BulletinFebruAry 2019 - Profile: Meet your 2019 ACMS president Groups launch campaign: 'Hep C Free Allegheny'
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Allegheny County Medical Society Bulletin February 2019 Profile: Meet your 2019 ACMS president Groups launch campaign: ‘Hep C Free Allegheny’
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Dr. Sauber treats a variety of adult and pediatric spinal conditions, including scoliosis,
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He uses minimally invasive, robotic-assisted techniques whenever possible.
Dr. Sauber graduated from Northeast Ohio Medical University in Rootstown and
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Dr. Shah specializes in plastic and reconstructive surgery for the periocular area,
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After earning her degree at the Boston University School of Medicine, Dr. Shah
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Allegheny County Medical Society
Bulletin February 2019 / Vol. 109 No. 2
Opinion Departments Articles
Editorial ................................. 37 Society News ........................ 47 Profile ....................................50
Stage fright • Pennsylvania Geriatrics Society – Newly installed ACMS president to
Deval (Reshma) Paranjpe, MD, FACS Western Division focus on unity, inclusion and support
• Pittsburgh Ophthalmology Society Christina E. Morton
Editorial ................................. 39 • Greater Pittsburgh Diabetes Club
A young woman in medicine: Facing • Pittsburgh Urological Association Materia Medica ...................... 52
challenges of patient-level bias • Local history of medicine books Epidiolex® (cannabidiol)
Anna Evans Phillips, MD, MS available Anne Williams, PharmD
Emily Bonrzynski, PharmD, BCPS
Editorial ................................. 41 Classifieds .............................59
Game changers Legal Report ..........................55
Richard H. Daffner, MD, FACR The next level of ‘criminal medicine:’
Serial bad surgeries
Perspective ........................... 44 Beth Anne Jackson, Esq.
The handicapped police
Andrea G. Witlin, DO, PhD Special Report .......................57
Allegheny County launches Hepatitis C
Perspective ........................... 45 elimination campaign
‘Black lung’ and the history of Jennifer Fiddner, MPH, CIC
occupational pulmonary medicine
Kristen Ann Ehrenberger, MD, PhD
On the cover
Dali Museum Staircase,
St. Petersburg, Fla.
Maria Paul, MD
Dr. Paul specializes in dermatology.
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Editorial
Stage fright
Deval (Reshma) Paranjpe, MD, FACS
I n December, I had the singularly de-
lightful experience of an impromptu in-
vitation to the Pittsburgh Ballet Theatre
I operated completely alone – it was
a lonely, scary, adrenaline rush of an
experience to realize that no mentor or
If you’ve practiced nonstop, you have
muscle memory and you know you’ll be
able to perform whenever it’s asked of
(PBT) employee holiday dinner. I found colleague was there at my side to offer you. And repetition. You know what your
myself seated at a table at DiAnoia’s in tips or jump in if I ran into difficulties. I body can do, because you’ve trained
the Strip, scarfing down sublime pizza asked my father (also a surgeon) for over and over again, and that gives you
and pasta dishes in the company of advice, and he said: “Pray at the scrub confidence.” This is the rote memori-
PBT’s principal dancers. sink, leave all other thoughts at the OR zation, the knot-tying, the repetition of
This was truly surreal. I had seen door as you walk through, and remem- procedures until we attain mastery.
these phenomenally talented young ber: If not you, then who? You’re the His fiancée agreed, and added: “And
women and men on the stage many only one there. You have to fix it. Your practicing with your partner, so you
times, but to be sharing pizza with patient is depending on you.” That last know exactly what the other will do or is
them during their off hours? And yet bit is what he told himself as a surgery thinking.” This is the teamwork to which
there we all were – what a privilege. intern in New York City in the 1960s we aspire in our medical and surgical
I listened, fascinated, as they ex- – long before the Libby Zion case, teams – making processes look and feel
changed stories and gossip and wolfed 80-hour work week rules and all the effortless because everyone knows their
down meatballs – these incredibly tight regulations regarding precepting role and plays it smoothly.
disciplined and talented professionals and supervision that we have now. The
Another engaged pair of dancers
at the peak of their craft were still kids interns in those days really knew fear,
had wildly different personalities. His
at heart. Two ex-dancers who had risen and exhaustion, with nearly continuous
perspective was this: “Sometimes I
to great heights and then gone on to q2 call. If that was the mantra my father
have to remember what a privilege it
reach the pinnacle of the teaching and and his generation of physicians swore
is to be on stage doing what I love.
management sides sat down. The tone by, I would certainly use it. It’s the best
When I look at all the people in the
of the conversation instantly changed, advice I’ve ever heard in that regard.
and the younger dancers stiffened up a During a lull in the dancers’ conver- audience, I have to remember that they
little the way medical students might if sation, I asked a question of the entire have made an effort to dress up and be
two respected professors suddenly sat group: “How did you get over stage there, and that I get to make them hap-
down in the student lounge. fright?” I bet myself that not only would py as part of my work. The audience is
A conversation I’d had earlier in the there be common ground between either already happy and looking to cel-
day was still on my mind. A medical professional ballet performers and ebrate, or needs an escape from their
student had wondered aloud how and physicians, but also teaching points everyday life, and what a privilege it is
when the confidence to operate alone – that physicians could take away. The to be able to provide that joy through
and make management decisions alone answers I got were these: my art.” What better reminder is there
– arises in the process of becoming an One of the principal male dancers for us? Isn’t it a privilege for us to be
attending. I thought back to the first time answered first: “Complete preparation. Continued on Page 38
ACMS Bulletin / February 2019 37
Editorial
From Page 37 the preparation and practice to back up their underwear to make myself laugh
able to do what we love, and to often that lack of hesitation is key, as in any and relax.” Which proves that everyone
high-wire act.) is afraid of something – even the most
make people healthier and happier
Finally, it was the turn of the two seasoned performers have an Achilles
through our efforts? When we can’t do
retired professionals. The teacher, who heel. No different for us – my theory is
that, isn’t it a privilege to share in the
had danced on stage all over Europe, that whatever appeals to you and does
lives of our patients, to earn their trust,
told of her experience of stage fright in not scare you as a medical student
and to ease their pain where we can?
dancing before one of the most famous determines your eventual specialty.
Her perspective is what impressed
ballerinas of her day; in the taxi on So, remember, if you have anxious
me the most that evening – and it was the way to the theatre, she realized trainees on your watch, or whether you
seconded heartily by her friend and that if she was too nervous to get on yourself need bucking up now and then
colleague who cited her as inspiration. stage, she needed to find a new line of in your career:
“My mantra is: ‘No *bleeping* hesita- work. As she loved ballet too much to • Prepare until it’s second nature.
tion.’ I trained with a dancer who had consider quitting, she went ahead and • If not you, then who?
performed with Cirque du Soleil, and danced. Just as for us, at some point, • It is a privilege to make people
they perform hundreds of feet in the it’s too late to turn back now. We can better and bring joy.
air without nets. If you hesitate in that branch out but never really turn back, • And lastly, no *bleeping*
situation, you die. And I don’t want to for our experiences have shaped us. hesitation.
die. So, no *bleeping* hesitation.” The dancer who had transitioned
In the heat of battle, in a trauma, in into the upper echelons of management Dr. Paranjpe is an ophthalmologist
a code; in surgery, in the clinic, and in said he had never had stage fright, at and medical editor of the ACMS Bul-
necessary patient and family discus- which everyone laughed. “No, really!” letin. She can be reached at reshma_
sions; isn’t that our mantra, too? Physi- he protested. “I can still dance in front of paranjpe@hotmail.com.
cians don’t hesitate to put themselves anyone, anywhere, without getting ner-
The opinion expressed in this column is that of the
in difficult situations: If not you, then vous. But I am deathly afraid of public writer and does not necessarily reflect the opinion
who? If we hesitate, our patient might speaking. I use that old trick of imagin- of the Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
die. No *bleeping* hesitation. (Having ing that everyone in the audience is in
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38 www.acms.org
Editorial
A young woman in medicine:
Facing challenges of patient-level bias
Anna Evans Phillips, MD, MS
“Does your Mommy know you’re rates for patients in areas from myo- eyes and the fatigue in my face during
here?” asks the patient as he enters cardial infarction to elderly care.3,4 In a week on call do not enhance my
my clinic. The 76-year-old man has put addition to closer adherence to evi- youthfulness, of this I am sure. Neither
me in an impossible situation. He may dence-based guidelines and higher does the fact that I have spent nearly
or may not know my age, but he knows standardized test scores, the authors a decade in specialty training after
full well that he’s put the young woman of one these studies partially attribut- medical school. I suspect instead that
in her place, leaving little room for us to ed this difference to female internists seeing a young woman in my position
graciously acknowledge our differences offering “more patient-centered care.”4 is somewhat disconcerting. The sep-
or his surprise at seeing a young wom- Women are supposed to be more tuagenarian mother of another patient
an in charge. He sidesteps me and sits emotionally skilled and more inclined put it best when she exclaimed, “Why,
down in the chair I offer, saying nothing to communicate with and connect with if I saw you on the street, I’d never
more in the silence that follows. their patients. What is not discussed, believe you were a doctor!”
For the record, my mother is indeed however, is the difficulty that gender Historians and sociologists of
aware that I am there. Admittedly, my bias on the part of our patients adds to medicine have noted for decades how
efforts to become an academic gas- our everyday practice. I suspect that reforms in medicine also have changed
troenterologist also have bewildered my experiences are not rare. We may the nature of the doctor-patient rela-
her alongside my other life choices: to do better for patients, and are certainly tionship, but as a profession we haven’t
obtain more than a bachelor’s degree, just as skilled as our male counter- sufficiently discussed the jarring ques-
to marry only in my 30s, to delay parts, but it doesn’t feel that way when tioning of female authority, in part be-
having children. Although matriculation we walk into a room. cause it’s largely invisible. When male
rates in medical schools have been During a recent week on call as colleagues join me in an examination
higher for women than men for the past an attending gastroenterologist, I room with a patient, the comments
two years, and young female doctors noted that seven days out of seven, aren’t made. Nevertheless, over the
populate training programs and junior someone – usually a patient or family next decades we will face a profound
faculty positions across the country, pa- member – commented directly to me change as the profession becomes
tients are still getting used to us.1 There on how young I looked. Not all took the increasingly more diverse, even as
has been increasing attention focused form of inquiring about my parents, but our patients will, in some cases, have
on the systematic ways women face remarks along these lines were uttered had decades of experience without
discrimination within medical institu- multiples times every day. One patient, regular contact with female physicians.
tions and from peers, but we have so after his colonoscopy and a conver- Medical schools and training programs
far paid relatively little attention to the sation in which I delivered a diagnosis will need to find ways to address this
experience of female physicians upset- of colon cancer, told me that he “felt reality directly, because it affects nearly
ting the expectations of our patients.2 comfortable with me [telling him this every aspect of being a physician, from
Studies have consistently suggested news], even though I was so young.” how we respond to questions about
that female physicians lower mortality The crow’s feet at the corner of my Continued on Page 40
ACMS Bulletin / February 2019 39Editorial
From Page 39 became the first female African Ameri- That’s not a problem. Equality will be
our competence to how we choose to can to earn a medical degree. Despite achieved not when exceptional women
these high-profile successes, change succeed, but when ordinary women are
physically present ourselves.
came slowly, and as recently as 1970, treated no differently than ordinary men.
In some regards, I have sympathy
only 7.1 percent of physicians were At best, I am a highly qualified and ded-
for my patients’ confusion: Female phy-
female, and those were concentrated icated physician, one who consciously
sicians have indeed become normal-
in pediatrics and psychiatry.5 Barriers strives each day to improve. For now,
ized in a relatively short time. Most of
are nowhere near this high for women when a patient enters the room with
us don’t have mothers who also went that misguided question, I embrace the
to enter medicine in 2018: This reality
into medicine, and the examples we represents the triumph of these earlier opportunity to challenge existing biases.
have of pioneering female physicians pioneers, for which I am incredibly I consider my options, and then I smile
are by presumption never about ordi- grateful. It has never been a better broadly and say, “Why yes, sir. Yes, she
nary experiences. Female physician time than now for women in medicine, does.” And then we carry on.
narratives almost universally highlight but its normalcy presents precisely the
the great odds that women have over- conundrum. In 2018, it is not Dr. Tauss- Dr. Evans Phillips is associate editor
come in order to enter the profession. ig or Dr. Crumpler who walks into the of the ACMS Bulletin and assistant
Dr. Helen Brooke Taussig succeeded room: Odds are that it is an ordinary professor of Gastroenterology at UPMC;
as a female cardiologist, becoming the physician who does. her research is focused on pancreatitis
first female president of the American I count myself incredibly fortunate and genetic cancer syndromes. She can
Heart Association in addition to over- despite these challenges. The op- be reached at evansac3@upmc.edu.
coming adult-onset hearing loss. Dr. portunity I have been given to take
Elizabeth Blackwell was rejected mul- the Hippocratic Oath, to improve my The opinion expressed in this column
tiple times from medical schools and patients’ health and well-being, is one I is that of the writer and does not
then ridiculed when she was admitted would trade for no other. necessarily reflect the opinion of the
as a joke. Dr. Rebecca Lee Crumpler But I am no Helen Brooke Taussig. Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
overcame racial discrimination as she And neither are my female colleagues.
References 2018;378:2255-7. L. Patient-physician gender concordance
1. Applicants and matriculants data, 3. Tsugawa Y, Jena AB, Figueroa JF, and increased mortality among female heart
2017. Washington, DC: Association of Ameri- Orav EJ, Blumenthal DM, Jha AK. Compar- attack patients. Proc Natl Acad Sci U S A
can Medical Colleges (https://www.aamc.org/ ison of Hospital Mortality and Readmission 2018;115:8569-74.
data/facts/applicantmatriculant/). Rates for Medicare Patients Treated by Male 5. Kletke PR, Marder WD, Silberger AB.
2. Rotenstein LS, Jena AB. Lost vs Female Physicians. JAMA Intern Med The growing proportion of female physicians:
Taussigs - The Consequences of Gender 2017;177:206-13. implications for US physician supply. Am J
Discrimination in Medicine. N Engl J Med 4. Greenwood BN, Carnahan S, Huang Public Health 1990;80:300-4.
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For more information, email Meagan K. Sable at msable@acms.org.Editorial
Game changers
Richard H. Daffner, MD, FACR
W e live in an age of unprecedented
medical progress. Sometimes,
it is nice to look back, lest we forget
just how far we have come regarding
patient care.
At the time, late 1977, the medical
intern’s request was not unusual. He
had a 70-year-old man who had been
admitted with a history of malignant
hypertension, and on whom he had
discovered a vague abdominal mass
several days earlier. The intern was
asking for an emergency barium ene-
ma to evaluate the mass. I told him that
we had a study that was much better
than that, and I recommended we do
an abdominal ultrasound (U/S) exam.
The U/S showed a vague retroperito-
neal mass on the left. I then suggested
we use our new CT scanner for a more
definitive look at the mass. The abdom-
inal CT scan showed a large bleeding Figure 1. Chondrosarcoma of the pelvis, 1970. Intravenous urogram shows
abdominal aortic aneurysm with a a soft tissue mass displacing the contrast-filled bladder and right ureter
massive retroperitoneal hematoma. (arrow) to the left.
The patient was rushed to the operat- most are Pasteur’s and Koch’s germ influence may be better appreciated
ing room, but unfortunately died before when one considers that in the 1940s,
theories (1864-70), Lister’s antisep-
the aneurysm could be repaired.
sis (1870s), Roentgen and the X-ray imaging affected a medical or surgical
I have been teaching a course on
(1895), Banting and Best isolating diagnosis in one of 12 patients. This
the history of diagnostic imaging for
the Osher (Lifelong Learning Institute) insulin (1921), Fleming and penicillin ratio had changed to one in six in the
programs at Carnegie Mellon Univer- (1928) and Hounsfield producing the 1950s, to one in three in the 1960s
sity and the University of Pittsburgh first workable CT scanner (1972). Of and to one in two in the 1970s. By
for several years now. Among the all of these, and excuse my prejudices, 1980, with ultrasound, CT and MRI
landmark discoveries/developments X-ray and the CT have revolution- available, virtually every medical and
that have influenced medical practice ized the practice of medicine. Their Continued on Page 42
ACMS Bulletin / February 2019 41Editorial
From Page 41
surgical diagnosis depended on some
form of imaging. CT and later MRI
were significant game changers. What
was it about these new imaging modal-
ities that made them game changers?
When I began my residency in
1970, our diagnostic armamentarium
consisted of X-ray, barium studies and
a variety of studies that used water-sol-
uble contrast material. In addition,
patients often underwent some rather
unpleasant diagnostic procedures –
pneumoencephalograms for suspected
brain tumors, lymphangiography for
Figure 2. Chondrosarcoma of the pelvis, 1985. The mass on the right (*) is
suspected nodal involvement in cancer,
clearly visible.
Sweet’s eye localization for ocular
foreign bodies and exploratory lapa- masses in the skull or abdomen, we intravenous and intraarterial contrast
rotomy for staging Hodgkin disease would opacify those structures we (brain, abdomen) (Figure 1 – Page 41),
and lymphoma. For the evaluation of could reach with barium (abdomen), and air (brain). CT and MRI allowed
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us, for the first time, to directly image
masses (Figure 2 – Page 42) as well TABLE 1
as the internal anatomy of the brain. IMAGING STUDIES NO LONGER PERFORMED
Further refinements in imaging tech- AND THEIR REPLACEMENTS
nology have now allowed CT, MRI
and U/S to depict not only tumors and
Conventional Tomography.......................... CT
their extent of spread, but also infec-
tions, blood clots, vascular anomalies,
Pneumoencephalography...........................CT, MRI
muscle, tendon and ligament injuries, Sweet’s Eye Localization............................CT
cartilage injuries, and cardiac valves Lymphangiography......................................CT
and chambers in a relatively non-inva- Oral Cholecystectomy.................................CT
sive manner. Intravenous Cholangiography.....................CT, MRI
Multiplanar (sagittal and coronal) Pelvimetry................................................... Ultrasound
and 3-D reconstruction now allow Bronchography/Laryngography.................. CT, Endoscopy
orthopaedic and oral and maxillofa-
cial surgeons to view the positions
of bone fragments prior to fracture
repair. Ultrasound and MRI studies TABLE 2
can be obtained in virtually any plane
“ENDANGERED” LIST AND STUDIES THAT WILL REPLACE THEM
as primary images. Furthermore,
U/S– and CT-guided techniques
permit biopsies and fluid drainages Upper GI Exam.......................................... Endoscopy
that otherwise would have required Barium Enema........................................... Endoscopy
surgery in the operating room. And, Intravenous Urogram................................. CT
as a result, many of the older invasive Ventillation/Perfusion Lung Scan............... CT
diagnostic procedures mentioned
above are now relegated to the trash
bin of medical history (Tables 1 and 2).
invasive manner. Whenever a new mo- Dr. Daffner is associate editor of the
Positron emission tomography (PET)
dality appears on the horizon, I reflect ACMS Bulletin. He is a retired radiologist
is combined with CT to actively identify
on how things were back in the “Dark who practiced at Allegheny General Hos-
tumors and infections. This has proven
Ages.” I have shown my residents and pital for more than 30 years. He also is
most useful for certain tumors such as
carcinoma of the tail of the pancreas, students many examples of how far emeritus clinical professor of Radiology
which frequently were undetectable we have come (Figure 1). Readers at Temple University School of Medicine
until late in the course of the patient’s who are unfamiliar with pneumoen- and the author of nine textbooks. He can
illness. cephalography, lymphangiography, the be reached at bulletin@acms.org.
Modern imaging has revolutionized Sweet’s localization technique or the
The opinion expressed in this column is that of the
how we evaluate patients today, allow- other studies listed in the Tables are writer and does not necessarily reflect the opinion
ing us to directly see into the patient invited to do a little research on these of the Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
in a relatively safe, non- or minimally topics on the Internet.
Allegheny County Medical Society
Improving Healthcare through Education, Service, and Physician Well-Being.
ACMS Bulletin / February 2019 43Perspective
Perspective
The handicapped police
Andrea G. Witlin, DO, PhD
Y ou ask – who exactly are the
“handicapped police?” Essentially,
I characterize them as our do-gooder
campus in my motorized scooter during
my last several years of work. Hidden
from view was how difficult it was to get
morphed into breathing issues. Short-
ness of breath when unaccompanied
by my oxygen are/were definite show
friends and neighbors who “patrol” with in and out of the elevator without the stoppers for the “police.” How can
a vengeance those coveted parking doors closing on me. Or navigating for there be anything wrong (i.e., how can
spaces, restrooms, seats and just blocks out of my way, because there one be disabled) when one looks so
about anything else designated as re- were no curb cuts to cross the street. good? You can add many neurological
served for those with disabilities. They But, for the most part, I still looked and cardiac issues to the “You look
are rarely disabled themselves. But, “disabled.” so good, therefore, you must not be
for some indeterminate reason, it’s of For four years, I walked with a cane disabled” list.
paramount importance to them to make at the behest of several of my phy- Despite numerous setbacks, I’ve
sure that anyone using those facilities sicians. My gate was unsteady, I fell tried to maintain some semblance of
meet “their definition” of disability. and had injured myself multiple times. normality in my daily life. I diligently
Therein lies the rub – how do we Unfortunately, my “designer” cane was anticipated, prepared and planned. I’ve
define disability? A wheelchair is the mistaken for a fashion statement. I learned over the years how far I can
universal symbol for “handicapped.” was in my 40s at the time and wanted ambulate unassisted. But some days
But not all physical disabilities (let a support that didn’t make me look I get “stuck” and can scarcely return
alone non-physical ones) necessi- like I was in my 80s. Every step was to my car. The etiology du jour varied
tate the use of a wheelchair, or even extremely painful and fraught with the – dangerously low oxygen saturation,
manifest any outward sign of physical fear that I might fall and injure myself pain, fatigue. My never-ending quest
deformity or need for tangible support. again. If the cane wasn’t immediately for normalcy obscures these symptoms
To be honest, some of the easiest visible, I ceased to look “disabled.” to the average observer. Yet, I foolishly
experiences that I had maneuvering My next physical challenge was expected the “handicapped police” to
were while using my wheelchair. It was sporting a cast on my left arm (of comprehend.
like the Red Sea had parted for me! course hidden by my coat sleeve) and So, it is with this backdrop that the
That said, it took a toll on my husband navigating with a cane on my right arm. confrontation with the handicapped po-
as he lifted the wheelchair in and out Carrying anything was next to impos- lice occurs. Perception belies reality. I’m
of the trunk, struggled to safely place sible. Speaking of hidden disabilities, not worthy in their eyes. I look good to
me in its seat, and push me around to even without the cast, grasping and them. I’m not in a wheelchair. Display-
my appointments. I was adorned with carrying, writing, and turning door ing a handicapped hang tag or license
a cervical collar and cast from foot to handles and locks also were next to plate doesn’t assuage the do-gooders.
knee. I met everyone’s definition of impossible. It was during this phase of Invariably, the “handicapped police”
disability. my life and multiple illnesses that I first pick a fight and threaten to call the
I was a curiosity to my colleagues met the “handicapped police.” “real” police. Pointing out my license
and friends when I rolled around My “recognizable” physical ailments plate or offering my state-issued card
44 www.acms.orgPerspective
Perspective
never seems to help. dark, cold winter’s morning. I was three months before I had a serious,
Over the past 20 years, I’ve become gathering my many belongings in almost life-threatening complication to
accustomed to confrontations with the preparation for my day-long, every that same infusion. But how was any-
“handicapped police” at public places three-month chemo infusion. The one to know what was worrying me?
such as airports, public parking lots guard accosted me as I was exiting my The “handicapped police” had
and restaurants. In anticipation, I tell car and told me I couldn’t park in my struck again!
myself that next time, I’ll moderate my “usual” handicapped spot. I pointed to
emotions and that friendly education my handicapped license plate to no Dr. Witlin is a retired maternal/fetal
will suffice to quell the animus from the avail. The “friendly education” that I medicine physician and researcher.
“police.” had preached about to others was lost She can be reached at agwmfm@
Most recently, I let my guard down. in translation and could no longer be gmail.com.
I was blind sighted and thus unsettled summoned.
by the latest iteration and altercation My “Zen-like” trance was rudely The opinion expressed in this column
with the police. Much to my chagrin, disrupted as I erupted at the guard and is that of the writer and does not
this time the “handicapped police” then at the “greeter” unknowingly wait- necessarily reflect the opinion of the
was the security guard at the medical ing inside. I was in patient mode and Editorial Board, the Bulletin, or the
Allegheny County Medical Society.
center parking lot. It was early on a was worried about my infusion. Just
Perspective
Perspective
‘Black lung’ and the history of
occupational pulmonary medicine
Kristen Ann Ehrenberger, College in Philadelphia, where he sur- roots in a classical education and the
MD, PhD vived multiple shakeups of the faculty fact that Paris was the epicenter of
by virtue of his reputation as “the Great clinical advances in the middle of the
I recently came into possession of an
old medical lexicon, an 11th edition
of Robley Dunglison’s “A New Dictio-
Peacemaker.”
As a historian of medicine, I find
1800s. Dunglison continues with an
accurate description of the anatomy
dictionaries to be fruitful sources for re- and physiology of the lungs, according
nary of Medical Science and Litera-
search, because they are chock full of to today’s standards. But this sentence
ture” (1854). Often called “the father
information to help a reader – whether caught my eye: “Along the partitions or
of American physiology,” Dunglison
(1798-1868) released this forerunner to 19th-century practitioner or 21st-century septa is deposited, in greater or less
“Stedman’s Medical Dictionary” while scholar – understand medicine at that quantity, black pulmonary matter, ([in
a young professor of anatomy and time. On a whim, I looked up “pulmon- French]) Matière pulmonaire noire,
medicine at the University of Virginia in ology.” The entry starts with Greek and as it has been called, which seems
the 1830s. He went on to have a dis- Latin roots and includes synonyms in to be natural.” “Well that’s not right,”
tinguished career at Jefferson Medical French, demonstrating both medicine’s Continued on Page 46
ACMS Bulletin / February 2019 45Perspective
Perspective
From Page 45 irregular cavities. … The rest of the predominantly surface mining. The pre-
I thought. “I wonder what he means.” lung was also somewhat condensed, vailing theory is that the more rock has
I looked up related words such as and very oedematous. … Some minute to be blasted to expose thinner seams
“anthracosis” (aka “black lung”) and hard points could be felt in various of coal, the more silica and iron-rich
“melanosis,” of which he writes, “Its parts of both lungs.” Gregory observed pyrite (fool’s gold) dust miners inhale.
causes are very obscure.” I had run out that neither the clinical history nor The combination of inflammation due to
exam findings pointed to the most fine silica and destructive reactive oxy-
of clues in the text. So, I did what most
widespread lung disease of the time, gen species due to the iron appears to
historians would probably do next,
tuberculosis, then thought to be he- be causing an epidemic of early-onset
which was Google “black pulmonary
reditary rather than infectious. Rather, end-stage lung failure. That’s neither
matter.”
he reasoned by analogy to the “form natural nor right.
From the combination of old and
of phthisis [lung disease] … found to • For a history of spirometry and
new sources now available on the
be particularly prevalent among those its use in occupational medicine, read
Internet, I learned that there were two
who by their occupations are more Lundy Braun, Breathing Race into the
theories for its origins, one internal
exposed to the inhalation of small irri- Machine: The Surprising Career of the
and one external. Leading pathologists
tating particles, such as stone-cutters, Spirometer from Planation to Genetics
such as Rene Laennec (1781-1823)
millers, and needle-grinders” that the (Minneapolis, MN: Univ. of Minneapolis
and Rudolf Virchow (1821-1902)
man’s disease was due to his exposure Press, 2014).
assumed the blackened tissue they
found on autopsies had precipitated to coal dust. In fact, the miner’s lungs
were preserved at the Royal College Dr. Ehrenberger is an internal med-
from the blood. If it wasn’t metastases
of Surgeons of Edinburgh anatomical icine-pediatrics resident at UPMC. She
from advanced melanoma, then it
museum, and it is evident he had can be reached at bulletin@acms.org.
must not be pathological, because it
was so common, especially in older what is now called complex massive The opinion expressed in this column
individuals. The other theory for “black pulmonary fibrosis (cPMF), seen in is that of the writer and does not
pulmonary matter” was that it repre- both silicosis and coal workers pneu- necessarily reflect the opinion of the
sented soot inhaled from smoky lamps moconiosis (CWP). Gregory cinched Editorial Board, the Bulletin, or the
his pioneering argument by having Allegheny County Medical Society.
or domestic fires. The latter strain of
thinking was greatly advanced by an a colleague do chemical analysis of
1831 case report by Scottish physician black pulmonary matter recovered from
James Craufurd Gregory (1801-32). He the specimen that proved to be coal. Where to turn…
described a previously healthy 59-year- Complex massive pulmonary Domestic Abuse
old ex-soldier who developed dyspnea, fibrosis is in the news again, thanks Palm Cards Available
chest pain and cough productive of to investigative reporting by Howard
Berkes at NPR and Elizabeth Sheldon Where-to-Turn cards give important
dark sputum after working in a coal information and phone numbers for
mine for about a decade. Over the next at PBS/Frontline. In the early 2000s, victims of domestic violence. The cards
16 months, his condition deteriorated physicians in Appalachian clinics and are the size of a business card and are
into cardiac and renal failure, and he a few mine safety regulators started discreet enough to carry in a wallet or
purse.
died. sounding alarms about a rise in black Quantities of cards are available
On autopsy, Gregory noted, lung disease that was not only more at no cost, for distribution within
“When cut into, both lungs present- severe than what had been seen since Allegheny County, by contacting the
the advent of the Coal Act in the 1970s, Allegheny County Medical Society at
ed one uniform black carbonaceous (412) 321-5030.
colour, pervading every part of their but in much younger workers. Classic
* Please note the phone numbers and
substance. The right lung was much CWP presents after 25 years of under- information contained on the palm card is valid
disorganized, and exhibited in its ground mining. These newer cases are only for Allegheny County, Pa.
upper and middle lobes, several large developing after just 7.5-10 years of
46 www.acms.orgSociety News
Perspective
2019 Clinical Update in er-Rapport, MD, will please contact Nadine Popovich,
Geriatric Medicine set present highlights of administrator, at npopovich@acms.org
recent advances/con- or (412) 321-5030.
Registration is open for the 27th troversies
annual Clinical Update in Geriatric • State of the Art
Neil Resnick, MD, named
Medicine conference, jointly provided updates on common AGS COSAR co-chair
by the Pennsylvania Geriatrics Soci- geriatric conditions, The American
ety – Western Division (PAGS-WD), Dr. Messinger-
and tailored to each Geriatrics Society
UPMC/University of Pittsburgh Insti- Rapport
setting, i.e., office, (AGS) announced
tute on Aging, University of Pittsburgh hospital, home, nurs- that Neil M. Resnick,
School of Nursing, and University of ing home MD, AGSF, will be
Pittsburgh School of Medicine Center • Geriatric Cardiol- the next co-chair for
for Continuing Education in the Health ogy Symposium and its Council of State
Sciences. The conference will be held Cardiology Expert Affiliate Representa- Dr. Resnick
April 25-27, 2019, at the Pittsburgh Panel Q&A – featuring tives (COSAR). Dr. Resnick is Thomas
Marriott City Center. guest faculty Parag Detre Professor of Medicine and chief
The fastest-growing segment of Dr. Goyal
Goyal, MD, MSc, and of Geriatric Medicine at the University
the population comprises individu- Benjamin Wessler, of Pittsburgh and UPMC.
als above the age of 85 years. The MD, with local faculty Dr. Resnick brings a wealth of
purpose of the conference is to provide presenters Daniel For- leadership and knowledge to the role.
an evidence-based approach to help man, MD, and Jared His experience includes 15 years as a
clinicians take exceptional care of Magnani, MD. Board member and COSAR represen-
these often-frail individuals. Designed • Special topics, tative for the Pennsylvania Geriatrics
by course directors Shuja Hassan, including: Ask the Society – Western Division (PAGS-
MD, and Neil Resnick, MD, along with Expert Sessions (Psy- Dr. Wessler WD). PAGS-WD is a three-time winner
members of the PAGS-WD planning chiatry, Oncology and Rheumatology), of the State Affiliate Achievement
committee, this award-winning course Orthostatic Hypotension, Case Studies Award, including in 2018.
is designed for family practitioners, in- in Geriatric Pharmacology, Approach Dr. Resnick also has been active
ternists, geriatricians and other health- to Anemia, Vignettes in Palliative Care in AGS, having won its Outstanding
care professionals who provide care to and more. Excellence Award for Research in 2004
older adults. • Multiple breakout sessions al- and having served as an AGS Leader-
Speakers are selected by a mul- lowing attendees to design their own ship Scholar, a member of three AGS
tidisciplinary committee of academic course and affording close interactions committees, and serving as a mentor in
and practicing clinicians and based on with experts on challenging topics and its national mentorship program.
two criteria: (1) expertise – nationally real-world cases Dr. Resnick is excited by his new
recognized and often responsible for • Board Review for Clinicians. This role as he believes that State affiliates
advances relative to practice, and (2) year’s conference offers a two-part should serve the national organization
ability – to share it in a practical, suc- review. in two ways: by providing AGS with in-
cinct and entertaining way to facilitate Conference credits include AMA formation from the trenches regarding
its easy incorporation into a practice. PRA Category 1 credits™, AAFP, practitioners’ insights and priorities and
Conference highlights include (visit Nursing, Risk and ACPE credits. To by serving as AGS’ implementation arm
www.dom.pitt.edu/UGM for complete register, visit https://dom.pitt.edu/UGM. for its education and policy initiatives.
schedule): Members of the Society receive a He plans to use a team approach to
• “Year in Review for Geriatric Med- discount when registering. To become learn from each affiliate’s success
icine,” guest faculty Barbara Messing- a member or for conference details, Continued on Page 48
ACMS Bulletin / February 2019 47Society News
Perspective
From Page 47
and challenges and to identify ways to
increase the value of each affiliate. His
hope is to help increase the number
and membership of affiliates. He will
assume his new position after the
American Geriatrics Society national
meeting in May 2019.
COSAR, the governing body of the
AGS State Affiliates, is recognized as
an important, deliberative body to pro-
mote and support affiliates. It consists
of elected member representatives, one
from each of the proposed, provisional
and active State Affiliate. The group
meets regularly to exchange informa-
tion on State Affiliate activities, and to
share new ideas on development, ad-
vocacy, education, membership, public
policy and other affiliate business.
Carl C. Awh, MD, speaks Nadine Popovich / ACMS
at January POS meeting Pictured at the Jan. 10 Pittsburgh Ophthalmology Society (POS) meeting,
The POS welcomed Carl C. Awh, from left, are Sharon Taylor, MD (POS president); Andrew Eller, MD; Carl Awh,
MD, Tennessee Retina, Nashville, MD (guest speaker); Benjamin Botsford, MD; and Thierry Verstraeten, MD.
Tenn., as presenter at the Jan. 10,
Benjamin Botsford, MD, resident at Dr. Alward completed his glaucoma
2019 meeting. Thank you to POS
the University of Pittsburgh Eye Center, fellowship at the Bascom Palmer Eye
member Thierry Verstraeten, MD, for
presented a case for review and dis- Institute. Following his fellowship, he
inviting Dr. Awh to speak, and to Spark
cussion. became director of the Glaucoma Ser-
Therapeutics and Regeneron for sup-
vice at the University of Iowa, where he
port of the program. POS announces 39th Annual is professor and vice-chairman. Since
Dr. Awh, founding co-director of the
Harvey E. Thorpe Lecturer 2006, he has held the Frederick C. Blo-
Johns Hopkins Microsurgery Advanced
Design Laboratory, is an internationally Sharon L. Taylor, di Endowed Chair in Ophthalmology.
recognized clinician, surgeon, and MD, president of Dr. Alward has co-authored more than
educator. His special interests include the Pittsburgh Oph- 150 peer-reviewed papers. He served
macular surgery, diabetic retinopathy, thalmology Society as a director of the American Board of
macular degeneration, and the devel- (POS), is pleased to Ophthalmology from 2006 to 2013 and
opment of surgical devices and tech- announce Wallace was chair in 2012.
niques. L.M. Alward, MD, as Dr. Alward’s real passion is teaching.
Dr. Alward
The program featured two lectures the 39th annual Harvey He has trained 35 glaucoma fellows.
by Dr. Awh: “An Incomplete Review of E. Thorpe Lecturer. The 55th Annual He also has authored two textbooks:
Vitreoretinal Technology: Past, Present Meeting will take place Friday, March “Color Atlas of Gonioscopy” and “The
and Future” and “Genetics and AMD 29, 2019, at the Pittsburgh Marriott City Requisites: Glaucoma.” The Archives
Management.” Center. of Ophthalmology listed the “Color Atlas
48 www.acms.orgSociety News
Perspective
of Gonioscopy” as one of the 100 important ophthalmology p.m., with dinner and presentation at 7 p.m.
books of the 20th century. It has been translated into Russian, Dr. Argarwal is assistant professor, director of Diabetes
Polish and Portuguese. Transition Clinic, Albert Einstein College of Medicine, Center
He maintains a free website to teach gonioscopy (gonios- for Diabetes Translational Research, Fleischer Institute of
copy.org) that contains more than 250 gonioscopy videos. Diabetes and Metabolism, 1180 Morris Park Avenue, Bronx,
In 2017, gonioscopy.org had 51,000 users in 174 countries. N.Y.
His most recent website (curriculum.iowaglaucoma.org) was CME is available with this program. To register, visit
released in late 2015. It is a 50-lecture curriculum aimed at https://TBD.eventbrite.com.
beginning ophthalmology residents. This site contains more For information on upcoming programs, or information on
than 900 still images and more than 90 video clips. The the GPDC, please contact Dottie Hostovich at (412) 321-
curriculum has most recently been made into a free iBook. 5030 or dhostovich@acms.org.
Several distinguished guest faculty also have confirmed
their participation: Andrew G. Lee, MD, neuro-ophthalmol- Pittsburgh Urological Association to host speaker
ogist and chairman of the Department of Ophthalmology, The Pittsburgh Urological Association
Blanton Eye Institute, Houston Methodist Hospital; and will host guest speaker Edouard Trabulsi,
professor in the Departments of Ophthalmology, Neurology MD, FACS, March 26, 2019, at Ruth Chris’
and Neurosurgery, Weill Cornell Medical College; Peter Steak House, Pittsburgh. Registration be-
Veldman, MD, assistant professor of Ophthalmology and gins at 6:15 p.m., followed by the program
Visual Science, and director, Residency Program, Univer- and dinner at 6:45 p.m.
sity of Chicago Medicine; and Sophie Bakri, MD, professor Dr. Trabulsi will present: “A Treatment
of Ophthalmology, Mayo Clinic, Rochester, Minn.; and Option for Castration-Resistant Prostate Dr. Trabulsi
José-Alain Sahel, MD, professor and chairman, The Eye Cancer (CRPC).”
and Ear Endowed Chair, Department of Ophthalmology, Dr. Trabulsi received his medical degree from The
director, UPMC Eye Center, University of Pittsburgh School University of Buffalo School of Medicine and Biomedical
of Medicine. Sciences. He completed his fellowship in Urologic Oncology,
Online registration is available at www.pghoph.org. Memorial Sloan – Kettering Cancer Center in 2003, and his
fellowship in Minimally Invasive Urologic Oncology at Memo-
40th Annual Meeting for Ophthalmic Personnel set rial Sloan Kettering in 2004.
The 40th Annual Meeting for Ophthalmic Personnel, pre- He is director of the Minimally Invasive Urology Oncol-
sented by the Pittsburgh Ophthalmology Society (POS), will ogy, as well as director of Clinical Trials in the Department
run concurrently with the POS Annual Meeting Friday, March of Urology, Jefferson Medical College at Thomas Jefferson
29, 2019, at the Pittsburgh Marriott City Center. University. He also is director of the Division of Urologic
Online registration is available at www.pghoph.org. Con- Oncology in the Department of Urology.
tact Nadine Popovich, administrator, for details and more Registration is required by March 21. For more informa-
information at npopovich@acms.org. tion or to register, please contact Dottie Hostovich, adminis-
trator, at (412) 321-5030 or dhostovich@acms.org.
Greater Pittsburgh Diabetes Club to meet
The Greater Pittsburgh Diabetes Club Local history of medicine books available
(GPDC) will welcome guest speaker The Allegheny County Medical Society announces the
Shivani Argarwal, MD, MPH, Thursday, May publication of “A Tradition of Leadership, Innovation and
16, at the ACMS building. Caring,” a 200-page history of medicine in Pittsburgh and
Dr. Argarwal will present: “Transition Allegheny County.
from Pediatric to Adult Care for Type 1 Di- Copies are available from ACMS for $49.95, plus ship-
abetes: The Good, the Bad, and the Ugly.” ping and handling. Please call (412) 321-5030 for more
The program will begin with a reception at 6 Dr. Argarwal information.
ACMS Bulletin / February 2019 49Profile
Newly installed ACMS president to
focus on unity, inclusion and support
Christina E. Morton in the Division of Geriatric Medicine.
Her prior roles include medical director,
A dele L. Towers, MD, MPH, FACP,
became the 154th president of the
Allegheny County Medical Society
Primary Care, at Western Psychiatric
Institute and Clinic; vice chair of Quality
Improvement and Patient Safety for
Jan. 1, 2019. Only the fourth woman to the Department of Medicine; medical
hold the position, Dr. Towers originates director of UPMC Health Information
from Connecticut, but has considered Management; and medical director of
Pittsburgh her home since she moved UPMC Home Health. She also served
to the Steel City in 1986 to complete as president, Medical Staff, UPMC
her internal medicine residency at the Presbyterian.
University of Pittsburgh School of Med- As medical director of UPMC Health
icine. A fellowship in geriatric medicine Information Management for nearly
and a master’s degree in Public Health seven years, Dr. Towers oversaw med-
followed in 1991. ical records at every UPMC hospital.
Dr. Towers was introduced to the Dr. Towers The position required her to attend all
medical profession at a young age. the hospitals’ medical staff meetings,
Her father passed away when she was like mentors and helped to steer Dr. which enabled her to meet physicians
14 years old, and the physicians and Towers toward the specialty of geriatric throughout the health system and learn
nurses that took care of him when he medicine. about the issues at each hospital.
was ill had a lasting impact on her. As a medical student, Dr. Towers “Fulfilling that position made me aware
After completing an engineering de- had the opportunity to travel to Sri Lan- of the need for physicians to communi-
gree at Cornell University, Dr. Towers ka for six weeks, which was a mem- cate with each other and to be con-
entered the University of Connecticut, orable and eye-opening experience. nected. We shared a lot of the same
where she earned her medical degree. Describing it as very primitive and ob- issues, and a lot of the same solutions
Her interest in internal medicine and serving undesirable care of the elderly, could be applied at each hospital.”
geriatrics stemmed from her childhood, Dr. Towers recalls seeing patients with During her tenure, the department
growing up around a lot of older adults rabies, tuberculosis and other diseases developed two computer-assisted
as a result of her grandmother, aunt that were not prominent in the states. coding (CAC) tools that became quite
and uncle each having personal care The experience was life-changing, successful. In 2013, Dr. Towers was
facilities in their own homes. “I enjoyed and she would encourage all medical invited to join the staff at UPMC Enter-
hearing their stories and was interested students to participate in an overseas prises, which is dedicated to technolo-
in their medical issues,” Dr. Towers mission trip if the opportunity presents gy development for medical providers
said. “It made sense to pursue internal itself. and insurance companies. She current-
medicine and transition into geriatrics.” Dr. Towers has been on the faculty ly serves as senior clinical advisor and
She also was influenced by several at the University of Pittsburgh since director of Risk Adjustment.
professors of geriatrics during her 1992 and is currently an associate “I have been very fortunate to work
medical training. They became more professor of Medicine and Psychiatry with several of the start-up companies
50 www.acms.orgYou can also read
