January 2009

official publication of the san diego county medical society • January 2009

scope practice of

Physician-led NetWOrks Caring for Patients

Responding to In-flight Medical Emergencies P.20 Get Specific About Quality and “Unacceptable” Cross-cultural Behavior P.22 Healthcare p.26

Emerging Microbial Resistance in San Diego County p.34

“ P H YSI C IANS UNITED F OR A H EALT H Y SAN DIEGO ”

Donald J. Palmisano, MD, JD, FACS Board of Governors, The Doctors Company Past President, American Medical Association

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We hate lawsuits. We loathe litigation.

We help doctors head off claims at the pass. We track new treatments and analyze medical advances. We are the eyes in the back of your head. We make CME easy, free, and online. We do extra homework. We protect good medicine. We are your guardian angels.

We are The Doctors Company.

The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety. In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer. And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look out for the doctor is to start with the patient. To learn more about our medical professional liability program for San Diego County Medical Society members, call (858) 452-2986 or visit us at www.thedoctors.com.

Dona Board Past P

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Contents VOL. 96 | NO. 1

scope practice of

[ F e a t u r e s ]

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Scope of Practice

• Physician Assistants: PArtners in Medicine • Nurse Practitioner Scope of Practice: An Essential Component of Providing Quality Healthcare in California • “Psychopharmacology for Dummies”: Legislative Battles Over Prescription and Hospital Privileges for Psychologists

[ D e p a r t m e n t s ]

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Contributors

This Issue’s Contributing Writers

Editor’s Column

What Do Physicians Do That Is So Special?

SDCMS Seminars and events Briefly Noted

New and Rejoining Members, and More …

Ask Your Physician Advocate EMERGENCY PREPAREDNESS

Responding to In-flight Medical Emergencies

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Practice Management

Get Specific About “Unacceptable” Behavior

Public Health

2008 Physical Activity Guidelines for Americans

Risk Management Medical Record Retention

Evidence-based medicine

CT Colonography • Negative Screening Colonoscopy

Physician Marketplace Classifieds

HISTORY OF MEDICINE Dragon Bone Fever

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Contributors Laura A. Dixon Ms. Dixon is director of the Department of

William Haney, MD Dr. Haney, a retired ophthalmologist,

Patient Safety, Western Region, for The Doctors Company.

has held a longtime interest in the history of medicine, often contributing articles to San Diego Physician.

Amethyst C. Cureg, MD, MPH Dr. Cureg is the County of San Diego Health and Human Services Agency maternal and child health medical director.

Jeffrey J. Denning Mr. Denning is a principal management consultant with SDCMS-endorsed partner Practice Performance Group (PPG).

Miguel Medina Mr. Medina is the current president of the California Academy of Physician Assistants.

Jill Olmstead Ms. Olmstead is president of the California Association for Nurse Practitioners.

Steven A. Ornish, MD Dr. Ornish is double-board-certified Adam Frederic Dorin, MD, MBA Dr. Dorin, anesthesiologist, is the author of the recently published Jihad and American Medicine: Thinking Like a Terrorist to Anticipate Attacks via Our Health System.

DynaMed The DynaMed editorial team includes physicians, other clinicians, and scientists who systematically monitor the literature with a seven-step, evidence-based process.

in general and forensic psychiatry and has a private practice in Mission Valley. He is an associate clinical professor (voluntary), UCSD School of Medicine, Department of Psychiatry.

Joseph E. Scherger, MD, MPH Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

Marisol Gonzalez Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership.

Send your letters to the editor to Editor@SDCMS.org East County Director Hillcrest Director Kearny Mesa Director EDITOR MANAGING EDITOR

Joseph Scherger, MD, MPH Kyle Lewis

editorial board

Van Cheng, MD Adam Dorin, MD Robert Peters, PhD, MD David Priver, MD Roderick Rapier, MD Joseph Scherger, MD, MPH

La Jolla Director North County Director South Bay Director At-large Director

Young Physician Director Resident physician director Retired Physician director MEDICAL Student Director

Published by

PRESIDENT PUBLISHER DIRector, BUSINESS DEVELOPment & MARKETING MARKETING & PRODUCTION manager

William Tseng, MD Woody Zeidman, MD Roneet Lev, MD Thomas McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steven Poceta, MD Wayne Sun, MD James Schultz, MD Douglas Fenton, MD Arthur Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD Robert Peters, PhD, MD David Priver, MD Wayne Iverson, MD Paul Kater, MD John Allen, MD Kevin Malone, MD Mihir Parikh, MD Kimberly Lovett, MD Glenn Kellogg, MD Geraldine Kang

Jim Fitzpatrick Maureen Sullivan Heather Back Jennifer Rohr

SDCMS EXECUTIVE COMMITTEE PRESIDENT president-elect past president secretary treasurer COMM. CHAIR DELEGATION CHAIR Board REP. Board REP. LEGIslative chair executive director

Stuart Cohen, MD, MPH Lisa Miller, MD Albert Ray, MD Robert Wailes, MD Susan Kaweski, MD Joseph Scherger, MD, MPH Jeffrey Leach, MD Sherry Franklin, MD Robert Peters, PhD, MD Robert Hertzka, MD Tom Gehring

SDCMS cma trustees

Theodore Mazer, MD Albert Ray, MD Robert Wailes, MD

OTHER cma trustees

Catherine Moore, MD Diana Shiba, MD

ama delegates alternate delegate

ACCOUNT EXECUTIVE PROJECT DESIGNER ADVERTISING ART DIRECTOR COPY EDITOR

James Hay, MD Robert Hertzka, MD Albert Ray, MD Lisa Miller, MD

Dari Pebdani Lisa Williams Geneen Montgomery Adam Elder

1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to cpinfo@sandiegomag.com. San Diego Physician is published monthly on the first of the month.

Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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Union bank of California

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Editor’s Column

By Joseph E. Scherger, MD, MPH

Physician Scope of Practice What Do Physicians Do

That Is So Special?

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cope of practice is one of the major advocacy efforts of organized medicine. Preserving the physician’s unique professional role in the care of patients is a never-ending battle. Many other healthcare workers, some professional and some not, are annually trying to invade the practice of medicine. Every year, the incredibly effective lobbying group of the California Medical Association (CMA) beats away the many bills coming from other groups wanting to practice a part of medicine. Is this just a turf battle, or is there something special about physicians in the practice of medicine that others simply are not appropriately trained to do?

Is this just a turf battle, or is there something special about physicians in the practice of medicine that others simply are not appropriately trained to do?

The too-often reflex response of physicians to the attempts at sharing the scope of medical practice with others is, “If they wanted to practice medicine, they should have gone to medical school.” Does that do justice to the physician’s position of preserving the scope of medical practice? What is it about medical school and residency training that makes physicians different?

Being a physician is a unique professional role in society. Since Hippocrates, physicians have lived by an oath and code of ethics to place the needs of the patient above all else. Physicians, no matter what the specialty, care about and are responsible for the whole patient. The many years of medical school and residency ingrain that professional duty, and physicians take their role very seriously. Other healthcare providers have shorter lengths of training and learn certain skills but do not have the deep, professional role of the physician.

Today, elements of medical practice are shared among many healthcare workers, both professional and not. Even medical assistants are trained to participate as team members to help better the health of patients. Some physicians train their medical assistants to assume special responsibilities with patients, such as in helping patients

lose weight or with the care of chronic illnesses such as diabetes.

Nurse practitioners (NPs) and physician assistants (PAs) emerged in the late 1960s and became a force in the 1970s as “extenders” of the physician, both in primary and specialty care. These “midlevel” providers often substitute for physicians in the care of patients with certain clinical problems.

Their training for this clinical role is usually about two years on top of whatever health education they had prior. NPs and PAs are a valuable asset to physicians as members of the healthcare team. In primary care they are able to manage common problems, allowing the physician to focus on more complex patients. In specialty care, they are able to provide basic clinical services such as preoperative histories and physician exams.

Left alone, NPs and PAs are able to provide some clinical services such as are currently being done in retail clinics. However, when faced with the complexity of undifferentiated, complex patients, their limited skills become visible. As the medical director of the San Diego County Medical Services (CMS) Program overseeing the specialty referrals from 42 community clinics, it is clear to me that NPs and PAs lack the depth of skills to provide complex primary care. The efficiency of primary care gets lost when NPs and PAs act alone, since many unnecessary referrals are done for what should be managed at the primary care level. Most seriously ill patients are complex and quickly overwhelm the skills of NPs or PAs trying to act like physicians.

Other health professionals such as psychologists, optometrists, podiatrists, and physical therapists are eager to expand their clinical licenses to do things beyond their traditional roles. Attempting medical practice beyond their training would be dangerous to patients and create confusion as to who is really trained to practice medicine.

These healthcare professionals provide valuable services to patients and work well in a health system with physicians. Again, team practice with complimentary skills results in the best outcomes for a community of patients, not expanding the scope of individual practice.

Some “alternative” professionals, such as chiropractors and naturopaths, want to have the same recognition as physicians without

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the commitment to medical science. They practice according to a set of beliefs, with knowledge and skills that have remained unchanged for more than 150 years. When a physician educator recently went to the Bastyr University of Naturopathic Medicine outside Seattle to give a talk on evidence-

Some think that physicians today have receded from the Hippocratic tradition and have become skill providers with a limited scope of practice. This would be a great loss not only for the medical profession, but also for all of society. based medicine, the students objected that they did not want to practice medicine based on scientific evidence. They said that they practiced an alternative type of medicine, an alternative to “Western science.”

Some think that physicians today have receded from the Hippocratic tradition and have become skill providers with a limited scope of practice. This would be a great loss not only for the medical profession, but also for all of society. When serious illness strikes, people need real physicians to care for them. Medical school and residency training create the physician. The work is magical in its ability to evaluate and heal complex patients. Physicians are correct in defending this special role from others who want to grab it without the same education.

Physicians need to be sure that their work stays deserving of the Hippocratic tradition of medicine, putting the needs of the patient above all else and taking responsibility for the whole person.

Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of AmeriChoice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

About the Author:

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SDCMS Members-only Benefits

2009

Seminars and Events

January

12 Monday 9:00AM–12:00PM Palmetto GBA J1 Post-transition Seminar/Webinar 15 Thursday 11:30AM–1:00PM Collections Seminar/Webinar (Office Managers Forum) 21 Wednesday 6:30PM–7:30PM Risk Management Webinar: “Dealing With Demanding and Challenging Patients” 22 Thursday 11:30AM–12:30PM Risk Management Webinar: “Dealing With Demanding and Challenging Patients”

28 Wednesday 6:30PM–8:30PM Marketing Seminar/Webinar 29 Thursday 11:30AM–1:00PM Marketing Seminar/Webinar (Office Managers Forum)

February 11 Wednesday 6:30PM–8:30PM Contract Negotiations Seminar/Webinar 12 Thursday 11:30AM–1:00PM Contract Negotiations Seminar/ Webinar (Office Managers Forum) 18 Wednesday 6:30PM–8:30PM Coding Seminar/Webinar

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19 Thursday 11:30AM–1:00PM Coding Seminar/Webinar (Office Managers Forum)

March 18 Wednesday 6:30PM–8:30PM Insurance Services Seminar/Webinar 19 Thursday 11:30AM–1:00PM Insurance Services Seminar/Webinar (Office Managers Forum)

April 15 Wednesday 5:00PM–9:00PM Practice Management Seminar/Webinar 16 Thursday 9:00AM–1:00PM Practice Management Seminar/Webinar (Office Managers Forum) 18 Saturday 8:30AM–3:30PM Resident and New Physician Seminar: “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” 22 Wednesday 6:30PM–8:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)” 23 Thursday 11:30AM–1:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)”

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Free to Member Physicians and Their Office Staff!

SDCMS strives to build a robust schedule of free seminars and events for our member physicians and their office staff. All SDCMS member physicians and their office staff attend SDCMS seminars free of charge (including Office Managers Forums). Our seminars cover a broad range of practice management topics, including legal issues, HIPAA, riskmanagement issues, contract negotiations, and more. For further information about any of these seminars and events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, or contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org.

Imaging Healthcare

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Community Healthcare Calendar

2009 Radiology at Alta and snowbird Covering the applications of imaging techniques in the diagnosis of diseases of the brain, spine, musculoskeletal system, and body. Jan. 10–15, Jan. 25–29, or Mar. 8–12 at the Rustler Lodge or Cliff Lodge, Alta or Snowbird, Utah. Visit http://cme. ucsd.edu/radiology.

ANESTHESIA UPDATE 2009 State-of-the-art elements in all the anesthesia subspecialties and important new problems and their solutions. Jan. 14–17 at the Kona Kai Resort, San Diego. Visit http://anes-som.ucsd.edu/update1.htm.

Natural Supplements: An Evidence-based Update Practical information for healthcare professionals who make nutritional recommendations or manage dietary supplement use. Jan. 22-25 at the Paradise Point Resort and Spa, San Diego.

Contact (858) 652-5486 or med.edu@scrippshealth.org.

MELANOMA 2009: 19TH ANNUAL CUTANEOUS MALIGNANCY UPDATE Designed for healthcare professionals with an interest in, and basic understanding of, skin cancer.

Jan. 24 at the Omni San Diego. Contact (858) 652-5486 or med.edu@scrippshealth.org.

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a focus on issues of current interest the third day and breast cancer the final day. Feb. 14–17 at the Omni Hotel, San Diego. Contact (858) 652-5400 or med.edu@scrippshealth.org.

2nd Annual UCSD urology postgraduate course Physicians in the field of oncology, surgery, and urology encouraged to attend this informational conference. Feb. 20–21 at The Lodge at Torrey Pines, La Jolla. Visit http://cme.ucsd.edu/events. cfm for details.

WEST COAST GERIATRIC psychiatry conference Up-to-date, clinically relevant information to assist psychiatrists, primary care physicians, and other health professionals in delivering quality care for the older person. Feb. 25–28 at the Catamaran Resort Hotel. Visit http://cme.ucsd. edu/geriatricpsych.

THE FUTURE OF GENOMIC MEDICINE II Examines the salient progress and challenges in the field of genomics. Feb. 27–28 at the Neurosciences Institute Auditorium, Scripps Research Institute, La Jolla. Contact (858) 652-5486 or med.edu@scrippshealth.org.

“I Guess That’s Why They Call It The Blues”: Depression Diagnosis and Treatment in the 21st Century Jan. 27, 6:30 p.m. – 8:30 p.m., at Scripps Memorial Hospital, Schaetzel Center. Contact (858) 279-4586 or KDotson@SDCMS.org.

FRESH START’S SURGERY WEEKEND A team of dedicated medical volunteers donates their time and expertise to provide disadvantaged children with the highest quality medical services and ongoing care. Feb. 28-Mar. 3, Apr. 18-19, Jun. 13-14, Jul 25-26, Sep. 12-13, and Nov. 7-8 at the Center for Surgery of Encinitas. Contact (760) 448-2021 or mimi@freshstart.org, or visit www. freshstart.org

MEDICAL SYMPOSIUM: MAIMONIDES SOCIETY OF ADAT YESHURUN Charitable event with volunteer faculty. Clinical update plus Jewish medical ethics. 30 hours CME. Feb. 12-15 at the Glatt Kosher Winter Retreat, La Jolla. Contact (858) 535-0037 or maimonides@ adatyeshurun.org, or visit www.adatyeshurun.org/ maimonides

32ND ANNUAL SAN DIEGO POSTGRADUATE ASSEMBLY IN SURGERY Five-day course presented by the UCSD School of Medicine. The practicing surgeon will be brought up-to-date on the latest developments in general surgery. Mar. 3 at the Westin San Diego at Emerald Plaza. Contact (858) 534-3940 or ocme@ ucsd.edu

Scripps Cancer Center’s 29th Annual Conference: Clinical Hematology and Oncology 2009 Program focuses on selected hematologic subjects the first day, hematologic malignancies the second day, new developments in oncology with

TOPICS AND ADVANCES IN INTERNAL MEDICINE Topics include neoplastic diseases, rheumatology, geriatrics, infectious diseases, and hospital medicine, among others. Mar. 5–11 at the Hilton San Diego Resort. Visit http://cme.ucsd.edu/ internalmed/index2.html.

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PERCUTANEOUS CATHETER ABLATION OF ATRIAL FIBRILLATION Directed at those interested in incorporating percutaneous catheter ablation into their clinical management of patients with atrial fibrillation.

Mar. 7 at the Hilton La Jolla Torrey Pines. Contact (858) 652-5400 or med.edu@scrippshealth.org.

2009 RADIOLOGY AT ALTA AND SNOWBIRD Covering the applications of imaging techniques in the diagnosis of diseases of the brain, spine, musculoskeletal system, and body. Mar. 8-12 at the Cliff Lodge, Snowbird, Utah. Visit http://cme. ucsd.edu/radiology.

ADVANCES IN THE NEUROPSYCHOLOGICAL ASSESMENT AND TREATMENT OF SCHOOL-AGED CHILDREN WITH COGNITIVE DEFICITS Presentation of the latest findings on the assessment and remediation of cognitive and behavioral impairments in school-aged children. Apr. 2–5 at the Hilton San Diego Resort. Visit http://cme.ucsd. edu/neuro.

14th Annual Primary Care in Paradise Will assess current trends in preventive healthcare with an emphasis on endocrinology, orthopedics, obesity, migraines, COPD, melanoma, and sleep apnea; summarize recent developments and changes in the treatment of disease processes likely to be seen in the primary care office setting; and identify and treat problems commonly encountered in primary care clinical practice. Apr. 6–9 at the Hapuna Beach Prince Hotel, Big Island, Hawaii. Contact (858) 652-5400 or med.edu@ scrippshealth.org.

To submit a community healthcare event for possible publication, email KLewis@SDCMS.org.

All events should be physicianfocused and should take place in San Diego County.

Alliant Insurance services

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Risk Tip

Patients Who Are Hard of Hearing or Deaf

By SCPIE Insurance/ The Doctors Company

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ffective communication, especially when special challenges arise, requires more of the physician than brushing up on basic people skills. For instance, patients who are hard of hearing or deaf are protected from discrimination by the Americans with Disabilities Act (ADA). This law requires physicians to use auxiliary aids and services to communicate fully and effectively with these patients.

The ADA also allows the deaf patient to choose which communication method to use, i.e., sign language through an interpreter, lip reading, written notes, or telecommunication devices for the deaf.

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The law does not mandate the provision of an American Sign Language (ASL) interpreter in all cases. Federal regulations indicate that a public accommodation (the medical practice) may choose among various alternatives as long as the result is effective communication.

In a recent court case, a New Jersey jury awarded a deaf patient $400,000 for denial of interpreting services by her

In a recent court case, a New Jersey jury awarded a deaf patient $400,000 for denial of interpreting services by her physician. physician. The patient claimed that she repeatedly asked her rheumatologist to hire an ASL interpreter. This is the largest verdict in the country against a doctor for failure to provide an interpreter to a deaf patient.

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The following advice on working with interpreters may help physicians communicate effectively: • Seat the interpreter slightly behind and to the side of the physician.

• The chairs should be arranged in a well-lit area free of glare.

• Speak clearly in a normal tone and at a natural pace.

• Look at and speak directly to the patient. Avoid glancing at the interpreter and using phrases such as “Tell him” and “Ask her.”

• Do not attempt to confer privately with the interpreter.

Although the cost of providing professional interpretation services usually lies with the physician, there are ways — such as tax credits and cost-effective scheduling tips — to help absorb some of the cost. Being aware of the potential language barriers with patients can help physicians plan strategies to overcome them.

Call for Papers 19th Israeli Medical Association World Fellowship International Conference 19th Israeli Medical Association World Fellowship International Conference First Announcement and Call for Papers “Advanced Technologies in Medicine: Medical Ethics, Health Policies” Hilton Tel Aviv Hotel, Israel (pre- and post-conference tours available)

April 22–26, 2009

One of the activities of the Israeli Medical Association is the World Fellowship (WF), instituted with the aim of involving doctors around the world with the medical profession in Israel and with their Israeli counterparts. The WF embodies the solidarity of physicians who share common values of support for the State of Israel and the Israeli medical profession. Last year physicians from 22 countries attended the international conference, with Shimon Peres as special guest speaker. You are invited to be part of this unique event.

Please refer to www.ima-wf-usa. org for additional information.

Personal: • Income Tax Planning • Wealth Management • Financial Planning

Local: • Employee Benefit Plans • Profitability Reviews • Outsourced professional services (CFO, Controller)

Ron Mitchell, CPA Director of Health Services rmitchell@aktcpa.com 760-431-8440

Global: • Organizational Structure • Succession Planning • Internal Control Review and Risk Assessment 5946 Priestly Drive, Ste. 200 Carlsbad, CA 92008

CPA’s and Consultants

“Cyberchondria” As defined by Ryen White and Eric Horvitz of Microsoft: The unfounded escalation of concerns about common symptomatology, based on the review of search results and literature on the World Wide Web.

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Noted

january statistic

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Physicians Per 10,000 Population: from www.globalhealthfacts.org

SDCMS Physician Appointed to Commission on Cancer Position Julie L. Barone, DO — new SDCMS member — received a three-year appointment as Cancer Liaison Physician for the cancer program at Sharp Memorial Hospital. Cancer Liaison Physicians are an integral part of cancer programs accredited by the American College of Surgeons Commission on Cancer. Dr. Barone, who is among a national network of more than 1,600 volunteer physicians who are responsible for providing leadership and direction to establish, maintain, and support their facilities’ cancer programs, is a member of the multidisciplinary cancer committee at Sharp Memorial.

474

1) San Marino

333 2) cyprus

58

59 3) cuba

4) monaco

A Poem From

1918

San Diego Physician (then called The Bulletin)

How short the year!

The seasons follow each a course most true; All things must change.

Again will spring smiles, summer roses bloom; God doth arrange.

How short is life!

This house of flesh is but a transient home; It seeks the sod.

Eternity awaits the human soul.

A house with God.

By A.J. Elliot, MD

52 50

5) Saint Lucia

48 47

6) greece

7) belarus

8) georgia

43 42

9) russian federation

10) belgium

26

22) united states of america

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Get in Touch Your SDCMS Support Team Is Here to Help!

Address 5575 Ruffin Rd., Ste. 250 San Diego, CA 92123 Telephone Dareen Nasser, office manager, at (858) 565-8888 or at DNasser@SDCMS.org Fax (858) 569-1334 CEO/Executive Director Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org

Director of Membership Development Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org

sdcms foundation associate executive director Tana Lorah at (858) 300-2779 or at TLorah@SDCMS.org

Director of membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org

Director of Communications and Marketing Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org Specialty society advocate Karen Dotson at (858) 300-2787 or at KDotson@SDCMS.org

Office Manager Advocate Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org

Director of Engagement COO/CFO 1 9/11/08 11:15 AM Page 1 HMB_SDP_08:Layout Jennipher Ohmstede at (858) 300-27811 TCS_SDP_08:Layout James Beaubeaux at (858) 300-2788 or or at JOhmstede@SDCMS.org at Beaubeaux@SDCMS.org sdcms foundation executive director Kitty Bailey at (858) 300-2780 or at KBailey@SDCMS.org

Letters to the Editor Editor@SDCMS.org 8/15/08

10:16 AM Page 1 General Suggestions SuggestionBox@SDCMS.org

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Noted

Welcome New and Rejoining SDCMS-CMA Members!

New Members Fouad Mohamed Farouk Abdelhalim, MD • Anatomic Pathology • Clinical Pathology Carlsbad, (760) 268-6211 Derrick Ross Allen, MD • Vascular Radiology • Interventional Radiology San Diego Valerie Cynthia Altavas, MD • Internal Medicine National City, (619) 470-7000 Nassir Ahmad Azimi, MD • Interventional Cardiology La Mesa, (619) 462-9353 Riem El-Sabbagh Badr, MD • Anatomic Pathology • Clinical Pathology Carlsbad, (760) 268-6211 Randall Dwight Bass, MD • Anatomic Pathology • Clinical Pathology Carlsbad, (760) 268-6211 Jeffrey Allen Vallee Benabio, MD • Dermatology San Diego Sue Beruti, MD • Anatomic Pathology • Clinical Pathology Carlsbad, (760) 268-6211 Rae Felice Boganey, MD • Internal Medicine San Diego

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Steven William Kohler, MD • Emergency Medicine San Diego, (619) 528-6084 Kalyani Korabathina, MD • Neurology Oceanside, (760) 631-3000 Anna Andranik Kulidjian, MD • Orthopedic Surgery San Diego

Rachel Castle, MD • Anesthesiology San Diego, (858) 565-9666

Zachary Mikhael Gordon, MD • Anesthesiology San Diego, (858) 565-9666

James Jee-Ling Chao, MD • Plastic Surgery San Diego, (619) 543-2696

Erwin Guzman, MD • Family Medicine San Diego

Richard Hsiao Chen, MD • Emergency Medicine San Diego, (619) 528-5000

Ali Hariri, MD • Internal Medicine San Diego

Xun Li, MD • Anatomic Pathology • Clinical Pathology Carlsbad, (760) 268-6211

Jana Rosenberg Cooke, MD • Pulmonary Disease San Diego, (858) 350-4357

Nicholas Matthew Holmes, MD • Urology San Diego, (858) 279-8527

Andrew M. Lowy, MD • Surgery La Jolla

Christopher David Costanza, MD • Gastroenterology San Diego

Gordon Charles Hunt, MD • Gastroenterology San Diego, (619) 581-8035

Guy Louis Lund, MD • Nephrology San Diego, (858) 637-4700

David Alan DeRiemer, MD • Anesthesiology San Diego

Mayuko Imai, MD • Anatomic Pathology • Clinical Pathology Carlsbad, (760) 268-6211

Kiran Mahl-Sansone, MD • Internal Medicine Vista, (760) 726-2180

Hong Liu Drum, MD • Hematology Carlsbad, (760) 268-6211

Kim Afsaneh Janatpour, MD • Hematology Carlsbad, (760) 268-6211

Sherwin Quiba Gallardo, MD • Family Medicine San Diego Nikhil Ramniklal Gandhi, MD • Internal Medicine San Diego, (619) 589-2535 Leslie Ann Giesemann, MD • Surgery San Diego, (760) 534-4557 Rebecca L. Gilbert, MD • Anesthesiology Poway, (858) 735-5510

S A N D I E G O P H Y S I C I A N . o r g | J an u ary

Ahmad Kabakibi, MD • Internal Medicine San Diego, (619) 937-6328 Kelly Shannon Keefe, MD • Ophthalmology San Diego, (619) 516-7140

Pamela June Lammers, MD • Pediatric Hematology- Oncology San Diego

Thomas Wayne Martin, MD • Hematology Carlsbad, (760) 268-6211 Shana Day McDaniel, MD • Anesthesiology San Diego, (858) 565-9666 Lisa Marie Nyberg, MD • Transplant Hepatology San Diego

Gus William Kefalopoulos, MD • Anesthesiology San Diego, (858) 565-9666

Linda Petroff, MD • Anatomic Pathology • Clinical Pathology Escondido

Monika Grant Kiripolsky, MD • Dermatology Oceanside, (760) 758-5340

Jeffrey Anthony Ramos, MD • Internal Medicine San Diego, (858) 626-7780

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Mark David Rasmussen, MD • Anesthesiology El Cajon, (858) 565-9666

Elaine J. Watkins, DO • Internal Medicine San Diego, (619) 221-6900

Dorna Rezania, MD • Anatomic Pathology Carlsbad, (760) 268-6211

Eric Xueying Wei, MD • Hematology Carlsbad, (760) 268-6211

Steven Robert Shackford, MD • Surgical Critical Care San Diego, (619) 299-2600

Stefan A. Willging, MD • Internal Medicine San Diego, (619) 298-1318

Gregory Scott Stearns, MD • Otolaryngology San Diego

Jenny Wong, MD • Family Medicine La Mesa, (619) 644-6500

William Logan Tontz, MD • Orthopedic Surgery San Diego, (619) 299-8500

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Tracy Zweig Associates A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Rejoining Members Piyush Kumar, MD

12/12/08 • Gastroenterology 2:20 PM Page 1

George Gregory Ulrich, MD • Ophthalmology Coronado, (619) 435-8800

9/22/08

San Diego, (760) 436-8881 Louis Maletz, MD • Family Medicine Poway, (858) 451-2966

Locum Tenens Permanent Placement V oic e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FAX : 8 0 5 - 6 4 1 - 9 1 4 3

tz w e ig @ tra c y z w e ig .c o m w w w.tra c y z w e ig .c o m

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Ask Your Physician Advocate

By Marisol Gonzalez

Q

uestion: If a silent PPO is offering us a good rate, why would it be bad to contract with them?

Answer: Silent PPOs are rental networks and bring little value to physicians. The big issue with these entities is that they lease the physician’s discounts and names out to other payers. They don’t pay claims, as they are not insurance companies. CMA’s main concern with these entities is the lack of regulation. They are not licensed or regulated by anyone. For example, if you have a contract dispute or are having any problems getting paid, you can’t go to the Department of Insurance (DOI) or the Department of Managed Health Care (DMHC). Stopping these entities from practice is one of CMA’s big priorities.

It’s impossible for physicians to get out

Once you become contracted with a silent PPO, it is difficult to extract yourself from that relationship.

• Silent PPOs • • Appealing Palmetto Claims • • Modifier 25 • Your Physician Advocate Has the Answers!

of these contracts once they sign, and the discounts that are taken are large. Once you become contracted with them, it is difficult to extract yourself from that relationship.

Q

uestion: I am trying to send Palmetto an appeal for one of my claims. What address do I need to send this to?

Answer: Palmetto GBA-J1 Mac, P.O. Box 1252, Augusta, GA 30903-1252

Q

uestion: I thought if someone came in for a physical/wellwoman exam you would bill a preventative medicine service code, and if there were additional medical problems that came up during the exam, a

Does Your Office Manager Have a Question Too? Lauren Wendler, your SDCMS office manager advocate, is on staff and ready to help your office manager with any questions he or she may have. Feel free to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help.

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separate E&M code could be billed. I did this, and Blue Shield denied it.

Answer: Modifier “-25” needs to be used for the second/additional E&M codes. This alerts the payer that there were two separate and distinct services.

The payment policy on the Blue Shield website states, “Preventive Care Visits: Blue Shield provides separate reimbursement for E&M services performed at the same time as a preventive care visit.

To ensure payment, providers are reminded to append a modifier 25 to the E&M code. Blue Shield has consulted with members of the AMA CPT coding committee, and it is noted that the E&M code should only be added when significantly separately identifiable cognitive services are documented as having been performed.”

The physician may wish to re-bill using the appropriate modifier.

If your medical license or privileges are on the line…

Rosenberg, Shpall & Associates, APLC A P R O F E S S I O N A L L A W C O R P O R AT I O N

Members Of The Firm: David Rosenberg, J.D. Tomas A. Shpall, J.D. Annette Farnaes, J.D. Steven H. Zeigen, J.D. Corey Marco, M.D, J.D. Jason L. Nienberg, J.D. Amy C. Lea, J.D. Wells Fargo Bank Plaza 401 “B” Street, Suite 2209 San Diego, California 92101 Telephone: (619) 232-1826 Facsimile: (619) 232- 1859 Email: RSALAW@yahoo.com

Ms. Gonzalez is your SDCMS physician advocate.

She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org with any questions you may have about your practice or your membership.

About the Author:

• More than 50 years of combined experience in Medical License/Hospital Privilege Disputes • Medical Board accusations • Hospital privilege disputes • Wrongful termination • Civil actions/Independent counsel for medical malpractice claims • Provider Membership Disputes/Exclusion • Medical Corporations/Partnership Formation/Disputes

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In the December 2008 issue of San Diego Physician, Reza Hakimzadeh Tirgari, MD, new SDCMS member, should have been listed as specializing in emergency medicine as well as being board certified in internal medicine.

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Emergency Preparedness

Responding to

In-flight Medical Emergencies A Brief Primer

L

ast spring, on a nonstop flight from Miami back to San Diego, I was the only physician on board when the call “Is there a doctor on board?” went out from a flight attendant. By the time the call was repeated by the pilot over the intercom system, I was trying to wake myself up and already making my way from the back of the coach section toward the first-class seats.

It turned out that the head of a Southern California-based, multi-state law firm had experienced what I diagnosed as a vasovagal reaction. Upon arriving to “patient’s” seat and identifying myself (at which time two registered nurses, who had also just arrived to the scene, said “thank you” and quickly scurried back to their seats), I examined the middle-aged gentleman. He was demonstrating a depressed mental status and had his face in an airline-supplied “barf bag.”

I quickly established that this slightly cold and clammy man had relatively stable vital signs, before requesting an oxygen mask and tank, and placing a #20 gauge upper-

extremity intravenous line.

While treating the gentleman, who was already beginning to look better, I was asked for my California medical license card, which was given to the pilot along with a small questionnaire establishing my medical credentials and diagnosis of this patient.

The pilot later came out to meet me. I had been asked to stay in first-class next to the

Speaking to several commercial pilots, I was apprised of the fact that about 75 percent of all in-flight emergencies are minor and handled by the flight attendants themselves. patient for the remainder of the flight (the lady in that seat gladly agreed to go back and sit in my seat). I had the patient talking and smiling and resting comfortably.

He still felt a bit nauseous, so we decided to slowly drip in the two 500 cc. 0.9 NS IVF

By Adam Frederic Dorin, MD, MBA

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bags (that were the only intravenous fluids on the plane) until we arrived at Lindbergh Field. It turned out that this attorney’s personal paralegal was flying with him; we recognized each other, as I had recently given her a labor epidural for the delivery of her child, which, she reminded me, was a “godsend.”

When we arrived in San Diego, my new patient and friend walked out of the plane looking great; out of routine, he was greeted by an EMT who had been called to see if he needed anything and perform a routine exam.

I enjoyed being able to help out, get to know the pilot and flight attendant staff, and become friends with my new patient and his companion. There were, however, some interesting observations made about the state of preparedness — or lack thereof — on this airplane. After some later research, I found similar conditions existed on all major airlines and that many major airlines had recently cut back on the contents of their medical kits out of economic necessity. Here is some of what I learned: The medical kit I was given had one ampule of epinephrine, IV supplies and two

rubber tourniquets, one 500 cc. 0.9 NS IVF bag, gauze, band aids, two #20 gauge jelco catheters, nitroglycerine tablets, one vial of 50 mg. Benadryl, two 10 cc. syringes with two #19 gauge hypodermic needles, a tube of antibacterial ointment, a manual bloodpressure cuff, two pairs of large (the flimsy plastic type) gloves, and a stethoscope. It was accompanied by a small oxygen tank and a clear oxygen face mask. There were a total of two such kits on the airplane.

The plane itself was supposed to have one early-model, portable, automated, external cardiac defibrillator device (they had decided not to upgrade to the fully automated, newer model), but I was told that the one on my flight was broken. There were no anti-arrhythmic meds, no anti-emetic drugs, and clearly no pharmaceuticals to carry out an ACLS-type resuscitation. Interestingly, as we approached the airspace over Phoenix, Arizona (where this airline had its emergency-room contact physician on the ground), the pilot came back to tell me that the ER doc had requested we give the patient intravenous “Benadryl” and consider landing at the Phoenix airport instead of continuing on for another 45 minutes to San Diego. I completely disagreed with this recommendation as the patient was looking great and had, at no time, demonstrated any indication of an allergic reaction. As I expressed my opinion, the pilot was smiling and nodding his head in agreement. He laughed and said, “I agree with you doc.

We’ve had a history of some strange opinions from that emergency-room physician over the years!”

A review of The New England Journal of Medicine (Volume 346:1067-1073, April 4, 2002, Number 14) revealed the following statistics: • In-flight emergencies occur in roughly one out of every 33,600 to 39,600 U.S. flights.

• This correlates to roughly 30 to 33 emergencies on airline flights in the United States each and every day.

• The vast majority of in-flight “emergencies” are vasovagal episodes.

• Thirteen percent of all airline medical emergencies result in “diversions” to land the plane and treat the patient on the ground (of these, 46 percent are cardiac in origin, 18 percent are neurologic events, and 6 percent are respira-

tory events).

Some other interesting facts: • The cabin pressure on most commercial planes may often contain a barometric pressure of 5,000 to 8,000 feet above sea level, despite the fact that the plane is likely to sustain altitudes of three to five multiples above this level for most of the flight. This effects a decrease in the partial pressure of arterial oxygen from about 95 mm Hg. to about 56 mm Hg., resulting in a 4 percent reduction in the oxygen carried by the blood.

The risk of “hypobaric” hypoxemia in patients with advanced pulmonary disease, however, is very real.

• Boyle’s Law states that air and gas in cavities of the body will expand in direct proportion to decreases in cabin pressure. Passengers who have recently had surgery are at the potential risk of wound dehiscence due to gas expansion in surgical site tissues.

• Airline cabin humidity is low (10 to 20 percent range); this can exacerbate reactive airway disease.

According to the Federal Aviation Administration (FAA), the minimum medical supplies required to be on commercial aircraft is as follows — depending on the number of passengers, there must be one to four first-aid kits; the first aid and medical kits must be readily accessible to the flight attendant staff: • First-aid kit containing:

bandages, compresses for applying pressure, moisture, heat, or cold, antiseptic swabs, arm and leg splints, tape, scissors.

• Medical kit (for use only by licensed medical professionals) containing:

blood pressure cuff, stethoscope, plastic airways to deliver oxygen to help with breathing, nitroglycerin tablets for chest pain, dextrose solution for hypoglycemia, epinephrine for asthma or allergic reactions, injectable diphenhydramine HCl for serious allergic reactions, hypodermic needles, protective latex gloves.

Speaking to several commercial pilots, I was apprised of the fact that about 75 percent of all in-flight emergencies are minor and handled by the flight attendants themselves. It is obvious that the mandated supplies for a true medical emergency are

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rather meager, and frankly, inadequate to sustain many conditions until a patient can be stabilized and/or further treated on the ground. In fact, one could argue that beginning to treat a passenger with some medications, but without the full arsenal of drugs at one’s disposal, is a potentially slippery slope. Even the presence of latex gloves (although not on my flight) and latex stop-

There were some interesting observations made about the state of preparedness — or lack thereof — on this airplane. pers in medication vials could predispose a treated latex-sensitive passenger to a lifethreatening allergic reaction. I found it odd that diphenhydramine was the only medication on board to treat an allergic reaction, as clearly the presence of both H1 and H2 blockers and an intravenous corticosteroid have been documented to be helpful in such circumstances.

Nevertheless, I found my in-flight experience assisting a fellow airline passenger with a medical “event” to be rewarding, and the flight attendant staff to be extremely responsive and helpful. A familiarity with what is available to a physician responding to an “Is there a doctor on board?” call may be valuable the next time you travel.

References: • Urwin, A., Ferguson, J., McDonald, R., Fraser, S. (2008). A five-year review of ground-to-air emergency medical advice. J Telemed Telecare 14: 157-159 • Shepherd, B, Macpherson, D, Edwards, C M B (2006). In-flight emergencies: playing The Good Samaritan. JRSM 99: 628-631 • Zuckerman, J. N (2002). Recent developments: Travel medicine. BMJ 325: 260-264 • Gendreau, M. A., DeJohn, C. (2002). Responding to Medical Events during Commercial Airline Flights. NEJM 346: 1067-1073

Ab o u t the A u t h o r : Dr. Dorin, anesthesiologist, is the author of the recently published Jihad and American Medicine: Thinking Like a Terrorist to Anticipate Attacks via Our Health System.

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Practice Management cian would countenance mistreating a practice or hospital employee or colleague. But plenty of practices have just these kinds of malignantly narcissistic personalities among the physicians and do nothing about it, beyond complaining (privately) about it or, maybe, calling a consultant. They’re seeking the magic pill that will make Harry change or “go away” without having to actually do anything requiring gumption.

Get Specific

About “Unacceptable” Behavior

S

ometimes we get to group practice consulting engagements only to find out the real agenda is for us to “do something about Harry.” It’s surprising how many surgeons can stand for hours at an operating table without any backbone.

Here’s one of our recommendations to a surgery group near here: reate a Physician Code of Conduct C for the group. This may seem unnecessary but there were several anecdotes of physician behavior that apparently breaches your assumptions of good conduct. When you have a code that is agreed upon, it is easier to ask the question, “How did your

22

behavior fit the code or help the group?” You make assumptions about each others’ motives, often erroneous, and resentment has built up among you. If behavior is unacceptable, make a motion to deal with it in some specific way. Record the vote, and if anyone votes no or refuses to vote, consider it an indication you’re dealing with a nonmember individual. And, if you can’t get a second, move on.

A group that continues to accept “unacceptable” behavior by not acting on it has a problem with definitions. Good groups are the ones that create a culture of interdependence, trust, and friendship where no physi-

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Code of Conduct?

First Step: Make clear just what really is unacceptable behavior. You can’t deal with the problem fairly if you haven’t put the group on record defining terms and listing what can get a physician into hot water. Michael Josephson’s Character Counts! coalition (CharacterCounts.org) lists six key “pillars of character” that form a good place to start: 1. Trustworthiness 2. Respect 3. Responsibility 4. Fairness 5. Caring 6. Citizenship Here are some example values and prescribed and proscribed behaviors we’ve collected from groups we’ve visited, adopted in an effort to deal with problems physicians preemptively.

Values •H onesty and Integrity: We will always be honest with ourselves, patients, suppliers, and clients, and we will continuously demonstrate integrity in our profession and our business. We will do what we say we will do, and we will not do what we say we will not.

•E thics: We will do what we know is right and not do what we know is wrong.

•E xcellence: Quality care, quality staff, quality patients, and quality of life.

•P rofessionalism: We will perform our roles and responsibilities with the highest level of professionalism.

•C ustomer Service: We treat patients (and those who refer them to us) right.

We meet their needs, and we are always friendly and courteous.

•P roductivity: We strive to do more with the same or fewer resources.

•E fficiency: We do things right.

Mainly

• Effectiveness: We do the right things.

• Safety: We want no harm to come to our patients or ourselves.

• Compliance: We follow the rules and obey the laws, even the unwritten ones.

• Accountability: We will accept responsibility for our actions and behaviors.

What We Do • We use appropriate channels to express dissatisfaction or grievances with any practice staff or physician, and always in privacy.

• We display respect for the dignity of others.

• We respond to on-call responsibilities by dedicating the time for that purpose and fulfilling those responsibilities with a willing attitude. Call coverage is a critical reMozart_SDP_09:Layout 1 community.

12/12/08 flection on the group in the • We are candid about our opinions and participate fully in policy discussions.

• We follow the policies set by the group even if we personally prefer not to.

willingness to confront physicians can acWhat We Don’t Do tually do more harm than good. A group • Make negative assumptions of motives of that goes on record in this way but doesn’t our colleagues. actually enforce the code sends the message • Show disrespect or discourtesy. loud and clear to employees: Group ethics •M ake degrading or sarcastic remarks. is a pretense without a practice here.

•M anipulate the staff or other providers.

•E ngage in social relationships with staff apart from practice functions.

• Discuss our dissatisfactions and criticisms of our group, our staff, our hospital, our Ab o u t t h e A u t h o r : Mr. Denreferral sources, or our competition with ning is a principal management consultant nonmanagement staff or outsiders. with SDCMS-endorsed partner Practice Forget about charging each other fines Performance Group (PPG). PPG profor bad behavior. This just puts a money vides high-performance medical practice value on it. If fines were the only penalty for management services for physicians, inspeeding, David Letterman would always cluding consulting, expert witness, workdrive 130 mph. The job of the traffic court shops, speaking, and a monthly newsletis to stop high-speed driving, not just make ter.

SDCMS members receive practice it expensive, so expect other sanctions — management consulting discounts on 2:37 PM really Page 1Project3:Layout some distasteful ones — if you 1keep10/9/08 11:45 AM Page 1 productivity and patient flow, personnel, it up. governance and management, market A code of ethics or good conduct won’t strategy and tactics, practice acquisitions, work in a vacuum though. Publishing one and sales and mergers. and hanging it on the wall without the

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County Public Health Officer’s Update

By Amethyst C. Cureg, MD, MPH

2008 Physical Activity Guidelines for Amercians

Chronic Disease Prevention in Your Practice

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The third week of January is Healthy Weight Week and presents an opportunity to inform you about the U.S. Department of Health and Human Services’ 2008 Physical Activity Guidelines, a science-based physical activity guide for Americans as a component of chronic disease prevention in your practice. The release of the Guidelines is timely as more and more Americans young and old continue to exhibit sedentary behaviors conferring significant health risks throughout their lifespan. It is a comprehensive review and analysis of the scientific literature on physical activity and health published, since 1995, by an external Physical Activity Guidelines Advisory Committee, with comments from the public and government agencies.

The review documents very strong scientific evidence that physically active people derive higher levels of health-related fitness, a lower profile for developing a number of disabling medical conditions, and lower rates of chronic diseases compared to inactive people. The benefits of regular physical activity apply to all regardless of age, sex, race/ethnicity, socioeconomic status, and to those with physical or cognitive disabilities. Regular physical activity also promotes healthy weight, weight reduction when combined with diet, better cardiovascular and muscular fitness, and improved cognitive function in older adults. The 2008 Physical Activity Guidelines were designed to complement the Dietary Guidelines for Americans to emphasize that being physically active and eating a healthy diet go hand in hand.

The Health Benefits of Physical Activity: Major Research Findings

• Regular physical activity reduces the risk of many adverse health outcomes.

• While some physical activity is better than none, higher intensity, greater frequency, and/or longer duration provide additional benefits for most health outcomes.

• At least 150 minutes per week of moderate-intensity physical activity is needed for most health benefits, and additional benefits occur with more physical activity.

• Both aerobic (endurance) and musclestrengthening (resistance) physical activity promote better health.

• Health benefits occur for children and adolescents, young and middle-aged adults,

older adults, and those in every studied racial and ethnic group.

• Health benefits of physical activity also occur for people with disabilities.

• The benefits of physical activity far outweigh the risk for harm.

Health Benefits of Physical Activity: A Review of the Strength of the Scientific Evidence

Adults and Older Adults • Strong Evidence • Lower risk of:

early death

stroke

type 2 diabetes

high blood pressure

heart disease

adverse blood lipid profile

metabolic syndrome

colon and breast cancers • Prevention of weight gain • Weight loss when combined with diet • Improved cardiorespiratory and muscular fitness • Prevention of falls • Reduced depression • Better cognitive function (older adults) • Moderate to Strong Evidence • Better functional health (older adults) • Reduced abdominal obesity • Moderate Evidence • Weight maintenance after weight loss • Lower risk of hip fracture • Lower risk of lung and endometrial cancers • Increased bone density • Improved sleep quality

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Children and Adolescents • Strong Evidence • Improved cardio-respiratory endurance and muscular fitness • Favorable body composition • Improved bone health • Improved cardiovascular and metabolic health biomarkers • Moderate Evidence • Reduced symptoms of anxiety and depression Key Physical Activity Guidelines

Young and Older Adults (18–65 plus years) • Avoid physical inactivity.

• At least 150 minutes per week of moderate-intensity, or 75 minutes per week of vigorous-intensity aerobic physical activity or an equivalent combination of moderate-intensity (walking briskly, water aerobics, ballroom dancing, gardening) and vigorous-intensity (race walking, jogging, running, swimming laps, hiking uphill, jumping rope) aerobic physical activity.

• Increase moderate-intensity aerobic activity to 300 minutes for more extensive health benefits.

• Perform aerobic activity in episodes of at least 10 minutes, preferably spread throughout the week.

• Muscle-strengthening activities (weight training, push-ups) that involve all major muscle groups performed on two or more days per week.

• Older adults should determine their level of physical activity relative to their fitness level in consultation with healthcare provider.

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• Older adults with chronic conditions in consultation with healthcare provider should engage in activities as their abilities and conditions allow.

• Do exercises that maintain or improve balance if they are at risk of falling.

The benefits of regular physical activity apply to all regardless of age, sex, race/ethnicity, socioeconomic status, and to those with physical or cognitive disabilities.

Pregnant and Postpartum Women • Healthy women who are not already doing vigorous-intensity physical activity Lankford_SDP_08:Layout 1 10/27/08 1:22 PM should get at least two hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity a week, preferably spread throughout the week. Women who regularly engage in vigorous-intensity aerobic activity or high amounts of activity can continue their activity provided that their

condition remains unchanged and they talk to their healthcare provider about their activity level throughout their pregnancy.

Children and Adolescents (6–17 years) •O ne hour (60 minutes) or more of ageappropriate physical activity daily that is enjoyable and offers variety.

• Most of the one hour or more a day should be either moderate-intensity (hiking, skateboarding, bicycling, brisk walking) or vigorous-intensity (jumping rope, running, basketball, ice or field hockey) aerobic physical activity.

•A t least three times per week of vigorousintensity, muscle-strengthening (rope climbing, sit-ups, tug-of-war), and bonestrengthening activities (jumping rope, Page 1 running, skipping).

Children and Adolescents with Disabilities • Provide guidance to identify the types and amounts of age-appropriate physical activity as much as their condition will al-

low. Avoid physical inactivity.

Resources: • The Physical Activity Guidelines Advisory Committee Report is available at www. health.gov/PAGuidelines/Report/Default.aspx.

• Go to www.health.gov/PAGuidelines/ toolkit.aspx to get a toolkit.

• Patients can get Active Your Way: A Guide for Adults at www.health.gov/PAGuidelines/adultguide/default.aspx.

• The Dietary Guidelines for Americans, 2005 can be accessed at www.health.gov/ DietaryGuidelines/dga2005/document/ default.htm.

Dr. Cureg is the County of San Diego Health and Human Services Agency maternal and child health medical director. She is a past vice president of the American Academy of Pediatrics (AAP), Chapter 3, District 9, and serves on the AAP advisory board.

About the Author:

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• Located at 10672 Wexford Street, off the I-15 at Scripps Poway Parkway (92131) • Strategic Scripps Ranch/Poway location perfectly situated off the I-15 to serve the North County Communities of Scripps Ranch, Rancho Bernardo, Poway, Mira Mesa and Carmel Valley • Minutes from SR-52 and SR56 for easy access to the coastal communities

For more information, please call Ed Muna at 619-702-5655 or e-mail ed@lankfordsd.com. • www.PinnacleMedicalPlaza.com

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SDCMS Members BE SURE TO TAKE ADVANTAGE OF THE FOLLOWING MEMBERS-ONLY BENEFITS FROM SDCMS’ ENDORSED PARTNERS!

˘

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˘

PRACTICE PERFORMANCE GROUP (PPG)

AKT has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. AKT understands physician practices, and their personal, local, and global services can help you achieve success. SDCMS members receive a 15% discount on standard rates for professional services, with an unconditional satisfaction guarantee: Disappointed clients pay only what they thought the work was worth. Call Ron Mitchell (760) 268-0212 or email him at rmitchell@aktcpa.com.

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Practice Performance Group provides high performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and management, market strategy and tactics and practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense ®. PPG also conducts free half-day seminars for members and their employees at SDCMS (watch your faxes and emails). Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com, or visit www.PPGConsulting.com.

As California’s largest premier specialty insurance broker, and ranking among the 13th largest in the nation, Alliant Insurance delivers a comprehensive portfolio of insurance products and services. SDCMS members THE DOCTORS COMPANY (TDC) receive a savings of 5–10% or more off of the cost of insurance, or cash TDC enjoys a reputation as the industry vanguard for low Calirebates related to practice size, a savings of 7–12% on long-term disabilfornia rates, aggressive claims defense, expert patient safety ity income protection, and no-cost human resources consulting. Contact programs, superior customer service, and exemplary member benefits. EveryMark Allan at (800) 654-4609 or at mallan@alliantinsurance.com, call Alliant day, The Doctors Company relentlessly strives to reduce unreasonable legal Insurance Services at (888) 849-1337, or visit www.alliantinsurance.com. liability,Ad improve the environment in which all healthcare professionals SDCMS House practice, lead legislative and judicial reform, and enhance patient safety for the benefit of its members. Most SDCMS members are eligible for a 5% discount on insurance premiums, and a 7.5% dividend credit. To learn AMERICAN SECURITY RX more, contact Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org.

American Security Rx (ASRX) is a California Department of Justice and California Board of Pharmacy approved security printer (SP-9) to provide tamper-resistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamper-resistant TORREY PINES BANK prescription forms. Call American Security Rx at (877) 290-4262, email them Torrey Pines Bank is familiar with the business challenges facing at info@americansecurityrx.com, or visit ww.americansecurityrx.com. medical professionals. Their goal is to be a “low maintenance” bank, meeting business owners’ high expectations, with the absolute minimum time and effort required of them. They offer a full array of banking services.

Approved SDCMS members receive no-fee lines of credit, $1,000 fee CHMB SOLUTIONS discounts on commercial real estate loans, waived monthly maintenance CHMB provides outsourced medical billing, revenue cycle managefees on personal accounts for practice partners and employees up to ment services, information technology support, and hardware solu$10/month, free first order of standard checks for personal accounts, tions to physician practices, clinics, and multi-specialty organizations. SDCMS increased deposit interest rates, waived monthly maintenance fee for members receive a 50% discount on startup fees, a $33 per physician per business online banking and bill pay services, ATM fees waived up to month services credit, and a free coding hotline. Contact Ron Anderson $15/month, and free courier service or remote deposit service. Contact (CHMB Solutions) at (760) 520-1340 or at randerson@chmbsolutions.com.

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Risk Management

Medical Record Retention What Are a Physician’s Responsibilities?

By Laura A. Dixon

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P

hysicians have many responsibilities with respect to retaining medical records. A number of variables affect the length of time a physician should keep a medical record, such as state and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient record).

The following information can guide physicians in developing their medical record retention policies.

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Basis for Keeping Medical Records: The most important reason for keeping medical records is to provide information on a patient’s care to other healthcare professionals. Another major rationale is that a medical record that is well documented provides support for the physician’s defense in the event of a medical malpractice action. Without the medical record, the physician might not be able to show that the care he or she provided was appropriate and met the standard of care.

State and Federal Laws: For the most part, state and federal laws regarding mandatory record retention timeframes apply to hospitals or similar facilities rather than to a physician’s clinic. The Medicare Conditions of Participation (COP) require hospitals to retain records for five years (six years for critical access hospitals) (1), whereas OSHA requires an employer to retain medical records for 30 years for employees who have been exposed to toxic substances and harmful agents (2). HIPAA privacy regulations have a six-year retention requirement (3), which follows the federal statute for limitations for civil penalties (4).

malpractice action was several years after the care was provided.

Recommendations: The Doctors Company recommends that physicians retain medical records for at least 10 years after the last visit for adult patients and up to age 28 for minors, or 10 years after the patient reaches majority. For California physicians, medical records should be retained for 25 years after the patient’s last visit. Some states allow records to be retained in an electronic format. For example, a paper record may be scanned to a computer or kept in another electronic format, such as microfilm. Paper records should be stored with a reputable document-storage company.

Medical Board and Medical AssociaSuch companies may offer alternative tion Policies and Recommendations: methods for document management, When state or federal laws are silent on such as electronic scanning and storage, medical record retenwhich physicians tion, medical boards may want to considFor the most part, may have policies or Storing closed or state and federal laws er. recommendations archived records at regarding mandatory on how long a physirecord retention time your residence puts cian should keep re- frames apply to hospitals you at risk of damage cords. For example, from fire or flood, or similar facilities the Colorado State loss due to theft, or rather than to a Board of Medical Exother unauthorized physician’s clinic. aminers Policy 40-07 access. You should recommends retaining medical records also check state statutes and professional for a minimum of seven years after the licensing agencies for state-specific relast date of treatment for an adult and quirements or recommendations. for seven years after a minor has reached the age of majority, or age 25 (5). The What Records Should You Retain?

California Medical Association (CMA) Retain all records that reflect the clinihas concluded that while a retention cal care provided to a patient, including period of at least 10 years may be sufprovider notes, nurses’ notes, diagnostic ficient, it recommends that all medical testing, and medication lists. Retain rerecords be retained indefinitely or, in the cords obtained from another provider for alternative, for 25 years (6). the same length of time as those in your record. This is especially true if you have Case Law: A decision by the Califorrelied on any of the previous records or nia Court of Appeals (7) challenged the information when making current cliniprotection traditionally afforded to phycal decisions. sicians by the statute of limitations. The As to billing records, physicians court held that when an injury or abshould review bills for any reference to normality did not manifest itself within care provided. For example, review the the statute of limitation or if the patient bill to determine if it shows a limited could not have discovered the problem examination or an annual physical with within the required time frame, the statdiagnostic tests obtained or requested. If ute of limitations was suspended until the billing document shows that care was the injury became apparent. As such, provided, it may be in your best interest the time frame for the patient to bring a to keep the bill for as long as you retain

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the medical record. Otherwise, you need to retain it for the same length of time as other business records and in accordance with federal and state income tax requirements.

The Doctors Company understands that there are financial implications behind these recommendations. However, given the importance of the medical record in defense of a malpractice action, it is vital for the physician to have the record available to defend proper care.

References: 1. 42 CFR § 482.24(b)(1) and 42 CFR § 485.638(c).

2 .29 CFR § 1910.1020(d)(1).

3. 45 CFR § 164.530(j)(2).

4. 42 CFR Part 1003.

5. Colorado State Board of Medical Examiners Policy 40-07.

6. Hanson CI, Meghrigian AG, Penney SL, Abrams GM. California Physician’s Legal Handbook. Vol. 4. San Francisco: California Medical Association; 2007:27:10.

7. Brown v. Bleiberg, 32 Cal. 3rd 426, 186 Cal. Rptr. 228 (1982).

Ab o u t t h e A u t h o r : Ms. Dixon is director of the department of patient safety, western region, The Doctors Company.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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Evidence-based Medicine

CT Colonography • Negative Screening Colonoscopy CT Colonography Identifies 90% of Asymptomatic Adults With Polyps > 10 mm Computed tomography (CT) colonography identifies 90% of asymptomatic adults with polyps > 10 mm (level 1 [likely reliable] evidence), based on a prospective cohort study with 2,600 participants ≥ 50 years old who had colon cancer screening with multidetector CT colonography and same-day colonoscopy. Prevalence of lesions was 5.2% for lesions ≥ 10 mm and 10.2% for lesions 5–9 mm. For adenoma or carcinoma ≥ 10 mm, per-patient predictive performance of CT colonography had 90% sensitivity, 86% specificity, 23% positive predictive value, and 99% negative predictive value. For adenoma or carcinoma ≥ 6 mm, per-patient predictive performance of CT colonography had 78% sensitivity, 88% specificity, 40% positive predictive

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value, and 98% negative predictive value.

Current limitations of CT colonography include serious adverse events (0.24%), lower sensitivity for smaller polyps, positive results require follow-up colonoscopy, and unknown effects of cumulative radiation dose if repeated every five years (N Engl J Med 2008 Sep 18;359(12):1207).

These results are consistent with a previously published cohort study with 1,233 asymptomatic adults (N Engl J Med 2003 Dec 4;349(23):2191). For more information, see the virtual colonoscopy topic in DynaMed. In DynaMed Virtual Colonoscopy Under Computed Tomography Colonography (CTcolonography): Cohort studies in asymptomatic adults (screening): • CT colonography identifies 90% asymptomatic adults with polyps > 10

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mm (level 1 [likely reliable] evidence) • based on 2 prospective cohort studies • 2,600 participants ≥ 50 years old had colon cancer screening with multidetector CT colonography and same-day colonoscopy • 2,531 participants (97%) with complete colonographic and colonoscopic results were analyzed • high compliance rates with protocol • 2,482 (98%) took barium sulfate for fecal tagging • 2,390 (94%) took iodinated contrast for fluid tagging • 2,328 (92%) had glucagon given • reference standard was colonoscopy and histological confirmation • prevalence of lesions • 5.2% for lesions ≥ 10 mm (132 participants) • 246 adenoma or carcinoma • 146 nonadenomatous • 10.2% for lesions 5–9 mm (258 participants) • 128 adenoma or carcinoma • 27 nonadenomatous • per-patient predictive performance of CT colonography for adenoma or carcinoma ≥ 10 mm • sensitivity 90% • specificity 86% • positive predictive value 23% • negative predictive value 99% • per-patient predictive performance of CT colonography for adenoma or carcinoma ≥ 6 mm • sensitivity 78% • specificity 88% • positive predictive value 40% • negative predictive value 98% • per-polyp sensitivity of CT colonography • 84% for lesion ≥ 10 mm • 70% for lesion ≥ 6 mm • limitations of CT colonography • serious adverse events reported in 0.24% • lower sensitivity for smaller polyps, but clinical value of detecting smaller polyps uncertain • positive colonography requires followup colonoscopy • extracolonic findings sufficient to trigger additional testing or urgent care in

16%, but few of these findings can be treated effectively • effects of cumulative radiation dose if CT colonography repeated every five years unknown •R eference: N Engl J Med 2008 Sep 18;359(12):1207, editorial can be found in N Engl J Med 2008 Sep 18;359(12):1285 • 1,233 asymptomatic adults (mean age 58 years) had same-day virtual and conventional colonoscopy • c olonoscopists were blinded to virtual colonoscopy findings on initial exam, final unblinded conventional colonoscopy used as reference standard • f or adenomatous polyps > 10 mm • v irtual colonoscopy had 93.8% sensitivity and 96% specificity • conventional colonoscopy had 87.5% sensitivity, specificity not reported • for adenomatous polyps > 8 mm • v irtual colonoscopy had 93.9% sensitivity and 92.2% specificity • conventional colonoscopy had 91.5% sensitivity, specificity not reported • for adenomatous polyps > 6 mm • v irtual colonoscopy had 88.7% sensitivity and 79.6% specificity • conventional colonoscopy had 92.3% sensitivity, specificity not reported • 2 polyps were malignant, both were seen on virtual colonoscopy, 1 was missed on initial conventional colonoscopy • Reference: N Engl J Med 2003 Dec 4;349(23):2191, editorial can be found in N Engl J Med 2003 Dec 4;349(23):2261, commentary can be found in N Engl J Med 2004 Mar 11;350(11):1148, CMAJ 2004 Apr 27;170(9):1392, Am Fam Physician 2004 May 1;69(9):2197, ACP J Club 2004 Jul-Aug;141(1):22 Low Incidence of Advanced Colorectal Neoplasia Five Years After Negative Screening Colonoscopy The incidence of advanced colorectal neoplasia is low five years after negative screening colonoscopy (level 2 [mid-level] evidence), based on a retrospective cohort study of 1,256 patients with no colorectal adenomas at time of first screening. Rescreening occurred at mean 5.34 years later.

The prevalence of adenoma at rescreening was 16% for ≥ 1 adenoma and 1.3% for advanced adenoma. No cancerous lesions were found at rescreening (N Engl J Med 2008 Sep 18;359(12):1218). For more information, see the colonoscopy topic in DynaMed. In DynaMed Colonoscopy Surveillance Intervals — General Population: • incidence of advanced colorectal neoplasia low five years after negative screening colonoscopy (level 2 [midlevel] evidence) • based on retrospective cohort study • 1,256 patients > 50 years old with no colorectal adenomas at first screening (at mean age 56.7 years, 56.7% men) were rescreened at mean 5.34 years later • prevalence of adenoma at rescreening • one or more adenoma in 16% (201 participants) • advanced adenoma in 1.3% (16 patients, total of 19 adenomas, 10 distal to splenic flexure) • no cancerous lesions found at rescreening • men significantly more likely that women to have any adenoma (relative risk 1.88) and advanced adenoma (relative risk 3.3) • Reference: N Engl J Med 2008 Sep 18;359(12):1218, editorial can be found in N Engl J Med 2008 Sep 18;359(12):1285 • DynaMed commentary — by coincidence, mean age was 56.7 years and proportion of men was 56.7%

The DynaMed editorial team includes physicians, other clinicians, and scientists who systematically monitor the literature with a seven-step, evidence-based process. DynaMed provides the best available evidence to healthcare professionals at the point of care. DynaMed (www.ebscohost.com/dynamed) is updated daily, is advertisement free, and is published by EBSCO Publishing.

About the Author:

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{ Scopeofpractice }

T

he physician assistant profession officially was born with the graduation of the first three physician assistants on October 6, 1967, from Duke University in North Carolina. Today there are approximately 80,000 physician assistants (PAs) in the United States. In California, approximately 7,500 PAs practice in medical teams with their supervising physicians.

Physician assistants hold strongly to the tenet of the profession: PAs are part of a physician-lead team.

In 2007, PAs nationwide provided more than 245 million outpatient visits and generated about 303 million prescriptions. According to the U.S. Department of Labor, the number of PA jobs will grow by 27 percent from 2006 to 2016. Currently, there are 141 PA programs in the United States. In California, there are 10 PA programs: • Charles R. Drew University of Medicine and Science • Keck School of Medicine of the University of Southern California • Loma Linda University • Riverside County Regional Medical Center/Riverside Community College

Physician

Assistants PArtners in Medicine

By Miguel Medina 32

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• Samuel Merritt College • San Joaquin Valley College • Stanford University School of Medicine • Touro University at Mare Island College of Health Science • University of California Davis • Western University of Health Sciences.

PA programs must be accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). This is the national accrediting agency for PA programs. The prerequisites to enter a PA program are a minimum of 60 college semester units including biological sciences, chemistry, mathematics, and social and behav-

{ Scopeofpractice } ioral sciences. Most programs require some previous medical experience with direct patient contact exposure. The profession is moving toward awarding a master’s degree as a terminal degree. The length of training varies from 16 months to three years. PAs are taught in programs located at medical schools and teaching hospitals. PA students commonly share classes, facilities, and clinical rotations with medical students (1).

The first year of physician assistant school consists of studies in anatomy, physiology, pathophysiology, pharmacology, pharmacotherapeutics, and genetics. The programs must include training in techniques of interviewing and eliciting a medical history, physical exams across the lifespan, differential diagnosis, ordering and interpretation of lab and radiological studies, documenta-

Physician assistants hold strongly to the tenet of the profession: PAs are part of a physician lead team. tion of physical exam and lab data, and appropriate use of referrals and consultations.

The programs must also include instruction in behavioral and psychological counseling.

In addition, students are provided with in-

struction on oral case presentations and the development of treatment plans. The average length of PA programs is 26 months.

The clinical phase of the programs consists of about 2,000 hours of supervised clinical practice in family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry (2). This broad scope of training prepares the PA to work in primary care. After graduation, some PAs have the option to attend residency programs to extend their fund of knowledge. Some PAs choose to receive on-the-job-training in specialty areas without residency.

All 50 states in the union have PA practice laws. To be licensed, each state requires PAs to graduate from an ARC-PA-accredit-

ed program and to take and pass the Physician Assistant National Certifying Exam (PANCE). State laws are primarily delegatory, i.e., they allow the supervising physician to delegate to the PA patient care tasks that are within the scope of practice of the supervising physician. Each PA’s practice is determined by the supervising physician’s delegation of tasks to the PA. Supervising physicians can observe the competency of the PA and, with time, increase the responsibilities assigned to the PA. The delegatory relationship is unique to the PA/physician team.

In 1995, the AMA House of Delegates adopted the following guidelines for the physician/PA team.

1. The physician is responsible for managing the healthcare of patients in all settings.

2. Healthcare services delivered by physicians and physician assistants must be within the scope of each practitioner’s authorized practice, as defined by state law.

3. The physician is ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of the physician assistant, ensuring the quality of healthcare provided to patients.

depend on the complexity and acuity of the patient’s condition and the training, experience, and preparation of the physician assistant, as adjudged by the physician.

8. Patients should be made clearly aware at all times whether they are being cared for by a physician or a physician assistant.

9. The physician and physician assistant together should review all delegated patient services on a regular basis, as well as the mutually agreed upon guidelines for practice.

10. The physician is responsible for clarifying and familiarizing the physician assistant with his or her supervising methods and style of delegating patient care (3).

Physician assistants in California work in all medical subspecialties. The Physician Assistant Committee is a branch of the Medical Board of California and is in charge of regulating PA practice in the state.

The following are excerpts from the laws and regulations pertaining to PA practice in California: A physician assistant and his or her supervising physician shall establish in writing guidelines for the adequate supervision of the physician assistant, which shall include

e physician is responsible for the Th supervision of the physician assistant in all settings.

5. The role of the physician assistant in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the physician assistant and based on the physician’s delegatory style.

6. The physician must be available for consultation with the physician assistant at all times, either in person or through telecommunication systems or other means.

7. The extent of the involvement by the physician assistant in the assessment and implementation of treatment will

one or more of the following mechanisms: 1. Examination of the patient by a supervising physician the same day as care is given by the physician assistant; 2. Countersignature and dating a 5 percent sample of medical records written by the physician assistant within thirty (30) days that the care was given by the physician assistant. The physician shall select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient; 3. The supervising physician may adopt protocols to govern the performance of a physician assistant for some or all tasks.

4.

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{ Scopeofpractice } PAs must have a written agreement (known as the Delegation of Services Agreement) with their supervising physician, which stipulates the delegation of duties to be performed by the PA. The typical duties performed by PAs include: • Taking a patient history; • Performing a physical examination and making an assessment and diagnosis; • Initiating, reviewing, and revising treatment and therapy plans, including plans for those services, recording and presenting pertinent data in a manner meaningful to the physician; • Ordering or transmitting an order for X-ray, other studies, therapeutic diets, physical therapy, occupational therapy, respiratory therapy, and nursing services; • Ordering, transmitting an order for, performing, or assisting in the performance of laboratory procedures, screening procedures, and therapeutic procedures; • Recognizing and evaluating situations that call for immediate attention of a physician and instituting, when necessary, treatment procedures essential for the life of the patient; • Instructing and counseling patients regarding matters pertaining to their physical and mental health. Counseling may include topics such as medications, diets, social habits, family planning, normal growth and development, aging, and understanding of and longterm management of their diseases.

• Initiating arrangements for admissions, completing forms and charts pertinent to the patient’s medical record, and providing services to patients requiring continuing care, including patients at home.

• Initiating and facilitating the referral of patients to the appropriate health facilities, agencies, and resources of the community.

• Administering or providing medication to a patient or issuing or transmitting drug orders orally.

• Performing surgical procedures without the personal presence of the supervising physician which are customarily performed under local anesthesia. Prior to

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delegating any such surgical procedures, References: the supervising physician shall review 1. American Academy of Physician Assisdocumentation that indicates that the tants. http://www.aapa.org physician assistant is trained to perform 2. Accreditation Review Commission on the surgical procedures. All other surEducation for the Physician Assistant. gical procedures requiring other forms http://www.arc-pa.org/index.html of anesthesia may be performed by a physician assistant only in the personal presence of an approved supervising physician.

• A physician assistant may also act as first or second assistant in surgery under the supervision of a supervising physician (4).

The major benefits of utilizing a PA include giving the physician more time for other functions, increased patient satisfaction as the PA often spends more time with the patient, and also the generation of additional revenue for the practice.

Services provided by PAs are reimbursed by most insurance entities such as Medicare, Medi-Cal, and commercial insurers. PA services under workers’ compensation are also Miguel Medina, left, and his supervising physician, Alan Cundari, DO. Mr. Medina and Dr. Cundari have authorized by the labor code. Genworked together at the Western University of erally, medical services that would Health Sciences for 17 years. otherwise be provided by physicians are covered when delivered by PAs within their scope of practice.

As with any professional, the salaries for 3. American Medical Association. Policy PAs may cover a wide range depending H-160-947. www.ama-assn.org/ama/noinupon the practice setting, the geographic dex/category/11760.html location, and responsibilities assigned. The 4. Physician Assistant Committee of Caliaverage annual total income for PAs in fornia. http://www.pac.ca.gov California in 2007 was generally between 5) California Academy of Physician Assis$80,000 and $100,000. Contracts may tants. https://www.capanet.org include on-call responsibilities, hospital and/or nursing home rounding, a production bonus, and other types of duties and About the Author: Mr. Medina benefits. served in the United Sates Army from 1972 In a busy medical practice, it makes good to 1974 as a medical corpsman. He then sense to hire a PA. Prior to considering such graduated from the University of Southern action, there are excellent resources available California Physician Assistant Program to learn more about how PAs can best be inin 1977 and was appointed to the faculty corporated to meet your specific needs (5). of the Primary Care Physician Assistant Physician assistant laws to practice mediProgram at Western University of Health cine were established in California in 1974.

Sciences in 1991. Mr. Medina is the curToday, PAs work in a variety of medical setrent president of the California Academy of tings and together with their supervising Physician Assistants. physicians provide competent and compassionate care.

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{ Scopeofpractice }

Nurse Practitioner Scope of Practice An Essential Component of Providing Quality Healthcare in California

By Jill Olmstead California’s medical infrastructure is in intensive care. Why? Across the country and particularly here in California, there is a continuing shortage of physicians and nurses. According to a September 2008 Associated Press article, only 2 percent of graduating medical students plan to work in primary care internal medicine, which raises significant concerns about the looming shortage of “first-stop” doctors who once were the foundation of our current medical system.

Increasing access to preventive care, which keeps people healthy and saves the system money, should be a top priority. The California Association for Nurse Practitioners (CANP) has been pushing for solutions that will benefit all Californians, from inner-city residents to rural families, who all need the same access, the same quality, and the same benefits from the healthcare system. In order to increase preventive care, a scope of practice must be defined for nurse practitioners in the state of California.

Nurse practitioners are registered

36

nurses with advanced clinical training and education, most with master’s or doctorate degrees. Nurse practitioners have the ability, training, education, and expertise to diagnose patients, prescribe medications, treat illnesses, and counsel patients on healthcare issues. NPs work side-by-side in collaboration with physicians and other healthcare providers.

Because of our focus on primary care, disease prevention, and counseling, nurse practitioners serve as healthcare first responders for many families. Especially for preventive care and everyday

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issues like weight management, bloodpressure control, dangerous infections and common injuries, nurse practitioners truly are the front-line professionals in California’s health team.

There are now more than 100,000 nurse practitioners nationwide and more than 13,000 right here in California. We often refer to the work we do as “bridging the gaps in healthcare” to meet the needs of patients. Nowhere are these gaps more pronounced and the needs greatest than in rural areas and inner cities.

{ Scopeofpractice } Three out of every five NPs work either in rural settings or in inner cities, where critical preventive care is needed most but is often difficult to come by.

Moreover, the problem could get much worse as budget cuts may make access to healthcare services even more limited. Nurse practitioners serve a very necessary role in our existing healthcare system, particularly in these urban and rural communities.

Here’s the problem we currently face: California is the only state in the country that does not have a defined scope of practice for NPs. That means state law does not explicitly authorize us to diagnose patients, order tests, or refer patients to specialists. These functions are performed on an ad hoc or case-by-case basis and often mean significant delays or outright denial of care.

In other words, bureaucratic and outdated regulations prohibit us from providing care that we are trained and qualified to perform. The lack of a de-

Increasing access to preventive care, which keeps people healthy and saves the system money, should be a top priority. fined scope of practice also means we cannot order “durable medical goods” for patients. That sounds arcane, but let me tell you what it means for patients: • NPs cannot order a walker or wheelchair for a patient who needs one to get around; • NPs cannot order diapers or formula for a newborn baby; • NPs cannot order a blood-pressure cuff for a patient who needs it to manage his or her condition.

State law requires a defined scope of practice in order for insurance companies, Medicaid or Medi-Cal to directly reimburse healthcare providers for their services, meaning more delays and barriers to delivering important patient care.

Without a defined scope of practice, nurse practitioners are finding it difficult and cumbersome to be reimbursed for the services provided, which in turn results in fewer opportunities for nurse

practitioners to provide care.

Some of you may ask, how effective are nurse practitioners? Studies have been done by prestigious medical journals about the quality of NP care and the research is clear: NPs provide highquality care, have high rates of patient satisfaction, and already work in many of the most underserved areas in California.

In January 2008, an issue brief was released by the California Healthcare Foundation on scope-of-practice laws for nurse practitioners. The brief highlighted a state-by-state survey on varying scope-of-practice laws conducted by The Center for Health Professions at the University of California, San Francisco. The survey found that “NPs deliver comprehensive medical services in a variety of settings and specialties, which are largely comparable to physicians, both in scope and medical outcomes.”

Freeing us from needless bureaucracy will enhance our ability to continue to meet the needs of the patients we already serve and allow us to meet the needs of so many more.

Defining a scope of practice is simple and, at the same time, a catalyst for dramatic change. It codifies much of the work we are already doing, such as diagnosing patients and referring them, when necessary, for more specialized treatment.

Unfortunately, current law requires separate “standardized procedures” be developed for every healthcare facility around the state. These “standardized procedures” can and do vary from facility to facility, creating inconsistencies and gaps in care. By having one state standard, we will provide certainty and consistency where it is desperately needed.

Having a scope of practice for nurse practitioners will also strengthen the requirements to be an NP in the state of California and provide more consumer protection by clarifying the responsibilities of the role NPs play in the current healthcare system.

By creating a formal “scope of practice,” NPs will be directly reimbursed for the care they provide to patients — once again, a positive change that will lead to J an u ary

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better, faster care and an increased ability for NPs to see more patients.

Nurse practitioners are fighting for a defined scope of practice in order to make the system more efficient. Nurse practitioners are focused on providing preventive care to ensure patients are healthy and receiving quality care. Expanding access to nurse practitioner services will improve the overall health of patients across the spectrum and minimize the occurrence of more serious conditions that rise from a lack of ongoing preventive care. A healthier population is less likely to utilize the most expensive emergency-room care, improving treatment times for serious emergencies and decreasing the cost to provide such coverage. After all, providing quality healthcare for patients is what physicians and nurse practitioners strive for on a daily basis.

Ms. Olmstead is president of the California Association for Nurse Practitioners. She g r a du a t e d from California State University in Long Beach in 1997 with a master’s of science degree in nursing and a nursepractitioner certificate. She practices full time in Southern California for St. Joseph Heritage Health Foundation in Fullerton.

She was recently awarded the American Academy for Nurse Practitioners’ 2007 Astra Zeneca grant for developing a nurse practitioner-directed program for a “community-outreach program for improving colon cancer screening for the underserved and uninsured population.” She is a current member of the board of directors for the California Colorectal Cancer Coalition (C4), www.cacoloncancer.org.

Ab o u t t h e A u t h o r :

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{ Scopeofpractice }

y g o l o c a m r a h p o h c Psy for

s e i m Dum

r Psychologists

spital Privileges fo o H d n a n o ti p ri sc s Over Pre Legislative Battle

By Steven A. Ornish, MD

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{ Scopeofpractice }

Psychologists’ relentless legislative attempts to gain prescribing rights in the state of California and other states is medicine’s Hydra: that multi-headed mythological beast whereby you lop off one head and two grow back. Senate Bill 1427, the Psychology Licensing Law, giving psychologists the right to prescribe drugs for specific psychiatric disorders, went down in defeat this year, this time. Psychologists’ prescription-privilege legislation has been introduced in innumerable states and has passed in two states and one territory: New Mexico, Louisiana, and Guam.

In 1990, in California Association of Psychology Providers v. Rank, the Supreme Court of California ruled that psychologists could have primary responsibility for patient care in a hospital. Writes the sharply divided majority: “Such disputes over the competence of the professions must be decided by the Legislature, not the courts …we conclude that under California law a hospital that admits clinical psychologists to its staff may permit such psychologists to take primary responsibility for the admission, diagnosis, treatment, and discharge of their patients.”

Since this ruling, the battle has returned to state legislative and regulatory fronts.

Psychologists’ latest strategy in California is to propose changes in state regulations granting hospital privileges permitting “attending” psychologists to oversee patient care on inpatient psychiatric units, hospitals, skilled nursing facilities, intermediate care facilities, chemical dependency hospitals, and correctional facilities without physician supervision. The California Department of Public Health has proposed regulations that grant medical decision-making authority and responsibility to hospital-based psychologists. The regulations would allow psychologists to direct overall care without physician supervision, including the authority to admit, discharge, write orders, perform consultations, and order seclusion and restraint. Essentially, psychologists would be given equal footing as physicians and permitted to function as psychiatrists on psychiatric units and in other institutions and facilities without the years of req-

uisite medical and residency training that psychiatrists undergo.

What is driving this movement by psychologists is primarily economics: an oversupply of doctoral-level psychotherapists; a decrease in reimbursement for psychotherapy with preferential reimbursement for medication monitoring; and a concurrent increase in the demand for less-costly mental health services (1). As psychiatric treatments have become more scientifically and biologically based, psychologists are feeling increasingly squeezed in our managed-care era and want to expand their scope of practice into areas that currently fall within the purview of medicine.

An additional driving force is PhRMA, which has an economic interest in expanding the number of professionals who can prescribe psychotropic medications. For example, the cost of the medication alone for treating one patient for one year with one of the newer antidepressants such as Cymbalta is $1,512 (assuming $4.20/pill) (2). Psychologists with prescribing privileges would provide a greatly expanded pool of prescribers of psychotropic medications for the pharmaceutical industry and likely an increased pool of patients receiving their products, thus increasing profits.

Since July 2002, New Mexico psychologists have been permitted to gain prescribing privileges, after completing 450 hours in neuroscience, pharmacology, psychopharmacology, physiology, “laboratory assessment,” and clinical pharmacology. Psychologists in New Mexico must also spend

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at least 400 hours treating at least 100 patients with mental disorders under the close supervision of a psychiatrist or other physician. The supervising “other physician” can be a family physician, or from any specialty for that matter. Dr. Joel Yager, professor of psychiatry at the University of New Mexico, described this training as “psychopharmacology for dummies” (3). In 2004, Louisiana became the second state authorizing psychologists to prescribe psychotropic medications.

In contrast to the 450 hours of requisite didactic study and 400 hours “treating” patients by psychologists seeking prescribing privileges, to receive a doctor of medicine (MD) degree in the state of California requires a minimum of 4,000 hours of study learning biochemistry, physiology, pathology, neurology, internal medicine, general pharmacology, etc. The average number of hours spent by a psychiatry resident learning patient evaluation and treatment selection, psychopharmacology, adult psychopathology, behavioral science, social psychiatry, psychosocial therapies, differential diagnosis, growth, and development is 11,520 hours (4). Therefore, a board-certified psychiatrist has more than 15,000 hours of supervised medical school and psychiatric residency training, or fifteen times the hours required by a psychologist attempting to qualify for prescribing privileges in New Mexico.

The late Maurice Rappaport, MD, PhD, both a psychiatrist and a psychologist, and a past president of the California Psychiatric Association, was particularly outspoken over this issue: “What the psychologists are What is driving this movement asking for is the by psychologists right to practice is primarily medicine without economics. going to medical school — that’s as dangerous as it is ludicrous. ... Psychologists are trying to achieve through legislation what they don’t achieve through education”(5).

In 1991, the Military Health System (MHS) of the Department of Defense (DoD) instituted the Psychopharmacology Demonstration Project, which was

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{ Scopeofpractice } permitted to write a prescription for some Biaxin or a Z-pak — that’s a no-brainer.

Headaches are a common psychosomatic symptom presenting to psychologists; how much training is required to prescribe a few Vicodin or Percocet to relieve the somatic suffering of their patient in front of them?

The erroneous belief by some psychologists that practicing psychopharmacology is relatively simple may stem from their observing a competent physician prescribe psychotropic medications to an uncomplicated patient. One’s ability to recognize the complexities of a patient, and competently manage his or her psychotropic medications and adverse reactions, is directly proportional to the depth and breadth of one’s medical education and experience, and flows from the deep culture of medicine. Hypothetically, a psychologist could designed to train and use military psychologists to prescribe psychotropic medications. Ten psychologists were trained, and in 1997, after spending $6.1 million, the DoD canned the program as a failure after

sure by these psychologists (or supervising psychiatrists), since under the Feres Doctrine active duty military personnel are immune from lawsuits for injuries that they have caused to other military personnel by their negligence, gross or otherwise.

Dependents, however, can still sue the federal government if subject In contrast to the 450 hours to medical malpractice. While psyof requisite didactic study and chologists often disingenuously re400 hours “treating” patients by fer to this experiment as a success, psychologists seeking prescribing the DoD cancelled the program, privileges, to receive a doctor of medicine (MD) degree in the and there are no psychologists prestate of California requires a scribing in the Navy today. minimum of 4,000 hours of study.

Despite the failed and defunct DoD Psychopharmacology Demonstration Project, psychologists the General Accounting Office (GAO), working within the California Department the congressional “watchdog” agency, perof Corrections have proposed a similar pilot formed a detailed audit and concluded that project for prescription training. Interestthe average yearly cost of using a psycholoingly, in California, the Office of Statewide Health Planning and Development has the gist to prescribe medications in contrast to authority to waive scope of practice laws for treating patients with the combination of “innovative pilot projects.” psychiatrists and psychologists in their traWhy not give psychologists prescribing ditional roles was 7 percent higher and not privileges? After all, how much skill does it cost-effective. From the GAO report: take to write a prescription for Lexapro for “Training psychologists to prescribe medication is not adequately justified because MHSS a depressed patient? And why stop there? has not demonstrated a need for them, the cost is If the psychologist’s patient complains of a substantial, and the benefits are uncertain” (6). productive cough during his or her therapy Moreover, there was reduced legal exposession, why should the psychologist not be

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be trained to do an uncomplicated appendectomy after 450 hours of training, but it is inconceivable that the state of California would grant a psychologist surgical privileges. Nor would we permit airline mechanics to fly commercial jets after a crash course (no pun intended) to save costs and serve underserved areas.

The issue at hand is not whether a nonphysician can be trained to write for a standard dose of a psychotropic medication in

{ Scopeofpractice } an uncomplicated patient. In fact, they can agents, have effects not only on the brain but and physician nurse practitioners and assisalso on multi-organ systems, have potential tants do it routinely throughout the counserious side-effects and adverse reactions, try, but only after years of medical training and can cause disability and death, which and always under the supervision of a phyis why they are not sold over-the-counter. sician. How can anyone reasonably believe Making correct diagnoses and recognizing that psychologists, with absolutely no medicomplex and potentially life-threatening cal training whatsoever, not even knowing adverse reactions of psychotropic medicahow to take a blood pressure, could adtions requires a deep, multidimensional, equately prescribe medications without any in-depth understanding not only of pharphysician supervision? macology, but also of physiology, internal The “deep structures” of psychiatry medicine, pathology, neurology, drug-drug and psychology are also quite different. interactions, mitochondrial enzyme pathAlthough both disciplines deal with the ways, receptor functionality, and biovaripsyche, psychiatry’s roots are firmly planted ability. Psychologists simply do not have in the healing arts of the Hippocratic trathe requisite training to formulate medical dition dating back to ancient Greece in differential diagnoses and rule out medi400 BCE. Psychology, in contrast, has its roots in the clinic established by LightWhy not give psychologists ner Witmer at the Universiprescribing privileges? After all, ty of Pennsylvania in 1896, how much skill does it take to whose work involved treatwrite a prescription for Lexapro ing intellectually impaired for a depressed patient? children with remedial education (7). Since psychologists are trained in human development and cal causes of psychiatric symptoms. Nor behavior, and not medicine, their approach do psychologists have the necessary medito psychiatric diagnoses is psychosocial and cal training to recognize and manage comsymptom-based, not medical. As Hippoplex adverse reactions from psychotropic crates wisely stated, “Life is short, science is medications such as prodromal neuroleptic long; opportunity is elusive, experiment is syndrome presenting as a low-grade fever; dangerous, judgment is difficult”(8). lithium-induced nephrogenic diabetes inIt is naive to suggest that a didactic crash sipidus presenting as polyuria; delirium course in pharmacology with 10 weeks’ secondary to low-dose benzodiazepines in equivalent of supervised patient care will the elderly with a superimposed urinary safely supplant what otherwise requires tract infection; the serotonergic syndrome eight years of intensive study in medical from SSRIs presenting as fever and confuschool and residency, especially in the absion; and the metabolic syndrome presentsence of any grounding in the basic mediing with secondary diabetes mellitus from cal sciences. A study by Robert Sbordone, atypical antipsychotics — to name a few.

PhD, found that clinical psychologists In the state of California, medical malfailed to recognize that a patient required a practice or medical negligence occurs referral to a neurologist 50 percent of the when a doctor or other healthcare provider time when presented with clinical vignettes breaches his or her duty to perform treatof patients with obvious neurologic disease ment to a patient in accordance with the (9). If psychologists can purportedly safely “standard of care.” The “standard of care” and competently prescribe psychotropic in California requires that a healthcare promedications after remedial course work and vider exercise adequate skill, knowledge, limited supervision by a nonpsychiatrist, and care ordinarily possessed and exercised why not be more egalitarian and permit by other members of the profession actsocial workers, psychiatric nurses, marriage ing under similar circumstances. Should and family counselors to do the same? psychologists be granted prescription priviPsychotropic medications are potent leges, what does this mean for the standard

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of care? Will there be a double-standard of care: one for physicians and one for psychologists?

Should psychologists prevail in California and other parts of the country with this dangerous experiment now being performed in New Mexico, Louisiana, and Guam, the result will be harm to patients and increased litigation. Psychologists with prescribing privileges will diminish the hardearned professional identity not only of psychiatrists, but of all physicians, because the public will not discern the blurred differences among “doctors.” The power granted to physicians by the state to prescribe is not a “right,” it is a privilege earned by the topof-the-class students who were carefully selected to undergo an average of eight years of intensive medical and residency training in institutions with high, uniform standards carefully monitored for quality.

References: 1. Lavoie K, Barone S. Prescription privileges for psychologists. CNS Drugs. 2006;20(1):51-66.

2. www.costco.com 3. Goode E. “Psychologists get prescription pads and furor erupts.” NY Times. March 26, 2002.

4. Private communication from the Student Affairs Office, UCSD School of Medicine.

5. www.mdpsych.org/Feb96_nWarres.htm 6. U.S. General Accounting Office. Report to the Chairman and Ranking Minority Member, Committee on Armed Services, U.S. Senate. Defense healthcare: Need for more prescribing psychologists is not adequately justified. April 1997.

7. Pies RW. The “deep structure” of clinical medicine and prescribing privileges for psychologists. J Clin Psychiatry. 1991; 52(1):4-10.

8. Lloyd, GER, Chadwick J, Mann WN. Hippocratic Writings. Penguin Classics 1984.

9. Sbordone RJ, Rudd M. Can Psychologists recognize neurological disorders in their patients? J Clin Exp Neuropsychol. 1986;285-291.

the A u t h o r : Dr. Ornish is double-board-certified in general and forensic psychiatry and has a private practice in Mission Valley. He is an associate clinical professor (voluntary), UCSD School of Medicine, Department of Psychiatry. Dr. Ornish holds a seconddegree black belt in karate.

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(619) 659-9555. [657] Mission Hills Office for Sale: Why rent when you can own? North Mission Hills physician’s office for sale. Beautifully restored house located in the West Lewis Planned District. Classic hardwood floors, stained glass, craftsmanship woodwork throughout, recessed lighting, complete exam rooms, two patient waiting areas, and four offices.

Neighborhood atmosphere; perfect for primary or specialty practice. Ample street parking. Mills Act designation with significant tax savings. Call Annamarie Clark at (619) 962-2095 for photos and appointment. [610]

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.

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History of Medicine

Dragon Bone Questions Fever Answered

By William Haney, MD

T

raditional Chinese Medicine, or “TCM,” includes some rather bizarre and even offensive substances when viewed through Western eyes. One such medication even borders on the mythical. “Dragon bones” have existed in Chinese apothecary shops for hundreds of years, indeed right up to the present day. The dragon has deep roots in Chinese legend and myth. It is the traditional symbol of the “Dragon Throne” of China. Ornamental dragons abound in Chinese art, sculpture, clothing, celebrations, ceremonies, and more.

In distinction to the evil, warlike dragon of today’s movies and literature, the Chinese dragon was a benevolent and protective deity.

Traditional Chinese believed that “fossilized” animal bones dug out of the earth were the remains of these dragons and that they were associated with good fortune, fertility, and powers to heal.

Ground to a powder and taken with tea, they were recommended for malaria, kidney disease, female troubles, dysen-

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tery, gallstones, liver disease, insomnia, palpitation, and other maladies.

And there would end this interesting and rather amusing footnote in the history of pharmacology but for a serendipitous event.

Two hundred miles south of Beijing lies the valley and village of Anyang. In this fertile pastoral countryside, peasant farmers have been unearthing fossilized animal bones for hundreds of years.

These “dragon bones” found their way into apothecary shops throughout China. In 1899 a Chinese scholar named Wang Yirong prepared to grind up “dragon bones” that had been prescribed for his malaria. He noted some strange symbols and scratches on the surface of the fragments that looked like the modern Chinese symbols for “moon” and “sun.” He became convinced that these markings represented an ancient script identifying the prehistoric Shang Dynasty, which had heretofore been regarded as only a myth. Experts agreed! A veritable “bone fever” gripped scientists

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and profiteers alike. The bone rush was on. To date more than 100,000 pieces of bone displaying carved words have been found in the Anyang Valley. These are the earliest significant written records in Chinese history. China’s earliest dynasty, the Shang (1523–1028 BCE) has been dated and verified.

The Anyang bones represent a specific category of “Dragon Bones.” The scapula of the ox and the tortoise shell in particular were used in royal ceremonies as “diviners.” Apparently, symbols were carved into the bone. Heat was then applied to crack the bone. The pattern of the cracks was then “read” by diviners or fortunetellers. Questions regarding weather, illness, agriculture, births, deaths, etc., were answered. The Anyang bones became known as “oracle bones.”

The apothecary shops and their bones along with the bone fever that followed their recognition led to several significant discoveries in Chinese history: 1. The Shang Dynasty, one of the world’s earliest civilizations, was identified and validated.

2. Chinese history was lengthened by almost 2,000 years.

3. The earliest significant Chinese writing was discovered.

4. Dragon bone fever led directly to the discovery of the Peking Man in 1927, one of the world’s first hominids.

5. The science of archeology was established in China.

6. A school of historians known as the “Doubters of Antiquity” was silenced.

Whatever their value in modern pharmacology, “dragon bones” occupy a unique position in history, archeology, anthropology, and in the understanding of traditional medicines of the past.

Ab o u t the A u t h o r : Dr. Haney, a retired ophthalmologist, has held a longtime interest in the history of medicine, often contributing articles to San Diego Physician.

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