July/August 2014 by San Francisco Marin Medical Society

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

Sugar | Tobacco | Nuclear Weapons Guns | Saturated Fat | Radiation

LEGAL BUT LETHAL Physicians Challenging Lethal but Legal Corporate Practices

Plus

MICRA/Update on Prop 46

VOL.87 NO.6 July/August 2014

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IN THIS ISSUE

SAN FRANCISCO MEDICINE June 2014 Volume 87, Number 6

Legal but Lethal FEATURE ARTICLES

MONTHLY COLUMNS

12 Physicians Making Change: Challenging Lethal but Legal Corporate Practices Nicholas Freudenberg, DrPH

Membership Matters

President’s Message Lawrence Cheung, MD, FAAD, FASDS

14 Chocolate-Flavored Nicotine: Taming the “Wild West” of Electronic Cigarettes Robert K. Jackler, MD 17 Sugar: The Ditch of American Health Care Robert H. Lustig, MD, MSL

19 Food and Beverage Advertising: The Science That Supports a Ban Jeff Ritterman, MD

20 Flying Blind: The Public Health Impacts of Wireless Radiation Devra Davis, PhD

11 Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH 28 Medical Community News 30 Ask the SFMS 32 Ten Questions: Interview with Dexter Louie, MD, JD, MPA 34 Classified Ads 34 Upcoming Events

23 Disarming Nuclear Weapons: Countering the Nuclear War Profiteers Robert Gould, MD

OF INTEREST

27 Fed Up: A Movie Review John Maa, MD

24 Maligned but Benign: Readjusting Perspectives on Dietary Fat Sean Bourke, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

6 Oppose the Proposed MICRA Ballot Measure In My Opinion: Time to Stand Up for Women and Contraception Mervyn F. Silverman, MD, MPH; Harvey J. Cohen, MD, PhD; Steve Heilig, MPH

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

The proposed rule was published in the Federal Register on July 11. CMS will accept comments until September 2.

MICRA Lawsuit Measure Assigned Proposition Number; Physicians Asked to Support “No on 46” Campaign The trial lawyer-sponsored measure that would alter California law to increase the limits on medical malpractice compensation to about $1.1 million and mandate random drug testing for doctors has qualified for the November ballot as Proposition 46. If approved by voters, Proposition 46 would increase health costs, reduce access to care, and threaten patient privacy, all to make it easier and more profitable for lawyers to sue doctors and hospitals. In addition to increasing the overall number of medical lawsuits and the cost of health care across the board, Proposition 46 contains a number of unrelated provisions designed to mislead and deceive voters—including a little-discussed mandate relying on a massive expansion of a government-run prescription drug database, which third-party analysts say cannot be implemented as written and will leave personal medical information vulnerable to privacy breach. For these reasons, CMA/SFMS, health providers, education groups, labor unions, business organizations, educators, and community clinics have all announced their opposition to Proposition 46. For more information on the negative impact of Proposition 46 on Californians and access to health care, please see page 6 or visit www.noon46.com.

2015 Medicare Fee Schedule Includes Chronic Care Billing Code, Telehealth Service Coverage

CMS’ 2015 Medicare Physician Fee Schedule (PFS) proposed rule contains updates to the PFS, adds several services that Medicare could cover under its telehealth benefit, and makes changes to some of the disclosure provisions in the Physician Payment Sunshine Act. If adopted, physicians could begin billing separately for chronic care management (CCM) services. The proposed rule establishes a code with a payment rate of $41.92 that could be billed no more than once per month per qualified patient for Medicare beneficiaries with “multiple, significant chronic conditions (two or more),” according to CMS. In addition, the rule would allow more flexibility in supervising clinical staff providing CCM services. Telehealth services CMS proposes to cover under Medicare include annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services. 4

DMHC Investigating Anthem and Blue Shield Provider Networks

The Department of Managed Health Care (DMHC) recently began conducting a “non-routine audit” of Anthem Blue Cross and Blue Shield of California to investigate the accuracy of the plans’ provider directories and identify whether either plan violated any network adequacy laws. According to the DMHC, consumer complaints about access issues for both plans prompted the investigation. Blue Cross and Blue Shield are the only two exchange plans using narrowed provider networks for their exchange and “mirror” products. The state is looking at whether the networks are too narrow in some counties, making it difficult for enrollees to find participating providers. A recent survey of California physicians found that there is also widespread confusion about exchange plan contracting among providers, with 80 percent of physicians stating they had been confused about their participation status. SFMS/CMA has urged Covered California to address this and other issues before the next open enrollment period. As part of the audit, DMHC has hired pmpm Consulting to contact practices to survey the accuracy of the networks both plans have posted on their websites. SFMS/CMA strongly encourage practices to respond to their questions if contacted by pmpm Consulting. This is an investigation into the accuracy of the plan directories and whether the plans have violated any laws, not an investigation of physician practices. DMHC expects to complete its investigation in approximately sixty days. Findings of the survey will be released publicly prior to the next Covered California open enrollment period, which is scheduled for November 15.

Error on Anthem ID Cards Results in Claim Denials

Many Bay Area physician practices report claim denials from Anthem Blue Cross for providing services to patients that Anthem had confirmed to be in Covered California/mirror PPO. While Anthem is offering a PPO product for their Covered California/mirror patients in most counties, they are only offering an EPO product in San Francisco, Los Angeles, Orange, and San Diego counties. The Anthem EPO product does not provide any benefits if patients receive services from out-of-network physicians/facilities. SFMS/CMA escalated the issue to Anthem and learned that Anthem had mistakenly distributed incorrect ID cards and information. At our urging, Anthem corrected the affected patient ID cards and reissued new cards to EPO patients in May. Anthem

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

also confirmed they have updated the information that displays when physicians verify eligibility to accurately reflect the correct product type. However, Anthem has stated it will not automatically reprocess affected claims, and it requires patients to appeal each individual claim. Patients who are unsuccessful in their appeal to Anthem can contact the Department of Managed Care’s Help Center at (888) 466-2219.

Health Net Requesting Amendment to Physician Contracts to Disclose Reimbursement Rates

Health Net recently notified physicians who are currently participating in its Covered California individual/exchange and/or SHOP HMO and PPO products of a request to amend the Health Net Provider Participation Agreement. The notice explains that Covered California has imposed a requirement that qualified health plans (QHPs) make reasonable efforts to obtain agreement from participating physicians to allow plans to share physicians’ reimbursement rates with the exchange. It is each physician’s decision as to whether or not he or she is interesting in amending the contract to allow the sharing of reimbursement rates with Covered California. Physicians who are interested in amending their agreements should contact Health Net Provider Services at hnprovidercontracts@healthnet. com by July 30. Physicians’ participation status will not be affected should they decide not to amend their contracts.

Medical Board of California Physician Licensing Delays

The Medical Board of California is asking physicians who need to renew their medical licenses to do so early due to delays associated with the implementation of a new online licensing and enforcement system. This transition is resulting in disruptions in cashiering and other services and is affecting both online and mail renewals. Currently, the medical board is experiencing delays of six to eight weeks to update its website and provide physicians with a current wallet license. If your license expiration date is approaching and you have submitted your renewal application but it has not yet been successfully processed, SFMS recommends that you contact the medical board at (916) 263-2382 for an update on your licensing status. If you have not yet submitted your renewal application to the medical board, do not submit it to the P.O. box listed on the renewal notice, as it may not be processed prior to your expiration date. For faster service, the medical board recommends submitting the renewal application to Medical Board of California, 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815.

SCOTUS’ Contraception Ruling Will Have Little Effect on California

California health insurance officials predict that most women in the state will not be affected by the U.S. Supreme Court’s 5-4 ruling that closely held companies can claim a religious exemption from the Affordable Care Act’s contraceptive coverage mandate. Observers say that California women’s access to contraceptive coverage largely will not be affected by the ruling because it applies to federal laws, not state laws. Planned Parenthood Chief Counsel Beth Parker said California in 1999 enacted the Women’s Contraceptive Equity Act, which “ensures that insurance companies must provide coverage for a variety of FDA-approved contraception.” Corporations that self-insure for coverage—and therefore pay their own medical claims—are exempt from WCEA. California Department of Insurance spokesperson Janice Rocco said the number of companies like Hobby Lobby that fall into both the categories of “closely held” and selfinsured is likely to be small in California. WWW.SFMS.ORG

July/August 2014 Volume 87, Number 6 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD Payal Bhandari, MD David Pating, MD SFMS OFFICERS President Lawrence Cheung, MD President-Elect Roger S. Eng, MD Secretary Richard A. Podolin, MD Treasurer Man-Kit Leung, MD Immediate Past President Shannon UdovicConstant, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Ariel Young BOARD OF DIRECTORS Term: Jan 2014-Dec 2016 Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Adam Schickedanz, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2012-Dec 2014 William J. Black, MD Andrew F. Calman, MD John Maa, MD Todd A. May, MD Kimberly L. Newell, MD William T. Prey, MD Steven H. Fugaro, MD

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

PREVENT COSTS. PROTECT ACCESS.

Protecting Access to Quality Healthcare and Patient Privacy - Oppose the MICRA Measure.

CMA HAS FOUGHT TO PROTECT MEDICAL LIABILITY REFORM, HELPING TO KEEP HEALTH CARE COSTS DOWN AND ACCESS A REALITY FOR PATIENTS THAT NEED IT MOST.

CMANET.ORG/MICRA Oppose the Proposed “MICRA” Ballot Measure A Costly Threat to Your Personal Privacy Californians Can’t Afford In less than 150 days, voters will be asked to weigh in on the MICRA (Medical Injury Compensation Reform Act) health care lawsuit measure, Proposition 46, which will hugely jeopardize the privacy of patients’ personal prescription medical information. The initiative will force doctors and pharmacists to use a massive statewide database known as the Controlled Substance Utilization Review Evaluation System (CURES), which is filled with patients’ personal prescription drug information. Though the database already exists, it is underfunded, understaffed and technologically incapable of handing the massively increased demands that this ballot measure will place on it. While the general concept of the CURES database may be helpful, Prop 46 will force the program to respond to tens of millions of inquiries each year— something it simply isn’t set up to do in its current form or functionality. A system unequipped to handle these requirements will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing some patients 6

much needed medications. Most concerning, the massive ramp up of this database will significantly put patients’ private medical information at risk and the ballot measure doesn’t contain any provisions or funding to help upgrade the system or increase the database’s security standards. The CURES database contains highly sensitive patient information including personal and potentially stigmatizing details about their health. Prescription information including medication used to treat obesity, narcolepsy, conditions related to cancer and AIDS, asthma and other sensitive information are all contained within the CURES database. The ballot measure’s massive ramp-up of the CURES database comes with no funding for technological improvements and will lead to unintended problems. In recent weeks and months, the coalition to oppose the MICRA health care lawsuit initiative continues to grow. Teachers, health care workers, local community groups and hundreds of others have pledged to vote NO in November because they too understand the implications this measure would have on patients, taxpayers and consumers across the state. We know that if this measure passes, it won’t just be putting patients’ personal medical information at risk, but malpractice lawsuits and payouts will also skyrocket, adding “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Leg-

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

islative Analyst. State and local governments face higher costs in two ways: • They provide health care for current and retired employees; • They provide health care for low income residents through Medi-Cal and other locally run health care programs like community clinics and hospitals. Someone will have to pay for these increased costs, and that someone is providers, taxpayers and consumers. The campaign opposed to the initiative—“Patients and Providers to Protect Access and Contain Health Costs”—is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals.

MICRA UPDATE: CALIFORNIA DEMOCRATIC PARTY REMAINS NEUTRAL ON PROP. 46

You’ve been hearing about the campaign to oppose the costly MICRA health care lawsuit initiative for many months now, so how can you get engaged?

were to pass, health care costs would go up,

• Signed up to be a hospital coordinator in your area. We’re always looking for informed and engaged physicians to help educate about the dangers of this initiative. Visit http://www.cmanet.org/issues-and-advocacy/cmas-topissues/micra/join-the-fight/ for more information.

Backers of Proposition 46, the MICRA lawsuit measure, were dealt another severe blow when the Executive Board of the California Democratic Party (CDP) rejected their efforts to gain an endorsement, instead voting to remain neutral. Over the course of the three-day meeting, Democratic Party leaders and activists who reviewed Prop. 46 found that, if the initiative access to care would go down, community clinics would be harmed and personal privacy will be put at risk. Understanding its potentially devastating effects, traditionally Democratic groups such as the American Federation of State, County

• Add your name on the growing list of individuals and groups opposed to the MICRA health care lawsuit initiative.

and Municipal Employees (AFSCME), Service

• Need more information? Check out the campaign website www.NoOn46.com to learn more about the impacts this ballot measure would have on health care and your patients.

California Teachers Association, Planned

Employees International Union (SEIU), the Parenthood, and the American Civil Liberties Union (ACLU) have all opposed Prop. 46, and advocated against the measure throughout the weekend, helping secure the neutral

United as one voice, advocating for patients across the state, we can defeat this ballot measure in November, but we need everyone to commit and become engaged along the way. Thank you in advance for all that you do and all that you’ll continue to do.

position. These groups were also joined by physicians, medical students and health care providers from around the state, each of whom would have their practices threatened by the flawed and deceptive Prop. 46. The CDP has been a stronghold of the trial attorneys so getting it to take a neutral stand on the proposition is a big success for the No on 46 campaign. More information about Prop. 46’s dangerous impacts, as well as a list of the unprecedentedly broad coalition opposing the measure, can be found at www.NoOn46.com.

WWW.SFMS.ORG

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

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A N o r c A l G r o u p c o m pA N y

PRESIDENT’S MESSAGE Lawrence Cheung, MD, FAAD, FASDS

Guns and Mental Health: Past Time for Action After the Sandy Hook Elementary School shooting in Newtown, Connecticut, and the more recent Isla Vista shooting, it is clear that gun control, particularly in regard to circumstances involving mental illness, should come under greater scrutiny and regulation. Specifically in the case of Isla Vista, it is appalling that the parents of the perpetrator were so perturbed by his behavior that they had tried in vain to help their son by requesting law enforcement officers to check on him, but no action was taken. In response, California Assembly members Nancy Skinner (D-Berkeley), Das Williams (D-Santa Barbara), and State Senator Hannah-Beth Jackson (D-Santa Barbara) introduced a bill (AB 1014) that would allow a temporary gun violence restraining order. In brief, AB 1014 (Gun Violence Restraining Order) prohibits the possession, ownership, or purchase of firearms by someone who may pose a danger to him- or herself or to others; it also allows for law enforcement officers to search and remove those firearms. This bill is modeled after California’s current domestic violence restraining order system; however, there are several key differences. Compared with a domestic violence restraining order (DVRO), which only a person with a close relationship to the individual may request, anyone would be allowed to request a gun violence restraining order (GVRO). In addition, for a court to issue a DVRO there must be a showing of abuse, while in GVRO, the standard is lowered to that of a risk of harm to oneself or others. Furthermore, there are three types of domestic violence restraining orders, each with clear due process: (1) Emergency Protective Order (which takes effect immediately and can last up to seven days), (2) Temporary Restraining Order (which can last twenty to twenty-five days), and (3) Permanent Restraining order (which can last up to three years). The process to request a GVRO differs in that once it has been issued, law enforcement agents would be required to serve the order on the restrained person, at which time all firearms and ammunition would be removed and the restrained person would be informed that he or she is entitled to a hearing within fourteen days. The initial GVRO is only valid for fourteen days unless the petitioner requests the court (with an additional hearing) to extend the GVRO for up to one year. A final note on GVRO is the successful enforcement of the order. Already, all persons under a DVRO must surrender their firearms, but the rate of recovery ranges from approximately 22 percent in San Mateo County to 51 percent in Butte County. Since the mechanism of enforcement is conceivably the same with GVRO, these figures will serve as an approximate successful recovery rate of firearms. It is of considerable interest that similar national legislative efforts are also under way. U.S. Senators Dianne Feinstein and Barbara Boxer (both D-CA) introduced the Pause for SafeWWW.SFMS.ORG

ty Act in the Senate, while Congresswoman Lois Capps (D-CA) introduced the bill in the House. This act is very similar to AB 1014 in that a GVRO may be temporarily imposed on someone who poses a threat to him- or herself or others and that the GVRO will prohibit the purchase and possession of firearms. A law enforcement officer would be able to take temporary possession of the firearms from the restrained individual. Additionally, the Act specifically directs law enforcement to make use of all existing state and local gun databases when evaluating a GVRO request. There is also an additional provision to create a new grant program that would help support these efforts. Why is this important to us? As physicians, we deal with patients who may potentially pose harm to themselves or others. It is important that we educate our patients and their families that there are harm-reduction means available. As the current debate about implementation of Laura’s Law in San Francisco illustrates, it can be difficult to balance individual rights with medical needs and, more important, public safety. In most cases such a balance is possible, and we have a moral imperative as a society to continually strive to achieve this balance. To achieve this requires a certain amount of compromise by all concerned, and mechanisms of due process must be meticulously implemented. The gun control debate is one of the most polarized and acrimonious in our society, but with respect to mental illness, almost everybody agrees that gun access should be limited. And while most agree that better access to quality mental health services is imperative as well, this is not an “either-or” issue—limits on gun access and better monitoring of high-risk individuals are also crucial. Arguing against even that is arguing in favor of a tragic status quo.

SFMS General Meeting—All Members Welcome RSVP today for SFMS’s General Meeting at the Golden Gate Yacht Club, September 8, from 6:00 p.m. to 7:30 p.m. This is a good opportunity both to meet with SFMS leadership and to learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California. Dinner will be provided. Please RSVP before September 2 to Posi Lyon at (415) 561-0850 extension 260 or at plyon@sfms.org. JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

Following—and Fighting—The Money Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.—Rudolph Virchow, MD, 1821–1902 What role should the medical profession play in nonclinical efforts to better health? It’s a huge question, with answers ranging from “taking care of patients is enough and all we should be concerned with” to the perspective of the famed Dr. Virchow, quoted above. We choose to believe that this is not an either/ or issue—medicine can and does and should do both. Despite many assaults, deserved or not, physicians remain among the most respected and trusted professionals. Our collective voice can matter and can influence policies that improve health— depending, of course, on how we use it. The SFMS has a long tradition of being advocates for the public’s health—our earliest archive contains a report from the 1800s, when SFMS leaders were enlisted to do some form of “harm reduction” at opium dens in Chinatown. The SFMS has been involved in many health issues ever since. A century later, for example, it became embroiled in analogous debates about syringe exchange and other harm-reduction issues. One of primary routes of our advocacy is via our elected delegation to the California Medical Association. The CMA policy process is democratic in the true sense of the word, and adopted policies can be influential in Sacramento—and even nationally, if adopted by the AMA to guide their legislative and other agendas. Examples of our impact are legion, but here are just a few. And, per our journal’s theme this month, it is notable that many of them unavoidably involve some conflict with those who profit from the status quo. Sugar taxation: The current San Francisco “soda tax” campaign is about both battling health impacts of sugar in individuals and covering some of the “external costs” of overconsumption. The backlash from the high-profit beverage industry is predictably intense. Which elicits a déjà vu reaction regarding . . . Tobacco limits and taxes: SFMS was an early advocate for banning smoking in workplaces and restaurants and other public places, and for increased taxes to compensate for costs and to fund antitobacco efforts. A new frontier here, where SFMS has also been active, involved regulation of electronic cigarettes. The tobacco industry’s pushback has amounted to a predictable “world war”—with commensurate casualties. Antibiotic overuse: It is clear that overuse leads to dangerous bacterial resistance; the discovery that three-quarters of all antibiotics produced are used in agriculture spurred SFMS to take a lead on curtailing such use—with predictable and continuing resistance from “Big Pharma.” Environmental health: Since the founding at the SFMS in 2002 of a national environmental health network chaired by UCSF Chancellor Phil Lee, MD, SFMS has brought forward numerous policies aimed at decreasing human exposure WWW.SFMS.ORG

to harmful industrial chemicals. As the success of those policies would have a financial impact on the chemical industry (and others), the resistance has been strong. Firearms: The “gun control battlefield” is a bloody one, and SFMS efforts have been to find helpful approaches that might stay out of the central fray; thus our policies to tax ammunition for health costs, preserve physician-free speech related to guns, and so forth. But all are resisted by a gun lobby that has been shown to be more focused on profits than on any Constitutional arguments. Pharma/device marketing: SFMS has advocated for restrictions on off-label promotions, and a ban, or at least severe curtailing, on marketing embedded at the bedside—in hospitals, medical schools, conferences, and so forth. We have also called for “take-back” programs to reduce medication diversion and pollution. Response so far: as expected. Road safety: SFMS has advocated for more restrictions and higher fines on use of phones while driving. The telecommunication industry has so far neutralized such efforts. And so on—there are many more examples. As evidenced by our authors in this issue, much of this advocacy has recently moved into the food arena. Now, it should be acknowledged that some of our adversaries in these efforts are otherwise our partners—pharmaceutical and hospital interests being the most obvious examples—but we are certainly not “antifarmer” either. As Professor Nicholas Fruedenberg, our lead author here, notes in his new book Lethal but Legal: Corporations, Consumption, and Protecting Public Health—which has inspired our own theme title—this does not mean that people working in those industries are “bad.” They are doing their jobs in the system we live and work within, and each of us must work within our own needs, constraints, and conscience. But that doesn’t mean that those of us trained in and concerned about health cannot and should not take a leading role in “following the money” as we heed scientific evidence and medical imperatives to improve our patients’ and communities’ health. For as Edmund Burke, a renowned eighteenth-century statesman who, perhaps ironically, is often regarded as the father of modern conservatism, warned, “All that needs to be done for evil to prevail is that good men do nothing.”

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

Legal but Lethal

PHYSICIANS MAKING CHANGE Challenging Lethal but Legal Corporate Practices Nicholas Freudenberg, DrPH Today the decisions made by executives and managers in the food, tobacco, alcohol, pharmaceutical, firearms, automobile, and other industries have a far

greater impact on public health than the decisions of health officials, hospital directors, and doctors. Moreover, evidence suggests that the impact of corporations on our health, lifestyle, economy, and political system is growing. Meanwhile, many governments around the world have abdicated their responsibility for protecting public health by reducing their oversight of business, privatizing key services, weakening regulations, and making individuals more responsible for their health. At the same time, many of the countervailing powers that had in earlier times challenged corporate advances are in decline. Changes in family structure and job opportunities allowed corporations to take over what had been family responsibilities:

McDonald’s replaced Mom’s cooking; TV became the new babysitter; and Hollywood and Madison Avenue taught children about food, shopping, sex, and relationships. Patients learned about new drugs from advertisements rather than from their family doctor or local pharmacist. Churches and faith organizations, which had been an arena for social interactions and sometimes offered critiques of unrestrained markets, lost parishioners to the mall or decided to endorse wealth as the

new virtue. Labor unions declined in membership and political influence. As a result of these changes, the unchecked business and political practices of consumer corporations have become major causes of the increasing burden of premature deaths and preventable illnesses from the leading killers of the twenty-first century—chronic diseases and injuries. As shown in Table 1, the products and practices of six industries—alcohol, automobile, firearms, food and beverages, pharmaceutical, and tobacco industries—now account for hundreds of thousands of annual deaths in the United States and several million deaths globally.1,2,3,4 These six industries sicken, injure, and kill people prematurely in different ways, and their various products play very different roles in our lives. Yet the corporations in the consumer economy have used many of the same strategies to advance their business interests at the expense of public health. They use modern science and technology to seek profits in ways that harm health (e.g., blending fat, sugar, and salt into hyperpalatable foods that contribute to diet-related diseases).5 They design and aggressively promote products without adequately testing their impact on health (e.g., SUVs and Vioxx).6,7 They make false or misleading claims about the health benefits of their products (e.g., sugary cereals with added vitamins8) and minimize the known harms or seek to obfuscate the science that demonstrates this harm (e.g., menthol in tobacco or wine coolers).9,10 They price unhealthy products cheaply to maximize their

Table 1: Annual U.S. and Global Deaths Attributable to Products and Practices of Selected Consumer Industries1 Industry

Main Health Conditions Related to Products and Practices

Estimated Annual U.S. Deaths in 20051

Estimated Global Annual Deaths, 2010 Source2 unless otherwise noted

Tobacco

Heart disease, lung and other cancers, respiratory diseases

467,000

6,297,287 (includes exposure to secondhand smoke)

Accidents, homicides, liver cancer, cirrhosis

64,000

4,860,168

43,6674

1,300,000 (from collision injuries)5 3,223,540 (from particulate-matter air pollution, of which motor vehicles are the largest contributor)

Food and beverages

Alcohol

Motor vehicles

Obesity, diabetes, heart disease, some cancers

Injuries, respiratory diseases including cancer, heart disease

216,000 Deaths attributed to overweight/obesity

3,371,232 (attributed to high Body Mass Index)3

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

market penetration (e.g., Saturday night special handguns11 or fast-food “value” meals12) but charge high prices that put healthy products out of reach of many who need them (e.g., fresh fruits and vegetables13 or antiretroviral).14 They transfer—externalize—the costs of their harmful practices onto consumers and taxpayers, allowing the companies to keep their prices low and profits high, but bankrupting the governments and families who need to pay for health care or environmental cleanups (e.g., tobacco, automobile, and firearms industries). They encourage lifestyles and patterns of consumption known to harm population health, especially vulnerable populations such as children (e.g., global practices of tobacco and alcohol industries).15 They elicit brand loyalty for risky blockbuster products by appealing to customers’ fears, insecurities, and addictions (e.g., vodka drinks targeted at women).10 They undermine regulations and standards designed to protect public health or the environment (e.g., auto and firearms industries)16,17 when these protections are perceived to jeopardize profits or market share. And they distort democracy by using campaign contributions and lobbying to overcome popular support for stronger public health protections (all industries). So what can doctors do about this growing threat to the health of our patients—and the world? Fortunately, health practitioners have already forged practical strategies for preventing corporate-induced illnesses in their interactions with patients, communities, health care institutions, researchers, and policy makers. Here I suggest five practical steps by which health professionals can limit the adverse impact of the world’s most powerful promoters of hyperconsumption, health behaviors, and lifestyles that contribute to premature death.

1. Immunize patients to resist corporate appeals to consume.

In their practices, physicians encounter individuals ravaged by excess use of tobacco, alcohol, and unhealthy food. Evidence has shown that physician counseling can reduce these risk behaviors.18 By helping patients critically analyze and resist corporate appeals for hyperconsumption, health providers can contribute to the eviction of marketers from the privileged and often hidden spaces they occupy within our minds.

2. Create health care institutions that are commercialfree zones.

Corporations have increasingly appropriated public space, from schools and hospitals to parks, buses, and shopping malls, for marketing and consumption. Despite the contributions of unhealthy products to chronic diseases, some schools and universities still sell soda, some hospitals still house fast-food outlets, and some public facilities and parks still permit public smoking and drinking. Health professionals can remind their institutions that they have the right to determine the rules for their property and the opportunity to set an example for health stewardship that others can follow. By creating public spaces where individuals can escape appeals to hyperconsumption, where parents can take their children without fear they’ll be incited to nag, and where sports followers don’t need to worry some drunken fan will vomit on them, we expand the places where healthy rather than unhealthy choices are the default option. WWW.SFMS.ORG

3. Develop and enforce strong conflict-of-interest rules for institutions and professional organizations. Organizations like No Free Lunch and the Prescription Project have recognized that hospitals and doctors should not profit from special relationships with pharmaceutical companies.19 By establishing and enforcing guidelines that prevent physicians from benefiting by prescribing or promoting branded drugs, health care institutions increase the credibility of all their providers.20 Conversely, when organizations like the American Academy of Family Practice or the Academy of Diet and Nutrition accept contributions from Coca-Cola, PepsiCo, or General Mills, corporations that actively resist public health regulation, they tarnish their credibility, a price hardly worth the modest corporate contributions.21,22

4. Urge professional organizations to support democratic reforms that take corporate money out of politics.

As long as corporations and trade associations can use their disproportionate wealth and power for lobbying, litigating, and making campaign contributions, ordinary citizens—and the health professionals who support them—will have a hard time getting their voices heard in our political institutions. For that reason, urging our professional organizations to join campaigns for expanding democracy and limiting corporate manipulations of our political system is a public health priority. Too often our professional organizations have made advancing the status and income of their members a higher priority than improving health and reducing health inequalities—a shortsightedness that, in the long run, jeopardizes our standing with the public. By actively participating in the political process, health professionals and their organizations can contribute to healthier policies for all.

5. Pressure the endowments and pension funds of our hospitals, universities, and professional organizations to divest from corporations that promote disease.

Most health professionals and health and research institutions invest their endowments and pension funds in big corporations. A growing number of individuals and some institutions now believe that their investment decisions should reflect their values. CALPERS, the pension fund of California state workers, has decided to stop investing in tobacco and firearms.23 Stanford University recently decided to drop its investment in coal.24 These and similar decisions show that mobilized students, professionals, and citizens can force institutions to reconsider their investment choices. What if the endowments of every hospital and university decided to stop investing in companies that promote products associated with premature death to children? No single health professional can change the world. Not every provider can take on all the tasks on this list. But almost everybody can do more than they are doing now. And all of us can consider our potential as health professionals, citizens, voters, taxpayers, and health advocates to protect individuals and communities from corporations that value profit over human health.

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Legal but Lethal

CHOCOLATE-FLAVORED NICOTINE Taming the “Wild West” of Electronic Cigarettes Robert K. Jackler, MD Over the past few years, electronic cigarettes (eCigs) have burst into the American consciousness. They

were invented in China in 2004 and were introduced to the U.S. market in 2007. What was formerly confined to a small, youthful subculture is now receiving enormous media attention, including a recent series of front-page New York Times articles. The technology comes in three sizes: eCigs about the size of typical cigarette; vape pens, which are favorites for delivering marijuana extracts; and the large ehookahs or “hoses.” While still a small fraction of the U.S. combustible cigarette market, at $1.8 billion in 2013, sales are tripling every year and some analysts predict that eCigs may exceed conventional tobacco products within a decade. The eCig market is populated by hundreds of start-up companies, most of whom simply stick their label on one of a mere handful of device types emanating from China. This early entrepreneurial phase is now transitioning to a more mature market in which the major tobacco companies (Lorillard-Blu, RJ Reynolds-Vuse, and Altria-Mark Ten), with their vast marketing resources and immense distribution systems, are asserting dominance. Rather than smoking, eCigs uses are said to be “vaping.” The devices vaporize a liquid known as “ejuice” or “eliquid,” which contains a mixture of propylene glycol and glycerin together with flavoring and variable concentrations of nicotine (from 0 to 36 mg per ml). Brands compete to create the most impressive plume, with some devices generating impressive clouds several feet in length. Some eCigs strive to emulate the look and feel of a regular cigarette (e.g., NJOY), while others proudly differentiate themselves by distinctive designs (e.g., Blu). All eCigs have three major components: a chamber containing ejuice, a heating coil to atomize it, and a lithium ion battery. When the user draws vapor, a light illuminates at the tip. Sometimes the tip glows orange to simulate a lit cigarette, while others use fanciful colors. Some eCigs are single-use disposables while others are rechargeable and employ replaceable eliquid cartridges. Technologically sophisticated systems include chargers, USB interfaces, Bluetooth connectivity, and even smartphone apps to record usage and order supplies. The business model is similar to inexpensive computer printers: a cheap device with profit residing in costly refills of proprietary liquid cartridges. As physicians, we would prefer that people not smoke. Studies show that adult smokers try eCigs out of a desire to quit smoking entirely. From a public health perspective, the hope is that eCigs would prove effective as nicotine cessation devices, or at least be a less harmful replacement for combustive cigarettes. As of mid-2014, scientific data is sparse on both accounts. Disappointingly, a recent study from UCSF showed no tobacco cessation effectiveness, while a British study showed that eCigs 14

worked roughly twice as well as patches, but still well under 10 percent efficacy.1,2 Most experts believe that if a cigarette smoker transitions entirely to eCig use, it is likely to reduce health risk. One reason is that the carcinogenic fraction of cigarettes derives primarily from the products of leaf combustion. While one might speculate that eCigs are a safer alternative, they are almost certainly not safe. The effects of inhaled nicotine have been extensively studied, but little is known about the long-term effects of breathing copious amounts of aerosolized propylene glycol and glycerine into alveoli. Chronic inhalation of large quantities of flavorants made of aldehydes, ketones, and other chemicals is also of concern. Eosinophilic pneumonia from eCigs has been reported and, over the long term, we may recognize a pattern of eCig-caused pulmonary diseases. A big problem with weaning adult smokers from regular cigarettes is the dual-use phenomenon. Discontinuities of nicotine dosing helps smokers quit. Today smoking is widely prohibited in work places, restaurants, bars, public parks, airports, etc.

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

Presently, in most cities (but not San Francisco), vaping is permitted in many places where smoking is not allowed. This enables smokers use eCigs to sustain nicotine levels and thereby discourage cessation. A major concern is the upsurge of eCig use among teens. Smoking typically starts as an act of teen rebellion and, once hooked by nicotine addiction, adults cannot break free even though surveys show that some 90 percent wish they could. As teen starters account for almost all adult smokers, the highest priority should be to discourage teens from becoming nicotine addicted. Evidence is accumulating that eCigs are a gateway to nicotine addiction. A recent CDC report found a doubling of eCig use among students between 2011 and 2012, with an estimated 1.78 million students having tried eCigs.3 The 2014 rate is undoubtedly substantially higher. Especially troubling is that many middle schoolers who use eCigs have never used regular tobacco products. Studies also have identified a high rate of dual use among teens. Rather than target committed adult smokers, as the industry professes in its correspondence with Congress, their advertising unmistakably targets youth. Advertising features young models engaged in patently adolescent behavior, including overtly sexual themes (Image 1, left). With slogans such as “Rewrite the rules” and “Inhale the freedom,” eCig advertising appeals to teen rebelliousness. A patently obvious device used by eCig companies to attract teens is youth-oriented flavors (Image 2, upper right). In its flavored product lines, eCig makers have greatly exceeded anything that the tobacco industry was willing to do. It appears as though they went through flavorant-company catalogs and created ejuice varieties in every conceivable flavor that might appeal to young people. Use of flavored tobacco is well recognized as a gateway to nicotine addiction. Flavored ejuice types include candy (e.g., bubble gum, gummy bear, cotton candy, chocolate), ice cream (e.g., mint chocolate chip, banana split), pastry (e.g., cinnamon bun, maple pancake), fruit (e.g., peach, pineapple), alcoholic beverage (e.g., beer, mojito), pepperoni pizza, and many others. Poison centers report a rash of poisoning among toddlers who imbibe sweetened ejuice, including a number of fatal cases. As of mid-2014, eCig production and advertising is completely unregulated. No government agency evaluates the purity of eliquids. Some are produced in unsterile facilities (care to breathe some aspergillus?), while others have been shown to contain contaminants such as heavy metals and even carcinogens. In April 2014, the FDA proposed rules to address this concern, but the process is so cumbersome that it is likely to be a couple of years before the proposed rule takes effect. Advertising of eCigs has been characterized by many as a “Wild West” with an attitude that anything goes. Immune from stringent cigarette regulations, eCig marketers have recapitulated every long-banned advertising device used by tobacco companies and, in many cases, exceeded them in outrageousness. How else could you get six companies touting pink breast cancer-prevention eCigs? Eversmoke uses the colorful slogan: “Save a life, save a lung, save a boob” (Image 3, lower right). My research group’s website contains more than 4,000 eCig advertising images and hundreds of promotional videos (tobacco. WWW.SFMS.ORG

stanford.edu). These includes images of doctors and nurses, pictures of healthy pink vaper’s lungs contrasted with blackened smokers lungs, and brand names such as Lung Buddy, O2 Easy, e-Health Cigarette, and SafeCig. Some even go so far as touting medicinal effects such as nutritional value (VitaminSmoke) and weight-loss effect (NutriCigs). Famous endorsers include rock stars (e.g., Courtney Love), movie stars (e.g. Stephen Dorff), and

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Physicians Making Change Continued from page 13 . . .

famous athletes (e.g., NASCAR’s Reed Sorenson). They use cartoons, event sponsorships (e.g., Oscars, Go Daddy Bowl), brand merchandise (e.g., t-shirts), and outdoor advertising, and they give away free samples at street fairs—all methods banned for cigarettes. Remarkably, eCigs are now advertised on television and radio, including the last two Superbowls, marking the first appearance of a smoker’s product in more than forty years. Most eCig advertising involves new media channels such as websites, online video, blogs, wikis, and a heavy presence on social media (Facebook, Tumblr, Twitter, etc.). My personal view is that I would not want eCigs to be banned, as they are likely less harmful that combustible tobacco products. I do feel that regulation is urgently needed. Both advertising and place-of-use policies need to be aligned with those for cigarettes. Because flavors entice youthful starters, the combination of flavor and nicotine should not be permitted. As teens have limited discretionary income, taxation of eCigs is important so that they do not remain a cheaper source of nicotine. Unless these measures are adopted, any possible public health gain from conversion of current smokers will be offset by youth initiation and dual use. Regrettably, the FDA process currently underway is lethargic and the initial proposed regulations are tepid. It would seem logical that any vapor intended to be inhaled deeply into the lungs on a daily basis ought to be carefully evaluated for safety before it could be introduced into the mass market. That the burden of proof in the federal regulatory process requires scientific proof that eCig vapors are unsafe is a serious failing of its responsibility to protect the public. We are now engaged in a large-scale experiment in which our youth are principal participants. Congress has the ability to accelerate the regulatory process, and I applaud Bay Area Congresswoman Jackie Speier for her efforts in this regard. Should it takes years to reign in the eCig industry’s targeting of our young, an entire generation of America’s youth, attracted by the irresistible lure of chocolate-flavored eCigs, will be at risk of suffering lifelong nicotine addiction.

As individuals and organizations, we can join the many coalitions and movements that are acting to protect public health, the environment, and democracy. By doing so, physicians and other health care providers will follow in the footsteps of our predecessors, who risked the disapproval of powerful elites in order to fulfill their medical oaths. We will also ensure that we are part of the solution to our era’s most pressing health problems, the legacy every health professional hopes to leave future generations.

Robert K. Jackler, MD, is a Sewall Professor and Chair in the Department of Otolaryngology, Head and Neck Surgery, at Stanford University School of Medicine. He and his wife Laurie Jackler founded the interdisciplinary research group Stanford Research into the Impact of Tobacco Advertising (SRITA). SRITA conducts research on the ways the tobacco industry targets teens, women, and African Americans as well as how recently introduced products such as electronic cigarettes are marketed.

References 1. Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Intern Med. 2014; 174:812-3. 2. Bullen C, Howe C, Laugesen M et al. Electronic cigarettes for smoking cessation: A randomised controlled trial. Lancet. 2013; 382(9905):1629-37. 3. Corey C, Wang B, Johnson SE et al. Electronic cigarette use among middle and high school students—United States, 20112012. MMWR. 2013; 62:729-730. 16

Nicholas Freudenberg, DrPH, is Distinguished Professor of Public Health at the City University of New York School of Public Health and Hunter College and founder and director of Corporations and Health Watch (www.corporationsandhealth.org), an international network of activists and researchers, which monitors the business practices of the alcohol, automobile, firearms, food and beverage, pharmaceutical, and tobacco industries. He is author of Lethal but Legal: Corporations, Consumption, and Protecting Public Health (Oxford University Press, 2014). A full list of references is available online at www.sfms.org.

Tax on Sugar-Sweetened Beverages to Fund Food and Health Programs San Francisco Office of Economic Analysis | City and County of San Francisco | July 14th, 2014

Conclusion

• The robust reduction in SSB consumption that the tax is projected to cause suggests the City can expect a reduction in future obesity rates, and long-term economic benefits associated with higher productivity and lower health-care costs. • As this is a new tax, and limited data is available to understand how a tax on distributors will be passed through to consumers, revenue estimates will necessarily be uncertain. Reasonable assumptions lead to estimates ranging from $35 million to $52 million per year. • The proposed tax is expected to have a modest employment impact of between 0.01% and 0.04% of city employment. Losses in the private sector, concentrated in the restaurant and retail trade industries, will largely be offset by jobs supported directly and indirectly by the tax revenue. • Like any flat tax targeting items that are disproportionately consumed by lower- income people, the tax could be seen as regressive. However, both the programs and services supported by the tax revenue, and the long-term health and economic benefits, will also be primarily realized by low-income groups.

Authors

Jay Liao, Economist, Ted Egan, Ph.D., Chief Economist, Asim Khan, Ph.D., Principal Economist

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

Legal but Lethal

SUGAR The Ditch of American Health Care Robert H. Lustig, MD, MSL The individual food choices made by millions of Americans are individual, aren’t they? Each of us gets

to choose what we eat and drink. Yet what I eat matters to you, and what you drink matters to me. Because the consequences of each of our “personal” dietary choices not only have consequences for our personal health but also for our public health and our public coffers. The toll that our collective diet has already placed on the American health care system has plunged us into a very deep ditch from which there appears to be no escape. The economic toll from our collective ill health, wastage of medical resources, costs of drugs for chronic disease, and loss of productivity is already catastrophic. At this rate, Medicare will be broke by 2026.

We used to have the best health care in the world. Now we’re #38; we rank just below Slovenia. What happened?

In the last thirty years, the nutritional composition of the average American diet has been radically changed—for the worse. Processed food and sweets accounted for 11.6 percent of our diet in 1982, yet by 2012 they accounted for 22.9 percent, a doubling in thirty years. Added sugar (that is, compounds containing the sweet monosaccharide fructose, including sucrose, high-fructose corn syrup, agave, maple syrup, honey, etc.) figures prominently in why processed food is such a problem. Added sugar is a proximate cause for obesity, diabetes, heart disease, and fatty liver disease. Health care of the obese costs double that of normal-weight people. Costs for diabetes alone jumped from $171 billion in 2007 to $245 billion in 2012 in the U.S. But these translate into costs for everyone. For instance, employers pay an extra $2,751 dollars per employee for obesity, whether the employee is obese or not. This is dragging down economic growth and jobs. This is unsustainable. Unless we reverse course, it is alarmingly clear where we are all going to end up. There are some who say how we got here is unimportant. On the contrary, in order to back out of the ditch, you need to know how you drove into it. Otherwise, you just spin your wheels and get stuck further in the mud, as we’ve done for the past thirty years. Of the various components of our processed food diet, added sugar has received the most attention. In part because this is the hook that the food industry uses to get you to buy more; and in part because science has now demonstrated causation for these chronic diseases. Let’s examine the science more closely.

Metabolic Effects of Fructose

Fructose (and sugar in general) is an energy source, but it is not a nutrient (similar to alcohol). There is not one human WWW.SFMS.ORG

biochemical reaction that requires dietary fructose (or alcohol, for that matter). The only place in the body where fructose is of physiologic import is in semen, and the fructose is manufactured de novo from glucose using the aldose reductase/sorbitol pathway. Indeed, patients with hereditary fructose intolerance (HFI) who are missing the enzyme fructose-1-phosphate aldolase B and cannot consume fructose lest they become hypoglycemic not only have fewer dental caries but they are quite healthy provided they maintain their fructose restriction.

1. Hepatic insulin resistance and metabolic syndrome

After a large fructose bolus is ingested, it is transported from the duodenum straight to the liver via the portal vein, where it overwhelms the capacity of mitochondria to metabolize it via the tricarboxylic acid cycle. The hepatocyte has no choice but to convert the excess energy substrate into fatty acids, through a process known as de novo lipogenesis. These excess fatty acids have one of two fates: to get packaged into very low-density lipoproteins (VLDL, measured in the triglyceride fraction of the lipid profile), which promote cardiovascular disease; or get stuck in the liver, where they lead to fatty liver disease and promote hepatic insulin resistance, which drives hyperinsulinemia, weight gain, and puts you at risk for type II diabetes.

2. Reactive oxygen species (ROS) formation and aging

Any nutritional substrate with a free reactive aldehyde or ketone moiety can bind to proteins (the Maillard or “browning” reaction), which reduces protein flexibility (leading to cell dysfunction) and releases ROS’s, which, if not quenched by an antioxidant, lead to cell damage. This is why bananas brown. While glucose can undergo the Maillard reaction (this is why we all have a measurable hemoglobin A1c), fructose does it seven times faster due to its unique stereochemistry. Protein inflexibility and ROS generation together contribute to cell dysfunction and aging.

3. Central nervous system effects to increase consumption

The hedonic pathway that motivates the “reward” of food intake uses the neurotransmitter dopamine. Sugar leads to dopamine release, which then binds to the dopamine D2 receptors in the nucleus accumbens to transduce pleasure. But dopamine down-regulates its own receptor. More sugar leads to more dopamine and fewer receptors, which means you need more sugar to get less effect. And after a while you’re consuming a whole lot to get nothing—this is the phenomenon of tolerance, which is onehalf of addiction.

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Sugar Continued from the previous page . . .

Empiric Role of Sugar in Chronic Metabolic Disease It has been assumed by many physicians that obesity is the underlying cause of the diseases of metabolic syndrome. While it’s true that 80 percent of the obese have metabolic dysfunction, so do 40 percent of the normal-weight population, and these people harbor the same biochemical defects. Indeed, 33 percent of Americans now have nonalcoholic fatty liver disease, and 8.3 percent have diabetes, and they’re not all obese. In other words, it’s not about obesity; rather, obesity is a marker for the metabolic dysfunction, not the cause. It has also been assumed that the negative effects of sugar were mediated through its caloric content and its role in fomenting obesity. In the last two years, several peer-reviewed studies have provided causative evidence for sugar’s effects on fatty liver disease, type II diabetes, and cardiovascular disease death; apart from its calories, and apart from its effects on obesity, and in doses commonly used. These data argue that sugar is an independent risk factor for chronic metabolic disease. In other words, sugar is a dose-dependent, chronic hepatotoxin, similar to alcohol. Sugar is the “alcohol of the child.” And similar to alcohol, the only treatment is reduction of consumption. Since one-half of the sugar in our diet is in foods that we didn’t know had it (e.g., tomato sauce, yogurt, salad dressing), this means changing the food supply. Change is always hard, and it often appears most impossible right before it is seen in hindsight as having been inevitable. It’s time to extricate ourselves from the ditch of American health care, before the wheels fall off.

RESIDENTS Gregory Adamson, MD | Pediatrics Hakeem Afuwape, DO | Radiology Ahmad Ahmad, MD | Neurology Ayman Ahmed, MD | General Surgery Eric Morris Bomberg, MD | Pediatric Endocrinology Peggy Bui, MD | Internal Medicine Josemine M. Carey, MD | Anesthesiology Marina Cervantes, MD | Family Medicine Katherine Chau, MD | Internal Medicine Caroline Crooms, MD | Neurology Emilia DeMarchis, MD | Family Medicine Geoff Hart-Cooper, MD | Pediatrics Mellody Roxxanna Hayes, MD | Anesthesiology Michael Healy, MD | Internal Medicine Bradley Hunter, MD | Internal Medicine Nabia Sharin Ikram, MD | Radiology Bethany Johnson-Kerner, MD | Pediatrics David Kohanchi, MD | General Surgery Anne Linker, MD | Internal Medicine Giselle Lopez, MD | Pathology Emily Lu, MD | Family Medicine Tyler Murray, MD | Internal Medicine Audrey Nguyen, MD | Plastic Surgery Robert H. Lustig, MD, MSL, is professor of pediatrics in the DiviQuoc-Hung Nguyen, MD | General Surgery sion of Endocrinology at the University of California, San Francisco Michael Podolsky, MD | Internal Medicine Bahram Razani, MD | Dermatology (profiles.ucsf.edu/robert.lustig). He is also the president of the InMichael Reid, MD | Infectious Disease stitute for Responsible Nutrition (responsiblefoods.org), a nonprofAlison E. Schultz, MD | Anesthesiology it dedicated to improving the global food supply and eradicating Hannah Snyder, MD | Family Medicine type II diabetes and chronic metabolic disease in children. He is the Christine Soran, MD | Internal Medicine author of Fat Chance: Beating the Odds against Sugar, Processed Tiffany Tello, MD | Dermatology Jeffrey Tyler, MD | Internal Medicine Food, Obesity, and Disease; Sugar Has 56 Names: A Shopper’s Long Vinh, MD | Pediatrics Guide; and The Fat Chance Cookbook. Max Wattenberg, MD | Internal Medicine Kwun Wah Wen, MD | Pathology Sharon Wietstock, MD | Child Neurology SAN FRANCISCO MEDICAL SOCIETY HAILS Michelle Yu, MD | Pulmonary Critical Care Medicine LANDMARK SODA TAX LEGISLATION TO FUND Kreshnik Zenjullahu, MD | Internal Medicine Saqib Ahmed, MD | General Surgery FOOD AND HEALTH PROGRAMS Cindy Chai, MD | Pain Management (Anesthesiology) Serah Choi, MD | Radiation Oncology Earlier this month, legislation to raise the price of sugar sweetened Esteban Figueroa, MD | Internal Medicine Irina Khrenova, MD | Pain Medicine beverages in the City and County of San Francisco was signed by Sindhura Kodali, MD | Pediatrics Mayor Ed Lee and formally passed the San Francisco Board of SuperNatalia Leva, MD | Urology visors to be placed on the November 2014 ballot. The legislation has Su-Yang Liu, MD | Pathology been endorsed by both the San Francisco Medical Society, California Ryan McConnell, MD | Gastroenterology Medical Association, and American Heart Association to reduce the Zoltan Nagymanyoki, MD | Pathology incidence of obesity, diabetes, and tooth decay. SFMS Executive DirecMark Nguyen, MD | Nephrology tor Mary Lou Licwinko stated “We are delighted with the actions of Heyman Oo, MD | Pediatrics the Mayor and the Board of Supervisors. SFMS has long championed Anna Paulsson, MD | Radiation Oncology Adi Jonathan Price, MD | Radiology a soda tax and, once again, San Francisco is leading the country on an Rajan Puri, MD | Internal Medicine important public health issue.” San Francisco’s proposed soda tax will Krishna Ramaswamy, MD | Urology reduce soda consumption and fund active recreation and nutrition Nicholas Reeves, MD | Psychiatry programs in city public schools, Recreation and Park Department rec Sara Richards, MD | Anesthesiology centers and sports programs, and food access and nutrition education Anoop Sheshadri, MD | Nephrology through the Department of Public Health. Katia Vaisberg, MD | Pediatrics Hao MD | Internal Medicine JULY/AUGUST 2014 WWW.SFMS.ORG 18 Wang, SAN FRANCISCO MEDICINE

Legal but Lethal

FOOD AND BEVERAGE ADVERTISING The Science That Supports a Ban Jeff Ritterman, MD There is a national discussion about the impact of advertising food and beverages to our children. The

overwhelming majority of these ads are for products high in calories, with significant amounts of added sugar. Many health authorities believe that the unhealthy messages that children receive are a leading cause of excess calories. Research studies provide strong support. Children exposed to food advertising while watching television ate 45 percent more junk food than children who watched the same TV program with nonfood ads. At that rate, a child exposed to TV with food ads for 30 minutes a day would gain almost 10 pounds a year. With the rising popularity of social media and video games, the food and beverage industry madmen have found wholly new ways to reach and influence our children and youth. Have you heard of advergames? They are video games with advertisements embedded. They can be found on the webpages of food and beverage companies. Children exposed to advergames with unhealthy food messages embedded (Pop-Tarts and Oreos advergames) ate 56 percent more junk food after playing than those who played an advergame with embedded ads for fruit. A recent study published in Pediatrics showed similar findings. The researchers found that advergames that promote junk food led to increased caloric intake. The evidence that food and beverage ads aimed at children leads to increased consumption seems firmly established. The corollary is that a decrease in food and beverage advertising should lead to less junk food consumption. Research done in Quebec, where there has been a children’s food advertising ban since 1980, has shown exactly that. The Quebec researchers looked at fast-food consumption as a measure of excess calories. Prior research had shown that frequent fast-food ingestion by eleven- to eighteen-year-olds resulted in marked increases in weekly caloric intake. Other research showed that four- to seven-year-olds who regularly frequented fast-food restaurants were twice as likely to be obese as those who did not. The Quebec researchers compared several populations in Quebec with their counterparts in Ontario. They concluded: The current study provides evidence that a ban on advertising targeting children can be effective in lowering or moderating consumption, and estimates of the effect in expenditures suggest that the social-welfare impact of such a ban can be significant. Quebec is not alone. Both Norway and Sweden have instituted similar bans. But what about adults? The research on adults, while sparse, supports the hypothesis that food ads result in excess caloric consumption. WWW.SFMS.ORG

Researchers from the Rudd Center compared adults who watched a TV show with food commercials to those who watched the same show with nonfood commercials. Those who watched the food ads ate significantly more. Those who were on diets consumed the most in response to the food ads. Interestingly, the participants in the experiment were not aware that they were affected. The effects persisted for some time after the TV show was over. Why is food advertised at all? The USDA’s Economic Research Service estimates that per capita caloric intake increased by 530 calories between 1970 and 2000. It is those extra calories that demonstrate the “success” of the advertising. The research shows that eating junk food in response to food ads happens regardless of whether or not we are hungry. The “genius” of advertising is that we eat even when we are not hungry, and we do so without even being consciously aware of our eating behavior. Advertisers also take advantage of our sense of thirst. We evolved to drink water to maintain our body’s fluid balance. Now we “open happiness” and “live for now” as the soft drink ads tell us to do. Since these sugary drinks do not produce fullness, they bypass a key component of our energy balance system and their calories are not offset by subsequent decreases in consumption. In addition, the large dose of fructose floods the liver and gets converted to unhealthy fats. We now have evidence that excess sugar is linked to tooth decay, obesity, type II diabetes, heart attacks, strokes, high blood pressure, cancer, and fatty liver disease. Most beverages and foods advertised are loaded with sugar, raising the question of whether these food ads border on criminality. Should food companies be allowed to expose us, and our children, to ads aimed at increasing their profits even when those ads cause diabetes and heart attacks? We should not underestimate the power of these food ads. I can still remember that “Wonderbread builds strong bodies in eight ways” from watching The Howdy Doody Show in the 1950s. Now, each of us and each of our children must match our wits with the highly paid madmen and their teams of psychologists. It would be a lot wiser and much healthier to simply ban the advertising of food and beverages.

Dr. Jeff Ritterman is the retired chief of Cardiology of Kaiser Richmond Medical Center and a former Richmond City councilman. He led the Richmond Soda Tax Campaign. He is the vice president of the SF chapter of Physicians for Social Responsibility and serves on the steering committee of the San Francisco Soda Tax effort (www.ChooseHealthSF.com).

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

Legal but Lethal

FLYING BLIND The Public Health Impacts of Wireless Radiation Devra Davis, PhD As uses and users of wireless transmitting devices are skyrocketing in our homes, schools, and even our national parks, one would think that scientific research

on the human health and environmental implications of wireless electromagnetic radiation would be exploding with fierce competition. Yet as I write this article fresh from the Capetown, South Africa, meeting of the Bioelectromagnetics Society, research funding and training in this field is at its lowest point in modern history in both the government and private sectors. Motorola’s once-vaunted laboratory is no more. At the meeting, the society awarded its highest accolade to Environmental Protection Agency Senior Scientist Carl Blackman. The EPA’s most distinguished and prolific investigator in the field, Blackman retired just two days after receiving the D’Arsonval Medal. Blackman explained that funds for research in this field at EPA had been wiped out. This is a tragedy for the field and bespeaks an unfortunate policy direction.

Despite the extraordinary growth in wireless transmitting devices, we lack the resources to study their impacts in any systematic way. The absence of research on the health or environmental impacts of wireless radiation should not be confused with proof of safety. Other presentations highlighted the exciting new field of electroceuticals—where electric current is being applied to treat a range of diseases including cancer. Thus the biological impact of electromagnetic fields is not in dispute. The meeting also heard presentations showing that cows, bats, and carp orient their bodies along lines that reflect the earth’s magnetic field. When asked what this might mean for mammalian migration and even for human health, Uwe Bregger, the animal ecologist who presented this work, quipped, “I would certainly never live near a wireless tower.” The issue of exposures to towers is one of many on which we simply have no serious research underway, despite growing public concerns. The last national survey on exposures to electromagnetic fields in America took place in 1980. Standards for cell phones were set eighteen years ago. Would you fly in an airplane that met old safety standards? While the Israelis have established a national institute to evaluate wireless transmitting devices, no serious research is underway in the U.S., except one large-animal study that was first proposed fourteen years ago. In fact, this past week researchers in China published a study on pregnant women planning to have an abortion. Those results are mind-boggling: Women with the highest exposures to elec20

tromagnetic fields had much smaller embryos. Conspicuously missing from the Bioelectromagnetics meeting are young students from America. Frank Barnes, a member of the U.S. National Academy of Engineering and mentor to a generation of students, has no funding to continue his groundbreaking work at the University of Colorado showing the impacts of magnetic fields on experimental variability. In 2008, he chaired the committee that presented a National Research Council Report, “The Identification of Research Needs Relating to Potential Biological or Adverse Health Effects of Wireless Communications Devices,” as requested by the U.S. Food and Drug Administration, identifying research gaps and the critical need to increase our understanding of any potential adverse effects of long-term chronic exposure to RF energy on children and pregnant women. That report identified several important data gaps—none of which has been addressed in the meantime. When will the U.S. take action on these recommendations? What research continues in the states appears to be that which cannot be publicly discussed, as it is sponsored by the Department of Defense. While none would dispute the value and importance of devising nonlethal uses of electromagnetic weapons, this is one of the few areas where research continues. One notable instance where the public is poorly informed about the need to promote safer uses involves the rapid proliferation of tablets such as iPads. These devices are tested at a distance of twenty centimeters from a large male adult body. Indeed, tablets are wellnamed—they belong on tables, not on laps. Manufacturers advise that tablets can exceed the “as-tested levels” when held next to the pregnant abdomen or gonads, especially those of children. Yet advertisements on television and print—include lovely ads from Pottery Barn—tout these products for use by young expectant people holding them close to the body. Of course, these devices also are not tested for use directly against elementary school students, who nowadays hold them tightly to their small frames, often seated with their young organs directly exposed. Recently, medical doctors Maya ShetreetKlein and Hugh Taylor have brought attention through the Baby Safe Project to the fact that pregnancy is a time when special precautions should be taken to keep wireless exposure as low as is reasonably achievable (ALARA). Our ability to study any of these phenomena is hampered by the lack of funds that propelled Blackman to leave a field he had helped create nearly four decades earlier. Professor Emeritus Barnes rues the situation: “If a young investigator comes to me seeking to work in this field, I have to advise them of the facts. We have no money. There are no incentives to proceed. They are better advised to choose another career focus.” As the former director of the Center for Environmental Oncology at the University of Pittsburgh Cancer Institute, I had to offer similar counsel

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

to students and young faculty. We can fix this problem. Here’s a solution every grandparent can support. The U.S. and the European Union need to implement a five-year program of a dollar-a-phone fee to be paid equally by phone manufacturers, cell providers, and consumers to generate funding to train physicians, biomedical researchers, and engineers; provide independent research funding; and support monitoring and evaluation of the potential impacts of cell phones and other wireless transmitting devices on our health. Blackman’s retirement is an omen. We have already lost one generation of researchers, as he recounted. We must invest in ensuring that our growing and important electromagnetic technologies are used and developed to be as safe as possible. Assuming things are safe until we have incontrovertible evidence they are not—as happened with tobacco and asbestos—is not a path we can afford to take. At this point, our failure to develop evidence of harm cannot be regarded as proof of safety. Devra Davis, PhD, is president and founder of the Environmental Health Trust, www.ehtrust.org. She lectures at UCSF, Berkeley, Dartmouth, Georgetown, Harvard, and other universities, and was founding director of the Center for Environmental Oncology, University of Pittsburgh Cancer Institute, and professor of epidemiology at the Graduate School of Public Health). She is spending 2013-2014 as a visiting scholar with the Goldman School of Public Policy and Management at the University of California, Berkeley. This article originally appeared on the Huffington Post Website, July 7, 2014, http://www.huffingtonpost.com/.

WWW.SFMS.ORG

Whooping Cough Reaches Epidemic Levels in California California is facing an epidemic of pertussis, or whooping cough, with more than 4,500 cases reported this year in the state, including 46 in San Francisco. The highest rates of the illness are in Marin, Napa, and Sonoma counties. Of the cases this year, 84 percent occurred among individuals ages eighteen or younger. The Tdap vaccination for pregnant women is the best way to protect infants who are too young to be vaccinated. All pregnant women should be vaccinated with Tdap in the third trimester of each pregnancy, regardless of previous Tdap vaccination. In addition, infants should be vaccinated as soon as possible. The first dose of pertussis vaccine can be given as early as six weeks of age. Older children, preadolescents, and adults should also be vaccinated against pertussis according to current recommendations. It is particularly important that persons who will be around newborns also be vaccinated. More information is available here: http://bit.ly/1oxsNek.

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

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Legal but Lethal

DISARMING NUCLEAR WEAPONS Countering the Nuclear War Profiteers Robert Gould, MD Physician and other health professional associations have long recognized the dire environmental and public health consequences of the research, development, testing, and use of nuclear weapons.1-4 Less attention has been given to the immense expen-

ditures incurred in the pursuit of developing nuclear arsenals, which constrain our ability to deal with pressing issues such as global warming and other health threats. Nuclear weapons states (NWS) at present possess approximately 16,400 nuclear weapons, most of which are vastly more powerful than the bombs that destroyed Hiroshima and Nagasaki.5,6 However, all the NWS are currently modernizing their deadly arsenals, with the United States planning to spend more than $1 trillion over the next thirty years for its often-redundant nuclear weapons programs, an enormous boon to military contractors.7 For example, the United States is proposing to develop a new long-range bomber that can field both conventional and nuclear weapons, with a projected cost of approximately $100 billion for 100 aircraft. Such aircraft could be paired with B-61 warheads that are being modernized as part of a $10 billion “life-extension” program, or a potential new cruise missile that might require a new nuclear warhead that might add an additional $20 to $30 billion to the military budget.7 In addition to providing such renewed support for deadly nuclear weapons, the U.S. is planning to spend an estimated hundreds of billions of dollars on a dozen new ballistic missile submarines and the next generation of intercontinental-range ballistic missiles.7 Many of these expenditures can be traced to the intense lobbying efforts of nuclear weapons contractors, profiled in the June 2012 report “Bombs Versus Budgets: Inside the Nuclear Weapons Lobby,” by William D. Hartung and Christine Anderson. The report reveals that during the 2012 election cycle alone, the leading fourteen nuclear weapons contractors gave a total of at least $2.9 million to key members of Congress having decision-making power over nuclear weapons budgets.8 Hartung and Anderson report that by 2012, these top fourteen contractors, spearheaded by Lockheed Martin, Honeywell International, Northrup Grumman, and Boeing, had donated $18.7 million to the same members of Congress during their careers. Members of the four key subcommittees with jurisdiction over new nuclear weapons spending received more than $11 million.8 These vested interests are institutionalized via the “revolving door” through which members of these congressional offices pass to subsequently work for the very contractors they had previously been in charge of funding and/or regulating. As of 2012, nuclear weapons contractors employed 137 lobbyists who were former employees or key members of Congress or WWW.SFMS.ORG

congressional committees, the Departments of Defense and Energy, or the military.8 The overall military budget is conditioned by this same pattern of influence and wasteful expenditures, and it continues to grow to the point that the United States accounted for $640 billion, or 37 percent, of the total global military expenditures of $1.75 trillion in 2013.5,9 These expenditures are more than egregious missed opportunities to support health—they directly threaten global health and stability. For example, from 2008 to 2011, the United States financed more than half of all the world’s arms transfer agreements to the developing world, at a cost of nearly $113 billion.10 Advanced conventional weapons sales are of direct concern when fueling volatile areas of nuclear confrontation—whether in the Middle East or in South Asia. For example, the rush of global arms representatives to modernize the Indian military serves to heighten tensions between nuclear-armed India (and Pakistan) and China.11 Increasingly, health professionals and our allies have been building a counter to these powerful forces of weapons and war profiteering.12 For example, Rotary International, which has spearheaded global vaccination campaigns for many years, has now developed a Rotarian Action Group for Peace, recognizing the essential connection between peace and the health initiatives they support.13 As part of this new Rotary project, Physicians for Social Responsibility (PSR) is speaking on the “Humanitarian Impacts of Nuclear Weapons” at Rotary Clubs throughout the country, as our global partners in the International Physicians for the Prevention of Nuclear War are doing worldwide.14 By harnessing the voice of health to issues of war and peace, exemplified by the November 2011 joint resolution of the Council of Delegates of the International Red Cross and Red Crescent Movements, calling for the elimination of nuclear weapons,15 we seek to give voice to the current call of a majority of the world’s nations to ban nuclear weapons—in direct contravention of the immense power of the weapons lobbies and coffers. If you’d like to participate in this unfolding Rotary/PSR campaign, please contact the author through PSR at action@sfbaypsr.org. Robert M. Gould, MD ia an associate adjunct professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the UCSF School of Medicine and director of Health Professional Outreach and Education for the UCSF Program on Reproductive Health and the Environment (PRHE). Since 1989, he has been President of the Bay Area Chapter of Physicians for Social Responsibility (PSR) and has served as President of the National PSR. A full list of references is available at www.sfms.org. JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

Legal but Lethal

MALIGNED BUT BENIGN Readjusting Perspectives on Dietary Fat Sean Bourke, MD When Dr. Conrad Lai and I started JumpstartMD in 2007, we approached the venture from the standpoint of two

Stanford-trained emergency medicine physicians passionate about creating a medically supervised weight-loss and wellness program designed to provide a practical, sustainable, and preemptive response to the chronic and preventable medical conditions that account for 75 percent of our nation’s health care spending. At the time, our thinking echoed the conventional wisdom that we learned in medical school—namely, that a low-fat diet pays the most dividends for health. It’s advice that’s aligned for the last fifty years with that of the American Diabetes Association (ADA), American Heart Association (AHA), and the U.S. Department of Agriculture’s (USDA) Dietary Guidelines for Americans and Food Guide Pyramid. But the years of patient interactions; engaging with thought leaders, many from the Bay Area (Gary Taubes and Drs. Robert Lustig, Steve Phinney, Peter Attia, and Ronald Krauss); and my own reading, including Bay Area native Nina Teicholz’s recent book The Big Fat Surprise, which informed many of the arguments in this article, have brought me to the conclusion that the vast majority of contemporary dietary recommendations that we’ve assumed to be correct are simply wrong, the product of weak data overinterpreted by well-intentioned experts eager to end the rising tide of diseases of modernity.

A “Great Experiment”

This “great experiment” in low-fat living begat an era unprecedented in human history. We now consume, and export, what can arguably be described as the world’s deadliest diet, the nutritional equivalent of cigarettes. The spark? Amid an ambient fat phobia and obsession—first with total cholesterol and later with low-density lipoproteins (LDL) as primary risk factors for cardiovascular disease—experts made low-fat dietary recommendations that, despite being premature and unfounded, became institutionalized and entrenched. These events triggered a reciprocal—and unanticipated—creep in the consumption of refined carbohydrates, which now make up the bulk of our modern diet in the face of increasing evidence that they are (1) precursors to the most atherogenic small LDL particles (particles that can predict a proclivity to develop diabetes even prior to a rise in insulin), (2) promoters of fat formation through the insulin response, (3) proinflammatory, and (4) associated with advanced glycation end (AGE) products that may accelerate aging. I see the consequences of this misguided thinking in my practice regularly. Recently a patient, expressing frustration at her poor weight loss during a diet recall, was surprised to learn 24

that the 38 grams of carbohydrates in her daily Frappuccino—32 of which came from added sugar, which is 7 grams higher than the daily added sugar limits now recommended for women by AHA— were not “completely innocuous” from a weight-loss and health standpoint. And why wouldn’t our fellow Americans assume as much when every trip to the grocery store bombards them with messaging that this or that product is “low fat” or “low in cholesterol.” (Dietary cholesterol, meanwhile, was definitively shown as far back as the 1950s to have minimal—that is, a “trivial”—effect on serum cholesterol, yet you’d never know it given our low-fat, lowcholesterol emphasis.) Shouldn’t we own up to our contribution to the disastrous public health debacle that is our country today? The Food Guide Pyramid has had it all wrong since its formation, and yet it’s been propelled upward by misguided politics posing as science. The path forward? It starts with education and awareness. And that education and awareness begins with an understanding of the flimsy science behind the dietary recommendations that our friends, families, and patients accepted in good faith long before they’d been definitively proven. Unfortunately, support for that science still exists.

Where It All Started

In the second half of the twentieth century, no man and no study had a greater influence on our arguably misguided direction than Ancel Keys, the scientist who secured a seat in 1961 on the AHA’s Nutrition Committee and who led the famous “Seven Countries Study,” the first multicountry epidemiologic study ever undertaken. Further review of this pivotally influential study has shown that, aside from the fact that epidemiologic studies can identify associations but not causality, the scientific rigor and methodologies on which Keys based his conclusions were deeply flawed for a host of reasons: selection bias and lack of randomization, incomplete data, postwar dietary aberrations from the norm, flawed sampling (such as one-third of the diet recall surveys for the population of Crete occurring during the Lenten period, when saturated fat intake was halved), and more. These flaws were buried while Keys’s recommendations were pushed forward through his great force of will, savvy leveraging of media and other influencers, and marginalization of dissenting viewpoints.

Evidence Mounts

And what of the controlled studies to definitively prove Keys’s diet-heart hypothesis that fat, and saturated fat specifically, led to heart disease? In fact, alternative hypotheses, many implicating sugar and refined carbohydrates as a primary cause of ath-

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

erogenic dyslipidemia (something Keys described as a “mountain of nonsense”) and a key culprit in our obesity epidemic, are now being borne out by science. By 1993, after the AHA had been recommending a low-fat diet for thirty years and the USDA for fifteen, the Women’s Health Initiative followed 20,000 women in a low-fat diet group to study whether this recommendation actually worked. After a decade of follow-up, the low-fat cohort was no less likely to contract various cancers, suffer from stroke or heart attack, or lose more weight. (JAMA, 2006; 295, no. 6:29-42, 643-54, 655-66; JAMA, 2006; 295, no. 1:39) In 2007, Stanford’s Christopher Gardner compared premenopausal women on the Atkins diet with those on the Zone (moderately low carbohydrate), LEARN (moderately low in fat, moderately high in carbohydrate), and Ornish (very low in fat and very high in carbohydrates) diets. The conclusion: The Atkins group lost more weight and had better “overall metabolic effects” than the lower-fat (higher-carb) groups. (JAMA, 2007; 297:969) In 2008, Iris Shai et al performed a well-controlled twoyear study of 322 individuals comparing outcomes on three diets: the AHA low-fat diet, a Mediterranean diet, and the Atkins diet. Atkins dieters not only lost the most weight but also saw the greatest decline in risk factors. The low-fat group fared the worst. In fact, the more fat one ate, the healthier one appeared. (NEJM, 2008; 359: 229) In 2009, Jeff Volek and others showed a more favorable impact of a carbohydrate-restricted, high-fat diet on metabolic syndrome than a low-fat diet. (Lipids, 2009; 44:297) In 2010, Dr. Ron Krauss and others published a 350,000-patient meta-analysis stating that “there is no significant evidence for concluding that dietary saturated fat is associated with increased risked for coronary heart disease or cardiovascular disease.” (AJCN, 2010; 91:535) Chowdhury et al recently corroborated the same result with a nearly 650,000-patient meta-analysis that concluded that saturated fat does not cause heart disease and that “current evidence does not support cardiovascular guidelines that encourage . . . low consumption of total saturated fats.” (Annals Int Med, 2014; 150:398) In April 2014, UCSF’s Laura Saslow et al published a study comparing type II diabetics on a medium-carbohydrate, lowfat, calorie-restricted American Diabetes Association diet with a group on a very low-carbohydrate, high-fat, non-calorie-restricted diet meant to induce nutritional ketosis. Over three months, the nutritional ketosis group lost twice as much weight (5.5 kg versus 2.6 kg) and was able to discontinue diabetes medication and sulfonylurea medications at four and six times the rate, respectively, of the moderate carbohydrate group. (PLOS ONE, 2014; vol. 9, issue 4) One-year data is pending.

The Cholesterol Connection

For decades, part of the rationale against saturated fats stemmed from concerns that saturated fat can affect total and calculated LDL (LDL-C) cholesterol. Yet the march of science has shown that both total cholesterol and LDL-C are not the best predictors of cardiovascular risk. LDL-C isn’t even a biologically active entity but instead an indirect estimate. For example, thirty years into the Framingham follow-up study, total cholesterol was shown to be an ineffective marker of risk. In fact, 80 percent of the people who develop coronary arWWW.SFMS.ORG

tery disease have the same total cholesterol as those who do not. (Lloyd-Jones et al, Arch Int Med 2001; 161:949) Of nearly 137,000 patients hospitalized with coronary artery disease, more than 75 percent had LDL-C levels below 130 mg/dl and 23 percent had LDL-C levels below 70 mg/dl. (Sachdeva et al, AHJ; 157:111) To the contrary, increasing evidence—as presented in the Malmo Trial (Musunuru et al, ATVB; 29:1975, 2009)—shows that carbohydrates, and refined carbohydrates in particular, confer cardiovascular risk independent of saturated-fat intake by acting as precursors to atherogenic smaller LDL particles. (Krauss et al, AJCN; 83:1025) By contrast, saturates tend to drive generation of larger LDL particles, which are generally considered benign.

Seeing the Big Picture

When I think about the studies above and marvel at the tide of illnesses that parallel our rising obesity rates (http://www.cdc. gov/obesity/data/adult.html), I pause in knowing that the major macronutrient changes we have made since the onset of the diabesity epidemic was a recommended reduction in our percentage of calories from fat, and saturates in particular, and a reciprocal unintended 25 percent rise in our consumption of carbohydrates. That’s not to say that we’ve definitively determined that all fats are fine—relatively new industrialized oils and solid polyunsaturated fats, for example, reveal another untested experiment, a matter of importance given that they now account for 8 percent of our total caloric intake and there is some suggestion they may drive cancer risk or, more generally, a proinflammatory state through an unprecedented excess of omega-6 fatty acids— or that there might not be issues with saturates for some people, or that, more generally, we shouldn’t make blanket nationwide nutrition recommendations when what we need is to personalize optimal dietary recommendations in a way that matches human heterogeneity. But it is to say that for decades the U.S. had a stable prevalence of obesity of around 12 percent and that in 1961, the prevalence of diabetes in the adult population was 1 percent. Today, those numbers are closer to 35 percent and 11 percent, respectively, with 25 percent of the country being “prediabetic.” The diabesity epidemic is arguably happening to people in large part because of misguided recommendations about dietary fat that were founded on flawed science. If true, the problem is eminently fixable, if we can let the truth surface and use education and awareness to move us forward. At JumpstartMD, our practice continues to evolve in response to the latest thinking and observes unparalleled outcomes in weight loss and health improvements in the process.

Sean Bourke, MD, is CEO of JumpstartMD (www.jumpstartmd. com), Northern California’s largest medical weight loss and wellness practice. A member of the SFMS and the American Society of Bariatric Physicians, Dr. Bourke is a graduate of Yale College and the University of Southern California School of Medicine. He received his postgraduate training in emergency medicine at Stanford University. JumpstartMD has two offices in San Francisco and nine others encircling the greater Bay Area.

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

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Legal but Lethal

FED UP A Film Review John Maa, MD Fed Up is a documentary by Stephanie Soechtig and Laurie David (the Oscar-winning producer of An Inconve-

nient Truth) that examines the obesity epidemic in America. Narrated by television journalist Katie Couric, the film upends the conventional wisdom that obesity results from an imbalance between dietary intake and physical activity, and instead focuses on an overlooked cause: the large quantities of hidden sugar in processed foods, even those advertised as “healthy,” “lightly sweetened,” or “all natural.” Animated, fast paced, and well choreographed, Fed Up is an educational and thought-provoking call to action, encouraging viewers to begin grassroots local public health campaigns to promote healthier diets and nutrition. The successes of the tobacco control efforts to curb smoking’s deadly toll are highlighted, and the current state of affairs in nutrition and obesity control are compared to the early days of the antismoking public health campaigns in the 1960s. The stated hope of the producers is that watching the film will “change the way you eat forever,” perhaps by reducing the intake of foods that don’t look like naturally occurring fruits, vegetables, or meats (i.e., processed and packaged foods). Through firsthand interviews with elected officials such as President Clinton and Senator Tom Harkin, health policy experts such as Michael Pollan and former FDA Commissioner David Kessler, archival footage, and case studies, the film traces the impact of the federal government’s first dietary guidelines, which were issued during the Nixon Administration forty years ago, and how they subsequently led to the unlimited addition of sugar to foods consumed by America’s children and adults. We meet obese children and parents in America who struggle with their weight and associated health concerns, despite vigorous exercise and attention to their diet. Alarmingly, the key to success for sustained weight loss appears to come only after bariatric surgery. We learn that sugar is more addicting than cocaine and is disguised on many food labels by unfamiliar names such as dextran, maltodextrin, diastase, xylose, sorbitol, and sorghum syrup. We also learn why the nutrition labels on foods at the grocery store do not include a “recommended daily allowance” for the sugar content—the food industry lobbying groups have successfully thwarted public policy efforts by our government to curb the skyrocketing rates of obesity, diabetes, and tooth decay through greater food regulation and sugar labeling. UCSF pediatric endocrinologist Robert Lustig is featured in the discussion of the specific harms of soda as “liquid sugar.” Lustig challenges the myth that counting calories alone is the key to controlling obesity by explaining why “a calorie is a not a calorie.” The average twelve-ounce soda contains ten packs WWW.SFMS.ORG

of sugar, and the normal signals to the brain that one is full are not activated by sugar in its liquid form, resulting in a metabolic stress on the pancreas and liver that releases insulin and results in a greater weight gain than from consuming solid food with an equal calorie content. The movie emphasizes that the current approach to controlling the obesity epidemic in America needs to be reframed. It also questions whether the government has inadvertently exacerbated the problem through farm subsidies for corn production, compromises in food policies, and cuts to school nutrition due to budgetary constraints. Fed Up empowers viewers with knowledge to become champions in this important public health endeavor, which will likely require a sustained, multipronged campaign over decades for ultimate success. A related local public health effort will be launched in July 2014, when the San Francisco Sugar Sweetened Beverage legislation moves through City Hall. For those advocates of the San Francisco soda tax, the film is a must-see to better understand the complex societal, scientific, public health, and industry forces that will shape the final outcome at the ballot box in November 2014. John Maa, MD FACS, is chair of the University of California Office of the President Tobacco-Related Disease Research Program SAC. He is on the board of directors of both the SFMS and the American Heart Association, San Francisco Division, and he is the Choose Health SF finance lead. He practices general surgery at Marin General Hospital.

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

MEDICAL COMMUNITY NEWS KAISER

Maria Ansari, MD

Kaiser Permanente San Francisco has led significant efforts to reduce tobacco use rates among our patient population. Smoking is a major public health problem that affects the entire health care system, and tobacco is the number-one cause of preventable death in the United States. Despite declining usage in our patient population, smoking remains a leading cause of cancer, cardiovascular, and pulmonary disease. Although smoking rates have dramatically decreased over the years at Kaiser Permanente, there is still a substantial number of smokers in San Francisco. Both counseling and tobacco cessation medications are important in continuing to improve tobacco quit rates, and Kaiser Permanente is uniquely poised through our integrated system to leverage resources that provide tobacco users the support they need to help them quit. One tool that assists providers in keeping track of patient health issues, including tobacco use, is our advanced electronic medical record system, KP HealthConnect. A very successful program we initiated, called “Smoking as a Vital Sign,” provides medical assistants with a rooming tool that prompts them to ask every single patient, every single time they come to the medical center, whether they smoke or not. The medical assistants then document the information in the electronic chart for providers to use when assisting with smoking cessation. Once smokers are identified, there are numerous resources for them, including oneon-one coaching with on-site health educators, tobacco cessation courses, and online programs. In addition, our telephonic wellness coaching program offers patients motivational counseling and tobacco cessation medications. In continuing to innovate, we are engaging in a “50,000 Quitters” campaign to get 50,000 smokers to quit within two years in Northern California. In San Francisco, the medical assistants are starting to wear shirts with a tobacco-cessation message on every “TobaccoFree Tuesday” to bring awareness to the issue and to offer smoking cessation resources. 28

SFVAMC

Diana Nicoll, MD, PhD, MPA

Aortic stenosis (AS) affects 16.5 million Americans over age sixty-five. AS is typically progressive but asymptomatic in its early stages, until it reaches a tipping point and produces cardinal symptoms of angina, syncope, and/or heart failure. At that point the prognosis changes dramatically. Without surgery, half of patients will die within two years, and the five-year survival rate is only 3 percent. For eligible patients, traditional open-heart surgery can restore normal life expectancy by replacing the aortic valve with a biological or mechanical aortic valve prosthesis. Unfortunately, many patients with severe AS have comorbidities that place them at high or prohibitive risk for traditional surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) is a novel means of implanting a normally functioning aortic valve percutaneously, from the groin in most cases. Weekly San Francisco VA Medical Center (SFVAMC) TAVR team conferences bring together expertise in cardiac surgery, interventional cardiology, radiology, anesthesiology, and echocardiograhy, nursing, and other specialties to evaluate potential candidates. TAVR procedures are performed in a state-of-the-art hybrid operating room, built to stringent VA standards, combining key features of the cardiac OR and catheterization laboratory into one space. TAVR is currently offered at SFVAMC and at a small handful of leading VA medical centers. In our several cases, recoveries have been noticeably quicker and smoother, and quality of life is restored much earlier than with SAVR, making TAVR truly transformative for those patients. Europe preceded the U.S. in implementation of TAVR, but the FDA has now approved two TAVR devices. SFVA TAVR team leaders Drs. Kendrick Shunk (interventional cardiology) and Elaine Tseng (cardiac surgery) each recently delivered invited lecture presentations to overflow audiences at the annual EuroPCR meeting, which provides a unique European vision into the future of TAVR for the U.S.

Sutter Pacific

Bill Black, MD, PhD

The health effects of sugary drinks and tobacco use and the critical importance of firearm safety are some of the top preventive messages that Sutter Pacific Medical Foundation pediatricians relay to patients and families. Drinks with high levels of sugar and low levels of vitamins include sports drinks, sodas, and juices. High levels of sugar increase the calorie intake, putting young adults at risk for obesity and diabetes. Too much sugar can lead to a failure to grow among infants. “There’s no use for juice and I emphasize that from an early age,” says Cindy Greenberg, MD. “Don’t keep it in the house.” Starting from infancy, kids should get used to drinking water and learn that eating fruit is better than drinking juice. Sodas are off limits. “They shouldn’t be a routine drink,’’ advises David Tejeda, MD. He finds that kids who struggle with weight issues will often see their weight stabilize if they drastically reduce or eliminate juice and sodas. He coaches kids to focus on one or two healthy habits and stick to a new routine for a few weeks. During that time, a healthier habit is being established. A concern with tobacco use is a child’s exposure to second- or third-hand smoke. Parents can be directed to smoking cessation classes. Even if parents say they do not smoke around children, they need to be reminded that chemicals seep into clothes and can negatively affect health—their own and a child’s. Sadly, firearm-related deaths continue to be one of the top three causes of death among American youth, according to the American Academy of Pediatrics. Guns should not be kept in the house, and if they are, they should be kept unloaded and locked in a safe place. Dr. Tejeda asks patients, “What do you do if someone shows you a gun?” He reinforces the answer, “Don’t touch it and go talk to the grown-up in charge. “

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

CPMC

Edward Eisler, MD

After a distinguished career at CPMC, Susan Day, MD, will be stepping down from her position as chair of the Ophthalmology Department, director of our Ophthalmology Residency Program, and medical director of our Graduate and Undergraduate Medical Education Programs at CPMC. On October 1, Dr. Day will take on a prestigious position as vice president of the Accreditation Council for Graduate Medical Education (ACGME)-International. The ACGME, located in Chicago, is responsible for overseeing and accrediting the vast majority of residency and fellowship programs for physicians in the U.S. She will direct the program in international accreditation, working with countries such as Singapore, Oman, Ghana, Japan, Trinidad, Ecuador, and China, so that physicians can acquire advanced, high-quality training within their own countries. Dr. Terri Slagle will assume the role of director of Newborn Services at CPMC, which was previously held by Dr. Steven Goldman. Under Dr. Goldman’s leadership, CPMC’s newborn services have grown into a renowned regional referral center for the care of sick premature and term newborns. Dr. Slagle will continue to provide leadership and expertise to CPMC’s neonatal programs. Dr. Mohammed Kashani-Sabet, MD, a physician with Sutter Pacific Medical Foundation and medical director for the Center for Melanoma Research and Treatment at CPMC, was honored with the sixth annual Humanitarian Award from the Washington, D.C.-based Melanoma Research Foundation on May 28. The Humanitarian Award is presented to those in the local community who have committed to fighting melanoma through exemplary patient care, cutting-edge research, and scientific leadership. Dr. Kashani-Sabet is an internationally recognized dermato-oncologist whose clinical focus is on the care of patients with cutaneous malignancies, specifically melanoma and cutaneous lymphoma. His federally funded laboratory research program at the CPMC Research Institute focuses on the development of novel biomarkers for melanoma and the identification of novel targets for cancer therapy. WWW.SFMS.ORG

ST. MARY’S

Robert Weber, MD

St. Mary’s Medical Center recently took center stage before a San Francisco Giants game at AT&T Park, as we showed off our hard work that helped transform our Infusion Center. On Saturday, May 24, our president and CEO Anna Cheung, Nurse Navigator Cheri Goudy, and I were all guests of the Giants on the field for a pregame ceremony dedicating the new “Giants-themed” Examination Room in our Cancer Center. While we were still on the field, and with 42,000 fans in their seats, a video recapping the project played on the large video screen in center field. It was a proud moment for all of us at St. Mary’s. Another highlight came moments later, when one of St. Mary’s Cancer Center patients, Danny Gambol, threw out the first pitch to Sergio Romo. So many of us at St. Mary’s have been with Danny throughout his journey, and it was a fantastic and emotional moment for us all as he threw a perfect strike to home plate just before the Giants took the field. Special thanks also goes out to Giants star pitcher Matt Cain, who helped launch the redesign by visiting St. Mary’s to “throw out the first paintbrush” on the opening day of work. We also thank Rooms That Rock 4 Chemo, a local nonprofit organization that helped coordinate much of the project’s scope, materials, and volunteers. With their assistance and the helping hand of their great volunteers, we were able to complete a large project in just a couple of days. It was hard work but incredibly worthwhile! Our Cancer Center opened in 2011 and is nationally accredited by the American College of Surgeons (ACOS) Commission on Cancer (CoC). Not only do we have one of the finest facilities in San Francisco but now we have a unique environment for our patients, and we think it can help make their stay at St. Mary’s a bit more comfortable.

SAINT FRANCIS Robert Harvey, MD, MBA

Saint Francis Memorial Hospital and the Saint Francis Foundation are proud to be committed to being the backbone of the Tenderloin Health Improvement Partnership (TLHIP). The multisector-impact partnership is dedicated to improving community health, safety, and well-being for the more than 30,000 residents of San Francisco’s Tenderloin neighborhood. Working collaboratively and in alignment, TLHIP seeks to address both the social determinants impacting the overall health of the people who live and work in the Tenderloin and the underlying health disparities and inequities that perpetuate the status quo. Partners and stakeholders engaged in TLHIP believe the Tenderloin can be a dynamic, diverse urban community where health, safety, and well-being are within the reach of all who live and work there. Both Saint Francis Memorial Hospital and the Saint Francis Foundation are working to ensure that: 1) Not-for-profit agencies are free to focus resources on alignment and programming. 2) Foundations and corporate and business allies are able to support a broad spectrum of organizations, initiatives, and efforts through one conduit. 3) Hospital, academic, and research institutions can share expertise within a collective forum. 4) Civic leaders and government agencies can engage in finding policy, financing, planning, and technical alignment, efficiencies, and solutions informed by committed stakeholders. 5) Most important, residents of the Tenderloin can have a cohesive multisector collaboration focused on collectively addressing the seemingly intractable challenges in the neighborhood, giving them a powerful and more high-profile representative voice in the community, working in concert with long-standing community coalitions and organizations. I am very proud to be the chief of staff of an organization that takes such pride in the community in which we reside. At Saint Francis, we embrace a responsibility to serve a greater benefit to our neighborhood and its residents. I am grateful that our staff works daily to ensure that our mission is being met.

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

PAYOR REIMBURSEMENTS HEALTH CARE

PROFESSIONAL DEVELOPMENT

KEEPING

SFMS

DISPUTES

PHYSICIAN

MEDICAL RECORDS

CME

REFORM

CODING

FINANCIAL MANAGEMENT

BILLING

& IMPLEMENTATION

ASK THE

CONTRACT NEGOTIATIONS

EHR SELECTION

PRACTICE MANAGEMENT

ICD-10, What Do We Do Now? For those of us in the health information management field, “March Madness” had a very different meaning. Watching the Senate vote on HR 4302, otherwise known as the “doc fix” bill, we bit our nails as the vote climbed toward the 60 required votes to pass it. Most people in the country were unaware of the little piece slipped in at the last minute that would delay ICD-10 for at least another year, and most news reports didn’t mention it either. Whether you heaved a sigh of relief or shook your head in disbelief at yet another postponement of the new code set, you are probably wondering what to do now. If you are among the majority of practices that were on track for preparation of the transition on October 1, 2014, don’t despair. Any training is not wasted. Staff who have received training in the new code set know that many of the differences between ICD-9 and ICD-10 are a few new concepts that are easily mastered and a new alphanumeric structure to the codes. The key to ICD-10 is mastery of the guidelines, and these have not changed much more than we are used to their changing from year to year. Some simple tasks will keep coders active in using ICD-10, and with practice they will be better prepared next year for the change than they would have been this year. Furthermore, any practice that was behind schedule for the original implementation date now has time to catch up.

Dual Coding

“Dual coding charts” means to code in both ICD-9 and ICD10, and it serves two purposes. It keeps coders in practice and helps highlight areas ripe for provider documentation education. Any staff educated in the new code set should pull ten to fifteen coded charts per month and recode them using ICD-10. After the coding exercise, discrepancies in documentation will be apparent. Instances of nonspecific coding should be inspected for improved documentation opportunities. Of course, you don’t have to wait until ICD-10 implementation to include increased documentation on a patient’s chart. Make the changes now and repeat the exercise every couple of months to see if the documentation improvements make a difference in your ability to more accurately code the charts in ICD-10.

trained staff members are also prime candidates to keep the office on track for the new implementation date. Keeping up to date on any new changes within the field, creating an implementation timeline, and making sure the practice hits the milestones on time will give the entire office a sense of progress and organization that will make the goals easier to achieve. As the new implementation date arrives, look again for more opportunities for formal training of new staff, as well as any opportunities for refresher courses and continuing education for those who have already been trained.

Physician Education

Physician staff members should take the opportunity to become familiar—in small bites—with the similarities and differences in the codes frequently used within the practice. Absorbing the steps needed to properly document conditions within the specialty will take care of the majority of work needed for physician documentation improvement. Unusual cases can be dealt with as they arise, but learning everyday codes will make the new code set seem less frightening and, by the time implementation gets here, there will be fewer things to learn. Keep in mind that we’re not talking about more paragraphs of documentation—sometimes a few tweaks to the current wording are all that’s needed.

Vendor Communication

Talk with your electronic health record and practice management software vendors, and keep those lines of communication open. Make sure they are on track with preparations for implementation on their end. Ask the vendor to come out and educate your staff about changes they’ll be making and how those changes may affect current office procedures. Make sure you can schedule end-to-end testing as the implementation date nears. Remember that the new implementation date will change vendor plans as well. By the time ICD-10 implementation takes place (in at least another year), new guidance on meaningful use will certainly arise. Vendors may have been on track to be ready for implementation in 2014, but by the time final implementation occurs, even more improvements to their systems may be mandated. A little understanding on everybody’s part can go a long way toward a smooth transition.

Jennifer Della’Zanna, MBA, CMT, CPC, CGSC, CEHRS, has worked in the health care industry for twenty years. She has written and edited courses and study guides on medical coding and the use of technology in health care. Della’Zanna is an AAPC ICD-10 trainer and a member of the American Academy of Professional Coders, AHIMA, and the Association for Healthcare Documentation Integrity.

Staff Training

There is no better way to learn a new skill than to teach it to another person. Encourage staff who have received training to pass on their knowledge to other staff members. Already30

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

IN OUR OPINION Mervyn F. Silverman, MD, MPH; Harvey J. Cohen, MD, PhD; Steve Heilig, MPH

Time to Stand Up for Women and Contraception Our elected officials and the Obama administration must take decisive action to assure that contraception is covered and paid for on the exact same terms and for the same reasons as other essential preventive health care benefits. California Senator Barbara Boxer recently introduced legislation in the U.S. Senate titled, “Protect Women’s Health from Corporate Interference Act.” It would restore the legal guarantee under the Affordable Care Act that women have access to contraceptive coverage through their employment-based insurance plans and would also protect coverage of other health services from employer interference. Evidence establishes conclusively that ready access to contraception is accountable for important improvements in the lives of women, families, and communities. However, the $1,000 up-front cost of the most effective forms of contraception, such as intrauterine devices (IUDs), can put them out of reach of many low-income women who would benefit from them the most. In the past, health plans that covered Viagra and vasectomies too often did not cover contraception for women. This was the case for Hobby Lobby. The U.S. Equal Employment Opportunity Commission determined in 2000 that this practice was discriminatory on the basis of sex and required health plans for federal employees to cover contraception. The Affordable Care Act (ACA) appropriately follows suit and includes contraception on the list of required services. The ACA also waives additional out-of-pocket financial barriers, including co-payments and deductibles, for women’s preventive health services recommended by the Institute of Medicine, to facilitate use and save on future health care costs. These services include contraception and screenings for sexually transmitted diseases, including HIV. In 2012, the San Francisco Medical Society’s delegation to the California Medical Association developed this policy statement, which was then adopted by the CMA:

CONTRACEPTION AS A FULLY-COVERED HEALTH INSURANCE BENEFIT

Whereas, the United States Institute of Medicine in July 2011 strongly recommended that “the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity” be a fully covered benefit of all health insurance plans; and Whereas, the costs of contraception have long been identified as a barrier to many women’s optimal use of contraception, with negative impacts on their health and in terms of unwanted pregnancies, as well as discriminatory implications; and Whereas, the Federal administration has just mandated that contraception be a covered benefit, but health insurance industry representatives have voiced their opposition to this measure and might try to repeal it; now be it RESOLVED: That the California Medical Association supports WWW.SFMS.ORG

the coverage, without co-payments, of all FDA-approved contraception methods as a mandated health benefit of all health plans. The Supreme Court’s decision in the Hobby Lobby case would authorize a wide array of for-profit employers to single out birth control for discriminatory treatment. As Justice Ginsburg has pointed out, the decision is inconsistent and sweepingly broad. It redefines corporations as capable of religious beliefs, by claiming a corporation is simply an association of individuals rather than the standard legal definition that it is a fictitious entity purposely created to shield individuals from liability for business risks. It then privileges the corporation’s beliefs over the rights and interests of employees or the public. The subsequent Wheaton College decision seems to cement the Court’s views. Several state laws now assert that most religiously affiliated employers cannot discriminate in hiring based on religion, or in the design of health care benefits. Only a narrow set of organizations, explicitly created for the purpose of worship, are exempted. In creating rules for the ACA, the administration mistakenly stretched beyond this very narrow boundary and created an accommodation on contraception coverage for a wider group of religiously affiliated employers. Compounding that error by seeking further compromises will clearly do nothing to appease Hobby Lobby and Wheaton College. It is time for the nation to stand up in support of women’s health and of contraception, as is done almost everywhere else. In addition, we must motivate the Supreme Court to restore the legitimacy of this right and recognize the Court’s responsibility to evaluate cases on the basis of facts and evidence, and not on religious doctrine.

Reference Gostin, LO. The ACA’s contraceptive mandate: Reli-

gious freedom, women’s health, and corporate personhood. JAMA. Published online July 11, 2014. Mervyn Silverman, MD, MPH, is former president of the American Foundation for AIDS Research and former director of Public Health, San Francisco. Harvey J. Cohen, MD, PhD, is a Deborah E. Addicott, John A. Kriewall, and Elizabeth A. Haehl Family Professor of Pediatrics and the Katie and Paul Dougherty Medical Director of Palliative Care at Lucile Packard Children’s Hospital, Stanford University School of Medicine. Steve Heilig, MPH, is with the SFMS, a former Planned Parenthood director, and coeditor of the Cambridge Quarterly of Healthcare Ethics. This piece was authored for Men Who Trust Women, a network of men who support reproductive rights, free access to birth control, and keeping abortion legal and accessible: http://menwhotrustwomen.com/. JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

TEN QUESTIONS SFMS Member Profile: Dexter Louie, MD, JD, MPA The San Francisco Medical Society has launched a new member spotlight column to feature profiles of leading stakeholders from the medical community and to get their personal views on medicine. We hope to showcase members from across the SFMS spectrum to reflect the rich tapestry of our membership and help highlight some of the great work of our community.

1. What’s the biggest barrier to practicing medicine today? The biggest barrier is probably change, and change is always difficult. There are many new external demands, and we have no idea how health care reform will play out. Physicians still practice medicine, but it is and will be very different than the past practice of medicine. The health care system has not been efficient, access has been limited, and care has been fragmented. The system now demands more efficiency, less waste, more access, better integration of health care, and EHR. So, for clinicians who are mid- or late-career, it can be difficult to fully embrace all the changes, and this is probably the main challenge for most established clinicians. For both established and new physicians, there will be less or no opportunity for independence and autonomy, as the health care system evolves into large and integrated group practices and various employment models.

2. If you could change or eliminate something about the health care system, what would it be?

I would like to change the perception of what is good medicine, from a more global perspective. Our health care system has evolved into an uncontrollable system of spending more money and providing more care but receiving less value, with little thought or concern for equity and consumption of resources. We, as a society, demand more care, perfect care, immediate care, futile care, and unnecessary care. Unfortunately, the current system (on a legal, political, and economic basis) is designed to provide all this care. Good medicine should have some boundaries as to what and how the health care system provides, taking into consideration the issues of equity and limited resources as well as quality and value.

3. Why are you an SFMS member?

As an individual physician, I am but one voice. Through SFMS and organized medicine, my voice and my values are amplified. There is the opportunity to join with others who want to influence policy, to improve health care and the practice of medicine, 32

and to take a leadership role in health care issues. Specifically, I remember in the ’80s when HIV/AIDS was just beginning to be understood. Against great opposition, the SFMS delegation led the discussion on the science in and public health approach to HIV/AIDS, at the CMA’s House of Delegates (HOD). This went on year after year until finally the CMA HOD, as a body, recognized that HIV/AIDS was a public health and medical issue for physicians to address.

4. What advice would you give to a medical student or resident just starting out today?

Being a physician brings respect, a good living, and membership in an honorable profession. Going forward, you have the opportunity and the responsibility to do more than practice medicine. You can and should advocate for and help provide access and quality care for the underserved and most vulnerable. I hope you seek these opportunities and that you fulfill these greater responsibilities. You will be well rewarded.

5. What’s the best piece of advice you’ve gotten in your career so far?

One of my mentors, Dr. Rolland C. Lowe, a member of SFMS and past president of the CMA, always emphasized the importance of “giving back,” and specifically giving back to the community. Again, as physicians, we are advantaged, and we should look for opportunities to give back and to help make things better for others.

6. What is the most rewarding aspect of being a doctor? Helping others and being trusted.

7. What is the most memorable research published since you became a physician? What I remember most is not a document in medical research but the DVD Unnatural Causes (www.unnaturalcauses.org). I had been a community physician in Chinatown for about thirty years, treating patients one on one, isolated in what I call the “four walls,” my office, the hospital, the operating room. Unnatural Causes is a powerful documentary. It has helped me to better understand the relationship between socioeconomic and racial inequities, public policy, and health/health care. I was inspired and motivated to become more involved in advocacy and policy work, trying to make a difference, not just for my one-on-one patients but in the whole system of health care, the social determinants of health, and care for the underserved and most vulnerable.

8. What is your advice to other physicians on how to avoid burnout?

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

Taking things into perspective, prioritizing, and learning to say no. Here are two memorable statements that have helped me practice medicine while still maintaining a relatively calm, orderly, and happy life. A very close friend told me years ago, when he saw me overburdened with work and other activities, “Remember, Dexter, you can do anything, you just can’t do everything.” With regard to your work-life balance and your family and friends, are you committed to spending as much time and effort with your family and friends as with work? During this same busy period, one of my then-teenaged daughters told me to heed the “Serenity Prayer.” The short version is, “God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference” [theologian Reinhard Neibuhr]. I listened, and now I can thankfully say that I am very content, looking forward to many more years in medicine and community work, and enjoying my health, my family, and my friends.

9. Do you have a favorite hospital-based TV show?

No, I don’t. After a day at work, over many years of medical practice, I find that I am constantly reminded how much is out there to enjoy and learn about in addition to medicine. My wife likes the history and wildlife channels, so I will watch these shows with her. Otherwise, I enjoy reading in the backyard, with birds, squirrels, and my dogs for company. In fact, getting away from medicine on a regular basis has helped me avoid burnout.

10. If you weren’t a physician, what profession would you like to try? I would probably go into law. I attended law school after being in practice for about ten years, thinking that health care law and policy would be both interesting and challenging. However, when I was faced with the option of practicing law or medicine, I chose medicine. Looking back, after being a physician for forty-five years, I cannot see myself in another profession. It has been both enjoyable and rewarding. In fact, it’s been just great!

Dexter Louie, MD, JD, MPA, is an otolaryngologist who has been based in San Francisco’s Chinatown since 1977. He was also associate medical director of the Chinese Community Health Plan, a community-based HMO, for fifteen years. Dr. Louie was born in San Francisco and received his BA from Stanford University and his MD and residency training from Tulane University. He received his JD and MPA degrees from Golden Gate University, San Francisco. He is a past president of the San Francisco Medical Society and past chair of the CMA Foundation board. Dr. Louie currently serves as chair of the Board of the National Council of Asian Pacific Islander Physicians and is a member of the AMA Commission to End Health Care Disparities. He also sits on tbe Steering Committee of the Network of Ethnic Physicians Organizations, a project of the CMA Foundation. These organizations focus on issues of health and health care disparities, health care access, and meaningful and effective patient engagement. Dr. Louie was recently appointed to the Advisory Committee of the Office of Health Equity, California Department of Public Health.

Mayo Clinic Nutrition and Wellness in Health and Disease September 18-19, 2014 Marriott Marquis • San Francisco, CA Gain the knowledge you need to support your patients’ nutrition, physical activity and wellness needs.

JULY/AUGUST 2014 SAN FRANCISCO MEDICINE

CLASSIFIED ADS

UPCOMING EVENTS

San Francisco Financial District Medical Office

9/8: SFMS General Meeting

1,200 sq feet. Two furnished exam rooms. Available 3 to 5 days per week. (415) 377-9517 or lewsuzy@comcast.net.

6:00 p.m. to 7:30 p.m. | Commodore Room inside the Golden Gate Yacht Club | Calling all SFMS members! Save the date for SFMS’ General Meeting. The event is a good opportunity to network with colleagues, meet with SFMS leadership, and learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California. Dinner will be provided. Detailed information is available at https:// www.sfms.org/Events.aspx.

Discover Health Medical Partners, Inc.–N1 Health

The physicians of Discover Health are pioneers in direct access medicine in the San Francisco Bay Area. We provide clinic and house call medical and naturopathic services to adults and children throughout the region. We seek an energetic, self-directed team player to join our group as a full- or part-time associate in clinical practice. The ideal candidate is a board-certified or eligible FP, IM, or Med/Peds physician. In addition, the candidate is able to share in call coverage and make house calls in the Bay Area. You will join a multi-disciplinary and comprehensive care team that includes internal medicine, pediatrics, and naturopathy. In addition to a top-notch facility, experienced administrative and medical assistant staff will support your clinical practice. Our EHR is user friendly and enables office and mobile charting. We are a familyfocused practice that takes pride in caring for entire families across generations. Discover Health is a membership-based private practice that limits provider panels to allow you to spend the time necessary to address the physical and emotional needs of your patients. Discover Health is an Equal Opportunity Employer medical, dental, vision, and paid time off benefits to qualified associates and employees. If you are interested in joining our team, please send your cover letter and CV to: manager@discoverhealthmd.com.

Tracy Zweig Associates INC.

REGISTRY

PLACEMENT

FIRM

~ Physicians ~ Nurse Practitioners Physician Assistants

9/20: Zero Prostate Cancer Run/Walk

9:30 a.m. | Crissy Field, San Francisco | Join SFMS physician members from Golden Gate Urology for the second annual Zero Prostate Cancer Run/Walk. This tight-knit community activity brings together athletes, doctors, cancer survivors, and those who care about them to end prostate cancer. Visit http://bit.ly/1u0RQ9G for more information on how to get involved.

9/18–20: AAPC Regional Conference

Disneyland Hotel, Anaheim | SFMS/CMA members can save $130 on a conference registration and hotel package for AAPC’s Regional Conference. Members and their staff enjoy a discounted rate of $795 for conference registration plus two nights at the Disneyland Hotel. The conference includes more than 50 educational sessions, covering hot topics in coding, auditing, practice management, compliance, and electronic health records. There are tracks in ICD-10-CM, ICD-10-PCS, medical auditing, and practice management. Attendees can earn up to 19 CEUs. To register with the special SFMS/CMA pricing, please contact AAPC Regional Director Brad Eagar at (801) 236-2234 or brad.eagar@aapc.com.

9/19-21: Network of Ethnic Physician Organizations (NEPO) Leadership Summit

Riverside Conference Center | The NEPO Summit is an opportunity for physicians, public health professionals, and community leaders who work with underserved communities to learn about emerging health care policy issues, share best practices on how to reduce health disparities and increase access to health care services for the populations they serve. As in previous years, CME will be offered and the agenda will include a thought-provoking array of plenary sessions and workshops. For more information or to register, please contact Liza Kirkland at (916) 779-6643 or lkirkland@thecmafoundation.org.

9/27–28: Leader’s Toolkit – Physician Leadership Course

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com 34

San Diego County Medical Society | CMA’s two-day leadership course, Leader’s Toolkit, is a free members-only program for SFMS members who are seeking leadership roles in organized medicine. Participants will learn real-world skills and will leave with actionable behaviors, tools, and concepts to help them be effective leaders in organized medicine. Some of the issues covered include change management, leading a team, responsibilities of a leader, setting boundaries and priorities, time management, parliamentary procedure, and understanding and leveraging critical relationships. For more information or to register, please contact Jennifer Moller at (916) 551-2541 or jennifer@cmsservices.org.

SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG

A former employee sued me for wrongful termination.

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. SFMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are: A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

For more information on these important benefits, and the special SFMS First-Time Buyers Program, please contact Mercer at: 800-842-3761 or email us at CMACounty.Insurance.service@mercer.com

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim. Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.