Marin Medicine Winter 2015

Volume 61, Number 1

Winter 2015 $4.95

THE BRAIN THE BOATING LIFE UNSUSTAINABLE SGR

The magazine of the Marin Medical Society

Group

Dental Long Term Disability Level Term Life Employment Long Term Care Business Owners Policy Group Professional Liability Workers’ Compensation Acc

Health Insurance Are you aware that small groups can change their health insurance at any time throughout the year?

Mercer provides a wide range of health insurance options and guidance to members of the Marin Medical Society. We connect you with the top group insurance carriers and help you choose the coverage that best fits your needs and budget. We offer flexibility and value so you can provide quality health, dental, life and disability plans to your employees.

Small Group (2 to 50 employees) coverage is available for all business forms that include at least one non-spouse W-2 employee in addition to the owner(s). Tax form verification of your status as a small group is required. We can help you to determine whether your business structure and enrollment will qualify for small group coverage if you are not sure.

Plus, members who purchase their group health insurance through Mercer, the Society’s sponsored insurance program broker and administrator, are eligible to receive Mercer Select H&B KnowHow. Developed by Mercer, a leader in human resource consulting, outsourcing and investments, Mercer Select H&B KnowHow is a tool that helps provide employers with important human resources information such as the latest health and benefit requirements for California, and it provides the forms needed for compliance.

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Volume 61, Number 1

Winter 2015

Marin Medicine The magazine of the Marin Medical Society FEATURE ARTICLES

The Brain

5 7 11 15

EDITORIAL

Our Squiggly Blob

“Our understanding of the brain is rudimentary. We are building artificial hearts and cloning kidneys, but scientists don’t have a clue about how to raise my IQ.” Sal Iaquinta, MD

COMORBID CONDITIONS

Bipolar Disorder and Cannabis Use

“Substance use is highly comorbid with mood and anxiety disorders, and the prevalence of these comorbid disorders has been increasing rapidly among teens and young adults.”

Adam Nelson, MD

IMPRESSIVE BENEFITS

Exercise as a Treatment for Parkinson’s Disease

“Even with all our knowledge about exercise, there is still no agreement concerning the optimal exercise intensity or prescription strategy for patients suffering from Alzheimer’s disease or Parkinson’s disease.”

Jonathan Artz, MD

HEADACHE UPDATE

Expanding Our Horizons

“Headache continues to be a major cause of disability worldwide.

Migraine alone affects 15–20% of the female population and 8–10% of the male population in the United States.”

Allan Bernstein, MD

DEPARTMENTS

19

LOCAL FRONTIERS

Here Come the Dogs

“According to the National Institute of Mental Health, at least one in four American adults has some form of mental disorder. Many of these people are entitled to an emotional support dog and will be consulting with their physicians for documentation.”

Irina deFischer, MD Table of contents continues on page 2.

Cover: Dr. Jim Dietz’s flybridge trawler Thunder Road docked in Shoal Bay, British Columbia. Photo by Dr. Dietz.

Marin Medicine Editorial Board Irina deFischer, MD, chair Dustin Ballard, MD Peter Bretan, MD Sal Iaquinta, MD Jeffrey Stevenson, MD Jeffrey Weitzman, MD

Staff Steve Osborn Editor Cynthia Melody Publisher Linda McLaughlin Designer Susan Gumucio Advertising 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, and additional mailing offices.

POSTMASTER: Send address changes to Marin Medicine, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403.

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 society.

E-mail: mms@marinmedicalsociety.org The subscription rate is $19.80 per year (four quarterly issues).

For advertising rates and information, contact Susan Gumucio at 707-525-0102 or visit marinmedicalsociety.org/magazine.

Printed on recycled paper. © 2015 Marin Medical Society

Marin Medicine The magazine of the Marin Medical Society

DEPARTMENTS (continued)

21 24 26 28 29 30 33

OUTSIDE THE OFFICE

My Boating Life

“My fascination with boats and traveling by sea began when my college buddy Jon, who had grown up in a New England boating family, purchased a wooden Sparkman Stephens 36-foot sloop in need of repair and invited me to help.”

Jim Dietz, MD

PRACTICAL CONCERNS

The Unsustainable SGR

“Every time American physicians celebrate a temporary reprieve from a Sustainable Growth Rate (SGR) mandated cut in Medicare compensation, the bottles of champagne are uncorked with a little less gusto, a little more battle fatigue.”

Mac Sterling, MD, and Melvyn Sterling, MD

CURRENT BOOKS

Coping with the Constraints of Our Biology

“Dr. Atul Gawande’s newest book, Being Mortal, is on several bestseller lists, which is intriguing because many people would consider his subjects potentially depressing.”

Jeff Weitzman, MD

HOSPITAL/CLINIC UPDATE

Kaiser Permanente San Rafael

“Kaiser Permanente was an active player in the health insurance exchanges, and the San Rafael Medical Center received its fair share of the newly insured.”

Gary Mizono, MD

MMS NEWS

Dr. Bretan Receives AMA Award for Public Service

“The American Medical Association recently presented Dr. Peter Bretan Jr., a Marin County urologist and transplant surgeon, with the Benjamin Rush Award for Citizenship and Community Service.”

PRESIDENT’S REPORT

Letter to Marin County Physicians

Jeffrey Stevenson, MD

CMA NEWS

2015 New Health Laws

“The California Legislature had an active year, passing many new laws affecting health care.”

25 NEW MEMBERS 25 CLASSIFIEDS 29 AD INDEX

2 Winter 2015

Our Mission: To enhance the

health of our communities and promote the practice of medicine by advocating for quality health care, strong physician-patient relationships, and for personal and professional well-being for physicians.

Officers President Jeffrey Stevenson, MD President-Elect Peter Bretan, MD Immediate Past President Irina deFischer, MD Secretary/Treasurer Michael Kwok, MD Board of Directors Larry Bedard, MD Lori Selleck, MD Paul Wasserstein, MD

Staff Cynthia Melody Executive Director Rachel Pandolfi Executive Assistant Steve Osborn Managing Editor Linda McLaughlin Graphic Designer Susan Gumucio Advertising Representative Alice Fielder Bookkeeper

Membership Active: 267 Retired: 104

Address

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

www.marinmedicalsociety.org

Marin Medicine

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Guests BECAUSE WE’RE REAL PEOPLE HELPING REAL PEOPLE.

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EDITORIAL

Our Squiggly Blob Sal Iaquinta, MD

T

here are not many frontiers left to explore. The bottom of the ocean, Mars and deeper space all seem so inaccessible, and thus far they haven’t produced any discoveries that add significantly to our daily lives.

Space exploration did popularize Velcro and astronaut food, but where are the big payoffs?

Perhaps we would be better served by exploring the frontier inside our heads: the human brain. Our understanding of the brain is rudimentary.

We are building artificial hearts and cloning kidneys, but scientists don’t have a clue about how to raise my IQ. An outside look at the human brain reveals almost nothing about how it works. You can look at a hand with its wonderful system of muscles and tendons acting together to coordinate a movement. But looking at a brain you see a squiggly blob. What does it do?

For centuries our understanding of the brain’s functions came from traumatic injuries. These are the findings taught in medical school. Left frontal lobe injury yields pseudo depression.

Cerebellar injury causes loss of coordination. In essence, we have mapped the brain, but we don’t really understand it. I can open up my computer and map out the components, but that doesn’t mean I understand how they work.

Nonetheless, the last 20 years have produced major advances in brain science. Functional MRI has demonstrated that our brains are always active. Mental tasks increase energy consumption in the active parts by about 5%. This is Dr. Iaquinta, an otolaryngologist at Kaiser San Rafael, serves on the MMS Editorial Board.

Marin Medicine

not the same as the urban myth that we “only use 5% of our brain.” Many of us get by on far less.

Brain scientists recently discovered the glymphatic system. This glial lymphatic system, long thought impossible, appears to clear interstitial waste from the brain. A 2013 study found that glial lymph flow increased about 60% during sleep. It is hypothesized that the proteinopathies (ALS, Alzheimer’s, Parkinson’s and Huntington’s) might be related to a failure of the glymphatic system. A study of mice lacking a specific astrocyte water channel found that their clearance of amyloid-beta decreased by over 50%. Amyloid-beta plaques are found and implicated in Alzheimer’s.

The discovery of the glymphatic system and other brain mechanisms may be just in time, because our society is in for an epidemic. Census data show that seniors are the fastest growing population worldwide. One recent study found that 44% of American citizens between the ages of 75 to 84 have Alzheimer’s disease. As our ability to treat other diseases advances, we only increase the number of people who will suffer from brain disease. Should targeted inhibitors or immune-mediated treatments for cancer be even modestly successful, there will be many more people living into their 80s and beyond.

At the other end of the spectrum are the psychiatric diseases. Although they don’t only affect younger brains, it is true that 75% of all psychiatric disorders begin before age 25. Over the past few decades, the incidence of these disorders has been increasing. Some say it is just our ability to define and recognize more diseases that accounts

for the growth in diagnoses. Either way, more diagnoses mean more patients needing help.

Our current medicinal treatment for psychiatric illness is based on known neurotransmitters. Perhaps the biggest breakthrough in this regard was the development of selective serotonin reuptake inhibitors. Their success has made antidepressants the most commonly prescribed medicines in the United States. But not all psychiatric illness benefits from such directed therapy. The best long-term medication for bipolar disorder is still lithium, yet after more than six decades of use, its exact mechanism is still not fully understood.

In time, we will learn to identify more neurotransmitters and their receptors.

With enough effort, there will be a drug that alleviates my arachnophobia.

Age-related brain disease and psychiatric illness have a huge impact on our quality of life. But so do headaches.

Often enigmatic and astoundingly common, headaches plague the world.

Nearly one-half of adults report having a headache during the last year. Recent studies have found genes associated with migraines, but the cause of cluster headaches remains a mystery. Joking with the inquisitive patient that their problem “is all in their head” might get a smile, but some real answers would be far more satisfying.

These mysteries are just a few of the many brain teasers to be found within our squiggly blob. For each one we straighten out, the squiggles get easier to follow, and soon what seemed like an inaccessible frontier will be in our rearview mirror.

Email: salvatore.iaquinta@kp.org

Winter 2015 5

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COMORBID CONDITIONS

Bipolar Disorder and Cannabis Use Adam Nelson, MD

Note: The following is a composite of actual cases. Some details have been changed to protect patient identity.

A

few years ago, I received a referral for a young man who was taking Suboxone for opioid dependence. The referring physician was trying to taper the Suboxone, and other than mild anxiety, the patient had appeared to be doing well. But when his dose was reduced further, he developed worsening anxiety, insomnia, weight loss, anhedonia and panic. He felt overwhelmed, depressed, helpless and hopeless, and had begun having suicidal ideation.

The referring physician had initially diagnosed major depression and prescribed an SSRI antidepressant. When the patient failed to respond to treatment, his Suboxone dose was raised back up, and he became psychotic, with paranoid delusions of reference and guilt. He was convinced that he was possessed by an evil spirit, and that he was being targeted on the Internet.

Further history revealed several years of difficulties with anxiety, which caused social discomfort, avoidance, and episodic isolation from friends and family. At home, he sometimes retreated to his room for several days at a time, surfing the Internet and avoiding contact with others. He Dr. Nelson is a Mill Valley psychiatrist with a special medical interest in bipolar disorder.

Marin Medicine

also engaged in reckless and impulsive “extreme” physical acts of daring, such as leaping from high walls.

The patient had apparently turned to substance use as a means of selfmedicating his anxiety. Initially, he used cannabis that he got from his older brother, who had a “cannabis card.” Then he began stealing opioid pain medications prescribed to his father for chronic back pain. During his Suboxone detox, the patient began smoking marijuana more often.

Table 1. Depressive Episode Depressed mood and/or loss of interest or pleasure in life activities for at least two weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day: 1. Depressed mood most of the day.

2. Diminished interest or pleasure in all or most activities.

3. Significant unintentional weight loss or gain.

4. Insomnia or sleeping too much.

5. Agitation or psychomotor retardation noticed by others.

6. Fatigue or loss of energy.

7. Feelings of worthlessness or excessive guilt.

8. Diminished ability to think or concentrate, or indecisiveness.

9. Recurrent thoughts of death or suicide, suicide attempt or plan.

(SOURCE: American Psychiatric Association, 2013)

Table 1 summarizes the DSM-5 diagnostic criteria for a depressive episode.1 Antidepressants, and SSRIs in particular, are among the most frequently prescribed medications, including for teens and children. Recently, however, the efficacy and safety of antidepressants have come under further scrutiny.2 The FDA now requires a black-box warning of increased risk of suicidal thinking in adolescents and young adults in package inserts of all antidepressant medications. Some experts believe the problem of overuse or misuse of antidepressants may be due to misdiagnosis.

Many pediatric and young adult patients can present with a depressive episode that may eventually evolve into a diagnosis of bipolar disorder. Depression can present at nearly any age, ranging from childhood, to early adulthood, to late adulthood. 3 Some have suggested that a history of a depressive episode in a young person, along with a family history of bipolar disorder, may be a significant risk factor for eventually developing a diagnosis of bipolar disorder.4 Others have suggested that a younger age of onset for an initial depressive episode may more likely predict a diagnosis of bipolar disorder, while older age of onset may predict a diagnosis of major depression.5 There are exceptions, of course, so when evaluating a patient with depression, it is essential to inquire about current or previous episodes of depression, mania or hypomania, especially if the patient is under 40 or has had a poor initial treatment response (see tables 2a and 2b).

Winter 2015 7

In the young man’s case, previous history of hypomanic or possibly manic episodes suggested a differential diagnosis of bipolar 1 disorder (depressed, with psychotic features) or bipolar 2 disorder (depressed, with substanceor medication-induced mood and/or psychotic disorder).

The DSM-5 specifies three bipolar disorder types and requires the clinician to exclude other possible condi-

Table 2a. Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, 3 (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree: 1. Increased self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli).

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. (manic) Sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization, or there are psychotic features.

D. Not attributable to a medication, substance use, or medical condition.

8 Winter 2015

tions that can present with similar symptoms (see Table 3). These include PTSD, anxiety disorders, adjustment disorders, personality disorders, mood disorders due to a medical condition, as well as substance- or medicationinduced disorders.

Substance use is highly comorbid with mood and anxiety disorders.6 The prevalence of these comorbid disorders has been increasing rapidly among teens and young adults.7 In the young man’s case, he did not appear to become severely depressed or psychotic until very late in his Suboxone taper, without any evidence of delirium or physical withdrawal symptoms. He did, however, report a significant increase in cannabis use over the preceding several weeks.

T

he use of medical marijuana is legal in California, and it continues to gain legal status, both medicinally and recreationally, in several other states. Cannabis exerts much of its effect via the endocannabinoid CB1 receptor found in many regions of the brain. Studies have shown that cannabis can affect mood and memory formation (hippocampus, amygdala and thalamus), and motor skills and coordi nat ion (basal ga ngl ia a nd cerebellum, and brainstem).8 Because of increasing public interest, several professional groups,

including the AMA and the American and California psychiatric associations, have extensively reviewed the currently available literature on the neuropsychiatric effects of marijuana. They and others have released several papers and position statements regarding potential difficulties with marijuana use.

Perhaps the most significant position statement comes from the American Academy of Child and Adolescent Psychiatry.9 The statement warns about the immediate and long-term harmful consequences of cannabis use on the developing brain of a minor or young adult. Several research studies seem to support this concern, demonstrating significantly deleterious physiological and clinical effects of cannabis on areas of the frontal and prefrontal cortex.10 These areas are responsible for memory formation, attention, executive function, decision making, and motivation. In adults, these areas are not fully developed until age 25.

Another growing body of evidence has linked marijuana use to psychiatric problems and to increased severity of psychopathology in patients with

Table 3. Bipolar Disorder

Same as manic episode, except: 1. Duration of at least 4 days.

2. An unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

3. Change in mood and functioning observable by others.

4. Not severe enough to cause social and occupational impairment or require hospitalization and no psychosis.

Bipolar disorder is characterized by more than one bipolar episode. There are three types of bipolar disorder: 1. Bipolar 1 disorder, in which the primary symptom presentation is mania, depression, or rapid (daily) cycling episodes of mania and depression.

2. Bipolar 2 disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes.

3. Cyclothymic disorder, a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder.

(SOURCE: American Psychiatric Association,

(SOURCE: American Psychiatric Association,

2013)

2013)

Table 2b. Hypomanic Episode

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Marin Medicine

Figure 1.

Distribution of THC in the body

THC concentration (%)

genetic and epigenetic predisposition and risk of mental illness, including schizophrenia-spectrum disorders and bipolar disorders.11 One study suggests that ongoing cannabis use can significantly prolong the acute symptoms of mood disorder and psychosis and can substantially delay recovery.12 In some cases, the response to treatment of cannabis-induced psychiatric disorders may require several months, or even years. By comparison, the natural history of treatment response for other acute mood disorders tends to be considerably shorter. Perhaps the prolonged treatment latency may correlate with the detection of cannabinoids in the serum of chronic heavy users (see Figure 1).8 The risk of cannabis provoking or exacerbating symptoms of severe mental illness has been known for decades, but the frequency of such problems used to be relatively low. In the past decade, however, the frequency has jumped.

One possible cause is that the THC content of marijuana has been increasing significantly over the past 20 years, to a level that is estimated to be several times the potency available during the 1960s and 70s (see Figure 2).13 I prescribed risperidone for the young man and switched the SSRI to lamotrigine, slowly titrating to 200 mg daily. In addition, he agreed to stop using cannabis for 90 days. Over the next several months, his symptoms began to improve and eventually remitted. After six months, his risperidone was successfully tapered and discontinued. After six more months, his lamotrigine was discontinued. Six months later, he was discharged from care.

Two years later, however, he had a relapse of symptoms similar to his previous presentation, again preceded by several months of gradually increasing cannabis use. This time, I prescribed lurasidone, and he immediately halted his use of cannabis. It was unclear in the telling if any mood or anxiety disorder symptoms may have preceded his brief return to cannabis. Again, his symptoms responded to treatment and were in remission within six months.

THC distribution (hours)

Figure 2.

Non-normalized average THC % vs. year of confiscation

T H C %

Confiscation year

He remains on a lower daily dose of lurasidone.

What is the final diagnosis? For now, the answer is uncertain. The natural history of mood disorders may include several months or years of quiescence between acute episodes. The natural history of substance-induced disorders typically relates to the pattern of substance use. At this point, only time will tell.

Email: apnelsonmd@gmail.com

References

1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed, APA (2013).

2. Bridge J, et al, “Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment,” JAMA, 297:15 (2007).

3. Kessler R, Bromet E, “Epidemiology of depression across cultures,” Ann Rev Public Health, 34:119-138 (2013).

4. Miklowitz D, Chang K, “Prevention of bipolar disorder in at-risk children,” Development & Psychopathology, 20:881-897 (2008).

5. Benazzi F, “Does age at onset support a dimensional relationship between Bipolar II disorder and major depressive disorder?” World J Biol Psych, 8:105–111 (2007).

6. Merikangas K, et al, “Comorbidity of substance use disorders with mood and anxiety disorders,” Addictive Behaviors, 23:893–907 (1998).

7. Kandel D, et al, “Psychiatric comorbidity among adolescents with substance use disorders,” J AACAP, 38:693-699 (1999).

8. Ashton CH, ”Pharmacology and effects of cannabis,” Brit J Psych, 178:101–106 (2001).

9. AACAP, “AACAP marijuana legalization policy statement,” www.aacap.org (2014).

10. Filbey F, et al, “Long-term effects of marijuana use on the brain,” Proceedings of Nat Acad Sci, 111:16913-18 (2014).

11. Regier D, “Comorbidity of mental disorders with alcohol and other drug abuse,” JAMA, 264:2511–18 (1990).

12. Kuepper R, et al, “Continued cannabis use and risk of incidence and persistence of psychotic symptoms,” BMJ, 342 (2011).

13. Mehmedic Z, et al, “Potency trends of Δ9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008,” J Forensic Sci, 55:1209–17 (2010).

Winter 2015 9

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IMPRESSIVE BENEFITS

Exercise as a Treatment for Parkinson’s Disease Jonathan Artz, MD

D

espite intensive research and ongoing clinical trials, there is still no effective cure for the two most common neurodegenerative diseases: Alzheimer’s disease (AD) and Parkinson’s disease (PD). For the last decade, clinicians have prescribed acetylcholinesterase inhibitors to ameliorate and temporize the cognitive, behavioral and memory-related deficits of these diseases, yet these medications have not been shown to either delay the underlying neurodegenerative process or prevent brain decay.

Neurologists prescribe dopaminemodulating compounds—such as carbidopa/levodopa, dopamine agonists and monoamine oxidase inhibitors (MAOIs)—to enhance motor system activity in the extrapyramidal pathways and alleviate features such as tremor, bradykinesia, rigidity and, to a much lesser extent, postural instability.

Some questionable and hotly debated data suggest that the MAOI Azilect may “protect” against declining motor functioning in patients with PD, yet the drug does not prevent or treat the Dr. Artz is a neurologist at Kaiser San Rafael.

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underlying neurodegenerative process. There is, however, evidence that a supplemental exercise regimen can improve walking and transferring abilities and reduce the risk of falls, even as the primary neurodegenerative process continues.

The benefits of exercise are impressive. Animal studies have found that it can help with learning and memory1 and may enhance neurogenesis.2–5 Sustained exercise may facilitate axonal transport of acetylcholinesterase and other proteins;6 it may even alter the antioxidant status of the brain under certain circumstances.7 Exercise may induce dopamine release and enhance dopamine transmission via upregulation of DA-D2 receptors.8,9 A systematic review on the effects of exercise in the elderly showed that moderate-intensity exercise can effectively increase peripheral brainderived neurotrophic factor (BDNF).

Serum BDNF crosses the blood-brain barrier, so these results may have implications for brain neurotrophin levels.10 One animal study found that exercise increased BDNF in the brain’s striatum.11 A recent review on the benefit of exercise to improve cognition emphasized the potential neuroprotective effects of vigorous exercise in PD.12

E

ven with all our knowledge about exercise, there is still no agreement concerning the optimal exercise intensity or prescription strategy for patients suffering from AD or PD. Basic guidelines for an exercise regimen for PD patients include vigorous exercise in patients who are capable, as well as a structured program for cognitively impaired patients.12 There is now a national movement in the Parkinson’s community to encourage exercise, given its benefits for mobility and cognitive function. Importantly, the effects of vigorous exercise can last up to 60 days.13,14 Studies have found a high retention rate for PD patients committing to a 2–3 times per week exercise program, suggesting that these interventions could be implemented as a treatment strategy.

A recent meta-analysis showed that very light to vigorous exercise seems to have a small effect on cognition in the acute phase following exercise, but that larger and longer-lasting effects are possible with more intense exercise.15 Preclinical studies have shown that exercise results in behavioral and corresponding neurobiological changes in the basal ganglia related to cognition. Specifically, learning and memory improved after exercise in rodents, although the exact mechanisms remain unclear.

Winter 2015 11

Other preclinical studies have shown that any exercise is better than inactivity and that forced exercise has a greater impact than self-paced voluntary exercise. Clinical studies have shown that various types of exercise—including aerobic, resistance and dance—can improve cognitive function, especially executive function, in PD patients. Nonetheless, the “best” type, amount, mechanisms and duration of exercise are still unknown. The evidence from clinical studies suggests that a more intensive aerobic exercise program, including strength and balance training, can promote greater cognitive gains; but low-intensity exercise and balance-based exercises also showed benefits.

T

he benefits of exercise to human brain tissue and its cognitive functions are voluminous, and have been thoroughly reviewed.1,16,17 In AD patients, recent trials have shown that exercise can help slow disease progression both directly and indirectly.18-20 It is postulated that exercise could help to clear amyloid-beta peptide (main pathological driver) in AD patients.21 Exercise-induced nerve growth factor production could prevent the death of cholinergic neurons and perhaps attenuate cognitive decline.22 Cognitive dysfunction in PD is commonly associated with impaired executive function. However, evaluating research on executive function in PD is challenging because mild cognitive impairment in PD has only recently been defined, and formal diagnostic criteria are still being developed.23 Selecting and interpreting measures of executive function in PD is equally challenging, and the clinical implications are not yet fully appreciated.24 Executive function is generally related to goal-directed behaviors processed by the frontal lobes of the brain.

The function has four components: planning, purposive action, effective performance and volition.25 The most effective frequency, intensity, type or timing of exercise needed to improve executive function in PD is unknown.

12 Winter 2015

There is, however, evidence in older adults without PD that light aerobic exercise (walking)—but not anaerobic exercise (stretching and toning)—selectively improves executive functions processed in the frontal and prefrontal areas of the brain.26 The effects of aerobic and anaerobic exercise on cognition in PD have not yet been studied.

M

uscular strength is reduced in Parkinson’s patients, but the cause of the decrease is unclear.27,28 Central mechanisms may be responsible because of the reduction of facilitative stimulus of motor neurons.29 Patients with PD often complain of weakness in their lower limbs; clinically, researchers have observed an inability of proximal and axial muscles to generate adequate power, especially the extensors of the trunk and hip. The ability of PD patients to perform various functional activities, such as sitting to standing and walking, can be compromised due to muscle weakness in the lower limbs.30 One study found that strength training programs are effective in increasing muscular strength and, in some cases, mobility of patients with PD.31 The study programs were implemented in a short period of time with a training frequency of 2–3 times per week. They included one set of exercises per muscle group and involved only concentric contraction. A later study showed that functional gains and muscular strength are greater with high-intensity protocols that primarily involve eccentric contraction.32 The principle of this type of exercise is that high levels of force are generated during muscle stretching, with minimal oxygen consumption in relation to the amount of work produced.33 Some studies have found that highintensity strength training is better for motor and functional performance in patients with PD than training based on flexibility exercises, balance and concentric strength training of limbs.32 High-intensity training can minimize loss in bone integrity, preserve eccentric muscular strength and promote structural plasticity in the musculo-

skeletal system.34 Thus, it is reasonable to believe that high-intensity exercises are most desirable to minimize the progressive dysfunction of PD.

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bout five years ago, researchers developed an exercise program with the goal of delaying progressive loss of mobility associated with balance and gait disorders in patients with PD.35 Movements using Tai Chi, Pilates and other methods were combined in order to facilitate sensory integration in postural control. Somatosensory information was encouraged by large, coordinated movements in order to move the center of mass with speed, safety and balance.35 A further study showed that PD patients who practiced Tai Chi for 13 weeks achieved gains in balance and functional performance when compared to a control group without intervention.36 The authors concluded that Tai Chi can be a safe and beneficial exercise for treating moderately to severely affected PD patients.

Physical disability in PD is often related to gait impairment and transferring from a sitting to a standing position. Ambulation and transfer problems are considered the most disabling aspects of the motor features of PD. Gait-related mobility problems in particular have a negative impact on the quality of life and well-being of patients with PD.37 Several physical therapy studies have emphasized the value of specific exercises and intervention strategies to improve gait in PD patients. Two studies found that treadmill training can promote a more stable and dynamic gait pattern, and the authors suggested that treadmill training is more effective in improving gait than other traditional approaches. 38,39 Training on a treadmill can be seen as a kind of external cue to trigger the motor activity to be performed.40 Long-term treadmill training without weight bearing is a safe and economical method to increase gait speed, restore gait rhythm and improve quality of life for PD patients; these effects can last for several weeks after the end of training.41 Marin Medicine

I

been adopted and modified by Kaiser n PD patients, exercise may alter the Permanente and Sutter Health. course of the disease.16,34,42,43 ExerIMPACT dovetails with the concept cise can also improve postural stabilof the “medical home” outlined above. ity, balance and tremor, and it can help It provides a one-stop solution for paovercome musculoskeletal deficientients with mild to moderate mental cies.34,44,45 It could also possibly allevihealth needs in a primary care setting. ate the depression or negative mood Eventually, mental and physical health often associated with PD.46 In addition, providers will come to share record exercise-induced growth hormone keeping, laboratory facilities, and even changes may play a role in promoting physical facilities to provide a seamless neuroregeneration by increasing neural integrated home for the vast majority of stem cells.47 our clients. Exchange of medical, psyThe benefits of exercise on cognition chiatric, and laboratory findings bein PD are comparable to those seen in tween providers will be instantaneous. healthy older adults. A recent review Substance users will also find a home showed that endurance and resistance in these centers, since both medical and exercise can improve cognition in psychiatric providers recognize that healthy seniors.48 There is less research a large percentage of our clients have on the effects of exercise in frail older substance problems. Administrative adults, but recent evidence showed that overhead and costs could be combined a three-month physical activity interand reduced as well. vention improved physical abilities, One of the principles of IMPACT executive functions, processing speed is to start small. The vision outlined and working memory.49 The effects in above may not occur in the immediate older adults with mild cognitive impairfuture, and will certainly not be realment are less promising: a recent metaized by our modest trial proposals. But analysis showed that exercise had only as our clinical sophistication grows, the limited potential to improve cognition vision of a fully integrated mental and in this population.50 Whether cognition physical health center with rapid and in PD is improved due to dopaminerseamless communication and consulgic mechanisms of exercise or other tation between treating professionals mechanisms—such as increased neuis becoming not only desirable, but rotrophic factor availability or reduced inevitable. □ neuro-inflammation—remains to be determined.

E-mail: llanes@co.marin.ca.us Questions remain regarding the optimal prescription of exercise. UnderReferences standing the mechanism of benefit from 1. Unützer J, et al, “Collaborative-care manexercise could help us harness its potenagement of late-life depression in the tialprimary as a viable neuroprotectant. In any care setting,” JAMA, 288:2836-45 case, the findings discussed above pro(2002). vide further rationale for“Long askingterm patients 2. Hunkeler EM, et al, outto increase theirthe daily physical activity, comes from IMPACT randomized whether thatdepressed be riding aelderly bike, swimming, trial for patients in primary care,” dancing Brit Medor J, 332:259-263 walking, jogging, doing yoga and(2006).

Tai Chi. With growing support for 3. Callahan CM, et al, “Treatment of depresexercise to improve not only the motor sion improves physical functioning in symptoms of PD, but also its cognitive older adults,” J Am Ger Soc, 53:367-373 and mood-related impairments, health (2005). care providers and health systems should 4. Areán PA, et al, “Improving deprespromote and recommend exercise as part sion care for older, minority patients in of routine neurorehaprimarymanagement care,” Medicaland Care, 43:381-390 bilitation for this disease.

(2005).

Member of American Speech Language Hearing Association Member of American Academy of Audiology Member of California Academy of Audiology

Specializing in Diagnostic and Industrial Audiology, VNG, ABR/AABR, OAE, Digital Hearing Solutions, Listening Skills Training, Individual Communication Enhancement Plans and Hearing Assistance Technology (HAT).

Peter J. Marincovich, Ph.D., CCC-A

Director, Audiology Services

Judy H. Conley, M.A., CCC-A

Clinical Audiologist

Amanda L. Lee, B.A.

Clinical Audiology Extern Visit our new web site for additional information. audiologyassociates-sr.com

Four Offices Serving the North Bay Toll Free: 1-866-520-HEAR (4327) NOVATO 1615 Hill Road, Suite 9 415-209-9909 MILL VALLEY 7 N. Knoll Road, Suite 1 415-383-6633 SANTA ROSA 1111 Sonoma Ave, Suite 308 707-523-4740 FORT BRAGG Mendocino Coast District Hospital Audiology Department 700 River Road, Fort Bragg 707-961-4667

a member of

t Custom Orthotics and Prosthetics t Nationally Accredited Facility t American Board Certified Practitioners John M. Allen CPO Leslie A. Allen CP 1375 S. Eliseo Dr. Suite G Greenbrae, CA 94904 415-925-1333 telephone 415-925-1444 fax

Helping our patients one step at a time.

Email: jonathan.artz@kp.org

Marin Medicine Marin Medicine

Spring 2010 7 Winter 2015 13

References 1. Winter B, et al, “High impact running improves learning,” Neurobiol Learn Mem, 87:597-609 (2007).

2. Aberg E, et al, “Running increases neurogenesis without retinoic acid receptor activation in the adult mouse dentate gyrus,” Hippocampus, 18:785-792 (2008).

3. Naylor A, et al, “Voluntary running rescues adult hippocampal neurogenesis after irradiation of the young mouse brain,” Proc Nat Acad Sci, 105:14632-37 (2008).

4. Van Praag H, et al, “Neurogenesis and exercise,” Neuromolecular Med, 10:128-140 (2008).

5. Wu C, et al, “Exercise enhances the proliferation of neural stem cells and neurite growth and survival of neuronal progenitor cells in dentate gyrus of middleaged mice,” J Appl Physiol, 105:1585-94 (2008).

6. Jasmine B, et al, “Fast axonal transport of labeled proteins in motoneurons of exercise-trained rats,” Am J Physiol, 255:C731-736 (1988).

7. Ozkaya Y, et al, “Effect of exercise on brain antioxidant status of diabetic rats,” Diabetes Metab, 28:377-384 (2002).

8. Petzinger GM, et al, “Effect of treadmill exercise on dopaminergic transmission,” J Neuroscience, 27:5291-5300 (2007).

9. Vuckovic MG, et al, “Exercise elevates dopamine D2 receptor in a mouse model of PD,” Mov Disord, 25:2777-84 (2010).

10. Sartorius A, et al, “Correlations and discrepancies between serum and brain tissue levels of neurotrophins after electroconvulsive treatment in rats,” Pharmacopsychiatry, 42:270-276 (2009).

11. Tajiri N, et al, “Exercise exerts neuroprotective effects on PD model of rats,” Brain Res, 1310:200-207 (2010).

12. Ahlskog J, “Does vigorous exercise have a neuroprotectant effect in PD?” Neurology, 77:288-294 (2011).

13. Dos Santos Mendes FA, et al, “Motor learning, retention and transfer after virtual reality based training in PD,” Physiotherapy, 98:217-223 (2012).

14. Mckee KE, et al, “Effects of adapted tango on spatial cognition and disease severity in PD,” J Motor Behav, 45:519-529 (2013).

15. Chang YK, et al, “Effects of acute exercise on cognitive performance,” Brain Res, 1453:87-101 (2012).

14 Winter 2015

16. Dishman RK, et al, “Neurobiology of exercise,” Obesity, 14:345-356 (2006).

17. Ang ET, et al, “Potential therapeutic effects of exercise to the brain,” Curr Med Chem, 14:2564-71 (2007).

18. Rolland Y, et al, “Physical activity and Alzheimer’s disease,” J Am Med Dir Assoc, 9:390-405 (2008).

19. Rolland Y, et al, “Exercise program for nursing home residents with Alzheimer’s disease,” J Am Geriat Soc, 55:158-165 (2007).

20. Lautenschlager NT, et al, “Effect of physical therapy on cognitive function in older adults at risk for Alzheimer disease,” JAMA, 300:1027-37 (2008).

21. Bates KA, et al, “Clearance mechanisms of Alzheimer’s amyloid-beta peptide,” Mol Psych, 14:469-486 (2008).

22. Scott SA, et al, “Nerve growth factor and Alzheimer’s disease,” Rev Neuroscience, 5:179-211 (1994).

23. Litvan I, et al, “Diagnostic criteria for mild cognitive impairment in PD,” Mov Disord, 27:349-356 (2012).

24. Kudlicka A, et al, “PD,” Mov Disord, 26:2305-2315 (2011).

25. Lezak MD, Neuropsychological Assessment, Oxford Univ Press (1995).

26. Kramer AF, et al, “Aging, fitness and neurocognitive function,” Nature, 400:418-419 (1999).

27. Inkster LM, et al, “Leg muscle strength is reduced in PD,” Mov Disorders, 18:157162 (2003).

28. Allen NE, et al, “Bradykinesia, muscle weakness and reduced muscle power in PD,” Mov Disorders, 24:1344-51 (2009).

29. Glendinning DS, “Rationale for strength training in patients in PD,” Neuro Rep, 21:132-135 (1997).

30. Schiling BK, et al, “Impaired leg extensor strength in individuals with PD,” Parkinsonism & Rel Mov Disorders, 15:776-780 (2009).

31. Scandalis TA, et al, “Resistance training and gait in patients with PD,” Am J Physical Med & Rehab, 80:38-43 (2001).

32. Dibble LE, et al, “High intensity eccentric resistance training decreases bradykinesia,” Parkinsonism & Rel Mov Disorders, 15:752-757 (2009).

33. Lastayo PC, et al, “Chronic eccentric exercises improvement in muscle strength can occur with little demand for oxygen,” Am J Physiology, 276:R611615 (1999).

34. Falvo MJ, et al, “PD and resistive exercise,” Mov Disorders, 23:1-11 (2008).

35. King LA, et al, “Delaying mobility disability in people with PD,” Phys Ther, 89:1-10 (2009).

36. Hackney ME, et al, “Tai Chi improves balance and mobility in people with PD,” Gait & Posture, 28:456-460 (2009).

37. De Boar AG, et al, “Quality of life in patients with PD,” J Neurolog Neurosurg & Psych, 61:70-74 (1996).

38. Miyai, et al, “Treadmill training with body weight support,” Arch Phys Med Rehab, 81:849-852 (2000).

39. Miyai, et al, “Long-term effect of body weight-supported treadmill training in PD,” Arch Phys Med Rehab, 83:1370-73 (2002).

40. Frenkel-Toledo, et al, “Effect of gait speed on gait rhythmicity in PD,” J Neuroengin & Rehab, 31:2-23 (2005).

41. Herman T, et al, “Six weeks of intensive treadmill training improves gait and quality of life in patients with PD,” Arch Phys Med Rehab, 88:1154-58 (2007).

42. Crizzle, et al, “Is physical exercise beneficial for persons with PD?” Clin J Sport Med, 16:422-425 (2006).

43. Goodwin VA, et al, “Effectiveness of exercise interventions for people with PD,” Mov Disorders, 23:631-640 (2008).

44. Dibble LE, et al, “Effects of exercise on balance in persons with PD,” J Neuro Phys Ther, 33:14-26 (2009).

45. Schalow G, et al, “Integrative reorganization mechanism for reducing tremor in PD patients,” Electromyogr Clin Neurophys, 45:407-415 (2005).

46. Peluso MA, et al, “Physical activity and mental health,” Clinics, 60:61-70 (2005).

47. Blackmore DG, et al, “Exercise increases neural stem cell number in a growth hormone-dependent manner,” Stem Cells, 27:2044-52 (2009).

48. Muller T, et al, “Cysteine elevation in levodopa-treated patients with PD,” Mov Disorder, 24:929-932 (2009).

49. Langois, et al, “Benefits of physical exercise training on cognition and quality of life in frail old adults,” J Gerontol, 68:400-404 (2013).

50. Gates, et al, “Effects of exercise training on cognitive function in older adults with mild cognitive impairment,” Am J Geriat Psych, 21:1086-97 (2013).

Marin Medicine

HEADACHE UPDATE

Expanding Our Horizons Allan Bernstein, MD

H

eadache continues to be a major cause of disabilit y worldwide. Migraine alone affects 15–20% of the female population and 8–10% of the male population in the United States, with the greatest impact during ages 35–45, the “working years.”1 Migraine occurs in all ethnicities and has a disproportionate prevalence in lower socio-economic groups.

While tension headaches are generally less disabling than migraine, their incidence is higher, leading to significant medication overuse. The lifelong impact of trauma, both physical and emotional, in creating new headache types and aggravating existing headache conditions is now being recognized. The economic impact of headache due to medical costs alone is over $10 billion yearly in the U.S., and that does not account for the indirect cost of time off work or working impaired, also known as “presenteeism.”2 The triptan-t ype medications, which are serotonin 1B/D agonists, have been available to treat migraine for over 20 years. They have proven to be relatively safe, neither triggering serotonin syndromes nor raising the incidence of cerebrovascular or cardiovascular events when used appropriately. When overused, i.e., more than 10 days a month for three or more months, they may induce medication overuse headaches and convert episodic migraine to chronic migraine.

Dr. Bernstein, a Sebastopol neurologist, has a special medical interest in headaches.

Marin Medicine

Although some triptans have become generic, their price hasn’t significantly decreased, limiting their availability to a large segment of the population.

Ergotamine, another serotonin agonist, has been used for over 50 years to treat migraine, but its strong vasoconstrictive properties and associated nausea limit its usefulness in a condition that already has nausea as a symptom. The derivative dihydroergotamine (DHE) is less vasoactive but is still associated with nausea, even in sublingual and nasal forms. A newer version of inhaled DHE is coming to the market with reports of less or no associated nausea.3 The antiepileptic medications valproate and topirimate have been used for migraine prevention with moderate success. The teratogenic risk of valproate limits its use in young women.4 Topirimate, in addition to causing cognitive problems in many users, may interact with oral contraceptives, reducing their efficacy.5 Beta blockers continue to be useful in migraine prevention, though side effects of asthma, exercise intolerance, hypotension and depression are significant drawbacks in the young population being treated.

Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are being reevaluated for migraine prevention. The underlying physiology is not entirely clear, but the effectiveness can be significant, with relatively few side effects. ARBs seem more effective than ACE inhibitors. with candesartan being the preferred medication.6 Funding for formal research on these drugs has been limited, so most data is consensus-driven.

B

otox has been approved for chronic migraine, i.e., more than 15 headache days per month.7 It requires 15–30 subcutaneous injections per treatment, including the face, hair line around the scalp, and occipital region down to the upper trapezius muscles. It can be very effective in some individuals, but the benefit typically wears off in 10–14 weeks and needs to be repeated, potentially for years. Some insurance providers cover the cost, but Botox is currently a very expensive modality.

Calcitonin gene related peptide (CGRP) rises with the onset of acute migraine. CGRP receptor blockers and CGRP monoclonal antibodies are being investigated for both acute migraine attacks and migraine prevention.8 The first medication in this class, telcagepant, was studied for treating acute migraine. It produced results comparable to the triptans. Moreover, it was not vasoconstrictive and could be used in subjects with pre-existing stroke and cardiovascular disease. The development of hepatic abnormalities, however, halted further development of this drug.9 Other trials on related drugs have been started. Monoclonal antibodies to CGRP for the prevention of migraine have shown positive results in phase 2 testing.10 Larger trials are planned.

Local nerve blocks for acute headache have been underused. They are typically done with 0.5% bupivacaine, using 1 cc over each occipital nerve at the occipital protuberance. The relief is rapid, with no systemic side effects.

The effect lasts 3–6 hours, and when the headache eventually returns, it is usually at a much lower level of intensity. Trigger-point muscle injections to both upper trapezius muscles at the Winter 2015 15

same time as the occipital nerve blocks seem to increase the effectiveness of the nerve blocks.11 Oxygen by mask (10 liter/min for 10 minutes) is the accepted treatment for cluster headaches, but it may also be effective for acute migraine. The vasoconstrictive properties of oxygen, along with its tendency to decelerate respiration, may be part of the effect.

The safety of this treatment makes it ideal for patients who may be pregnant.

Dental disclusive devices and transmandibular joint manipulations have long been espoused by dentists and chiropractors. These treatments are typically used for acute events but are less effective for prevention. Since most physicians are unfamiliar with them, they remain underused.

The ultimate migraine medication, with the best safety record, is caffeine. It can be used preventively and during an attack. When traveling on an airplane or to altitudes over 3,000 feet, 50-100 mg of caffeine taken an hour before travel may prevent headaches. Excedrin and other AAC tablets (aspirin 500 mg, acetaminophen 500 mg, caffeine 130 mg) remain the most popular medications for treating headaches in general and migraine in particular.12

M

igraine diets have been around for many years, but they are still not considered “real medicine.” The headache-triggering effect of red wine and carbonated alcoholic beverages is well known.13 Migraineurs usually learn this as teenagers. Other alcoholic beverages are less consistent in their headache-triggering capacity. Most patients are able to identify specific triggers and either eliminate them or reduce the amount used. A good example is chocolate: small amounts rarely trigger headaches, but large amounts are likely to do so. Other migraineinducing items in diets include MSG, aspartame and pork (but not nitrates).14 Some people think gluten is a trigger, but evidence is lacking. The ketogenic diet, also known as a modified Atkins or low-carb diet, has proven useful in preventing headaches as well as 16 Winter 2015

seizures. The diet is currently being tested as a symptomatic treatment for Alzheimer’s disease.

Behavior modification in multiple forms is a component of comprehensive headache care. Stress management, exercise programs, yoga, Pilates and cognitive behavioral therapy (CBT) are used increasingly as more and more people try to minimize their use of medications. Biofeedback has a long history, especially locally, in the treatment of headaches of all types.15–17 Flickering lights and bright lights in general are triggers for all types of headaches. People with low-level headaches tend to have chronic mild pupil dilation. Bright light acts as an irritant on their retinas, leading to increased headaches. Changing to incandescent bulbs with dimmer switches has reduced the frequency of headaches in many workplaces. The newer buildings with LED lighting do not seem to trigger headaches with the same frequency as those with fluorescent bulbs. Polarized sunglasses help reduce the frequency of sunlight-induced headaches.

Strong smells induce headaches in many people. The ban on scented products in medical facilities attests to the recognition of this issue. The staff may be compliant, but it is more difficult to get patients to buy in.

Sleep disorders are being recognized as triggers for headache disorders.18 Identifying and treating sleep disorders is important not only for headache management, but also for reducing the risk of heart attacks and strokes.

N

eurostimulation devices represent a new wave of headache treatments. Occipital nerve stimulators have been successfully used to reduce headaches and pain for the last few years. The unit is implanted in the chest, with a wire going up the back of the neck. The day-to-day motion of the neck frequently disconnects or breaks the wires, however, making the current models less than ideal.

Transcutaneous nerve stimulation (TNS), long used to treat spinal pain, is now being used for migraine. A unit

attached to a band that wraps around the forehead is the latest iteration of TNS technology.19 Headache reduction with TNS is reported to be in the 50% range, and the lack of side effects seems encouraging. The treatment is not yet covered by insurance, but its $300–$400 price range allows many patients to consider it.

A TNS device placed over the vagus nerve in the neck is being tested in Europe for migraine prevention. A transcutaneous magnetic cerebral stimulator is also being investigated.

In response to the increasing number of noninvasive and invasive approaches for treat ing primar y headache — including hypothalamic deep-brain stimulation, occipital nerve stimulation, cervical spinal cord stimulation, vagus nerve stimulation, transcranial direct-current stimulation, repetitive transcranial magnetic stimulation, and transcutaneous electrical nerve stimulation—the European Headache Federation issued a consensus statement on these neuromodulation treatments in October 2013. Their overall recommendation is “wait for better data.”

I

n summary, headache remains a major public health issue. There are substantial direct costs to the health care system and significant indirect costs to the affected patients, families and employers. Most current research is industry-funded and therefore directed at drugs and devices, even though there is strong evidence that behavior changes are efficacious.

Online resources for patients and medical professionals include the American Headache Society, the American Academy of Neurology and Promyhealth.org.

Email: bernsteinallan@gmail.com

References

1. Lipton RB, et al, “Prevalence and burden of migraine in the United States,” Headache, 41:646-657 (2001).

2. Hawkins K, et al, “Direct cost burden among insured U.S. employees with migraine,” Headache, 48:553-563 (2008).

Marin Medicine

3. Tepper SJ, “Orally inhaled dihydroergotamine,” Headache, 53;S2:43-53 (2013).

4. “In brief: Warning against use of valproate for migraine prevention during pregnancy,” Med Lett Drugs Ther, 10;55:45 (2013).

5. Viana M, et al, “Topiramate for migraine prevention in fertile women,” Cephalalgia, 34:1097-99 (2014).

6. Stovner LJ, et al, “Comparative study of candesartan versus propranolol for migraine prophylaxis,” Cephalalgia, 34:523-532 (2013).

7. Aurora SK, et al, “OnabotulinumtoxinA for chronic migraine,” Acta Neurol Scand (Jan 2014).

8. Russo AF, “Calcitonin gene-related peptide,” Ann Rev Pharma Toxicol (Oct 2014).

9. Ho TW, et al, “Randomized controlled trial of the CGRP receptor antagonist telcagepant for migraine prevention,” Neurology, 83:958-966 (2014).

10. Dodick DW, et al, “Safety and efficacy of ALD403, an antibody to calcitonin gene-related peptide, for the prevention of frequent episodic migraine,” Lancet Neuro, 13:1100-07 (2014).

11. Robbins MS, et al, “Trigger point injections for headache disorders,” Headache, 54:1441-59 (2014).

12. Goldstein J, “Results of a multicenter, double-blind, randomized, parallelgroup, placebo-controlled, single-dose study comparing the fixed combination of acetaminophen, acetylsalicylic acid, and caffeine with ibuprofen for acute treatment of patients with severe migraine,” Cephalalgia, (Nov 2014).

13. Krymchantowski AV, Jevoux CC, “Wine and headache,” Headache, 54:967-975 (2014).

14. Bernstein AL, Del Tredici AM, “Migraine in children: a dietary study,” Headache, 23:142 (1983).

15. Seng EK, Holroyd KA, “Behavioral migraine management modifies behavioral and cognitive coping in people with migraine,” Headache, 54:1470-83 (2014).

16. Wells RE, et al, “Meditation for migraines,” Headache, 54:1484-95 (2014).

17. Behel P, Bernstein AL, “Use of biofeedback in the treatment of chronic persistent headaches,” Pain Practititioner, 24;2 (2014).

18. Holland PR, “Headache and sleep,” Cephalalgia, 34:725-744 (2014).

19. Schoenen J, et al, “Migraine prevention with a supraorbital transcutaneous stimulator,” Neurology, 80:697-704 (2013).

Marin Medicine

hear today, hear tomorrow Specializing in: Diagnostic and Industrial Audiology, Balance Care Program, Tinnitus Care Program, VNG, ABR/AABR, OAE, Individual Communication Needs Assessment, Digital Hearing Solutions, Lip Reading/Listening Skills Training, Hearing Assistance Technology (HAT) for TV, Telephone, Music and T-Coil Looping, and Auditory Mapping MA5P™ Method for the prescriptive/ individualized fitting of hearing aids.

Peter J. Marincovich, Ph.D., CCC-A DIRECTOR, AUDIOLOGY SERVICES

Judy H. Conley, M.A., CCC-A CLINICAL AUDIOLOGIST

Amber Powner, Au.D. CLINICAL AUDIOLOGIST

Cindy Ross, Au.D., F-AAA CLINICAL AUDIOLOGIST

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MIEC Belongs to Our Policyholders! “ As your MIEC Claims Representative, I will serve your professional liability needs with both steadfast advocacy and compassionate support.”

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Service and Value MIEC takes pride in both. For over 35 years, MIEC has been Keeping true to our mission steadfast in our protection of California physicians. With conscientious MIEC has neverexcellent lost sightClaims of its original mission, and always putting Loss Underwriting, management hands-on policyholders (doctors like you) first. For 40 years, MIEC has been steadfast Prevention services, we’ve partnered with policyholders to keep in our protection of California physicians with conscientious Underwriting, premiums low. excellent Claims management and hands-on Loss Prevention services; we’ve partnered with policyholders to keep premiums low.

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LOCAL FRONTIERS

Here Come the Dogs Irina deFischer, MD

D

o you love dogs? Ever wish protects disabled people by allowyou could take your dog ing them to bring their service dog with you wherever you with them to most places where go? I sure do. Those of us who the public is permitted, includhave traveled on the Continent may ing restaurants, hotels, medical have noticed that Europeans bring facilities, housing complexes and their dogs everywhere. I remember airplanes. Any dog can be a sergoing out to eat with my aunt and vice dog, and service dogs do not uncle (and their dachshund) in have to be professionally trained.

Switzerland with my husband Scott The important thing is that the dog and daughter Jeanne-Marie when is trained to be a working animal she was a toddler. Jeanne-Marie and not a pet. Service dogs are was getting restless at the table, so often identified by wearing a sermy aunt suggested we let her sit on vice dog vest or tag. You are not the floor. She and the dachshund allowed to ask a person with a serhappily shared a bowl of spaghetti vice dog what type of disability under the table while the rest of us they have: only if it is a service Dr. deFischer’s beloved Tassel, a Guide Dog breeder. finished our meal in peace. dog, and what tasks the service Our family later had a lovely dog is trained to perform for them. yellow Labrador named Tassel who was public places? That depends on whether a Guide Dog breeder. She brought us they are pets, service dogs, emotional hat about emotional support great joy and helped us get through the support animals or therapy animals. animals, also known as ESAs? A children’s teen years with her uncondiService dogs are individually trained growing number of people are requesttional love. She was always happy to see to perform a specific task for people ing letters from physicians certifying us when we came home from work, and who have disabilities. The disabilities that they need an ESA. For a recent New she made sure we got out for regular can vary greatly, and so do the tasks Yorker article titled “Pets Allowed,” walks. I miss her, and I hope to have that service dogs perform. Service dogs author Patricia Marx obtained ESA ceranother dog someday. can aid in navigation for people who are tification for a series of animals, includhearing- or visually impaired, assist a ing a turtle, an alpaca, a snake, a turkey hat are the rules person who is having a seizure, calm a and a pig. She was able to bring them for dogs in the person who suffers from post-traumatic along everywhere she went, including workplace and other stress disorder, and even dial 911 in the museums, boutiques, delis, restaurants, event of an emergency. trains and luxury tour buses. When Dr. deFischer, a family Under the Americans with Disabiliquestioned, she merely produced the physician at Kaiser ties Act (ADA), a person with a disabilESA certification she had obtained for Petaluma, serves on the ity is entitled to a service dog to help $150 online after completing a questionMMS Editorial Board. them live their lives normally. The ADA naire about her emotional condition.

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Marin Medicine

Winter 2015 19

Emotional support dogs provide affection and companionship for a person suffering from various mental and emotional conditions. Unlike service dogs, emotional support dogs are not required to perform any specific tasks for a disabled person. They are meant solely for emotional stability and unconditional love, and they can assist with anxiety, depression, bipolar and mood disorders, panic attacks, phobias, and other psychological and emotional conditions.

Any dog can be an emotional support dog, and they do not have to be professionally trained.

Emotional support dogs are also protected under federal law. Under the Fair Housing Amendments Act (FHAA) and the Air Carrier Access Act (ACAA), a person who meets the proper criteria is entitled to an emotional support dog to assist them with their life. The FHAA allows emotional support dogs to live with people, even if their housing unit has a no-pet policy.

The ACAA allows emotional support dogs to fly in the cabin of an airplane without having to pay any additional fees.

According to the National Institute of Mental Health, at least one in four American adults has some form of mental disorder. Many of these people are entitled to an emotional support dog and will be consulting with their physicians for documentation. How should a physician respond when asked for such documentation? First, you need to determine if the person does indeed

have one or more of the qualifying disabilities. Second, do you think the dog or other animal would really benefit them? And lastly, do you feel the patient is capable of properly caring for the animal and controlling it when out in public? This might be the most difficult piece to determine. It is important to

Dr. deFischer’s daughter Jeanne-Marie with friend Toffee.

remember that, unlike service dogs, emotional support animals may not be allowed in food establishments and many other businesses.

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herapy dogs are used to bring comfort and joy to people who are ill or in dire circumstances, such as being affected by a natural disaster.

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Many people are able to connect with dogs and to feel the love that they provide, which has a therapeutic effect. Therapy dogs are generally calm and well behaved, and they are often found in hospitals and nursing homes. They generally don’t have any special training, and they don’t perform specific tasks for disabled people.

A doctor’s letter is not required for a therapy dog. Since these dogs are not covered under any specific federal laws, their owners have to receive permission before taking them to a facility. Many places are welcoming to therapy dogs if the dog is trained and obedient, does not pose a threat to others, can benefit those present at the facility, and does not adversely affect the facility’s operations.

Then there are companion animals, or pets. They have no legal status but can also provide a multitude of benefits. According to the Centers for Disease Control and Prevention (CDC), pets can decrease blood pressure, cholesterol and triglyceride levels, and feelings of loneliness, while increasing the opportunities for exercise, outdoor activities and socialization.

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ven unabashed animal lovers have to admit that there can be problems with dogs in public places: they can make messes, shed, bark, bite, and fight amongst themselves. They may help themselves to unattended food and potentially spread diseases. They can also knock down frail elders and intimidate children.

In a perfect world, service and emotional support animals would always be on their best behavior, as would pets and children. Since we live in an imperfect world, it is reasonable to ask a person to remove their animal if it is misbehaving or inconveniencing someone. Meanwhile, we can expect to see more and more dogs and other animals out and about.

Email: irina.defischer@kp.org

Marin Medicine

OUTSIDE THE OFFICE

My Boating Life Jim Dietz, MD

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ond Sound was cut into the rugged coast of British Columbia by a glacier at the end of the last ice age. Last summer, Paige and I were anchored in a safe cove far within this 40-mile-long fjord. We had read that the Ahta River, at the head of the sound, winds through old-growth forests, and that grizzly bears live along its banks.

We arrived on a misty September afternoon, launched our motorized dinghy, and prepared to explore the river. The first challenge was to find the actual river mouth, which we knew was emptying somewhere among the tidal flats and clumps of trees that we saw further up the sound. Our charts hinted as to where the river lay, but there was not enough detail to tell us how to access it.

Although the water in most of the sound is about 800 feet deep, we waited for the tide to rise in order to cross the shallows. After about an hour of exploration, we discovered the river mouth.

We then dinghied back to Thunder Road, our 37-foot Nordic Tug flybridge trawler, and prepared an early dinner.

We planned to spend the evening venDr. Dietz, an emergency physician, is chief of emergency medicine at Marin General Hospital.

Marin Medicine

Dr. Dietz sailing the California coast in 1987. Photo by Dan Rosen.

turing up the river, knowing that we had hours of summer sunlight left in this northern latitude.

We were six weeks into our planned nine-week cruise and were as far away from civilization as we had ever been.

We had seen many species of wildlife, but had not yet crossed a grizzly bear off our “must see” list. This was our chance, justifying our long passage to this beautiful yet eerie spot.

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y fascination with boats and traveling by sea began when my college buddy Jon, who had grown up in a New England boating family,

purchased a wooden Sparkman Stephens 36-foot sloop in need of repair and invited me to help. I had no previous experience repairing boats and could offer only my hard work and enthusiasm. I became Jon’s grunt for the rehabilitation and then maintenance of Crystal Flute, and his deck hand when we sailed her on the Chesapeake Bay. I sailed with Jon through most of my med school years and then moved to Sacramento for residency.

While an intern, I did a silly thing: I bought a Cal 20 20-foot sailboat, Sticky Fingers, and moored it in Vallejo. Just a 50-minute drive from Sacramento, my boat offered me a world of experience apart from residency. Whenever we had the chance, my friends and I would head out to the Carquinez Straits. This body of water, spanned by the Carquinez Bridge, is subject to strong wind and currents that can create steep seas. Sailing here is often hazardous, and in retrospect, we had no business being out there. But we didn’t know anything different, were having great times, and really learned how to sail. On some days, instead of bashing our way around the straits, we cruised up the lovely and gentle Napa River. There I learned another part of the boating experience: access to peace and natural beauty.

Winter 2015 21

Thunder Road at anchor in Desolation Sound, British Columbia. Photo by Dr. Dietz.

After residency, I purchased a Luders Cheoy Lee 36-foot sloop, Thunder Road, and spent five years living aboard her in Sausalito. I learned how to work on the diesel, manage the 12-volt electrical system, and care for her teak decks and spruce spars. I sailed often around San Francisco Bay and cruised the California coast.

At that time, I was able to take extended periods off work, so I traveled aboard sailing ships in other parts of the world. I sailed on a 100foot schooner from Sausalito to Hilo and on a 400-foot square-rigged barque that launched from Cabo San Lucas.

We explored the west coast of Central America, then passed through the Panama Canal into the Caribbean. Our guest lecturer was James Michener, who had just published his novel Caribbean.

22 Winter 2015

In the evenings, he discussed the sea’s history and civilization with passengers on the lido deck. Those were my pirate years, and seawater seemed to be coursing through my veins.

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n the late 1980s, about when I began working at Marin General, I realized it was time to come back on shore. I met and married Paige, bought a house on the water in Bel Marin Keys, fathered our only child, Molly, and sold Thunder Road. Paige and I bought a series of rowing and sailing craft to use in our lagoons. Much can be learned from operating small boats because they are so sensitive to shifts in wind, alterations of sea conditions, distribution of weight and adjustment of sail.

The saying goes that a sailor talks about nothing but home when he is at

sea and about nothing but the sea when he is at home. I began to miss having a “real” boat and venturing on the water, so I crossed over to the dark side and bought Bertha, a 34-foot diesel trawler.

You sailors are rolling your eyes. Why would I do such a thing? The simple answer is that there is a different tool for every job. I knew that spending time on the water with my wife, daughter and friends would require a relatively calm, controlled environment. Buying a motor trawler was a wise decision, and we spent far more hours boating than if I had insisted on using a sailboat for the rough conditions in San Francisco Bay. We had so much fun on Bertha. We spent 17 summers in the delta, anchored in a flooded track of what was once a farming parcel called Mildred Island.

The average seasonal air temperature Marin Medicine

was 93 degrees and the (fresh) water temperature was 84 degrees. During the other seasons of the year, we found temporary berthing in either Sausalito or at South Beach Marina, just next to AT&T Park. For years we went out for the Blue Angels and the stellar KaBoom fireworks shows. We anchored in McCovey Cove for World Series games and for one rocking Rolling Stones show.

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hen Molly went off to college four years a g o, Pa i g e a n d I b e g a n considering what to do with the next phase of our lives. We agreed to buy a bigger boat for more far-range cruising.

After two years of research, we purchased our second Thunder Road, a Nordic Tug, in Anacortes, Washington.

This has been the best stupid idea we ever had.

We spent our first season (2012) aboard Thunder Road becoming k nowledgeable about her complex systems while cruising the San Juan Islands (Washington) and Gulf Islands (British Columbia). In the summer of 2013, we traveled to the spectacular Princess Louisa Inlet and then spent one month in the phenomenal scenery and warm waters (yes, the water is 75 degrees) of Desolation Sound, British Columbia. Last summer, we returned to the sound, then headed further north to the Broughton Archipelago, which extends to the northern tip of Vancouver Island. This mountainous island protects the waters in these remarkable cruising grounds from the open sea and from marine weather.

Summer here is a delight, with warm days, mild winds and long hours of sunlight.

What is it about owning, maintaining and cruising a boat that I find so satisfying? One answer is the ability to spend long periods of time with family and friends, surrounded by the natural beauty of the environment Marin Medicine

and undistracted by the intrusion of “breaking news” media. We have also met wonderful people from all over North America who cruise their boats.

Exploring by boat feels a bit like a working vacation. There is always something to plan, something to fix, some system upon which to improve, a meal to be prepared. Perhaps most powerful is that all of our creative energy, planning and work is directed

The Dietz family in Sidney, British Columbia.

entirely towards our own safety, wellbeing and enjoyment. Health care providers give so much of our energy away to others. I find this direct correlation between our efforts and what we experience to be rejuvenating.

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ack on T hunder Road i n Bond Sound, we waited for the tide to rise, then boarded the dinghy and returned to the mouth of the Ahta River. During the rainy months, the river flows mightily, and we would not have been able to beat its current with our eight-horsepower outboard motor.

But this was the dry season, and we ran into just the opposite problem: not

enough water. We slowly motored as far up as the depth would allow, then tilted the outboard’s shaft out of the water and began rowing and poling our way up the river.

There was an abundance of wildlife. Along the bottom, flat fish that looked like flounder swam alongside running crabs. Salmon were jumping, but none were biting the lured lines that we offered them. Eagles soared overhead, and osprey scavenged fish remnants on the shores. We found dismembered salmon floating in the water and aground on sand banks, a sure sign that bears were present. We assumed that we would see a grizzly around each new bend in the river.

But we never encountered a grizzly, and frankly, that was good. Imagine being in an eight-foot dinghy, poling along and encountering an 800-pound, angry, fierce, fast carnivore! We were about a mile up the Ahta, all alone, when we realized that we wouldn’t stand a chance. So we turned around, and as quickly as possible poled back to deeper water, restarted the outboard, and returned to Thunder Road.

The next morning, we took a short dinghy ride back up the river, but not far up enough as to be in harm’s way. We enjoyed the company of the fish, crabs and birds, but again saw no grizzlies. So we motored back to Thunder Road and headed south to warmer, safer environs, through Desolation Sound and eventually to Seattle.

There are 800 miles of cruising grounds between Seattle and southeast Alaska. We are told that the scenery and experience get more dramatic as you head farther north. We have barely touched on the first 300 miles of this experience, so we have a ways to go, and the grizzly is still on the list.

Email: jdietz17@gmail.com

Winter 2015 23

PRACTICAL CONCERNS

The Unsustainable SGR Mac Sterling, MD, and Melvyn Sterling, MD Making predictions is difficult, especially about the future.

—Niels Bohr

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very time American physicians celebrate a temporary reprieve from a Sustainable Growt h Rate (SGR) mandated cut in Medicare compensation, the bottles of champagne are uncorked with a little less gusto, a little more battle fatigue. As of the end of 2014, we have opened 17 bottles of this ill-tasting brew. If Congress fails to approve an SGR patch by this March, all Medicare physician providers will see a cut of 24% on their next Medicare check.

After years of watching the Sword of Damocles hang over our heads—by threads of the narrowest Congressional majorities—we physicians are manifesting the negative consequences of living under the perennial assault of financial insolvency. And it’s not just physicians.

It is also their patients. The harvest of the grotesquely misguided SGR policy has been served up to the general population of Medicare beneficiaries, and they are getting sick from it—or at least they are not getting medical help to alleviate their sickness.

How many of us are no longer accepting new Medicare patients compared to 10 years ago? What is the effect of this reduced access to care on the quality and quantity of life for seniors?

Members of Congress can throw seniors under the bus—there is no Hippocratic Oath for politicians. But physicians did Dr. Mac Sterling is a hospitalist at Alta Bates Hospital in Berkeley. Dr. Melvyn Sterling is an internist and palliative care physician in Orange County.

24 Winter 2015

take that oath, and we have an obligation to protect our patients individually and to advocate for their well-being on a national level.

Some observers criticize this argument as being self-serving. They say we are trying to milk the national purse for our own enrichment. The actual fact is that the cost of providing patient care since the inception of the SGR has increased 24% while physician compensation from Medicare has increased by only 4%. If primary care, and being a physician in general, was so well compensated, we would not be facing major physician shortages in the coming decade.

Like unpredictable shocks to a lab rat, the unpredictable SGR patches have left physicians in an anxious ferment, not knowing how their balance sheets will look from year to year. Ironically the SGR—a scheme designed by Medicare—increases fiscal uncertainty and decreases physician investment in electronic health records and other costly practice improvements, thereby hindering efforts to improve the quality of care for Medicare beneficiaries. But diminished quality is not the only issue that plagues any argument against repealing the SGR; there is also the issue of diminished access to care for seniors.

Primary care physicians suffer the worst damage from the SGR. On the one hand, they experience increased attrition due to the closures of bankrupt medical practices. On the other hand, replenishment of their ranks is diminished because of the chilling effect that SGR-induced financial insecurity has on steering medical students toward primary care.

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he SGR was formulated in 1997 to address the relentless increase in the cost of Medicare. Currently, Medicare and Medicaid account for 22% of the national budget. The SGR automatically cuts Medicare payments t o do c t o r s w h e n e v e r M e d i c a r e spending exceeds growth in the overall economy.

The primary failure of the SGR is that it mandates the same cut in payment to all doctors providing Medicare services, irrespective of issues of quality or efficiency of care. As both physicians and the nation try to improve the quality of care that we provide to our citizens, it is imperative that financial incentives be aligned with the provision of high quality, efficient care.

With these concerns in mind, several members of Congress wrote a bill last year that would repeal the SGR and replace it with a law known as the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. Provisions in the bill called for streamlining Medicare quality reporting rules and giving higher payments to physicians who participate in quality improvement programs such as the Patient-Centered Medical Home.

Had the bill passed, it would have guaranteed a 0.5% annual increase in Medicare payments each year for five years, as opposed to the 24% decrease that will occur if Congress fails to patch the SGR in March. Although the idea of an annual increase is laudable, 0.5% is grotesquely inadequate.

Which grocer, gas station operator or plumber is going to accept such constraints and still provide their products or services?

Marin Medicine

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he Amer ica n demog raph ic continues to shift toward t he elderly. According to estimates, the number of Medicare beneficiaries will grow rapidly. The current number (52 million) is expected to increase to 73 million by 2025.

Who will care for them? The Association of American Medical Colleges projects that there will be a shortfall of 130,000 physicians in America within 10 years, and that half of that shortfall will occur in primary care. The SGR formula does nothing to ameliorate this decline. Indeed, the SGR is partially responsible because primary care physicians, as the relative low earners in the medical field, are more vulnerable to practice closure from revenue shortfalls. They are also prone to burnout from hamster-wheeling so they can see enough patients to make ends meet.

Niels Bohr, his reticence to make predictions aside, would have been confident in predicting this: either the SGR will be scuttled, or Medicare beneficiaries will see a further decline in their access to care. Anyone care to bet their health on it?

Emails: Mac Sterling: maclsterling@yahoo. com; Melvyn Sterling: macpml@gmail.com

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Marin Medicine

The SGR: Here We Go Again!

Elizabeth McNeil Note: The following is excerpted from the latest Federal Government Relations Update for the CMA board of trustees.

ON THE HEELS of one of the most maddening Congressional sessions in history, angry yet determined CMA physician leaders will return to Washington to once again push Congress to pass the bipartisan, bicameral Medicare SGR repeal and payment reform legislation.

This last Congress has been appropriately labeled “The Worst Congress Ever” for their permanent state of acrimony and lack of productivity which has brought them, the Medicare program and even the United States government to the brink of collapse.

Congress neglected or failed to reach agreement on hundreds of significant issues that need to be addressed immediately—including important health care issues, such as the Medicare SGR, the Medicaid Primary Care Rate Increase and Graduate Medical Education.

While this was not the first time Congress failed to repeal the SGR, it was particularly frustrating because they were so close to enacting a comprehensive Medicare payment reform bill that had bipartisan, bicameral support as well as the support of nearly every physician group within organized medicine. It was the most progress Congress had made in a decade.

However, that progress came to a halt when they failed to reach agreement on the funding sources, known as “offsets.” Instead, they passed another temporary patch (the 17th patch in a decade) to prevent the larger SGR payment cuts. What’s even more frustrating is that the 17 patches now cost more than the total cost of the permanent SGR repeal legislation. Continuing to patch the SGR is not fiscally responsible!

CMA President Dr. Luther Cobb was in Washington, DC, during the Lame Duck session urging Congressional leaders to get the SGR bill passed once and for all.

But Congress fell short once again, diverting all of their limited time and attention to the bitter debate over the President’s immigration order.

Where do we stand in 2015?

The good news is that both the Republican and Democratic Congressional leadership tell AMA and CMA that they continue to support the comprehensive Medicare SGR bill from last session. This bill will be the starting point for negotiations in 2015.

The only remaining work is to identify funding sources that both sides can agree upon.

There is also growing support for the notion that the SGR repeal portion of the bill does not need to be fully offset with other funding sources. Many conservative organizations—such as the Wall Street Journal, the Galen Institute and Americans for Tax Reform—have recently opined that because Congress consistently stops the SGR cuts, the SGR will never go into effect and therefore, the cost of getting rid of it should be $0. This would reduce the cost of the bill by about $120 billion and only require Congress to find another $80 billion to fund the new physician payment systems and a package of Medicare “extenders.”

Timing The next 24% SGR payment cut occurs on April 1—no joke. AMA, CMA and all of organized medicine will join forces to urge Congress to adopt the permanent repeal legislation before March 31. We plan to put a lot of pressure on the leadership.

As we get closer to the deadline, we will be asking all physicians to call and email their Representatives. We will need a loud, large volume of calls to Congress in March.

So hang on . . . here we go again!

Ms. McNeil is vice president for federal government relations at the California Medical Association.

Winter 2015 25

CURRENT BOOKS

Coping with the Constraints of Our Biology Jeff Weitzman, MD

callousness, inhumanity and extraordinary suffering. This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing.”

Being Mortal: Medicine and What Matters in the End, Atul Gawande, MD, Metropolitan, 297 pages (2014).

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r. At ul Gawande’s newest book, Being Mortal, i s on several bestseller lists, which is intriguing because many people would consider his subjects potentially depressing: elder and end-of-life care, nursing homes, assisted living, hospitals, hospice, palliative care, assisted suicide, and ultimately death and dying. Perhaps the book is popular because our society is finally moving toward a real discussion on mortality, t he one c er t a i nt y of t he hu ma n condition. As Gawande observes, “Decline remains our fate; death will someday come.”

Gawande’s own journey to this discussion may be of particular interest to physicians. He is a general surgeon, not an oncologic surgeon or an internist, so the topic may at first seem like it would be distant to him. How did he get from general surgery to hospice care?

Dr. Weitzman, who serves on the MMS Editorial Board, is an emergency physician at Marin General Hospital, an internist at The Tamalpais and a Student Health physician at UC Berkeley.

26 Winter 2015

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The answer to that question begins with his own experiences. As an intern, he was asked to obtain surgical consent for a spinal decompression from a patient with metastatic prostate cancer.

The patient had failed radiation therapy and was in the late stages of his disease.

He wanted aggressive treatment and consented to the procedure. His eighthour surgery went well, but then he spent his few remaining weeks dying of complications in the ICU. Gawande wonders whether this type of aggressive surgery was indicated. He observes that “for a clinician … nothing is more threatening to who you think you are than a patient with a problem you cannot solve.” Yet he finds that the need to fix at all costs “has caused

n Being Mortal, Gawande intertwines the story of his dying father with a history and analysis of hospitals, geriatric care, nursing homes, assisted living facilities, hospice care and palliative care. He carefully examines what has been, what is slowly changing and what could indicate a better future.

A hundred years ago, death came quickly. Acute infections, complications of cancer and results of trauma took you out in days to weeks. There was no need for a nursing home, no hospital to stabilize your condition, and no time for a chronic illness to develop.

In some regions, old age was in your 40s, and you died at home. “In 1945,” notes Gawande, “most deaths occurred in the home. By the 1980s, just 17% did.”

Unfortunately the family unit has changed, and many elderly now find themselves alone. Disease that would end life quickly in the past can now be stabilized, at which point it becomes chronic, leading to a slow decline in function that threatens independence.

Ultimately, many elderly can no longer stay home alone, especially if they have no family to assist them. In the industrialized world, writes Gawande, “the Marin Medicine

experience of advanced aging and death has shifted to hospitals and nursing homes.”

Gawande examines the history of this change in detail. In 1946, the HillBurton Act provided massive amounts of government funding for new hospitals. Two decades later, there were 9,000 new medical facilities across the country. For the first time, most people had a hospital nearby, and the facilities “became an attractive place to put the infirm.” Hospitals were then faced with housing patients with chronic illness and advancing age. Additional government funding led to the construction of custodial units for patients needing an extended period of “recovery.” These units were not set up to help the frail and elderly deal with dependency in old age. Instead, they “were created to clear out hospital beds,” giving rise to the name “nursing homes.” With the passage of Medicare in 1965, the number of nursing homes exploded, and 13,000 were built by 1970.

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ursing homes became the new paradigm for where we aged.

Unfortunately they required giving up your independence and losing your privacy, with an open unlocked front door and a roommate. Gawande ob s er ve s t h at “We e nd up w it h institutions that address any number of societal goals—from freeing up hospital beds to taking burdens off families’ hands to coping with poverty among the elderly—but never the goal that matters to the people who reside in them: how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore.”

Many elderly fared poorly in nursing homes. The search for alternatives led in 1980 to the concept of assisted living.

The initial vision was to do away with nursing homes altogether, “to provide an alternative that would let frail elderly people maintain as much control over their care as possible, instead of having to let their care control them.” The goal, according to Gawande, was “that no one ever had to feel institutionalized. People could lock their door, have a kitchen Marin Medicine

to cook and a private bathroom. Help was provided for things they could not do. Most importantly, residents could refuse strictures imposed for reasons of safety or institutional convenience.”

By 2010, almost as many people resided in assisted-living facilities as in nursing homes.

Unfort unately, assisted living became so popular that developers began applying the term to housing that often didn’t provide the expertise or quality initially intended. As Gawande notes, “safety and lawsuits increasingly limited what people could have in their assisted-living apartments, mandated what activities they were expected to participate in, and defined ever more stringent move-out conditions that would trigger discharge to a nursing facility. Things were moving back from where they came.”

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here do we go from here? Do we seek quality of life in our remaining years or length of life at any cost? Who makes the decisions: patient, doctor or family? What is the doctor’s role?

Gawande addresses t hese and many other questions in the last part of his book, which I leave readers to discover for themselves. The new paradigm of quality of life vs. length of life involves decisions that are often hard and complex. Although physicians are often blamed for making these choices strictly on a medical basis, patients and families are just as responsible for being unwilling to accept their own mortality or that of a loved one.

IHM

My own takeaway from Being Mortal is to ask the following questions when faced with a patient or loved one with serious illness or end-of-life decisions: • What is your understanding of the situation and its potential outcomes?

• What are your fears and what are your hopes?

• What are the trade-offs you are willing to make and not willing to make?

First ask these questions and then stop talking: listen! At this point you will be better equipped to provide advice on an appropriate course of action. Let the patient lead the way, but provide structure for them to do so.

Being Mortal is a beautiful book, a must-read for physicians and anyone who will experience the struggle of friends or family with disease or the frailty and physical deterioration of aging. It will help put into perspective choices to be made and advice that can be given, and it helps us face our patients’ mortality in a more rational fashion than we see at present.

In Gawande’s own words, “Being Mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.”

Amen.

Email: jweitzmanmd@gmail.com

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Winter 2015 27

HOSPITAL/CLINIC UPDATE

Kaiser Permanente San Rafael Gary Mizono, MD

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

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hat a difference a year makes.

Last time I wrote this update was in the fall of 2013, during the turbulence and growing pains of the Affordable Care Act. During its first open-enrollment period, more than 1.3 million Californians enrolled in health coverage through Covered California.

Kaiser Permanente was an active pl aye r i n t h e h e a lt h i n s u r a n c e exchanges, and the San Rafael Medical Center received its fair share of the newly insured. Our physicians and staff worked diligently to prepare for the opening of the state exchange and to meet the varied needs of our new and existing members.

Moving into 2015, we remain well positioned and competitively priced. I am optimistic that we will continue to grow within the exchanges and among our traditional commercial groups and Medicare.

G

rowth and stability are great for our medical center, but only if they translate into maintaining our standards of quality care. I am gratified to share that over the course of 2014, Kaiser Permanente continued t o de mo n s t r at e it s nat ional leadership in providing the best Dr. Mizono, an otolaryngologist, is physicianin-chief at Kaiser Permanente San Rafael.

28 Winter 2015

clinical results, safety ratings and member satisfaction scores in the nation.

Leading the way in quality for the fourth year in a row, Kaiser Permanente health plans received top rankings in the 2014 annual report of the National Committee for Quality Assurance. The NCQA rated our Northern California commercial plan eighth in the nation and our Medicare plan second. We were also the only Medicare plan in California to receive the prestigious five-star quality rating. In fact, our Northern and Southern California plans were the only ones in the state to be ranked in the nation’s Top 20, and the only ones to achieve perfect scores for clinical quality in the latest California Office of the Patient Advocate’s Health Care Quality Report Card. According to that report, we were also the only plan in California and the only medical group in Marin County to earn a perfect four stars for providing the recommended care for our patients, including cancer screenings and care for asthma, diabetes, maternity and heart disease.

T

he U.S. Department of Health and Human Services recently announced that our Oakland and South Sacramento medical centers will be part of the nation’s Ebola preparedness and response plan. This recognition i s a te st a me nt to ou r c onc er te d organizational efforts to prepare for potential Ebola patients. All Kaiser Permanente emergency departments, hospitals and medical offices in Northern California—including the San Rafael Medical Center—are being trained and

equipped to safely screen, identify and isolate patients at risk for Ebola.

The expanded San Rafael emergency department will be particularly well equipped to handle Ebola and other emergencies. This spring, the department will nearly triple in size, from 6,000 to 17,500 square feet.

In keeping with our rapid-care model, the expanded space will enhance the patient experience. We will focus on treating all patients in a timely and expeditious manner, and our goal will be “care without delay.”

Thanks to our integrated group practice and fully deployed electronic medical record, patients who may need to be admitted will be evaluated simultaneously by both our hospital and emergency department physician staff.

For patients who present with communicable diseases, our medical team will be able to respond more effectively by using our new negative-pressure and isolation rooms.

As part of our ongoing commitment to Emergency Medical Services, paramedics and EMTs will have a dedicated workstation and access to a shower, as well as an indoor hazmat shower for disaster preparedness. Because patients are at the center of everything we do, the new and enlarged waiting room lobby includes expansive windows, natural light and calming hillside views.

The emergency department is not the only new space planned for 2015.

Our patients will also benefit from our new behavioral health offices at 111 Smith Ranch Road. The offices feature soothing interiors, remodeled rooms, and easier access and parking.

Marin Medicine

L

ooking forward, I continue to be honored to serve The Permanente Medical Group and to work side-byside with the excellent physicians at the San Rafael Medical Center. Our brand recognition is strong because of their commitment to doing the right thing for our patients, every day and every time.

Together we provide our members with the best possible care and outcomes, as shown year after year by our quality ratings.

Still, no system is perfect, nor can Kaiser Permanente rest on its past laurels. What we will do is to continue building on our strong tradition of prevention and evidence-based medicine to provide high-quality care, whether our members are the picture of health or faced with a serious health concern.

We look forward to caring for all our members, today and into the future.

Email: gary.mizono@kp.org

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AMA President Dr. Robert Wah (left) presenting Benjamin Rush Award to Dr. Bretan.

The American Medical Association recently presented Dr. Peter

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Mercer

Dr. Bretan Receives AMA Award for Public Service

Bretan Jr., a Marin County urologist and transplant surgeon, with the Benjamin Rush Award for Citizenship and Community Service. The award recognizes physicians who have gone above and beyond their professional call of duty to make an outstanding public service contribution.

Dr. Bretan, a former president of the Marin Medical Socieety and current CMA trustee, was chosen by the AMA for his exceptional work as an innovator in renal transplant surgery and urology, in addition to his unwavering disaster relief efforts around the globe to help save lives. He is the founder of Life Plant International, a charitable organization that promotes disaster preparedness, organ donation and early disease screening worldwide.

Following the devastating impact of Hurricane Katrina on New Orleans in 2005, Dr. Bretan provided free medical care as part of “Team Orleans.”

Since 2002, he has also made several medical mission trips to the Philippines to perform and teach local physicians about kidney transplantation and laparoscopic kidney removals. More recently, he served as part of a medical mission to the Philippines to provide care to victims of Typhoon Haiyan.

“It is an honor to present Dr. Bretan with this AMA award honoring his dedication to helping those in greatest need of care,” said AMA President Dr. Robert Wah. “He is an inspiration to all physicians, and his commitment to the betterment of public health sets a high bar to which we should all strive to attain.”

Dr. Bretan currently serves as an adjunct clinical professor of urology at Touro University as well as chief of surgery at Novato Community Hospital, where he has worked since 2008. He is a member of the U.S. Surgeon General’s Deployable Surgical Team and also serves on county and state panels to educate physicians on disaster preparedness.

The award was presented to Dr. Bretan during the opening session of the 2014 AMA Interim Meeting in Dallas, Texas.

Winter 2015 29

To All Marin County

Physicians:

her Association and many ot l ica ed M ia rn lifo Ca e th November 4 ical Society joined with osition 46. The vote on op Pr t Last fall, the Marin Med fea de to n tio ali co collectively, ut California in a gaged in this campaign en A CM d an organizations througho S M M %. ition lost by 67% to 33 so deeply care about. was decisive: the propos enting the patients we res rep , ne ici ed m of olvement as one unified voice political process, our inv e th in ice vo a ve ha to health policy and ia physicians continue powerful infl uence on a To ensure that Californ t er ex A CM d an S M to help identify is critical. M ey invite all physicians th d an , in leg islative advocacy els lev l na tio na islation the local, state and health care through leg ing ov pr im public health issues at for as ide reaucracy, improved let us know if you have r coverage, reduced bu de needed changes. Please oa br ts, en m rse bu m can, join us. increased rei us anyway, and if you t ac nt co and policy, whether for r, be em m a t dollars r issue. If you are no practices thousands of ed sav ve ha A CM work flow, or any othe d an S rsements. You t $91.25 per month. MM ds by defending reimbu san ou MMS/CMA dues are jus th al ion dit ad d an inmedicalance premiums MS online at www.mar M n joi or a year in liability insur 32 ge pa on rship application for m can submit the membe society.org. ll deserved.

15 ? That renewal is we 20 for ip rsh be em m ur the have you renewed yo accomplishments from nt ca nifi sig al er For current members, sev to point t, MMS and CMA can Thanks to your suppor protect past year: d raised $52 million to an s ve er res its of on ed. CMA spent $8 milli • Prop. 46 was defeat MICRA. resolved. unty was permanently Co n ari M for ity qu ine repaid.

• The GPCI e cut will not have to be th g rin su en s, ar ye 3 was held off for almology.

• A 10% Medi-Cal cut s from practicing ophth ist etr tom op pt ke cy ca e victories, CMA advo • Among many legislativ dinners and by sponsoring seasonal lity gia lle co s ter fos S ine, Marin advocacy, MM iewed quarterly magaz rev erpe s ty’ In addition to leg islative cie So e th rts. local physicians. Also, ysicians and other expe ph al loc by en itt wr infor mal receptions for les artic evant topics and features er your Medicine, focuses on rel es invoice. She can answ du ur yo of py co a ed 415-924-3891 if you ne Call Rachel Pandolfi at yment over the phone. questions or handle pa Sincerely,

Jeffrey Stevenson, MD MMS President PO Box 246, Corte Mader

a, CA 94976

(415) 924-3891

Fax: (415) 924-2749 ww

w.marinmedicalsociety.org

REASONS

TOP

To Join MMS and CMA

COMMITMENT TO THE PROFESSION

Thanks to MMS, CMA and other medical associations, recent attempts in Congress to cut the Medicare reimbursement rate have all been rebuffed.

IMPROVING COMMUNITY HEALTH MMS is actively involved in several initiatives to improve community health in Marin County, such as boosting disaster preparedness and increasing access to specialists.

LEGISLATIVE ADVOCACY

PROTECTING MICRA MMS and CMA work diligently to protect the Medical Injury Compensation Reform Act (MICRA), spearheading a successful campaign to defeat Prop. 46 in the 2014 Election.

PRACTICE MANAGEMENT

By speaking with a united voice, MMS/CMA members exert a powerful influence on the political process at the local, state and national levels.

FOSTERING COLLEGIALITY

Through their magazines, newsletters and websites, MMS and CMA encourage physicians to stay in touch with each other and with current medical news and events.

FREE MEDICAL-LEGAL INFORMATION Both MMS and CMA offer free medical-legal information on contracts, subpoenas, employee relations, collections and many other topics.

ASK YOUR COLLEAGUES ABOUT MMS AND CMA

MMS and CMA offer a wealth of resources to help physicians manage their practices, implement electronic medical records and qualify for federal incentive payments.

STAYING IN TOUCH

MMS and CMA bring doctors from all parts of the medical community together—through leadership, cooperation and social gatherings.

IT’S EASY AND FUN To join MMS and CMA, go to www.marinmedicalsociety.org and click on Join Now! Once you belong, it’s fun to get involved in medical society projects and events.

One of the best ways to learn more about the benefits of membership in MMS and CMA is to ask your colleagues. The physicians listed below have leadership roles at MMS and would be happy to take your call.

President Jeffrey Stevenson, MD Internal Medicine 415-897-5400 jeffreystevenson@gmail.com

Immediate Past President Irina deFischer, MD Family Medicine 707-765-3540 irinadefischer@gmail.com

President-Elect Peter Bretan, MD Urology 415-892-0904 bretan.surgery@usa.net

Secretary/Treasurer Michael Kwok, MD Internal Medicine 415-444-2000 michael.k.kwok@kp.org

Directors Lori Selleck, MD Internal Medicine 415-899-7627 lori.selleck@kp.org

and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining MMS and CMA, 10 stand out:

PRESERVING MEDICARE

By joining MMS and CMA, physicians affirm their commitment to the profession of medicine and to preserving its honored place in modern society.

Larry Bedard, MD Emergency Medicine 415-332-1893 lbedard@aol.com

Working together, the Marin Medical Society

Paul Wasserstein, MD Pathology 415-925-7174 pwasserstein@pathgroup.com

RIGHT NOW is the best time to join MMS and CMA. Complete application on reverse and return to MMS

–OR–

Join online at www.marinmedicalsociety.org/Join Now!

–OR–

Contact Rachel Pandolfi at MMS 415-924-3891 or rachel@marinmedicalsociety.org

Marin Medical Society / California Medical Association

MEMBERSHIP APPLICATION (

= Required Information)

Name (as shown on California MD/DO License)

CA MD/DO License #

Office Address Office Fax

Office Phone

Email Address

Specialty & Year of Board Certification Date of Birth

Subspecialty & Year of Board Certification Place of Birth

Home Address Home Phone

Spouse’s Name

Medical School

Graduation Year

Internship

Year To Year

Residency

Year To Year

Previous CMA Member?

Yes

No

The foregoing is true and complete, and I endorse the Principles of Medical Ethics of MMS and CMA (available at cmanet.org).

Signature

Date

Indicate Mode of Practice: Solo/Small Group (1–4) Medium Group (5–149) Large Group (150–999) Very Large Group (1,000+) Academic Hospital-Based Government-Employed Administrative Medicine

Indicate your Membership Status: Active (living or practicing in Marin County with a physician’s & surgeon’s certificate issued by the MBC or OMBC): $1,095 Active, New Member (never been a CMA member or applying during first year in practice): $547.50 Active, Half-time and 65+ Years Old (working 1–20 hours/week and are 65+ years of age): $547.50 Active, Young Physician (40 years old or under, or in first five years of practice): $284 Government (receive more than 50 percent of practice income from county, state or federal employment): $547.50 Multiple (active member of another CMA county medical society): $303 METHOD OF PAYMENT:

CHECK ENCLOSED $ CHARGE $ Account Number

to my credit card:

(Circle One) Exp.

Signature

Fax completed application to 415-924-2749, or mail to MMS, PO Box 246, Corte Madera, CA 94976 (phone: 415-924-3891).

You can also join online at www.marinmedicalsociety.org/Join Now!

CMA NEWS

New Health Laws

THE CALIFORNIA LEGISLATURE had an active year, passing many new laws affecting health care. Below are highlights of the new laws likely to impact physicians next year and beyond.

For more details, see “Significant New California Laws of interest to Physicians for 2015,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.

ALLIED HEALTH 9 new laws, PROFESSIONALS including: AB 1841 (Mullin)

MEDICAL ASSISTANTS

Clarifies that medical assistants (MAs) may hand out properly labeled and prepackaged prescription drugs to patients as part of their existing authorization to provide “technical supportive services.” Permits MAs to hand out prescription drugs in non-state operated facilities licensed by the Board of Pharmacy. Requires that a licensed physician and surgeon, a licensed podiatrist, a physician assistant, a nurse practitioner, or a certified nurse-midwife provide the appropriate patient consultation regarding use of the drug.

CONFIDENTIAL INFORMATION

2 new laws, including:

AB 1755 (Gomez)

MEDICAL INFORMATION

Revises provisions of law requiring licensed health facilities to prevent disclosure of patients’ medical information by extending the deadline for health facilities to report unauthorized disclosures from five to 15 business days after unlawful or unauthorized access, use, or disclosure has been detected.

This bill also authorizes the report made to the patient or the patient’s Marin Medicine

representative to be made by alternative means, including email, as specified by the patient. This bill also extends the deadline when reporting is delayed for law enforcement purposes, as specified, from five to 15 days business days after the end of the delay. This bill gives the Department of Public Health full discretion to consider all factors when determining whether to conduct investigations under these provisions.

14 new DRUG laws, PRESCRIBING AND DISPENSING including: AB 467 (Stone)

PRESCRIPTION DRUGS: COLLECTION AND DISTRIBUTION PROGRAM

Establishes a license and regulatory framework for a “surplus medication collection and distribution intermediary” to facilitate the donation of surplus medications in California.

Requires the Board of Pharmacy to license a surplus medication collection and distribution intermediary, established for the purpose of facilitating the donation or transfer of medications between entities under a specified unused medication repository and distribution program. Authorizes the intermediary to charge specified fees.

Relates to license renewal. Requires the keeping and maintaining of complete records. Provides that fees collected would be deposited in the Pharmacy Board Contingent Fund.

AB 1535 (Bloom)

PHARMACISTS: NALOXONE HYDROCHLORIDE

Authorizes a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both the Board of Pharmacy and the Medical Board. Requires the development of protocols on the education of the person to whom the drug is furnished and notification of the patient’s primary care provider. Requires the pharmacists to complete related training.

Prohibits furnishing the medication to the patient without consultation.

Authorizes related regulations.

AB 1735 (Hall)

NITROUS OXIDE: DISPENSING AND DISTRIBUTING

Makes it a misdemeanor for any person to dispense or distribute nitrous oxide to a person if it is known or should have been known that the nitrous oxide will be ingested or inhaled by the person for the purposes of causing intoxication, Winter 2015 33

and that person proximately causes great bodily injury or death to himself, herself, or any other person. Requires each transaction to be recorded in a written or electronic document.

Requires a signature and proper identification. Makes it a crime to misuse customer information.

AB 1743 (Ting)

HYPODERMIC NEEDLES AND SYRINGES

Deletes the limit on the number of syringes a pharmacist has the discretion to sell to an adult without a prescription and extends, until January 1, 2021, the statewide authorization for pharmacists to sell syringes without a prescription, as specified. Exempts the possession of a specified amount of hypodermic needles and syringes that are acquired from an authorized source.

HEALTH BENEFIT 1 new law: EXCHANGE AB 617 (Nazarian)

HEALTH BENEFIT EXCHANGE: APPEALS

Establishes an appeals process for eligibility determinations for insurance affordability programs (including Medi-Cal and tax credits available through the California Health Benefit Exchange (Covered California) and requires Covered California to contract with the Department of Social Services to serve as the designated entity to hear appeals.

HEALTH CARE COVERAGE

5 new laws, including:

SB 959 (Hernandez, E.)

HEALTH CARE COVERAGE

Prohibits a change in premium rate or coverage for an individual plan contract or policy unless the plan or insurer delivers a written notice of the change at least 15 days prior to the start of the annual enrollment period applicable to the contract or 60 days prior to the effective date of renewal, whichever occurs earlier in the calendar year.

Makes several corrections and clarifications to provisions of law governing individual and small group health 34 Winter 2015

insurance, including clarifying that health plans and insurers have a single risk pool for enrollees and insureds.

SB 964 (Hernandez, E.)

HEALTH CARE COVERAGE

Increases oversight of health care service plans with respect to compliance with timely access and provider network adequacy standards. Authorizes a health plan to include in its contracts with providers, provisions requiring compliance with timely access and network adequacy data reporting requirements.

Requires DMHC to annually review health plan compliance with timely access standards and to post its final findings from the review, and any waivers or alternative standards approved

by DMHC, on its website. Authorizes DMHC to develop, and requires health plans to use, standardized methodologies for timely access reporting, and exempts the development and adoption of the standardized reporting methodologies from the Administrative Procedures Act, the body of law governing state regulations, until January 1, 2020.

SB 1052 (Torres)

HEALTH CARE COVERAGE

Requires a health care service plan or insurer that provides prescription drug benefits or maintains drug formularies to post those formularies on its website and to update that posting with changes at specified times. Requires the development of a standard formulary template. Requires plans and insurers to use that template to display formularies. Requires the Covered California website provide a link to the formularies for each health plan through the Exchange.

SB 1053 (Mitchell)

HEALTH CARE COVERAGE: CONTRACEPTIVES

Requires, effective January 1, 2016, most health plans and insurers to cover a variety of Food and Drug Administration-approved contraceptive drugs, devices, and products for women, as well as related counseling and follow-up services and voluntary sterilization

procedures. Prohibits cost-sharing, restrictions, or delays in the provision of covered services, but allows costsharing and utilization management procedures if a therapeutic equivalent drug or device is offered by the plan with no cost-sharing.

HEALTH CARE FACILITIES AND FINANCING

25 new laws,

including:

AB 1570 (Chesbro)

RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

Increases training requirements for licensees and staff of Residential Care Facilities for the Elderly (RCFE). Deletes the existing requirement of 40 hours of classroom instruction for RCFE licensee certification training programs and replaces it with 80 hours of required coursework, which shall include at least 60 hours of coursework that shall be attended in person.

Adds personal rights, management of antipsychotic medication, managing Alzheimer’s disease and related dementias, and managing the physical environment, including maintenance and housekeeping to the list of items covered in the RCFE licensee certification training program.

AB 2044 (Rodriguez)

RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

Relates to residential care facilities for the elderly. Requires that at least one administrator, facility manager, or designated substitute who has adequate qualifications be on the premises of a facility 24 hours per day. Requires a facility to employ, and an administrator to schedule, a sufficient number of staff members. Requires certain training to include building and fire safety and the appropriate response to emergencies.

SB 1004 (Hernandez, E.)

HEALTH CARE: PALLIATIVE CARE

Requires the Department of Health Care Services (DHCS) to assist MediCal managed care plans in delivering palliative care services, and requires DHCS to consult with stakeholders and Marin Medicine

directs DHCS to ensure the delivery of palliative care services in a manner that is cost-neutral to the General Fund, to the extent practicable. Authorizes implementation through all plan letters and similar instructions.

SB 1299 (Padilla)

WORKPLACE VIOLENCE PREVENTION PLANS: HOSPITALS

Requires the Occupational Safety and Health Administration Standards Board, no later than July 1, 2016, to adopt standards that require specified hospitals to adopt a workplace violence prevention plan as part of their injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior. Requires the Division of Occupational Safety and Health to post a report on violent incidents at hospitals on its website. Exempts certain hospitals.

MEDI-CAL SB 396 (De León)

11 new laws, including:

PUBLIC SERVICES

Repeals the unenforceable provisions of Proposition 187 relating to public social services, public health care services, public education and other activities of state and local agencies.

SB 1341 (Mitchell)

MEDI-CAL: STATEWIDE AUTOMATED WELFARE SYSTEM

Requires the Statewide Automated Welfare System to be the system of record for Medi-Cal and to contain all Medi-Cal eligibility rules and case management functionality. Authorizes the Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) to house the business rules necessary for an eligibility determination. Requires CalHEERS to make the business rules available to the System consortia to determine Medi-Cal eligibility. Requires notices for the Medi-Cal and premium tax credit programs.

SB 1457 (Evans)

MEDICAL CARE: ELECTRONIC TREATMENT AUTHORIZATION

Requires requests for authorization for Marin Medicine

treatment or services in the Medi-Cal program, California Children’s Services (CCS) Program, and the Genetically Handicapped Persons Program (GHPP), excluding those submitted by dental providers enrolled in the MediCal Dental Program, to be submitted in an electronic format determined by the Department of Health Care Services (DHCS) via DHCS’ website or other electronic means designated by DHCS. Requires DHCS to implement an alternate format for submission when DHCS’ website is unavailable due to a system disruption. Implements this requirement by July 1, 2015, or a subsequent date determined by DHCS. Authorizes all-county letters, plan letters, or provider bulletins.

MEDICAL EDUCATION

3 new laws, including:

AB 496 (Gordon)

MEDICAL EVALUATION: SEXUAL ORIENTATION: GENDER IDENTITY

Amends existing law that requires continuing medical education accrediting associations to develop standards for compliance with the cultural competency requirement. Authorizes such associations to update these compliance standards in conjunction with an advisory group with expertise in such issues. Expands a recommendation

regarding such care to include appropriate treatment and care of the lesbian, gay, bisexual, transgender, and intersex communities.

AB 2214 (Fox)

EMERGENCY ROOM PHYSICIANS AND SURGEONS

Enacts the Dolores H. Fox Act to require the Medical Board of California to consider including a course in geriatric care for emergency room physicians and surgeons as part of its continuing education requirements.

MEDICAL PRACTICE AND ETHICS

4 new laws, including:

AB 1577 (Atkins)

CERTIFICATES OF DEATH: GENDER IDENTITY

Requires a person completing a certificate of death to record the decedent’s sex to ref lect the decedent’s gender identity. Requires identity to be reported by the informant, unless the person completing the certificate is presented with a specified document, in which case the person would be required to record the decedent’s sex as that which corresponds with the gender identity as indicated in document.

Provides the procedure in the absence of such document.

Winter 2015 35

PROFESSIONAL LICENSING AND DISCIPLINE

4 new laws, including:

SB 1159 (Lara)

LICENSE APPLICANTS: INDIVIDUAL TAX IDENTIFICATION

AB 2365 (Perez, J.)

CONTRACTS: UNLAWFUL CONTRACTS

Seeks to make clear in California law that non-disparagement clauses in specified consumer contracts are void and unenforceable. Provides that a contract or proposed contract for the sale or lease of consumer goods or services may not include a provision waving the consumer’s right to make any statement regarding the seller or lessor or its employees or agents concerning the goods or services. Makes it unlawful to threaten or to seek to enforce a provision made unlawful under this bill, or to otherwise penalize a consumer for making any statement protected under the bill. Provides that a provision in violation of this bill is deemed unconscionable and against public policy. Relates to online reviews or comments.

Prohibits licensing boards under the Department of Consumer Affairs from denying licensure to an applicant based on his or her citizenship or immigration status, and requires a licensing board and the State Bar to require, by January 1, 2016, that an applicant for licensure provide his or her individual taxpayer identification number or a social security number for an initial or renewal license.

PUBLIC HEALTH

19 new laws, including:

AB 1559 (Pan)

NEWBORN SCREENING PROGRAM

Requires the Department of Public Health to expand statewide screening of newborns to include screening for adrenoleukodystrophy as soon as the disease is adopted by the federal Recommended Uniform Screening Panel.

AB 1819 (Hall)

FAMILY DAY CARE HOME: SMOKING PROHIBITION

SB 2399 (Perez, J.)

Prohibits the smoking of tobacco in a private residence that is licensed as a family day care home without regard to whether the act occurs during the hours of operation of the home. Makes a conforming change.

ORGAN AND TISSUE DONOR REGISTRY: DRIVER’S LICENSE

AB 1898 (Brown)

ORGAN TISSUE AND DONATION

1 new law:

Authorizes an organ procurement organization to swipe a driver’s license or identification card to transmit information to the registry for the purpose of allowing an individual to identify himself or herself as a registered organ donor, subject to a specified procedure.

Requires the information gathered comply with a Department of Motor Vehicles Information Security Agreement. Revises the reference to general characteristics of donors to refer to non-identifiable information.

36 Winter 2015

PUBLIC HEALTH RECORDS: REPORTING: HIV/AIDS

Adds hepatitis B, hepatitis C, and meningococcal infection to the list of diseases that local health officer reports to the Department of Public Health (for the purpose of the investigation, control, or surveillance of human immunodef iciency virus/ acquired immune deficiency syndrome and co-infection).

AB 2069 (Maienschein)

IMMUNIZATIONS: INFLUENZA

Requires the Department of Public Health to post specified educational information regarding influenza disease and the availability of influenza vaccinations on the department’s website. Authorizes the department to use additional available resources to educate the public regarding inf luenza, including, among other things, public service announcements.

AB 2217 (Melendez)

PUPIL AND PERSONNEL HEALTH: AEDS

Authorizes a public school to solicit and receive non-state funds to acquire and maintain an automated external defibrillator (AED). Provides that the employees of the school district are not liable for civil damages resulting from certain uses, attempted uses or non-uses of an AED. Exempts a public school or district, that is in compliance with AED requirements, from civil damage liability.

REPRODUCTIVE ISSUES

2 new laws, including:

SB 1135 (Jackson)

INMATES: STERILIZATION

Prohibits sterilization for the purpose of birth control of an individual under the control of the Department of Corrections and Rehabilitation or a county correctional facility. Prohibits any means of sterilization of an inmate, except when required for the immediate preservation of life in an emergency medical situation and when medically necessary to treat a diagnosed condition and certain requirements are satisfied.

Requires reports of procedures. Relates to notification regarding sterilization.

These are just a sampling of the new laws impacting healh care in 2015 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2015”, in the California Medical Association’s online resource library at www.cmanet.org/ resource-library.

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