2014 March/April by SCCMA

MARCH/APRIL 2014 | VOLUME 20 | NUMBER 2

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2 | THE BULLETIN | MARCH/APRIL 2014

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS

Feature Articles

Billing/Collections

10 Fight to Protect MICRA Begins in Earnest as Trial Lawyers Submit Ballot Signatures

CME Tracking

11 Thank You to SCCMA-MCMS CALPAC Donors

Discounted Insurance

13 Congress Passes California Medicare GPCI Fix, ICD10 Delay and SGR Patch

Financial Services

14 Choosing Wisely

Health Information Technology

22 Is There a Misperception of the Risks of Tonsillectomy?

Resources House of Delegates Representation Human Resources Services Legal Services/On-Call Library

26 Greening the O.R. 30 Responding to Online Negative Comments

Departments 5 Message From the MCMS President

Legislative Advocacy/MICRA

6 Message From the SCCMA President

Membership Directory iAPP for

8 From the Editor’s Desk

the iPhone Physicians’ Confidential Line Practice Management

18 Save These Dates 31 Letter From Santa Clara County Public Health Department

Resources and Education

32 California Public Protection and Physician Health

Professional Development

33 Disruptive Physician Behavior: Use and Misuse of the Label

Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount

34 CMA News 38 Medical Times From the Past 39 In Memoriam 40 Welcome New Members 42 Classified Ads 44 MEDICO News MARCH/APRIL 2014 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Sameer Awsare, MD President-Elect James Crotty, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Peter Cassini, MD VP-Professional Conduct Seham El-Diwany, MD Secretary Eleanor Martinez, MD Treasurer Scott Benninghoven, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Imtiaz Qureshi, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Seema Sidhu, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Michael Champeau, MD Santa Clara Valley Medical Center: Richard Kramer, MD

AMA TRUSTEE - SCCMA James G. Hinsdale, MD

CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Martin L. Fishman, MD (District VII) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

Editor

President Kelly O'Keefe, MD President-Elect Jeffrey Keating, MD Past President John F. Clark, MD Secretary Patricia Ruckle, MD Treasurer Steven Vetter, MD

THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2014 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MARCH/APRIL 2014

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

John Jameson, MD

E. Valerie Barnes, MD

Jeff Keating, MD

Ronald Fuerstner, MD

Eliot Light, MD

James Hlavacek, MD

R. Kurt Lofgren, MD

David Holley, MD

AMA TRUSTEE - MCMS David Holley, MD

MESSAGE FROM THE MCMS PRESIDENT

KELLY R. O'KEEFE, MD President, Monterey County Medical Society

Beads on a Wire By Kelly R. O’Keefe, MD President, Monterey County Medical Society Recent events across a range of disciplines have rekindled a long-standing interest of mine in uncertainty. Not the uncertainty of Heisenberg that operates most obviously at quantum scales, but the everyday uncertainty that plagues so many of our daily decisions. Bear with me, while I share some of the events, and then what they have to do with beads on a wire. Two of the events are from deeply basic sciences: cosmology and particle physics. The first event was the announcement of the discovery of a new elementary particle in the summer of 2012 that was subsequently confirmed to have the characteristics of the previously theorized Higgs boson. The second was the announcement, a few days ago, of the discovery of inflationary gravitational waves in the Cosmic Background Radiation. As important as they now seem, each of these discoveries may turn out to be wrong. We have a pretty good estimate of how likely that is. Here is a quote from the abstract related to the former, “This observation, which has a significance of 5.9 standard deviations … is compatible with the production and decay of the Standard Model Higgs boson.” And from the later, “We find an excess of B-mode power… inconsistent with the null hypothesis at a significance of > 5σ.” In medicine, we may have had such seminal discoveries announced recently, but in any case, we have had many high-impact activities implemented that sometimes affect patients by the dissemination of new medical knowledge about diagnosis and treatment, and other times by delivery system changes. What does the medical literature have to say about each of these mechanisms? As I noted a couple of months ago, PubMed is adding almost two-thirds of a million new citations each year, many of them describing new diagnostic or therapeutic approaches, and many of those including statistics that we use to estimate the likelihood that the results are “real.” A p-value <0.05 is often treated as if it separates important from unimportant. Further, the care approaches added to our knowledge base by these papers underpin our technical approach to the patient. John P. A. Ioannidis, MD, C. F. Rehnborg Professor in Disease Prevention in the School of Medicine at the Stanford University School of Medicine, is concerned about whether our reliance on published studies may lead us astray. The title of one of his published papers doesn’t pull any punches, “Why Most Published Research Findings Are False.” Mayo Clinic Proceedings recently described medical reversal, where new trials contradict current practice, “A decade of reversal: an analysis of 146 contradicted medical practices.” Vinay Prasad, MD, and Adam Cifu, MD, state in an abstract from a paper on medical reversal, “Famous examples include the class 1C anti-arrhythmics post-myocardial infarction (contradicted by the CAST trial) or routine stenting for stable coronary disease (contradicted by the COURAGE trial),” and note, “… importantly, it creates a loss of faith in the medical system by physicians and patients.” Also, along the lines of loss of faith in the medical system are recent

findings related to delivery system changes. Some of these findings are from the so-called Oregon Medicaid Experiment, where a Medicaid lottery allowed a randomized, controlled experiment of insuring previously uninsured adults. While this study found some positive effects, it also found that emergency department use by the insured increased 40% in comparison to the control group, health expenditures increased, and overall physical health was not improved. These findings were in stark contrast to those expected from the change in insured status. A recent New England Journal of Medicine article dashed a similar dose of cold water on the patient-centered medical home concept with an article entitled, “Almost No Benefit of Medical Home Interventions in Community-based Practices.” I’m not quite sure if this is a medical reversal or the initial, uncontrolled, study, but these types of findings are especially troubling because system delivery changes affecting millions of people and costing billions of dollars are routinely implemented with even less evidence of likely positive effects than practices subject to medical reversals. About 35 years ago, I read an essay by British astronomer R. A. Lyttleton in The Encyclopedia of Ignorance in which he proposed a mental model to be adopted in evaluating any hypothesis, which includes all of the above situations. He suggested that one think of their belief in a hypothesis as a wire with a bead on it, with one end of the wire representing certainty that the hypothesis is true (1) and the other end representing certainty that the hypothesis is false (0). His advice is, “Never let your bead ever quite reach the position 0 or 1.” He says that is when the bead falls into the emotional pit of pride and prejudice and it cannot be recovered. Our Bayesian friends would put it more formally and quantitatively, but I take their point to be the same. When we become too certain of our ideas, we fall into a frame of mind that does not do justice to the fundamental uncertainties of our ability to understand the world. Somehow, it seems to me that that degree of skepticism would be very helpful in avoiding some of the errors that clinging too tightly to positions informed by p<0.05 evidence, or worse yet, no evidence at all, brings us. Our physicist colleagues seem to be able to make do with waiting for p<0.0000003 results to declare adequate certainty. Although human variability and a need to bring diagnoses and treatments to patients in a timely fashion, undoubtedly, make waiting for five sigma significance unrealistic, could we strike a better balance? Is this part of the meaning of, “First of all, do no harm.” That seems to me to be a sensible interpretation. But I have to admit, I am not certain.

Kelly R. O’Keefe, MD, is the 2013-2014 president of the Monterey County Medical Society. He is a board certified pathologist and is currently CEO of Adaptive Clinical Solutions, Inc. MARCH/APRIL 2014 | THE BULLETIN | 5

MESSAGE FROM THE SCCMA PRESIDENT

SAMEER V. AWSARE, MD, FACP President, Santa Clara County Medical Association

Prescription Drug Overdoses – A Deadly Epidemic By Sameer V. Awsare, MD, FACP President, Santa Clara County Medical Association March is Prescription Drug Abuse Awareness Month throughout California. Drug overdose deaths have continued to increase, year after year, over the last decade. According to the latest available data from the Centers for Disease Control, drug overdoses were responsible for 38,329 deaths in 2010, making them the leading cause of death in this country. This equates to one death every 14 minutes and surpasses even deaths by motor vehicle accidents, suicide, and firearms. Nearly 60% of the drug overdose deaths involved pharmaceutical drugs. Opioid analgesics, such as oxycodone, hydrocodone, and methadone, were involved in about 3 of every 4 pharmaceutical overdose deaths. In addition to the toll they take on human lives, opioids take a significant economic toll on the communities in which we live. It is estimated that the total cost in the U.S. from the non-medical use of prescription opioids amounts to $53.4 billion: $42 billion from lost productivity, $8.2 billion from criminal justice costs, $2.2 billion from the cost of treatment, and $944 million from medical complications. Without further intervention by the medical community, this epidemic will only grow. For about 6,000 years, opioids have been used to treat not only pain, but a variety of conditions. The initial source of opioids was opium, which was derived from the Eurasian poppy (Papaver somniferum). It was not until the 1800s when morphine was isolated and synthesized, after which it became available commercially. The question of the appropriateness of opioids as a mechanism for treating pain in the United States is not a new one. In the 1960s, there was a significant increase in the use of prescription as well as illicit drugs. The government began to crack down on prescription drug abuse in the 1970s by enacting laws developed to curtail false and fictitious prescriptions. This legislative change was accompanied by a cultural shift within the field of medicine, resulting in a significant decrease in the utilization of opioids to treat chronic pain. Though these developments successfully drove down the quantity of opioids prescribed for pain, they may have gone too far. Studies conducted in the late ‘80s and early ‘90s confirmed that health care providers were under-treating pain. In the early- and mid-1990s, the pendulum swung yet again as the field of medicine shifted its stance on pain management towards an increased acceptance of opioids as a reliable treatment modality. There was a belief that a patient experiencing pain should be given as high of a dose of opioids as necessary to treat their pain. As a result of this latest shift in perception, we find ourselves, yet again, in a position where the high utilization of and reliance on opioids creates significant patient safety concerns. As a nation, we have become the dominant prescribers and con6 | THE BULLETIN | MARCH/APRIL 2014

sumers of pain medications. While the U.S. makes up only 4.6% of the world’s population, we consume 80% of the world’s opioids and 99% of its hydrocodone, which is found in Vicodin. The spillover beyond medicine is significant. According to the White House, nearly a third of people using illicit drugs for the first time began by using a prescription drug illegally. Hence, it is imperative that the medical community comes together for the sake of protecting our patients. To begin with, we need to use opioids based on evidence-based principles which have shown that they are effective in treating acute pain, and pain during terminal illness. Physicians need to assess whether patients are at risk for drug addiction, abuse, or overdose, and prescribe the appropriate amount of opioids for a particular medical condition. For instance, if a patient’s pain is expected to resolve after three days after a procedure, then giving the patient a three-day supply of opiods would be prudent, instead of a 100-day supply with multiple refills. Opioids are powerful drugs Sameer V. Awsare, MD, FACP, is the 2013-2014 president of the Santa Clara County Medical Association. He is a board certified internist and is currently practicing with The Permanente Medical Group in Campbell.

and should be avoided in conditions like axial low back pain, fibromyalgia, and headaches, where they have not shown to be effective. Physicians and patients should be aware of the 90-day cliff, since people who use opiods continuously for more than 90 days are likely to use them for the rest of their lives. People taking over 100 mg of morphine equivalents are at highrisk of overdose. This risk of overdose and death significantly increases when people take medications like muscle relaxants and benzodiazepines along with their opioids. We also need to acknowledge that some patients who are addicted to opioids might try to take advantage of the health care system and extract prescriptions from multiple providers. While some integrated health care systems with electronic medical records can look for signs of this type of gaming within their system, it is only through utilizing broader statewide or regional systems, like the Controlled Substance Utilization Review and Evaluation System (CURES) database set up by California’s Department of Justice, that providers can be certain to have a full picture of all the various opioids that their patient has been prescribed. The most recent California data shows that only 9.5% of eligible prescribers are even registered on CURES.

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In order to stop the epidemic of prescription opioid overdoses, we must educate physicians regarding the optimal management of patients on opioids, and build the necessary infrastructure to support them in: • Weighing the risks/benefits of long-term opioid use as part of a broader multi-modal treatment plan, • Ensuring that opioids are prescribed for patients with conditions shown to respond well to them, and in the appropriate dosages, • Monitoring patients for signs of side effects and for abuse, and • Ensuring that patients who are starting long-term opioid therapy are aware of the risks inherent in long-term use. We owe it to our patients to stop the swinging of the pendulum and need to work together to stop this growing epidemic. We must make sure that every patient with pain receives compassionate and appropriate treatment while doing our best to ensure their safety and protecting their lives.

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FROM THE EDITOR’S DESK

JOSEPH S. ANDRESEN, MD Editor, The Bulletin

Finding that Balance By Joseph S. Andresen, MD Editor, The Bulletin Russia invades Crimea. Malaysian flight 370’s disappearance remains a mystery. A massive mudslide buries the rural town of Oso, Washington. The Hobby Lobby contraception case goes before the Supreme Court. Six million are newly insured with private insurance through health care exchanges, as the deadline for enrollment approaches. We are continually bombarded with this 24-hour, 7-day-aweek news cycle. This frenetic world hovers over our daily lives, adding weight to the many responsibilities of a busy clinic schedule, hospital rounds, or the care of our sickest patients. What do we do when this all becomes a bit too much? How do we find a reasonable distraction and departure from the pressures and worries of our daily professional and personal lives? Seeking new challenges, finding a renewed purpose, and recognizing the need for a new equilibrium may answer these questions. A brisk walk outside, liberating us briefly from fluorescent office habitat, may do the trick. An unscheduled day with nothing planned provides simple pleasures that surprise us. Should we make more time for that hobby that always caught our interest or for renewing a dormant friendship? Rejuvenation is the key. A recent and spontaneous trip opened my eyes to many of these questions. How long will I continue to be able to be active and independent? How many more years will I be able to do the things I choose to do and not take them for granted? Is this not what our patients ask of us? To help them maintain their own balance. “Come down to Miami and we can get you sailing on a Moth,” replied Ian Andrewes, the manager for the 2013 Red Bull America’s Cup America Youth Sailing Force team. I was one of many thousands who became mesmerized by the sight of America’s Cup 72-foot catamarans flying above the water as much as sailing across the San Francisco bay last summer. The Moth became a one-person training platform for many of the skippers learning to “fly” their boats in a seemingly precarious new way. I couldn’t pass up this opportunity and one hour after my 24-hour call shift ended, 8 | THE BULLETIN | MARCH/APRIL 2014

was on a Virgin America flight bound for Florida. A Northeasterly wind whipped across Biscayne Bay, as I drove across a bridge bringing me to the Miami Rowing Club. With a setting sun, I arrived just in time as sailing coaches Ian Andrewes and Jonny Goldsberry were stowing gear at day’s end. “It’s pretty windy today from a low pressure system passing through. Hopefully, the wind will moderate a bit tomorrow for your first lesson. See you then,” Ian replied, as I departed. Indeed it was windy the next morning, with gusts sending darkened ripples and whitecaps in a chaotic dance across the water. “Steady 22 mph with gusts to 28 mph,” I called out while reading a wind meter app on my smartphone. “Let’s go get lunch at this great Cuban café and check back after lunch,” Ian suggested. It sounded like a great idea as I nervously eyed the 62-pound narrow carbon fiber hull, bounded by small trampoline seats on each side and sharp wing-like foils underneath. In fact, the Mach 2 Moth looked more purpose built for flying than floating. That afternoon, the wind subsided a bit and I donned a shorty wet suit, gloves, and booties and jumped into a small RIB powerboat that took us out in a more central part of Biscayne Bay. The setting was spectacuJoseph S. Andresen, MD, is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara Valley area.

lar as downtown Miami high-rise buildings peered directly at us in the distance. I stepped carefully off the RIB into the cockpit of the Moth and it immediately rolled over, capsizing. The sudden shock of being immersed in the water caught me by surprise, but was much warmer than I expected, as I hung on to the side of the boat. “Grab the mainsheet and slide back on,” Ian shouted from the RIB. I pulled myself up and grabbed the line attached to the boom, controlling the sail. Suddenly, the Moth came to life and I hung on, trying to balance on this knife’s edge. A brief puff of wind filled the sail and over I went, falling back into the water on the far side. I tried fruitlessly for the next hour to find some point of equilibrium in this small and unforgiving vessel. Recognizing my complete fatigue, Ian came to my rescue. I barely found the strength to climb back inside the RIB for the ride back to the rowing club. “Don’t be discouraged,” Ian advised. “We all find this boat a real challenge to learn how to sail. I still do after six years and as a prosailor. That’s what makes it such a rewarding challenge.” The second day came quickly despite protests from my body. Sore yet undeterred, I was ready to go. “Hey, look at Cooper. He’s up and foiling on his first day!” Cooper was a teammate of Ian’s during the 2013 Red Bull America’s Cup event. The Moth had risen out of the water and was flying toward the horizon. An hour later, I was wet, exhausted, and no closer to successfully staying upright and afloat for more than a few moments.

“Use your weight more aggressively and find your balance,” Ian urged me as we began our third day on the water. It was a bright and sunny morning with a brisk, easterly wind. The small, light boat felt like a bucking bronco, flipping over repeatedly when I failed to quickly grab the reins (mainsheet) in time. “Joe, get your feet under the strap. Here comes a puff….ease, ease…good balance,” Ian called, as he rode nearby me keeping pace in the small powerboat. I began to move faster as the water rushed by. “You’re foiling! You’re foiling!” I heard a voice behind me yell. Suddenly, the sound of rushing water disappeared and I felt myself flying over the water, accelerating at a faster and faster rate. It was as though I was weightless, hurtling through space. And as soon as it began, the boat took an abrupt dive and my brief flight came to an end, crashing, bow first into a wave a meter below. “Good job. Good way to end the day,” Ian exclaimed, as I bobbed on the surface of the water with the overturned Moth a few feet away. After three frustrating days, I finally found the proper balance that propelled me over the water for those brief moments. I left Miami and headed home with much to share with family and friends. It was time to return to my professional life, but with a surprisingly renewed energy. And now I have a much deeper understanding and humbled respect for those who sail over the water, rather than in it. A renewed equilibrium and the many paths that lead to it were the take away lessons for me. Finding this balance allows us to bring our best to patients, family, friends, and most importantly, ourselves. The following is a video link for my article that may be of interest: http://youtu.be/vs6LOPoAOF0.

MARCH/APRIL 2014 | THE BULLETIN | 9

Oppose Trial Lawyers

Fight to Protect MICRA Begins in Earnest as Trial Lawyers Submit Ballot Signatures On March 24, 2014, Consumer Watchdog and the state’s trial attorneys submitted more than 800,000 signatures in county registrar or voters offices across the state, setting in motion a validation process that will likely land an initiative aimed at gutting California’s Medical Injury Compensation Reform Act (MICRA) on the November ballot. The trial attorneys’ ballot measure seeks to more than quadruple MICRA’s cap on non-economic damages, lifting the amount to roughly $1.2 10 | THE BULLETIN | MARCH/APRIL 2014

million. If successful, the trial attorneys’ ballot measure would have devastating effects on California’s health care industry and could also pass on “hundreds of millions of dollars” annually to state and local governments, according to an impartial analysis by the state’s Legislative Analyst. The initiative also contains provisions regarding drug testing of physicians and places unrealistic and infeasible requirements on the state’s prescription drug database, which proponents have said were only added

because they polled well and are the “ultimate sweetener.” With these signatures submitted, the fight to defend MICRA begins in earnest. California physicians must stand together in opposition of this ballot measure! The California Medical Association (CMA)-led coalition working to protect MICRA has published a patient education brochure to help inform California voters about the ballot initiative being pushed by trial attorneys. The pamphlet, available in English and Spanish, can be distributed to patients during office visits and will be accompanied by talking points for physicians so you can have meaningful conversations with patients on the real impacts the proposed ballot measure would have, if passed. There is no doubt that physicians understand how catastrophic a measure like this would be for access to affordable health care. To win this fight, voters, your patients – those you interact with everyday in your practices – must understand the fact that protecting MICRA goes handin-hand with protecting access to quality health care in California.

If you would like to receive brochures for your office, please contact Yna Shimabukuro at yshimabukuro@cmanet.org or 916/551-2567. For more information on the proposed initiative, as well as how you can help defeat this ballot measure, please visit www.cmanet.org/micra.

Thank You to SCCMA and MCMS CALPAC Donors

SCCMA-MCMS/CMA extends a huge thank you to the many members listed below who have already made generous contributions to CALPAC for the 2013-2014 fiscal year (as of March 27, 2014). SCCMA-MCMS/CMA genuinely appreciates your commitment to defending and protecting MICRA. Every physician in California owes a “thank you” to the CALPAC donors listed below for assisting the California Medical Association’s Political Action Committee in protecting and defending MICRA. All members are strongly encouraged to contribute to CALPAC at www.cmanet.org/ micra. All contributions are appreciated! We thank you in advance for your contribution.

MONTEREY COUNTY MEDICAL SOCIETY

SANTA CLARA COUNTY MEDICAL ASSOCIATION

Participation Level $500 - Congressional Club William Khieu

Participation Level $2,500 - Platinum Kenneth Blumenfeld Tanya Spirtos

$300 – Club James Ramseur, Jr. $150 – Sustainer Paul Anderson John Carlson Melvin Gorelick Richard Hambley David Holley Steven Johnson Susan Kubica R. Kurt Lofgren David Perrott David Ramos Cary Yeh Up to $50 – Honor Roll Donald Catalano Elaine Chiu John Jameson

$1,000 – President’s Circle Scott Benninghoven Thomas Dailey Martin Fishman $500 – Congressional Club Annu Navani $300 – Club James Crotty Jeffrey Coe Leonard Doberne Richard Kramer Thomas Kula, Jr. Joseph Mason, Jr. Mark McCormick Dennis Penner Rebecca Powers Julia Shuleshko Seema Sidhu Gloria Wu

$150 – Sustainer Jeffrey Anderson Krikor Barsoumian Arthur Basham George Block Sara Bunting Christopher Burke Richard Cherlin Sara Colby Miles Congress James Crane Dominick Curatola Michael Curtis Tiffany Davies James Davilla Eugene Della Maggiore, Jr. John Wesley (Wes) Emison Brandt Foreman William Fowkes, Jr. S. Robert Freedman Sandeep Gidvani Jennifer Grady Sterling Haidt Barbara Hom Francis Koch Rhonda Lappen

Ami Laws Jin Lee Peter Levin Melissa Lynch Eleanor Martinez Robert Marx Robert Matthews Jennifer Maw Michelle Maxey Andrew Menkes Michael Murray Michael Nagel Steven Naleway Suresh Nayak Anh Nguyen Lewis Osofsky Narciso Padua Samuel Pearl Karen Purcell Bernard Recht Veronica Rivera Marshal Rosario Jude Roussere Bassam Saffouri Hussein Samji Steven Schwartz Randall Seago Leo Semkiw

Mark Snyder Geoffrey Spencer Kevin Stuart R. Lawrence Sullivan, Jr. Ernest Thomas, Jr. Michael Tran Harsha Vittal Hugh Walsh William Waterfield, Jr. Gerald Weiss Elizabeth Wu Chi-Kwan Yen $50 – CALPAC Gerald Berner Harrison Chow John Damron Malini Daniel Patricia Diamond Benjamin Durkee Barbara Hastings Stuart Krigel Jennifer Zocca Up to $50 – Honor Roll Philip Miller

MARCH/APRIL 2014 | THE BULLETIN | 11

Protect Access to Quality Health Care and Patient Privacy OPPOSE THE MICRA MEASURE Here’s why a broad coalition of doctors, community health clinics, hospitals, local governments, public safety, business and labor opposes the proposed November ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals:

YOU MAY BE AWARE OF A TRIAL ATTORNEY-SPONSORED BALLOT MEASURE THAT WOULD UNDERMINE THE PROTECTIONS AFFORDED TO PATIENTS ACROSS CALIFORNIA AS PART OF THE MEDICAL INJURY COMPENSATION REFORM ACT (MICRA).

THIS NOVEMBER, these trial attorneys will ask voters to weigh

THE CALIFORNIA MEDICAL ASSOCIATION (CMA) has joined a

in on “The Troy and Alana Pack Patient Safety Act,” which

broad coalition of doctors, community health clinics, hospitals,

would make it easier and more profitable for lawyers to sue

local governments, public safety, business and labor to oppose

doctors and hospitals. This measure, according to California’s

the proposed November ballot proposition. Visit www.cmanet.

independent Legislative Analyst, could increase state and local

org/micra for more information about what CMA is doing in this

government malpractice and health care costs by “hundreds

fight and how to get involved.

of millions of dollars annually,” ultimately placing the burden of this additional cost on all of us. AS IT STANDS NOW, county and state hospitals have to pay medical malpractice awards out of the budgets they receive from

Community health care clinics, like Planned Parenthood, say this measure will raise insurance costs that will cause specialists, like OB/GYN’s to reduce or eliminate services to their patients.

taxpayers. If medical malpractice awards increase, government costs will increase too. Somebody has to pay, and that will be taxpayers through higher taxes and California citizens through higher health care costs.

NOT ONLY WOULD THIS MEASURE COST patients across the state, it’s a misleading measure intended to fool voters.

ADDITIONALLY, this measure would vastly increase the number

Written by trial attorneys, the measure makes it easier and

of lawsuits filed in California. That’s why the independent

more profitable for lawyers to sue doctors and hospitals —

Legislative Analyst says that county and state hospitals will see

even if that means higher health costs for the rest of us. Our

costs of tens of millions of dollars that taxpayers will have to

health laws should protect access to care and control costs for

pay.

everyone, not increase lawsuits and payouts for lawyers.

12 | THE BULLETIN | MARCH/APRIL 2014

MICRA > Protect Access

YOU’LL HEAR A LOT OF RHETORIC

patients. Finding doctors to deliver

OVER 1,000 GROUPS have joined

from the proponents of the measure

children in rural areas and community

together in support of MICRA and in

but really, this is another example of

clinics is already difficult and reducing

opposition to this dangerous, costly

special interest legislation trying to

services will make a bad situation worse.

measure. Be part of the effort to protect

fool the voters into thinking this about

patients by visiting

something that it’s not. The authors

www.cmanet.org/micra today!

of this proposal purposely threw in non- MICRA provisions, like drug testing doctors, to disguise the real intent, which is to increase the limits on medical malpractice awards so that trial lawyers make even more money. The main proponent of the measure was recently quoted in the LA Times, saying, “The drug rules are in the initiative because they poll well, and the backers figure that’s the way to get the public to support the measure. ‘It’s the ultimate sweetener.’” THIS MEASURE also requires a government database with personal information on patients’ prescription drug history. Hackers have already managed to access personal information from millions of Target customers and even the Pentagon, and another big database will only make our information more vulnerable. PHYSICIANS TAKE AN OATH to protect patients – and this dangerous initiative would put patients at risk of losing access to quality medical care. COMMUNITY HEALTH CARE CLINICS, like Planned Parenthood, say this measure will raise insurance costs that will cause specialists, like OB/GYN’s to reduce or eliminate services to their

Congress Passes California Medicare GPCI Fix, ICD-10 Delay, and SGR Patch On March 31, the U.S. Senate passed the “Protecting Access to Medicare Act of 2014” bill to postpone for one year the 24% cut to Medicare physician payments as called for under the fatally flawed sustainable growth rate (SGR). The bill (H.R. 4302) was signed into law by the President on April 1. The bill, which already passed the U.S. House of Representatives last week, provides a 0.5% physician payment update through December 31, 2014, and then a 0% update until April 1, 2015. On a bright note, the patch bill does include the California Medicare locality update, known as the California geographic practice cost index (GPCI) fix. The long overdue GPCI fix will update California’s Medicare physician payment regions and raise payment levels for urban counties misclassified as rural, while holding remaining rural counties harmless from cuts.

The bill also delays for one year the ICD-10 medical billing coding conversion, pushing the implementation date to October 1, 2015. The California Medical Association is waiting for guidance from the Centers for Medicare and Medicaid Services on how ICD-10 will ultimately be implemented. Watch www.cmanet. org for future news regarding ICD-10 implementation.

MARCH/APRIL 2014 | THE BULLETIN | 13

Choosing Wisely Choosing Wisely

REPRINTED WITH PERMISSION FROM THE SAN FRANCISCO MEDICAL SOCIETY

CHOOSING WISELY CHOOSING Up Close and PersonalWISELY Up Close and Personal

Catherine Lucey, MD, FACP Catherine Lucey, MD, FACP

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SAN FRANCISCO MEDICINE JANUARY/FEBRUARY 2013

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Table 1: Original Specialty Societies Joining the Choosing Wisely Campaign # ( $ #/ % "" ( /1 )* # 1 $ ##+$%"% / # ( $ #/ % # "/ /) $) # ( $ %"" % ( %"% / # ( $ %"" % /) $) # ( $ %"" % %"% / # ( $ )*(% $* (%"% " ))% * %$ # ( $ % */ % " $ " $ %"% / # ( $ % */ % & (%"% / # ( $ % */ % + " ( ( %"% /

Table 2: Consumer Organizations Endorsing Choosing Wisely "" $ "* & (% (%+& - )* +) $ )) (%+& %$ "* $$ )%* "* * %$ (%+& * %$ " +) $ )) % " * %$ %$ "* * %$ " +) $ )) (%+& %$ "* * %$ " $* ( %( (#-%(! ( "* * %$ " %)& $ "" * , ( ( $ 0 * %$ * %$ " (*$ () & %( %# $ $ # " ) H +) $ )) (%+& %$ "* $ %$ "+) ! &

Table 3: New Specialties Joining the Campaign

# ( $ #/ % # "/ /) $) # ( $ #/ % %)& $ "" * , $ # ( $ #/ % +(%"% / # ( $ #/ % & * "#%"% / # ( $ #/ % *%" (/$ %"% /; $ ! +( (/ # ( $ #/ % *( ) # ( $ %"" % )* *( $) $ /$ %"% )*) # ( $ %"" % +# *%"% / # ( $ ( *( ) % */ # ( $ % */ %( " $ " * %"% / # ( $ % */ % % ( % ( & / # ( $ (%"% " ))% * %$ % */ % ( %, ) +" ( %#&+* %#% ( & / % */ % %)& * " $ % */ % + " ( $ $ %" +" ( # $ % */ % %( +( %$) % */ %( ) +" ( $

See www.ChoosingWisely.org for more!

MARCH/APRIL 2014 | THE BULLETIN | 15 JANUARY/FEBRUARY 2013 SAN FRANCISCO MEDICINE

PUBLIC HEALTH

Choosing Wisely An initiative of the American Board of Internal Medicine (ABIM) Foundation SCCMA-MCMS is publishing various Choosing Wisely® lists of "Things Physicians and Patients Should Question." Choosing Wisely - see page 17 - is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

16 | THE BULLETIN | MARCH/APRIL 2014

Originally conceived and piloted by the National Physicians Alliance through a Putting the Charter into Practice grant, leading medical specialty societies along with Consumer Reports, have identified tests or procedures commonly used in their fields whose necessity should be questioned and discussed. The resulting lists of "Things Physicians and Patients Should Question" will spark discussion and the need - or lack thereof - for many frequently ordered tests or treatments.

HOW THIS LIST ON PAGE 17 WAS CREATED

The American Academy of Family Physicians (AAFP) list is an endorsement of the five recommendations for Family Medicine previously proposed by the National Physicians Alliance (NPA) and published in the Archives of Internal Medicine, as part of its Less is MoreTM series. The goal was to identify items common in primary care practice, strongly supported by the evidence and literature, that would lead to significant health benefits, reduce risks and harm, and reduce costs. A working group was assembled for each of the three primary care specialties; family medicine, pediatrics and internal medicine. The original list was developed using a modification of the nominal group process, with online voting. The literature was then searched to provide supporting evidence or refute the activities. The list was modified and a second round of field testing was conducted. The field testing with family physicians showed support for the final recommendations, the potential positive impact on quality and cost, and the ease with which the recommendations could be implemented. More detail on the study and methodology can be found in the Archives of Internal Medicine article: The “Top 5” Lists in Primary Care.

American Academy of Family Physicians American Academy of Family Physicians

Fifteen ThingsPhysicians Physicians Five Things and patients Patients Should Should Question Question and Fifteen Things Physicians and Patients Should Question

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Don’t do imaging for low back pain within the first six weeks, unless red flags are present. Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis Don’t do imaging for low back pain within the first six weeks, unless are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason forare all physician visits. red flags present.

1 1

Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.

2 2 3 3 4 4 5 5

Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinicalantibiotics improvement. Don’t routinely prescribe for acute mild-to-moderate Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is sinusitis unless symptoms last for seven or more days, or symptoms due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient for acute clinical sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs. worsen aftervisits initial improvement. Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with nodual-energy risk factors.x-ray absorptiometry (DEXA) screening Don’t use DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients. for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. DEXA is not cost effectiveannual in younger, low-risk patients, but is cost effective in older patients. or any other cardiac Don’t order electrocardiograms (EKGs) screening for low-risk patients without symptoms. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health Don’t order annual electrocardiograms (EKGs) or any other cardiac outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceedpatients the potential benefit. screening for low-risk without symptoms. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, Don’t perform Pap smears on women younger than 21 or who have additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved had aoutcomes. hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about BULLETIN the items MARCH/APRIL 2014 | THE on this list or their individual situation should consult their physician.

| 17

Save These Dates! SCCMA Annual Awards Banquet and Installation

Tuesday, June 17, 2014 6:15 pm Social | 7:00 pm Dinner & Program The Fairmont Hotel, San Jose Installation: James R. Crotty, MD, SCCMA President 2014-15 Honoring: Sameer V. Awsare, MD, SCCMA President 2013-14 Award Honorees: Martin L. Fishman, MD – Benjamin J. Cory, MD Award Gary E. Hartman, MD – Outstanding Achievement in Medicine Jonathan H. Blum, MD – Contribution in Medical Education David H. Campen, MD – Contribution to the Medical Association Keith A. Fabisiak, MD – Contribution to the Community Gay Crawford – Citizen’s Award Lisa Krieger – Special Recognition Award Formal invitations will be mailed in May

MCMS Annual Physician of the Year Banquet & lnstallation Thursday, June 5, 2014 6:15 pm Social | 7:00 pm Dinner & Program Nicklaus Club (formerly Pasadera Country Club) Installation: Jeffrey Keating, MD, MCMS President 2014-15 Honoring: Kelly O’Keefe, MD, MCMS President 2013-14 Physician of the Year: To Be Announced Formal invitations will be mailed end of April

18 | THE BULLETIN | MARCH/APRIL 2014

Thursday, May 29, 2014 Ryan Ranch

Cypress Conference Room 5 Lower Ragsdale Drive Monterey, CA 93940

Presentation Starts at 12 PM and 6 PM Complimentary Lunch / Dinner

May 29 th, 2014

OFFICE MANAGERS AND PHYSICIANS THURSDAY, MAY 29, 2014:

COVERED CALIFORNIA LUNCH SEMINAR FROM 12 NOON – 2:00 PM and DINNER SEMINAR FROM 6:00 PM – 8:00 PM This presentation discusses the importance of understanding the changes taking place in the individual health insurance market; the impact of the new eligibility rules on patients accessing services; and consumer cost sharing responsibilities; determination of premium assistance; current issues regarding eligibility determination; physician status in the exchange market; and other things physicians need to know to survive this first year of Covered California.

REGISTRATION REQUIRED PHONE: 831-455-1008 x3010 FAX to: JEAN CASSETTA 408-289-1064 eMAIL: jean@sccma.org

Monterey County Medical Society

FAX 408-289-1064

Please complete the following and fax back to the office at 408-289-1064

Yes, I will attend the Office Managers’ Forum LUNCH on May 29, 2014 • 12 - 2 pm Name/Attendee:

Yes, I will attend the Physicians’ Presentation DINNER on May 29, 2014 • 6 - 8 pm Name/Attendee:

MARCH/APRIL 2014 | THE BULLETIN | 19

Latino Health Conference Is improving health and engaging the Latino community important to you? Are you interested in learning and networking with colleagues and health care leaders about evidence based approaches to Latino health? Would you benefit from practical tools you can implement right away in your practice? We invite you to join The Permanente Medical Group, UC Davis Health Systems, and Latino Physicians of California on May 30 -31, 2014 for an innovative clinical education conference. You will not want to miss this exceptional program.

REGISTER TODAY Friday, May 30 - Saturday, May 31, 2014 Santa Clara Convention Center Who should attend the Latino Health Conference? The conference is designed specifically for physicians, physician assistants, nurse practitioners, fellows, residents, and medical students. Cost: $175 for physicians, physician assistants, and nurse practitioners. Registration is free for medical students and residents. Registration includes access to all sessions, an online certificate of attendance, refreshment breaks, continental breakfast, luncheon, and hosted networking reception on Friday, May 30, 2014.

CME: 11.25 AMA PRA Category 1 Creditsâ&#x201E;˘ Follow us on Twitter: @LatinoHealth14 or #LatinoHealth14 Questions? Visit the conference website at http://events.SignUp4.com/LatinoHealthConference. Contact us at Latino-Health-Conference@kp.org, or call (510) 625-6937.

Statement of Disclosure: TPMG Physician Education and Development has determined that the speakers and the planning committee members for this program do not have affiliations with any corporate organizations that may constitute a conflict of interest with this program. TPMG Physician Education and Development is accredited by the Institute for Medical Quality/ California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. TPMG Physician Education and Development designates this live activity for a maximum of 11.25 AMA PRA Category 1 Creditsâ&#x201E;˘. Physicians should only claim credit commensurate with the extent of their participation in the activity.

20 | THE BULLETIN | MARCH/APRIL 2014

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MARCH/APRIL 2014 | THE BULLETIN | 21

IS THERE A MISPERCEPTION OF THE RISKS OF TONSILLEC TOMY?

by Steve Kmucha, MD, JD, FACS The lay press has well-publicized a recent tonsillectomy in the local community that was associated with postoperative complications that ultimately resulted in a devastating outcome. Soon after that sentinel event, medical experts were quoted suggesting an average rate of serious or life-threatening complications after tonsillectomy with an incidence of approximately 1:25,000 operations.

onsillectomy remains a common operation, with approximately 737,000 procedures performed annually in the U.S. The two most common indications for tonsillectomy include sleep-disordered breathing and recurrent tonsillitis. These indications have changed from being a surgery performed primarily for recurrent infections in the 1970s to a surgery performed more commonly for sleep-disordered breathing today. A large number of recent clinical trials and medical reports have repeatedly confirmed that adenotonsillectomy improves quality of life, behavior outcomes, quality of sleep and polysomnographic findings, especially in children with documented obstructive sleep apnea. Relatively minor surgical complications such as minor hemorrhage, soft tissue injuries, abnormal taste, TMJ dysfunction and others are well-recognized and reported following tonsillectomy. Prior analyses of post-tonsillectomy malpractice claims has documented that hemorrhage is a predominant cause of mortality following tonsillectomy. Based upon data from the 1970s, total post-tonsillectomy mortality has been estimated at between 1:16000 and 1:35000. A 2009 European study documented a post-tonsillectomy mortality rate again of approximately 1:16000. Therefore, post-tonsillectomy mortality appears unchanged over more than 4 decades of monitoring and numerous studies/reports despite significant improvements in surgical technique, surgical 22 | THE BULLETIN | MARCH/APRIL 2014

technology, anesthesia equipment and monitoring and an intense system-wide focus on surgical quality and patient safety. Perioperative arrhythmiae, cardiac death and other anesthesia complications are also associated with tonsillectomy surgery. A 2008 malpractice claims review documented that when monetary awards were paid to plaintiffs associated with perioperative or postoperative tonsillectomy claims, monetary awards against anesthesiologists were more frequent and higher than against otolaryngologists. The role of obstructive sleep apnea in tonsillectomyrelated malpractice claims remains somewhat controversial. With an increase in obesity, with an increase in the diagnosis of sleep apnea, with an increase in ambulatory surgeries, otolaryngologists and anesthesiologists would appear to be increasingly exposed to new areas of liability. Also, with the shift in the indications for tonsillectomy from recurrent infections in the 1970s to treatment of sleep apnea more recently, it would appear that both otolaryngologists and anesthesiologists are similarly being exposed to increasing liability when treating this growing population of patients with documented sleep apnea. For those patients without documented sleep apnea, only formal polysomnography (PSG) can provide such

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 11

documentation; due to the (geographic and financial) inaccessibility of PSG for many patients, such a study may not be available. As there are no clinical metrics that diagnosis OSAS other than PSG, a diagnosis based on patient reporting, family reporting and other clinical symptoms alone may under-diagnose a significant proportion of patients with true OSAS. While most otolaryngologists and anesthesiologists are familiar with postoperative post-obstructive “flash”

Tonsillectomy-Related Malpractice Awards, 1984-2012 There were 242 claims, 98 of which (41%) were fatal. Median age of plaintiffs: 8.5 years Primary causes of fatal claims were related to: • surgical factors (39.8%) • anesthesia-related factors (26.7%) • Post-operative opioid-related factors (16.3%) Primary causes of non-fatal claims were related to: • surgical factors (70.1%) • anesthesia-related factors (22.2%) • Post-operative opioid-related factors (4.2%) Sleep apnea was recorded as co-morbidity in 17 fatal and 15 non-fatal claims. Opioid-related claims had the largest awards for both fatal ($1,652,892) and non-fatal injuries ($3,484,278). Anesthesia and opioid-related claims, though fewer in number than surgical claims, are associated with larger median monetary verdicts. Monetary claims paid for non-fatal injuries was higher than those for fatal injuries. This is likely related to the ongoing medical expenses required to care for these injured individuals and the continued emotional trauma.

received less opioid doses after tonsillectomy than black children, white children had higher numbers of opioidrelated adverse events. The most commonly reported opioids associated with post-tonsillectomy claims were codeine, morphine, fentanyl and meperidine. Despite its well-known efficacy and safety problems, codeine remains one of the mostly commonly prescribed opioids for home pain management after adenotonsillectomy in the US likely due to cost, availability and perceived safety. Black box warnings were issued in 2013 by the FDA against the use of codeine following tonsillectomy in children. Ultra-rapid metabolizers of codeine have greatly enhanced rate of conversion of codeine to morphine in the blood stream rapidly increasing the possibility of morphine toxicity with associated respiratory depression and death. These risks are not limited to codeine but are associated with all other opioids. Many otolaryngologists have already switched to protocols which maximize analgesia provided by non-opioids administered on a scheduled basis (choosing medications which do not simultaneously increase the risk of bleeding such as acetaminophen) while reserving the lowest effective dose of opioids not dependent upon pathways present in “ultrametabolizers” on a limited and as needed basis such as hydromorphone, oxycodone and morphine with detailed safety instructions to parents and patients about potential side effects and appropriate use. Many studies suggest less pain and postoperative nausea is associated with a pre-operative dose of dexamethasone; a recent 2014 report suggests that significant variations persists around the US in the use of perioperative antibiotics, dexamethasone and analgesics. ■ References

pulmonary edema that often occurs after tonsillectomy in a patient with OSAS, some studies also suggest that the frequent episodes of hypoxemia associated with OSAS result in increased opioid sensitivity of mu-receptors such that a normal dose of opioid can be a relative overdose in patients with OSAS. Posttonsillectomy complications also appear to be more commonly associated with OSAS in younger children. The obvious fact that smaller children have smaller and more difficult airways is another important factor. Another recent report published in Pediatrics in 2012 documented that while younger white children 12 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

Subramanyam R et al. Paediatr Anaesth 2014 Jan 13, pp 1-9. About the Author Steve Kmucha, MD, JD, FACS, is board certified in otolaryngologyhead and neck surgery and in the subspecialty of ear, nose and throat allergy. He also holds a law degree specializing in health and healthcare law.

MARCH/APRIL 2014 | THE BULLETIN | 23

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Greening the O.R. Anesthetic gases have been demonstrated to be powerful greenhouse gases. Nitrous oxide, in addition to being a greenhouse gas, is also destructive to the ozone layer By Ken Yew, MD Global climate change is a real phenomenon that poses significant challenges to our way of life. According to the latest report from the U.N.’s Intergovernmental Panel on Climate Change,1 each of the last three decades has been successively warmer than any preceding decade since 1850. Over the last two decades, the Greenland and Antarctic ice sheets have been losing mass, and glaciers worldwide have continued to shrink. These observations correlate with a 40% rise in carbon dioxide concentration since pre-industrial times. Climate change, air pollution, toxics in our water and food, all contribute to human health problems, both currently and in our future. And yet, the health care sector, largely by inefficient or unconscious practices, is a significant contributor to these health-threatening problems. The health care sector accounts for about 8% of greenhouse gas emissions in the United States, with hospitals being, by far, the greatest contributor. Operating rooms produce about 20%-30% of total hospital waste.2 Operating room design and practice choices can have a tremendous impact on the magnitude of hospital waste and greenhouse gas emissions. Those of us who practice in the operating room can make a number of changes to limit our carbon footprint, reduce the amount of waste, and 26 | THE BULLETIN | MARCH/APRIL 2014

save money for the hospital and our practices in the meantime – all while keeping patient safety and community health firmly in mind.

REDUCE, REUSE...

One simple way to reduce hospital waste is to use less equipment in the first place. Individual practitioners can easily challenge themselves to avoid opening excess equipment or medications. However, in addition, many ORs use pre-packaged supply kits for individual surgeries. The kit may include up to 100 items that are opened, but are unused. All of these unused items must be discarded, once opened. By redesigning surgical kits to minimize the “overage,” a hospital in Minnesota reduced their waste stream by 2.5 tons and saved $81,000 in 2010.12 Many hospitals have switched to disposable equipment because of issues of cost, cross-contamination, and reduction of labor. Both reusable and disposable equipment have potential impacts on the environment. Reusable equipment often takes special processing to clean, sometimes involving toxic chemicals, which are harmful to the environment. On the other hand, disposables can contribute significantly to the bulk waste of the facility, with corresponding increases in landfill and incinerator use. Incineration, in particular, is expensive and contributes to toxic air pollution. Unfortunately, the “disposable” versus “reusable” dilemma must be

answered on a case-by-case basis related to local resources and practices. However, working from the premise of avoiding excess disposable items provides a starting point. New “reprocessing” technologies exist, which make it possible to reuse single use items such as sequential compression devices, laryngeal mask airways, surgical trocars, harmonic scalpels, and pulse oximeter probes. A number of reprocessing companies will assure equipment integrity and sterility as required by the FDA, and sell these items at a price point significantly below new equipment. Such reprocessed items need to be labeled as such and tracked by the reprocessing company. In this way, data has been collected since 2002 on adverse events related to reprocessed equipment. A recent Government Accountability Office report stated that reprocessed equipment is as safe and effective as new equipment. Between 2003 and 2006, there were 434 adverse device events reported to the Food and Drug Administration, 65 of which involved reprocessed equipment, and all events were similar to adverse events found in new equipment.3 Coordination between physicians, administrators, and purchasing managers can help identify equipment that can be reused at a cost savings to the hospital, while also creating a net reduction in environmental impact. A program at the University of California, San Francisco reduced over 15,000 pounds of hospital waste and saved over $900,000 in fiscal year 2012 by implementing a reprocessing system, according to Gail Lee, REHS, MS, sustainability manager at UCSF. Donation of expired or unused items is another excellent way to reduce waste. Many such items that would be sent to a landfill can instead be used in a developing country. One such non-profit organization that collects items for use in the developing world is Medshare International (www.medshare.org).

RECYCLE

hospital waste manager is an important first step. Many machines and monitors can also be refurbished and either sold or donated to a lab, another facility, or a veterinary clinic. Medical missions will sometimes take donations of equipment.

ANESTHETIC AGENTS: THE HIDDEN GREENHOUSE GAS

Anesthetic gases have been demonstrated to be powerful greenhouse gases.5 Nitrous oxide, in addition to being a greenhouse gas, is also destructive to the ozone layer.6 The global warming potential (GWP) for a particular gas is based on the amount of heat it captures when radiation is emitted as heat, and its persistence in the atmosphere. The atmospheric lifetime of newer inhaled anesthetics is from 1-14 years. Nitrous oxide has a lifetime of 114 years. The GWP value is on a relative scale comparing the effect of the gas with that of carbon dioxide over a specified time period. The GWP of carbon dioxide is, by definition, one. Desflurane has the highest GWP with a value of 2450, followed by isoflurane at 510, nitrous oxide at 310, and sevoflurane at 130. Since desflurane and nitrous oxide are much less potent agents than sevoflurane, higher amounts are typically used in clinical practice, which further compounds their greenhouse gas potential. The choice of anesthetic agents can therefore affect the environmental impact of anesthetic practice to a great extent. A study by Ryan and Nielsen7 compared an hour of anesthetic administration at standard fresh gas flows to emissions from automobiles and found stark differences based on the drug chosen. An hour of sevoflurane at two-liters-per-minute fresh gas flow was equivalent to driving a car about eight miles. A comparable dose of desflurane at the same gas flow was equal to driving 400 miles. The greenhouse impact of propofol is much less compared to inhaled agents,14 though wasted propofol does not biodegrade and is potentially toxic to aquatic wildlife. Changing vial sizes may mitigate wastage of propofol and save costs as well.15 Educating anesthesia departments about the environmental impact of anesthetic drugs may help anesthesia providers make more informed decisions about choice of drugs. Adjusting anesthetic techniques, such as using lower gas flows, can also conserve the amount of vapor used, and therefore released, into the atmosphere.13 Furthermore, use of regional anesthetics, whenever possible, would likely have less environmental impact. There are exciting new technologies to actually trap waste anesthetic vapor for later reuse. One company makes a filter that can be placed on the scavenger system of the anesthesia machine, which absorbs waste gases. The filters are collected and used to extract anesthetic vapor for reuse. This system is available for commercial use in Canada.8 The experience of hospitals adopting this program is that it is either cost neutral or provides a small savings.

Hospitals are among the most energy-intensive types of buildings in use.

Many hospitals report significant cost savings when an effective recycling program is instituted. This is because regulated medical waste such as pharmaceuticals, biohazard/infectious waste, trace chemo, pathology, and sharps is much more expensive to dispose of than clean solid waste. Most of the waste found in the OR is solid waste, which can be recycled if not contaminated by bodily fluids. The Centers for Disease Control and Prevention estimates that only 2%–3% of hospital waste needs to be disposed of as infectious waste. Contrast that with the 50%–70% waste that is generally disposed of as red bag waste! Cutting back on inappropriately processed red bag waste can mean a significant cost savings, since it can cost five times as much to treat red bag waste before it goes for disposal. Recycled materials also have monetary value and can be sold to recycling facilities. One of the most common barriers to OR waste recycling is failure to separate contaminated from clean waste.4 Successful OR recycling programs often have procedures to separate plastics, glass, blue wrap, and paper before the patient enters the room. Much of the solid waste is generated when the equipment for the case is opened. The recycling bins can then be closed before the patient comes into the OR to ensure they are not contaminated. The bins would have to be kept in the room for the duration of the case to ensure accurate sponge and needle counts. The disposal of durable goods such as machines, computers, and monitors, poses special problems from an environmental perspective. Separating recyclable materials such as steel, copper, nickel, etc., from non-reusable materials can be a challenge. A dedicated metal or electronics recycler may be more successful in this process. Coordinating with the

GREEN BY DESIGN

Hospitals are among the most energy-intensive types of buildings in use. According to a 2003 survey by the U.S. Energy Information Administration,9 hospitals spend an average of $675,000 per year on energy costs, exceeding the energy costs of other buildings by a factor of 10. The U.S. Department of Energy (DOE) has recommended a retrofit program which can garner significant cost savings with minimal up front costs, in most cases achieving payback in under a year. This program can be found in the “Advanced Energy Retrofit Guide-Healthcare Facilities” distributed by the DOE.10

Continued on page 28 MARCH/APRIL 2014 | THE BULLETIN | 27

Greening the O.R., from page 27 As an example, Connecticut’s Greenwich Hospital implemented a retrofit using the guide, saving 1.7 million kilowatt-hours of energy and $303,000 in costs. The retrofit required a less than six-month payback on the effort.11 Gail Lee cited another example at UCSF, in which the hospital replaced a standard chiller with an electric one, saving over 3.7 million gallons of water, 470,000 kWh, and $1.3 million in one year. A single intervention, smartly applied, can thus provide significant cost savings as well as help protect the environment. Health care facilities considering plans for new construction can follow multiple available programs available to design new operating areas for minimal environmental impact. One of the most utilized, the U.S. Green Building Council, provides a way for a facility to obtain certification under its Leadership in Environmental and Energy Design program (LEED). LEED certification consists of accumulating points in six areas of design: sustainable sites, water efficiency, energy and atmosphere, materials and resources, indoor environmental quality, and innovation and design. Points are based on a 100-point scale and the certification ranges from “certified” for 40 points to “platinum” for over 80 points. Lee says that UCSF will open a new LEED-Gold certified women’s, children’s, and cancer hospital in 2015 that addresses all these issues.16 Additional information on green design for hospitals can be obtained from the Green Guide for Health Care (www.gghc.org) and Practice Greenhealth (www.practice greenhealth.org). These groups also offer programs for “green renovations” in existing hospitals.

HOW TO GET STARTED

Most facilities will not have a designated sustainability coordinator, but many have staff persons interested in improving the environment. Raising awareness of sustainability issues is the first step in forwarding a green hospital program. Physicians can attend committee meetings and ask to speak with other physicians, nurses, and staff members about sustainability. Highlight what the hospital already does to save costs and minimize environmental impact. Then identify other areas that can be leveraged for additional savings. Having a dedicated group of volunteers in various departments to act as a point of contact for greening the hospital can be extremely helpful. These “green champions” help to identify areas of improvement, educate staff, monitor progress, and further optimize the program, particularly in their area of expertise. Green champions would be needed from a variety of operating room departments including nursing, anesthesia, housekeeping, purchasing, facilities, surgery, scrub technicians, and administration. Such programs have been successfully implemented in other hospitals with significant cost savings. Additional resources for green hospital practices can be found at: • Practicegreenhealth.org • American Society of Anesthesiologists, Committee on Equipment and Facilities: “Greening the Operating Room” www.asahq.org/For-Members/Clinical-Information/~/media/ For%20Members/documents/2012%20Greening%20the%20 Operating%20Room.ashx • Cleanmed.org • Healthierhospitals.org • Health Care Without Harm: noharm.org Making a commitment to green operating room practices will take 28 | THE BULLETIN | MARCH/APRIL 2014

time and considerable up-front effort. However, recruiting a group of dedicated staff members makes carrying the load much easier. Keep goals simple, at first. Make small changes. Work on just recycling waste, or just limiting desflurane, or just reducing unnecessary equipment in surgical kits or your individual workplace. Remember that this is just as much a cultural change as it is a change in practice – even small changes have a positive psychological impact. Greener operating room practices are becoming increasingly popular and common in hospitals, both large and small, can save a significant amount of money, and are well worth the effort in the long run for the health of our patients, health care systems, and communities.

REFERENCES

1. Intergovernmental Panel on Climate Change: Climate Change 2013: The Physical Science Basis, Nov 2013, pp TS5-TS10. 2. Chung JW, Meltzer DO. “Estimate of the carbon footprint of the U.S. health care sector.” JAMA 2009; 302(18):1970-1972. 3. United States Government Accountability Office. Report to the Committee on Oversight and Government Reform, House of Representatives: Reprocessed Single-Use Medical Devices: FDA Oversight Has Increased, and Available Information Does Not Indicate That Use Presents an Elevated Health Risk Washington, DC: United States Government Accountability Office; 2008. 4. McGain E, Hendel SA, Story DA “An audit of potentially recyclable waste from anesthetic practice” Anaesth Intensive Care 2009;37(5):820-823. 5. Sulbaek Andersen MP, Nielsen OJ, Wallington TJ, Karpichev B, Sander SP “Medical intelligence article: assessing the impact on global climate from general anesthetic gases” Anesth Analg 2012;114(5):1081-1085. 6. Ravishankara AR, Daniel JS, Portmann RW “Nitrous oxide (N2O): the dominant ozone-depleting substance emitted in the 21st century” Science 2009;326(5949):123-125. 7. Ryan SM, Nielsen CJ “Global warming potential of inhaled anesthetics: application to clinical use” Anesth Analg 2010;111(1):92-98. 8. Gupta D “Capturing Greenhouse Inhalation Anesthetics for Better City Atmosphere” WebmedCentral ANAESTHESIA 2012;3(5):WMC003397. 9. U.S. Energy Information Administration, Commercial Buildings Energy Consumption Survey, 2003. 10. U.S. Department of Energy, Advanced Energy Retrofit Guide Healthcare Facilities, September 2013. 11. Connecticut Energy Efficiency Fund, Case Study-Greenwich Hospital, www.CTEnergyinfo.com. 12. Practice Greenhealth. “Greening the OR:Guidance Documents” http://www.c4spgh.org/HCW1_Presentations/GOR_Fullset_ Guidance%20Docs_Web_042711.pdf. 13. Feldman JM “Managing Fresh Gas Flow to Reduce Environmental Contamination” Anesth Analg 2012 May ; 114(5): 1093-1101. 14. Sherman J, et al “Life Cycle Greenhouse Gas Emissions of Anesthetic Drugs” Anesth Analg 2012 May; 114(5): 1086-90. 15. Mankes R “Propofol Wastage in Anesthesia” Anesth Analg 2012 May; 114(5):1091-2. 16. http://missionbayhospitals.ucsf.edu/about-project/sustainabilitystory.

MARCH/APRIL 2014 | THE BULLETIN | 29

MANAGING PROFESSIONAL RISK

Responding to Online Negative Comments By Josh Hyatt With the advent of social media and online marketing outlets, physicians, health care practitioners, and facilities are experiencing, in a new medium, a not-so-new phenomenon — bad publicity. There are many online sites that allow patients to rate their physicians on various scales, and oftentimes they can leave narratives about their experiences. “Dozens of websites that permit people to rate, review, spin, or flame their doctors have sprung up in the last year, operating in much the same way as online services that help people find the best hotels or avoid plumbers who overcharge,”1 reported the Los Angeles Times in 2008. As such websites increase in popularity, so does the significance of such ratings. Many patients are using the sites to report negative comments about physicians, and physicians often feel unable to defend themselves due to HIPAA and other privacy regulations. Negative reviews can come from angry patients, disgruntled employees, and sometimes even members of the public just trying to create unsubstantiated problems. When these attacks occur, sometimes the physician wants to go into a defensive mode to preserve both integrity and reputation. But impulsive responses may do more harm than good.

RECOMMENDATIONS

Because negative online reviews can affect a physician and his or her practice, the issue warrants a two-fold plan of action that is both proactive and reactive in nature.

PROACTIVE STEPS

• Setup your own practice web page where you can control the content and message you want to share with the community. Work with your group administrator or medical director, as necessary. • Develop a social media plan for your practice. This could include Facebook or Twitter accounts where postings can be controlled. • Periodically check websites for yourself or your practice to identify any specific issue or trends. You may want to explore setting up online alerts that advise when comments have been posted about you as a physician. • Ask patients to go online and rate your services. Positive ratings will help to counter-balance negative comments. • Provide a patient complaint process so disgruntled patients can receive timely resolution.

REACTIVE STEPS

• Don’t panic. • Do not respond immediately or impulsively. Take time to consider the comment, to reflect on why the individual felt compelled to post, and to decide if it warrants a response. Not all negative comments are worthy of your time to respond. A response may start a chain reaction of negative slurs and

30 | THE BULLETIN | MARCH/APRIL 2014

comments, potentially leading to litigation. • If you feel the information is “clearly false, inappropriate, and solely inflammatory, contact the (Internet) site administrator.”2 Legitimate sites have content guidelines and will probably remove information that violates them. • If you are considering suing a reviewer, there are many potential issues you need to be aware of to avoid pitfalls and countersuits. Consult with your attorney as soon as possible, before taking any steps in that direction. • Periodically follow up with positive information about your practice on the sites. NEVER post fake consumer reviews, as this may result in significant fines and penalties. • If you choose to respond in writing, limit the response to general information, NEVER use patient identifiers or reveal any protected health information, and do not directly or personally attack the individual posting the comment. 1. Roan, Shari. The Rating Room. Los Angeles Times. May 19, 2008. 2. California Medical Association. CMA On-Call, Document 0822: Online Consumer Review and Rating Sites, www.cmanet.org. This article has been adapted from “Responding to Online Negative Comments,” one of 100+ risk management articles, sample forms, and sample policies available online to NORCAL Mutual Insurance Company policyholders. Josh Hyatt is a Risk Management Specialist with NORCAL Mutual. Copyright 2012.

County of Santa Clara Public Health Department Health Officer 976 Lenzen Avenue, 2nd Floor San José, CA 95126

April 1, 2014 Dear Healthcare Provider: April is national STD Awareness Month. You may know that one in two young people will get a sexually transmitted disease (STD) by the time they are 25 years old. Locally, you play a pivotal role by talking with your patients about their risk for STDs and testing when needed. The Santa Clara County Public Health Department hopes to partner with you to promote STD testing and education for STD Awareness Month and beyond. How many people actually have STDs? Nationally, the CDC estimates there are approximately 20 million new STD cases each year. Here in Santa Clara County, there were more than 5,000 new Chlamydia infections and 990 new Gonorrhea infections reported in 2012, as well as a 44% increase in primary and secondary Syphilis cases. What can healthcare providers do to help? You can help reduce STD rates by integrating the following prevention and treatment strategies into your routine care: 

conduct a sexual history and STD risk assessment with each of your patients



advocate to include sexual health risk assessment into your Electronic Medical Record



assess your patients’ risks and test accordingly



talk to your patients about testing



talk with your patients about pre-exposure vaccines such as human papillomavirus and Hepatitis A & B



provide or refer your patients to risk reduction counseling



provide or refer partner of patient for partner services



report HIV and STD cases (go to www.sccphd.org to the “For Providers” tab and click on the “Disease Reporting” link to download a Confidential Morbidity Report (CMR) form

If you would like a copy of A Guide To Taking a Sexual History developed by the US Department of Health & Human Services, Centers for Disease Control and Prevention or for additional information please contact us at 408-792-5030 or at stdprevention@phd.sccgov.org. California STD screening guidelines can be found at: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STDScreening-Recommendations.pdf. The Santa Clara County Public Health Department is here to help. If you have any other questions, please contact us at the number listed above. Sincerely, Sara H. Cody, MD Health Officer Board of Supervisors: Mike Wasserman, Cindy Chavez, Dave Cortese, Ken Yeager, S. Joseph Simitian County Executive: Jeffrey V. Smith MARCH/APRIL 2014 | THE BULLETIN | 31

PHYSICIAN WELL-BEING

California Public Protection and Physician Health, Inc. By Rebecca Powers, MD Chair of SCCMA Physicians Well-Being Committee Now that the Medical Board of California’s Diversion Program has been closed for nearly five years, it is the committees in our hospitals and medical groups that identify, refer, and monitor physicians with substance abuse issues, mental or physical health matters, or behavior problems, as well as address the professional stresses – even burnout – that can have serious effects on the physician workforce today. California Public Protection and Physician Health (CPPPH) has stepped up to help address those issues, in partnership with us, and has evolved into an important resource for all those

with responsibility for patient safety, quality of care, and physician health. CPPPH sponsors workshops three times a year in four regions of California, and posts the materials from the workshops on its website www.CPPPH.org. They are just finishing a twopart series on aging, in each region of the state. The first workshop is on the clinical elements of neuropsychological testing and the second is on the legal aspects of age-based screening of physicians over a certain age. In the San Francisco Bay Area, the second workshop in that series will be on June 7 in Oakland. In addition, CPPPH has published guidelines (http://cppph.org/resources/) for management of physician health issues and sends an enewsletter (http://us2.campaign-archive2.com/

?u=01bf7589494a7e0529ade7063&id=c4a59663 5a) on current topics related to physician health to everyone in its growing network. CPPPH also helps hospital medical staff committees with information and examples of how to address the issues that all physicians face now, including burnout and all the increasing stresses: http://cppph.org/proactive-approaches-to-physician-health-and-wellness/. The SCCMA Physicians Well-Being Committee invites comments from everyone in the SCCMA medical community about these activities. Contact the SCCMA committee (pjensen@ sccma.org) or contact CPPPH through “contact us” on its website: http://cppph.org/contact-us/.

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tzwe ig@tracyzweig.com www.tracyzweig.com 32 | THE BULLETIN | MARCH/APRIL 2014

MEMBER SPOTLIGHT

Disruptive Physician Behavior: Use and Misuse of the Label By Norman Reynolds, MD In 2012, the Federation of State Medical Boards (FSMB) published the article “Disruptive Physician Behavior: Use and Misuse of the Label” by Norman Reynolds, MD. In 2014, at its Annual Conference, the FSMB is honoring Dr. Reynolds with its “Award for Excellence in Writing.” The following is an abstract of the article. Beginning in 2009, The Joint Commission (TJC) requires medical leaders to address disruptive behaviors in accreditation organizations and this includes addressing disruptive physician behaviors. The Federation of State Medical Boards (FSMB) has acknowledged the importance of addressing disruptive physician behavior, as reflected in the 2000 Report of the Special Committee on Professional Conduct and Ethics and in the 2011 Policy on Physician Impairment. The article by Dr. Reynolds provides in-depth information about disruptive physician behavior that informs hospitals, medical staffs, and physician well-being committees regarding responsibilities and best practices for addressing them. The article includes discussion of disruptive behavior causes and contributing factors, strategies to manage such behavior, formulation of medical staff policies, and appropriate and inappropriate use of the “disruptive” label. Although not a diagnosis, the disruptive label is useful in screening for disruptive physician behaviors. However, the disruptive label should not be applied to physicians just because they present controversial ideas or offer criticism of the medical system. Disruptive physician behavior consists of a practice pattern of personality traits that interferes with the physician’s effective clinical performance in relating to others. Manifestations are behavioral. The behaviors include inappropriate anger or resentment manifesting as tantrums, bullying, and demeaning behaviors. The disruptive behaviors negatively impact the persons with whom the physician interacts. At times, the disruptive behavior may be in response to real problems and issues. Both the unprofessional behavior, as well as the issues, should be addressed. Unfortunately, the underlying issues that spark the behavior may be ignored because of the egregious expressions of behavior. It is estimated that approximately 3%–5% of physicians present with a problem of disruptive behavior. According to a 2004 survey of physician executives, more than 95% reported regularly encountering disruptive physician behaviors, and 70% reported that the disruptive behaviors nearly always involved the same physicians. Disruptive physician behaviors most commonly involved conflict with a nurse or other allied health care staff. Nearly 80% of the respondents said that disruptive physician behavior is under-reported because of victim fear of reprisal, or it is only reported when a serious violation occurs. Putting things in perspective, physicians, like all human beings, manifest a wide range of behaviors and ways of relating to others stemming from their individual personalities and environmental influences. Anyone can have an occasional expression of inappropriate behavior. The disruptive behavior label differs from peer physicians in the sense that

manifestations of inappropriate behavior represent an ongoing pattern that is pervasive, deep-seated, and resistant to change. Expected behavioral standards have been established by professional organizations and, when incorporated in medical staff policy, may prevent and/or redress disruptive physician incidents. When pervasive violations of behavioral and interpersonal norms persist and medical staff attempts to mediate are met with physician resistance, denial, and even aggressive responses, consideration should be given to referral for in-depth professional evaluation of the physician. The feasibility of offering assistance should be considered before automatically invoking discipline. Comprehensive evaluation determines a diagnosis, identifies contributing causes, and formulates a specific remediation and monitoring plan for the individual physician. The goal of remediation does not involve silencing physicians. Instead, physicians should be assisted in learning techniques to express concerns about real problems in professional ways. In all cases, a balanced, respectful, and compassionate perspective toward both perpetrators and their targets should guide the work of hospitals and medical staff committees, while having to set appropriate limits—a “tough love” approach aimed at constructive problem solving and remediation whenever possible. The full article “Disruptive Physician Behavior: Use and Misuse of the Label,” Journal of Medical Regulation, Volume 98; No 1, 2012 can be downloaded at the FSMB website (http://www.fsmb.org/pdf/pub-jmrmisuselabel.pdf). Or, for a reprint of the article, contact Dr. Norman Reynolds directly at 408/264-3064 or by email at cpcs2001@hotmail.com.

MARCH/APRIL 2014 | THE BULLETIN | 33

Governance Reform: CMA Envisions a New Future for Organized Medicine By Steven E. Larson, MD, MPH Chair of the CMA Governance Technical Advisory Committee Change is never easy. But oftentimes it is necessary, and even invigorating. The California Medical Association (CMA) is about to embark on a journey of change that will position our association as a nimble, proactive organization ready to lead the practice of medicine into a brave new world. In 2013, the CMA House of Delegates (HOD) approved a plan to reform the way our association is governed. Will it be easy? No. Will it be worth it? There is not a doubt in my mind. In a nutshell, the reforms will make CMA more relevant and effective by focusing the association on, and bolstering its resources to address, the critical issues of universal importance to physicians. By doing so, CMA will be better able to protect the interests of its physician members and, even more importantly, guide the future of our profession, not only in California, but nationwide.

150 YEARS OF TRADITION

For 150-plus years, CMA has been guided by the HOD, which meets once a year to set policies and direct resource allocation. This has led to a sometimes unwieldy 581-member HOD, a Board of Trustees numbering more than 50, a seven-member Executive Committee, and hundreds of other members serving as alternate delegates and in various capacities on dozens of councils, committees, sections, and mode of practice forums. Over the years, there have been several task forces assigned to this 34 | THE BULLETIN | MARCH/APRIL 2014

subject. It wasn’t until this year, however, that the abstract discussions about “governance reform” began to produce concrete results. These discussions resulted in big questions. Does the HOD foster a reactive culture rather than a proactive one? Does it inhibit CMA’s ability to take quick action in a rapidly evolving health care environment? While these questions were being asked, the HOD was spending most of its time on a growing number of resolutions that struggled to be assigned or implemented because of resource limitations. The CMA Board of Trustees, realizing that a floundering governing style prevented the organization from quickly acting on issues of universal import to the membership and their patients, created a committee— the Governance Technical Advisory Committee (GTAC)—to look at this issue. The GTAC confirmed what the executive committee had feared— the association was unable to quickly address universal issues that arose faster than the once-a-year HOD meetings could handle. And, there were other inefficiencies in CMA’s governing bodies and processes. And there was the cost. An independent study commissioned by CMA (an activity-based costing, or “ABC” study) found that CMA governance is far more resource-intensive than previously thought, accounting for almost one-third of CMA’s operating budget—an allocation that commensurately reduces resources available for advocacy and other member services. The GTAC began its discussion of how to bring relevance, democracy, and cost-effectiveness to governing the association. It became clear

The Governance TAC Report

The full report of the CMA Governance Technical Advisory Committee, as amended by the House of Delegates at its October 2013 meeting in Anaheim, is available for download on the California Medical Association website. To access the report, available to members only, visit www.cmanet.org/hod and click on the “documents” tab. The report begins on page 12 of the “Actions of the 2013 House of Delegates” document. to us that the rank-and-file members want more advocacy, while the delegates and trustees are heavily invested in leadership.

TACKLING THE BIG ISSUES

A proposal to reform CMA’s governing structure, put before the 2013 CMA HOD by the GTAC this past October, proposed that instead of a diffuse focus on many issues, the HOD take on a limited number of big issues—the most important, most pressing matters facing physicians and the practice of medicine. CMA’s long-standing traditions of democratic participation and representative governance would continue; the difference, as envisioned by the GTAC, is that specific issues that are of concern to a narrow spectrum of the membership would no longer command HOD’s limited time. Rather, the democratically-elected Board of Trustees would act on those issues, as it already does on the increasing number of matters referred to the board for action by a House that is aware of its policy-making constraints. The HOD would continue to set policy on major issues, and its decisions would be informed through a year-round process not constrained

by 15-minute limits on debate of recommendations developed in a rushed overnight exercise, as is currently the case. More focused expertise would be brought to bear in a more careful development of recommendations for action. Policy on other issues would realize the same benefits of a more careful and expert deliberative process throughout the year. We would like to improve the discussion at the House of Delegates to deal with the big issues of the day and to utilize the valuable resources of our delegates for the collective development and direction of important policy matters. We believe this proposal has real potential for a robust discussion around issues that will impact all physicians. The reforms would also open the discussion to individual members who could continue to bring forth their ideas and proposals through a year-round resolution process provided for in the CMA bylaws. Such proposals would be studied, with recommendations acted on by the board. A year-round dialog about timely issues should result in well-thought out policy pieces that could be brought to the floor during HOD.

CHARTING A COURSE FOR THE NEXT 150 YEARS

This year’s discussion and debate at HOD on governance reform has set the stage for the GTAC to make proposals to modify the bylaws to begin the changes needed to set CMA’s course for the next 150 years. I am optimistic that this will result in an improvement for our entire organization. It will make CMA more effective in reaching the average member and give them a direct voice in policy, bringing broader input into our more difficult decisions. Dr. Larson, a Riverside physician, has served as chairman of CMA’s Board of Trustees since 2011. He is also the chair of CMA’s Governance Technical Advisory Committee.

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Wealth Management

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Member Savings! Legacy offers a one-hour complimentary financial planning check-up to Association members (this is a $500 savings). For more information, please call Lawrence Pizzella at (408) 452-7700 or email lawrence@lwallc.com

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MARCH/APRIL 2014 | THE BULLETIN | 35

Medical Studentâ&#x20AC;&#x2122;s Idea Sparks Bill That Calls for Warning Labels on All Sugary Drinks

36 | THE BULLETIN | MARCH/APRIL 2014

Gaither said sugary drinks are the biggest contributor of added calories in the American diet, responsible for 43% of the 300 additional calories added to the average American’s daily consumption since the 1970s. He got the idea for a bill that would mandate a warning label for sugary drinks from the students he taught in his high school science class. Teaching in a low-income public school in San Jose, Tom Gaither, now a first-year medical student at the University of California, San Francisco School of Medicine, said students were allowed to bring drinks to class— and many of them brought sugar-laden sodas and energy drinks. “So many of the kids didn’t know how bad sugary beverages were for them,” says Gaither. The Indiana University graduate chose to teach science in public school, in between undergraduate school and medical school, as part of the “Teach for America” program, a nonprofit that places high achieving undergraduates in schools with high levels of poverty. His idea for the bill was part of a California Medical Association (CMA) contest for medical school students and residents. The contest, called “My CMA Idea,” collected ideas for public health legislation from medical students and residents, allowing future physicians to help craft public policy to improve the health of all Californians. All physicians were invited to vote for and comment on their favorite ideas. Gaither’s idea was selected from the top-ranked ideas and through this legislation the idea will, hopefully, become a reality. Most kids that attend inner city schools have higher rates of obesity and drink more sugary drinks, he says. The health implications are felt most acutely by California’s communities of color, which are the largest consumers of sugary drinks. One in three children born after 2000 – and nearly half of Latino and African-American children – will develop type 2 diabetes in their lifetime. The fact that his students didn’t know that these drinks could be unhealthful prompted him to organize a unit within his regular science class about the effects of diet, particularly sugar, on health. “The science on sugary drinks is very clear,” he says. “I thought this was a good way to start a dialog about these drinks,” he said. He hopes that by labeling sugary drinks as hazardous to health that the public will come to understand that choices about food, like smoking tobacco, are important.

Field Poll Shows Broad Voter Support for Health Warning Labels on Sugar Sweetened Beverages

A recent field poll suggests that California voters support the notion of applying health warning labels on sodas and other sugar sweetened beverages. The poll, which was conducted by The Field Poll and The California Endowment, found that 74% of voters support the requirement to apply health warning labels to sugar sweetened beverages, with 52% of voters “strongly” endorsing the requirement. Support for the labeling of potentially harmful beverages was also bipartisan, with 80% of Democrats, 64% of Republicans, and 75% of non-partisan voters endorsing the labeling requirement. “California voters are now echoing what the scientific and medical communities have been saying for some time, that sugar sweetened beverages pose serious, and unique, health risks and should be treated as such,” says Richard Thorp, MD, president of the California Medical Association. CMA introduced his bill (SB 1000) at a press conference on February 13, 2014. The bill, carried by State Senator Bill Monning (D-Carmel), would mandate that a simple warning be placed on the front of all beverage containers with added sweeteners that have 75 or more calories per 12 ounces. The label, developed by a panel of national nutrition and public health experts, would read: “STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay.” If passed, the bill would require universal sugary drink labeling by July 1, 2015. The bill is backed by a coalition that includes CMA, the California Center for Public Health Advocacy, the California Black Health Network, and the Latino Coalition for a Healthy California. Gaither said sugary drinks are the biggest contributor of added calories in the American diet, responsible for 43% of the 300 additional calories added to the average American’s daily consumption since the 1970s. Drinking just one soda a day can increase an adult’s likelihood of being overweight by 27% and a child’s by 55%. Research shows that a soda or two a day increases the risk of diabetes by 26%. Gaither has hopes that this bill will spark a dialogue about these drinks not just in California, but throughout the rest of the country. “I am hoping that California will set the precedent for the nation.” Complete information on the legislation can be found at http://www. publichealthadvocacy.org/resources/warninglabel/sodawarninglabel. html. MARCH/APRIL 2014 | THE BULLETIN | 37

MEDICAL TIMES FROM THE PAST

Gold Rush Medicine By Michael A. Shea, MD SCCMA Leon P. Fox Medical History Committee 1849 saw the greatest migration of native and foreign pioneers in California history. The non-Indian population grew from 15,000 to over 100,000 in one year. By the end of 1852, it had reached 224,435. Adventure and gold were the motivators for this growth, and doctors were not immune. Hundreds of doctors made the trek during the first few years. Most came for gold, but soon gave up the pan for the practice of medicine. There was more than enough medical work to be done. Diseases, such as malaria, scurvy, typhoid, erysipelas, smallpox, tuberculosis, cholera, and dysentery were found throughout California. Trauma was, however, the largest component of medical practice. Amputation, bone setting, and wound treatment were everyday challenges for the local “doc.” Unfortunately, he had minimal training or experience in these areas. Most physicians of this time were trained in preceptorships. They would pay a fee and work for the doctor for one to two years. If the doctor was a good teacher, they received good training. If he was not, they suffered for it. Medical schools, at this time, were available to some of these students, but for only four-month periods, each year, for two years. There were three methods of practice in America at this time—Allopaths (regulars), Homeopaths, and Eclectics. Allopaths were in the majority and followed the teachings of Dr. Benjamin Rush, a nationallyrecognized leader. He taught that all diseases could be treated by a combination of (1) bloodletting and (2) purging (laxatives and emetics), and (3) poultices (a warming compound applied to the skin). Listed below are some of the common medicines found in Dr. Benjamin Cory’s diary, which he had kept on his 1847 journey overland. He was the first physician to live and practice in San Jose. • Calomel tablets (mercurous chloride) - used to induce copious diarrhea. • Laudanum drops - an alcoholic preparation from the opium poppy (similar to morphine). • Tartar Emetic (potassium antimony nitrate) - used to induce vomiting and as an expectorant. • Potassium Iodide - used to thin secretions. • Oil of Cloves - used as a topical analgesic for toothaches. • Camphor - from the bark of the Camphor tree. Used topically to relieve pain and itching of the skin. • Blue Mass Pills - contained mercury salts. Used to treat a variety of diseases including depression. Abraham Lincoln used this drug for his mood disorder, but discontinued them because they caused irritability. • Asafoetida (stinking gum) - found in the root of an herb, ferula. It actually had some anti-microbial properties and was used in bronchitis patients. • Corton Oil - from the seeds of a small tree native to India. Used 38 | THE BULLETIN | MARCH/APRIL 2014

topically to cause burning and redness of the skin (poulticing). Although not in Dr. Cory’s diary, quinine was a very popular treatment for fevers of any etiology. Doctors of the day made a very decent living. Income from medical practice was $75.00 - $100.00 per day. Office visits were two ounces of gold dust ($32.00 dollars). Laudanum charges were one dollar per drop and quinine one dollar a grain. These prices were not out of line as boots sold for $40.00 a pair, potatoes, a dollar a pound, and a haircut was five dollars. Surgery in 1849 was in its infancy. Anesthesia was either whiskey or laudanum, with or without restraints. Morbidity and mortality rates were unacceptably high. Most surgeons were restricted to setting fractures, draining abcesses, and performing amputations. It would be a few years before anesthesia (ether and chloroform) and aseptic technique would lower morbidity and mortality rates and allow general surgical procedures to become more commonplace. The gold rush physician relied on his savvy and his senses, plus an array of chemicals and botanicals to bring relief to the suffering. He gave it his best with what he had to work with.

WANTED: MEDICAL MEMORABILIA PROJECT: NEW MEDICAL MUSEUM AT SCVMC

A new, innovative, state-of-the-art medical museum is being planned at SCVMC. It is a joint project with SCVMC and SCCMA. We are looking for any medical artifacts or antiques that would be connected with any medical or surgical field. Equipment, books, displays, instruments, etc., would be welcomed. If you wish to donate any of the aforementioned items, please contact Michael Shea, MD, at 408/2685820 or md6996@sbcglobal.net.

In Memoriam Roger Bartels, MD

Duke D. Fisher, MD

Robert J. O’Neill, MD

*Plastic Surgery 2/2/32 – 9/18/13 MCMS member since 1985

*Psychiatry Psychoanalysis 11/3/38 – 1/9/14 MCMS member since 1969

*Family Medicine 10/19/24 – 1/5/14 SCCMA member since 1955

William A. Frey, MD

*Internal Medicine 3/25/31 – 2/18/14 SCCMA member since 1963

Louis L. Buzaid, MD *Diagnostic Radiology 7/17/09 – 2004 MCMS member since 1965

Hugh Elliott, MD *General Surgery 3/12/23 – 9/12/13 SCCMA member since 1955

Anthony S. Felsovanyi, MD *Internal Medicine 12/20/1914 – 10/7/13 SCCMA member since 1947

*Internal Medicine Cardiovascular Disease 8/21/26 – 11/19/13 SCCMA member since 1964

Abraham A. Goetz, MD *Internal Medicine Cardiovascular Disease 5/7/23 – 11/16/13 SCCMA member since 1953

Robert W. Johnson, MD General Practice 1/1/22 – 10/6/12 SCCMA member since 1956

Robert A. O’Reilly, MD

Donald R. Stewart, MD *Pediatrics 7/29/27 – 9/2/13 SCCMA member since 1957

Fernand Williamson, MD General Surgery General Practice 1/1/22 – 12/13/13 SCCMA member since 1964

Help Create an AIDS-Free Generation Include routine HIV testing for all patients, regardless of their risk status, starting at age 13. HIV screening is recommended for all patients in all healthcare settings. Persons at high risk for HIV infection should be tested at least annually. For information or to view a video on how to incorporate routine testing into your practice, please scan the QR code or visit http://bitly.com/ bundles/prxinc/2.

MARCH/APRIL 2014 | THE BULLETIN | 39

MEMBERSHIP

Welcome 283 SCCMA Members Santa Clara County Medical Association

Name Gaurav Abbi Susan Abraham Jack Ackerman Sweetheart Ador-dionisio Mohammed Ahmed Teeb Al-Samarrai Shazia Ali Sweet Allen Jessica Ansari Jordan Apfeld Usa Aroonlap Jordan Arora Karishma Arora Timothy Au Khin Aye Tej Azad Huma Aziz Quentin Baca Nicole Baier Mohammed Bailony Scott Baldwin Leandra Barnes Pamela Basto Daniel Berenson Lindsey Bergman Christopher Bernardi Dinesh Bhuva Brice Blatz Sailaja Bommakanti Nicole Borau Lindsay Borg Monica Brocco Matthew Brown Jamie Busch Hazel Carranza Virginia Chan Hamsika Chandrasekar Angela Chang Kathleen Chang Samuel Chang Jin Chang-Yu Edward Chaw Marina Chechelnitsky Ashley Chen Chwen-Yuen Chen Frances Chen Jenny Chen Annie Chern Sarah Cheyette Jason Choi Jeff Choi Benjamin Chou Clement Chow Irene Chuang

City Specialty San Jose ORS San Jose PD San Jose HOS Santa Clara IM San Jose US San Jose MPH San Jose GE Cupertino IM Palo Alto AN Stanford US San Jose P Mtn View OBG Sunnyvale AN Santa Clara IM San Jose PTH Stanford US San Jose IM Stanford AN San Jose PD San Jose HOS San Jose SO Stanford US Stanford US Stanford US Palo Alto AN San Jose FP San Jose ORS Campbell FP San Jose IM San Jose END Palo Alto AN San Jose EM Milpitas OM San Jose FP San Jose PD San Jose OBG Stanford US Milpitas PD San Jose PD Palo Alto SM San Jose OBG San Jose PMD San Jose OPH San Jose P Redwood City IM Stanford US San Jose GE San Jose FP San Mateo PD Santa Clara AN Stanford US San Jose R Campbell OPH San Jose P

40 | THE BULLETIN | MARCH/APRIL 2014

Name Molly Cirone Shara Cohn Scott Crow Cristina Cunanan Eduardo Da Silveira Jenny Daci Yang Michael Deftos Jay Desai Anjali Deshmukh Manjushree Deshpande Riaz Dhanani Ashley Dragoman Esther Dunn Sekar Eadula Isabel Edge Melissa Egge Katie Ellerbrock Joselito Endaya Ishai Erez Mahsa Esfahani Jacob Evans Victoria Fahrenbach Maria Falcocchia Arthur Feldman Clayton Feldman Dan Feng Kurt Fink Michael Friedberg Julius Fu Matthew Garabedian Alvin Garcia Jonathan Gardes Benton Giap Sandeep Gidvani Michael Gifford Andrew Grose Gemma Guillermo Ibrahim Hakim Valerie Halls Nathan Hart Gavin Hartman Sejal Hathi Michael Henehan Kelsey Hirotsu Allen Ho David Hong Shirin Hoodei Raymond Hsieh Emily Huang Paul Huang Wendy Hui Henry Huie Jim Hur Lucy Huynh

City Specialty San Jose PD Palo Alto AN San Jose US San Jose AN San Jose GE San Jose GE San Jose PTH San Jose R San Jose R Santa Clara FP San Jose R San Jose PD San Jose EM San Jose FP Mtn View FP San Jose PD San Jose AN Santa Clara IM Santa Clara AN San Jose HOS San Jose FP Stanford AN Campbell IM San Jose IM San Jose IM Stanford US Palo Alto AN San Jose PD San Jose PM San Jose US Stanford AN San Jose AN San Jose PM Campbell OSS Campbell D Saratoga EM San Jose P Stanford US Campbell FP San Jose ORS Stanford AN Stanford US San Jose FP Stanford US Stanford US San Jose PD San Jose P San Jose APM San Jose PM San Jose PUD San Jose PD San Jose PM Saratoga OBG Milpitas PD

Name Paul Hwang Zarah Iqbal Jodilana Jackson Julia Jezmir Sejal Jhatakia Amit Joseph W. Brian Joyce Lyth Kaileh Manjula Kamaraju Jason Kang Kirandeep Kaur Lelanya Kearns Monica Kenney Rebecca Kershnar Beemen Khalil Amna Khan Farah Khan Samina Khan Shalla Khan Rita Khodosh Amy Khong Shahe Komshian Eliana Krulig Amanda Kumar Sunny Kumar Matthew Kwan Rachel Lapidus Bonnie Lau Neil Lawande Grace Lee Jason Lee Lisa Lee Sandra Lee Yu Jin Lee Brian Levitt Matthew Lilly Ruth Lin Taylor Liu Jeffrey Livingston-Carr Justin Lo Michelle Loftis Joshua Lopez Peggy Lu Jenwei Luu Kim-Oanh Ly Belinda Magallanes Margaret Mahony Tahira Malik Jerry Manoukian Cesar Marquez LaCrista Mazeke-Kelley Dararat Mingbunjerdsuk Oana Mischiu Brita Mittal

City Specialty Santa Clara NPM Stanford US Santa Clara OBG Stanford US San Jose ON Stanford AN Morgan Hill IM San Jose IM San Jose FP Stanford ORS Santa Clara OPH San Jose OBG Mtn View PD Gilroy FP Stanford US San Jose PD San Jose P San Jose P San Jose UC San Jose D San Jose P San Jose IM San Jose D Stanford AN Stanford US Santa Clara GS San Jose P Santa Clara EM San Jose AN San Jose R Santa Clara PTH San Jose OTO San Jose PD San Jose US San Jose GE Santa Clara P San Jose PD Santa Clara US San Jose P San Jose APM Los Gatos PD San Jose FP San Jose ON Santa Clara EM San Jose P San Jose FP Santa Clara GYN San Jose PD Mtn View IM Stanford US San Jose PD Santa Clara PD Cupertino R Palo Alto AN

MEMBERSHIP Name Nuriel Moghavem Diana Mokaya Tamara Montacute Jing Moy Jason Much Christine Mulkerin Amanda Munoz Jennifer Naidu Ajit Nair Archana Nair Preeti Nargund Trishna Narula Nanda Nayak Aaron Nayfack Anca Neacsu Harley Negin Andrew Nevitt Ilene Newman Ann Ng Hiep Ngo An Nguyen Bao Nguyen Thanhan Nguyen Thuy Nguyen Arlene Noodleman Ramon Ortiz Vladimir Oykhman Carolyn Pan Dhanu Panchal Vidya Parameswaran Vida Parsi Roeliza Pascua Manjul Patwardhan Laura Phan Loi Phan Eric Pridgen Charulata Ramaprasad Maria Ramirez-Caceres Priya Rao Rema Rao Divya Reddy

City Specialty Stanford US San Jose FP Palo Alto FP Los Gatos FP Palo Alto US San Jose PD San Jose OTO San Jose PD San Jose DR Stanford US San Jose NEP Stanford US San Jose P San Jose PD San Jose OBG Saratoga EM San Jose EM San Jose OBG Palo Alto AN San Jose N San Jose P Gilroy IM Mtn View US Stanford US Campbell PM San Jose IM San Jose EM San Jose GS Morgan Hill US San Jose RHU San Jose OBG San Jose IM Cupertino FP Los Gatos OPH San Jose FP Stanford US San Jose IM San Jose IM San Jose HOS Santa Clara PTH San Jose P

Name City Specialty Laura Reis San Jose FP Daniel Reyes-Villa San Jose FP Tedde Rinker San Jose P Mark Ritchie San Jose P Frain Rivera San Jose AN Cole Rojas Stanford US Jonathan Ronquillo San Jose HOS Craig Rothbach San Jose PD Ashley Rowinski Santa Clara PD Gabriel Rubio Stanford US Mauro Ruffy San Jose OTO Paul Russell San Jose PD Christina Ryan Santa Clara PD Varsha Saha San Jose IM Gurpreet Sarao San Jose FP Sheila Savur San Jose GE Andrew Schechtman San Jose FP Luwam Semere Santa Clara OBG Nimeesh Shah San Jose GE Rina Shah Los Gatos FP Vidhi Shah San Jose HOS Shashi Sharma San Jose FP Christina Sheridan San Jose PDC William Shirer Stanford US Leo Sifflet San Jose IM Nicholas Sikic San Jose PD Vanila Singh Palo Alto AN Monica Sinha-Evenson Palo Alto P Jennifer Sirois San Jose IM Neal Slatkin San Jose PLM Joanna Staunton San Jose AN Lauren Steffel Palo Alto AN Stephanie Steinhoff San Jose AN Michael Stevens San Jose FP Jessica Su Stanford US Meera Sukumaran San Jose PD Terry Sullivan San Jose U Frances Sun San Jose FP Saigeetha Sundaramurthy San Jose RHU Jeffrey Sung San Jose R Rachael Sussman San Jose FP

Name Jeff Svoboda Anna Swenson Raafay Syed Terrence Tam Yong Tang Valerie Teng Alisha Tolani Elise Torres Eric Trac Kathleen Tran Matthew Tranduc Tony Truong Bobby Tsang Balaji Venkat Thai Vo Kevin Vong Phillip Wang Adam Was Linda Waters Henry Weinstock Louise Wen Chih-Hisang Weng George Whang Lee White Patrick Whiteley Michael Wickham Christina Williams Trevor Williams David Wong Caroline Woods John Workman Benjamin Wu Yufan Fred Wu Swati Yanamadala Lisa Yang Grace Yu Bing Zhang Qin Zhao Liangxue (Julia) Zhu

City Specialty San Jose P Palo Alto AN Stanford US San Jose PD Stanford US San Jose FP Stanford US San Jose FP Stanford US San Jose D San Jose GS Santa Clara FP San Jose AN San Jose EM San Jose HOS San Jose EM Palo Alto AN Palo Alto AN San Jose PS San Jose FP Palo Alto AN Stanford US San Jose EM Stanford US San Jose EM San Jose PTH Stanford US Santa Clara PD San Jose IM Santa Clara PD Santa Clara AN San Jose CD Stanford US Stanford US San Jose EM San Jose FP Palo Alto PTH Santa Clara IM San Jose FP

US - Unspecified

Welcome 10 MCMS Members Name Debra Bunger David Gardner David Goldberg Christian Hansen

City Specialty Aptos P Carmel PTH Monterey PS Carmel PTH

Name Francis Hardiman Radhika Mohandas Kenneth Nowak Samip Patel

City Specialty Aromas OBG Monterey FP Salinas OTO Carmel PTH

Name Robert Sugar Kathleen Tonti-Horne

City Specialty Salinas AN Monterey FP

US - Unspecified MARCH/APRIL 2014 | THE BULLETIN | 41

Classifieds OFFICE SPACE FOR RENT/ LEASE MEDICAL SUITES • LOS GATOS – SARATOGA

Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital. Both units currently available. Call 408/3551519.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA

Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.

MEDICAL SUITES • GILROY

First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE

Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

MEDICAL SPACE AVAILABLE • CAMPBELL

State-of-the-art medical space available to share on Bascom and White Oaks. Up to three exam rooms with shared common areas. Ideal for primary care or specialist. For more information, please contact Davina at Age Defying Dermatology at 408/369-4210.

OFFICE FOR RENT • SAN JOSE

2395 Montpelier Dr #5, San Jose 95116. Rent $2,000 per month. Lease required. Owner pays

METRO MEDICAL BILLING, INC. • • • • • •

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com 42 | THE BULLETIN | MARCH/APRIL 2014

triple net and monthly H/O dues. Two doctors set up. Three examination rooms. Approximately 1,100 sq. ft., furnished or unfurnished, adequate parking, walk to Regional Med Ctr. Close to X-Ray and lab. Previous tenant doctor retired. Call Marie at 408/268-2040.

employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or email riflovin@allianceoccmed.com for additional information.

MEDICAL OFFICE SPACE TO SHARE • SUNNYVALE

INTERNAL MEDICINE PHYSICIAN NEEDED

Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.

MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW

Mountain View medical office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El Camino Hospital. Basement storage, untilities included. Large treatment rooms, small lab space, BR, private office, etc. Call Dr. Klein at cell 650/2691030.

PERFECT SATELLITE OFFICE • MTN VIEW

Beautiful medical office across from Palo Alto Medical Foundation. Professional office with vaulted ceilings, new interior, digital x-ray, natural light, and Wi-Fi. Trained receptionist to schedule patients, make reminder calls, collect paperwork and insurance info. Rent exam room one to five days per week, excellent office – low overhead. Call 650/814-8506.

MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS

Second story of professional building across from SVMH. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $1.25/sq. ft. Rent is $1,544/month. Contact Steven Gordon at 831/757-5246.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY

Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured

We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@gmail.com.

PART-TIME GENERAL DERMATOLOGIST NEEDED

Sunnyvale Dermatology (Dr. Bernard Recht) is looking for a part-time Dermatologist. We are a well established, busy office and we are looking for someone to work one to two days per week. Please email your CV to judy@sunnyvalederm. com.

PRACTICE MANAGER

Salinas Pediatric Medical Group, Salinas – seeks an experienced Practice Manager with Accounting/Finance, HR, and Office Administration experience. Degree, plus five years relevant work experience required, including supervision of staff. Great stable work environment, competitive comp, including bonus potential. Email resume and cover letter, including salary expectations to lauralj@tpohr.com.

CAREER OPPORTUNITY

Make San Jose State University Your University of Choice Psychiatrist Job ID: 22841 Full/Part time: Full-time Regular/Temporary: Regular Department: Student Health Center About the Position: Applicants interested in PART-TIME EMPLOYMENT are encouraged to apply. The Student Health Center (SHC) provides a variety of medical services, which are similar to outpatient care provided in a physician’s group practice. These services for students include primary and urgent/acute care, evaluation, treatment and guidance for individual health problems, family planning services, public health prevention programs, and health education. In addition, the SHC provides limited initial care for work injuries of employees, and, if necessary, assists in referring such persons for ongoing care. The SHC may also provide first

aid to campus visitors. The Student Health Center (SHC) provides limited psychiatric services for regularly registered students. Psychiatric services include diagnosis and treatment of acute and chronic psychiatric illness. The psychiatrist is expected to obtain a detailed intake assessment, as well as to order appropriate laboratory tests to support diagnostic evaluations. In addition, the psychiatrist is expected to be knowledgeable about and able to refer patients to community resources and to other practitioners within the Health Center when appropriate. Patients with severe chronic psychiatric illness may require referral to community resources for more extensive follow-up and treatment. The psychiatrist reports directly to the SHC Medical Chief of Staff, while receiving some

work direction from the senior psychiatrist. Much of the psychiatrist’s responsibilities are carried out independently, performing assigned psychiatric evaluations, treatment, and psychotherapeutic activities that require a licensed physician and are in accordance with the overall operation of the SHC and within the scope of the program established by the Board of Trustees. The incumbent has the added responsibility of providing highly specialized and/or broad clinical duties that include planning, coordinating, and evaluating ongoing psychiatric care of students. Collaboratively supporting student success is the bottom line purpose of this and all SHC positions. The psychiatrist works in a consultative capacity with Clinicians of the Student Health Center, which includes Physicians and Nurse Practitioners. He/she must also be able to work in a

collaborative way with the Counseling Program at SJSU and with individual counselors in this department. Link to Apply to the Position: http://apptrkr. com/448016.

FOR SALE 2004 Porsche 911 Carrera 4S C4S Cabriolet

The car has flawless black paint with black full leather interior trim. This six-speed manual 911 Carrera 4S is in exceptional condition, garaged, fully loaded…the ultimate driving experience! This is a low mileage (30,000) C4S Cab in pure Porsche Black on Black, $45,000. For more information, contact Bill Parrish, 408/529-1856.

NOW AVAIL ABLE!

2014 Physician Membership Resource Directory ORDER YOUR COPIES TODAY! There are a lot of updates and changes in the new 2014 edition. Make sure to order enough copies for you and your staff! Contact Maureen Yrigoyen at 408/998-8850 today! MARCH/APRIL 2014 | THE BULLETIN | 43

MEDICO NEWS

San Jose-Sunnyvale-Santa Clara Tops All Large Communities in Well-Being Congratulations to each of you. San Jose-Sunnyvale-Santa Clara residents report the highest well-being among the nation’s 52 largest (1 million or more residents) communities, followed by San Francisco-Oakland-Fremont, and Washington, D.C.Arlington-Alexandria, VA-MD-WV. These three metros are commonly among the top of the list of large cities each year. San Jose-Sunnyvale-Santa Clara’s overall rank of fifth across well-be-

ing areas of all sizes is the highest ever for a large metro area. MinneapolisSt. Paul-Bloomington, MN-WI, also typically ranks in the top five, while Denver-Aurora, CO, makes its first appearance on the list this year. To read entire article, visit http://www.centralvalleybusinesstimes. com/stories/001/?ID=25492. (Central Valley Business Times, March 25, 2014 issue)

Report says CURES database provisions in MICRA ballot measure “cannot be implemented” On March 13, the Patients, Providers and Healthcare Insurers to Protect Access & Contain Health Costs campaign released a report that raises serious doubts about whether a key provision of the trial lawyers’ proposed anti-MICRA ballot measure can be feasibly implemented. Even worse, according to the report, the ballot measure would put physicians and pharmacists in the impossible position of choosing between denying or delaying needed prescription medication to legitimately suffering patients and violating the law. In addition to more than quadrupling MICRA’s cap on non-economic damages, the trial attorneys’ proposed initiative would require licensed health care practitioners and pharmacists to consult California’s Controlled Substance Utilization Review and Evaluation System (known as CURES) database prior to prescribing or dispensing Schedule II or Schedule III controlled substances to patients. The non-partisan report found that although this system has the potential to allow prescribing health care providers to check on the relevant prescription drug histories of their patients, as required by the proposed initiative, in practice it lacks important functionality needed to allow doctors and other prescribing health care providers to comply. According to the report, the CURES database, without a major change to its currently proposed timeline for upgrades and improvements, would be unable to accommodate the more than 200,000 new users that would need to be added in order for the system to be universally utilized.

According to the authors of the report, Tim Gage, former finance director for the State of California, and Len Finocchio, former associate director for California’s Department of Health Care Services, the provision “would almost certainly result in a situation in which prescribing health providers would be legally required to use a database that was, in practice, not available.” The measure’s proponents, who have already admitted that the nonMICRA provisions were “sweeteners” written by focus groups, not health professionals, submitted 830,000 signatures to qualify the measure for the November ballot. “This report underscores what we already know – that the nonMICRA provisions of this measure were hastily written in focus groups without providing language to actually make it work. The drafting errors make it impossible to practically implement,” says Jim DeBoo, campaign manager for Patients, Providers and Healthcare Insurers to Protect Access & Contain Health Costs, the political committee organized to oppose the ballot measure. “In the meantime,” said DeBoo, “this measure would increase costs, reduce access, and cause statewide chaos as physicians and pharmacists wrestle with figuring out how to provide needed medicines to patients without violating a new, poorly-drafted law.” (CMA Alert, March 24, 2014 issue)

Attention NORCAL Insured Members Please vote online for NORCAL Mutual’s Board Members at https://groupnet.norcalmutual.com/14prox.nsf/proxy?OpenForm= As an incentive to policyholders who vote electronically by April 25, there will be two chances to win an iPad Air™, an iPad mini™, or a $200 Visa® Gift Card. Proxy votes submitted between April 25 and May 26 will count towards the election of directors, but will not be included in the 44 | THE BULLETIN | MARCH/APRIL 2014

prize drawing. The election of board members will take place at the Annual Meeting of Members held on May 31, at NORCAL Mutual headquarters in San Francisco. All votes must be received by May 26 to count towards the quorum.

MEDICO NEWS

CMA announces sponsored bill package for 2014 The California Medical Association (CMA) recently announced its sponsored bill package for 2014, which includes legislation that would increase access to care in California, restore the 10% Medi-Cal provider rate cut and strengthen physicians’ rights when contracting with managed care plans. Below are summaries of CMA’s eight sponsored bills: All Products Clauses (AB 2400): This bill would prohibit health service plans from executing agreements with physicians that contain provisions requiring them to participate in all networks or products that are currently offered or that may be offered by the health plan. The bill would allow physicians to opt-in in each network or product.   Sugar-Sweetened Beverages Safety Warning Act (SB 1000): This bill would prohibit the sale of most non-alcoholic beverages with added sugar and over 75 calories per 12 fluid ounces without the following warning label, “STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay.”  Medi-Cal Reimbursement (AB 1805): This bill would restore the 10% cut to Medi-Cal provider reimbursement rates that was enacted as part of the 2011 State Budget Act. It seeks to bolster provider participation in the Medi-Cal program as the State implements the rollout of health care reform.  Funding for Primary Care Residency Programs (AB 2458): This bill would appropriate funding to graduate medical education programs in primary care specialties (internal medicine, pediatrics, obstetrics and gynecology, and family medicine) to ensure an adequate and properly distributed supply of physicians, immediately and over the long term.   UC Merced (SB 841): This bill would appropriate $2.8 million in an effort to recruit and retain physicians in the Central Valley. Specifically, SB 841 would appropriate $1.8 million for the University of California San Joaquin Valley Program in Medical Education (PRIME) beginning in fis-

cal year 2015-16, and would appropriate $1 million to begin the planning effort for the establishment of a medical school at UC Merced.   Allied Health Professional Supervision Numerical Limits (AB 2346): This bill seeks to increase the capacity of California’s health care system to provide quality, physician-led access to care. It would change current law to allow a physician to supervise up to six (current limit is four) physician assistants, nurse practitioners, or certified nurse midwives at any moment in time.   Telehealth Reimbursement: Telephone and Electronic Patient Management Services (AB 1771): This bill would require health insurance companies licensed in the State of California to pay physicians for telehealth services, including telephone, or other electronic patient management.  Administrative Efficiency for Health Facilities (AB 1755): The bill would adopt the Health Information Technology for Economic and Clinical Health (HITECH) Act as the standard for health care data breaches and move state law closer to federal law.  CMA will also take a position on hundreds of additional bills over the course of the next few months. CMA’s Council on Legislation (COL) will be meeting in Sacramento to discuss the association’s legislative priorities for 2014. COL is composed of more than 60 physicians from around the state who are nominated by their delegation, county medical society, or specialty society, and meet annually to discuss and recommend CMA’s positions on numerous pieces of legislation pertaining to the house of medicine.   All of the recommended positions taken by COL will be presented to the CMA Board of Trustees for finalization at its April 15 meeting. These then become CMA’s official positions throughout the current legislative cycle.  (CMA Alert, March 10, 2014 issue)

CMA attends California Democratic, Republican Party Conventions to showcase health care efforts The California Medical Association (CMA) sent a large contingent of physicians, medical students, and staff to the California Democratic Party Convention in Los Angeles, March 7-9. As the trial lawyers are major Democratic party financial contributors, our presence was critical to the ongoing battle over the Medical Injury Compensation Reform Act (MICRA). Joining the group of 3,000 California Democratic delegates and guests, CMA’s physicians and medical students, donning their crisp white lab coats, had a major presence. Roaming the halls, lining the backs of caucus rooms, and speaking to delegates, CMA’s representatives were the talk of the convention.

Physicians and students spoke out regarding CMA’s commitment to access to health care in California, particularly the effects any changes to MICRA would have on our state’s health care system. Our volunteers at the CMA booth engaged hundreds of people in conversation about the importance of MICRA – leaving a truly lasting impression. And, during the huge general session, students greeted hundreds of delegates with information regarding the trial lawyers’ ballot measure “sweetener” ploy. CMA is extremely grateful to the over 100 physician members and medical students for their time, enthusiasm and dedication. Their energy was impossible to ignore, and the “white

coats” created wonderful opportunities to start conversations about health care in California. CMA also sent a contingent of physicians and staff to the California Republican Party Convention in Burlingame. California Republicans have been consistent supporters of MICRA and other tort reform efforts, and this year is no different as we face the trial lawyers’ latest challenge. CMA’s representatives to the Republican convention not only spoke to the delegates about the critical importance of continuing to support MICRA, but also touched on many other health care issues facing physicians in Sacramento this legislative session. (CMA Alert, March 24, 2014 issue) MARCH/APRIL 2014 | THE BULLETIN | 45

California's Great America

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Disney Theme Parks & Southern California CITYPASS Please visit www.wildatwork.com

Enter your email address under “Not Yet a Member?” and enter organization/company name: SCCMA/MCMS. Proceed to create your own unique username and password to login anytime!

Gilroy Gardens

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Monterey Bay Aquarium

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Santa Cruz Beach Boardwalk http://www.beachboardwalk.com/gad/

Discount Code: SCCMA2013 Rides + Attractions Ticket $39.95 $32.95

See’s Candies Gift Certificates Sold From SCCMA/MCMS Office Only Call Danielle at (408) 998-8850 Ext. 3008 1 lb box of candy $16.90 $14.20

46 | THE BULLETIN | MARCH/APRIL 2014

All websites, links, and promo codes are case-sensitive. Many more discounts available, call Danielle!

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

800-252-7706 www.CAPphysicians.com

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For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Francisco facial plastic surgeon Corey Maas, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT). Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors. CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection. MARCH/APRIL 2014 | THE BULLETIN | 47

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Address service requested

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NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. For more information contact a NORCAL Mutual broker.

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