September/October 2019 Bulletin: Physician Wellness by SCCMA

September / October 2019

Volume 25 | Number 5

Practice Managment Workshop

REDESIGNING YOUR PRACTICE The Latest Trends to Stay Independent and Increase Profitability Health care reform and the rise of large medical groups have made it difficult for solo practitioners to remain independent. Despite the challenges, well-informed practices are thriving. Led by Debra Phairas of Practice & Liability Consultants, in collaboration with Santa Clara County Medical Association and Physicians Medical Group of San Jose, this free workshop will deconstruct real-life examples of successful practices — and impart critical skills you’ll need to remain independent and build a lucrative practice on your terms. All members of SCCMA and PMG are invited to attend.

WHERE:

WHEN: Wednesday, Nov. 13, 2019 6:00-8:00pm

PMGSJ/ Excel MSO 2304 Zanker Road San Jose, CA 95131

Secure your spot by emailing sameera@sccma.org or visiting www.sccma.org. For assistance, please call 408.998.8850 ext. 3011.

MEMBER BENEFITS Collections CME Tracking Discounted Insurance Financial Services Health Information Technology Resources

How Headspace Helps Physicians, Medical Students Tame Stress

In This Issue

House of Delegates Representation Human Resources Services Legal Services/ Health Law Library Legislative Advocacy/MICRA Membership Directory APP for the iPhone Physicians’ Confidential Line Practice Management Resources and Education

Featured Articles 7 Dealing With Physician Depression and Related Issues 10 How to Recognize and Respond to Burnout in a Fellow Physician 12 The Heart Plays an Important Role in Reducing Stress and Anxiety 14 How Headspace Helps Physicians, Medical Students Tame Stress

Professional Development Publications

Community News

Referral Services With Membership Directory/Website

18 Public Health Announcement

Reimbursement Advocacy/ Coding Services

20 Medical Times from The Past 21 Classified Ads 22 Help and Healing — Mental Health and Substance Dependency Resources

September / October 2019 The Bulletin

The Santa Clara County Medical Association Santa Clara County Medical Association (SCCMA) was founded in 1876 by a small group of physicians who understood it was their duty to fight for their patients and profession. Confronted with the challenges of rampant quackery, epidemics of contagious disease, and a desperate need to establish standards for the profession, physician leaders of the time called upon their colleagues to help them form the Medical Society of the County of Santa Clara “to develop, in the highest possible degree, the scientific truths embodied in the profession.”

OFFICERS

COUNCILORS

President Seema Sidhu, MD

El Camino Hospital of Los Gatos: Shahram S. Gholami, MD

President-Elect Cindy Russell, MD

El Camino Hospital: Gloria Wu, MD

Past President Kenneth Blumenfeld, MD

Good Samaritan Hospital: Kirkor Barsoumian, MD

VP-Community Health Lewis Osofsky, MD

Kaiser Foundation Hospital - San Jose: Priya Rao, MD

VP-External Affairs Erica McEnery, MD VP-Member Services Randal T. Pham, MD VP-Professional Conduct Open Secretary Martin Wong, MD Treasurer Anh T. Nguyen, MD

CHIEF EXECUTIVE OFFICER April Becerra, CAE

CMA TRUSTEES - SCCMA

Kaiser Permanente Hospital: Joshua Markowitz, MD O’Connor Hospital: David Cahn, MD Regional Medical Center: Heather Taher, MD Saint Louise Regional Hospital: Scott Benninghoven, MD Stanford Health Care/Children's Health: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD

Thomas M. Dailey, MD (District VII) Kenneth Blumenfeld, MD (District VII)

The Bulletin September / October 2019

Printed in U.S.A.

Managing Editor MIke Wamungu

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, or SCCMA. 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 of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: MIke Wamungu, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 mike@sccma.org © Copyright 2019 by the Santa Clara County Medical Association.

A Letter from the SCCMA CEO Dear Member,

MESSAGE FROM THE

SCCMA CEO

My team and I hope that this issue will help contextualize an alarming, though reversable trend in our profession, provide resources to combat it, and help catalyze your own wellness practice. It’s time we took care of you. And it’s time you took some time for yourself. Your patients, your community — and most importantly, you — will be better for it.

APRIL BECERRA

For this reason, this month’s issue is dedicated to physician wellness. SCCMA wants you to know that you are not alone. Your work is invaluable, but you, like the rest of us, are human. And as stewards of the profession, we’re committed to doing our best to meet your needs as a doctor, but as a person as well.

CEO, Santa Clara County Medical Association

Admittedly, this issue is a personal one. Physician wellness (or lack of) is a topic that’s often neglected and yet, the consequences of it play out openly in our hospitals and in our homes. The truth is, physicians are stressed. In fact, over 44% of physicians report feeling burned out, 11% report feeling colloquially depressed, and 3% as clinically depressed (Medscape, 2019). You know this more than we do — but we’d be remised if we didn’t address the topic explicitly.

Sincerely, April Becerra | CEO Santa Clara County Medical Association |Your Voice. Your Partner. Your Home. P.S. We’ve partnered with a dynamic tech and wellness company to bring you accessible, mobile mental health care. Keep an eye on your email for a formal announcement in the coming weeks.

September / October 2019 The Bulletin

The Bulletin September / October 2019

September / October 2019 The Bulletin

ood disorders and other mental health conditions are common in the U.S. population; about 18.3 percent of adults had a mental illness in 2016, according to the National Institute of Mental Health. Unfortunately, physicians are not exempt from these conditions. “Depression is very common among physicians, at least as high as the general population, and probably, it’s starting to be more,” said Louise B. Andrew, MD, JD, medical-legal, risk management and trial consultant and litigation stress counselor in Victoria, British Columbia, Canada. In the worst cases, untreated physician depression can even lead to suicide. But greater awareness, preventive measures and appropriate treatments can make a difference. LEARN more about your physician career options with Merritt Hawkins.

PTSD IN PHYSICIANS

Physicians often experience traumas and tragedies. Patients die despite one’s best efforts, and daily stressors occur during the practice of medicine. All of these things can lead to post-traumatic stress disorder (PTSD) in physicians. A 2014 study published in the Journal of Medical Practice Management reported emergency physicians, those practicing in underserved areas, residents, doctors who have been sued for malpractice and those indirectly exposed to trauma are most likely to develop PTSD. While many hospitals and practices may offer the opportunity for debriefing and counseling after adverse incidents, physicians may not always take advantage of these services, or may continue to suffer the after-effects in silence.

ANXIETY IN PHYSICIANS

Physicians also may experience anxiety, ranging from temporary anxious thoughts to a full-blown anxiety disorder that interferes with daily life. Heather Fork, MD, CPCC, career coach and owner and founder of the Doctor’s Crossing, recommends taking some concentrated time to understand and address any worries and anxiety you may be feeling. In one of her blogs, she suggested physicians write down anxious thoughts and then assess how likely that thought is to happen and if there is anything that can be done to mitigate the

The Bulletin September / October 2019

threat. She also suggests taking slow, deep breaths and focusing on the present.

CHANGE COULD BE AN ANSWER FOR SOME

Tom Davis, MD, FAAFP, principal of Tom Davis Consulting in St Louis, said that depression, anxiety and burnout often result when the physician has a “poor fit” with his or her job. Health care has become more corporate, with a focus on productivity, making it hard for “emotional givers” to perform assembly-line patient visits. Physician burnout is a different issue. It is an occupational stress syndrome, Andrew explained, and it does not lead to depression. Recognition is the first step in combatting depression. Davis said that physicians should recognize that depression or anxiety are not their fault, but rather the fault of a system which “puts them on a treadmill cranking out data” and being measured by patient satisfaction scores. Another proactive thing that Davis recommends is getting at least eight hours of sleep daily.

Go part-time if you have to, but do something—nothing is going to get better if you don’t make a change

Next, he suggests changing the situation, learning to say “no” to performing more nonclinical work” and considering other options. “Go part-time if you have to, but do something—nothing is going to get better if you don’t make a change,” said Davis, adding, “Fall back on the three principles of motivation: autonomy, mastery, purpose.” Once the changes have been made and the physician is feeling better, Davis recommends mentoring colleagues and students. “The only strategy left is for individual clinicians to take control of their own mental health by practicing medicine in a way sustainable for them,” Davis said. FIND a new practice environment with Merritt Hawkins’ physician placement experts.

CHALLENGES OF DEPRESSION TREATMENT

Physicians routinely diagnose and treat patients dealing with mood disorders, but they are less likely to recognize their own depression. Additionally, when the doctor is the one with a mood or

other disorder, treatment can become far more complicated than for people in other professions. Physicians often fear seeking treatment will lead to the loss of their medical license, which Andrew said can happen. Yet physician depression is readily treatable. Some physicians will seek treatment in another city under an assumed name, Andrew said. Others live in a state of being miserable, because they are afraid. Physicians appear to try self-medication, which Andrew said is not illegal but not a good practice. Some physicians have tried it with disastrous results. “It may take many different trials of medication to get what works for you,” Andrew said. “If it doesn’t work [at first], you might come to the conclusion nothing will work for you.” Andrew recommends seeking care from a psychiatrist or mental health facility and paying cash, so the insurance company is not involved.

BEWARE OF PHYSICIAN HEALTH PROGRAMS

While physician health programs (PHPs) have been established and operate with the expectation of helping physicians, they may not be the right choice. “I would not send anyone to a physician health program,” Andrew said. Physicians referred to a PHP will be drug tested, and even evidence of a single glass of wine could be considered an alcohol-use problem, Andrew said. The doctor at that point will be referred to a specific treatment center and kept there up to 90 days, which could cost $100,000 up front, Andrew explained. If a physician leaves, the center reports it to the board of medicine, and he or she is disciplined, including the possible loss of the medical license. Florida recently passed legislation (HB 229) to require the Department of Health to establish terms and conditions of the impaired practitioner programs by contract. It also requires the department to refer practitioners to consultants and revises grounds for refusing to issue or renew a health professional’s license. Louisiana’s Senate has unanimously passed a Physician’s Bill of Rights (SB286), which will grant physician’s rights against improper investigations and to provide due process. Andrew recommends caution with such programs and to seek care elsewhere. Whatever you do, don’t ignore the problem. A physician’s mental health and well-being cannot be overlooked.

September / October 2019 The Bulletin

How to Recognize and Respond to Burnout in a Fellow Physician Sara Berg Senior News Writer, American Medical Association Whether you are in a small practice, hospital or health system, here is how to recognize and how to respond to physician burnout in a colleague.

PAY ATTENTION TO THOSE AROUND YOU

When physicians are burned out, they noticeably go from happy and inquisitive to rushed and indifferent. As a result, both the patient and physician suffer. “It’s a tough job. It’s hard work. Everybody is going to be down at some point in time and it will often feel like you’re barely keeping your head above water,” AMA member Kevin Hopkins, MD, said in an interview with AMA Wire®. “When you’re struggling to keep your head above water, make sure you are looking for people around you, because you will notice co-workers—and even partners and physicians—who are drowning.” Look to others around you. Changes in personality, such as making less eye contact or asking fewer questions, are often signs of depersonalization and fatigue. If left unaddressed, they can lead to inattentiveness and indifference—neither of which improve patient care or physicians’ experience. “If you are only concerned about keeping your own head above water, you’re never going to throw them a line to help them when they’re drowning,” said Dr. Hopkins, a family physician and medical director at the Cleveland Clinic Strongsville Family Health and Ambulatory Surgery Center in Strongsville, Ohio. “Be aware of your surroundings, be aware of the mood, the level of burnout of the people with whom you work most closely,” he added. “And when you see someone is in trouble, do something about it.”

WATCH OUT FOR CYNICISM

The strongest sign of burnout is when a physician feels that nothing she does will make a difference. Watch out for physicians who might display an increase in biased comments about patients and the ineffectiveness of treating them. Physician burnout comes with a sense of despair, hopelessness and isolation. While that can be intimidating when you spot it in a colleague, the first response can be basic.

The Bulletin September / October 2019

“It is amazing what a difference just being kind and treating people with respect makes,” Dr. Hopkins said. “Treat other people the way you would want your mom treated.” Approach a fellow physician with empathy and let them know you care about them or have noticed they are struggling.

EXHAUSTED BY THEIR PROFESSION

No one is expected to be upbeat all the time, but there is a big difference between being tired at work and being exhausted by your profession. Too often, Dr. Hopkins hears from patients who have gone to see another physician and report, “He has no personality” or “He didn’t answer any questions.” Those can be signs of burnout. Physician burnout might begin with exhaustion, but it can lead to something worse if not identified. Unfortunately, early in training, physicians often learn that seeking help is a sign of weakness—it is not. Reassure your colleague that asking for help is a sign of health and recommend they speak with their family, other physicians or even seek professional help. The AMA offers online CME on physician burnout that helps doctors redesign their medical practices to minimize stress and improve job satisfaction. AMA’s STEPS Forward™ is an open-access platform featuring more than 50 modules that offer actionable, expert-driven strategies and insights supported by practical resources and tools. Based on best practices from the field, STEPS Forward modules empower practices to identify areas or opportunities for improvement, set meaningful and achievable goals, and implement transformative changes designed to increase operational efficiencies, elevate clinical team engagement, and improve patient care. Several modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve largescale health transformation through TCPI’s Practice Transformation Networks. The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.

Serving those who provide care.

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by Gaby Boehmer and Carol Thompson

P © Can Stock Photo / Kurhan

sychologists once maintained that emotions were purely mental expressions generated by the brain alone. We now know that this is not true — emotions have as much to do with the heart and body as they do with the brain. Of the body’s organs, the heart plays a particularly important role in our emotional experience. The experience of an emotion results from the brain, heart, and body acting in concert. The HeartMath Institute, a Central California research center dedicated to the study of the heart and the physiology of emotions, has conducted numerous studies identifying the relationship between emotions and the heart. A number of their studies have provided new insight into understanding how the activity of the heart is indeed linked to our emotions and our health, vitality and well-being.

EMOTIONS AND THE HEART

HeartMath studies have defined

The Bulletin September / October 2019

a critical link between the heart and brain. The heart is in a constant two-way dialogue with the brain — our emotions change the signals between the heart and brain in complex ways. The heart sends more information to the brain than the brain sends to the heart. And the brain responds to the heart in many important ways. This research explains how the heart responds to emotional and mental reactions and why certain emotions stress the body and drain our energy. As we experience feelings like anger, frustration, anxiety and insecurity, our heart rhythm patterns become more erratic. These erratic patterns are sent to the emotional centers in the brain which it recognizes as negative or stressful feelings. These signals create the actual feelings we experience in heart area and body. The erratic heart rhythms also block our ability to think clearly. Many studies have found that the risk of developing heart disease is significantly increased for people who experience frequent stress. Stress is an umbrella term that embraces emotions such as irritation, anger or frustration, judgement, guilt and depression. These emotions create a chain reaction in the body — stress hormone levels increase, blood vessels constrict, blood pressure rises, and the immune system is weakened. If we consistently experience these emotions, it can put a strain on the heart and other organs, and eventually lead to serious health problems. Conversely, HeartMath’s research shows that when we experience heart-felt emotions like love, care, appreciation and compassion the heart produces a very different rhythm. In this case it is a smooth pattern that looks like gently rolling hills. Harmonious heart rhythms, which reflect positive emotions, are considered to be indicators of cardiovascular efficiency and nervous system balance. This lets the brain know that the heart feels good and often creates a gentle warm feeling in the area of the heart. Learning to shift out of stressful emotional reactions to these heartfelt emotions can have profound positive effects on the cardiovascular system and our overall health. It is easy to see how our heart and emotions are linked and how we can shift our heart into a more efficient state by monitoring its rhythms.

BEING APPRECIATIVE HAS BENEFITS

The feeling of appreciation is one of the most concrete and easiest positive emotion for individuals to self-generate and sustain for longer periods. Almost anyone can find something to genuinely appreciate. By simply recalling a time when you felt sincere appreciation and recreating that feeling, you can increase your heart rhythm coherence, reduce emotional

stress and improve your health. For people who may initially find it difficult to self-generate a feeling of appreciation in the present moment, experts suggest that they recall a past memory that elicits warm feelings. With practice, most people are able to self-generate feelings of appreciation in real time and no longer need the past time reference. Dr. Rollin McCraty, Director of Research for the HeartMath Institute, says, “It’s important to emphasize that it is not a mental image of a memory that creates a shift in our heart rhythm, but rather the emotions associated with the memory. Mental images alone usually do not produce the same significant results that we’ve observed when someone focuses on a positive feeling.” Positive emotion-focused techniques, like those developed by HeartMath, can help individuals effectively replace stressful thoughts and emotional patterns with more positive perceptions and emotions. One of the long-term benefits to be gained from the practice of these kinds of techniques is increased emotional awareness. This increased awareness can help individuals maintain a more consistent emotional balance, a fundamental step in the process of improving health. As individuals develop self-regulation skills they can proactively participate in creating their own improved health and greater sense of well-being. HeartMath Inc. is a cutting-edge performance company that provides a range of unique services, programs for health professionals and technologies to improve health and well-being, while dramatically reducing stress and boosting performance and productivity. Their awardwinning Inner BalanceTM and emWave® technologies have more than 300,000 users. HeartMath Inc. supports over 27,000 health professionals in over 100 countries. The HeartMath techniques and technologies have been the subject of over 400 peer-reviewed and independent published studies. The HeartMath Institute, a nonprofit 501(c)(3) research and education organization has been researching emotional physiology, optimal function, resilience and stressmanagement for more than 25 years. The Institute’s research has been published in peer reviewed journals such as the American Journal of Cardiology, Stress Medicine, Global Advances in Health and Medicine, Alternative Therapies in Health and Medicine and Preventive Cardiology. The two companies represent what is called The HeartMath System, a comprehensive ecosystem of compelling research and solutions for stress relief that have been scientifically validated.

September / October 2019 The Bulletin

How Headspace Helps Physicians, Medical Students Tame Stress by Sara Berg — Senior News Writer, American Medical Association

here are many system-level drivers of physician burnout, which require the attention of medical organizations. There are also some ways that physicians can work to cut stress on their own time. A surgeon, pathologist and medical student have found one way—by practicing mindfulness meditation with the Headspace app.

CHANGING THE CULTURE OF BURNOUT

See how AMA members are changing the culture and stigma associated with physician burnout in the latest issue of AMA Moving Medicine. Headspace is a meditation and sleep app that can have a positive impact on health professionals’ personal and professional lives. AMA members can get a free, two-year subscription to Headspace.   Three AMA members—a surgeon, pathologist and medical student—shared how they are using the Headspace app to reduce the impact of stress on their lives in medicine.

PREOPERATIVE PREP

Ravi D. Goel, MD, a comprehensive ophthalmologist and cataract surgeon in Cherry Hill, New Jersey, often uses the Headspace app for meditation before surgery. Because ophthalmologists and microsurgeons often have “back and neck issues,” mindfulness meditation can help with relaxation, he said.  “Initially, it helps with focus and relaxation. We all have different places where we throw stress—your back, your neck—and mindful meditation can help you with an almost instant relaxation,” he said. “Mindfulness meditation can have a similar effect on me as a one-hour yoga session. And with a 10-minute session before I start the day, the positive effects can last for many hours each day. Dr. Goel has found that he can destress while becoming more mindful in the present moment for increased focus during surgeries because “it’s a power tool in my mission of protecting sight.”

WINDING DOWN

Nicole Riddle, MD, a pathologist in Tampa, Florida, and member at-large of the AMA Young Physicians Section governing council, uses the Headspace app to help her sleep at night.  “I have a racing mind and it helps me to have something to

The Bulletin September / October 2019

focus on that is relaxing and helps me fall asleep,” said Dr. Riddle. “I also use the tools—either with the phone or on my own—to get back to sleep in the middle of the night. “I also try to use it for a five to 10-minute moment of mindfulness to help relieve stress and relax myself or calm myself down during the work day.” Dr. Riddle said that she has felt her heart rate and perceived stress level fall when she uses the app’s exercises, whether during the day or at bedtime. “As it helps me sleep, that definitely leads to better overall health, as well as lessening stress,” she said.

RELATED COVERAGE KEEPING UP IN MED SCHOOL Heather Bird, an osteopathic medical student at Pacific Northwest University of Health Sciences in Yakima, Washington, almost ended medical school after her first year because of burnout and low-back pain. Fortunately, during the summer after her first year of medical school, she found meditation, which helped her regain her focus. “My meditation practice is comparable to my tooth-brushing practice—it is as important to maintain my mental wellness hygiene as it is to keep up on my physical hygiene,” said Bird. “It is one of the tools I use in the morning to greet the day and in the evening to fall asleep.” She will also use the Headspace app in the middle of the day if she begins to “feel anxiety creeping into my day,” and uses the download capability for walking meditations. “I am currently on a clinical rotation that is close enough to walk to,” said Bird. “While listening to the app on my walk, I notice the beautiful colors of the plants, birds hopping about seem to emanate joy and the sunshine energizes my vibe! It makes going to clinic a lovely journey and I arrive happy, ready to work.” Committed to making physician burnout a thing of the past, the AMA has studied, and is currently addressing, issues causing and fueling physician burnout—including time constraints, technology and regulations—to better understand and reduce the challenges physicians face. By focusing on factors causing burnout at the system-level, the AMA assesses an organization’s well-being and offers guidance and targeted solutions to support physician well-being and satisfaction.

Legacy Wealth Advisors Managing the reserve investment accounts of the Santa Clara County Medical Association (SCCMA) and the Bureau of Medical Economics (BME) since 2000 1900 The Alameda Suite 510 San Jose, CA 95126 P: (408) 452-7700 F: (408) 452-7470 Email: Info@lwallc.com

Wealth Management

Legacy offers a broad range of wealth management services to SCCMA and MCMS physician members and their families. Such services include: • Financial Planning, Risk Management, Educational & Retirement Planning Projections • Liquidity Management and Cash Flow Analyses • Estate Tax and Charitable Planning • Existing Portfolio Analysis • Design and Implementation of Investment Strategies 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 Michelle Hamilton, CFP®, MBA at (408) 452-7700 or email michelle@lwallc.com.

www.lwallc.com

Member Appreciation Party Enjoy appetizers, beverages and holiday music with old and new friends as we transform our space into a Winter Wonderland!

SAVE the DATE

Special VIP guests will be in attendance! Each member will receive a special gift from SCCMA. Watch your email for future announcements.

Thursday, December 5, 2019 from 5:30 - 8:30 pm 700 Empey Road, San Jose, CA 95128 Call us: 408-998-8850 x 3011 Email: sameera@sccma.org

U.S. Marine’s

Bring a new, unwrapped toy or call to request an SCCMA staff member to pick up your unwrapped toy from your office.

September / October 2019 The Bulletin

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The Bulletin September / October 2019

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September / October 2019 The Bulletin

Mr R. is a 37 year old lifelong resident of Santa Clara County. He also carries a diagnosis of severe opioid use disorder (OUD); he’s been injecting heroin for more than half his life. Predictably -- and tragically -- heroin is causing significant havoc in his life, rippling through his health, relationships, and housing status. He has been frequently incarcerated, including stints in both county jails and state prison. Recently this trend is accelerating for him; he’s been booked into our county jail seven times in the past two years alone. During his most recent booking, however, Mr R. was eligible for expanded medication assisted treatment (MAT) services now available in the Santa Clara County jails. He was admitted to the jail infirmary where he was started on a sublingual buprenorphine taper to treat his withdrawal symptoms of nausea, diarrhea, insomnia and bone aches. The following day, he met with a custody physician who made a diagnosis of OUD and offered Mr. R. the chance to start maintenance MAT in jail with the hope of solidifying his recovery by the time he’s released back to the community. When he heard this treatment might be possible in jail, Mr. R started crying. “I’ve lost six friends including my sister to overdose in the past two or three months,” he said through tears. “I’m ready to get treatment. My parents can’t lose another child.”

FENTANYL IN SANTA CLARA COUNTY

Historically, Santa Clara County has had lower rates of overdose deaths from opioid use than other regions of the country, including the Midwest and East Coast. In large part this decreased risk was due to the relative absence of fentanyl, a very potent synthetic opioid, from our local heroin supply. Unfortunately there is mounting evidence that this trend is reversing as more and more local users are reporting fentanyl use and more local supply is found to contain fentanyl. In fact, in the past months law enforcement agencies in Santa Clara County have seized a large number of counterfeit Percocet pills that contain fentanyl as their sole active ingredient. In a widely circulated warning letter, a representative from the county’s District Attorney’s office reported numerous fatal overdoses tied to these tablets, with a “strong uptick in fatal overdoses in August 2019”. Especially given this evolving situation, it will be critically important for physicians in our county to recognize, screen, diagnose and treat patients with OUD to prevent further overdose deaths as fentanyl continues to become increasingly available here. “All Things Substance Use” is a county-wide working group including participants from public and population health, Substance Use Treatment Services (SUTS), Valley Homeless Healthcare Program (VHHP), Valley Medical Center including representatives from emergency medicine, inpatient medicine and primary care, and custody health. The group meets monthly to tackle initiatives around Narcan availability, increasing the number of county providers who prescribe buprenorphine and other projects. Here’s how these groups are each responding to the growing opioid crisis in Santa Clara County:

SUTS SUTS has six addiction specialist physicians who offer induction, stabilization and maintenance for people with OUD with either methadone or buprenorphine depending on individual patient factors. Additionally, SUTS provides counseling and case management for all MAT patients. They serve as the main referral intake from VMC (including the emergency department, the inpatient setting and the outpatient clinics) and custody health. SUTS aims to transition stable buprenorphine patients back to primary care after 90 days while providing mentoring and support to primary care physicians who are caring for people with OUD.

The Bulletin September / October 2019

Public Health Department The County of Santa Clara’s Needle Exchange Program (NEX) is one of over 40 authorized needle exchange programs in California. Syringe access programs are community- or street-based programs that provide sterile, unused needles and other injection equipment to persons injecting drugs, or other substances. At seven locations throughout the county, clients are encouraged to deliver used syringes when sterile syringes are provided in order to promote safe disposal of used syringes as well as access to safer injection equipment and other harm reduction resources. In addition, NEX sites provide clients with training on recognizing an overdose, calling for emergency medical response and caring for someone experiencing an overdose until help arrives. Clients then receive Opioid Overdose Prevention kits that include naloxone to help reverse the life-threatening effects of opioids, and they receive instructions on safe administration of the medication in accordance with law. In order to reduce the consequences of intended and unintended fentanyl exposure, the NEX program distributes fentanyl testing strips for people interested in testing their drugs for the presence of fentanyl. For additional information, please contact hivprevention@phd.sccgov.org or check out SCCNEX.org for NEX hours and locations.

VHHP All 15 providers, including psychiatrists, are x-licensed to prescribe buprenorphine which allows VHHP to perform inductions at all 14 clinical sites and provide stabilization and maintenance at Alexian Clinic, Gilroy Mobile Unit, and the Re-Entry Center. VHHP also runs MAT groups at several sites. VHHP provides all of its care through an integrated team, using social work, psychology, and psychiatry to more effectively care for the whole patient and promote sobriety.

Custody health All full time physicians are x-licensed. They provide a fixed five day taper of buprenorphine in the jail infirmary for recently booked people with moderate or severe withdrawal symptoms. They also offer maintenance buprenorphine using a long acting injectable formation (Sublocade) and will begin offering methadone inductions in collaboration with SUTS physicians. The custody MAT program is supported by a medical social worker who coordinates both the in-custody program and discharge planning for this population. After release from custody, people follow up at the Re Entry Center and may chose to continue with Sublocade or transition to the sublingual preparation. Custody also offers Vivitrol injections prior to release for interested people with either OUD or alcohol use disorder; methadone maintenance for people who enter custody already on methadone treatment and methadone induction and maintenance for pregnant women with OUD.

VMC: emergency medicine The VMC emergency department provides buprenorphine induction for eligible patients who are then linked to SUTS for ongoing treatment. All patients are followed up the next day in an outpatient clinic for medication and counseling

services.

VMC: inpatient medicine Currently buprenorphine induction is provided in the hospital with support from SUTS physicians for complex cases. After hospital discharge, patients are referred back to their primary care provider (VHHP or Moorpark) or to SUTS for stabilization and maintenance. In the future, there is a plan to create an addiction/pain team available for inpatient consultation; this team, composed of an addition medicine specialist, counselor, case manager, social worker and peer mentor, will perform buprenorphine induction and transition patients to outpatient treatment after discharge. The team will also provide consolation for peri-operative patients or other patients with acute pain already on buprenorphine.

VMC: primary care Currently there is a small scale MAT clinic at the Moorpark clinic providing buprenorphine inductions, stabilization and maintenance. In addition there are at least 34 x-licensed physicians in family and internal medicine who are interested in providing maintenance MAT to their primary care patients. These physicians have indicated via recent survey that if they were provided with increased support including mentorship and longer clinic visits, they would add maintenance of MAT patients to their practice. Work is ongoing to establish at least one provider per clinical site with the necessary support to provide MAT to primary care patients in the clinic.

Where to send patients for help

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Call Gateway at (800)488-9919 to get into any of Substance Use Treatment Services (SUTS) clinics Valley Homeless Healthcare Program for homeless patients VMC emergency room is an option for buprenorphine induction

How you can get involved!

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Remember that opioid use disorder is very common! Ask patients about their opioid use and refer patients with possible OUD for further evaluation and treatment Discuss the risk of overdose with all patients for whom you prescribe opioids; always provide a Narcan kit and discuss its use with any opioid prescription that is long term or higher dose Consider becoming an X-licensed provider. This designation requires a free 8 hour training that can be completed in person or online; after training providers are eligible to prescribe buprenorphine for the treatment of OUD Become a member of the Santa Clara County Opioid Overdose Prevention Coalition (SCCOOPP) to help with outreach into our community and collaborate with different organizations for safe prescribing and treatment access © Can Stock Photo / artursz

September / October 2019 The Bulletin

Medical Times From the Past 20

Organ Transplant History By Michael Shea, MD Leon P. Fox Medical History Committee

rgan transplantation has become one of medicine’s great benefits to mankind. The history of this subject reveals many difficulties to overcome and many brilliant pioneers who overcame them. Managing the immune response, vascular anastomoses technique, preservation solutions, and overcoming the shortage in suitable organ donors are all topics that needed to be addressed before organ transplants would be successful. In 1912, transplant pioneer, Alexis Carrell received the Nobel Prize for his work in the field of vascular surgery. The French surgeon had developed methods for connecting blood vessels and conducted successful kidney transplants in dogs. He later worked with aviator Charles Lindbergh to invent a device for keeping organs viable outside the body, a precursor to the artificial heart. In the late 1940’s and early 1950’s, a team of doctors at Boston’s Peter Bent Brigham Hospital, carried out a series of human kidney grafts, some of which functioned for days and even months. In 1954, the surgeons, led by Dr. Joseph E. Murray, transplanted a kidney from 23 year old Ronald Herrick into his twin brother, Richard; since donor and recipient were identical, the procedure succeeded. The first successful agent was azathioprine, a purine analogue. It is thought to act by inhibiting DNA replication and thus blocking proliferation of lymphocytes. Coupled with prednisolone, azathioprine enabled transplantation of kidneys to achieve a fifty percent success at one year. The modern immunosuppressive era came with the discovery of cyclosporin in the mid 1970’s. Cyclosporin inhibits T cell proliferation by blocking activation of these cells. This resulted in transplant success of 90-95 percent over one year. Side effects of the drug are neurotoxicity, nephrotoxicity, and diabetogenesis. Further work in the field has produced monoclonal and polyclonal antibodies. They neutralize activated T cells. Although these drugs are safer, the risk of long term use does predispose patients to infection and malignancy. On March 21, 1984, UNOS was incorporated as an independent, non-profit organization, committed to saving lives through uniting and supporting the efforts of donation and transplantation professionals.

The Bulletin September / October 2019

Also in 1984, the National Organ Transplant Act (NOTA) called for an Organ Procurement and Transplantation Network (OPTN) to be created and run by a private, non-profit organization under federal contract. As part of the OPTN contract, UNOS 1. has established an organ sharing system that maximizes the efficient use of deceasedorgans through equitable and timelyallocation 2. Established a system to collect, store, analyze, and publish data pertaining to thepatient waiting list, organ matching, and transplants 3. Informed, consulted and guided persons and organizations concerned with humanorgan transplantation in order to increase the number of organs available for transplantation The following is a list of time sequenced important organ transplantfirsts: ■■ 1954 the first kidney transplant by Dr Joseph E. Murray 1966 The first successful pancreas/ kidney transplant ■■ 1967 The first successful liver transplant by Dr. Thomas Starzl ■■ 1968 The first successful heart transplant by Dr Norman Shumway at Stanford University Hospital. Currently, the Mayo Clinic reports a five year survival rate of 75 percent. The longest surviving heart transplant patient was John McCafferty who died at age 73, thirty three years after his surgery. ■■ 1981 First successful heart-lung transplant Dr Bruce Keith Stanford University Hospital 1983 First successful single lung transplant by Dr. Joel Cooper ■■ 1989 First successful small intestine transplant into a child by Dr. Olivier Goulet in Paris France ■■ 1998 First successful hand transplant led by Australian Dr. Earl Owen and Frenchman Dr. Jean- Michel Dubernard in Lyon France ■■ 2001 For the first time, the total number of living organ donors for the year(6528) exceeds the number of deceased organ donors(6081). ■■ 2006 UNOS launches Donornet, a secure internet based system in which organ procurement coordinators send out offers of newly donated organs to transplant hospitals with compatible candidates. ■■ 2014 Vascularized composite allographs (VCAs such as hands and face) are added to the definition of organs covered by federal regulation

Classifieds OFFICE SPACE FOR RENT/LEASE 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 408/2280454.

1100 SQ. FT. • MTN VIEW-CUESTA PARK Recently remodeled modern - 3 Exams - 4 Work Stations - Parking - Partnership, LLC - Cat 5 Wiring - Kitchenette - Workroom/ Lab. Light - High Ceilings - Storage. Contact greatoffice2017@gmail.com.

PART TIME OFFICE SUBLEASE AVAILABLE Text: Los Gatos office up to 2 days per week. Offers exam room, waiting room, office with handicap bathroom. Call for details (408) 921-8255

OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.

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 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 e-mail riflovin@allianceoccmed.com for additional information.

WANTED FAMILY PHYSICIAN Family medicine physician needed to share a growing outpatient practice. Start at 16 hours/week and share patient load. Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@yahoo.com / 408/839-6564.

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GREAT BUSINESS OPPORTUNITY • PART-TIME OR ADD-ON TO YOUR EXISTING PRACTICE Medically-supervised weight loss program with 30-year track record. Cash, no insurance. Practice obesity medicine and help patients overcome their weight problems and improve their health. Seeking an associate to train with eventual sale. Contact me at southbayweightloss@gmail.com.

OTHER MEDSKILLS INC. MEDICAL SCRIBES MedSkills is a local Bay Area medical scribe matchmaking service. MedSkills offers physicians medical scribe candidates and specialized scribe training. Sign up for MedSkills monthly subscription by downloading the MedSkills Mobile Application or contact info@medskills.com for more information.

PRIVATE PRACTICE AND BUILDING FOR SALE Family Practice for sale, including inventory, equipment and Real Estate (can also be leased). Great downtown San Jose location. Financing may be available. Minor Laser Surgery performed as well. Call 415/308-3064.

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September / October 2019 The Bulletin

HELP AND HEALING MENTAL HEALTH AND SUBSTANCE DEPENDENCY SERVICES MENTAL HEALTH SERVICES Valley Medical Center: Emergency Psychiatric Services (EPS) (408) 885-6100 | 871 Enborg Lane, San Jose, CA 95128 The Acute Psychiatric Services Division of Santa Clara County Valley Medical Center (VMC) operates Emergency Psychiatric Services (EPS). Emergency Psychiatric Services (EPS) is the only 24-hour locked psychiatric emergency room, which provides emergency psychiatric care to residents of Santa Clara County.

Santa Clara Department Of Alcohol And Drug Programs: South County Clinic (408) 683-4053 | 90 Highland Ave, San Martin, CA 95046 Primary Focus: Mix of mental health and substance abuse services. Type of Care: Outpatient.

HELP AND HEALING — WEBSITES, BOOKS, PODCASTS, AND MORE Websites:

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Hopeline Suicide & Crisis Service (800) 784-2433 | 828 South Bascom Avenue, San Jose, CA 95128 Trained volunteers provide crisis intervention and emotional support to individuals in crisis.

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Santa Clara County Behavioral Health Services: Suicide & Crisis Services

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(855) 278-4204 The Suicide and Crisis Services of Santa Clara County (SACS) provides a crisis hotline where highly trained volunteers are available 24 hours 7 days a week to talk with individuals in crisis. The goal of SACS is to assist in defusing and de-escalating the crisis and helping to return the individual to his/her usual level of functioning.

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HeartMath INC. (800) 450-9111 | 14700 West Park Ave, Boulder Creek, CA 95006 HeartMath Inc. is a cutting-edge performance company that provides a range of unique services, programs for health professionals and technologies to improve health and well-being, while dramatically reducing stress and boosting performance and productivity. The HeartMath techniques and technologies have been the subject of over 400 peer-reviewed and independent published studies and the backbone of HeartMath’s web-based programs specifically for healthcare professionals.

SUBSTANCE DEPENDENCY SERVICES CADS (Countywide Alcohol And Drug Services) (408) 370-9688 | 1925 S Winchester Blvd, Campbell, CA 95008 Primary Focus: Substance abuse treatment services. Type of Care: Outpatient.

Kaiser Milpitas: Chemical Dependency Program

TED Talks:

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Santa Clara County Department Of Alcohol & Drug Services: Central Valley Clinic

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The Bulletin September / October 2019

Atul Gawande: How we heal medicine: https://www.ted.com/ speakers/atul_gawande_1 Brian Goldman: Doctors make mistakes: https://www.ted.com/ speakers/brian_goldman Abraham Verghese: A doctor’s touch: https://www.ted.com/ talks/abraham_verghese_a_doctor_s_touch Eric Dishman: Health care should be a team sport: https://www. ted.com/talks/eric_dishman_health_care_should_be_a_team_ sport Vivek Murthy – not a TED talk, but a great listen - https://hbr. org/video/5775734185001/whiteboard-session-the-problem-ofloneliness-at- work

Books:

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(408) 366-4200 | 19000 Homestead Rd, Cupertino, CA 95014 Primary Focus: Mix of mental health and substance abuse services. Type of Care: Outpatient.

(408) 885-5400 | 2425 Enborg Lane, San Jose, CA 95128 Primary Focus: Mix of mental health and substance abuse services. Type of Care: Outpatient.

https://www.stepsforward.org/modules/physician-wellness - AMA Steps Forward modules, with multiple strategies for reducing burnout and returning joy to medicine https://nam.edu/perspectives-on-clinician-well-being-andresilience/ National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience http://www.ihi.org/education/WebTraining/Webinars/joy-inwork/Pages/default.aspx Institute for Healthcare Improvement offers information on turning burnout to engagement and finding joy in practice http://wellmd.stanford.edu/ - Stanford School of Medicine website to promote physician health and resiliency. Many selfassessments available.

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Epstein R. Attending: Medicine, Mindfulness, and Humanity. 2017. Figley C, et al, Ed. First do no self-harm. Understanding and promoting physician stress resilience. 2013. Firth-Cozens J. How to Survive in Medicine: Personally and Professionally. 2013. Fischer-Wright H. Back to Balance: The Art, Science, and Business of Medicine. 2018. Rakel D. The Compassionate Connection: The Healing Power of Empathy and Mindful Listening. 2018..

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September / October 2019 The Bulletin

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