November/December 2019 Bulletin: A Year in Review by SCCMA

November / December 2019

Volume 25â&#x20AC;&#x201A; |â&#x20AC;&#x201A; Number 6

2020 UPCOMING EVENTS

February The SCCMA offers a wide variety of events throughout the year designed to help you manage your practice and keep patients informed, educated and healthy. Events shown here are subject to change or cancellation.

• Anti Vaping Workshop with FACES • Wellness Program

March • Women in Medicine Conference • Retired Physician and Past President Luncheon

April • Sexual Harassment (sexual assault awareness month)

June • Annual Awards Banquet

Most events are free and all are open to both SCCMA and non-SCCMA members.

September

Interested in partnering with us on an event? Email sameera@sccma.org to chat.

October

• Public Health Department Collaborative Event: Domestic Violence or the Peace Partnership, Climate Change

• Wellness Program

November • Legislative Event for Physicians

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

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

Five Things to Know About California’s New Vaccine Law

In This Issue

House of Delegates Representation Human Resources Services Legal Services/ Health Law Library Legislative Advocacy/MICRA Membership Directory APP for the iPhone

5 Membership Benefits Over-view 7 California Medical Association House of Delegates Recap 10 California Medical Association Strategic Plan

Physicians’ Confidential Line

Featured Articles – Year in Review: The Biggest Headlines of 2019

Practice Management Resources and Education

15 AMA Delivers Message to the White House on Protecting Kids from Vaping

Professional Development Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services

16 Five Things to Know About California’s New Vaccine Law 19 If Power Outages Are California’s New Normal, What About Home Medical Needs 21 The Most Remote Emergency Room: Life and Death in Rural America

Community News 30 Public Health Announcement: Expanded Resources for Providers to Help Patients Quit Tobacco 32 SCCMA Anti-Vaping Workshop 33 Medical Times From the Past: Cesarean Section History 35 Calling All Trailblazing Women

November / December 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: OPEN

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 Gloria, Wu MD 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 November / December 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

MEMBERSHIP PAYS FOR ITSELF Get to Know Your Benefits November / December 2019â&#x20AC;&#x192; The Bulletin

Your Practice

Practice Resources Legal Services: CMA’s legal department provides members with information and resources about laws and regulations that impact the practice of medicine. While CMA staff cannot provide physicians with individual legal advice, our health law information specialists, with the support of CMA legal counsel, will help you find legal information and resources on a multitude of health-law related issues. Call (800) 786-4262 for more information. Health Law Library: CMA’s Health Law Library has over 4,500 pages of up-to-date legal information for practicing physicians and is accessible free to members at cmadocs.org/health-law-library. Practice Management Assistance: Experts from CMA’s Center for Economic Services provide free one-on-one assistance to members and their staff on reimbursement, contracting and practice management related issues. Services include educational resources, one-on-one assistance, intervention with payors and seminars to empower your practice. Reach CMA’s reimbursement experts at (888) 401-5911. Payor Contract Analysis: CMA members have free access to objective written analyses of major health plan contracts designed to help physicians understand their rights and options when contracting with a third-party payor, as well as which contract provisions are prohibited by California law. Find more at at cmadocs.org/ces. Webinar Series: CMA’s webinar series gives physicians the opportunity to watch online presentations on important topics of interest and interact with legal and financial experts from the comfort of their homes or offices. The webinars are free to CMA members and their staff. CMA also has 100+ archived on-demand webinars available at cmadocs.org/webinars.

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CME Tracking/Credentialing: CMA’s Institute for Medical Quality certifies CME activity for credentialing purposes to the Medical Board of California, as well as to hospitals, health plans, specialty societies and others. CME Certification is $33 a year for CMA members, $57 for nonmembers. Visit imq.org or call (415) 882-5151 for more information. Seminar Series: Experts from CMA’s various centers travel to local county medical societies throughout the state, holding live seminars for members and their staff on a variety of issues. Contact your local county medical society for more information. Newsletters: CMA produces a number of publications to keep members up to date on the latest health care news and information affecting the practice of medicine in California. Subscribe to any of these newsletters online at cmadocs.org/newsletters. +

CMA Newswire: CMA’s bi-weekly e-newsletter provides up-to-date information on many issues of critical importance to California physicians.

CMA Press Clips: CMA’s daily news roundup provides a quick but meaningful overview of the day’s health care news.

CMA Practice Resources: CMA’s monthly email bulletin from CMA’s Center for Economic Services includes tips and tools to help physicians and their office staff improve practice efficiency and viability.

Your Insurance

Your Work and Life, Insured CMA works with Mercer and the insurance carriers to design and implement insurance plans that meet the coverage needs of physician members.

PROGRAMS FOR MEDICAL PRACTICES Workers’ Compensation: CMA members qualify for an additional 5% discount on top of Preferred Insurance’s already competitive rates for the one insurance policy all employers are required to carry. Preferred’s rates are set for long term consistency and are managed by focusing on safety and injury prevention, fraud protection and the control of medical costs for your practice by getting employees back to work as soon as is practical. Small Group Health Insurance: Request a quote or consultation with a Client Advisor who can help you navigate the carriers and plans available in California as the health care marketplace continues to change. Cyber Liability Policy: Get coverage for cyber attacks and data breaches with a hotline for assistance in the event of an incident. Business Owners Policy: Secure business liability and property coverage for your medical practice. Protect your personal and business assets, whether you own your building or rent space, with complete coverage at a lower price than insuring with separate policies. Business Overhead Expense: Overhead expenses don't stop just because you become disabled. Don't divert your long term disability benefits to pay for business expenses. Get disability coverage that protects the regular expenses of running a practice.

PROGRAMS FOR INDIVIDUALS & FAMILIES Group Level Term Life Insurance: Life insurance is one of the cornerstones of financial planning and CMA members can secure group rates for 10 and 20-year level term life insurance and optional AD&D coverage. Group Long-Term Disability: Find group rates for disability insurance. Individual & Family Health Insurance: CMA members can purchase individual and family plans through Mercer. Apply online: cmacountyhealth.com. Long-Term Care: Let Mercer find the right long term care insurance for you, so you can spend time on things that matter the most. Leave the worrying to us. Members are eligible for a 5% discount, which applies to members, their families, parents and grandparents. Group Dental: Members get access to affordable dental care. Group Universal Life: Permanent life insurance protection with an optional cash accumulation account. Assist Plus Travel Insurance: Discounted rates and coverage designed to protect you and your family when traveling more than 100 miles from your home. countycmamemberinsurance.com (800) 842-3761

November / December 2019 The Bulletin

Message from the President and CEO

A Year of Transformation SEEMA SIDHU President Santa Clara County Medical Association

his year we saw the transformation of Santa Clara County Medical Association (SCCMA) from an organization that focused on peripheral concepts — such as billing opportunities — to an organization that implemented its core mission of advocating for and serving the needs of its physician members. SCCMA has grown into an organization that is constantly influencing the health care environment and demonstrating the relevancy and absolute necessity of organized medicine in Santa Clara County. SCCMA is now actively leading the future of healthcare access in Santa Clara County through partnerships with legislators and individuals that understand the political and regulatory environment we medical professionals practice in. Some of the key events that demonstrated this new focus are:

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Launch of a novel branded SCCMA site - www.sccma.org.

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Partnering with CMA to develop a wellness program and hosting a physician wellness program to provide physicians with tools to provide professional fulfillment.

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Creating and hosting CME conferences to provide physician education on a variety of topics including retirement education for physician members.

APRIL BECERRA CEO Santa Clara County Medical Association

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Active role in STEM program events helping develop and engage future physicians.

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Developing relationships with Santa Clara County legislators and having a presence at community events and county health and hospital councils.

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Large delegation presence at Legislative Day in Sacramento and at the CMA House of Delegates.

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Active role in advocating for and passing legislation to increase vaccination rates and protect community health.

We end this year with heartfelt thanks to all who have helped us achieve our goals, including the entire medical association staff members who worked tirelessly, our current and past members for your support and work on our behalf, and to the council members and entire delegation who have shown incredible dedication and ability to work as a team on behalf of SCCMA. May 2020 bring you prosperity, joy, and health.

Sincerely, Dr. Seema Sidhu President, SCCMA April Becerra CEO, SCCMA

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“The most important goal, not just in this year of my presidency, but always, is to take back our profession by enabling physicians to lead the struggle to protect, expand and make universal access to health care for all of our patients in California,” Peter N. Bretan, M.D. CMA President

he California Medical Association (CMA) recently convened its 148th annual House of Delegates (HOD) meeting in Anaheim. Over 500 California physicians debated and outlined a policy agenda on major issues that have been determined to be the most important issues affecting members, the association and the practice of medicine. The association also installed its new officers, including new CMA President Peter N. Bretan, Jr., M.D., a urologist and transplant surgeon who gave up his Bay Area practice to serve patients at a safety net hospital in Watsonville. The major issues the delegates focused on this year were: ■ Augmented Intelligence (A.I.): The delegates explored pragmatic solutions that address medical decisionmaking, new liabilities and privacy concerns inherent with augmented and artificial intelligence in health care, with a focus on keeping physicians at the center of health care delivery. ■ Homelessness: Physicians witness the homelessness crisis in emergency rooms, clinics and on the streets of our communities. The delegates declared that stable and affordable housing is an essential community priority and an important social determinant of health. They also discussed evidence-based solutions that address the health care and social needs of those at risk of or experiencing homelessness. ■ Cannabis: The delegates weighed in on pressing issues, including health impacts associated with cannabis use, public health protections, federal legalization, data and surveillance efforts, high-quality research, marketing and advertising practices, cannabis equity programs and more. ■ Adverse Childhood Experiences (ACE): Recognizing that ACEs have a strong and life-long correlation to numerous health, social and behavioral problems, the delegates learned more about data collection, research and incorporating ACE screening practices into routine care. The final actions of the House of Delegates, including newly established policies, are now posted at cmadocs.org/hod.

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ELECTIONS Watsonville Urologist and Transplant Surgeon Installed as CMA President Peter N. Bretan, Jr., M.D., a urologist and kidney transplant surgeon who gave up his Bay Area practice to serve patients at a safety net hospital in Watsonville., was elected as the 152nd president of the California Medical Association. Dr. Bretan is the first Filipino-American physician to serve as president. “The most important goal, not just in this year of my presidency, but always, is to take back our profession by enabling physicians to lead the struggle to protect, expand and make universal access to health care for all of our patients in California,” said Dr. Bretan. “If we are successful in this state, it will lead the way for sustainable universal health care for all of America.” Dr. Bretan is the founder and CEO of LifePlant International, a charitable organization that furnishes lifesaving transplants in developing countries, for which he was recognized by the American Medical Association with the Benjamin Rush Award for Citizenship and Community Service. Dr. Bretan has also provided care around the world on medical missions. “I grew up as a child farm laborer, and I know what it is to be without adequate health care. My greatest motivation is in service to give back to society for my good fortune,” said Dr. Bretan. After years of practice in Marin and Sonoma counties, Dr. Bretan now provides urologic and laparoscopic surgical care at a safety net hospital in Santa Cruz County. Most of his patients speak no English and have no medical insurance. “My presidency will be dedicated to giving these patients,

and the millions of hard-working Californians like them, a voice,” said Dr. Bretan. “We have an incredible opportunity to boldly change the way health care is delivered. We know that to best serve patients, health care must be physician-led.” Dr. Bretan has served as a CMA trustee and delegate, and is a three-time county medical society president. He is the current president of the California Urological Association and serves as an adjunct clinical professor at Touro University, where he has taught classes in health care policy for the past 16 years. Dr. Bretan earned his B.S. degree in physiology from UC Berkeley and his medical degree from UC San Francisco, where he completed residencies in general surgery and urology, as well as a fellowship in radiology. He also completed a fellowship at The Cleveland Clinic Foundation in transplantation and renovascular surgery. Dr. Bretan is a member of the San Francisco Marin Medical Society and the Mendocino-Lake County Medical Society.

Sacramento Pain Specialist Named CMA President-Elect Sacramento pain specialist Lee T. Snook, Jr., M.D., was named president-elect of CMA. He will serve on the Executive Committee as president-elect for one year. Dr. Snook will be installed as president following next year’s House of Delegates. A CMA member since 1985, Dr. Snook has served as speaker and vice speaker of the CMA House of Delegates. He has also served as chair of the CMA Worker’s Compensation Technical

Advisory Committee for the past eight years and as a member of CMA’s Board of Trustees for the past 10 years. Dr. Snook is a member of the Sierra Sacramento Valley Medical Society. Dr. Snook is an outspoken advocate for physician wellness and was an advocate for approaches to preventing physician burnout long before it became a popular thing to talk about. He has spent the past 25 years working to develop policies and programs that have achieved positive results for the health and wellness of all physicians and for the practice of medicine. Dr. Snook is a medical director, president and founder of the Metropolitan Pain Management Consultants, Inc., in Sacramento. He is board-certified in anesthesiology, internal medicine, addiction medicine and pain medicine. He is a fellow of the American College of Physicians and the American Society of Addiction Medicine. Dr. Snook is also a certified medical review officer and a qualified medical evaluator. Dr. Snook graduated from the University of Nevada School of Medicine in Reno, NV. He did his internal medicine and anesthesiology residencies at the University of Wisconsin Hospitals and Clinics in Madison, WI. He is an American Medical Association delegate for the American Society of Interventional Pain Physicians and an alternate delegate for the California Society of Anesthesiologists. He is also a board member at California Public Protection and Physician Health, Inc.

November / December 2019 The Bulletin

2020–2025 STRATEGIC PLAN

The Bulletin November / December 2019

EXECUTIVE SUMMARY The California Medical Association (CMA) has pursued its mission to promote the science and art of medicine, protection of public health and the betterment of the medical profession since 1856. In recent history, CMA has contributed significant value to its more than 46,000 members with comprehensive practice tools, services and support including legislative, legal, regulatory, economic and social advocacy. Moving forward, California physicians are looking to CMA to further reduce administrative burden in their practices, support them in providing quality care and ensure they thrive amid industry consolidation. To best meet these needs, CMA has refined its value proposition to emphasize physician empowerment to lead the transformation of the health care system. To accomplish this goal, CMA will provide advocacy, tools, networks and services to help physicians improve their practice life and health, as well as the well-being of their patients. This ambitious proposition required CMA to re-envision its strategy and operations. In addition to developing three subsidiaries designed to further the key strategic priorities of the organization, in 2019 CMA developed a strategic plan to forge a pathway for the future. The 2020-2025 CMA Strategic Plan was based on extensive research conducted from January to August 2019. This process delved into the organization, environment, industry, stakeholders and competitors, as well as customer needs and preferences. Various customers and stakeholders provided input through group meetings and more than 35 individual interviews. Ultimately, CMA identified four strategic themes that represent the key priorities and aspirations to re-define CMAâ&#x20AC;&#x2122;s core business strategy: +

Advocate for Physician Practice, Accessible Health Care and Public Health Legislation

Champion of Vibrant, Diverse California Physician Workforce

Innovate Medical Practice Tools, Support and Resources

Lead Efforts to Improve Physician Professional Satisfaction

With these themes as a guidepost, the CMA Board will develop a comprehensive and measurable strategy to fulfill its mission as a leader in the betterment of the medical profession.

Strategic PlanBulletin |3 November2020â&#x20AC;&#x201C;2025 / December 2019â&#x20AC;&#x192; The

OVERVIEW OF THE ORGANIZATION AND HISTORY CMA is a professional organization representing California physicians. The association was founded in 1856 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, contagious disease epidemics and the desperate need to establish standards for the profession, physician leaders called upon their colleagues to help them form the Medical Society of the State of California, as it was then known, “to develop, in the highest possible degree, the scientific truths embodied in the profession.” More recently, CMA has successfully waged hard-fought battles to protect public health and the practice of medicine to ensure physicians remain at the center of health care delivery: +

1970s: Sponsored the Knox-Keene Health Care Services Act

1975: Championed the Medical Injury Compensation Reform Act (MICRA), a model for national medical liability reform

2000: Sued nation’s largest health insurance corporations under RICO, helping physicians recoup $600 million in monetary damages

2014: Defeated Proposition 46, which would have increased health care costs, reduced access to care and decimated MICRA protections

2016: Defeated Big Tobacco to institute the new Proposition 56 tax to prevent death from tobacco-related diseases and support increased Medi-Cal provider payments, including $40 million annually for graduate medical education

2018: Secured $220 million in loan repayments

Today, CMA serves more than 46,000 physician members, in all modes of practice and specialties. CMA is dedicated to serving its members through comprehensive services and support including legislative, legal, regulatory, economic and social advocacy. As lawmakers and regulators make health care decisions that impact millions of Californians, CMA has been fighting to ensure that the physician-patient relationship remains at the heart of all major health care decisions.

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2020–2025 Strategic Plan | 4

MISSION STATEMENT CMA’s mission is to promote the science and art of medicine, protection of public health and the betterment of the medical profession.

VALUE PROPOSITION As the largest physician-led organization in California, we empower physicians to lead and transform the health care system through advocacy, as well as provide tools, networks and services to improve their practice life, health and patient well-being.

November / December 2019 The Bulletin 2020–2025 Strategic Plan | 5

STRATEGIC THEMES The collective input and feedback into the 2019 Strategic Planning Process has produced four strategic themes representing key priorities and aspirations to define CMA’s core business strategy.

Advocate for Physician Practice, Accessible Health Care and Public Health Legislation Advocacy for medical practice sustainability within a health care system that meets patients’ needs and robust public health is at the core of CMA’s mission and competencies. CMA will guide priorities by building reliable two-way communication mechanisms with key stakeholders and continue a practical understanding of organizational resources. In addition, CMA will assess advocacy efforts through a systematic evaluation.

Champion a Vibrant, Diverse California Physician Workforce CMA will champion diversity, inclusion and sustainability for all modes of practice throughout the state to ensure a thriving physician workforce and patient access.

Innovate Medical Practice Tools, Support and Resources CMA will help medical practices innovate by committing to promising pilot projects, sharing best practices, leveraging technology breakthroughs and maximizing subsidiary impact.

Lead Efforts to Improve Physician Professional Satisfaction CMA will distinguish itself in California, and the nation, by identifying tools to allow physicians to thrive regardless of where and how they decide to practice. This includes developing resources to support practice sustainability and a meaningful wellness and professional fulfillment program.

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2020–2025 Strategic Plan | 7

Vaping: An urgent public health epidemic AMA delivers message to the White House on protecting kids from vaping By Andis Robeznieks Senior News Writer, American Medical Association

he message that bold action must be taken to prevent ecigarettes from addicting a generation of children to nicotine was delivered to the White House on Friday by AMA President Patrice A. Harris, MD, MA. “If e-cigarettes, in fact, help adults quit smoking, then the manufacturers should submit the evidence to the FDA (Food and Drug Administration),” Dr. Harris said. “Until then, we are asking the government to ban flavors, which has everything to do with placing another generation at risk of nicotine dependence.” The AMA, the American Lung Association, Campaign for Tobacco-Free Kids and other organizations urged the Trump Administration to follow through with the plan it announced in September to clear the market of all flavored e-cigarettes—including mint and menthol. “There is no time to waste as the youth e-cigarette epidemic continues to get worse and more than 5 million kids now use e-cigarettes,” the AMA and seven other organizations say in a joint

statement. “The evidence is clear that flavored products have fueled this epidemic as most youth e-cigarette users report using flavored products and cite flavors as a key reason for their use. Last year, the AMA declared e-cigarette use and vaping an urgent public health epidemic. “For decades, we have led the public health fight to combat the harmful effects of tobacco products, and we will continue to support policies and regulations aimed at preventing another generation from becoming dependent on nicotine,” Dr. Harris said. Learn more about the AMA’s work on e-cigarettes and vaping. Other organizations attending the White House meeting included: the American Cancer Society Cancer Action Network, American Academy of Pediatrics, Truth Initiative, Parents Against Vaping e-cigarettes (PAVe), and American Academy of Family Physicians.

November / December 2019 The Bulletin

By Elizabeth Aguilera Calmatters

Doctors will no longer be the final authority on medical exemptions and could be investigated if they write too many. Opponents say physicians may now be afraid to provide waivers, even for kids who need them. California has a new vaccination law on the books. It cracks down on inappropriate use of medical exemptions that allow kids to skip some or all vaccines and still enter school. It gives power over the exemption process to public health officials and will create a vaccination database of all children with medical dispensation. Supporters of the law are pleased that doctors will no longer be the final authority on medical exemptions and could be investigated if they write too many. The more children who get vaccines, the safer schools will be for all kids, the proponents say. Critics fear the law will effectively shut down access to waivers for kids who could be harmed by vaccines, which carry some risk, or who need them for other medical reasons. Doctors may fear the investigative provisions of the law, opponents say, and thousands of children could even be tossed out of school if they are not fully up-to-date on vaccines. Here are five things to know about the law, which goes into effect Jan. 1.

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WHAT DOES THE NEW LAW DO?

In California, children are required to be vaccinated, or have a medical exemption, to attend school. The new law creates a review process that gives public health officials the final say on those waivers, with the authority to reject them. Reasons for medical exemptions must still follow strict guidelines, and doctors will now be barred from charging any fees for exams or forms related to such dispensation. STARTING NEXT YEAR, THE STATE WILL REVIEW ALL MEDICAL EXEMPTIONS AT SCHOOLS WHERE FEWER THAN 95% OF STUDENTS ARE VACCINATED, FROM DOCTORS WHO SUBMIT FIVE OR MORE EXEMPTIONS IN ONE YEAR AND FROM SCHOOLS THAT HAVEN’T SHARED VACCINATION RATES. Democratic state Sen. Richard Pan, the law’s author, said he was concerned when the number of medical waivers rose across the state after a previous law that he wrote eliminated personal-belief exemptions in 2016 but kept medical exemptions intact. Pan said his goal this year was to keep physicians from issuing waivers for pay or for reasons that are not allowed. The law, signed by the governor Monday, requires doctors to examine patients and submit their recommendations to the state Department of Public Health. State officials will then crosscheck recommendations against guidelines from the Centers for Disease Control’s Advisory Committee on Immunization Practices or the American Academy of Pediatrics. Currently, the state is not involved in how students are granted medical exemptions. Parents get them from doctors and submit them to schools, and schools with kindergartens are required to submit aggregate data to the state each autumn.

November / December 2019â&#x20AC;&#x192; The Bulletin

The state does not receive exemption forms or information about doctors writing exemptions, according to the Department of Public Health. Starting next year, parents will continue to get waiver letters from doctors, as they do now, and submit them to schools. Starting in 2021, the state is to have a standardized form and a new submission process: Doctors will send exemptions directly to the state for review and dissemination to schools. Once the law takes effect in January, a state health official will begin reviewing all medical exemptions at schools in which fewer than 95% of students are vaccinated, from doctors who submit five or more exemptions in one year and from schools that have not shared vaccination rates with the state. If the state determines a physician is “contributing to a public health risk,” it will report the physician to California’s medical board. The state will cancel waivers written by doctors who are under investigation by the medical board. “It is my hope that parents whose vulnerable children could die from vaccine-preventable diseases will be reassured that we are protecting those communities that have been left vulnerable” by local doctors selling inappropriate exemptions, Pan said in a written statement. Kids with medical exemptions issued before next Jan. 1 may keep their exemptions until they move into the next grade span. The spans are defined as birth to preschool, kindergarten to 6th grade and 7th to 12th grades. After July 1, 2021, students with temporary exemptions will need a new one each year, and no exemptions will carry over when a child enters a new grade span.

HOW DID WE GET HERE?

Vaccinations have been a hot issue in California for several years, even though nearly 95% of kindergartners were fully vaccinated in the last school year. At the same time, the portion of kindergartners with medical exemptions has been rising since personal-belief exemptions were eliminated. Last year 0.9% of kindergartners — 4,812 of them — had exemptions. In some places rates are higher: The legislation notes that 16 counties had kindergarten vaccination rates lower than 90% in the last school year. Pan’s latest proposal brought opposition groups to the capital for weeks in protest. They were out in such force they some-

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times essentially shut down meetings and regularly scheduled operations in the Capitol building. Advocates for Physicians’ Rights, Physicians for Informed Consent and parents from across the state testified against the bill in committee hearings, saying their children had been injured by vaccines, they didn’t want to be required to obtain more immunizations, their children had autoimmune disorders or similar conditions and they feared doctors would no longer be willing to provide exemptions. O p p o n e nt s did the same in 2015, when Pan first proposed elimination of personal-belief exemptions. At that time he agreed that a medical exemption is absolutely up to a physician and argued that parents would be able to find a practitioner to sign a form, so when he went after those waivers this year the opposition fought back again. In addition, surprising some of the bill’s supporters, Gov. Gavin Newsom had reservations. Initially, he expressed concern about state involvement in the doctor-patient relationship. But after negotiations with the author and some amendments, Newsom said he would support the proposal. But as the bill advanced through the Legislature, Newsom signaled he wanted more changes. Pan agreed again and put them in a companion bill. Newsom signed both bills into law. The changes Newsom asked for allow kids who have medical exemptions before the law goes into effect Jan. 1 to keep them until they enter a new grade span. Doctors also gained some breathing room in the amended version: Initially, Pan’s proposal said they would sign exemptions under penalty of perjury, but that clause was removed.

THE VAST MAJORITY OF KIDS ARE VACCINATED, SO WHAT’S THE BIG DEAL?

A state Department of Public Health’s review shows that California’s vaccination rates are high: 94.8% of kindergartners in the last school year were vaccinated, a slight decrease from the year before. A slight increase in medical dispensations is simply families with previous personal-belief exemptions switching to medical waivers, say parents who oppose the new law.

California's Power Outages If Power Outages Are California’s New Normal, What About Home Medical Needs? By Mark Kriedler

Jay supervises a program that for 20 years has sent teams of workers throughout the Santa Rosa area to bring medicine and California Healthline treatment to those whose conditions prevent them from leavAUBURN, Calif. ― Fern Brown, 81, sat in the rear of a tent ing home or keep them bedbound. on the windswept fairgrounds of this historic Gold Rush town, Without power, though, almost all of those patients need drawing deep breaths through the mouthpiece of a nebulizer help immediately, she said. Air-pumped mattresses, used to plugged into a power strip atop a plastic folding table. prevent chronic bedsores, begin to deflate. Ventilators and nebAfflicted for years with asthma and chronic obstructive pul- ulizers cease to function. Electric wheelchairs don’t respond. monary disease, Brown uses the nebulizer twice a day to avoid And many of the affected people are reachable only by landline flare-ups that can be life-threatening. It turns her medicine into telephones, which don’t work in a shut-off. a fine mist that she can inhale. “It’s just kind of unconscionaHer machine runs on electricble,” Jay said.= ity, and when Pacific Gas & ElecHardened by experience of tric Co. cuts power in the region shut-offs imposed by their utilamid wildfire scares, as it did earity company, many residents of lier this week, Brown must scramthis region ― and others up and ble to find a place where she can down the state ― have concludadminister her treatment. ed they must prepare for future She knows the makeshift power cuts. “resource center” she visited on PG&E confirmed that notion Tuesday afternoon, one of several in an emailed statement, saying set up this week by PG&E, is not all its customers should “have an a viable long-term fix ― especialemergency plan to be prepared ly now that power outages and for any extended outages due to the uncertainty that comes with extreme weather or natural disasthem seem likely to be a more ters.” The statement referred cusfrequent feature of California’s fire tomers to PG&E’s website page season. on wildfire safety, adding that “I could rent a generator. Or local county emergency offices can you rent to own?” Brown said. may also offer help. “They’re expensive. But that’s The PG&E outages that have probably what I’ll do. We just want Steve Bast, of Auburn, Calif., has learned from experience to affected some 1.8 million Califorpack his insulin containers inside a soft cooler surrounded by to be ready for the next time.” nians in the past few weeks, amid freezer packs, which he keeps constantly at the ready. The The PG&E outages have afnerve-wracking warnings of wind cooler then goes back into his refrigerator for as long as it can fected some 1.8 million Califor- remain cold during a power outage. (Courtesy of Steve Bast) and fire, have only affirmed the nians in the past few weeks. For company’s message. those with home medical needs, the quest for a durable fix For those with home medical needs, the quest for a durable takes on real urgency.[/caption] fix takes on real urgency. “That is the real travesty of this PG&E plan,” said Sandy Jay, a Steve Bast, who lives in a rural section of Auburn in the Sierra nurse practitioner at Santa Rosa Memorial Hospital in Sonoma foothills, has Type 2 diabetes, and his insulin needs to be refrigerCounty, about 130 miles southwest of Auburn. “As the dominoes ated. Bast has been forced to deal with previous outages, both fall, it’s the poor and the disabled who are the most affected by weather-related and PG&E-driven, some lasting several days. this.”

November / December 2019 The Bulletin

Now, he said, he keeps ice packs in his freezer and puts them on the insulin containers as soon as his power goes down. He then stores the medication inside a soft cooler that zips closed and goes back in the refrigerator for as long as the unit remains cold. Bast also uses a CPAP machine for his sleep apnea, and it must be plugged in, so he says his next move is to buy a small, personal generator. He noted, however, that he would still need to find an open gas station for fuel to keep the generator running during an outage. Gas stations need electricity to run the pumps. Then there’s the cost: A personal generator sells for between $400 and $1,000, meaning it could be out of reach for people of limited means. PG&E’s temporary resource centers, of the type Fern Brown visited, are small, tented areas where up to 100 people at a time can power up devices of all kinds and get bags of ice, cases of water and snacks for free. The centers are set up when an area is plunged into a utility-ordered shut-off, and they close once power is fully restored to that area. But the centers cannot solve the bigger problems. During the last power shut-off a few weeks ago, Debrah Vitali went to check on her neighbor, 88-year-old Joan Casper. She and Casper have become close friends in their Rincon Valley neighborhood of Santa Rosa, and Vitali knows that Casper wears an emergency calling device around her neck, which she can use to alerts medics if she needs help.

The device is tied to Casper’s landline, but what neither woman realized was that the landline operated through her internet connection. When the power went out, so did the internet – and with it Joan’s ability to summon help. “I couldn’t believe it,” Vitali said. “So we’ve just agreed as a group of neighbors to take turns checking on her, because she’d have no way to let anyone know she was in trouble.” California’s Health and Human Services Agency this week established a nonemergency hotline (833-284-3473) to help residents find health services in their communities during a shut-off. Gov. Gavin Newsom, meanwhile, announced a $75 million fund that communities can tap to help purchase generators and other backup energy sources that would keep local emergency services going. For people whose medical treatment begins at home, however, the solutions also need to begin there. At the PG&E center in Auburn, Fern Brown completed her 30-minute treatment before speaking. She said that her asthma and COPD have become worse over the past couple of years and that skipping a nebulizer session is not an option. Brown and her sister, Lavina Suehead, who cares for Brown, drove a half-hour from their home in the remote town of Foresthill to reach the resource center at Auburn’s Gold Country Fairgrounds. They said they would be seeking another solution, both for Tuesday night’s treatment and beyond. “We’ll have to do something,” Brown said. “We’re out of power a lot.”

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www.lwallc.com 22

The Bulletin November / December 2019

By Eli Saslow The Washington Post

November / December 2019â&#x20AC;&#x192; The Bulletin

The number of ER patients in rural areas has surged by 60 percent in the past decade, even as the number of doctors and hospitals in those places has declined by up to 15 percent. SIOUX FALLS, S.D. — A flashing red light summoned Dr. He watched on the monitor as a few more nurses and a Brian Skow to his third emergency of the afternoon, and he physician assistant came into the hospital room to prepare for hurried to a desk in a suburban office building. He sat in front of an emergency intubation. They needed to insert a tube down an oversize computer monitor, which showed a live video feed the patient’s throat to put her on a ventilator, but first that from inside a hospital room in eastern Montana. Two nurses would require sedating and temporarily paralyzing her with were leaning over a patient on a stretcher, checking for a pulse, medication, which meant she would no longer be capable of and squeezing oxygen out of a bag and into the patient’s lungs. breathing on her own. “I’m Doctor Skow,” he said, waving into a camera attached “Let’s get her down nice and hard,” Skow said, instructing to his computer, introducing himself as the presiding emerthe nurse to give the sedative first and then the paralytic. He gency physician even though he was seated more than 700 zoomed in to check a bedside monitor that showed the pamiles away. “How can we help you today?” tient’s oxygen level at 100 percent and then switched over to “We have a female patient, comatose and unresponsive,” another camera adjacent to the breathing tube that allowed one of nurses in Montana said. The nurse was short of breath, him to see down the inside of the patient’s throat. and she looked up at the camera mounted to the wall of the “So there’s the epiglottis,” he said, directing the nurse as exam room as she attached monitors to the patient’s chest. she tried to navigate the breathing tube past the tongue and “She’s a known diabetic. Blood sugar over 600. I — I don’t really into the windpipe. “There are your vocal cords. You’ve got a nice know. I haven’t seen a whole lot of this.” view right there. Do you see it?” “You’re doing great,” Skow said. “We’ll walk through it to“There’s a lot of blood in the airway,” the nurse said. gether. That’s why we’re here.” “Yeah, I see that, too,” Skow said. He switched to another As hospitals and physicians continue to disappear from rural America at record rates, here is the latest attempt to fill a widening void: a telemedicine center that provides remote emergency care for 179 hospitals across 30 states. Physicians for Avera eCare work out of high-tech cubicles instead of exam rooms. They wear scrubs to look the part of traditional doctors on camera, even though they never directly see or touch their patients. They respond to more than 15,000 emergencies each year by using remote-controlled cameras and computer screens at what has become rural America’s busiest emergency room, which is in fact a virtual ER located in a suburban industrial park. At the cubicle to Skow’s left, another doctor was examining a head injury in Kansas. To his right, a phyA medical staff member uses a small tracking pad to maneuver a camera into a different area of sician monitored a possible heart the ER they are connected to. (Michael S. Williamson/The Washington Post) attack at a critical-access hospital in Minnesota. Meanwhile, Skow used a remote control to move camera to check the patient’s oxygen level on the bedside the high-resolution camera in Montana, zooming in to check monitor and watched as it dropped to 95 percent, 93 percent, the patient’s pupils for dilation and using a microphone to listhen 90. If the patient were deprived of oxygen for too long, ten for breathing sounds. it could cause permanent brain damage or heart failure. He “If she’s in respiratory failure, we need to take over her airswitched back to look down the patient’s throat. “Can you adway,” Skow told the nurse. “Let’s get all hands on deck.” vance a bit further?” he asked the nurse. “You’ve almost got it.

The Bulletin November / December 2019

Just an inch?” He watched the nurse maneuver the breathing tube as he drummed his fingers against his knee. During his own bedside

demonstrate as the nurse did the same. “Yes. That’s it!” he said, watching as the tube slid into position and the oxygen level began to rise. One of the nurses at the bedside looked up at the camera and gave a thumbs up. “Thanks,” she said. “That’s all you,” Skow said. “I didn’t even touch her.” If anything defines the growing health gap between rural and urban America, it’s the rise of emergency telemedicine in the poorest, sickest, and most remote parts of the country, where the choice is increasingly to have a doctor on screen or no doctor at all. The number of ER patients in rural areas has surged by 60 percent in the past decade, even as the number of doctors and hospitals in those places has declined by up to 15 percent. Dozens of stand-alone ERs are fighting off bankruptcy. Hundreds of critical-access hospitals either can’t find a doctor to hire or can’t afford to keep one on site. Often it is a nurse Dr. Kelly Rhone surveys a large map that notes the client hospitals that use the virtual ER or a physician assistant left in charge services offered by Avera eCare. (Michael S. Williamson/The Washington Post) of a patient, and for the most severe shifts at the hospital in Sioux Falls, a city of 180,000, Skow had cases many of them now hit a red button on the wall that conperformed dozens of similar intubations under what he had nects directly to Sioux Falls. come to think of as the standard conditions of an urban trauma In less than a decade, the virtual hospital has grown from center. He usually had another emergency physician nearby to a few part-time employees working out of a converted storprovide backup, plus a trauma surgeon, a cardiologist, an anesthesiologist, and a team of up to 20 residents, ER nurses, and paramedics competing for space at the patient’s bedside. But now on the screen in rural Montana, Skow counted a total of five people in the room. None were doctors. None had significant experience performing emergency intubations. He moved the camera again to check the patient’s oxygen level. Eighty-five percent. Seventy-six and dropping faster. “Let’s bag up and give it another shot,” he said, instructing the nurses to pause the intubation and squeeze air by hand into the patient’s lungs. Skow asked them to try intubating again with a smaller breathing tube, and then he looked again through the camera into the patient’s throat. “You’re right at the cords now. Can you advance just a bit?” he Signaling the number “one,” nurse Jennifer Canton, confirms that one more liter of fluid is asked, inching his hands forward to needed for an emergency room patient. (Michael S. Williamson/The Washington Post)

November / December 2019 The Bulletin

muted into Onawa from their homes in Omaha, which was an hour away. “In emergencies, every second counts!” read an introductory brochure from the virtual hospital, and Copple began researching telemedicine and sharing data with her staff. Doctors at the virtual hospital could begin treating a patient an average of 21 minutes faster than doctors on call, who often lost time driving from home to the hospital. Telemedicine helped hospitals retain and recruit doctors because it gave them more support and allowed for more time off. It also allowed hospitals to treat more patients on site rather than having to transfer them to bigger facilities, resulting in increased billing charges and more hospital income. Late in the summer, Onawa had signed a subscription deal with the virtual hospital for the standard annual rate of about $70,000 per year. Via video link, Dr. Katie DeJong guides members of an ER staff through a difficult intubation A charitable foundation offered to procedure. (Michael S. Williamson/The Washington Post) pay $170,000 to help cover initial age room into one of the country’s most dynamic 24-hour equipment and technology costs, and an IT crew spent the ERs, where a rural health-care crisis plays out on screen. Each next months outfitting two trauma rooms with fiber-optic camonth the monitors show an average of 300 cardiac episodes, bles, cameras and a microphone over the exam table, which 200 traumatic injuries, 80 overdoses and 25 burns. There are patients suffering from heat stroke in South Texas and frostbite in Minnesota — sometimes on the same day. There are drowning deaths in summer, gunshot wounds during hunting season, car accidents on icy roads, and snakebites in spring. And now there was a video call coming into the office park from the latest hospital to seek virtual help, a critical-access facility in Onawa, Iowa, which had just finished installing its cameras a few hours earlier. “Are we live?” asked Karla Copple, the hospital’s director of emergency services. She stood in an empty hospital room in Onawa, a farming town of 3,000 on the Missouri River, and looked up at a screen on the wall. “Yes, I can see you,” said a nurse at the virtual hospital. “How are you today?” Dr. Katie DeJong take a follow-up call from an earlier case in front of a library of logbooks “Just making a test call,” Copple containing information on the hospitals that subscribe to the Avera remote ER service. (Michael said. “It’s all working?” S. Williamson/The Washington Post) She had been trying to set up a Kopple was talking into now. partnership with the virtual hospital for the last year, ever since “You can hear me?” she asked. a car crash in Onawa sent four patients to the ER in critical “Loud and clear,” the nurse said. “We can hear you from condition when there was only one registered nurse on site. anywhere in the room. These microphones are amazing.” The hospital had a few doctors on staff, but they usually com-

The Bulletin November / December 2019

“Okay then,” Copple said. “Next time it’ll be for real.” that realization on its own time. The hospital served a commuThere are 15 doctors and 30 emergency nurses who rotate nity of fewer than 2,000, which meant someone on the nursthrough shifts at the virtual hospital, and while all of them have ing team probably knew the patient personally. Rhone wanted trained for years inside regular ERs, nothing compared to the staff members to feel they had done everything they could. intensity of the industrial park. During one 24-hour shift, they “Fifteen minutes since arrival,” she said, hoping to urge often saw more critical cases on screen than most ER doctors them toward a decision, and after another moment a few of encountered in a month: an average of one severe heart atthe nurses stopped administering CPR, stepped back from the tack each shift, one suicide attempt, two pediatric emergenbed and went into the hallway to get the patient’s wife. Rhone cies, three traumatic injuries, four intubations, and five patients watched her come in and kneel at the bedside. She watched whose hearts had already stopped beating and needed immeas the wife gripped her husband’s jeans and buried her head diate resuscitation. “Do you feel a pulse?” Dr. Kelly Rhone was asking into the camera one morning, as she watched a team of nurses perform CPR on a middleaged cancer patient at a small hospital in North Dakota. The patient’s shirt had been ripped in half, and his body shook from the force of the CPR compressions. “Pulse?” Rhone asked again. “I don’t have one,” a nurse said. “Pupils?” Rhone asked. “Fixed and dilated,” the nurse said. “Okay. Let’s do one of epi,” Rhone said, instructing them to inject the patient with epinephrine, a medication used as a last resort to restart the heart. She zoomed in on a camera to look at a bedside monitor of the patient’s vital signs and counted The telemedicine center run by Avera eCare has monitors throughout the workstation area off the seconds using a clock at her noting the origin of every call, who is responding to it and what station they are working at. desk. An emergency nurse sat next (Michael S. Williamson/The Washington Post) to her in the office park and worked on a separate computer to arrange for helicopter transport to a into his chest. “Oh, God. That’s it. That’s it,” the wife said, as trauma center, in case the patient’s heart started beating. Rhone pushed her chair back from the computer monitor and “Nice CPR,” Rhone told the nurses in the room. “You’re dochecked the clock on her desk. ing great.” “It’s 11:06 a.m.,” she said quietly, speaking to one of the nurs“I’m going to go talk to the wife,” one of the nurses said to es in the room, so she could mark that down as the official time Rhone, pointing toward the hallway. “She’s kind of hysterical. of death. Any update you want me to give her?” She watched as a paramedic pulled a white sheet over the “Just that we’re still working on it,” Rhone said, even patient’s body. Everyone in the room circled around the bed, though she already suspected how this would end. There was and the wife started to pray. Her prayers turned to cries and statistically almost no chance the patient could be revived afher cries became louder, until after a few seconds the camera ter several minutes without a heartbeat. “Tell her we’re doing felt to Rhone like an intrusion, and she reached to her desk and everything we can.” switched the monitor off. She ordered another injection of epinephrine and watched “Is that TV talking?” asked Silas Gruen, age 4. He adjusted as the nurses injected him. She called out for another pulse his glasses and sat up on his hospital bed in Abilene, Kan., lookcheck, and watched as the nurses in the room found none. ing at a television screen mounted on the wall. He could see a She zoomed in to see the patient’s cardiac monitor and saw a woman in blue scrubs smiling at him as she typed into a keyflat line indicating no cardiac activity. “Eight minutes since ar- board. rival,” she told the nursing staff, as they continued CPR. “Twelve “I think that’s actually your doctor,” said his mother, Amy. minutes since arrival,” she said. “Would his wife like a chance to “My doctor’s a TV?” come in?” “Well, kind of,” Amy said, but before she could explain more She believed one of the worst things she could do was the doctor on TV was talking again. withdraw care too quickly. Even if she already knew the patient “So what exactly brought you in here today?” the doctor was dead, she wanted the medical staff in the room to come to asked.

November / December 2019 The Bulletin

“What do you think, Mom?” she said. “What’s your intuition?” “He doesn’t seem like himself,” Amy said. She watched DeJong take notes on the screen. All Amy could see was a doctor, a nurse, and a blank yellow wall behind them. “Where are you, anyway?” she asked. “Kansas City?” “Actually, South Dakota.” “South Dakota?” “Yep. Believe it or not.” Amy rubbed Silas’s back and waited for DeJong to finish her evaluation. “My concern here with the blood sugar is we don’t know what’s causing it,” DeJong said. She explained that Silas needed further blood testing, specialized scans and maybe even an endocrine specialist — none of which was available at the Nurse Hannah Schulte sits at her desk during a quiet moment after a patient’s death. moment in Abilene. (Michael S. Williamson/The Washington Post) “I would definitely go ahead and “You mean in here?” Amy asked, pointing down at the floor transfer this,” DeJong said to the physician assistant in the of the only hospital within 40 miles of her house, where she room, and a little while later Amy and Silas were riding through knew many of the employees. A sign near the doorway read, soybean fields in an ambulance on their search for adequate “Local Care Is Loving Care,” and soybean fields stretched in medical care again, as a new wave of emergencies took their neat rows out the window. There was no doctor on site at the place on the monitors in Sioux Falls. hospital during the day, so a physician assistant was attaching A farmer had fallen into a grain elevator and injured his monitors to her son’s chest and pricking his finger for a blood head. sample while a nurse tried to distract him by offering a juice A drug addict was foaming at the mouth and turning blue. box. A woman with pneumonia and a life-threatening sepsis inThis was the first time Amy had seen a virtual doctor in the fection was lying motionless on her hospital bed as her oxygen ER, but at the moment she was more concerned about what levels dropped. had been happening that morning. She took a step closer to “Who is our most experienced emergency provider in the the screen and explained that Silas had woken up with nauroom?” DeJong asked, speaking to five staff members sursea and a fever — common symptoms that concerned her be- rounding the patient with sepsis, who was rolling her head cause of his complex medical history. He had been born with a cleft lip and an eye condition, which meant they traveled every few months to find the specialized medical care that didn’t exist in most rural areas. Silas’s primarycare doctor was an hour away. He had regular appointments with specialists across the state. Already this morning, Amy had taken him to a walk-in clinic and then to the hospital, where a physician assistant who saw him had pushed the red button. The doctor on the screen introduced herself as Katie DeJong. She said she could see on the bedside monitors that Silas’s blood sugar was dangerously low. She asked the physician assistant to give him medication and a chest Xray, and then she turned her attention back to Amy, who was holding her son’s hand and sitting on the edge of his hospital bed. Nurse Jennifer Canton talks via video link with Amy Gruen, left, who brought her 4-year-old son, Silas, to a hospital in Abilene, Kan. (Michael S. Williamson/The Washington Post)

The Bulletin November / December 2019

from side to side and had signs of a possible brain bleed. They “That’s okay,” DeJong said. “This is hard. Is there a more exneeded to protect her airway by inserting a breathing tube. perienced provider who wants to make our next try?” “Who has the most experience to perform the intuba“I think I almost had it,” said the more experienced providtion?” DeJong asked again, louder this time, and finally a nurse er, after taking over and failing on the next attempt. They had stepped away from the bedside and looked up at the camera. “I can try,” she said. “Great,” DeJong said. “That’s terrific.” She moved her camera around the hospital room, zooming into cabinets and drawers to help point out necessary supplies for the staff to gather at the bedside. She ordered them to give the patient a sedative and then a paralytic. Then she held up her fingers to the camera to demonstrate the best technique for intubation. “You’re doing great,” she said, as she watched the nurse try to insert a breathing tube for what DeJong could tell was probably the first time. The nurse leaned over the patient’s throat, twisting the tube back and forth without advancing it down the airway. “I’m not exactly sure what I’m seeing,” the nurse said. “No problem,” DeJong said, as the Dr. Katie DeJong demonstrates the proper angle of the head for an intubation. (Michael S. patient’s oxygen levels began to drop Williamson/The Washington Post)

Amy and Silas Gruen sit at their home in Abilene. Silas was born with a cleft lip and an eye condition, and he and his mother travel every few months to find specialized medical care. (Michael S. Williamson/The Washington Post)

been trying to intubate for 15 minutes. A nurse stepped away from the bedside and rubbed sweat from his head. “We’re doing fine,” DeJong said. “We just need to focus on technique.” She held up a pencil and pretended it was a breathing tube to demonstrate. She tilted her neck to show the proper position of the patient’s head. They began another attempt as she moved the camera around the hospital room, hovering over the patient’s throat and zooming in on the oxygen levels, pushing the boundaries of technology and bumping up against its limitations. She wanted to reach into the screen. She wanted to be at the bedside. She wanted to be using her own hands to intubate, but instead she was 400 miles away, and for the moment all she could do was remain calm and reassuring as she pressed in closer to the monitor. “You’re doing great,” she said, as the tube began to slide into place. “You’re giving the patient everything you can.”

on the bedside monitor. “Let’s bag up and try again.” “I still can’t seem to advance it through,” the nurse said, on a second attempt, as the patient’s oxygen level dipped again.

November / December 2019 The Bulletin

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Expanded Resources for Providers to Help Patients Quit Tobacco By Anna Aistrich, MPH County of Santa Clara Public Health Department, Tobacco-Free Communities

hanges in the tobacco product landscape mean new health risks for Santa Clara County’s most vulnerable residents. Practitioners can help stem the tide by screening for all forms of tobacco use, dispelling myths, and referring patients to free cessation services.

CURRENT TOBACCO USE IN SANTA CLARA COUNTY

Although California is a pioneer in tobacco control and boasts one of the lowest statewide smoking prevalences (10.5%), there is still work to be done before smoking ceases to be a health problem.1 Tobacco use remains the number one preventable cause of death and disease in California, killing nearly 40,000 Californians every year.2 Due to its huge population size, California has the largest number of adult smokers (3.2 million) of any state and, consequently, is the state with the highest number of smoking-attributable deaths and years of potential life lost. 3 In Santa Clara County, 1 in 8 deaths annually is attributed to smoking-related illness or diseases, such as cancer, heart disease, and respiratory diseases. 4 In addition to the burden of these diseases on individuals and their families, the annual cost of smoking in Santa Clara County is $689 million in direct health care costs ($431 million) and costs associated with lost productivity due to illness and premature death ($257 million).4

Many California jurisdictions, including several within Santa Clara County, have enacted strong tobacco control policies to help de-normalize tobacco use. Despite the decline in overall adult smoking, large disparities in tobacco use persist among subpopulations disproportionately impacted by social determinants of health. 5 Adult tobacco use is most prevalent among low-income populations, which account for about half of California’s adult smokers. 5 Other populations with high cigarette smoking rates include adults with mental health or substance use issues, Asian men, and LGBTQ-identifying individuals (see chart). 6,7,8 Among youth in Santa Clara County, cigarette smoking is at an all-time low (3%).9 However, more than 1 in 10 youth in the county currently use tobacco products,7 including the use of nicotine delivery systems (ENDS) (aka “vaping”). Vaping among youth across the US is at a record high, going from 1 in 100 (in 2011) to 1 in 5 (in 2018).10 In evaluating this trend, the 2016 Surgeon General report stated that, “E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults.”11 This present trend in vaping is no accident. With declining rates of cigarette smoking all across the US, tobacco manufacturers are attempting to expand their customer base with ENDS. By touting the benefits of these “safer” products, the tobacco industry hopes to lure in users who were too concerned about the health impacts of combustible cigarettes to smoke previously. As of 2018, all major tobacco manufacturers now have entered the ENDS market.12

Sources: Santa Clara County Public Health Department, 2013-2014 Behavioral Risk Factor Survey and LGBTQ Health Assessment, 2013; California Student Tobacco Survey, 2016.

The Bulletin November / December 2019

CHANGES EQUAL NEW CHALLENGES

With ever-increasing tobacco products on the market and re-doubled efforts by the tobacco industry to cultivate future tobacco users, it is more difficult to stay current on how and where to focus prevention and cessation efforts. Health systems may support the role of health professionals in tobacco cessation, but that does not always mean that providers have the information and tools to serve the patients who need it most. To help providers best support their patients’ cessation efforts, the California Smokers’ Helpline has expanded its resources to address the shifting landscape. The Helpline’s website dedicates an entire section to health care providers and strives to provide evidencebased tools and resources to enable providers to create systems for “identifying, documenting, and treating every tobacco user who wants to quit.”13

■ ■ ■

Advise that ENDS products are especially harmful to adolescents and pregnant women and help to dispel myths and the misleading advertising of these products. Advise and warn e‐cigarette users about the toxicity of these products to themselves and to anyone subjected to secondhand emissions, including other members of their household and pets. Inform parents and e‐cigarette users that e‐cigarette cartridges and e‐liquid bottles are potential sources of poisoning through ingestion, skin or eye contact. Store these materials out of the reach of children, and call the California Poison Control Center at 1‐800‐222‐1221 for expert help in case of accidental exposure.

Refer for cessation services

■ Source: California Smokers’ Helpline website, www.nobutts.org

THE CALIFORNIA SMOKERS’ HELPLINE (HELPLINE) AND ASIAN SMOKERS’ QUITLINE (ASQ)

The Helpline and ASQ offer free, evidence-based telephone counseling services, online self-help materials and resources in six languages, and a text messaging support program to assist patients in their cessation. Patients can call either line themselves (or at their health provider’s recommendation), but they can also be referred directly by their provider through the e-Referral process. For practitioners who would like to implement e-Referral, there are several options. The Helpline website provides a free, downloadable toolkit for providers to learn more about how to help patients access quit services through e-Referral. On the ASQ site, providers can register as a web referral provider and access the necessary materials. The Helpline and ASQ websites also provide free materials that can be ordered for use in the health care setting. Providers can access webinars on the Helpline website on a wide range of topics, including “New and Emerging Tobacco Products,” “Evidence-Based Tobacco Treatments,” “Smoking and Diabetes,” and “How to Talk to Your Patients” (about cessation). Some webinars even offer continuing education units for various types of providers. Special patient populations may qualify for free nicotine patches through the Helpline or ASQ. Such groups include Asian smokers, parents of children 0-5 or pregnant women. Helpline/ASQ staff screen callers – who request nicotine patches – for contraindications. Those with contraindications need to acquire physician approval before patches are provided.

HOW CAN MY PRACTICE INTEGRATE THE HELPLINE OR ASQ IN HELPING PATIENTS QUIT SMOKING AND VAPING? ASK, ADVISE, AND REFER: Ask patients about their tobacco product use

■

Ask patients about all tobacco use, including the use of e-cigarettes/ENDS

Advise patients about the harms of all tobacco products

■

Current smokers and e‐cigarette users should be advised to quit and offered support. Refer users to cessation resources offered by their health insurance plan or to The California Smokers’ Helpline.

THE CALIFORNIA SMOKERS’ HELPLINE13 1. Refer patients by phone (1-800-NO-BUTTS) 2. Refer patients by e-referral; download a free provider toolkit at www.nobutts.org (Health Care Providers section) to learn how 3. Order free materials in a variety of formats for general audiences, special populations, pregnant women or parents with children age 5 and under, and in multiple languages (English, Spanish, Chinese [both Mandarin and Cantonese], Korean, and Vietnamese) 4. Access online provider resources, including webinars that offer continuing education credits

REFERENCES

1. Schroeder SA. California Promotes Smoking Cessation for Medicaid Enrollees: Lessons for the Nation? Am J Prev Med. 2018;55(6S2):S123−S125. 2. Centers for Disease Control and Prevention (CDC) Smokingattributable mortality, years of potential life lost, and productivity losses—United States, 2000-2004. Morbidity and Mortality Weekly Report. 2008;57(45):1226–1228. 3. Ma, J et al. Smoking-attributable Mortality by State in 2014, U.S. Am J Prev Med. 2018;54(5):661-670. 4. Max W, Sung H-Y, Shi Y, & Stark B. The Cost of Smoking in California, 2009. San Francisco, CA: Institute for Health & Aging, University of California, San Francisco, 2014. 5. Roeseler A, Kohatsu, ND. Advancing Smoking Cessation in California’s Medicaid Population. Am J Prev Med. 2018;55(6S2):S126− S129. 6. Santa Clara County Public Health Department, 2013-2014 Behavioral Risk Factor Survey. 7. California Student Tobacco Survey, 2016 8. LGBTQ Health Assessment, Public Health Department. 9. California Healthy Kids Survey, 2015-16. 10. Tobacco Product Use Among Middle and High School Students — United States, 2011-2018. Morbidity and Mortality Weekly Report (MMWR), February 2019. 11. U.S. Department of Health and Human Services. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Atlanta, GA, 2016. 12. Craver R. Analyst projection: E-cigs will overtake traditional tobacco revenue at Reynolds in 2021. Winston-Salem Journal, 2013. 13. California Smokers’ Helpline website, www.nobutts.org/healthcare-providers-welcome. Accessed 2/26/2019.

November / December 2019 The Bulletin

ANTI-VAPING WORKSHOP Reversing an Epidemic Through Effective Healing Thousands of youth nationwide have developed lung-related illnesses from vaping. Some have died. Vaping poses health risks both acute and/or chronic if not properly and promptly addressed. To empower parents and physicians to reverse this trend, SCCMA has partnered with Silicon Valley FACES on an urgent anti-vaping workshop. The free workshop will feature a robust panel of carefully curated experts in lung disease addiction and rehabilitation that'll walk attendees through effective vaping addiction recognition, prevention, and transition protocols. Resources, collateral , and refreshments will be provided to all who register. This event is open to the public. Physicians, parents, and teachers are encouraged to attend.

WHERE:

WHEN: Monday, Feb. 6:00-8:00pm

10th,

Joseph George Middle School 277 Mahoney Dr, San Jose, CA 95127

2020

Secure your spot by visiting www.sccma.org or emailing sameera@sccma.org.

For assistance, please call 408.998.8850 ext. 3011.

The Bulletinâ&#x20AC;&#x192; November / December 2019

By Michael Shea, MD

Leon P. Fox Medical History Committee

he origin of the name cesarean section is unknown. Three principal explanations have been promoted. 1. Legend suggests Julius Caesar was born in this manner, with the result that the operation became known as the “Caesarean operation.” There are several reasons to doubt this. First, the mother of Julius Caesar lived for many years after his birth. In 100 B.C. the survival rate for the procedure was essentially zero. Second, the operation whether performed on the living or the dead, is not mentioned by any medical writer before the Middle Ages. 2. It has been widely believed that the name of the operation is derived from a Roman law, supposedly created by Numa Pompilius (eighth century B.C.) ordering that the procedure be performed upon women dying in the last few weeks of pregnancy in the hope of saving the child. This explanation then holds that this lex regia, as it was called at first, became the lex caesarea under the emperors, and the operation itself became known as the caesarean operation. The German term Kaiserschnitt reflects this derivation. 3. The word caesarean, as applied to the operation, was derived sometime in the Middle Ages from the Latin verb caedere, “to cut.” This explanation of the term caesarean seems most logical, but exactly when it was applied to the operation is uncertain. Since “section” is derived from the Latin verb seco, which also means “cut,” the term caesarean section seems redundant. In evaluating these references to abdominal delivery in antiquity, it is pertinent that no such operation is even mentioned by Hippocrates, Galen, Celsus, Paulus, Soranus, or any other medical writer of the period. If cesarean (US spelling) section were employed at that time, it is surprising that Seranus, whose extensive work written in the second century A.D. covers all aspects of obstetrics, does not refer to cesarean section. Several references to abdominal delivery appear in the Talmud (Jewish civil and religious law writings) between the second and sixth centuries A.D., but whether they were used in a clinical setting is doubtful. There is little doubt, however, that cesarean section on the dead was first practiced soon after the Catholic Church gained dominance, as a measure directed at the baptism of the

child. Locally there are records showing two post mortem sections performed. One done at Mission Dolores in Yerba Buena (San Francisco) in 1805 and the other at the Santa Clara Mission in 1825. Neither infant survived. Mission records do not indicate any cesareans were done on living subjects. The earliest report of a cesarean section done on a living woman was recorded in 1500. It was performed by Jacob Nufer, a castrator of pigs at Sigerhausen, Switzerland. The patient (who was his wife) and baby both survived. The fact that the mother went on to deliver vaginally five times does cast some doubt on the validity of the report. The first cesarean operation in the United States was reported by a reputable obstetrician, Dr. Robert P. Harris in 1822. Amazingly, it was done by the patient herself, a fourteen year old quadroon, and performed in a snowbank in Nassau New York. Her L-shaped incision was dressed by her employer Dr. Bassett. Both mother and baby survived. Maternal mortality rates due to cesarean sections in the 19th century were 85 percent or higher, with the operation done as a last resort to save the life of the mother. The turning point in the evolution of cesarean sections came in 1822 when Max Sanger, then a 28 year old assistant of Dr. Crede at the University Clinic at Leipzig, introduced suturing of the uterine incision. A report of seventeen cesarean sections using silver wire sutures for the uterine incision yielded a survival rate of eight mothers, an extraordinary record in those days. While suturing led to a decrease in blood loss, other factors such as blood banking, regional anesthesia, antibiotic coverage, and lower uterine transverse incisions all converged to dramatically lower the morbidity and mortality rates of cesarean sections. By 1950, D’Espo was able to publish a remarkable study reporting 1000 consecutive cesarean deliveries without a single maternal death. With the safety of the operation established, the frequency also rose. The birth by cesarean section in 1970 was five percent; in 1985 it was twenty-three percent.

Medical Times From the Past

Cesarean Section History

REFERENCES

■ ■ ■ ■ ■

Creasy M.D., Robert K. and Resnik M.D., Robert. Maternal Fetal Medicine Principles and Practice. Philadelphia Pennsylvania:W.B. Saunders Company, 1984. Cunningham M.D., F. Gary, and MacDonald, M.D., Paul C. and Gant M.D., Norman F. Williams Obstetrics Norwalk, Connecticut: Appleton and Lange. 1989. Eastman M.D., Nicholson J. and Helman M.D., Louis M. Williams Obstetrics. New York

November / December 2019 The Bulletin

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.

FOR SALE

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.

The Bulletin November / December 2019

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

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website: metromedicalbilling.com

CALLING ALL TRAILBLAZING WOMEN IN MEDICINE! The Santa Clara County Medical Association (SCCMA) is seeking dynamic women whoâ&#x20AC;&#x2122;ve demonstrated fearless creativity and innovation in healthcare leadership, research, education, medical practice, and community service to celebrate in our upcoming Trailblazing Women magazine issue. Is that you or someone you know? Nominate them by visiting sccma.org.

Eligibility: Nominees must be women medical professionals or students who reside and work in Santa Clara County with at least one year of healthcare work experience. Deadline to submit your nomination is January 1st, 2020. For support, please contact sameera@sccma.org or call (760) 671-2453.

November / December 2019â&#x20AC;&#x192; The Bulletin

CALLING ALL TRAILBLAZING WOMEN IN MEDICINE The Santa Clara County Medical Association (SCCMA) is seeking dynamic women who’ve demonstrated fearless creativity and innovation in healthcare leadership, research, education, medical practice, and community service to celebrate in our upcoming Women Trailblazers magazine issue. WHO WE’RE LOOKING FOR — RUCKUS-MAKERS ON THE FRONT LINES OF HEALTHCARE INNOVATION: Courageous and bold, charting new territory is in these women’s DNA. Perhaps they’ve discovered a groundbreaking new treatment or finding — or created new pathways to serving patients.

CHANGE-MAKERS CATALYZING NEW WAYS OF WORKING: Unsatisfied with the status quo and fiercely creative, these women have catalyzed change by launching new patient or physician programs, reviving an underperforming program, or combating a growing epidemic.

ALTRUISTS DEMOCRATIZING ACCESS: Compassionate and resourceful, these women have expanded access to treatment, medications, or programs for underserved communities through grassroots work and strategic coalition building.

ELIGIBILITY

Nominees must be women medical professionals or students who reside and work in Santa Clara County with at least one year of healthcare work experience. Do you know a Trailblazing Woman? Nominate them by visiting www.sccma. org. Deadline to submit your nominee is January 1st, 2020. For support, please contact sameera@sccma.org or call (760) 671-2453.

The Bulletin November / December 2019

HR Policies

Every Medical Practice Needs in 2019

Learn more about how CAP can support your practice by downloading our free customizable HR manual today! Download The 2019 Human Resources Manual for Medical Practices at CAPphysicians.com/HR22

The Cooperative of American Physicians, Inc. (CAP) is pleased to offer The 2019 Human Resources Manual for Medical Practices to help physicians and their staff implement proper HR procedures and policies that can help improve every aspect of your business operations. As a leading California medical professional liability provider, CAP is committed to protecting our physician members with superior coverage. CAP members also receive valuable risk and practice management benefits specially designed to help physicians succeed! Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.

November / December 2019â&#x20AC;&#x192; The Bulletin

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