June 2013

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

Keeping Kids Safe A Summer Guide to Pediatric and Adolescent Safety Summer Activities in San Francisco for Families of All Income Levels Preventing Sports Injuries

Gun Safety Bullying: How to Prevent It Ergonomics: Keeping Kids in Line

VOL. 86 NO. 5 June 2013

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IN THIS ISSUE

SAN FRANCISCO MEDICINE June 2013 Volume 86, Number 5

Keeping Kids Safe: A Summer Guide to Pediatric and Adolescent Safety FEATURE ARTICLES

MONTHLY COLUMNS

12 Keeping Kids Engaged: Talk to Your Patients About

Summer Activities

Janet Green, MSPH

4

Membership Matters

6

Ask the SFMS

8

Executive Memo Mary Lou Licwinko, JD, MHSA

14 Keeping Kids in Line: Ergonomics in the Modern Age of

Computers and Video Games

Chunbo Cai, MD, MPH 14 Notes from My Pediatric Practice

Shannon Udovic-Constant, MD

16 Safe Summer Sports: Prevention Tips for the Field

James L. Chen, MD

9

President’s Message Shannon Udovic-Constant, MD

11 Editorial

Gordon Fung, MD, PhD 15 Classified Ad

17 Caring for Young Athletes: Prevention Tips in the Office

Anthony Luke, MD, MPH

15 Welcome New Members

20 Bullying Examined: An Interview with Charles Wibbelsman, MD

33 In Memoriam

Nancy Thomson, MD

19 Bullying: From Insult to Injury

David Pating, MD, and Deborah Lee, PhD

21 Vitamin D: The Basics and Its Relevance Today

Melissa Lin, MD

23 Food for Hungry Families: San Francisco Food Banks and

Pantries and How to Help

Lucy Crain, MD, MPH 24 Pediatric Emergency Care: Renewing Richie’s Fund

Andrew Fenton, MD 26 Gun Violence: A Personal Story

Jeff Mains and Dustin Ballard, MD

27 Firearm-Related Injuries: Affects on Pediatric Populations

American Academy of Pediatrics 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.

30 Hospital News

OF INTEREST

7 Assemblymember Pan Visits the SFMS 15 SFMS Supports the Pediatric Advisory Council 28 Health Care Reform Heats Up: From the CMA 29 Medi-Cal Cuts Endanger Health Care Reform

Lloyd Dean and Shannon Udovic-Constant, MD 29 SFMS and CMA Support Medi-Cal Rally

32 Health Care Payment Reform: Overcoming

Barriers

Harold D. Miller 34 Health Alert: Hepatitis A Outbreak

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Physicians Networking Mixer a Great Success!

outpatients with uncomplicated illness, be treated with neuraminidase inhibitors as early as possible, without waiting for laboratory confirmation of influenza before initiating treatment.

Please visit http://bit.ly/15AgVhK to view the full advisory. For more information about health alerts, advisories, and updates from the San Francisco Department of Public Health, please visit http://www.sfcdcp.org/healthalerts.html.

SFMS/CMA Asks California Supreme Court to Depublish Case That Ignores MICRA’s Definition of Professional Negligence

Local physicians joined SFMS for a private networking event celebrating physician camaraderie and volunteer service on May 2. Attendees took advantage of the opportunity to meet SFMS leaders and connect with stakeholders from within our local medical community.

SFMS would like to thank our members, local physicians, Medical Insurance Exchange of California (MIEC), and especially our cohosts Drs. Sean Bourke and Paul Turek (pictured above with SFMS president-elect Lawrence Cheung, MD) for their support of this event and the medical society.

With great attendance and positive feedback from all, SFMS will host another evening networking mixer for physician members on July 18. Please visit http://www.sfms.org/

Events.aspx for a list of upcoming events and details.

SFDPH Health Advisory: Human Infections with Avian Influenza A:H7N9 The San Francisco Department of Public Health has released an updated advisory on H7N9. Due to the potential se-

verity of illness associated with avian influenza A:H7N9 virus infection, the CDC now recommends that all confirmed, probable, and suspect cases of avian influenza A:H7N9, including 4 5

San Francisco Medicine June 2013

CMA has asked the California Supreme Court to depublish an appellate court opinion that thwarts the long-standing definition of “professional negligence” in California’s Medical Injury Compensation Reform Act (MICRA). The ruling, if allowed to stand as precedent for future cases, could be misused to undermine the goals of MICRA and adversely affect the entirety of the health care system and safety net in California.

In Flores vs. Presbyterian Intercommunity Hospital, a hospital patient sued for injuries she allegedly sustained from a fall when her hospital bed rail collapsed. The appeals court ruled that the negligence did not occur in the rendering of professional services and as such was subject to the two-year statute of limitations for ordinary negligence rather than the one-year statute of limitations for professional negligence.

CMA, California Dental Association, and California Hospital Association filed a joint amicus letter urging the Supreme Court to depublish the Court of Appeal’s opinion on the grounds that the opinion was wrongly decided, having been based on a poor factual record and consideration of less than all the pertinent authority. For more information about this case, please visit http://bit.ly/10ggFQJ.

Medicare MAC Contract Protest Update

The U.S. Court of Federal Claims has denied two protests that were filed challenging a decision by the Centers for Medicare and Medicaid Services (CMS) to award the Medicare Administrative Contractor (MAC) contract for Medicare Parts A and B in Jurisdiction E to Noridian Administrative Services.

CMS and Noridian will now move forward to implement the new contract and expect this process to be complete by mid-September 2013. SFMS/CMA has worked and will continue to work closely with CMS and the new contractor to ensure a smooth transition.

Update on Scope of Practice Legislation

The California Senate passed three bills that aim to expand certain health care providers’ scope of practice as a www.sfms.org

means to address California’s primary care physician shortage. The bills were introduced by Senator Ed Hernandez (D-West Covina), (SB 491, SB 492 and SB 493) that, respectively, would expand the scope of practice for nurse practitioners, optometrists, and pharmacists to address the physician shortage.

SFMS and CMA strongly oppose these bills because they set a dangerous precedent of allowing non-physicians to practice medicine without being subject to the Medical Practice Act, which regulates the practice of medicine and in which violations may result in the loss of a medical license and possibly criminal prosecution. Ultimately, nurse practitioners, optometrists, and pharmacists would be providing the same services as physicians, with less training, while being held to a lower standard of care. For more details on the proposed legislations, please visit http:// bit.ly/ZtYTLL.

June 2013 Volume 86, Number 5 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD 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

Department of Defense Extends Temporary Waiver for TRICARE Authorizations and Referrals

Physicians have been reporting significant delays in processing of authorizations and referral requests since the transition of TRICARE managed care services from TriWest to United Health Military & Veterans (UMVS) on April 1, 2013.

While the standard time frame for processing of authorization and referral requests is two business days for urgent request and five business days for routine requests, the payor has been weeks behind in processing these requests. CMA/SFMS has been working closely with UMVS to seek a resolution to this and other issues related to the transition.

To address the delays, the Department of Defense (DoD) has waived authorization and referral request requirements for all TRICARE-covered services from April 1 through June 18, 2013. Physicians will not be required to seek or wait for an approval from UMVS for any covered services during this period.

The waiver will be in place for referrals received through June 18, 2013, for care with dates of service of April 1, 2013, through September 15, 2013. Referrals made during the waiver period with anticipated dates of service of September 16 and beyond will need authorization. Physicians are urged to call UMVS at (877) 988-9378 to arrange for such authorization so that claims for those services are paid correctly.

SFMS Hosts Practice Manager Forum

SFMS teamed up with the Northern California Medical Group Management Association to host a networking mixer for office managers at the SFMS office. This was a unique opportunity for local office managers to network with peers and share best practices on the smooth running of a medical practice. If you would like to join the SFMS Practice Manager Forum and be added to our e-mail distribution list to be notified of future events, please contact SFMS at (415) 561-0850 extension 200 or e-mail membership@sfms.org.

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

June 26: Meaningful Use: What You Need to Know for This Year and Stage 2 • 12:15 p.m. to 1:45 p.m.

July 24: Protect and Preserve Your Patient Relationships • 12:15 p.m. to 1:15 p.m.

August 21: HIPAA Compliance: The Final HITECH Rule • 12:15 p.m. to 1:15 p.m. www.sfms.org

SFMS OFFICERS President Shannon Udovic-Constant, MD President-Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Immediate Past President Peter J. Curran, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Associate Executive Director for Public Health and Education Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Lauren Estrada BOARD OF DIRECTORS 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

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Keith E. Loring, MD Ryan Padrez, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD John Maa, MD Edward T. Melkun, MD Justin V. Morgan, MD Kimberly L. Newell, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

CMA Trustee: Shannon Udovic-Constant, MD AMA Delegate: H. Hugh Vincent, MD AMA Alternate: Robert J. Margolin, MD

June 2013 San Francisco Medicine

5

Get answers to your important practice-related questions with the help of SFMS experts. SFMS’s Ask

the SFMS feature connects members with SFMS physicians and partners who can answer questions on a wide variety of topics dealing with the practice of medicine, ranging from practice management, patient education, and EHR assistance to health policy, legal/malpractice, financial management, and more! If you would like to submit a question to our experts, please email info@sfms.org.

Worker’s Compensation Insurance: Questions and Concerns

As required by state law, every medical practice with employees—even part-time employees—must provide workers’ compensation benefits. To help you choose the best policy, here are answers to some commonly asked questions.

Is there any difference in the benefits provided or the rates charged by companies?

The benefits due to a job-related injury or illness are standardized by state law and cannot vary by company. While the Workers’ Compensation Insurance Rating Bureau provides guidance on the base rate per $100 of payroll for each class, companies may charge different rates based on their own loss experience and expenses. Premiums may also vary by minimum premiums (the least amount they will charge to issue a policy).

Are there other charges that I should be aware of?

Yes, some companies charge an “expense constant” or policy fee. This is an additional fee charged to issue the policy and can add more than $100 annually to a policy. Some brokers may also add a broker fee in addition to commissions 6 7

San Francisco Medicine June 2013

contained in the premium. Additionally, the state charges additional fees and surcharges (same percentages apply regardless of company) to fund various initiatives to combat fraud, and to pay for claims of bankrupt companies and for injured employees of employers that were not insured.

Why is my policy audited each year?

Workers’ compensation premiums are based on estimated payroll at the beginning of each policy year. At the end of the policy, an audit is conducted to determine your actual payroll. If you payroll was lower, premium will be refunded; if higher, additional premium is owed.

Why is my premium increasing when I haven’t had a claim in the ten years I’ve been practicing?

Workers’ compensation premiums are based on the collective experience of employers statewide. Premiums, claims, loss expenses, and administration are pooled together and rates are established accordingly. Over the past few years, medical expenses have continued to increase significantly while premiums collected by insurers have remained flat or decreased based on class. In addition, investment returns on premiums have virtually disappeared. Consequently, insurers must increase premiums to pay for increased medical expenses and losses.

Roy Lyons is the managing director at Marsh, a global leader in insurance broking and risk management. For more information about the CMA/SFMS member discounts on insurance services, please visit www.CountyCMAMemberInsurance.com or contact Marsh/Seabury & Smith Insurance Program Management at (800) 842-3761. www.sfms.org

Assemblymember Pan Visits SFMS

Left to right: SFMS member John Maa, MD; Assemblymember Richard Pan, MD; SFMS President Shannon Udovic-Constant, MD; and SFMS Executive Director Mary Lou Licwinko, JD, MHSA California Assemblyman and senatorial candidate Richard Pan, MD, visited the SFMS for a lively discussion of current medical issues and political perspectives. A pediatrician and the only physician in our state legislature, Pan reflected that his time to date as an elected official has confirmed his feeling that having a medical perspective in “the (Capitol) building” was very important for informed policy-making. Sponsored by the SFMS Political Action Committee, the event raised funds for his senatorial campaign.

Left to right: SFMS board member Katherine Herz, MD; Assemblymember Pan; and SFMS past president George Fouras, MD

savings of $ over 95,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s trial lawyers have launched an attack to undermine MICRA and its protections, and we need your help.

Membership has never been so valuable!

WAYS SFMS-CMA IS WORKING FOR YOU! 2012 SAN FRANCISCO MICRA SAVINGS CHART General Surgery

Internal Medicine

OB/GYN

Average

(Non-invasive)

San Francisco

$26,612

$7,392

$36,964

$23,656

Miami & Dade Counties, FL

$190,088

$46,372

$201,808

$146,089

Nassau & Suffolk Counties, NY

$127,233

$34,032

$204,684

$121,983

Wayne County, MI

$121,321

$35,139

$108,020

$88,160

FL-NY-MI Average

$146,214

$38,514

$171,504

$118,744

MICRA Savings

$119,602

$31,122

$134,540

$95,088

* Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

www.sfms.org

San Francisco Medical Society 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415)561-0850 Fax: (415)561-0833

June 2013 San Francisco Medicine

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EXECUTIVE MEMO Mary Lou Licwinko, JD, MHSA

Knowing the Risks of Indemnification Clauses At a recent meeting of the Medical Insurance Exchange of California (MIEC) there was a discussion about how physicians have unwittingly signed contracts that contain indemnification clauses under which the physician assumes a duty to defend and indemnify third parties such as hospitals or medical centers for risks they have no control over.

This third-party indemnification is not, for good reason, generally covered under a physician’s individual professional liability insurance, so a physician who signs a contract with such a clause risks personal liability for harm caused by others. As this is an important issue for physicians, I asked MIEC to send information that could be shared with San Francisco Medicine readers.

The following was adapted from an article written by Susan F. Halman, Esq., of the law firm Selvin Wraith Halman, LLP, for the MIEC publication The Exchange.

Advice from MIEC

An indemnification clause operates to allocate legal risks between the parties to the professional services agreement (PSA). For example, a risk-transferring indemnification clause in a PSA may state: Physician shall defend, indemnify, and hold harmless the Medical Center from any and all liability claims, losses, damages, expenses, costs, and attorney’s fees which Medical Center may incur, suffer, or sustain or be threatened with arising in whole or in part from or related to Physician’s professional services, medical conduct, medical acts or omissions, including specific directions given by Physician to nonphysician personnel, or performance or failure to perform any service set out in this Agreement, or in any manner related to Physician’s performance at the Medical Center.

Under this type of indemnification clause, the physician may be held liable to defend and indemnify the Medical Center for all of the Medical Center’s liability exposure for a claimant’s damages—even that portion of the damages that are not arising directly from the physician’s own professional services. This contractual obligation can place a tremendous financial burden upon the physician. In addition, some states interpret an indemnification clause that contains a duty to defend as requiring the physician to begin defending immediately upon receiving the Medical Center’s tender of a claim merely alleging the physician’s liability for the claimant’s injury, rather than to reimburse the Medical Center for its attorneys’ fees and costs after the physician’s liability for the claimant’s injury is proven.

Recently, professional liability companies have seen an increase in cross-claims for contractual indemnity filed against its physician policyholders by codefendants—e.g., a medical

8 9

San Francisco Medicine June 2013

center or a medical equipment manufacturer—to enforce the codefendant’s indemnity rights under contractual indemnification clauses. In these cross-claims, the codefendant seeks to hold the physician liable to pay the codefendant’s attorneys’ fees and costs incurred in defending against the claim, as well as to indemnify the codefendant for all sums it pays in settlement or in satisfaction of an adverse judgment.

Most professional liability companies work from the belief that physicians should be responsible for their own negligence but should not assume financial responsibility for the negligence of third parties. Accordingly, most professional liability policies do not provide coverage for liability for damages or for defense fees or costs incurred in connection with a claim that seeks to hold a physician liable because of a written or oral agreement to hold harmless, indemnify, or otherwise assume another’s obligation or liability, if liability or the amount of damage sought or imposed upon the physician is greater than that which would exist in the absence of such an agreement. Policyholders who enter into a PSA containing an indemnification clause must understand that they may be assuming personal obligations beyond the scope of their policy’s insurance coverage.

Most professional liability companies do not offer “additional insured” coverage to a third party on their policies. By executing a PSA that includes an indemnification clause in favor of a third party, a physician has accepted responsibility for a liability exposure that is likely not insured by his or her insurance carrier.

Whenever an indemnification clause is included in a contract, it is recommended that physicians attempt to have it removed entirely. If this is not possible, it may be replaced by a simple clause that requires each party to maintain liability insurance for its own negligent acts and to provide evidence of insurance on request.

It is recommended that physicians review their professional service agreements to determine whether they contain an indemnification clause and, if so, the scope of liability to be assumed under the agreements.

Questions about whether the indemnification clause in a PSA may present an uninsured exposure should be directed to the physician’s insurance carrier’s underwriting or claims department. www.sfms.org

PRESIDENT’S MESSAGE Shannon Udovic-Constant, MD

I Need a Hero: Physicians Rise to the Occasion In the days following the Boston Marathon bombing, there was a quote circulating on Facebook

by Fred Rogers, the man made famous by the old television show Mr. Roger’s Neighborhood.

The quote was, “When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’

To this day, especially in times of disaster, I remember my mother’s words, and I am always comforted by realizing that there are still so many helpers—so many caring people in this world.” That day in Boston there were many amazingly brave and caring people, including all of the emergency workers and hospital staff who spent countless hours caring for the injured.

At the same time this quote was being circulated, I signed onto a petition being circulated on the Internet by Miss Representation, a nonprofit organization trying to improve media representation of women, urging Disney to stop selling a women’s t-shirt with male superheroes on it and the statement, “I need a hero.” The argument is that women don’t need to be rescued, and also that women are just as able to be heroes. The t-shirt has been pulled due to the success of the petition. Miss Representation was urging everyone reading about the success of the campaign to acknowledge someone around them who is an everyday hero, in order to redefine what it means to be one.

As I thought of who around me should be thanked for being a hero, I immediately thought of physicians. Often in the day-to-day jobs of physicians, heroic things—such as saving lives—are being done. As I thought of summer safety and the idea of heroes, I thought of a group of pediatricians at Children’s Hospital Oakland a few years ago who saved lives.

They found that there were a lot of children presenting to their emergency room after falls through windows, resulting in morbidity and mortality. They saw an opportunity to do something. They got window locks, devices that only allow windows to open up to four inches, an amount a child couldn’t fit through. They started handing them out to their patients in the clinic. In addition, they pursued a public relations campaign entitled, “Children Can’t Fly,” regarding the importance of using window locks to prevent falls. They saw a dramatic reduction in falls in the zip codes where the media campaign was targeted. New York passed legislation requiring apartments to have window guards and also saw a dramatic decrease in falls from windows. Due to the success of this campaign and New York’s legislation, SFMS passed a resolution at the CMA House of Delegates last fall to require window locks.

In addition to the advocates who see a medical problem and seek to reduce it, there are the many physicians who quietly do their regular jobs of improving health or saving lives www.sfms.org

without much recognition. I was recently at a social function with a colleague who works in the emergency room at my hospital and has seen a number of my patients, to their great satisfaction. He was speaking with another colleague who said of a shared patient, “Remember that patient?” My colleague turned to me and stated, “I never like to hear that statement, because I know that it means that there is going to be something that didn’t go as planned.” I realized that he only gets the constructive criticism and doesn’t hear the thanks for a job well done. I quickly thanked him for the amazing care that he has given to my patients over the years. Then, I realized that there are many colleagues that I don’t give thanks to.

So by way of this column, I say thanks to all the specialists, hospitalists, emergency room physicians, radiologists, surgeons, and many others who don’t receive thanks for all of the daily acts of heroism they provide in healing my patients and the patients of San Francisco. Thanks, thanks, thanks, because, as stated by Susilo Bambang Yudhoyono, the current president of Indonesia, “Every society needs heroes. And every society has them. The reason we don’t often see them is because we don’t bother to look. There are two kinds of heroes.

Heroes who shine in the face of great adversity, who perform an amazing feat in a difficult situation. And heroes who live among us, who do their work unceremoniously, unnoticed by many of us, but who make a difference in the lives of others.”

June 2013 San Francisco Medicine

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EDITORIAL Gordon Fung, MD, PhD

Pediatric Safety When I was in medical school, my pediatrics rotation inflicted mental scars that have never left me. I remember spending time in the neonatal ICU and performing newborn physicals (for patients who had almost no “history” attached, of course).

I remember the terror I felt “handling” my first baby patient, whose only experience with medicine was being poked in the abdomen as I checked for liver and kidney size and searched for masses, having a cold stethoscope placed in eight positions on his naked chest, having bright lights in his eyes as I searched for cataracts, and having each limb pulled and repositioned as I checked out his joints. I really thought that babies were so fragile that I could possibly break or blind him. I remember looking at my attending with pleading eyes, asking, “Am I doing this right? Why is this baby crying like I’m torturing him?” The infant’s only response was to cry loudly while the nurses looked on and commented, “That baby has a good set of lungs!”

That part of the rotation was complemented by several weeks in clinic, where I saw several babies who were teething or colicky or had ear infections and well as sore throats.

Again, not much history, but a lot of crying—especially during examinations. Halfway through my rotation, I was wondering whether pediatricians ever really talked to their patients to develop relationships or whether I would go deaf unless I bought a good set of professional earplugs to protect myself from the decibel levels that some of these kids could reach— especially when my ears were less than six inches away at the peak of their screeching. Needless to say, I didn’t go into that field, but I have the ultimate respect for my pediatric colleagues.

What I have learned about pediatrics, primarily from my own children, is that this time of life can be the most challenging, with so many changes taking place internally as well as externally, much of which the patients have little to no control over. From the very first physical examination, which they obviously cannot give consent for, to developmental changes with puberty, to becoming an adult being able to make one’s own medical decisions—much of this is preprogrammed by the DNA inherited from one’s parents. Externally, a child’s exposure to home, location, and school are pretty much all decided by others until the child takes control and starts making his or her own decisions, or at least can influence the decisions and actions of family and friends.

So in one sense, this edition on pediatrics is for providers, family, and others who help shape the lives of our pediatric population. It looks at the world that children and adolescents live in and shares some thoughts on how we, as providers and families, can help make life safer and more personalized for them. Janet Green starts by sharing some great tips on how to www.sfms.org

engage parents and patients in planning a summer of activities to prevent boredom and obesity. One of the biggest concerns of society is the disease that is caused by lifestyle. Some of these children, born in the digital age, can spend days and days in one position playing video games or glued to a laptop or tablet. Dr. Chunbo Cai, a physical medicine expert, is already seeing young patients with musculoskeletal complaints caused by poor and sustained postures; she offers tips on the use of ergonomic support during these activities.

Summer is, for many others, a time for getting outside and enjoying sports activities. But these should be approached thoughtfully, with adequate preparation and guidelines to prevent injury. Drs. James Chen and Anthony Luke offer some great advice for summer sports. Other issues that children and adolescents have to deal with throughout the year are bullying, nutrition, and accidents. These are addressed by David Pating, Deborah Lee, Charles Wibbelsman, Melissa Lin, Lucy Crain, and Andrew Fenton. Gun violence is particularly heart-wrenching when it involves innocent lives, as discussed

by Jeff Mains and Dustin Ballard. All of these issues can and should be discussed with children and adolescents when appropriate for their specific ages. The more information youth learn, the more they will be empowered to take control of their own lives and make the lifestyle changes that will keep them healthy in the future.

These are the goals of prevention and of the San Francisco Medical Society and of organized medicine.

We hope you enjoy both this issue of the journal and a safe and relaxing summer!

June 2013 San Francisco Medicine

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Keeping Kids Safe

Keeping Kids Engaged Talk to Your Patients About Summer Activities Janet Green, MSPH In the early hours of the morning on a day this past March, tech-savvy parents were waiting to pounce on the San Francisco Rec and Parks website. They

had already spent hours coordinating weekly camps, classes, overnights, and clinics for their children. Now all they had to do was type quickly, with credit card in hand, and press “submit.” A big sigh and several cups of coffee later, they had run the gauntlet necessary to keep their kids active and happy while they are away at work. Rec and Parks is just one site, and parents have been waiting all year for myriad programs and schools to open enrollment for the summer. If timed correctly, these parents will have everything booked until the family vacation in August and the back-to-school date at the end of that month. Keep in mind: The kids might not be thrilled with the week-to-week precision planned by their parents. But for those with means, it’s what you do when you work and the schools are closed. However, SF Rec and Parks is for everyone, and many of us don’t know it.

Your families don’t have to be wealthy for your children to play or swim or sing and dance all summer.

Physician/Medical Provider Role

A conversation about summer activities often goes like this: Doctor (any specialty): “What are your children doing this summer?”

Patient: “I have no idea. They will probably just hang out, play video games. I don’t want them out on the street because it isn’t safe. Two of the kids will be taking summer school, and then they will just have to wait until I get home from work. I’m tired on the weekends and just want to sit. The kids will be fine.”

Doctor: “Do you know any activities the children could get involved in so they aren’t inside gaming and eating all day?”

Patient: “San Francisco is expensive, and all those camps and groups are for wealthy kids. I’m not even going to look, because I know we don’t have money for any of them. Those things are in neighborhoods I don’t know. Plus, the kids are safe in the house and they can go to the corner store for chips if they get bored.”

This is your opening, as a medical professional, to begin the dialogue with a patient. Summer vacation from school can be a nightmare for parents who don’t have money or access to programs for their children. Many parents assume there is nothing affordable. Many parents are intimidated by the process. Many parents don’t want to leave their children in neighborhoods where they don’t know anyone or how to get there.

The downside is that June is already late for some programs, but the upside is there is still so much to choose from for the family willing to give it a try.

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San Francisco Medicine June 2013

Problem Solving and Solutions What is reality for most San Francisco parents? Some parents don’t have computer skills or own a computer, or credit card, or have the linguistic confidence to call programs or traverse programs on line. In fact, without the money and the online skills, these aren’t choices for many San Francisco families.

How do you know what you don’t know? By that I mean, how are families supposed to know what is available for children in the summer? We live in a high-tech city. Unfortunately, many residents have low-tech skills and low-paying jobs. Websites are not always user friendly. Money for summer programs is not just sitting in the bank. What can you do?

Medical professionals can start out by asking about the kids. The power in asking about activity cannot be underestimated. Keeping our children active is not a choice but a medical and social necessity. Many parents listen when the doctor asks about the family. Parents will be more active listeners when you can offer more than interest.

Action plan

Almost one-third of children in the San Francisco Bay Area are obese. You have taken the first step by commenting on physical activity as important for well-being of children. Try to continue the dialogue by expressing your concern that kids are watching/playing video games all day. The American Academy of Pediatrics suggests no more than two hours per day of television and video games, and no television for children under age two.

It might be up to you to actually hand a flyer to a patient and suggest they look into activities for their children. We’ve included a list of potential activities on the adjacent page. Please photocopy and distribute to your patients!

Perhaps your patient has a neighbor, friend, or family member who can help get the children to some activities. Many times a parent assumes activities are too expensive and doesn’t even look. Watch for the shy parent who just doesn’t know how to engage. Finally, see if there is someone in your office or facility who can help give that parent some help.

Janet Green, MSPH, is a pediatric senior health educator at Kaiser Permanente, San Francisco. She is the colead of KP Passport to Health pediatric weight-loss program. She serves on the San Francisco Department of Public Heath Childhood Nutrition and Physical Activity Collaborative.

www.sfms.org

San Francisco Summer Activities For Children of All Ages and Income Levels YMCA has locations all over San Francisco. There are many classes, camps, and activities. The Y has family memberships as well. Try the website at www.ymcasf.org to find the one closest to you. “No child is denied access due to inability to pay.” The Y people are fantastic, and all you have to do is walk through the door and they will take it from there.

San Francisco Recreation and Parks has activities

all over San Francisco. There are swimming pools and swim instruction, opportunities to volunteer, adaptive play, playgrounds, tennis, archery, dance, basketball, football, and more.

They also have scholarships! Information is available in English, Spanish, and Chinese. Scholarship applications are available in those languages as well. Visit www.sfrecpark.org or call (415) 831-6800 for questions and help. The staff truly makes it easy to get your child enrolled.

Boys and Girls Clubs of San Francisco is at www. kidsclub.org or (415) 445-5437 and (415) 445-5477. It offers many locations and tons of fun activities. Kids can play games or basketball, go to camp, swim, and learn just about anything.

There is a fantastic staff at every location.

SFKIDS.org lists everything possible for kids in San Francisco. Choose your neighborhood or activity or month or day, and everything happening will appear. Find free days for museums and other free activities. Information online is available in Spanish too.

San Francisco Botanical Garden is at 9th Avenue and

Lincoln Way, Golden Gate Park; (415) 661-1316. Entrance is always free for San Francisco residents (with proof of residency).

Free for nonresidents on the second Tuesday of the month, Thanksgiving, Christmas, and January 1. MUNI serves the garden with several public transit routes, such as the 44, N-Judah, 71, and 5.

BART to the Embarcadero Station. Go upstairs and cross the Embarcadero to the Ferry Building. In front of the Ferry Building, take the “F” line trolley to Pier 39 Marina. Note: The “F” line trolley comes to Fisherman’s Wharf from Castro/Market for BART riders. But walking is more fun; let the tourists take the trolley. Walk any pier and let the kids run up and down along the Embarcadero. It is safe and fun to watch the boats, sea gulls, and tourists!

Ocean Beach remains unvisited by amazing numbers of families. It is not a swimming beach. There are no lifeguards. But you can walk for miles and build amazing sandcastles. There is lots of public transportation to the beach, and it’s great for the entire family. Remember to bring a hoodie for everyone.

Crissy Field is a safe place for the kids to run and play. This is also a wonderful place for the kids to bike. Take the Muni 20.

Sunday Streets provide great a way to learn about differ-

ent neighborhoods in San Francisco without fighting cars. And walking is free! See www.Sundaystreetssf.com; check out the website and find which neighborhood in San Francisco will be blocked off to cars on a Sunday afternoon. Walk, ride bikes, window shop, and discover your city for free.

Oakland Athletics baseball games are listed on http://

oakland.athletics.mlb.com/ticketing/singlegame.jsp?c_ id=oak&y=2013&mlbkw=195Z7T4U1-L0. Do you know about BART Wednesdays? Tickets for A’s games on Wednesday afternoons are $2.00! Not for all the seats, of course, but what a great deal.

Golden Gate Park’s JFK Drive is closed to automobiles ev-

Everybody Plays! is an adaptive recreation program for children and adults with intellectual and developmental disabilities. It’s located at Mission Clubhouse, 19th and Linda Streets, (415) 206-1546. The inclusion coordinator is Vicky Pitner, at vicky.pitner@sfgov.org. The adaptive recreation coordinator is Ellen McCarthy at ellen.mccarthy@sfgov.org.

Walk Pier 39 and see Fisherman’s Wharf, the sea lions,

You don’t need a car in San Francisco! Walk or take BART or Muni. Pick up schedules at any station or go to http:// www.bart.gov/docs/brochures/bart_dest_0909.pdf.

ery Sunday from Transverse Drive to Maclaren Lodge. Join the mass of bike riders enjoying the car-free parts of the park. On weekends and holidays, a fleet of 24-seat, ADA-accessible, alternative fuel buses pick up and drop off visitors at fifteen locations in and around Golden Gate Park. Koret Children’s Quarter is located just off of Kezar Drive (on the southeast side of Golden Gate Park). The playground is right next to the carousel at Bowling Green Drive, between John F. Kennedy Drive and Martin Luther King Jr. Drive. and the tourists. Take BART to the Embarcadero or walk: Take www.sfms.org

The San Francisco Public Library and its branches provide great summer options. It’s never out of style to read a book or be read to! Find out where there are storytelling sessions at the local branch of the library. Your children can get their own library cards for free. Each library has an age- or grade-appropriate summer reading list.

June 2013 San Francisco Medicine

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Keeping Kids Safe

Keeping Kids In Line Ergonomics in the Modern Age of Computers and Video Games Chunbo Cai, MD, MPH Information and communication technology (ICT) has become an important part of the lives of schoolchildren, who surf the Internet, chat, and play on-

line games. In the meantime, the prevalence of neck-shoulder and low back pain has increased among adolescents. Studies among adolescents confirm a connection between musculoskeletal symptoms and the use of ICT, especially computers and handheld devices.1 Musculoskeletal pain has become a major symptomatic complaint among children and adolescents and is increasingly occurring at a younger age. Prins et al have reported a systematic review on the studies evaluating the evidence for the contribution of posture and psychosocial factors to the development of upper-quadrant musculoskeletal pain in children and adolescents. The review included ten studies, which measured upper-quadrant musculoskeletal pain as an outcome measure. Five studies evaluated sitting posture and found an association between the duration of static sitting and upper-quadrant musculoskeletal pain. Six studies measured psychosocial factors, of which depression, stress, and psychosomatic symptoms were the factors most commonly found to influence the development of upper quadrant musculoskeletal pain. The review concludes that the duration of sitting posture and psychosocial factors may influence the experience of musculoskeletal pain among children and adolescents.2 By the anatomic sites of the musculoskeletal pain, headache, neck-shoulder pain, and lower back pain are more common among computer users than among nonusers. The risk of developing musculoskeletal pain increases with an increase in the amount of time spent on the computer. The findings of several studies indicate that computer use induces pain and discomfort not only in the neck-shoulder and back regions but also in the hands, fingers, wrists, eyes, and head. RothIsigkeit et al investigated the prevalence and characteristics of pain (e.g., pain intensity) among 735 children and adolescents aged ten to eighteen years. Girls reported pain that was significantly more severe than did boys, and half of the sample reported pain lasting longer than three months. Hakala et al suggest that musculoskeletal symptoms causing moderate and severe pain as well as inconvenience to everyday life are common among adolescent computer users. Daily computer use of two hours or more increases the risk at most anatomic sites. The prevalence of moderate to severe pain was 20.7 percent for neck-shoulders, 19.7 percent for head, and 13.8 percent for eyes. The prevalence of moderate to severe inconvenience to everyday life was 28.3 percent due to head pain, 20.7 percent due to neck-shoulder pain, and 15.4 percent due 14 15

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to low back pain. Pain intensity was reported as follows: Girls reported more moderate to severe computer-associated pain than boys at all anatomic sites, except the low back, for which the prevalence was higher among the boys.1 Other epidemiological studies also have found high prevalence rates of back pain among schoolchildren.

Community-based studies of back pain in childhood indicate that low back pain does have a relatively high prevalence during school years, varying from country to country: Finland, 20 percent; England, 26 percent; Canada, 33 percent; United States, 36 percent; and Switzerland, 51 percent. Murphy et al studied sitting postures of schoolchildren in the classroom using the Portable Ergonomic Observation Method (PEO). The study found significant associations between flexed postures and low back pain. Static postures and neck and upper back pain were also associated. The study has implications for schools, designers, and people in the fields of work related musculoskeletal disorders.3 All these research results call for more societal and medical attention on the implementation and reenforcement of the ergonomic applications in children and adolescents. Heyman

Notes from My Pediatrics Practice Shannon Udovic-Constant, MD In the past year, two separate friends have started having severe neck and shoulder pain that interfered significantly with their daily lives. It turns out that both of them were doing a lot of computer work on laptop computers, without regard for the ergonomics. Their pain required intensive physical therapy in order for them to be able to function. Having these scenarios front and center in my mind, I have recently begun to ask those of my patients with the chief complaint of any musculoskeletal pain about their computer habits. It turns out that a large number of my patients are being affected by this.

As a result, I’ve started to have this discussion at well-care visits in order to try to prevent these problems. I have begun sharing a resource from OSHA that is a checklist to make sure that their workspace is ergonomic. It can be found at http://www.osha.gov/SLTC/etools/computerworkstations/ checklist.html. I hope that by focusing on prevention, I can keep the children and adolescents in my practice out of my colleague, Dr. Cai’s, physical medicine and rehabilitation practice. In the meantime, I am very thankful for her expertise when I do need her. www.sfms.org

et al have proposed educating about balanced posture, body function, and movement patterns, as well as their ergonomic implications, to minimize and even prevent these problems.

Such an ergonomics awareness educational program has to start at childhood and should be an integral part of the curriculum in the schools.4 Cornell Human Factors and Ergonomics Research Group (CHFERG) has studied ergonomics in children extensively and proposed guidelines for neutral work posture for children and fitting of work/computer stations. The guidelines are detailed on its website.5 Chunbo Cai, MD, MPH, is a physician in the department of physical medicine and rehabilitation at Kaiser Permanente San Francisco. She is a member of the SFMS and of the editorial board of San Francisco Medicine.

References

1. Hakala PT, Saarni LA, Punamäki RL, Wallenius MA, Nygård CH, Rimpelä AH. Musculoskeletal symptoms and computer use among Finnish adolescents—pain intensity and inconvenience to everyday life: A cross-sectional study. BMC Musculoskelet Disord. 2012 Mar 22; 13:41.

2. Prins Y, Crous L, Louw QA. A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents. Physiother Theory Pract. 2008 Jul-Aug; 24(4):221-42.

3. Murphy S, Buckle P, Stubbs D. Classroom posture and self-reported back and neck pain in schoolchildren. Appl Ergon. 2004 Mar; 35(2):113-20.

4. Heyman E, Dekel H. Ergonomics for children: An educational program for elementary school. Work. 2009; 32(3):261-5.

5. http://ergo.human.cornell.edu/cuweguideline.htm

SFMS Supports the Pediatric Advisory Council The SFMS partners with leaders in the SFDPH’s Maternal and Child Health branch and local pediatricians to support the Pediatric Advisory Council. The Mission of the council is to improve children’s health by increasing coordination and collaboration among children’s health care systems in San Francisco.

The Goals Are To:

1. Improve quality of pediatric clinical care by sharing best-practices, efficiencies, and resources.

2. Increase appropriate access and utilization of health care services primary care, family planning, dental, and behavioral health services.

3. Improved understanding of the strengths and gaps in children’s health care.

4. Address social determinants of health in which multiple health care systems can significantly change policies and systems.

The Objectives Are To:

1. Share relevant information amongst the Pediatric Advisory Council members, representing the different health care systems in San Francisco.

2. Provide advice to the Maternal, Child & Adolescent Health Section of the San Francisco Department of Public Health on issues related to children’s health care.

3. Receive public health updates from various sections of the San Francisco Department of Public Health.

4. Build infrastructure for coordination and collaboration between health systems to improve children’s health.

5. Develop two-way communication between primary care providers of major institutions in San Francisco.

You will find resources developed by the Pediatric Advisory Council at http://www.sfms.org/ForPhysicians/ PediatricResources.aspx.

If you have any issues/concerns that you would like the group to consider please contact us through the website.

Classified Ad Private Offices Designed for Use by Psychologists, Psychiatrists, and Therapists Sound proofed and some with fireplaces. Located on Fillmore at Union Street. Separate waiting room provided.

High ceilings and hardwood floors. 24/7 access. Subletting permitted. Individual office rents range from $1,250$1,350 per month. Call (415) 433-3180 extension 200 for information.

www.sfms.org

Welcome New Members The SFMS would like to welcome the following members:

Physicians

Lynn Chung, MD | Plastic Surgery Dimitriy Kondrashov, MD | Orthopaedic Surgery Melissa Lin, MD | Family Medicine Susan Tibuni-Sanders, MD | Internal Medicine Jennifer van Warmerdam, MD | Orthopaedic Surgery

Residents

Linn Maung, DDS | Oral and Maxillofacial Surgery Elizabeth Grace, MD | Ophthalmology Brigitte Watkins, MD | Family Medicine

June 2013 San Francisco Medicine

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Keeping Kids Safe

Safe Summer Sports Prevention Tips for the Field James L. Chen, MD It’s that time of year in the San Francisco Bay Area when the sun is out and the ballparks and fields are filled with kids playing outdoor sports. Many parents are

wondering what they can do to help their children prevent injuries, given that many physicians are seeing children and adolescents with new sports injuries. Family practitioners, primary care physicians, and specialists will likely encounter many questions related to sports and athletic injuries. Here are a few tips practitioners can provide to their patients.

Exercise in Moderation, with Adequate Rest

The most common injuries among young athletes are overuse injuries. In the doctor’s office these manifest as strains, sprains, and tenderness at ligaments, tendons, or muscle. In a patient with open growth plates in his bones, there is greater risk for injury.

These injuries occur because of the differential strength between bone and tendons while children are growing. In adults, bone is stronger than tendon and thus injuries tend to occur in the tendon.

In children, the bone is growing and is softer, and thus traction injuries often occur at the bone. For this reason, point tenderness over the bone should be evaluated by a medical professional with radiographs (X-rays) to ensure that no fractures are present.

Overuse injuries are more common because present-day youth are more active than ever. Many play multiple sports or games during the same day or same weekend. Playing sports while already fatigued increases the risk of injury. Rest and activity modification are the common treatments for overuse injuries, and so it makes the best sense to participate in sports in moderation with at least one day off per week and at least one day between performance events. Adequate rest includes taking rest breaks or water breaks during practice, particularly during high heat or humidity conditions. For specific sports, children should adhere to restrictive guidelines for overexertion. For example, baseball pitchers should adhere to pitch count guidelines to prevent throwing injuries. Runners should limit the number of miles run per week. Adequate rest includes healthy eating and sleeping habits with periods of nondistractive rest.

Get a Preparticipation Physical Exam

If an athlete is participating in formal sports on a school or club team, then a preparticipation physical exam is recommended.

This physical exam is really a screening rather than a comprehensive physical exam. Its most important aspect is reviewing the athlete’s medical history and focusing on any current or historic injuries that would preclude them from participation. The cardiac history is of utmost importance because it provides the opportunity to detect a handful of cardiovascular causes of sudden death in young athletes, such as hypertrophic cardiomyopathy, congenital 16 17

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coronary artery anomalies, repolarization abnormalities, or Marfan syndrome. Key questions should include family history of heart disease and sudden death, and of exercise-related symptoms such as syncope, chest pain, and palpitations. In addition to auscultation of heart sounds, the physical exam should include blood pressure measurements and palpation of pulses. The preparticipation physical exam can be administered by any licensed physician. For specialists who don’t recall the nuances of heart sounds or the differences between murmur and a blow, it is always good to get a second set of ears to listen for any cardiac abnormalities.

The most common issues arising from the preparticipation exam involve ensuring that an athlete can play with current treatment. For example, a patient with a history of asthma may be advised to follow up with his primary care physician for an updated prescription rescue inhaler to bring to practice or competition.

Use Proper Equipment, Protective Gear, and Be Supervised

Injuries from contact sports far exceed injuries from noncontact sports. Of all of the modern discoveries in sports medicine, the use of protective equipment has been shown to best reduce and prevent injuries. This may sound like common sense, yet players don’t always—but should—wear appropriate and well-fitting pads, helmets, mouthpieces, face guards, protective cups, and eyewear.

In addition to proper equipment and gear, parents, coaches, and referees must work together to ensure that playing surfaces are safe. Playing fields filled with holes are an ankle sprain waiting to happen. High-impact sports should be played on appropriate surfaces rather than concrete. Any team sport or activity that children participate in should be supervised by adults. Additionally, the team coach should have training in first aid and CPR and have a first aid kit readily available at practice and games.

Conditioning, Stretching, and Technique

Whether participating in recreational or competitive play, sports participants should practice in a manner than incorporates stretching, conditioning, and improvement of technique. Stretching before and after play increases flexibility and reduces injuries.

Proper technique reduces the likelihood of injury and improves performance. Off-season or preseason instruction and training help prevent injury and improve in-season performance. Additionally, make sure your kids are matched for sports according to their skill level, size, and physical and emotional maturity.

Know When to Stop Playing

Injuries only get worse when athletes play through existing

Continued on page 18 . . . www.sfms.org

Keeping Kids Safe

Caring for Young Athletes Prevention Tips in the Office Anthony Luke, MD, MPH Summer is on the way. Sports for our young people are yearlong activities. For physicians, now is the right time

to remind your young athletes to think about getting ready for the next school year, since there are two to three months during which athletes and their parents have some time to think about getting any aches and pains taken care of and, importantly, promoting preventive measures that can make sports safer.

Sports are the number-one cause of injuries in young people. More than 7.6 million students play sports in high school each year, and this number increases to more than 60 million when considering athletes aged six to eighteen who are in some kind of organized sport. The most recent estimate of the overall injury rate in high school sports is reported to be 1.71 per 1,000 athlete exposures. This represents almost 3.7 million injuries that result in more than one day’s time lost from sports. Types of injuries are split almost equally between overuse and acute.

The PlaySafe Program provides sports medicine services at twenty local Bay Area high schools, representing approximately 20,000 students. Since 2006, our certified athletic trainers have evaluated 4,700 athlete injuries and provided treatment or care to 21,700 athletes. In the 2012–13 athletic season, our staff has assisted in the care of more than fifty athletes who received concussions as a result of their sport participation.

For physicians, we can make a few practical suggestions for caring for your athletes: • Ask what sports your young patient is engaging in (especially how many and how often).

• Get them to do their preparticipation physical exam early.

• Share information and resources with your patients.

UCSF PlaySafe Program The following suggestions come from our experience with the UCSF PlaySafe program, which has, since 2002, been dedicated to providing excellent medical and preventive care to high school athletes in the Bay Area, to mentor students in the field of health care, and to make participation in extracurricular sports safe for students. Safety in sports includes the incorporation of healthy lifestyle behaviors, including proper fitness and nutrition, which are emphasized to all students and not necessarily only athletes. Physicians and certified athletic trainers (ATCs) from the Division of Sports Medicine have partnered with, first, the San Francisco Unified School District and now the Tamalpais Unified High School District to provide sports medicine care and services to students at more than twenty high schools. Services www.sfms.org

provided include evaluation, treatment, and rehabilitation of athletic injuries; onsite event medical coverage; sports nutrition and healthy lifestyles counseling; and education for injury prevention for students, parents, and coaches. The impact of the PlaySafe program has been to work with staff and families to help facilitate the care needed for sports-related injuries, particularly in the public schools, to keep young athletes healthy and active.

How Athletes Can Get the Right Help

An athletic trainer is an extremely valuable school resource that athletes, parents, and coaches should take advantage of.

Athletic trainers are proficient in prevention, diagnosis, and intervention concerning emergency, acute, and chronic medical conditions involving impairment, functional limitations, and disabilities. Our certified athletic trainers do much more than assist with the outreach aspects of the PlaySafe Program. Working at the UCSF Orthopaedic Institute, the PlaySafe Athletic trainers function as physician extenders, assisting our physicians in a clinical setting on a daily basis. Our staff also contributes to administrative projects and events, such as performing sports preparticipation physical examinations and wrestling weightmonitoring assessments and providing medical event coverage at large community events (including as the San Francisco Marathon and San Francisco Golden Gate Rugby Club games).

For the fifth straight year, PlaySafe cardiac physicals will combine complete sports physicals with cardiac screenings through EKG and ECHO testing. Offered to San Francisco high school student athletes, this program provides a free opportunity to ensure safe athletic participation. Targeting HCM, EKG, and ECHO screenings is effective in identifying potentially harmful cardiac conditions in our student athletes.

Tips for Physicians Caring for Young Athletes

Here are some questions to ask both athlete and parents. As with any exercise history, the FITT mnemonic can be helpful.

Frequency

• How many days per week do you participate in a sport or exercise?

• How many practices/games per day?

• How many teams are you playing on right now?

Many young athletes are on more than one team and engage in multiple practices and games.

Intensity • How hard is your training?

• What are the hardest maneuvers that you do in practice?

Understanding some of the details of the training and sport

Continued on the following page . . .

June 2013 San Francisco Medicine

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Caring for Young Athletes Continued from page 17 . . . can help understand what loads and stresses the athlete may be experiencing.

Time • How long is each training period/practice?

• Do you keep a training log?

Make sure there is adequate time for recovery, including sleep and proper nutrition. A training diary is helpful for keeping track of what your athlete is up to.

Type • What sports do you do?

• Do you do any other sports for fun?

Different sports have different types of injuries and considerations for prevention. For example, a contact sport may require protective equipment.

Injuries • Have you had any aches and pains during sports? Has this affected your ability to play?

• Has your technique changed due to any symptoms you are feeling?

A significant injury is suspected when symptoms affect the athlete’s ability to properly perform maneuvers. A red flag for injury is raised whenever a motivated athlete doesn’t play his or her sport.

Preparticipation Physical Exams A yearly history and physical exam is required by schools and some organized sports in order to participate. The ideal time to perform these exams is at least six weeks before the sport begins, in case investigations and/or treatments are needed. Familiarize yourself with the preparticipation physical exam monograph, which is a great resource and includes the recommended standards and forms. Cardiac and orthopedic issues are the most common concerns addressed. Practical recommendations and perspectives on cardiac screening for healthy pediatric athletes can be found at http://www.ncbi.nlm.nih.gov/pubmed/21623290.

The more important you make these exams, the more important the athletes and their families will consider them.

Resources

California Interscholastic CIF Student handbook, http:// cifstate.org/images/PDF/Sports_Medicine_Handbook_4th_ Edition_March_31_2011.pdf.

American Academy of Pediatrics (AAP), http://www2. aap.org/sections/sportsmedicine/PolicyStatements.cfm. This site has the various policy statements from the AAP Council on Sports Medicine and Fitness, covering activities from baseball to trampoline safety to medical concerns affecting sports participation.

American Academy of Family Physicians, http://www. aafp.org/online/en/home/clinical/publichealth/sportsmed/ preparticipation-evaluation-forms0.html. This site has links to the Preparticipation Physical Evaluation (PPE) Monograph, fourth edition, recommendations and forms that are currently the standard for evaluation of young athletes.

American College of Sports Medicine Team Physician Statements, http://www.acsm.org/access-public-information/

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team-physician-consensus-conference-statements. This site contains links to various reviews on specific issues related to being a team physician.

New Concussion Statements. Concussion is currently a concern, since any athlete with a concussion will need medical clearance by a physician or qualified health professional. The following reviews will help you remain up to date on this issue. http://www.aan.com/globals/axon/assets/7913.pdf Zurich Concussion Guidelines 2013, http://bjsm.bmj. com/content/47/5/250.full. This includes the most recent recommendations from the sports medicine community, including tools for evaluating concussions in clinic.

American Medical Society for Sports Medicine Concussion Statement 2012, http://www.amssm.org/Content/ pdf%20files/2012_ConcussionPositionStmt.pdf. This is a comprehensive review with levels of evidence regarding concussion recommendations.

UCSF PlaySafe website, http://orthosurg.ucsf.edu/ outreach/programs/playsafe/. This site outlines the various facets of our UCSF high school sports medicine programs. It also outlines the various roles that athletic trainers can play in a sports medicine practice.

Anthony Luke, MD, MPH, is board certified in primary care for sports medicine. His special interests include the non-operative management of many sports medicine injuries along with prevention training and counseling. His research interests include epidemiology and injury prevention of high school sports injuries. At the 2010 Winter Olympics in Vancouver, he served as a volunteer sports medicine doctor for athletes.

Safe Summer Sports Continued from page 16 . . . injuries without allowing them to heal properly. Young athletes should be encouraged to notify parents and coaches when they have injury. Often the pressure to perform by coaches, teammates, and the athlete himself may cause further injury to an initially benign injury. Young athletes should understand that pain and swelling are the body’s signals that there is injury and activity should be modified. Parents and coaches should encourage reporting of injuries and allow athletes to fully recover before resuming activity.

When patients do have acute injuries that require medical attention, they should call their primary care physician or go to an urgent care facility or the emergency room. Parents and physicians should be aware of the closest health care facilities and have the contact information of their health care providers easily accessible.

For nonacute injuries or overuse injuries, a good rule of thumb is RICE: rest, ice, compression, and elevation. If serious injury is a concern, the athlete should see the primary care physician. In general, pediatric and adolescent athletes with sports injuries should expect full recovery. If they do not recover fully, then they should not return to sport unless they have been examined by their physician or specialist.

James L. Chen, MD, is an orthopedic surgeon fellowship-trained in sports medicine, knee, and shoulder surgery. He practices general orthopedics and sports medicine in Pacific Heights and serves the Chinese community in Chinatown. Dr. Chen is a SFMS member and the team physician for several local high schools. www.sfms.org

Keeping Kids Safe

Bullying From Insult to Injury David Pating, MD, and Deborah Lee, PhD The 6 p.m. news flash: Amanda, a 15-year-old high school student, committed suicide by hanging herself at a local school playground today. This

followed weeks of hostile Facebook tagging of Internet photos by cyberbullies. Friends say this kind of “‘Internet trashing’ happens all the time.” Her family laments, “I never knew why my daughter was so anxious. She was such a wonderful child.”

Local school administrators declare, “This is a tragedy that we don’t want repeated.” ***** If you haven’t noticed, bullying—or at least awareness of bullying—is on the rise. Bullying is defined as “aggressive behavior perpetrated by those who hold and/or try to maintain a dominant position over others with premeditated intent to cause mental or physical harm or suffering to another.” Research suggests that 28 to 47 percent of U.S. students have experienced bullying, and most (70 to 80 percent) have been affected as victims, bullies, or bystanders. Although it’s commonly thought to be a problem just on the playground, facts show differently. Among third graders, 35 percent of boys and 40 percent of girls report being bullied; among high schoolers, as many as 53 percent of boys and 50 percent of girls report being bullied. While bullying becomes less physical with maturation from childhood to adolescence, more insidious forms—verbal aggression, taunts, name-calling, or laughing at victims—take over.

At all ages, bullying is dangerous and can have a significant negative impact that persists into adulthood. Bullying increases risk for major mental disorders, including depression, anxiety, panic, posttraumatic stress, alcohol or drug abuse, eating disorders, ADHD, agoraphobia, dissociative disorders, and personality disorders. Consequences of bullying include lower self-esteem, school absenteeism, academic problems, and physical and/or psychosomatic conditions. Bullying can be particularly damaging for individuals from vulnerable populations, such as LGBTQ youth, who are at greater risk for suicide and more likely to be unable to function at school; youth with disabilities, who experience more severe forms of bullying; and children from Latino or African-American communities, who are more likely to suffer academically.

Bullying does not only affect victims. Bullies themselves are more likely to have been abused or to have lived in homes with domestic violence. As adults, they can become abusers and are more likely to be convicted of a crime. They are also vulnerable to anxiety and depression. Children who are both bullies and victims—identifiable as early as first grade—have the most serious psychological problems: They are three to four times more likely to report suicidal ideation than nonwww.sfms.org

bullied children. Bystanders also report distress and hopelessness and are at elevated risk for depression, anxiety, and substance abuse. When bullying is allowed to persist, everyone suffers.

Unfortunately, bullying often goes unreported. Victims of verbal bullying, like name-calling or other forms of social exclusion, are the least likely to disclose bullying. Younger children may inform adults about their problems, but older children may associate talking to adults about bullying with “snitching.” These difficulties talking about bullying make it essential that clinicians, adults, teachers, and administrators demonstrate interest and make inquiries to detect bullying.

Early screening and prevention are essential.

Simple questions can help: (BORRIS) Have you been bullied or have you bullied anyone? Have you observed bullying going on? How did you respond? Do you feel as though you are repetitively singled out as a bully or a victim? Have you sent or received things over the Internet that you think may represent bullying? Do you feel stuck in bullying situations?

For parents: (WART) Have you witnessed or heard about your child being picked on or picking on other kids? Have there been any recent changes in your child’s attitude, attention, concentration at school, grades, behavior, mood, socializing? What are the “rules” in your school/town/sports team/ home regarding bullying/intimidation/hazing? Has your child talked with you about getting picked on at school or seeing other kids being bullied?

Effective interventions for bullying address both individual and environmental dimensions. Most evidence-based bullying programs are based in schools, including social and emotional skills curriculums, peer norming programs, and other whole-school interventions for bullies, victims, bystanders, families, and teachers. In many cases, multiple interventions may be required to curtail and reshape aggressive behavior into more pro-social modes of communicating or problem solving.

No account of bullying would be complete without mention of cyberbullying. In 2011, 16 percent of high school students reported bullying over the Internet, cell phones, or other electronic media. This can occur twenty-four hours a day, seven days a week. It is important for parents to monitor their children’s Internet use and to have rules about online activity. If children are being harassed, parents should not respond nor repost on the Internet. Instead, the recommendation is to document and report the incident to the online service provider, police, or the school. Many schools now have policies to combat cyberbullying. For information, go to www.stopbullying.gov.

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Bullying Examined Dr. Chuck Wibbelsman applies his expertise to the issue of bullying.

The incidence and severity of bullying have received much media attention of late. What are the health risks associated with bullying? What is the role of the health professional when it comes to bullying? And what can communities do to prevent bullying or minimize its effects? Today, Chuck Wibbelsman, MD, chief of Adolescent Medicine for Kaiser Permanente San Francisco and president of the American Academy of Pediatrics’ Northern California Chapter, and former president of the SFMS, addresses these and other questions.

Dr. Chuck Wibbelsman, have you seen any increase in your practice in the number of adolescents with concerns related to bullying?

Yes, I’ve seen an increase, anecdotally speaking, and that increase is reflected nationally as well. I was reading in the Journal of the American Medical Association that 20 to 30 percent of students are involved in bullying—either as perpetrators or as victims.

Is bullying actually becoming more common?

Bullying has changed over the last 20 years. It used to be that bullying would occur in the schools—students making fun of or physically assaulting other students, guys beating each other up. But now you have cyberbullying—social media, texting, Twitter, Facebook, and online videos. Cyberbullying is twice as common among girls than boys. People are talking about bullying now. We’re seeing it covered in every type of media. Teachers and parents were unaware of it or were minimizing the issue.

Now, people don’t look the other way. They are taking some responsibility.

What are some ramifications of bullying?

There are serious health risks: low self-esteem, depression, substance abuse, and suicide attempts. In fact, there are over 250,000 attempted suicides and 5,000 completed suicides related to bullying each year in the U.S. The case of Tyler Clementi at Rutgers University, whose roommate filmed Tyler being intimate with another man in a dormitory room and uploaded the video, is an example of what can happen with bullying. Tyler committed suicide by jumping off the George Washington Bridge.

When is bullying at its apex, if you will?

I did a panel in San Francisco at the American Academy of Pediatrics, and there were lesbian, gay, bisexual, and transgender youth talking about their own experiences being the victims of bullying. They were in their late teens, and all of them said that their worst experiences with bullying were in middle school.

That’s the time when your body is changing, not everybody looks the same, there are school pressures, decreased self-esteem. Bullying is at its height. Many young adults and adolescents don’t have the defense mechanisms to handle a lot of this.

What are warning signs?

Warning signs of low self-esteem include unprotected sexual activity, isolation, cutting, failing grades. If one of my patients 20 San 21 SanFrancisco FranciscoMedicine Medicine June June2013 2013

says, for example, “I want to change schools,” that is a big red flag.

The bible of adolescent care is H-E-A-D-S—Home, Education, Activity, Drugs, and Sex. When I see a patient, at some point, I ask the parents to step out so the adolescent and I can discuss a whole host of concerns—ranging from how much TV they watch to whether there is gun in the house. But I start with the easier questions first, asking them what they like to do, and so forth.

It’s about building trust and rapport. We have a questionnaire for both parents and adolescents, to help fill in the picture. Also, I partner with other physicians in mental health. At Kaiser Permanente it’s seamless. We’re all under one roof.

What can communities and schools do to prevent or minimize the effects of bullying?

Schools need to educate teachers about bullying and prepare them to intervene, as well as work with student awareness. They need to step up to the plate, even after school’s out and everybody goes home. We need to involve the parents as well. Kids are not going to tell their parents some things. No matter what our role in life, parent or health care provider, we need to be aware so that we can help a child or an adolescent. We have to ask the questions to be able to help.

This interview was adapted from a longer piece in the Center for Total Health blog.

Bullying Continued from the previous page . . . ***** We are not Pollyannaish enough to believe that bullying—like teen alcohol use—will completely disappear. Indeed, bullying becomes more dangerous when the negative power of technology leverages our ready access to weapons.

Yet, at the same time, we have witnessed, and research substantiates, that bullying and hazing in our communities, scout troops, youth sports teams, and children’s schools can be curtailed when parents, teachers, and other responsible adults and students unite to create an environment grounded in zero-tolerance for violence and bullying. Equally powerful as the will to dominate is the desire to be loved and to belong.

Adult role models and youth peer support for good civil behaviors are powerful!

David Pating, MD, is chief of Addiction Medicine, Kaiser San Francisco, and vice chair for the California Mental Health Services Oversight and Accountability Commission (Proposition 63).

He is also a member of the SFMS and regular contributor to San Francisco Medicine.

Deborah Lee, PhD, is consulting psychologist to the California Mental Health Services Oversight and Accountability Commission (Proposition 63).

Reference Buxton D, Potter MP, Bostic JQ. Coping strategies for child bully-victims. Psychiatric Annals. March 2013; 43:3. www.sfms.org

Keeping Kids Safe

Vitamin D The Basics and Its Relevance Today Melissa Lin, MD For those who live north of latitude 37 degrees north, the line connecting San Francisco to Philadelphia, there is a good likelihood of being deficient in vitamin D. While this may be more common during the autumn and winter, it can also occur during the summer.

In recent years, vitamin D has received increasing attention from public and medical professionals. Vitamin D deficiency is common and affects persons of all ages. Vitamin D, a fat-soluble vitamin, is best known for its role with calcium in promoting and maintaining strong bones. Vitamin D deficiency has been linked to growth failure and rickets in children and osteomalacia in adults. Vitamin D also appears to play an important role in other body functions. Health effects that have been studied include protection against cancer, heart disease, diabetes, autoimmune disease, and multiple sclerosis. These studies warrant further investigation, as they have yielded mixed results.

Metabolism of Vitamin D

Vitamin D is synthesized in the skin after ultraviolet radiation exposure and is then converted to its metabolically active form in the liver and kidneys.

Vitamin D2 and vitamin D3 are two forms of vitamin D. Vitamin D2 (ergocalciferol), found in plant dietary sources, is formed when ergosterol in plants is exposed to irradiation. Vitamin D3 (cholecalciferol) is formed when ultraviolet-B (UV-B radiation) converts 7-dehydrocholesterol in skin cells to pre-vitamin D, which isomerizes to vitamin D3. This form is the main source of vitamin D for humans and is found in animal products such as fatty fish.

These forms are bound to vitamin D-binding protein and transported to the liver to form 25-hydroxyvitamin D (25[OH] D), calcidiol. This undergoes hydroxylation in the kidneys to form the active form of the vitamin, calcitriol.

Prevalence of Vitamin D Deficiency and Risk Factors

Vitamin D deficiency is being reported with increasing frequency and can be caused by low sun exposure and the lack of vitamin D-fortified foods or malabsorption. Recent estimates suggest the prevalence of vitamin D deficiency or insufficiency in the pediatric age group is about 15 percent. Populations at higher risk include infants who are exclusively breast-fed, those living at higher latitudes, those with darker skin pigmentation, and those with limited sun exposure. Other populations at risk include those who are obese, sedentary, and older than 65 years. Those who use medications such as anticonvulsants, which can increase catabolism and destruction of vitamin D, are also at risk. Individuals with medical conditions associated www.sfms.org

with fat malabsorption, such as cystic fibrosis and inflammatory bowel disease, may be at risk as well.

Measurement of Vitamin D and Definition of Vitamin D Sufficiency

25(OH)D is the main circulating form of vitamin D and the best indicator of vitamin D status and stores. Measurement of serum 25(OH)D concentrations is variable among the assays available and among laboratories that conduct the analyses. Because of this, discussion remains regarding cut-points for vitamin D sufficiency, insufficiency, and deficiency.

In adults, vitamin D deficiency has been defined as 25(OH) D of less than 20 ng/mL and insufficiency as 25(OH)D level of 20 to 30 ng/mL. In contrast, a committee of the Institute of Medicine (IOM) has concluded that people are at risk for vitamin D deficiency at serum 25(OH)D concentrations of <12 ng/mL and insufficiency at 12 to 20 ng/mL. Controversy exists regarding optimal levels for adults. Some suggest maintaining 25(OH)D levels between 20 and 40 ng/mL, while others suggest maintaining 25(OH)D levels between 30 and 50 ng/mL. In children, vitamin D deficiency is defined as 25(OH)D less than or equal to 15 ng/mL and vitamin D insufficiency as 25(OH)D between 16 and 20 ng/mL.

Sources of Vitamin D

Natural dietary sources of vitamin D are limited, and dietary intake alone is often insufficient to maintain adequate vitamin D levels. Food sources include egg yolks; liver and organ meats; cod-liver oil; and fatty fish such as salmon, mackerel, tuna, sardines, and herring. Fortified sources such as cereal, orange juice, and dairy products provide about 100 IU per serving.

Exposure to UV-B sunlight is another source of vitamin D as it triggers the natural production of vitamin D in skin. Just ten to fifteen minutes of direct sunlight can generate 10,000 to 20,000 IU of vitamin D. However, sun exposure varies greatly from person to person, and it is difficult to know the safe level of sunlight exposure needed for vitamin D synthesis. Dermatologists routinely caution against direct sun exposure to avoid risks of skin damage and skin cancer. Additionally, the American Academy of Pediatrics (AAP) recommends that infants younger than six months be kept out of direct sunlight. Sun exposure should also be limited in older children through the use of protective clothing with tightly woven fabrics, caps with visors, sunglasses with UV protection, and broad-spectrum waterproof sunscreen with a sun protection factor (SPF) of at least 15.

Multiple factors influence vitamin D synthesis from sunlight exposure. They include factors such as time spent outdoors,

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June 2013 San Francisco Medicine

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Vitamin D Continued from the previous page . . . time of the day, body mass, skin pigmentation, use of sunblock, geographic location, season, amount of cloud cover, extent of air pollution, and amount of skin exposed. UV rays are strongest between 10:00 a.m. and 4:00 p.m. Infants and children with darker pigmentation require a greater length of sunlight exposure to reach the same levels of 25(OH)D when compared to children with lighter pigmentation. Sunscreen, if correctly applied, can reduce the ability to absorb vitamin D by more than 90 percent.

Geography also determines how much vitamin D people are exposed to, as UV-B rays are stronger near the equator and weaker at higher latitudes.

Vitamin D Supplementation

For adults with vitamin D deficiency, a prescription of oral ergocalciferol at 50,000 IU per week can be given for eight weeks, with a goal of achieving a minimum serum level of 30 ng/ mL. After vitamin D levels are repleted, maintenance dosages of vitamin D3 at 800 to 1,000 IU per day can be instituted from dietary and supplemental sources.

Melissa Lin, MD, is a board-certified family physician at Pacific Family Practice Medical Group, where she has been since 2009. She is a member of the SFMS and is the mother of two young children. Practice interests include preventive medicine, family planning, womenâ&#x20AC;&#x2122;s health, pediatrics, continuity care for patients and their families, and optimization and management of chronic disease. See www.pacificfamilypractice.yourmd.com.

There have been discrepancies regarding the benefits of References vitamin D and how much to take. The AAP and the IOM recom1. Institute of Medicine, Food and Nutrition Board. Dietary mend a daily intake of 400 IU per day of vitamin D during the Reference Intakes for Calcium and Vitamin D. Washington, DC: first year of life and 600 IU of vitamin D for children one to eighNational Academy Press, 2010. teen years and adults through age seven. Those over age seventy 2. Bordelon P, Ghetu M, Langan R. Recognition and managemay need up to 800 IU. ment of vitamin D deficiency. Am Fam Physician. 2009 Oct 15; For pregnant and lactating moms, 600 IU is recommended 80(8):841-846. but higher levels may be necessary. For infants who are exclu3. Misra M. Vitamin D insufficiency and deficiency in chilsively breastfeeding, vitamin D supplementation of 400 IU daily dren and adolescents. UptoDate, Hoppin, AG (Ed). UpToDate, should be given, since human milk has low vitamin D content.

Waltham, MA, 2013.

Infants who are partially formula-fed also require supplementa4. Wagner C, Greer F. Prevention of rickets and vitamin D tion unless their formula intake is >1,000 mL daily. Similarly, all deficiency in infants, children, and adolescents. American Acadnonbreastfed infants ingesting <1,000 mL per day of vitamin Demy of Pediatrics. 2008; 111(4):908. fortified formula or milk should receive a vitamin D supplement of 400 IU per day.

Most infant formulas contain at least 400 units/L of vitamin D. Vitamin D3 drops (in formulations of 400, 1,000, and 2,000 INC. IU per drop) can be used for infants.

A REGISTRY & PLACEMENT FIRM Chewable and gummy vitamins (200 or 400 IU of vitamin D3) can be used for older children.

Vitamin D toxicity is rare but can result from excessive supplementation.

Nurse Practitioners ~ Physician Assistants Toxicity can manifest in signs and symptoms such as headache, metallic taste, nausea, vomiting, weight loss, polyuria, and heart arrhythmias. In more serious cases, it can lead to vascular and tissue calcification, which can in turn lead to damage to the heart, blood vessels, and kidneys. According to the National Academy of Sciences, there is little risk of toxicity at levels of up to 2,000 IU per day.

Vitamin D repletion is recommendLocum Tenens ~ Permanent Placement ed for infants and children with 25(OH) D levels below 20 ng/mL. Depending on V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 the degree of deficiency and the age of the individual, a six-week course of vitaFA X : 8 0 5 - 6 4 1 - 9 1 4 3 min D replacement can be given, ranging from 1,000 to 2,000 IU per day, followed tzweig@tracyzweig.com by maintenance dosing of 600 to 1,000 w w w. t r a c y z w e i g . c o m IU per day.

Tracy Zweig Associates Physicians

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www.sfms.org

Keeping Kids Safe

Food for Hungry Families San Francisco Food Banks and Pantries and How to Help Lucy Crain, MD, MPH It seems ironic that so much effort is expended toward addressing obesity, while so little is directed toward the equally important reality of hunger, es-

pecially among low-income children, families, and seniors in our society. “Food insecurity” (having too little food to prevent hunger) has escalated in the Bay Area and across the U.S. during the recent era of recession and high unemployment rates. The California Food Policy Advocate (a statewide policy and advocacy organization), using results from the California Health Interview Survey and UCLA Health Policy Research, in July 2012 data estimated that 3.8 million California adults— especially those with children—could not afford to provide adequate food for themselves and their families. In 2009, at the peak of the recession, with a California unemployment rate topping 11 percent, one in six low-income Californians had food insecurity and cut food intake to the point of hunger, an increase from one in 12 in 2001 prior to the recession.

In 2012, approximately 50 percent of low-income households with children could not afford sufficient food, and 51 percent of Spanish-speaking low-income adults experienced food insecurity regularly. Although the American Recovery and Reinvestment Act (ARRA) of 2009 boosted SNAP (previously the Food Stamp program) benefits by 17 percent, unemployment rates and numbers of families with low income continue to escalate. Of note, the ARRA is due to expire later this year. As a component of the much-debated Farm Bill within the Department of Agriculture, this legislation is crucially important for assuring adequate nutrition for low--income families and seniors. (There have already been numerous attempts to drastically cut the Food and Nutrition Assistance components of this bill, so watch for legislative action in this area.)

The San Francisco Food Bank was founded in 1988 and merged with the Marin Food Bank in January 2011. SFFB is the primary source of foods distributed to low-income residents of San Francisco and Marin Counties. An average of 45 million tons of food is distributed via this network each year—enough for more than 100,000 meals. These efforts serve more than 225,000 people, including 30,000 families and 11,000 children in public school classroom each school day. With the summer break approaching, families with children will need more food to offset that regularly provided by school lunch and “healthy, nutritional snack” programs made available to children of low-income families during the school year. While food pantries operate year-round in our community, the increased need during summer months is reflected by the increased numbers of children with families receiving groceries at the food pantries during summer vacation. www.sfms.org

For example, Temple United Methodist Church, in the Ocean View, Merced Heights, and Ingleside neighborhood of San Francisco, is one of 450 organizational partners for which the SF Food Bank provides discounted groceries and fresh produce. The TUMC food pantry, staffed by church members and other volunteers, was established about six years ago in response to neighborhood need. The pantry operates weekly in the church social hall and purchases discounted foods from SFFB. Groceries and fresh produce are distributed weekly to a growing number of people, now averaging about 425 families per week, with 1,100 individuals served. Individuals must register and confirm their residency in the City. Documentation of eligibility based on household income is required prior to receiving food distribution. Like the SF Food Bank itself, many of the organizational partners help refer families and individuals to other resources that can provide registration for federal programs like SNAP and referral to appropriate local health and educational services.

Lucy Crain, MD, MPH, FAAP, is a past member of the Board of Directors of SFMS. Dr. Crain is a developmental pediatrician and child health advocate and has volunteered at the Temple UMC Food Pantry.

While food pantries operate year-round in our community, the increased need during summer months is reflected by the increased numbers of children with families receiving groceries at the food pantries during summer vacation.

The SFFB is located at 900 Pennsylvania Avenue in San Francisco, (415) 282-1900.

To volunteer or donate to the SF-Marin Food Bank, check the website www.sffoodbank.org. The website gives more information about the various services provided, including the weekly home delivery of groceries to more than 250 homebound seniors in San Francisco. The website notes, “For each $1.00 donated, SFFB distributes $6.00 worth of food.” That’s money well spent.

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Keeping Kids Safe

Pediatric Emergency Care Renewing Richie’s Fund On May 1, 1987, a man decided to end his life in a vehicle collision. While traveling at 97 mph on a city street,

he ran a red light and broadsided a car driven by an elderly woman and carrying her three-year-old great-grandson. The child’s injuries were severe. Because there were no hospitals that specialized in providing emergency trauma care to children nearby, he had to be airlifted many miles away to a children’s hospital.

The boy died in his father’s arms the next day.

The child’s father, Richard Alarcón, vowed to give meaning to his son’s life and purpose to his son’s death. He committed himself to public service and eventually was elected to the California State Senate. Senator Alarcón partnered with physician groups and authored SB 1773, which was signed into law in 2006. The legislation allows counties to increase fines on criminal offenses, including drunk driving and traffic violations, and dedicates these dollars to emergency and trauma care.

Since its passage, the bill has provided an additional $45 million in annual funding for the emergency and trauma care safety net in California. Minus a small amount used to administer the monies, 85 percent of the remaining funds directly supplement the Maddy EMS Fund and another 15 percent is dedicated to pediatric trauma care. That money is named Richie’s Fund in honor of Senator Alarcón’s son.

In 2008, Senator Alex Padilla and physician groups extended Richie’s Fund and the Maddy EMS Fund supplementation through passage of SB 1236. That bill is set to sunset at the end of this year. Senator Padilla has agreed to author a reauthorization and renewal of these monies, and passage of this bill is a high priority for the house of medicine. The tragedy in Newtown remains fresh in our memory. The protection and, when necessary, emergency medical care of our children rightly remains the focus of our public discourse. Our political leaders cannot let a critical component of the funds used to provide this care expire.

The passage and signage of the Richie’s Fund/Maddy EMS Fund bill may prove to be difficult,but the emergency care safety net does need to be supported by the public. When EMTALA was made law in 1986, we decided emergency medical care was something we would provide to all of our citizens regardless of their financial status. This was the moral and right thing to do, but it was and is irresponsible to create such a mandate without creating a funding mechanism to provide that care.

The Maddy EMS Fund in California is the only funding source in the country designed to address this void. The dollars don’t come even close to paying for the cost of emergency care for the uninsured or those who cannot or do not pay for the treatment they received. But it is real money, and it makes the difference between staying open or closing shop and declaring bankruptcy for many emergency departments, especially in underserved and poor communities.

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Andrew Fenton, MD After the passage of EMTALA, and in response to a legislative report showing the state’s trauma care system was on the border of financial collapse, the CMA and physician groups worked with Senator Ken Maddy and sponsored initial and subsequent legislation establishing the EMS Fund (SB 12/SB 612). These laws allowed counties to voluntarily levy an additional penalty assessment of $2 per $10 on fines and forfeitures from criminal acts and motor vehicle violations. These monies would then go to uncompensated emergency care and to local EMS agencies. Since its inception, forty-nine counties (of fiftyeight) in the state have established a Maddy EMS Fund, and this provides $55 million dollars annually to emergency care providers and services and has helped stabilize our trauma system.

The California chapter of the American College of Emergency Physicians (California ACEP), with the support of other physician groups, then sponsored bills with Senator Alarcón and Senator Padilla (SB 1773/SB 1236) that allowed counties to add another penalty assessment of $2 per $10 and included Richie’s Fund for pediatric trauma care. For the more than twenty-five counties in the state implementing both the old and new penalty assessments, the total penalty assessment is $4 per $10 of fines and forfeitures. The Alarcón and Padilla bills have added an additional $45 million to the Maddy EMS Fund, and currently the total fund provides approximately $100 million annually to California’s emergency care safety net.

SB 12/SB 612 specifies, by law, that a maximum 10 percent of these revenues can be used for administration of the funds. The remaining 90 percent is allocated as follows: • Fifty-eight percent to physicians who care for patients who have no insurance coverage or who are unable to pay for their emergency care, including the undocumented.

• Twenty-five percent to hospitals for the provision of emergency care to the homeless, uninsured, or illegal residents.

• Seventeen percent to local EMS agencies for purposes determined by the county.

• The charts below detail the breakdown of funds, including administrative costs, for both the SB 12/SB 612 and SB 1773/SB 1236 allocations that make up the California Maddy EMS Fund:

www.sfms.org

It is estimated that, through the current implementation of both the original Maddy EMS Fund and the Alarcón/Padilla supplement, California physicians who provide EMTALA-obligated emergency services receive nearly $49 million annually. Pediatric trauma/emergency care through Richie’s Fund receives nearly $7 million annually. San Francisco County reported that in 2010, physicians received $531,075 from these funds and an additional $131,500 went to pediatric care through Richie’s Fund. These critically important investments in the emergency medical care of our children and fellow state residents are a relative drop in the bucket compared to California’s proposed 2013 general fund budget of $98 billion.

The money that flows from these funds has maintained an emergency care safety net that has been stretched thin. California consistently ranks in the bottom ten states in the country in terms of physicians per capita, hospital beds per capita, and Medicaid reimbursement. The fact remains that, for the typical insured Californian, if you become sick and believe you need to see a doctor today, it may be difficult to get into to see your primary care physician—and often the next step is the ER. For many of the uninsured, the underinsured (including MediCal patients), the undocumented, or the “undesirable,” the emergency room remains the only game in town, with lights on and doors open 24/7/365.

Will all this change with health care reform? Will the Maddy EMS Fund even be necessary in a world where everyone has health insurance? Currently, of all the states, California has the largest number of people under age sixty-five without health insurance, 7.1 million.1 A recent report predicts that as many as 4 million Californians will remain uninsured after all national health care reforms are in place, including the MediCal expansion and launch of the new Health Benefit Exchange, Covered California. “[Our report] should serve as a wake-up call for the need to maintain the safety-net system in California,” said Ken Jacobs, chair of the UC Berkeley Center for Labor Research and Education and coauthor of the report, along with the UCLA Center for Health Policy Research. “The most important takeaway from this report is to urge governments at every level— federal, state, and county—to maintain whatever they’re doing after [health care reform] arrives,” said Jacobs. “It’s fair to assume most programs won’t need as much money or attention because a lot of the people who use those programs now will be insured, but it won’t be everyone—not by a long shot.”2 The Maddy EMS Fund and Richie’s Fund remain critically important to the emergency care safety net and must be continued. These funds are also crucial to the institution of better pediatric trauma care throughout the state. In January 2012, under the leadership of emergency physician Dr. Marianne Gausche-Hill and in collaboration with the California EMS Authority, the California Hospital Association, and the California Emergency Nurses Association, the National Pediatric Readiness Project was launched.3 The project began with the first national survey designed to assess pediatric readiness in emergency departments based on guidelines developed by the American College of Emergency Physicians, the American Academy of Pediatrics, and the Emergency Nurses Association and sponsored by twenty-two other organizations, including the Joint Commission and the AMA. www.sfms.org

California was the first to participate in the survey, and 300 of the 335 hospitals in the state assessed their capability to treat pediatric patients in their emergency departments. Each hospital was given a readiness score on a scale of 0-100, and an ED attaining a score of 80 or higher was considered “pediatric ready.” The average readiness score for all participating California emergency departments was 71, which was about average compared to other states. The survey demonstrates that we have significant room for improvement in our preparation to treat pediatric patients in our emergency departments.

One area where hospitals can improve their preparedness is in obtaining the proper equipment and supplies needed for the care of pediatric patients. Studies have shown that only 6 percent of emergency departments have the recommended equipment and tools needed to care for children of all ages.4 The monies available within Richie’s Fund can help.

The process to access Richie’s Fund in the counties that have implemented SB 1773/SB 1236 is simple in most counties.

In my county, the hospital purchased the equipment, sent the invoice to the county EMS office, and received a check for the full amount back. In my ER, we have been able to purchase a bronchoscope, two new EZ-IO devices, and a Glidescope with pediatric airway capability. We are now planning on purchasing a new pediatric scale, a noninvasive hemoglobin monitor, an electronic pressure monitor (for CVPs, LPs, compartment syndrome), and a transilluminator. A checklist of pediatric supplies that all emergency departments should have is available here: http://pediatricreadiness.org/files/PDF/Checklist.pdf.

Pediatric trauma and injury remains the most significant health threat to children in the U.S. and in California. More children aged one to fourteen die of injury-related causes than from all other causes combined.7 Physicians provide critical and lifesaving care to injured children on a daily basis. But our health care system needs to do more for kids. We need our hospitals and emergency departments to be better prepared, with the equipment needed to treat children of all ages. We need all emergency departments to be “pediatric ready.” We need a statewide comprehensive and coordinated network that links even the smallest and most remote hospital to a trauma center.

And we need to renew Richie’s Fund and Maddy EMS Funds so that we will have the resources to make these improvements.

Richie Alarcón’s short life will always have meaning by continuing to help give life to so many other children.

Dr. Andrew Fenton is the president of the California Chapter of the American College of Emergency Physicians, which has more than 2,700 members. He represents his specialty at the CMA Council on Legislation and has been active within the CMA House of Delegates. He completed his residency training at U.C. Davis, and a fellowship in health policy and legislative advocacy. He is a partner of the Napa Valley Emergency Medical Group and staff physician at the Queen of the Valley Medical Center in Napa, California. References available online, www.sfms.org.

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Keeping Kids Safe

Gun Violence A Personal Story Jeff Mains and Dustin Ballard, MD On September 9, 2001, in suburban Sacramento, two CHP vehicles pulled up next to a dark blue Nissan. Without warning, a thin man in fatigues emerged

from the vehicle and opened fire with an AK-47. After wounding an officer, the shooter jumped back in the Nissan and barreled away. He crashed into a fire hydrant, stepped out of the car again, and resumed firing. In a nearby Jack in the Box parking lot, people sprinted for safety as round after round of ammunition peppered the ground and surrounding vehicles. “It was like a war,” said an on-scene detective.

Next, the shooter turned and directed his weapon at me.

My name is Jeff Mains, and I was on the way to the supermarket for a can of chew when a hollow-point bullet tore through the door of my pickup truck and hit me in the left flank. Hurtling through my body, the bullet did exactly what was it was designed to do—it created a cavity thirty times larger than itself. My bowel was pierced, my liver lacerated, and my diaphragm ruptured. Intestines spilled out of my abdomen as I opened my truck’s door, stumbled out, and collapsed in the road.

Later, the man who shot me, Joseph Ferguson, took his own life. In his wake, he left five others dead. I was on the verge of death myself and spent more than three weeks in intensive care and months in the trauma unit as my body embarked on the long (years-long) road to recovery. It’s been more than a decade, but my physical scars are still extensive and my psychological scars still present.

Is it any wonder that I believe that AK-47 assault weapons, hollow-point bullets, and high-capacity magazines should be more difficult to obtain? That I believe mental health services should easier to obtain? And that gun violence is ugly and terrifying? ***** My name is Dustin Ballard, and I was one of Jeff’s trauma physicians at U.C. Davis Medical Center. I remember him well and I remember being deeply disturbed by his wounds, as I have been by the scores of gunshot wounds I’ve helped to treat over the years. Despite the miles that distance us, Jeff and I have stayed in touch and he has stayed on my mind. Recently, I asked him to describe his experience and his thoughts about gun violence. I asked him this because I thought that his story, like so many others, can help inform the national discussion on gun violence.

Together, Jeff and I believe that the circumstances of his shooting expose many of the fallacies put forth in the current debate. Reflecting on that night, it would not have mattered if Jeff had had access to a self-defense firearm. In a random rain of bullets, self-defense was not an option. But it would have mattered if Joseph Ferguson had not had access to such a

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devastating weapon and so many rounds of ammunition. No matter what some say, it does make a difference what type of weapon you try to kill with. If the shooter had chosen to fight Sacramento police with a knife or hammer, we are quite certain that Jeff would not carry such physical and psychological scars. It might have mattered if the shooter had had good access to mental health services or had not grown up living in a culture of gun glorification.

Let’s focus on what we know would have mattered (limiting Ferguson’s access to weapons and ammunition). Today, Jeff and I are weighing in on preventive-minded legislation now before the California state legislature and the U.S. Senate.

We know that there is good evidence that background checks prevent crimes from occurring, and that good records help law enforcement solve crimes that have occurred. We know that straw purchases are one of the main sources of firearms for criminals and believe that the changes proposed in the Senate will make these types of purchases easier to prosecute.

We urge our state and national legislators to take these (and other) important steps toward addressing the ongoing public health scourge of firearm violence.

Dr. Ballard is an associate emergency physician at KaiserPermanente in San Rafael, California, and the cochair of the CREST ED Research Network. His writing credits include coauthorship, with Angela Ballard, of the award-winning travel narrative A Blistered Kind of Love: One Couple’s Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet’s Yaw (Universe, 2007). Dr. Ballard writes a biweekly medical column for the Marin Independent Journal.

www.sfms.org

Keeping Kids Safe

Firearm-Related Injuries Affects on Pediatric Populations American Academy of Pediatrics Editorâ&#x20AC;&#x2122;s Note: The following is excerpted from a 2012 policy statement by the American Academy of Pediatricsâ&#x20AC;&#x2122; Council on Injury, Violence, and Poison Prevention Committee.

Scope of the Problem Firearm-related deaths continue as one of the top three causes of death in American youth. The United States has the highest rates of firearm-related deaths (including homicide, suicide, and unintentional deaths) among high-income countries. Strong evidence indicates that a gun stored in the home is associated with a threefold increase in the risk of homicide and a fivefold increase in the risk of suicide. From a clinical perspective, it is important to note that this association is significant even in those teens without a previous psychiatric diagnosis. Evidence also suggests that firearm possession increases the risk of being shot in an assault.

Preventing Firearm Injuries in Children

A number of design options have been proposed to decrease the likelihood of unintentional injury by a firearm, as well as limiting access by unauthorized users. These include trigger locks, lock boxes, personalized safety mechanisms, and trigger pressures that are too high for young children. Keeping a gun locked and keeping a gun unloaded have protective effects of 73 percent and 70 percent, respectively, with regard to risk of both unintentional injury and suicide for children and teenagers. Brief physician counseling directed at parents, combined with distribution of gunlocks, may be effective in promoting safer storage of guns in homes with children.

The AAP endorses use of the Connected Kids: Safe, Strong, Secure violence-prevention program. The clinical guide and parent information provides parents with factual information from which they can make their own decisions. For parents of young children, handgun storage is placed in the context of preventing child access to other dangerous household products. Parents of adolescents have counseling and written materials that describe the relationship between the availability of lethal weapons and fatal teen suicide attempts. These concepts have been incorporated in the new Bright Futures toolkit. The AAP also advocates for reduction of television viewing by children, because media exposure results in increases in childhood and youth violence. In particular, media tends to romanticize the use of firearms as a means of resolving conflicts.

Health Information for Parents

Pediatricians and other child health care professionals are urged to counsel parents about the dangers of allowing children and adolescents to have access to guns inside and outside the home. The AAP recommends that pediatricians incorporate questions about the presence and availability of firearms into their patient history taking and urge parents who possess guns www.sfms.org

to prevent access to these guns by children. Safer storage of guns reduces injuries, and physician counseling linked with distribution of cable locks appear to increase safer storage. Nevertheless, the safest home for a child or adolescent is one without firearms.

The presence of guns in the home increases the risk of lethal suicidal acts among adolescents. Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them. This advice should be reiterated and reinforced for patients with mood disorders, substance abuse problems (including alcohol), or a history of suicide attempts.

Recommendations

The AAP affirms that the most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities. Pediatricians should continue to advocate for the strongest possible legislative and regulatory approaches to prevent firearm injuries and deaths.

The AAP urges that guns be subject to consumer product regulations regarding child access, safety, and design. In addition, the AAP continues to support law enforcement activities that trace the origins of firearms used in the commission of crimes and that these data be used to enforce regulations aimed at preventing illegal sales to minors. Evidence supports the effectiveness of regulation that limits child access to firearms.

The AAP supports efforts to reduce the destructive power of handguns and handgun ammunition via regulation of the manufacture and importation of classes of guns. Engineering efforts (eg, personalized safety mechanisms and trigger locks) may be of benefit and need further study. Trigger locks, lock boxes, gun safes, and safe storage legislation are encouraged by the AAP. Other measures aimed at regulating access of guns should include legislative actions, such as mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks.

The AAP recommends restoration of the ban on the sale of assault weapons to the general public.

The AAP supports the funding of research related to the prevention of firearm injury, including surveillance through the NVDRS; accurate evaluation of health careâ&#x20AC;&#x201C;based screening and intervention; and local, regional, and national efforts to identify and disseminate violence prevention resources.

The AAP supports the education of physicians and other professionals interested in understanding the effects of firearms and how to reduce the morbidity and mortality associated with their use.

The full, referenced version of this policy appeared in: Pediatrics Vol. 130 No. 5 November 1, 2012 pp. e1416 -e1423.

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Health Care Reform Heats Up

By James Noonan, CMA Staff Writer

More than three years have passed since the Affordable Care Act (ACA) was put into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento, and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state levels. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one. Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only nineteen states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas. Despite these problems, the march toward reform continues.

The Next Major Milestone

The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California. Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA. In order to navigate this massive undertaking, states will need to decide which plans will be offered through their ex28 29

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changes, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens—many of whom have never had the benefit of “open enrollment” or a similar purchasing period—understand how and where they can sign up for coverage under the reform law.

California Leads the Way

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines. In the days following the ACA’s passage, California was the first state to establish a health benefit exchange and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level. Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year.

The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s nineteen geographical rating regions.

Protecting Physician Interests

Unfortunately, several recent decisions by the exchange board have placed California’s physician community on its heels.

The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among QHPs. Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring www.sfms.org

networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented. Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014. To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.

For more information on the implementation of health reform in California, subscribe to CMA Reform Essentials. This newsletter, available to both members and nonmembers, covers the activities of the state’s health benefit exchange board and legislation significant to California’s ongoing reform efforts. Subscribe today at www.cmanet.org/newsletters.

CMA and SFMS Support Medi-Cal Rally

In the dispute over whether Governor Jerry Brown’s budget should do more to repair the state’s tattered safety net, the fate of a planned cut in Medi-Cal payments to providers has taken a prominent role. A coalition of health insurance firms and medical associations and the Service Employees International Union-United Healthcare Workers West attended a Medi-Cal Rally in Sacramento on June 4. www.sfms.org

Medi-Cal Cuts Endanger Health Reform Lloyd Dean and Shannon Udovic-Constant, MD

In a time of reform, if there’s one underlying truth that unites every health care provider in our state, it’s this: We cannot successfully implement the Affordable Care Act and open the doors of health care access to all Californians without a strong, adequately funded Medi-Cal system. Medi-Cal is nothing less than the foundation of California’s health care safety net. It provides coverage to millions of families who can’t afford traditional primary and preventive care and protects those of us who can pay from having to bear the cost-shifting burden for those who can’t.

Nearly one out of every four Californians who have health insurance receive it through Medi-Cal. Yet, at a time when the state needs to expand Medi-Cal to meet the new demands of federal health care reform, a law enacted in 2011 reduces access to Medi-Cal services by cutting the Medi-Cal payment rates by 10 percent. Health care leaders had challenged the law, but the federal court denied an appeal to rehear the case.

This will shred California’s safety net.

Together, we represent the largest private hospital provider of Medi-Cal services in California and the largest San Francisco-based organization representing physicians. We both have joined the “We Care for California” coalition comprised of nearly every health provider organization in the state - hospitals, community clinics, physicians, dentists, first responders, health plans and rank-and-file workers - to ensure that federal health reform is more than an empty promise. The coalition is sponsoring SB640 and AB900, which would stop the 2011 cuts from taking effect. California Medicaid reimbursement rates are the lowest in the nation, even though California is one of the most expensive states in which to provide care. Right here, the Jewish Home of San Francisco, the largest private nonprofit nursing facility in California, has issued pink slips to 300 workers and is contemplating bankruptcy, jeopardizing care for hundreds of seniors, because of Medi-Cal cuts.

No one is more committed than we are to reach the longsought-after finish line of universal health access for all Californians. Many of us have worked closely and collaboratively to make innovative programs such as Healthy San Francisco a successful model. But those of us who deliver high-quality, affordable care to those very Californians who need it most will never reach that finish line if Sacramento continues to cut our financial legs out from underneath us.

Lloyd Dean is the president and CEO of Dignity Health. Dr. Shannon Udovic-Constant is president of the San Francisco Medical Society. A longer version of this op-ed appeared in May in the San Francisco Chronicle.

June 2013 San Francisco Medicine

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HOSPITAL NEWS KAISER

SFVAMC

UCSF

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Gropper, MD

Summer is a great time for us, as doctors, to encourage activity in our pediatric population. The benefits of physical activity are widespread, but it’s really important that children are active in a safe way. There are lots of things we can do to encourage our patients to be active and safe.

It’s good to start the summer with a preseason physical. Early summer is the best time to have children checked, as this allows plenty of time to address health issues that may affect physical activity.

Parents, teachers, and coaches should encourage children to engage in a variety of different sports. There is ample evidence that early sports specialization leads to a significant increase in injuries, so the summer is a good time to try something new. The summer is also a great time for competitive athletes, who have often been playing year-round, to take a break from the activity so their bodies can recover from any overuse or injury.

Educating children about injuries can help them learn how best to avoid a potentially dangerous situation. Warming up and cooling down before and after activities is essential when playing any sport. It’s important to increase new activities slowly over a few weeks to allow the body to adjust to musculoskeletal stress. These two tips can help prevent many injuries, as well as aches and pains associated with physical activity.

Educating parents and children about head injuries, such as concussions, is something we take seriously at Kaiser Permanente.

These types of pediatric injuries are on the rise. We recently teamed up with the CDC and stopsportsinjuries.org to increase providers’ and patients’ awareness of head injuries and sports.

Be sure to encourage your pediatric patients to stay active, stay safe, and have fun!

The San Francisco VA Medical Center is pleased to announce the creation of the San Francisco Veterans Justice Court—a new collaboration between the San Francisco Superior Court, the Department of Public Health, community-based service agencies, and the SFVAMC. The Veterans Justice Court is a weekly criminal court docket dedicated to rehabilitating former members of the U.S. military who have been charged with misdemeanors and nonviolent felonies. The court’s goal is to link veteran defendants to medical and mental health care, substance abuse treatment, housing, and other VA services— often in lieu of incarceration and further involvement in the justice system. (Under California Penal Code 1170.9, defendants with service-related mental health or substance use problems may be sentenced to treatment as an alternative to other penalties.)

Judge Braden Wood presides over the Veterans Justice Court team, which includes SFVAMC’s Veterans Justice Outreach Specialist as well as representatives from the district attorney’s office, the public defender’s office, and Community Behavioral Health Services.

These dedicated professionals are familiar with the unique needs of veterans and the special challenges they face. Together, they develop an individualized treatment plan for each defendant and follow him or her throughout the term of court supervision (usually twelve to eighteen months). The weekly court process includes clinical team meetings, where treatment staff deliver updates to the court team, followed by court proceedings, where the judge provides direct feedback to each veteran and defines the court’s expectations for ongoing progress. The collaborative treatment court model has a proven track record in reducing recidivism and promoting community reintegration more effectively than traditional criminal courts. We are confident that the new court will give many of San Francisco’s justice-involved veterans the support they need to break the cycle of criminal activity and return to health and wellness.

30 San 31 SanFrancisco FranciscoMedicine Medicine June June2013 2013

In both the medical community and the general public, there is now widespread recognition that concussions and mild traumatic brain injury (MTBI) can cause lasting neurological damage. Despite this knowledge, there are very few places nationwide where community physicians can refer worried patients and families for a comprehensive diagnosis and expert care.

Mild traumatic brain injury is one of the major underserved public health issues in this country. While many individuals affected do not suffer lasting damage, far more do than was previously believed. Part of the reason is that clinicians tend to treat MTBI as one event, rather than a process or condition that demands ongoing follow-up.

To address these needs, we’ve recently set up the Bay Area Concussion and Brain Injury Program at UCSF, a clinical infrastructure where patients can be seen by a team of physicians who understand traumatic brain injury. Located at our Mission Bay campus, the program includes a multidisciplinary team of nationally recognized experts in sports medicine, physical medicine and rehabilitation, neuropsychology, neuroradiology, neurology, and neurosurgery.

To provide that care, the Bay Area Concussion and Brain Injury Program builds on the UCSF Department of Orthopaedic Surgery’s PlaySafe program, which works with school districts across the San Francisco Bay Area to treat and raise awareness about concussion and brain injury. In the new program, sports medicine experts and leading-edge imaging are available five days a week to evaluate and triage most concussions. In addition, there is a monthly multidisciplinary clinic for patients who need more extensive evaluation.

For more information on the Bay Area Concussion and Brain Injury Program at UCSF, visit www.ucsfhealth.org/concussion.

www.sfms.org

HOSPITAL NEWS St. Mary’s

CPMC

St. Francis

Peter Curran, MD

Michael Rokeach, MD

Patricia Galamba, MD

This individual is easy to identify in the health care setting. He is berating a nurse or resident on the wards in front of staff and patients. She is coming to work perpetually late or gives excuses for poor performance. We learned early as interns and residents that physicians sometimes behave badly, and the consequences impact the morale and safety of the individuals involved and work environment. Promoting a culture of safety in the health care arena comes in many flavors. Disruptive physician behavior is certainly a trend that undermines this culture of safety. The AMA Opinion regarding physicians exhibiting disruptive behavior states, “Personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care constitutes disruptive behavior.” A national survey conducted by the American College of Physician Executives (ACPE) reported that more than two in three U.S. physicians witness other physicians disrupting patient care or collegial relationships at least once a month. Dr. Barry Silbaugh, sponsor of the project, says, “Disruptive physician behavior is the issue that just won’t go away” and likened the situation to pilots “fighting in the cockpit.” Most of the survey respondents had witnessed physicians yelling, insulting, or refusing to cooperate with other health care personnel and refusing to follow established rules. St. Mary’s Medical Center medical staff recently updated its policy on medical staff professional conduct to create more consistency across the organization, recognizing that this issue is a critical component of the credentialing process and Joint Commission (JCAHO) standards. In the event that a physician’s disruptive behavior reflects a health problem, JCAHO directs medical staff to implement a process to identify and manage the individual physician’s health-related matters (i.e., Physician Wellbeing Committee referral for counseling, stress or anger management, and substance abuse problems). Because disruptive physician behavior directly impacts patient care, physicians at Dignity Health understand the importance of maintaining professional conduct in the work place. www.sfms.org

CPMC recently received a full, three-year reaccreditation from the Joint Commission for its California and Pacific campuses. The fourday survey, conducted by six surveyors, included thirty-seven tracers and reviews of fortyeight inpatient records to help assess CPMC’s performance against 275 standards. The survey team identified several best practices, including the GI lab, interdisciplinary rounding in the PICU, the twenty-four-hour goal sheet in the ICU, and medical staff credentialing and OPPE (Ongoing Professional Practice Evaluation) processes. The Joint Commission will conduct separate surveys of the Davies campus in the upcoming weeks.

Dr. Allan Pont will retire as VP of Medical Affairs and chief medical officer effective June 30, 2013. He will continue to work on CPMC special projects and will also continue his active medical practice in endocrinology, diabetes, and metabolism, as well as his longtime role as team physician for the Oakland A’s baseball team. Dr. Pont previously served as medical director and chair of the Department of Medicine, and program director for the Internal Medicine Residency. He also served as chair of the National Residency Review Committee for Internal Medicine. Dr. Pont is widely respected for his clinical acumen in endocrinology, particularly in thyroid disease, and he has worked with the Sutter Pacific Medical Foundation to develop a comprehensive program in endocrinology. We congratulate Dr. Pont on his many accomplishments and wish him all the best.

AARP Magazine has recognized CPMC as one of the safest hospitals in America. CPMC was one of just sixty-five hospitals nationwide to receive the magazine’s “safety superstar” designation for taking innovative steps to reduce medical errors.

In April, ABC 7 News aired a story that featured the CPMC Interventional Endoscopy Center. CPMC doctors are now fighting cancer with the help of the world’s smallest microscope. The device is being used to give doctors an unprecedented view while treating throat and stomach cancers.

The summer season is fast approaching, and with it comes warmer weather, outdoor activities, and the start of several youth sports leagues. Many of you have likely already planned fun, sun-splashed events involving family and friends. But with the increase in outdoor activity comes the reminder of an issue that has gained increased notoriety in recent years: the serious nature of concussions. The Centers for Disease Control estimates that 3.8 million Americans sustain a concussion each year. And yet many still downplay the severity of concussions, instead dismissively terming them “just getting your bell rung.”

At Saint Francis, we are acutely aware of just how serious a concussion is. Our Centers for Sports Medicine, located at Saint Francis Memorial Hospital, Walnut Creek, and Corte Madera, have concussion programs under the directorship of Dr. Artemio A. Perez, a boardcertified physician in three disciplines (sports medicine, family practice, and osteopathic manipulative medicine). He joins an experienced sports medicine staff that provides medical coverage for sports at all levels.

As our experts at the Centers for Sports Medicine will attest, even a mild bump to the head can cause a concussion and impact how the brain functions at a neurological level.

Because a concussion does not injure the anatomy of the brain, results of a CAT scan or MRI may be normal following a blow to the head. This is why, following head trauma, it’s crucial for a thorough examination to be conducted by experts, such as those at the Centers for Sports Medicine. Remember, don’t take anything for granted, and never believe someone can just “walk it off.” It’s always better to advise cautious, prudent follow-up. As a medical community, we can play a key part in concussion safety by remaining aware of its seriousness. We must have a team approach that involves the patient, family, and, where applicable, coaches and trainers. By accomplishing this, we’ll help build a better, more supportive environment in which all of us can engage in our physical activity of choice.

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Health Care Payment Reform Overcoming Barriers Harold D. Miller A major cause of the high cost of health care in America and of many of the serious quality problems in health

care is the way health care providers are paid. Under the current fee-for-service payment system, physicians and other health care providers are paid primarily based on how many services they deliver, not on the quality of those services or their effectiveness in improving a patientâ&#x20AC;&#x2122;s health. That is, they are paid for volume, not value. Moreover, physicians may actually be financially penalized for providing better-quality services; indeed, under most payment systems, physicians make less money if they help their patients stay healthy.

Although there is widespread agreement that changes in the way physicians and other providers are paid for health care are necessary to reduce costs and improve quality, progress has been

slow because there are many significant barriers to changing a payment system that has been in place for decades. Although these barriers seem daunting, they can be overcome. Ten of the biggest barriers that providers, payers, purchasers, and patients face in implementing payment reforms are described in the attached table, along with potential solutions that can be used to solve them. A detailed description of each of the barriers and the solutions for addressing them is available in a free report from the Center for Healthcare Quality and Payment Reform (www.CHQPR.org) entitled Ten Barriers to Healthcare Payment Reform and How to Overcome Them.

Harold D. Miller is the executive director of the Center for Healthcare Quality and Payment Reform. He was the keynote speaker at a seminar co-presented by the SFMS last year.

Ten Barriers to Healthcare Payment Reform and How to Overcome Them Barrier

Solutions

1. Continued use of fee-for-service payment in payment reform models

Use episode-of-care payment for acute conditions and global payments for all patients to eliminate undesirable incentives under fee-for-service and to give providers the flexibility and accountability to reduce costs and improve quality.

3. Physician compensation based on volume, not value

Change physician compensation systems to match incentives under payment reform. Modify federal and state fraud and abuse laws to permit gain-sharing between hospitals and physicians.

2. Expecting providers to be accountable for costs they cannot control 4. Lack of data for setting payment amounts 5. Lack of patient engagement

6. Inadequate measures of the quality of care 7. Lack of alignment among payers

8. Negative impacts on hospitals 9. Policies favoring large provider organizations

10. Lack of neutral convening and coordination mechanisms

32 33

Use risk adjustment and risk limits to keep insurance risk with payers, but transfer performance risk to providers. Use risk exclusions to give providers accountability only for the types of costs they are able to control.

Give providers access to timely analyses of both utilization and costs through community multi-payer claims databases.

Ask patients to designate who their primary care physicians are rather than using statistical attribution rules based on fee-for-service claims to assign them retrospectively. Use value-based benefit designs to enable and encourage patients to improve health, adhere to treatment plans, and choose high-value providers and services.

Develop quality measures for all of the conditions and procedures that drive significant amounts of cost. Use outcome measures instead of process measures to give providers flexibility to redesign care and support effective patient choice. Use Regional Health Improvement Collaboratives to collect patient-reported information on outcomes.

Ask physicians and other providers to define lower-cost, higher-quality ways to deliver care and the payment changes needed to support them. Encourage employers to support regional payment reforms and to choose health plans that will implement them in a coordinated way. Offer Medicare payment reforms to a broader range of providers on an ongoing basis. Use state government and/or Regional Health Improvement Collaboratives to facilitate agreement among payers.

Reduce fixed costs and improve efficiencies in hospitals. Change payment levels to hospitals to reflect higher costs per admission that accompany lower admission rates. Increase transparency about hospital costs to ensure that prices for hospital care are adequate but not excessive.

Remove antitrust barriers to small physician practices joining together to manage new payment models. Combat anticompetitive practices by large providers. Avoid unnecessary standards for structure and processes in payment systems and accreditation systems that increase costs and favor large organizations.

Support the creation and operation of multi-stakeholder Regional Health Improvement Collaboratives in all regions.

San Francisco Medicine June 2013

www.sfms.org

In Memoriam

Nancy Thomson, MD

Leo van der Reis, MD

Fridolin William Heer, MD

Leo van der Reis, MD, was born October 39, 1926, in Groningen, the Netherlands. After his basic schooling, he moved to the United States to attend medical school at the University of Chicago. He graduated in 1954 and came to UCSF in San Francisco to complete postgraduate training in internal medicine and gastroenterology.

He opened a private medical practice and worked at Seton Medical Center until his retirement. He was an active member of the San Francisco Medical Society and served on the editorial board of San Francisco Medicine. In addition to caring for his patients, he was a visiting professor at a number of universities. He also served as the United States Medical Director for KLM Royal Dutch Airlines.

In recognition of his efforts to further scientific ties between the Netherlands and the United States, the Queen of the Netherlands made him an officer in the knights’ Order of Orange-Nassau. He traveled extensively throughout the world, enjoyed reading and writing, advocated for health care reform, and cherished time with his friends and family. His wisdom, generosity, friendship, and love will be missed by many. He is survived by Margaret, his wife of forty-eight years; son William; daughter-in-law Judith; grandchildren Lucy and Jack; daughter Melinda; son-in-law Rick; and sister Leonora.

Fridolin “Bill” Heer was born March 12, 1929, in Indianapolis, Indiana, and raised in Springfield, Illinois. His family moved to California in 1946, where he attended U.C. Berkeley (class of ’49). After going through the NROTC program at UCB, he was commissioned in the U.S. Marine Corps and later served with distinction in Korea. In 1952 he returned to San Francisco to marry his UCB classmate Lola Griffis and to start medical school at UCSF. He received his MD in 1958 and served his internship at San Francisco General and his surgical residency at UCSF. He practiced general surgery at several San Francisco hospitals, served as chief of surgery at Ralph K. Davies and St. Luke’s, and was chief of staff at Davies. He was a member of the San Francisco Medical Society and the California Medical Association. He served as president of the San Francisco Surgical Society, the Nafziger Society, the California Academy of Medicine, and the Pacific Coast Surgical Association.

He also served on the board of governors of the American College of Surgeons. At UCSF he was long involved in the training of surgical residents, and upon retiring he was named Distinguished Clinical Professor Emeritus.

An avid sailor, Bill crossed both the Atlantic and Pacific Oceans by sailboat, and after retirement he sailed with his son’s family throughout the Mediterranean. He achieved his childhood ambition to fly by obtaining a private pilot’s license. He also enjoyed skiing. A member of the Medical Friends of Wine, he enjoyed touring California wineries.

Music was a great pleasure for him. He had studied violin and piano and later took up classical guitar. He regularly attended San Francisco Symphony and Opera performances. He was a member of the Olympic and the St. Francis Yacht Clubs.

Bill was also a devoted family man. He is survived by his wife Lola, daughter Lisa, son Fridolin Mark, daughter-in-law Louisa, and grandsons Fridolin Chester and Carlton. He passed away April 3, 2013, at age 84.

Clifford Clinton Raisbeck, Jr., MD

Clifford Raisbeck was born in Milwaukee, Wisconson, on May 13, 1928, and he passed away on Good Friday, March 29, aged 84, from complications of pneumonia. His first wife, Margaret, had predeceased him in 1991, but his second wife, Carole Henderson Ferguson, whom he had married in 1993, and his five children were by his side.

He attended Northwestern University in Evanston, Illinois, and was admitted after three years to Northwestern University Medical School. He interned at Charity Hospital, New Orleans. Following three years of active duty as a U.S. Navy flight surgeon, he did his orthopedic residency through Northwestern at St. Vincent’s Catholic Medical Center in New York and at Shriner’s Hospital in Winnipeg, Canada. Upon completion of his training, Dr. Raisbeck moved to San Francisco with his family, then to Sausalito. He founded the Orthopedic Group of San Francisco. He was chairman of orthopedic surgery at French Hospital and Mary’s Help/Seton Hospital. He was involved with orthopedic education at UCSF and the VA Medical Center in Livermore throughout the Vietnam War. For thirty-four years he remained in the U.S. Naval Reserve, where he consulted on complicated orthopedic cases. He retired as captain of the USNR in 1987.

A strong supporter of Northwestern’s Medical School, he served on the alumni board and funded a research fellowship chair. He was a member of the Rattlers Camp at the Bohemian Club, served on the vestry of Christ Episcopal Church in Sausalito, was a member of the Marin Ski Patrol, and patrolled the slopes of Sugar Bowl with the Doctors’ Ski Patrol. He continued to ride the Harley Davidson motorcycle he had purchased for commuting to university, sailed his boat from the Presidio Yacht Club, and rallied his 1911 Ford across the country three times in the Great America Race (scoring a perfect 00.00 on the Indianapolis Speedway). He made wine for thirty years and spent time on his Wisconsin farm. A world traveler, Dr. Raisbeck introduced joint replacement surgery in Jordan and Tunisia, taught orthopedics in Vietnam for many years, and with his wife Carole hiked remote areas of Burma, Laos, and Thailand. A service for Dr. Reisbeck was held at Grace Cathedral. www.sfms.org

Jules M. Weiss, MD

Jules M. Weiss, MD, was born May 8, 1928, in New York City to Isidor and Florence Weiss. After his primary education, he graduated from Harvard in 1947 with magna cum laude and Phi Beta Kappa honors. He received his medical degree in 1951 from New York University Medical School, where he was a member of Alpha Omega Alpha. Dr. Weiss was an anatomy instructor at Washington University Medical School, where he published a number of papers based on his research with the then-new electron microscope.

He was commissioned a captain in the U.S. Army Medical Corps and served from 1955 to 1957 in Robert-Espagne, France. Following his military service, he undertook training in psychiatry at Mt. Zion Hospital and the San Francisco Psychoanalytic Institute; upon completion he entered private practice in San Francisco. In addition, he was an active member of the Psychoanalytic Institute, where he held several offices and authored many papers on psychoanalysis. He was in practice for fifty-three years, up until two days before being admitted to the hospital where he later died of heart failure. He will be remembered as a kind and brilliant man with a whimsical sense of humor who was devoted to his family and his profession. He had a passion for music, literature, and art.

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June 2013 San Francisco Medicine

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He is survived by his wife of fifty-six years, Dorothy Schellenger, whom he married while serving his country in France; his two daughters, Patricia (Brendon Sweeney) and Susan (Christopher Alonzi); and his granddaughter, Sarah Alonzi. He is also survived by his nephew, Stephen Weiss, MD.

Thurml Banks, MD

Dr. Thurml Banks, a well-known San Francisco Obstetrician/gynecologist, died peacefully on March 19, 2013, shortly after celebrating his 90th birthday on March 2. He was born in Bolee, Oklahoma, to Boston and Susie Banks, the youngest of their six children. He attended public schools, graduating with honors as class valedictorian from Douglas High School in 1941. This earned him a scholarship to Iowa State University. After his freshman year he enlisted in the service for three years. After brief stints at Iowa State and Texas A & M, he earned his bachelor’s degree in animal husbandry at Langston University in 1953. He then went on to earn his medical degree from Meharry Medical College in 1960.

He was the first African-American to enter Mt. Zion Hospital’s residency program in San Francisco, after which he established a medical practice in ob/gyn that spanned thirty-five years with more than 7,000 live births. He was a dedicated medical instructor at UCSF and enjoyed hospital privileges at many hospitals throughout the city.

He was the recipient of the Outrstanding Teacher Award at Children’s Hospital and the Golden Bagel Award at Mt. Zion. He was active on numerous committees and boards over the years, including several committees of the SFMS, the Board of Directors of the SF Symphony, the Children’s Home Society, Sunny Hills Children’s Services, and the Minority Adoption Society. Thurml loved his work, his family, and his life. Nothing pleased him more than being surrounded by the laughter of his grandchildren, with his beloved miniature schnauzer, Matt, on his lap. He enjoyed planting and tending gardens, particularly tomatoes and bougainvillea, smoking and barbecuing meats, and watching the 49ers drive for the Superbowl.

He was predeceased by his wife, Joyce, in 1991; his five siblings; and his dog in 2010. He is survived by two daughters, Lynn (Gornick), and Toni (Sander), each of whom has two children; numerous nieces and nephews; and his best friend, Pringl Miller. Thurml’s family participated in a private memorial and scattered his ashes at sea off the coast of Marin County, in accordance with his last wishes.

Stephen Thomas Hufford, MD

Dr. Hufford passed away on November 6, 2012, at the age of 54 surrounded by his loving family. He graduated from University of Southern California School of Medicine in 1983 and specialized in hematology and internal medicine. He was a member of the SFMS for twenty-five years. Never knowing what life had in store, he made a lifelong practice of enjoying each day. Because of that philosophy, he had a rich and fulfilling life pursuing numerous passions— intellectual, musical, and athletic. Dr. Hufford was immensely proud of his daughters and loved spending time with them nurturing their interests, as well as sharing his love of the SF Giants. He leaves behind his devoted wife of twenty-eight years, Gretchen Frantz; daughters Justine (21) and Kendall (14); father Harry (Jan); brother Gary (Pat); nephews Jeff, Kevin, Bryan; stepbrother Lewis (Lisa); and numerous other relatives. Memories may be shared at: http://tributes.com/ stephenhufford. In lieu of flowers, the family requests donations to the Stephen T. Hufford Memorial Fund.

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San Francisco Medicine June 2013

Health Alert! Multi-State Outbreak of Hepatitis A Associated with a Frozen Berry Food Product In May the U.S. Centers for Disease Control and Prevention (CDC) announced an investigation concerning an outbreak of Hepatitis A in persons who consumed Townsend Farms Organic Anti-oxidant Blend frozen berry mix. So far thirty cases have been reported in five states including California (none in San Francisco). The product has been widely distributed by Costco markets. The product may also have been sold through other outlets. The San Francisco Department of Public Health (SFDPH) is working with the California Department of Public Health (CDPH) to provide further guidance for the public and clinical providers.

Early signs of hepatitis A appear two to six weeks after exposure.

Symptoms commonly include mild fever, loss of appetite, nausea, vomiting, diarrhea, fatigue, right upper abdominal pain, dark urine and jaundice.

Clinicians should report suspected cases to SFDPH Communicable Disease Control at (415) 554-2830.

Hepatitis A vaccination can prevent illness if given within two weeks of exposure to the contaminated product. Standard recommendations for post-exposure prophylaxis of exposed persons can be found here: www.cdc.gov/hepatitis/ HAV/HAVfaq.htm#protection. However before initiating prophylaxis please check the links below, as CDPH and CDC may update recommendations specific to this outbreak.

CDC outbreak notice

cdc.gov/hepatitis/Outbreaks/2013/A1b-03-31/index.html

CDC advice for consumers

cdc.gov/hepatitis/Outbreaks/2013/A1b-03-31/adviceconsumers.html

California Department of Public Health http://www.cdph.ca.gov/

San Francisco Department of Public Health http://www.sfdph.org/

SFDPH Communicable Disease Control and Prevention http://www.sfcdcp.org/

San Francisco residents who believe they may have been exposed to the contaminated frozen berry product should contact their medical provider, or may call 311 (from within the 415 area code) or (415) 701-2311 for more information.

www.sfms.org

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