance. To be able to help these patients is an honor, and furthermore, practicing medicine at CVIM allows me to practice the way I dreamed I would when I was in medical

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chester county medicine | spring 2016

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