Marin Medicine Winter 2012

Volume 58, Number 1

Winter 2012 $4.95

Marin Medicine The magazine of the Marin Medical Society

Cancer Cancer Screening in Primary Care Colonoscopies Lymphoma Update Marin Women’s Study PSA Test Controversy

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Volume 58 Number 1

Winter 2012

Marin Medicine The magazine of the Marin Medical Society FEATURE ARTICLES

Marin Medicine

Cancer

Editorial Board

5 7 9 12 15 17

INTRODUCTION

The Topic of Cancer

“Unlike Miller’s novel, this issue of Marin Medicine is literally about cancer. Far from despairing, five local physicians offer mostly positive reports on medical progress against this pervasive killer.”

Steve Osborn

CANCER SCREENING

Flickering Lights on the Christmas Tree

“The swing in cancer screening over the last 50 years is like putting hundreds of lights on a Christmas tree, then realizing that most of them don’t work and need to be removed.”

Joan Pont, MD, FACP

COLORECTAL CANCER SCREENING

Enough With the Excuses!

“As a gastroenterologist, probably the single biggest question I get asked is, ‘Do I have to get a colonoscopy?’”

Jeff Fox, MD

CANCER UPDATE

New Treatments for Non-Hodgkin’s Lymphoma

“The past decade has brought tremendous progress in both diagnostic and treatment approaches for Non-Hodgkin’s lymphoma, but we still have a long way to go and face many challenges.”

Jennifer Lucas, MD

Irina deFischer, MD, chair Peter Bretan, MD Georgianna Farren, MD Lori Selleck, MD

Editor

Steve Osborn

Publisher

Cynthia Melody

Production

Linda McLaughlin

Advertising

Erika Goodwin Marin Medicine (ISSN 1941-1835) is the official quarterly magazine of the Marin Medical Society, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403. Periodicals postage paid at Santa Rosa, CA. POSTMASTER: Send address changes to Marin Medicine, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403.

The Marin Women’s Study

Opinions expressed by authors are their own, and not necessarily those of Marin Medicine or the medical society. The magazine reserves the right to edit or withhold advertisements. Publication of an advertisement does not represent endorsement by the medical association.

PROSTATE CANCER

E-mail: sosborn@marinmedicalsociety.org

BREAST CANCER RESEARCH

“Odds are that every physician in Marin County encounters breast cancer in their practice, either in their patients or in their patients’ family members and friends.”

Mary Mockus, MD

PSA Screening and the Patient-Doctor Relationship

“I believe the task force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.”

Peter Bretan, MD, FACS Table of contents continues on page 2.

Cover: “The crab and its mother,” by Wenceslas Hollar (c. 1650)

The subscription rate is $19.80 per year (four quarterly issues).

For advertising rates and information, contact Erika Goodwin at 707-548-6491 or visit marinmedicalsociety.org/magazine. © 2012 Marin Medical Society

Marin Medicine The magazine of the Marin Medical Society

DEPARTMENTS

19 22 24 26 28

LOCAL FRONTIERS

Keeping Frequent Fred out of the ED

“Reliable data on the prevalence of frequent flyers is elusive, primarily because an established definition of frequent flyer does not exist.”

Dustin Ballard, MD

PRACTICAL CONCERNS

New Hospital-Physician Alignments in Marin County

“Changes in reimbursement are making it extraordinarily difficult for private practice physicians to survive financially.”

Jon Friedenberg

HOSPITAL/CLINIC UPDATE

Marin General Hospital

“A year and a half after the Marin Healthcare District regained control of Marin General Hospital, the facility is thriving.”

Susan Cumming, MD

CURRENT BOOKS

Costly Grace

“I was drawn to this biography because I had heard of Dietrich Bonhoeffer in the context of the German Resistance but knew little about him.”

Irina deFischer, MD

OUTSIDE THE OFFICE

In Search of the Vikings

“I have searched for my father’s family roots for years. Despite its size (338,000 square kilometers), Finland has less than 5.5 million inhabitants, some 40 of whom are my father’s family.”

16 NEW MEMBERS 27 CLASSIFIEDS

Our Mission: To support Marin County physicians and their efforts to enhance the health of the community.

Officers President Peter Bretan, MD President-Elect Irina deFischer, MD Past President Lori Selleck, MD Secretary/Treasurer Georgianna Farren, MD Board of Directors Larry Bedard, MD Anne Cummings, MD Scott Levy, MD Barbara Nylund, MD

Staff Executive Director Cynthia Melody Communications Director Steve Osborn Executive Assistant Rachel Pandolfi

Membership Active: 265 Retired: 92

Address

Marin Medical Society 2901 Cleveland Ave. #202 Santa Rosa, CA 95403 415-924-3891 Fax 415-924-2749 mms@marinmedicalsociety.org Printed on recycled paper

2 Winter 2012

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WE EARNED THE AWARDS. WE ALL REAP THE REWARDS.

Three-Year Accreditation with Commendation. We received eight out of eight commendations and are the only North Bay hospital to earn accreditation.

Accredited Breast Imaging Center of Excellence

Society of Chest Pain Centers Accreditation

As your local community hospital, we strive to maintain and strengthen our high standards of patient care.

The Joint Commission’s Gold Seal of Approval™ for the hospital, behavioral health services, as well as advanced certification as a Primary Stroke Center.

We have just received a three-year accreditation with commendation from the Commission on Cancer (CoC) of the American College of Surgeons (ACS). And in the past year, we were recognized by several national organizations for our stroke care, chest pain, behavioral health, and breast imaging programs.

We thank the dedicated staff and physicians who have made these achievements possible. We will continue raising the bar to deliver the health care the people of Marin County deserve.

The American Heart Association and American Stroke Association recognize this hospital for achieving 85% or higher adherence to all Get With The Guidelines® Stroke Performance Achievement indicators for consecutive 12 month intervals and 75% or higher compliance with 6 of 10 Get With The Guidelines Stroke Quality Measures to improve quality of patient care and outcomes.

OUR HOME. OUR HEALTH. OUR HOSPITAL.

INTRODUCTION

The Topic of Cancer Steve Osborn

H

enry Miller’s infamous novel Tropic of Cancer is not literally about the disease known as cancer, but it does use cancer as a metaphor for Miller’s own despairing view of the world. As he explained later when asked about the title, “To me cancer symbolizes the disease of civilization, the endpoint of the wrong path, the necessity to change course radically, to start completely over from scratch.”

Unlike Miller’s novel, this issue of Marin Medicine is literally about cancer.

Far from despairing, five local physicians offer mostly positive reports on medical progress against this pervasive killer. They describe encouraging steps in the detection and treatment of breast cancer, colon cancer, prostate cancer and lymphoma.

We begin with internist Dr. Joan Pont’s overview of cancer screening from a primary care perspective. While acknowledging that screening has proved effective for cervical, colorectal and breast cancer, Pont (an assistant physician in chief at Kaiser San Rafael) also observes that more work is needed to improve screenings for other forms of the disease. Cancer screening over the last 50 years, she writes, “is like putting hundreds of lights on a Christmas tree, then realizing that most of them don’t work and need to be removed.”

Kaiser gastroenterologist Dr. Jeff Fox furnishes a helpful overview of the half-dozen commonly available tests for colorectal cancer. While none of them is perfect, the buffet of options has lowered the incidence and mortality from colorectal cancer in the United States.

Above all, Fox urges both patients and physicians to get screened. “There are few diseases,” he writes, “where modern medicine has been more successful Mr. Osborn edits Marin Medicine.

Marin Medicine

than in preventing colorectal cancer.”

Unlike colorectal cancer, the incidence of Non-Hodgkin’s lymphoma continues to increase, a trend made all the more complicated by the bewildering variety of the disease, which has more than 30 distinct subtypes. In her article on new treatments for Non-Hodgkin’s lymphoma, medical oncologist Dr. Jennifer Lucas, who practices at Marin Specialty Care, focuses on two main forms of the disease. The treatments are diverse, but many involve the latest research in biologic approaches, some of which is being conducted locally.

Another local research effort is described by Dr. Mary Mockus, a Kaiser surgeon who serves as one of the principal investigators of the Marin Women’s Study, which includes representatives from the entire medical community.

The study grew out of the discovery in the 1990s that Marin County had the highest rate of breast cancer in the United States. To date, more than 14,000 Marin women have participated in the study, whose first results were published in 2010. The study, writes Mockus, “is an example of the power of cooperation and collaboration.”

We conclude our cancer articles with Dr. Peter Bretan’s perspective on the ongoing controversy surrounding the PSA test for prostate cancer. A urologist in private practice in Novato (and president of MMS), Bretan urges continued use of the PSA test, despite the recent U.S. Preventive Services Task Force draft recommendation against the screening. While acknowledging that false positives on the test can lead to overtreatment, Bretan observes that, “Failing to administer the PSA test would sacrifice patients with undetected high-grade cancer, unbeknownst to them.”

C

ancer can become all-consuming, but our departments cover a completely different range of topics, from frequent flyers to the German Resistance.

In “Keeping Frequent Fred out of the ED,” Kaiser emergency physician Dr. Dustin Ballard addresses the oftreturning patients who are placing an increasing burden on emergency departments. Like the patients themselves, the problem is complex, but Ballard details several potential solutions. “Given that frequent flyers take up such a significant chunk of ED time and resources,” he writes, “they are potentially a high-yield population for intervention.”

Another problem long in search of solutions is the ever-changing landscape of private practice. Jon Friedenberg, the chief fund and business development officer for Marin General Hospital, describes several new hospital-physician alignments that he believes will benefit everyone concerned.

Our rotating hospital update for this issue is also from Marin General. Dr. Susan Cumming, the hospital’s medical director, reports that the facility has launched several new initiatives, including a transition to electronic records and an effort to reduce readmissions.

Far from the hospital, Novato gastroenterologist Dr. Barbara Nylund writes about her recent journey to Sweden and Finland in search of her family’s roots.

Rounding out this issue is Dr. Irina deFischer’s review of the new biography of German Resistance leader Dietrich Bonhoeffer, whose struggles against the Nazis led to his eventual death in a concentration camp. He too was a victim of cancer, this one of human origin.

Email: sosborn@scma.org

Winter 2012 5

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CANCER SCREENING

Flickering Lights on the Christmas Tree Joan Pont, MD, FACP

T

he swing in cancer screening over the last 50 years is like putting hundreds of lights on a Christmas tree, then realizing that most of them don’t work and need to be removed. With current technology, screening is effective in very few diseases. Physicians want the repertoire extended, and we await new advances in accurate serology and imaging.

The structural concept of screening is that a disease begins. We use a modality to detect its presence, and we do something to avoid death from that particular disease in the future, i.e., find it at a curable stage.

We also need to consider balancing factors, such as not causing an equal amount of unintended morbidity or mortality in treating patients with false positives (no cancer altogether) or indolent disease that would not become manifest if left untreated (lead time bias). Specifically, knowing a patient has a disease eight years before death versus two years before death might make you think that treatment or detection lengthened survival time, whereas the natural history might be identical, and the six-year apparent difference is from acknowledging the disease’s presence at different times.

The idea of cancer screening goes back to Dr. Pont, an internist, is an assistant physician in chief at Kaiser San Rafael.

Marin Medicine

1928, when Dr. George Papanicolaou first reported cervical cancer cell detection. Careful follow-up brought this concept into a functional and mature state, leading to the publication in 1943 of Papanicolaou’s landmark book, Diagnosis of Uterine Cancer by the Vaginal Smear. The book launched widespread dissemination of the Pap smear and led to a dramatic reduction in deaths from cervical cancer.

T

o physicians, the Pap smear must have been a jolt, like landing on the moon or curing pellagra with niacin.

Yet these advances are diametrically opposed. Landing on the moon takes the efforts of many smart people and loads of money to create a machine safe and powerful enough to get there and back. Avoiding pellagra takes eating

corn prepared with alkali, or fruits and vegetables, or fortified foods—all simple maneuvers with great clinical benefit.

Cancer screening involves a little of both. There are huge endeavors involving technology and people for detection, screening, treatment and follow-up; but there are also simple steps we take every day in the office.

The evaluation of symptoms or signs suggestive of cancer is very different from cancer screening. Weight loss, fever, bleeding, and new and increasing localized pain require a diagnostic workup independent of screening recommendations. When a man has a breast lump, he may be evaluated for breast cancer. However, it would be of very limited value to screen all men for breast cancer.

My recommendations for cancer screening are aligned with programs that have shown aggregate benefit to the defined population. They are summarized in the U.S. Preventive Services Task Force recommendations.1 Cervical cancer screening for women between 21 and 65 years old reduces cervical cancer mortality. Colorectal cancer screening is estimated to increase aggregate life of adults over 50 by eight months compared with an unscreened population. Some people may have life extended, but many get tested and derive no benefit. That is where sophisticated risk/benefit calculations based on multiple studies boil down to practical recommendations.

Winter 2012 7

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Breast cancer screening with mammography every 1-2 years for women 50-75 years old reduces breast cancer mortality. We generally extend screening to women 40-75 years of age, acknowledging a delayed benefit. Lung cancer screening in ever-smokers is being better defined as research continues.

T

hose are the blinking lights on the Christmas tree. Other screening modalities have been explored, but with the technology available, they remain unproven. Ovarian cancer screening with ultrasound and serology did not diminish mortality from that dreaded disease. Prostate cancer screening with PSA may well represent a near-neutral balance of risk and benefit. Skin, pancreatic and esophageal cancers have not yielded their biologic destiny to being plucked out just in time. Essentially, by the time we can see them, it is too late for meaningful intervention.

Much research is ongoing. We need version 2.0 of the PSA test to exclude indolent disease not requiring surgery or radiation therapy. Thus we could use those tools only on cancers that are destined to progress.

If used correctly, streamlined cancer screening recommendations free up many health care personnel. Cervical cancer screening is a beautiful example of a win-win situation. Dropping down the frequency of testing to every three years and stopping at 65 years of age means primary care physicians, gynecologists and cytologists can address other health issues.

Cancer screening is an exciting subject. It is full of possibilities. Great technical challenges remain that we hope will lend themselves to efficacious solutions in the future.

Email: joan.pont@kp.org

Reference

1. USPSTF, “Recommendations for Adults: Cancer,” www.uspreventiveservicestaskforce.org/adultrec.htm#cancer (2011).

Marin Medicine

COLORECTAL CANCER SCREENING

Enough With the Excuses!

Jeff Fox, MD

A

s a gastroenterologist, probably the single biggest question I get asked is, “Do I have to get a colonoscopy?” In fact, many of my colleagues and friends confess that when they pass me on the street, they think of the colonoscopy they had, were supposed to have, or never got around to having. To them, I am like Katie Couric, “the face of colon cancer screening.”

Embarrassed, am I? Absolutely not!

There are few diseases where modern medicine has been more successful than in preventing colorectal cancer.

Efforts to prevent colorectal cancer (CRC) include many well-documented successes. In just the last 25 years, the incidence of CRC in the United States has been reduced by 33%, and death from CRC has dropped by 40%. Over half the mortality reduction is thought to be attributable to screening. Additionally, overall 5-year survival from CRC during the last 25 years has increased from 50% to 66%, largely due to early detection and improved treatments. Finally, more and more people are getting screened every year. At Northern California Kaiser Permanente, for example, nearly 80% of patients in the target 50-75 age range will have recorded up-to-date CRC screening in 2011, an all-time high.

To approach this high level of adherence for CRC screen ing was Dr. Fox is a gastroenterologist at Kaiser San Rafael.

Marin Medicine

once unheard of. Physicians should be very proud of these efforts.

Though some observers have attributed the declines in CRC incidence to an increase in colonoscopy screening, the procedure has only been used widely for screening during the last 10 years.

The rise in colonoscopy screening occurred precisely when Medicare began reimbursing for colonoscopies for patients with average CRC risk. Yet, CRC mortality had been steadily declining well before that policy change. Physicians have been screening for colorectal cancer for more than 20 years, though earlier efforts were mostly by occult blood testing and flexible sigmoidoscopy, with colonoscopy reserved for positive tests only. In other words, the successes in CRC screening aren’t just attributable to colonoscopies. Instead, they are successes of population-based screening with all available modalities.

S

o which modality should be used in which patient? I believe that every patient who is reasonably healthy and is in the appropriate screening age range (50-75 years, older than which the overall risk of screening outweighs the benefits) with at least a 5-year life expectancy should be offered CRC screening. In 2008, both the U.S. Preventive Services Task Force (USPSTF) and a multispecialty task force comprised of gastroenterologists, radiologists and oncologists (MTF) published lists of recommendations for colorectal cancer screening. Three screening modalities made both lists as “recommended”

tests: high-sensitivity fecal occult blood testing annually, flexible sigmoidoscopy every five years, and colonoscopy every 10 years. The other available tests (CT colonography, double-contrast barium enema and fecal DNA testing) were not supported by both task forces.

The pros and cons of all six tests are reviewed below.

Occult blood testing

PROS: Evidence-based means of reducing colorectal cancer incidence and mortality (i.e. randomized, controlled trials proving effectiveness). Convenient, inexpensive, well-tolerated by patients, zero risk. Fecal immunochemical testing (FIT) improves sensitivity for colorectal cancer to 60-90%. FIT is the form of occult blood testing used in most settings now, including at Kaiser Permanente, and the only kind that was recommended by both USPSTF and MTF. CONS: High false positive rate. Requires serial testing to show benefits.

Flexible sigmoidoscopy

PROS: Evidence-based means of reducing colorectal cancer incidence and mortality. Able to detect polyps/cancer in the distal (left) colon and biopsy/ remove at the same time. Convenience, cost and risk to patient are intermediate, relative to other modalities.

CONS: Patient discomfort when unsedated; sensitivity poor for proximal (right) colon disease as a standalone test.

Winter 2012 9

Colonoscopy

PROS: High sensitivity and specificity for polyps and cancer. Able to detect polyps/cancer in both proximal and distal colon and biopsy/remove at same time. Patient must be sedated.

CONS: Safety—has 10 times the perforation risk of a sigmoidoscopy (1/1000 vs. 1/10,000). Costly. Inconvenient. Use of colonoscopy is supported only by surrogate outcomes, not by randomized trials.

Colonoscopy is used to investigate positives from other modalities, but it appears to be limited in screening the proximal colon. Efforts to sharpen optics, prolong the examination time and improve bowel preparation could increase the sensitivity of colonoscopy in the proximal colon.

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CT colonography (virtual colonoscopy). Similarly high sensitivity as colonoscopy for polyps and cancer.

Concerns about radiation exposure risk (i.e., iatrogenic malignancies) and missed “flat polyps” make CT colonography a less than ideal screening tool (and not reimbursed by many insurance companies). However, CT colonography is a good alternative to colonoscopy as a reasonably accurate test when colonoscopy is not feasible.

Double contrast barium enema. Poor sensitivity and radiation exposure make this a less favored choice for screening when other modalities are available.

Fecal DNA testing. Initial promise was thwarted by relative costliness and nearly identical sensitivity to the much less expensive fecal immunochemical testing. Still primarily investigational.

T

he current buffet of screening options exists because there is no “perfect” screening test for CRC. The ideal test would be something as simple, tolerable and inexpensive as the occult blood test with the accuracy of colonoscopy (or better). This perfect test unfortunately does not appear to be on the near horizon, so I expect we will be making do with what we have Marin Medicine

for at least the separate next few functions years. emphasizing and Nevertheless, with the buffet had apexpertise, the entire department proach, we are continuing to improve to be restructured.

The providers were screening rates nationally.

And it’s asked to choose an area of expertise, working—colorectal incidence practice only that areacancer of expertise, and and mortality continue to decline. follow the inmate/patients to wherThe messageThis thatdenotes I advisea everimportant they were housed. significant departure from the is: typical physicians to give to patients Get institutional treatment screened.

Don’t get too model boggedwhere downa clinician is assigned to a unit.

In San on the details, and certainly don’t let Quentin’s restructured model,you thefrom mulindecision or excuses prevent tidisciplinary treatment team is not getting screened. assigned to the a location, but to their inHere are most frequent excuses mate/patients.

We now have individual I hear, along with sample responses: clinicians practicing their EXCUSE: “I’m too in busy toareas have of a strength, rather than trying to provide colonoscopy/sigmoidoscopy.� every service. “FIT takes five minutes RESPONSE: Working within an institution, local and can be performed in the comfort custody administration of your own home.� is an invaluable ally in the delivery of mental health EXCUSE: “Won’t FIT or sigmoidosservices. peace officer—including copy missEach something?� theRESPONSE: warden, chief deputy as“No test is warden, perfect, insociate wardens, captains, lieutenants, cluding colonoscopy.

Despite those limsergeants andoccult officers—plays a critical itations, both blood testing and role in our success.

San sigmoidoscopy are Local proven toQuentin reduce custody a safe working enviyour risk ensures of colorectal cancer and death. ronment serving as our access to If you arewhile willing to acknowledge the providingrisk care.and Absent this safety additional inconvenience ofor a this access, our environment colonoscopy, it isworking an acceptable method would be much less efficient and efof screening.� fective.

In part, our success derived EXCUSE: “I don’t want toisknow.â€? from our ability“Colon to provide services, RESPONSE: cancer is preand this without functionsurgery is uniquely tied to ventable or chemocustody operations. therapy when caught early or in the Finally, ourstage. professional pre-cancerous You can’t relationfind it in ship stages with various administrative those unless you get screened.â€? bodies has led our have success their EXCUSE: “I to don’t anyvia sympunwavering support, including worktoms, so why bother?â€? ingRESPONSE: relationships withcancer the Secretary’s “Colon and preOffice, thepolyps Office of Receiver, and cancerous arethe usually asympthe Division of too Correctional Health tomatic until it’s late.â€? â–Ą prep sounds horCare Services.

EXCUSE: “The rible.�

RESPONSE: “FIT requires no prep.

And there are lower-volume sigmoidoscopy and colonoscopy preps available through many providers.�

So tell your patients what I tell them: “Enough with the excuses! Get screened. Period.� I don’t mind being the face of colorectal cancer screening because I could save your life. entrance to San Quentin Email: Main jeff.fox@kp.org

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CANCER UPDATE

New Treatments for Non-Hodgkin’s Lymphoma Jennifer Lucas, MD

N

on-Hodgk i n’s lymphoma (NHL) consists of a diverse group of malignant tumors of the lymphoid tissues derived from the clonal expansion of B-cells, T-cells and natural killer cells or precursors of these cells. The incidence of NHL in the United States is over 65,000 cases per year. The average annual increase in incidence is approximately 2.7%, with an 82% rise in annual incidence since 1975. NHL has been extensively studied, yet the causes and increasing incidence of most forms of NHL are unknown.

The past decade has brought tremendous progress in both diagnostic and treatment approaches for NHL, but we still have a long way to go and face many challenges. The WHO Classification system characterizes over 30 distinct subtypes of NHL, a quantity that can lead to much confusion for both patients and physicians. Meanwhile, hundreds of lymphoma clinical trials are under way, and more than 40 new investigational agents are being studied worldwide.

Dr. Lucas is a medical oncologist and hematologist at Marin Specialty Care in Greenbrae, which is affiliated with the Marin Cancer Institute.

12 Winter 2012

This article summarizes advances in treatment for the two most common forms of NHL: diffuse large B-cell lymphoma and follicular lymphoma, which together represent more than half the diagnoses of NHL in North America.

Diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLCBL) is an aggressive B-cell malignancy that requires immediate treatment, without which survival is typically measured in weeks to months. With combination immunochemotherapy, however, up to 70% of DLCBL patients can be cured. The addition of rituximab, a monoclonal antibody that targets the CD20 antigen expressed on most B-cell lymphomas, has made the single biggest impact on improving survival rates in the last decade when combined with standard chemotherapy (R-CHOP).

Other strategies for improving outcomes over R-CHOP are under vigorous investigation. Both bone marrow transplant and maintenance rituximab have been studied in patients who achieve a remission, but clinical trials to date have not shown a definitive advantage to either approach. The current consensus is that cure rates will only be improved by adding new biologic agents to induction immunochemotherapy or as maintenance treatment after remission has been achieved.

New biologic approaches such as adding bortezomib or lenalidomide to the R-CHOP regimen are being evaluated in clinical trials. Lenalidomide (a relative to thalidomide) is an immunomodulatory agent that has a broad spectrum of anti-cancer activity and as a single agent has significant activity in relapsed DLBCL. At Marin Specialty Care, where I practice, we are evaluating a novel compound, RAD001, as maintenance treatment for patients who achieve remission with standard immunochemotherapy. As an mTOR inhibitor, RAD001 interferes with a cell-growth signaling pathway that is dysregulated in lymphoma cells and is key for cell survival.

Another area of research worldwide is the identification of different subtypes of diffuse large-B-cell lymphomas based on gene-expression profiles.

Gene-expression profiling measures the activity of thousands of genes at once, to create a global picture of cellular function. These profiles can, for example, distinguish between cells that are aggressively dividing and growing, or show how the cells react to a particular treatment.

Subtypes within DLBCL can now be categorized by gene expression into germinal center B-cell-like (GCB) and nongerminal center B-cell-like (nonGCB). Patients diagnosed with nonMarin Medicine

APP functions as aa molecular molecular switch, GCB type have a poorer prognosis and APP functions as switch, and its switching appears to be govsignificantly reduced survival and its switching appears to berates. governed by byare itsnow interaction with ligands. ligands.

Studies being designed to inerned its interaction with When APP APPnew interacts with netrin-1, an corporate drugs with standard When interacts with netrin-1, an axonal guidance ligand, it mediates treatment in an effort to overcome the axonal guidance ligand, it mediates processoutcomes extension.

When APP interinterinferior seen in patients with process extension.

When APP acts non-GCB with Abeta, Abeta, however, it example, mediates the subtype.

Forit acts with however, mediates process retraction, retraction, synapticinhibitor) loss, and and bortezomib (a proteasome process synaptic loss, programmed cell death.

During this may be effective in non-GCB DLBCL programmed cell death. During this interaction, Abeta begets morenuclear Abeta because of its ability to inhibit interaction, Abeta begets more Abeta (one of ofkappa the Four Four Horsemen) by favorfavorfactor B, aHorsemen) well-described sur(one the by ing the the processing ofisAPP APP to the the Four Four vival pathway thatof upregulated in ing processing to Horsemen.

In other words, Alzheimer’s non-GCB subtypes.

Horsemen. In other words, Alzheimer’s disease is is aa molecular molecular cancer. cancer. Positive Positive disease selection occurs occurs not at at the the cellular cellular level level Follicular lymphoma selection not butFollicular at the the molecular molecular level.(FL) Furthermore, lymphoma is an indobut at level.

Furthermore, Abeta itselfmalignancy is aa new new kind kind of prion, prion, since lent B-cell that to datesince still Abeta itself is of it is a peptide that begets more of itself. does not havethat a universally it is a peptide begets moreaccepted of itself.

We believe believe that all all of ofstrategy. the major majorPatients neurofirst-line treatment We that the neurodegenerative diseases may operate in in typically present withmay asymptomatic degenerative diseases operate an analogous fashion. peripheral lymphadenopathy and adan analogous fashion.

One stage of the thedisease. interesting ramificavanced Fifty percent of One of interesting ramifications of of have our new new model ofinvolvement AD is is that that patients bonemodel marrowof tions our AD wediagnosis. should be beToable able toFL screen for aa new newa at date, is considered we should to screen for kind of drug: “switching drugs” that treatable but invariably relapsing diskind of drug: “switching drugs” that switch the APP processing from the ease with long survival times,from typically switch the APP processing the Four Horsemen Horsemen to Survival the Wholly Wholly Trinity, measured in years. times have Four to the Trinity,

thus preventing the synaptic synaptic loss, neucontinued to improve in recentloss, decades, thus preventing the neurite retraction, and neuronal cell death but retraction, FL is still considered incurable. rite and neuronal cell death thatDepending characterize AD. Indeed,presentawe have have onAD. the clinical that characterize Indeed, we identifi ed candidate switchingoptions drugs tion, FLed patients have treatment identifi candidate switching drugs and are nowfrom testing these in inwaiting transgenic thatare range watchful to and now testing these transgenic mouse models of AD. We are also testbone marrow A modified mouse modelstransplants! of AD. We are also testing the effects effects of netrin-1 netrin-1 on this this system, prognostic scoring system, the Follicuing the of on system, and finding nding similar similar effects. Prognostic lar Lymphoma International and fi effects.

A corollary corollary of the the switching switching prinIndex (FLIPI), incorporates patientprinage, A of ciple is that we should now be able to stage,isnumber involved nodal areas, ciple that weofshould now be able to screen existing drugs, nutrients, nutrients, and serum lactate dehydrogenase, andand hescreen existing drugs, other compounds not just just for index their carcarmoglobin.

The resulting FLIPI has other compounds not for their cinogenicity (as is is done done using the Ames Ames helped oncologists takeusing a risk-stratified cinogenicity (as the test) but also for their Alzheimerogenictreatment approach FL. test) but also for their for Alzheimerogenicity.While We rarely rarely stop to to think that we we are are the FLIPI score is prognostic, ity.

We stop think that likely exposed to of many compounds the best predictor outcome is again likely exposed to many compounds that have positive or negative negative effects effects seenhave through gene-expression work that positive or on the likelihood that we will develop (notthe yet commercially available).

For on likelihood that we will develop AD, and ait itpredominance would be be helpful helpful to have have instance, of inflammaAD, and would to such information.

We hope thatfavorable our new new tory T-cells has a We strong and such information. hope that our model of AD may provide new insight impact on survival and denotes that model of AD may provide new insight into the pathogenesis pathogenesis of this thisresponse common the patient’s own immune into the of common disease and offer new new approaches to is criticaland in keeping theapproaches lymphoma in disease offer to h therapy. check. Having a prognostic tool that h therapy. can accurately predict which patients E-mail: dbredesen@buckinstitute.org can safely be observed versus which E-mail: dbredesen@buckinstitute.org patients should start immediately on

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treatment could be invaluable. treatment for patients with FL. * boardoption certified For Sale Treatment approaches for FL are di- Bendamustine, a newer chemotheraMember of American Speech COLLECTION of Mary Silverwood verse, and treatment choice is highly de- peutic agent, has shown excellent activLanguage Hearing Association original pastels, framed. All Sonoma pendent upon clinical presentation, the ity, evenMember in the refractory setting. of American County scenes. Call 707-539-4576.

Academy of Audiology biases of the physician, and the goals Despite a wide range of therapeutic California and expectations of the patient. Mono- optionsMember for FL,ofthere is a great need for Academy of Audiology HOW TO PLACE AN AD clonal antibodies, such as rituximab, developing new molecularly targeted are used either as a single agent or with treatment approaches, such as drugs Buy, Sell, Trade,alkylators Rent or that target unique biologic abnormalichemotherapy (typically – all for 1 dollar a word.

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present in approximately 85% of FL cases, places Bcl-2 under the control of an immunoglobulin heavy chain enhancer on chromosome 14, resulting in constitutive overexpression of Bcl-2. These Bcl-2 genes are extremely important in regulating apoptosis (cellprogrammed death) and have become an attractive target for developing new agents. There are currently several antibcl-2 molecules in clinical trials.

The ubiquitin-proteasome pathway plays a key role in the degradation of misfolded or unwanted intracellular proteins in cells and is a key mechanism in determining the activity of cellcycle regulatory proteins. Pre-clinical studies have demonstrated encouraging results with bortezomib, a proteasome inhibitor in NHL cell lines, and early clinical studies indicate impressive activity in FL. A large number of novel agents potentially useful in FL patients—including chemotherapeutics, monoclonal antibodies, apoptosis-inducing agents and immunomodulators—are in the clinical trial pipeline. Marin Specialty Care is participating in two such trials.

One is measuring various combinations of rituximab and other drugs for high-risk FL, and the other is evaluating a new antibody (ofatumumab) vs. rituximab for patients with relapsing lymphoma.

Despite the impressive biological and therapeutic progress made in dealing with FL over the last decade, there is still tremendous room for improving treatment. We need to develop therapies that extend the duration of remission without adding any additional toxicity.

Therapy for FL also needs to be adapted to the patient’s individual status while relying on a continuously growing repertoire of salvage therapies.

I am excited to see what the next decade of treatment offers our patients.

Perhaps the opportunity to cure follicular lymphoma is right around the corner.

Email: jlucas@marinspecialtycare.com

14 Winter 2012

Spring 2010 7

Marin Medicine

BREAST CANCER RESEARCH

The Marin Women’s Study Mary Mockus, MD

O

dds are that every physician in Marin County encounters breast cancer in their practice, either in their patients or in their patients’ family members and friends.

Breast cancer strikes one in seven women in Marin (compared to one in eight women nationally) and is of great concern to our patients.

When the final numbers from the 1990 census were applied to Marin’s breast cancer rates, we stood out as a community with the highest rate of breast cancer in the United States. The media soon labeled Marin as the “breast cancer capital of the world.” All this attention led to town hall meetings, the hiring of epidemiologists at the Marin County Department of Health and Human Services (DHHS), and a Centers for Disease Control award of $217,000 to fund community breast cancer projects.

These efforts were followed by the formation of a National Scientific Advisory Committee that included national experts, members of the Marin General and Kaiser medical staffs, and local community groups such as Zero Breast Cancer. The committee addressed the meaning and validity of the data on breast cancer in Marin County. A thorough analysis of several decades of data established that the elevated rates of breast cancer in Marin were real and could not Dr. Mockus, a surgeon at Kaiser San Rafael, is a principal investigator for the Marin Women’s Study.

Marin Medicine

be explained by the age of the population, mammography rates, or other known risk factors in Marin women.

In April 2005, DHHS obtained more than $400,000 in federal research money to launch the Marin Women’s Study, a prospective effort to link individual risk factors with biospecimens and breast cancer outcomes. A local steering committee and 15 community groups partnered to plan the study; I serve as one of the principal investigators.

The goal of the study was to obtain detailed risk factor information that could yield potentially immediate results as well as long-term, longitudinal data.

Researchers developed an exhaustive questionnaire for Marin women on lifestyle, medical and personal history and paired the findings with screening mammography results.

T

he Marin Women’s Study began in fall 2008 and accrued participants for about 18 months. To date, 14,100 surveys have been received and analyzed.

In addition, 8,000 of those participants have provided saliva samples to create a biorepository, which is processed and stored at the Buck Center. Specimens are available for hormone analysis and DNA testing, with results that can be paired with risk factor information and mammography results.

The generous participation of so many Marin women in the study has created a valuable resource that has caught the interest of cancer researchers worldwide. An adjunct to the study funded by the Avon Foundation includes specific analysis of the pos-

sible associations between hormones, reproductive history and increased breast density—a known risk factor for breast cancer. A second phase of the Avon study aims to develop a new risk model that links genes and the environment to other known cancer risk factors.

The first publication of Marin Women’s Study results appeared in the October 2010 issue of BMC Public Health.1 Our research team found that a dramatic decrease in postmenopausal hormone replacement therapy during the 2000s was followed by a 33% decline in breast cancer cases. The real rates of breast cancer in Marin during the 2000s were about 50 cases per year less than the rates seen in the late 1990s, while at the same time the mammography rate remained unchanged.

The adjunct Avon study has shown that certain reproductive risk factors seem to affect breast density but not hormone levels. Gestational hypertension in particular—along with age at first pregnancy and nursing—were associated with breast density, but not with changed hormone levels (based on our saliva analysis). These findings suggest that the risk factors mentioned above may be creating persistent morphologic changes in the breast tissue that can be related to breast cancer risk.

Our next focus in data analysis will be on breast density as it relates to lifestyle factors such as life-course alcohol use, exogenous hormone use, and socioeconomic status. SNP (single nucleotide polymorphism) data from the saliva samples will be examined to see if genetic changes can explain the Winter 2012 15

reproductive risk factors for increased or decreased breast density.

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h e M a r i n Wome n’s St udy i s a n e x a mple of t h e p owe r of cooperation and collaboration. The local steering committee includes Dr. Chris Benz of the Buck Institute; Rochelle Ereman, Dr. Mark Powell, Lee Ann Prebil and other members of the DHHS staff; Dr. Francine Halberg of Marin General; Fern Orenstein of Zero Breast Cancer; myself at Kaiser Permanente; and all Marin mammography centers regardless of hospital affiliation. We are all grateful to the 14,100 women of Marin County who have so generously given of their time.

As a physician investigator on this study, I feel a tremendous personal responsibility to the women of Marin, and I look forward to finalizing our data and sharing what we have learned with our wonderfully supportive community. More details and results of the Marin Women’s Study can be found on our website, marinwomensstudy.org.

Email: mary.b.mockus@kp.org

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1. Ereman RR, et al, “Recent trends in hormone therapy utilization and breast cancer incidence rates in the high incidence population of Marin County, California,” BMC Public Health, 10:228 (2010).

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www.lifelinenorthbay.com 16 Winter 2012

Marin Medicine

PROSTATE CANCER

PSA Screening and the Patient-Doctor Relationship Peter Bretan, MD, FACS

I

n October 2011, the U.S. Preventive Services Task Force released draft recommendations against prostatespecific antigen (PSA) screening for prostate cancer, asserting that there is “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” The task force further discouraged use of the PSA test by giving it a Grade D rating.

I am a board-certified, fellowshiptrained urologist and professor of urology. I have been treating men with diseases of the prostate, both benign and cancerous, for the past 26 years.

Along with my specialty society, the American Urological Association (AUA), I strongly oppose the task force’s recommendations. I believe the task force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.

In 2009, the AUA issued a PSA Best Practice Statement finding that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.1 Not all prostate cancers are life-threatening, and the decision to proceed to active treatment or use surveillance for a patient’s Dr. Bretan, a urologist in private practice in Novato, is president of MMS.

Marin Medicine

Prostate Cancer Death Rates (per 100,000 males)

39.22 35.11

34.15 28.18 23.50

1987

1992

1997

2002

2007

Source: National Cancer Institute

prostate cancer is one that men should discuss in detail with their urologists.

Following the release of the task force’s recommendations, AUA President Dr. Sushil Lacy released a statement urging men to speak with their physicians about the value of prostate cancer screening.2 The AUA is also coordinating a sign-on letter for lawmakers to send collectively to U.S. Health and Human Services Secretary Kathleen Sebelius, urging her to reject the task force’s recommendations. In addition, the AUA is convening an expert panel that will submit formal comments to the task force.

D

espite data from the National Cancer Institute showing decreasing mortality from prostate cancer since PSA testing began in the 1980s (see graph), the task force argues that the test can lead to harm. They don’t dis-

pute that PSA testing detects cancer, but they do claim that the test leads to widespread overtreatment, which to them outweighs the benefits of early detection. By averaging data over the entire population, the task force concludes that there is no net gain from PSA testing and perhaps substantial damage to patients, ranging from needless worry, to impotence and incontinence, and even to death.

Therein lies the dilemma for the older-than-50 male for whom averages mean little. Without PSA testing, if a high-grade prostate cancer is present, the disease might not be found until it is fatal. Although the five-year survival rate for localized prostate cancer is 100%, once the cancer reaches distant organs, the rate falls to 29%.

In tallying the damage from PSA testing, the task force makes some relatively small problems seem very big.

For example, they suggest that biopsies can be painful. In reality, the use of local anesthesia during biopsies makes pain an uncommon experience. Major complications after biopsies are rare.

Even if prostate cancer is found and the patient elects to have the prostate surgically removed, the complications of urinary incontinence and erectile dysfunction are usually temporary and highly treatable. They’re also preferable to metastatic cancer and death.

As articulated by Cleveland Clinic urologist Dr. Andrew Stephenson, “None of us would dispute that there are harms with screening for prostate Winter 2012 17

cancer, just as there are for screening for any other cancer, but the task force fails to acknowledge the benefits, which are clear.”3 The PSA test is painless, inexpensive and the only way to detect prostate cancer—the most common male cancer—before symptoms turn up.

What disturbs me most about the task force is that they recommend against gathering the information that leads to overtreatment, rather than reforming the treatment itself. The chair of the task force, Virginia Moyer, claims that once patients hear they have cancer, human nature drives them to demand aggressive action, necessary or not. While she has a point, the use of ignorance to help protect patients is not bliss, nor a medical practice I can condone.

Failing to administer the PSA test would sacrifice patients with undetected high-grade cancer, unbeknownst to them. The fact that such patients’ death prevention might be statistically offset by someone who receives unneeded treatment seems to be a cold-

hearted practice of pure bureaucracy and not the compassionate practice of medicine. Depriving people of information that empowers them to make choices is disturbing.

W

ith the cost of American health care rising rapidly, the rationale to reduce unproductive treatments is well appreciated, but not at the expense of practicing ethical, transparent and compassionate medicine. The task force’s recommendation against PSA testing, like their equally controversial suggestion in 2009 to do fewer mammograms, is a measure of how cost needs to be addressed—but cost control should not come at the expense of informed consent with the patient.

I believe that men older than 50 should continue to receive the PSA test, then get balanced information about prostate cancer and its treatment. That puts decision making back to patients, in close consultation with their physicians. I have always advocated for my patients and defend the patient-doctor

DocBookMD offers improved communications for MMS physicians Communication between physicians can be inefficient at times, and patient care can be delayed, resulting in frustration for everyone. These frustrations, however, may be short-lived. Two physicians from Texas have created a tool to help solve these communication delays: DocBookMD—a smartphone app that is free for MMS members.

“We wanted to change the way physicians communicate. We wanted to make it easier, more efficient, and more secure,” said orthopedic surgeon and DocBookMD cofounder Dr. Tim Gueramy. “We created a program that allows physicians to talk to one another with new technology.”

DocBookMD is a physicians-only iPhone, iPod and Android app that allows physicians to: • Send HIPAA-compliant text messages and photos

18 Winter 2012

• Assign an urgency setting to outgoing text messages • Search a local pharmacy directory • Search the MMS directory and sort by specialty “DocBookMD allows you to look up another doctor at the point of care,” Gueramy explained. “You can then either call the physician or send a text message with room numbers, medical record numbers, even pictures of wounds and x-rays. And all of this is sent securely and in a way that meets HIPAA requirements.”

MMS members can download their free copy of DocBookMD by visiting docbookmd.com/med_socs/marin.

Not a member? The MMS website at www.marinmedicalsociety.org has details on DocBookMD and other member benefits, as well as an online application form.

relationship as the backbone of medical practice. Physicians are messengers and educators for their patients, in the elucidation of the risks, complications and alternatives of all therapeutic options.

For many of my patients, I recommend no immediate therapy for low-volume, medium-grade prostate cancer. Can we all do better in this standard of care? Absolutely. Unfortunately, the task force implies that patients cannot make this decision because it is too emotionally laden, and that urologists are all going to push for interventional therapies that may be inappropriate or injurious to patient.

This is simply not true. Academic urologists are constantly studying ways to fine-tune the selection of patients for specific therapies.

The task force’s recommendations would restrict the patient-doctor relationship by holding back the results of a simple test that has been shown to save lives, because “on the average” they see the benefits to society as “marginal.” Perfect is often the enemy of good, but in this case “doing nothing” is the enemy.

We improve our way of living with science, not with denial, which has never helped anyone. There isn’t an “average” cookie-cutter template that fits all patients. If there were, there would be no need for the practice of medicine, only algorithms and protocols. Recommending against a valuable and simple screening test to “save” the general public from their perceived incapacity for making a rational decision is neither rational nor beneficial.

Email: bretan.surgery@usa.net

References

1. AUA, “Prostate-Specific Antigen Best Practice Statement: 2009 Update,” www. auanet.org (2009).

2. AUA, “AUA responds to new recommendations on prostate cancer screening,” www.auanet.org (Oct. 7, 2011).

3. Simon N, “Should you have a PSA test for prostate cancer?” AARP Bulletin (Oct. 12, 2011).

Marin Medicine

LOCAL FRONTIERS

Keeping Frequent Fred out of the ED Dustin Ballard, MD

I

’m certain every veteran emergency physician has had a thought process like this one: “Oh cripes, not Frequent Fred again? Back for chest pain … non-cardiac chest pain? …

Could there be something new going on? . . . Apparently not. … Is it possible that something’s been missed? … No, doesn’t seem like it. … Is there anything new I can offer? … Hmmm—perhaps not. … Soooo, how do I get Fred out the door?”

During my residency training at a county emergency department in Central California, thoughts like this often centered on a frequent flyer I’ll call Vincent. He was a self-declared COPDer who was always short of breath, but never for a discernible reason. His lungs were always clear, and he consistently registered 100% on pulse oximetry. We tried every approach—paper bags, oxygen, inhalers, Valium, steroids, even serial arterial blood gases—but Vincent always came back to the ED, sometimes four or five times a day. Clearly, Vincent had profound needs, but despite our best efforts (including psychiatric and social work consultations), we could not adequately address them.

“Kim” also visited us in the county ED. Many times. She was also short of breath without a discernible reason and was way too young to be in the hospital so ofDr. Ballard, an emergency physician at Kaiser San Rafael, writes a medical column for the Marin Independent Journal.

Marin Medicine

ten. Her family would drop her off on Friday afternoons for a “vacation.” Hers or theirs, we’d wonder. They wouldn’t answer their phone all weekend and then would show up on Monday to find Kim no better and perhaps worse (from “therapeutic” meddling). After several years of well-intentioned interventions, Kim ended up with a tracheostomy.

I’m quite certain Kim’s tracheostomy was preventable, but how? Looking back, I don’t think ED care could have prevented this unfortunate outcome, because the ED is just not a good place to pursue in-depth, multi-dimensional, long-lasting therapy. It’s too hectic for that. Fluctuations in patient volume, staffing considerations, and the acuity of patients with time-sensitive illnesses combine to make ED care of frequent flyers less than optimal. Yet, frequent flyers continue to place an increasing burden on EDs.

R

eliable data on the prevalence of frequent flyers is elusive, primarily because an established definition of frequent flyer does not exist. Nonetheless, a 2010 meta-analysis from the Annals of Emergency Medicine (using a “frequency” definition of four or more visits per year) found that frequent flyers make up 4.5% to 8% of American ED patients and account for 21% to 28% of all ED visits.1 These figures are attention-grabbing; frequent ED users clearly place a significant burden on our safety net system. But, after a deep breath or two, one wonders whether this is a problem we can fix. And if we were to try, would the effort be worth the cost?

ED frequent flyers have been labeled as “unscrupulous” and “uninsured,” and are accused of “unnecessarily clogging EDs by presenting with primary care complaints better treated elsewhere.” But, as the authors of the Annals meta-analysis note, evidence does not support these stereotypes. Frequent flyers are actually a diverse group of people who are much more likely to be insured than not. Their variety makes one-size-fits-all solutions ineffective.

From poorly controlled congestive heart failure, to paroxysmal atrial fibrillation, and from chronic pain to migraine syndrome—there are many reasons why someone might develop an ED habit. Besides, skeptics argue, even if we find a way to “fix” the Frequent Freds and Everyday Eddies, dozens of other frequent flyers will simply take their spots. According to some estimates, up to 75% of ED frequent flyers will be replaced within one year.

Let’s set aside this “regression to the mean” phenomenon for a moment and assume that the problem of frequent flyers is worth addressing. First, however, we need to consider an important and related question: Should EDs be in the business of treating non-emergency conditions? Considering that close to 50% of all ED visits are for non-emergent conditions, this is a valid question indeed. (The 50% estimate is based on both a New York University study that employed exhaustive chart review to associate certain diagnosis codes with non-urgent ED visits and on a Kaiser study using data from millions of ED visits.2,3) Winter 2012 19

People come to the ED for all kinds of non-urgent conditions, from toenail fungus to big, black, ugly moleitis. There are plenty of reasons why someone might choose ED care over other options for non-urgent medical problems—including convenience, lack of insurance, and timely access to specialists and specialized imaging.

As medical professionals, I think we all know that the ED—although expensive and sometimes insufferably slow—can accomplish most work-ups more thoroughly than most other venues. And, quite honestly, non-urgent visits keep some EDs in business. But by the time you reach the point, as we have in California, where 20% of patients leave the ED without being seen, your safety net is getting awfully frayed and in need of repair. So, approaches to providing alternate means for non-emergent care, like urgent care and Rapid Care pathways (as in our San Rafael Kaiser) will help. However, given that frequent flyers take up such a significant chunk of ED time and resources, they are potentially a high-yield population for intervention. Recognizing that managing frequent flyers is not easy, let’s nonetheless explore some options.

Case Management

What if we used ED visit data to identify frequent flyers and then implemented a multidisciplinary approach to manage them with personalized care plans? This type of preventive care, called “case management,” deploys a team of nurses, social workers and physicians to design and manage outpatient care and social support. With this type of team in place, perhaps Charlie COPD gets his exacerbation picked up earlier and is started on prednisone before he needs to come to the ED (for the seventh time this year).

Different forms of case management are in place across numerous locales and health systems. Within Kaiser’s Marin County facilities, for example, multiple programs exist to provide support, advice and medical management to patients who have been identified as high risk or high utilizers. With 20 Winter 2012

Medicare incentives now in place to reduce readmission rates, more such programs are surely on the way, but important questions remain inadequately addressed. Can this type of approach work on a consistent basis? Is it costeffective?

A recent meta-analysis in the Annals of Emergency Medicine reviewed 11 studies of interventions designed to reduce adult ED frequent flyer utilization.4 Of these, seven studies were of case management programs, two were randomized controlled trials that compared case-management intervention vs. usual care groups, and two were not case-management based. Results across the studies were mixed, with a consistent decrease in ED visits in the intervention groups, offset by the observation that in one of the randomized trials there was also a significant decrease in ED visits for the control group. (There’s that vexing “regression to the mean” problem again.)

The three studies that included cost-effectiveness analysis suggested that case management saved hospital costs—but only enough to pay for the case management program. The studies did not try to account for non-hospital societal costs, including charity care.

This consideration is noted by Maria Raven in her companion editorial: “To be sustainable in the long term, any intervention model must demonstrate the ability to pay for itself in reduced health and social care expenditures, including, but not limited to, those of the ED.”5 Thus, while clearly promising, further work is needed to evaluate how best to design and study case management for ED frequent flyers.

Community Paramedics

This approach is in its infancy. What if we used pre-hospital providers, such as paramedics, to enroll and deliver pre-hospital case management? Could this supplement existing health system programs? Perhaps. As described in a recent New York Times article, the underlying thesis of the community paramedic is that “emergency workers should not wait around for crises to

happen, but rather go out and prevent them.”6 Thus paramedicine becomes a version of case management provided by paramedics, who have the added benefit of the resources and on-scene expertise of the pre-hospital provider.

Who better to prevent unnecessary transport than the transporters themselves? A homeless outreach program implemented by the San Francisco Fire Department, for example, reduced emergency call volume among the homeless by about 75% in 18 months and saved an estimated $12 million.

Unfortunately, the program has been on hiatus since 2009, a victim of federal reimbursement structures that reward pre-hospital transport rather than preventive care. Nonetheless, other municipalities are looking at different angles of the same model.

Alameda County has proposed a pilot program that would offer free primary and preventive care to the public at five county fire stations. Called the Fire Station Health Care Portal, the effort envisions stations staffed by a firefighter paramedic, a care coordinator and a nurse practitioner. The stations would provide non-emergency care, 48-hour ED visit follow-up, and 911/211 phone advice and response. If everything goes well, the program could be up and running by next year, but it may not be sustainable without outside or philanthropic funding.

That funding dilemma captures the current challenge of community paramedicine. Nonetheless, if incentives evolve, we may see a rapid blossoming of paramedicine. Ted Peterson, EMS battalion chief for the Novato Fire Protection District, believes this can and should happen. “The fire service,” he says, “has a long history of both standing ready to respond to emergencies as well as working to prevent them from ever happening. This same philosophy can and should be applied to medical care. The fire service is here 24/7/365 with paramedic firefighters that have the training, equipment, resources and access to help people. It is only logical that they be used in the prevention of medical emergencies. Once the highMarin Medicine

risk patients have been identified and protocols established, the community paramedics can ‘check in’ on this population and interject preemptively with treatment or referrals to help patients stay out of the hospital. Not only is this possible, it is the right thing to do for our neighbors.”

Predictive Models

As already mentioned, ED frequent flyers are a diverse group with significant turnover, which makes retrospective-based identification and management problematic. Is it really possible to efficiently “react” when most frequent flyers will resolve their frequency issues on their own? Why not use multi-variable models to predict who will become a frequent flyer?

Some evidence suggests that we can predict frequent flyers. Several studies from the UK have derived and validated algorithms to predict hospital admissions and readmissions. One of those studies found that strong predictors of non-elective admission to UK

hospitals included age, male gender, history of previous visits, and the quantity of certain types of prescriptions such as analgesics, antibiotics, diuretics, inhalers, and nitrates.7 To date, such work has not been extended to the American frequent flyer population, but it is certainly possible and theoretically helpful.

Here’s one possible scenario for a predictive case management model.

Electronic medical records run regular reports based on an algorithm or identified risk factors and create a list of at-risk patients. A hospital-based case management team reviews these patients and selects some for intervention.

A multi-disciplinary team, including community paramedics, implements the interventions, which might include medication and home safety reviews.

Such a model will surely not eliminate the frequent flyer problem, but maybe it will help soften the burden.

And that would be good news not just for Frequent Fred, but also for everyone involved.

References

1. LaCalle E, Rabin E, “Frequent users of emergency departments: The myths, the data, and the policy implications,” Ann Emerg Med, 56:42-48 (2010).

2. Billings J, et al, “Emergency department use: The New York story,” Commonwealth Fund Issue Brief (November 2000).

3. Ballard DW, et al, “Validation of an algorithm for categorizing the severity of hospital emergency department visits,” Med Care, 48:58-63 (2010).

4. Althaus F, et al, “Effectiveness of interventions targeting frequent users of emergency departments: a systematic review,” Ann Emerg Med, 58:41-52 (2011).

5. Raven MC, “What we don’t know may hurt us: Interventions for frequent emergency department users,” Ann Emerg Med, 58:53-55 (2011).

6. Johnson K, “Responding before a call is needed,” New York Times (Sept. 18, 2011).

7. Donnan PT, et al, “Development and validation of a model for predicting emergency admissions over the next year,” Arch Intern Med, 168:1416-22 (2008).

Email: Dballard30@yahoo.com

The town of Visby on Gotland Island, Sweden. Photo by Dr. Barbara Nylund (see page 28).

Marin Medicine

Winter 2012 21

PRACTICAL CONCERNS

New Hospital-Physician Alignments in Marin County Jon Friedenberg

M

ajor changes in healthcare are inevitable—and soon.

But no one knows exactly what those changes will look like.

That’s why Marin General Hospital (MGH) is pursuing new physician and hospital alignments that we hope will strengthen our ability to deliver high quality, cost-effective care in any environment, while helping ensure that patients and physicians still have the choices they want.

In 2010, for example, MGH formed the nonprofit Prima Medical Foundation with Marin IPA and Sonoma Valley Hospital. The Foundation (which contracts exclusively with the locally owned Prima Medical Group) enhances the stability of the local medical community. Equally important, it allows Marin physicians to maintain autonomy and practice medicine in the way they want while continuing to put the patient first when making decisions.

Prima Medical Foundation is one of the cornerstones of our hospitalphysician alignment strategy. While the original goal was to provide a solution to the ever-growing shortage of primary care in our area, the Foundation soon realized there was an equally important need to address the full spectrum of medical and preventive Mr. Friedenberg is the chief fund and business development officer for Marin General Hospital.

22 Winter 2012

care. Today, Prima Medical Group has more than 60 physicians in Marin and Sonoma counties, and that number is expected to grow. Specialties include family medicine, internal medicine, pediatrics, obstetrics & gynecology, pulmonary & critical care medicine, and general surgery.

Proof that Prima is having the desired effect is the Foundation’s enhanced ability to bring new physicians into the community, such as the recent addition of three new surgeons to Prima’s general surgery practice. Prior to the recruitment of this multispecialty team, much of the trauma coverage at Marin General Hospital was provided by an out-of-county physician group.

Scheduling follow-up care was difficult, and such care was often delivered by a physician other than the operating surgeon. Now, the new surgeons and others based in Marin provide full trauma coverage for the hospital.

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he economics of private medical practice—particularly in Marin— have become a key driver of our strategy. Changes in reimbursement are making it extraordinarily difficult for private practice physicians to survive financially. The fact is the current reimbursement model is broken for primary care physicians, and even specialists find the economics challenging.

Through 1206(b)clinics and the Prima Medical Foundation, MGH can help

cover the rent, billing, collections— all the operational and management tasks for local physicians serving these offices. We can free them up to focus more on medical care and less on administration.

Recognizing that expanded capabilities are critical to our future, the hospital launched its own Spine & Brain Institute in collaboration with the Mt. Tam Spine Center and the UCSF Department of Neurosurgery. We have also developed a co-management agreement with physicians in Marin Specialty Care for their oncology and urology services, and we are in discussion with several other physician groups about aligning with the hospital via either Prima or our 1206(b) clinics.

Complementing our physician alignment strategy is our hospital alignment effort. To that end, we have signed a management services and affiliation agreement with Sonoma Valley Hospital, which is also served by the Prima Medical Group. Our partnership will enable both administrations to share more physicians, and possibly reduce our IT, billing and marketing services costs. By doing so, we strengthen our ability to compete with corporate giants. We also can develop an integrated model of care that shares capabilities— whether management or medical—to make us more cost-effective through economies of scale, while increasing patient services. We hope to reach simiMarin Medicine

lar agreements with other hospitals in the future.

These initiatives improve access to care and reduce costs, and they offer the possibility of enhancing the quality of care. Overall, quality in Marin is already high, but that doesn’t always extend to the quality of the patient experience. Here, we see huge opportunity for improvement. Ensuring that everyone can access the same information in real time—results of tests as well as bedside observations—means patients and providers spend less time repeating the same tests and chasing paper records. Shared information ensures stronger physician collaboration, including multi-disciplinary consults, without requiring the patient to travel from office to office repeatedly.

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he changes described above aren’t unique to Marin. They are occurring all over the country as hospitals and providers race to prepare for the national and statewide changes ahead. All over the Bay Area, physicians and hospitals are aligning to achieve economies of scale, better integration and quality of care, and the ability to offer patients the care they want without leaving their home communities. Throughout the country, private practice physicians and community hospitals are fighting to remain independent from giant corporate networks. The transition of Marin General Hospital to local control has accelerated these changes locally.

I believe the best healthcare in the United States is provided by those who are accountable solely to the community they serve—and our community is no exception. Whatever the future holds, Marin General is committed to providing both local physicians and patients with that choice. Physicians who align with us can get the benefits of being part of a larger organization without losing their autonomy and the ability to run their practices as they see fit. Likewise, their patients can continue to access high quality care without having to leave their community.

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Marin Medicine

Winter 2012 23

HOSPITAL/CLINIC UPDATE

Marin General Hospital Susan Cumming, MD

Note: Each issue of Marin Medicine includes a self-reported update from one local hospital or clinic, on a rotating basis.

A

year and a half after the Marin Healthcare District regained cont rol of Mar i n General Hospital, the facility is thriving. As a full-service, acute-care hospital, MGH provides a trauma center, comprehensive cardiac and neurological surgery programs, labor and delivery services, and a nationally recognized cancer care center.

Under our new leadership, MGH is pushing forward. With new industry awards and certifications, expansion of services, deployment of electronic health records, retention of nurses, staff and physicians, and significant community donations of nearly $9 million to date, this past year and a half have brought great change and activity.

Key to the hospital’s future are expanded capabilities, including elective neurosurgery at the new Spine & Brain Institute, the only program of its kind in Marin. The launch of the institute is just one example of Dr. Cumming, a senior fellow in hospital medicine, is medical director of Marin General Hospital.

24 Winter 2012

a broader strategy to align with our physician community for the benefit of our patients.

Many of our services have been recognized at a national level. In 2010, we earned the Joint Commission’s Gold Seal of Approval for both our hospital and behavioral health services, and we were designated a Breast Imaging Center of Excellence by the American College of Radiology. We also received accreditation from the American College of Surgeons’ breast-center accreditation program, and our Marin Cancer Institute was awarded eight out of eight possible commendations by the ACS’s cancer commission.

We are also the first hospital in Marin County to receive full accreditation for percutaneous coronary intervention from the Society of Chest Pain Centers for our treatment of acute coronary syndrome. Finally, our stroke program has been certified by the Joint Commission and has received a quality achievement award from the American Heart and Stroke associations.

I

n September 2011, MGH took a big step towards eliminating paper charting and enhancing patient safety. We deployed a new application, Clinical Care Station, to enable electronic charting, electronic clinical records and medication bar coding. The Para-

gon charting application allows bedside entry of clinical information and seamlessly interfaces with other clinical applications already in use at the hospital. Because patient handover between nurses at shift change can now occur in the patient’s room, the new system will allow for increased patient involvement and better communication. The medication bar-coding application is integral to preventing medication errors. And no more chasing down the chart on morning rounds!

The implementation of Clinical Care Station is the first step toward demonstrating “meaningful use” of electronic records under federal regulations. The next step, computerized provider order entry, will be implemented during 2012. MGH is also working on protocols needed to create a health information exchange, a central database that can be shared by all providers involved in a patient’s care, regardless of the site of care. Such an exchange will offer a patient-centered approach to accessing clinical information.

Recent technology purchases at MGH include a PET/CT scanner and new breast imaging equipment, both made possible through funding by the MGH Foundation. The new, state-ofthe-art scanner provides detailed 3-D images, especially useful for cancer and cardiovascular care, and has an open Marin Medicine

design that makes scanning more comfortable for patients. In September 2011, we opened a new electrophysiology lab, which will allow faster, safer ablations and device implantations. Plans are underway for a second 64-slice CT scanner and upgraded MRI equipment.

A

s an independent community hospital, collaborat ion with other organizations and with community partners is critical for MGH. The most significant recent example of our collaborative efforts is our work on reducing hospital readmissions. In September 2010, I attended the first meeting of the Avoiding Readmissions Collaborative, an initiative supported by the Gordon and Betty Moore Fou ndat ion. A RC ’s goal is to help participating organizations reduce 30- and 90-day readmissions by 30% by 2013.

Early in 2011, with funding from ARC, we established a cross-continuum work group, the Care Transitions Collaborative (CTC), which included representatives of hospital departments and leadership, Marin County Health & Human Services, Prima Medical Foundation, Hospice by the Bay and Palliative Care, Sutter Care at Home, Marin Community Clinics, Marin-Sonoma IPA, and a patient representative. The CTC team identified four key areas for intervention: patient education, medication management, team communications (both within the hospital and post-discharge), and post– discharge support systems, especially for older adults.

The CTC team is still developing Marin Medicine

plans to address those four areas, but MGH has already adopted an innovative technology for team communications: Carebook, a multidisciplinary care collaboration tool. Care providers inside and outside the hospital can use Carebook to form multidisciplinary care teams, collaborate on safe transi-

Foundation to implement the program, recognizing the need and our innovative community based approach. The work is just beginning, but we are optimistic the program will offer a new paradigm for improving not only the health of our patients, but also their experience of care.

W

Marin General HospItal

tion plans for their patients, coordinate care across the teams, and engage patien ts and caregivers with a patientcentered after-care map. MGH will deploy and administer Carebook and also make it available to community partners.

Our work with readmissions has evolved into a new initiative, the Collaborative for Older Adults Safe Transmissions Program. In late October 2011, we received a $750,000 grant from the Gordon and Betty Moore

e a re g ratef u l for the generous contributions received from the Marin County community since the hospital’s transition to publ ic cont rol — nearly $9 million to date. Our fundraisers during 2011 have included the “Night in Marin Gardens” gala, which raised more than $400,000, and the “Taste of Tokyo” golf tournament at the Meadow C lub, wh ic h ra i s ed more than $300,000.

Both will become annual events.

Wit h t hese a nd other contributions, we have been able to lau nc h t he Spi ne & Brain Institute, purc h a s e t h e P E T/C T scanner, begin major expansions and upgrades to our emergency department, and update our breast imaging equipment. We also plan to launch an outpatient diabetes program.

It has indeed been a busy year and a half for all of us at MGH, and the pace is unlikely to slow down in the near future. Change creates challenges, but it also creates opportunity. I believe this past year and a half have demonstrated that MGH remains strong. We are continuing to focus on our patients as we work to raise the bar on healthcare in Marin.

Email: cumminss@maringeneral.org

Winter 2012 25

CURRENT BOOKS

Costly Grace Irina deFischer, MD

Bonhoeffer: Pastor, Martyr, Prophet, Spy, by Eric Metaxas, 624 pages, Thomas Nelson (2011).

I

was drawn to this biography because I had heard of Dietrich Bonhoeffer in the context of the German Resistance but knew little about him. Eric Metaxas—who wrote the bestselling Amazing Grace: William Wilberforce and the Heroic Campaign to End Slavery—uses extensive research to paint a vivid portrait of Bonhoeffer in the setting of his family and early 20th century Germany. Metaxas also attempts to explain the evolution of Bonhoeffer’s theology, which has often been misunderstood.

What is certain is that, unlike most of his countrymen, Bonhoeffer was not afraid to stand up against the Third Reich.

The ethical challenges of Bonhoeffer’s era were famously summarized by one of his contemporaries, Pastor Martin Niemöller: First they came for the communists, and I didn’t speak out because I wasn’t a communist.

Then they came for the trade unionists, and I didn’t speak out because I wasn’t a trade unionist.

Dr. deFischer, a Petaluma family physician and geriatrician, is president-elect of MMS

26 Winter 2012

Then they came for the Jews, and I didn’t speak out because I wasn’t a Jew. Then they came for me, and there was no one left to speak out for me.

D

ietrich Bonhoeffer was born in Breslau, Germany, in 1906, the sixth of eight children of an upper-middle-class family. His father, Dr. Karl Bonhoeffer, who had studied under Wernicke, was a renowned neurologist and psychiatrist, and his mother, Paula von Hase, was a university-educated teacher who counted among her forebears theologians, artists and musicians. Paula ran the household and home-schooled the children in their early years. She taught them religion through hymns and scrip-

ture readings. Because Karl was an agnostic, the family did not attend church regularly.

When Dietrich and his twin sister Sabine were 6 years old, the family moved to Berlin, where Karl had accepted an academic appointment. Berlin in 1912 was an intellectual and cultural center, with one of the world’s finest universities. The family lived in an elite community near the university and enjoyed an active social life. Many of their friends were Jewish. Karl taught his children fairness and intellectual rigor.

The children spent idyllic summer holidays at their country home in the Harz Mountains, reading and playing outdoors.

Their holidays where cut short in 1914, when Germany declared war on Russia. The family was patriotic to some extent and followed the progress on the front with interest. The war really came home to them when two older sons were drafted and one of them, Walter, was killed in 1918. Paula was devastated and withdrew into herself for the better part of a year. Dietrich’s childhood ended, and Germany changed: the Kaiser abdicated and the Weimar Republic came into being.

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ife went on. Dietrich entered high school, and at the age of 14, though he was a talented musician, declared his intention to study theology. The decision was met with some resistance.

His brother Klaus, who had chosen a Marin Medicine

career in law, accused the church of being “a poor, feeble, petty bourgeois institution,” to which Dietrich replied, “I shall have to reform it!”

In 1923, Dietrich entered the University of Tübingen. At the time, Germany was going into a financial free-fall.

Meals cost a billion marks! Hitler led his first Beer Hall Putsch and began writing Mein Kampf. After a year at the university, Dietrich decided to travel with his brother to Rome for a semester abroad. The stay in Rome opened his eyes to the diversity and universality of the Catholic Church and sparked his interest in the ecumenical movement.

Upon his return to Germany, Dietrich transferred to the University of Berlin and began his theological studies in earnest. The leading theologians of the day were extremely liberal, and though Dietrich held his teachers in high regard, he differed from them in his more literal interpretation of the scriptures.

He contrasted the prevailing attitude of “Cheap Grace” (in which believers could live their lives as they pleased as long as they attended church services and received absolution periodically) with “Costly Grace,” which involved devoting one’s entire life to following the teachings of Christ as expressed in the Sermon on the Mount.

By the age of 21, Bonhoeffer had successfully defended his doctoral thesis and graduated summa cum laude. Too young to be ordained, he accepted a position as the assistant pastor of a German congregation in Barcelona, Spain.

His sermons challenged the congregation both spiritually and intellectually, and attendance at the services increased during his year-long tenure. Back in Berlin, he returned to the ivory tower and became a university lecturer. Soon afterward he was offered a Sloan Fellowship at Union Theological Seminary in New York.

Bonhoeffer’s stay in New York had a profound influence on him, particularly because of his exposure to the revivalist preaching of the Abyssinian Baptist Church in Harlem and the piety and spirituals of the former slaves. He became interested in the racial issues in Marin Medicine

America and travelled extensively on the East Coast and the South, and as far as Cuba and Mexico. During this time, he became a pacifist and got more involved with the ecumenical movement, which eventually led to his activities during the German Resistance.

B

ack in Berlin once again, Bonhoeffer resumed his work as a university lecturer and author. He became more and more troubled by the German church establishment, which was being co-opted by Hitler and the National Socialists. Bonheoffer’s brother-in-law, Hans von Dohnanyi, a lawyer at the German Supreme Court with access to privileged information, reported to Bonhoeffer the atrocities of the Third Reich that were not known to the general public. Another brother-in-law, Gerhard Leibholz, was subject to sanctions because he was of Jewish descent.

Bonhoeffer eventually helped Leibholz and others escape to relative safety in England. He also helped found the Confessing Church, which pledged to take a stand against the Nazis and was eventually driven underground.

Bonhoeffer lobbied his friends in the ecumenical community outside Germany to support the opposition, but he made little headway. Hitler’s power increased, and his critics were silenced through execution or imprisonment.

In 1938, Bonhoeffer learned that war was imminent. His friends, afraid for his safety, arranged for him to take a visiting professorship in New York, but after a brief stay Bonhoeffer returned to Germany, feeling he couldn’t abandon his country in its time of need. “I shall have no right,“ he wrote to a colleague, “to participate in the reconstruction of Christian life in Germany after the war if I do not share the trials of this time with my people. … Christians in Germany will face the terrible alternative of either willing the defeat of their nation in order that Christian civilization may survive, or willing the victory of their nation and thereby destroying our civilization.”

Bonhoeffer was forbidden to speak in public, or to print or publish his

works, and he was required to report his movements to the police. He was able to avoid conscription by joining the Abwehr, a branch of the military intelligence service, and he became a double agent and co-conspirator with his brother-in-law von Dohnanyi in the failed plot to assassinate Hitler. As a pacifist, joining the plot was a difficult decision for Bonhoeffer, but he felt it was the only way to stop Hitler, and he was willing to assume the guilt for his action. As he said, “It is not only my task to look after the victims of madmen who drive a motorcar down a crowded street, but to do all in my power to stop their driving at all.”

In 1943, Bonhoeffer was arrested along with Dohnanyi and spent a year and a half in a military prison in Berlin awaiting trial. When his connection to the conspiracy was discovered, he was transferred to the Buchenwald concentration camp and later to the Flossenburg camp, where he was executed just a month before the capitulation of Nazi Germany. He left a legacy of both finished and unfinished works, including The Cost of Discipleship, Ethics, and Letters and Papers from Prison.

Email: irinadefischer@gmail.com

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Winter 2012 27

OUTSIDE THE OFFICE

In Search of the Vikings Barbara Nylund, MD

I

had to write a family histor y in t he eight h grade and wrote to my “far mor” (Swedish paternal grandmother) to help me. She was born in the town of Visby on Gotland Island, off the southwest coast of Sweden.

She told me that her uncle was the Lutheran bishop of Gotland and that her father was the military commander of the island’s fort.

My “far far” (paternal grandfather) was raised in Jakobstad, Finland. When my father was in his teens, my grandfather gave him The Tales of Ensign Stål,

by Johan Runeberg, the national poet of Finland. My father gave the book to me when he thought I was old enough, and I will pass it on to my only living nephew. It is the epic poem of Finland.

I have searched for my father’s family roots for years. Despite its size (338,000 square kilometers), Finland has less than 5.5 million inhabitants, some 40 of whom are my father’s family. My dear cousins, Anna Britta and Nils Sundqvist, allowed me to live with them for several months in 1975 while I did an internal medicine rotation at Malmska Hospital in Jakobstad, whose Finnish name is Pietarsarri. All towns on the west coast of Finland have Swedish and Finnish names. Swedish is the predominant language, but Finnish is required at work. My cousins Dr. Nylund, a gastroenterologist in private practice in Novato, serves on the MMS board of directors.

28 Winter 2012

speak Swedish, Finnish, English, Spanish and French.

In September 2011, I returned to my father’s homeland via Belgium with my good friend, Wendy. After several days in Brussels, we were joined by an old friend from Vienna, Felicitas, with whom I had done medical relief work in Central America over 20 years ago.

We all took the train to Bruges, one of the most perfectly preserved medieval cities in western Europe.

Wendy, who is an artist, led us to the Church of Our Lady (Onze-LieveVrouwekerk), where the celebrated Madonna and Child sculpture is the only Michelangelo to have left Italy during the artist’s lifetime. Construction of the church itself began in the 1200s and continued for three centuries, with occasional renovations since then. The interior is Gothic, but there are Baroque flourishes to its statues and extravagant pulpit. The cathedral’s art collection includes “Supper at Emmaus,” a painting that was once ascribed to Caravaggio but is rather flat and uninspired when compared to true Caravaggios.

Bruges is also home to one of several beguinages found in the Low Countries

(see photo). These communities were founded in the 13th century as sanctuaries for the many women (Beguines) left single or widowed by the Crusades. Although a deeply pious residence, the beguinage was not a convent. The Beguines could leave to marry. They could also take their inheritance to the beguinage and work outside in the community.

From Belgium we traveled north to Sweden and Finland, spending time in both Visby and Jakobstad. Like Bruges, Visby is a well-preserved medieval town. It is surrounded by a long stone wall, and its skyline is dominated by the St. Nicolaus church ruin (see photo on page 21).

Farther north is Jakobstad, which was founded in 1652. Russians sacked the town twice in 1714. Despite the repeated drubbings, it became the leading shipping town in Finland during the 18th century. In 1844, Finland’s first round-the-world sailing expedition started from Jakobstad harbor. Today, Nautor, the manufacturer of the world’s most elegant, fastest production boat, the Swan, calls the port home.

Beyond Jakobstad, the countryside of Finland is forest and lakes and vast wilderness. There are more than 180,000 lakes and a nearly equal number of islands. The name Finland is thought to derive from fen (a swampy land), or from the French fin de lande, meaning “the end of the world.” For my father’s family, it was home.

Email: b.nylund@comcast.net

Marin Medicine

“A” (ExcEllEnt) RAting

renewal rate

in a row of a.M. Best

of last

95

28

years

totAl DiviDEnDs DEclARED

$425M

or very satisfied

total years deClared dividend

Customers satisfied

32 34

93%

To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.

Strenghten your Practice at norcalmutual.com Proud to support the Marin County Medical Society.

Marin Medicine

Our passion protects your practice

Winter 2012 29

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans.

We are The Doctors Company.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.”

Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical professional liability program, including the Tribute Plan, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293. You can also visit us at www.doctorsagency.com.

Any Tribute Plan projections shown here are not intended to be a forecast of future events or a guarantee of future balance amounts. For a more complete description of the Tribute Plan, see our Frequently Asked Questions at www.thedoctors.com/tributefaq.