March 2014

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

News and Breakthroughs Specialists Share the Latest Trends Plus: SFMS Annual Gala Photos Inside!

Covered California Special Insert

The Soda Tax Battle Begins

• Cancer Immunotherapy • Developments in Neurology and Neurosurgery • Movement to Separate Obstetrics and Gynecology • Collaborative Care for Psychiatric Illness • Ultrasound in the Emergency Department and for Pain • Hospital Medicine • Oral Sex and Cancer VOL. 87 NO. 2 March 2014

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IN THIS ISSUE

SAN FRANCISCO MEDICINE March 2014 Volume 87, Number 2

News and Breakthroughs: Specialists Share the Latest Trends FEATURE ARTICLES

MONTHLY COLUMNS

11 Neurology: Developments Since the “Decade of the Brain”

Donald C. Kitt, MD

4

Membership Matters

7

President’s Message Lawrence Cheung, MD

13 Less Is More: The Trend Toward Subdividing Obstetrics

and Gynecology

Lily Tan, MD

15 A Modern Paradigm: Collaborative Care for Psychiatric

Illness in Primary Care

Weston Scott Fisher, MD, and James Bourgeois, OD, MD 17 A Review of Neurosurgery: Trends on the Rise

Brian T. Andrews, MD, FACS, FAANS

18 Cancer Immunotherapy: An Integral Part of Future Treatments?

Bertrand Tuan, MD

9

Editorial Gordon Fung, MD

34 Medical Community News 38 Public Health Report: Electronic

Cigarette Roulette

Steve Heilig, MPH 38 Upcoming Events

19 Oral Sex and Throat Cancer: The Rising Rate of HPV-Related

Oropharyngeal Cancer

Man-Kit Leung, MD 21 Ultrasound Guidance: Many Uses for Interventional Pain Procedures

Justin McKendry, MD

23 Hospital Medicine: Advancing Patient Safety, Care Quality,

Communication, and Cost

Christopher Moriates, MD 25 Ultrasound in the ED: Rise in Emergency Department Use

Aparajita Sohoni, MD

OF INTEREST

Welcome New Members

The SFMS would like to welcome the following members: Pratima Gupta, MD | Obstetrics and Gynecology Zeenat Hasan, MD | General Surgery Sandra Hernandez, MD | Internal Medicine Victor Kwok, MD | Internal Medicine

26 SFMS Annual Gala Photos Asha N. Mehta, MD | Internal Medicine Payam Puya Sazegar, MD | Family Medicine 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.

Andrew Mark Snyder, MD | Pediatrics Elizabeth Sanseau | Student

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members SFMS Endorses Soda Tax Ballot Measure; Joins Choose Health SF Coalition SFMS has teamed up with several San Francisco Supervisors to introduce a proposal to tax sugary beverages, with the proceeds dedicated to nutrition, physical activity, and health programs in public schools, parks, and elsewhere. On March 24, St. Mary’s Medical Center will be hosting a Community Town Hall with SFMS President Lawrence Cheung, MD, and San Francisco Supervisors Scott Wiener and Eric Mar to discuss the soda tax measure. The event starts at 6:00 p.m. at Morrissey Hall and is free and open to the public.

The SFMS has been a strong advocate on combating childhood obesity, and has spearheaded a resolution on this topic that was adopted by CMA in favor of sugar taxes. Please show your support of the measure by completing the pledge at http://www. choosehealthsf.com/ or attending the town hall event.

CMA Introduces Bill That Calls for Warning Labels on Sugary Drinks; Based on UCSF Medical Student’s Idea

idea into a reality. The winner of the contest was a SFMS member and first-year UCSF medical student, Tom Gaither. Gaither says the idea came to him after teaching high school for two years in San Jose. “Kids would come to class with a soda or sports drink,” he said. “So many of the kids didn’t know how bad surgery beverages were for them.” He found himself so worked up about the subject that he taught a semester on sugar in foods for one of his classes.Additional information on SB 1000 can be found on the SFMS website, www.sfms.org.

Senate Pro Tem Introduces MICRA Legislation

Senate pro Tem Darrell Steinberg (D-Sacramento) has introduced SB 1429, a so-called “spot bill” that is intended to gut California’s Medical Injury Compensation Reform Act (MICRA) of its protections and lift the cap on noneconomic damages. As a spot bill, SB 1429 currently contains no specific changes to MICRA, reading only that it “is the intent of the Legislature to bring interested parties together to develop a legislative solution to issues surrounding medical malpractice injury compensation.”

It is expected that the bill will be amended to call for specific changes to MICRA, including an increase of the $250,000 cap on noneconomic damages. SFMS/CMA’s position on MICRA is that the cap on noneconomic damages keeps malpractice rates in California affordable, ensuring access to care for millions of Californians and keeping doors of providers open to the public.

Any increase to the cap would jeopardize these resources, and, therefore, SFMS/CMA remains committed to defending the law.

For more information about MICRA and what you can do to help in the fight, visit www.cmanet.org/micra.

SGR Repeal Gaining Momentum

CMA introduced SB 1000 which would mandate a simple warning on the front of all beverage containers with added sweeteners that have 75 or more calories per 12 ounces. State Senator William Monning (D-Carmel) will carry the bill and is backed by a collation that includes the CMA, the California Center for Public Health Advocacy, the California Black Health Network, and the Latino Coalition for a Healthy California. The idea for the bill was part of a CMA contest for medical school students and residents.

The contest, called “My CMA Idea,” collected ideas for public health legislation from medical students and residents, allowing future physicians to help craft public policy to better the health of all Californians. All physicians were invited to vote for and comment on their favorite ideas. The winner was selected from the top-ranked ideas, and this legislation will, we hope, make the 4

Congress is closer than ever before to enacting legislation that would permanently repeal the Medicare sustainable growth rate (SGR) formula. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (HR 4015/S. 2000), introduced in both chambers of Congress, offers a fiscally prudent opportunity for lawmakers to repeal the SGR formula and put Medicare on the path toward a stable, twenty-first century program that can meet the growing health care needs of the nation’s seniors.

The bill provides a 0.5 percent automatic payment update every year for five years during the transition to new payment models through which physicians can earn bonuses of up to 9 percent.

The new system will allow physicians to select from two payment tracks—a fee-for-service track and an alternative payment model track. Most important, the bill eliminates the flawed Medicare SGR once and for all. Congress has very few days to establish a pathway and enact this legislation before the scheduled 2014 Medicare physician payment cut of 24 percent takes effect on April 1. Follow SFMS (@SFMedSociety) on Twitter for up-to-date information on the SGR repeal.

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

California Assembly Bills Introduced to Reverse, Study Effects of 10% Cut to Medi-Cal Providers Assembly Budget Chair Nancy Skinner and Assembly Health Chair Richard Pan, MD, introduced two bills to reverse the 10 percent cut in Medi-Cal provider rates and extend the temporary Medi-Cal primary care rate increases called for under the Affordable Care Act. Â AB 1805 will improve health care access by bolstering provider participation in Medi-Cal, a program California expanded last year as the state moves forward in aggressively implementing the ACA. Specifically, AB 1805 will restore the 10 percent cut to Medi-Cal provider reimbursement rates that were enacted as part of the 2011 State Budget Act. AB 1759 extends through 2015 (and indefinitely beyond) the reimbursement increase for certain Medi-Cal primary care providers called for under the ACA and set to expire on December 31, 2014.

Update Your Practice Information for the SFMS Online and Print Pictorial Directory

Spotlight your practice and expand your referral base with an updated member profile! With the SFMS online Physician Finder and print directory, physician members have the opportunity to promote their practices on customizable individual Web profiles and connect with a larger patient and referral base. SFMS have sent out e-mail and mail notifications to all physician members currently engaged in the practice of medicine to update contact information for the directory. If you did not have your picture in the 2013 directory, or if your information is outdated, we encourage you to update your directory entry by contacting SFMS at ayoung@sfms.org or (415) 561-0850 extension 200.

Promote Your Practice with the SFMS Directory

If you would like to reach 1,000 health care professionals in San Francisco, please consider placing an ad in the 2014 SFMS Member Directory.

Members are eligible for an exclusive discount on quarter-page vertical ad placements. Advertising rates start at $395. To obtain the ad rate and contract agreement, contact Ariel Young at ayoung@sfms.org or (415) 561-0850 extension 200.

Anthem Blue Cross to Move Eligibility, Benefits, and Claim Status Inquiry Functions to Availity Web Portal Effective March 2014

Anthem Blue Cross has advised that effective March 14, 2014, patient eligibility, benefits, and claim status inquiry functions will transition from its ProviderAccess portal to the Availity Web portal. As of that date, practices will only be able to access this information via the Availity web portal. While BlueCard eligibility, benefits, and claim status functions will also transition to Availity, the BlueCard Advisor function that allows practices to determine which Blues plan to send the claim to will continue to be available on the ProviderAccess portal. In order to access information on the Availity Web portal, practices must first register and sign the Availity Organizational Access Agreement. To register for the Availity web portal, visit www.availity. com/providers/registration-details.

Covered California Removes Online Health Insurance Exchange for Small Businesses

Covered California has elected to temporarily shutter its online Small Business Health Options Program (SHOP) Marketplace only four months after it launched. Health plans available through SHOP will still be available but can only be purchased over the phone, via paper applications, or through insurance agents. The employer exchange is expected to come back online this fall. For more information about Covered California, please refer to the special insert in between page 37 of this issue.

WWW.SFMS.ORG

March 2014 Volume 87, Number 2 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 SFMS OFFICERS President Lawrence Cheung, MD President-Elect Roger S. Eng, MD Secretary Richard A. Podolin, MD Treasurer Man-Kit Leung, MD Immediate Past President Shannon UdovicConstant, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Ariel Young BOARD OF DIRECTORS Term: Jan 2014-Dec 2016 Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Adam Schickedanz, MD Rachel H.C. Shu, MD Paul J. Turek, MD

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

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

MARCH 2014 SAN FRANCISCO MEDICINE

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In San Francisco, the highest rates of diabetes hospitalization directly correspond with the highest rates of expenditures on soda.

Maps created by the City and County of San Francisco Department of Public Health Environmental Health Section

www.choosehealthsf.com | info@choosehealthsf.com

Paid for by Choose Health SF.

PRESIDENT’S MESSAGE Lawrence Cheung, MD

Taxing Soda: Fairness Instead of Obesity and Paralysis On the November election ballot there will be a proposal for a new tax on sugarsweetened beverages (SSB). I am personally in support of this tax, and I hope that you will be too. Specifically, this will be a tax of $0.02 per ounce on any sugar-sweetened beverages that contain more than 25 calories per 12 ounces. Milk, 100 percent natural juices, infant formulas, and diet drinks will be exempt from this tax.

This tax is expected to generate approximately $30 million in revenue per year, and the proposed legislation has earmarked the funds to go directly back to health promotion. Specifically, 40 percent to the SF Unified School District for nutrition education, healthy food access, and expansion and improvement of physical education; 25 percent to the Department of Public Health and Public Utilities commission for healthy food access initiatives, drinking fountains and water bottle filling stations, oral health services, chronic disease prevention, and public education campaigns; 25 percent to the Recreation and Park Department for recreation centers, organized sports, athletic programming, and grants to community-based organizations; 10 percent for grants to community-based organizations that support physical activity, food access, public outreach, and health programs. The funds will be used for new or expanded programs and will not replace current funding. Most important, the funds will be prioritized to neighborhoods disproportionately impacted by diseases related to the consumption of SSB. The evidence that demonstrates the correlation between SSB consumption and increase in rates of obesity, diabetes, and heart disease is overwhelming. The San Francisco Medical Society is developing a webpage that will provide links to the many scientific articles showing the deleterious effects of SSB consumption. They can be accessed here: www.sfms.org. Not surprisingly, a tax can serve as a deterrent to unhealthy behaviors; research has shown that even a $0.01 tax would lead to a minimum 10 percent reduction in calorie consumption—a reduction sufficient for weight loss and lessened risk.1 But more importantly, San Francisco will be generating additional tax revenue that will help fund efforts that will directly improve the health of our city, offsetting the cost that consumption of SSBs have on its health. What is surprising is the health-related cost of SSBs locally. According to a policy analysis report from the San Francisco Budget and Legislative Analyst Office, estimated direct health care costs to San Francisco attributed to SSBs is at $28 million.2 The $30 million in revenue generated by the tax will help offset this cost.

SFMS Immediate Past President Dr. Shannon Udovic-Constant and our own staffer Steve Heilig drafted a resolution in 2011 to support antiobesity/anti-soda drink campaigns and WWW.SFMS.ORG

this was passed by the California Medical Association (CMA) House of Delegates, making it official CMA policy. As a forward-thinking city, San Francisco is poised to make history in establishing a tax on SSBs. As of this writing, twelve cities have attempted to establish such a tax, but their proposals have either been defeated/stopped by legal action or significantly watered down.2 As the local papers have reported, this promises to be a “sour fight.” The sugar industry has already formed opposition groups to fight our proposal, and, as they did in Richmond two years back, will spend massive amounts of money to defeat it. I am sick of seeing children developing type II diabetes.

I am sick of seeing steatophatitis in my adolescent population caused by morbid obesity. If successful, San Francisco will be the first city to adopt this tax. Let’s make history, and let’s do it for our patients and our community.

References

1. Brownell et al. The public health and economic benefits of taxing sugar-sweetened beverages. NEJM. September 17, 2009.

2. Updated Study of the Health and Financial Impacts Caused by High Consumption of SugarSweetened Beverages.

Policy Analysis Report of the City and County of San Francisco Board of Supervisors Budget and Legislative Analyst. December 12, 2013.

Event March 24 Soda Tax Measure Medical Community Town Hall Meeting with SFMS President Lawrence Cheung and Supervisors Scott Wiener and Eric Mar. Event is free and open to all health care professionals. 6:00 p.m. at Morrissey Hall, St. Mary’s Medical Center, 2250 Hayes Street.

MARCH 2014 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD

Trends on the Rise This month’s edition focuses on some of the latest news, breakthroughs, and trends in medicine that have been in the lay press as well as in medical journals.

Probably everyone has heard of the “Decade of the Brain,” announced in 1990, as well as President Obama’s recent announcement supporting further brain research in the coming decade. As clinicians, we see patients with neurologic disorders and think that it wasn’t long ago that most neurologic disorders we could name had limited treatment, and those treatments were not very effective. But the rapid growth of neurologic research, from basic to translational and clinical research, has exploded and changed the field. There’s more than critical care and rapid response teams for acute stroke care and emergency cardiac arrests, or brain salvation during treatment and recovery of sudden cardiac death due to malignant arrhythmias. We now carry out much more comprehensive evaluations and diagnostic workups that include a series of genetic tests to look for specific markers and mutations for diagnosis and management. The basic research from the actual genetic mutations to phenotypic manifestations of these disorders has also fostered targeting specific treatments that are leading to improved outcomes. Some of the more common disorders, such as dementia, we can now categorize more logically so that management can be focused on the etiology.

It used to be that neurologists and psychiatrists were trained very differently in their residencies but their board certification examinations were very similar, since both these specialties deal with the brain, albeit from different perspectives. So we were fortunate to have our own past SFMS board member, Dr. Donald Kitt, write “Neurology: Developments Since the ‘Decade of the Brain.’” And Drs. Weston S. Fisher and James Bourgeois contributed “A Modern Paradigm: Collaborative Care for Psychiatric Illness in Primary Care.” Dr. Brian T. Andrews expounds on “A Review of Neurosurgery: Trends on the Rise.”

With increased knowledge and technology in each field, there is a subsequent change in actual practice for clinicians.

Dr. Lily Tan’s article discusses how the Ob/Gyn field is trending toward separating obstetrics and gynecology. Some of the changes have come about in the actual practice of obstetrics, with hospitalist obstetrics and with more support for midwives and other alternative practitioners. Other changes are due to the more technically demanding operations of limited tumor resections, rather than total hysterectomies, laparoscopic surgeries, and combined surgery with radiation therapy or chemotherapy. These advanced practices require high-volume, continuous practice throughout the career of a physician rather than limited exposure at one time during one’s practice.

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WWW.SFMS.ORG

Many recent advances in cancer chemotherapy have focused on immunotherapy, specifically targeting identified metabolic pathways that the malignant cells use. This treatment modality has really changed the practice of oncology toward more focused therapy, which patients can usually tolerate much better than the multiple toxic agents used in combination in the past. Although the older combinations are still being used now as new pathways are discovered and the reactions are delineated, specific antigenic targets for antibodies can be used to alter the reactions and actually kill cancer cells.

Dr. Bertrand Tuan authored “Cancer Immunotherapy: An Integral Part of Future Treatments?” to educate us on this very exciting area of the cancer armamentarium. Our own SFMS treasurer, Dr. Man-Kit Leung, is an otolaryngologist who has written “Oral Sex and Throat Cancer: The Rising Rate of HPVRelated Oropharyngeal Cancer.”

One of the fastest-growing specialties in medicine is hospital medicine. There are now hospitalists for general medicine services, pediatrics, surgery, obstetrics, and many other services. They care for inpatients and specialize in their acute hospital care, with emphasis on coordinating efficient and effective quality care and transitions back to the outpatient setting or to lower levels of care. Dr. Christopher Moriates writes about these trends in “Hospital Medicine: Advancing Patient Safety, Care, Quality, Communications, and Cost.”

Finally, noninvasive imaging can assist the clinician in the diagnosis and management of a whole assortment of disorders. Ultrasound imaging has been increasingly used in clinical practice at the bedside by practitioners, rather than only in radiology suites by technicians. Dr. Justin McKendry notes this trend in “Ultrasound Guidance: Many Uses for Interventional Pain Procedures,” and Dr. Aparajita Sohoni follows suit with “Ultrasound in the ED: Rise in Emergency Department Use.” We hope you find this issue informative and useful!

MARCH 2014 SAN FRANCISCO MEDICINE

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Specialists Share the Latest Trends

NEUROLOGY Developments Since the “Decade of the Brain” Donald C. Kitt, MD As a practicing neurologist of more than twentyfive years, I have seen developments in neurology explode exponentially since the American Academy of

Neurology’s “Decade of the Brain” in the 1990s, when neurology research was emphasized by the National Institutes of Health (NIH). Year 2013 was no exception. It included advances in neurogenetics and biomarkers, treatment of acute stroke, broadened recognition—and treatment—of clinical phenotypes for headache syndromes, emerging recognition of the sequela of mild head trauma, new therapies for multiple sclerosis, and validation of therapies for Parkinson’s disease.

We are on the cusp of identifying early treatment strategies for Alzheimer’s disease. General neurology is an academic field of private practice with momentous promise to affect the lives of an aging population.

The Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) initiative is included in President Obama’s fiscal year 2014 budget. This initiative consists of the NIH, the Defense Advanced Research Projects Agency (DARPA), and the National Science Foundation (NSF). With a $40 million investment to partner with private research foundations, BRAIN hopes to further understand and map the activity of the human brain. The initiative will energize projects already underway in nanotechnology, advanced optics for neuroscientists, and the clinical application of prosthetics.

Neurologists hope to better the communication between patients’ brains and their prosthetics and to advance the biological understandings of psychiatric illness, Parkinson’s disease, and autism.

An estimated 35 million people in the United States suffer from migraine annually. Of episodic migraine patients, 2.5 percent become chronic migraine patients who suffer headaches at least fifteen days per month. Eighty percent of these chronic migraine patients are women. Migraines may occur with or without medication overuse. Medication overuse/ rebound headache syndrome can occur with the use of opiates on eight or more days per month, triptans on ten or more days a month, or any combination of triptans and analgesic opioids on fifteen or more days per month, with any of these situations continuing on a regular basis for more than three months. Treatment of these patients is always challenging. Effective treatments include new strategies using older agents as well as new therapies. IV DHE with symptomatic treatment for nausea and muscle cramps or current hospitalization and IV valproate may produce as much as 75 percent headache freedom after one month, which is long enough to renew preventative medications that were previously ineffective. In multiple studies, FDA-approved onabotulinumtoxin A (BoWWW.SFMS.ORG

tox) has been established to reduce the number of headache days by 50 percent and, in some instances, has proven more effective than many of the oral preventative medications. The treatment course is two or three treatments separated by three months each. Despite the expense of Botox treatment, overall costs are lower due to a reduction in triptan use and a reduction in migraine-related emergency room visits, hospitalization, and urgent care visits. In addition, the adverse side-effect profile compared to daily oral medication may be significant.

The broader use of nerve blocks with impressive efficacy for occipital neuralgia, the greater recognition of indomethacin-responsive headache syndromes, and the study of trigeminal autonomic cephalgias in the absence of structural pathology have served useful in the clinic setting. Migraine with aura is now recognized as an independent risk factor for cardiovascular disease in women (second only to hypertension). This was found in a prospective cohort of 27,861 women ages >45 and studied over fifteen years of follow-up; 5,130 reported migraine and 1,435 reported migraine with aura. The results are magnified when combined with other risk factors, such as systolic blood pressure greater than 180 mm Hg, diabetes mellitus, family history of MI, lipid status, or current smoking. Furthermore, stroke specifically is of higher incidence in all women who have migraine with aura and are receiving estrogen-containing contraceptive medication (especially those who are over thirty-five and who smoke).

Continued on the following page . . .

MARCH 2014 SAN FRANCISCO MEDICINE

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Neurology Continued from the previous page . . .

Concussion has reached the headlines at all levels of contact sports. The effects of head impacts as measured by instrumented football and hockey helmet accelerometers have shown a significant association between head impact metrics and post-season white matter measures in a number of regions of the brain, including the corpus callosum, amygdala, cerebellum, and hippocampus, even in the absence of a clinical diagnosis of concussion. The white matter metrics were also correlated with a poorer than predicted post-season performance on measures of verbal learning and memory. Some individuals with mild head trauma who were not cognitively normal were associated with greater measured amyloid deposition, suggesting that head trauma may be associated with Alzheimer’s disease-related neuropathology. Studies have suggested that head trauma is associated with an earlier onset of Alzheimer’s disease, particularly among carriers of a biomarker such as ApoE-4 allele. Solving the mystery of chronic traumatic encephalopathy (conversion to Alzheimer’s disease pathology) is underway. Youth sports is a particularly sensitive topic with regard to concussion. Parents and coaches need to understand that children are at greater risk for concussion than adults by virtue of their body morphology; specifically, their head-to-body ratio and neck muscle strength relative to adults is thought to provide greater risk of concussion.

Parkinson’s disease treatment with deep brain stimulation (DBS) has provided a consistent 21 percent improvement in Parkinson’s disease-related quality of life as compared to medication alone, as well as a comparable percent improvement in activities of daily living. This has come after the initial FDA approval of DBS in 2002. Its safety and tolerability has been established for those with idiopathic Parkinson’s disease of greater than five years’ duration, motor fluctuations or dyskinesias despite medication, or resistant tremor with a stable support system. Exclusions are cognitive impairment, severe depression, or uncontrolled psychiatric disease. The most problematic of complications have been low rates of symptomatic hemorrhage, infection of the device or wound, technical malfunction of the DBS electrodes, or transient cerebral edema. The most common target for DBS currently is the subthalamic nucleus (STN). Effectiveness of DBS use in essential tremor and dystonia is established. Results are promising in Tourette’s syndrome. Nonmotor features of Parkinson’s disease including abnormalities of sensation, behavioral changes, sleep disturbance, abnormalities of respiratory function, autonomic dysfunction, and fatigue have received greater attention in the management of Parkinson’s disease.

Such nonmotor symptoms as impaired smell, visual dysfunction, pain, depression, anxiety, cognitive impairment, sleep fragmentation and REM sleep behavioral disorder, orthostatic hypotension, sialorrhea, dysphagia, constipation, and urinary and sexual dysfunction, as well as thermoregulatory dysfunction, can consume more than an average neurology follow-up visit with therapeutic options, beyond the simple adjustment of the levodopa doses.

Multiple sclerosis disease-modifying therapy trials have 12

produced a timeline of recent and future drug approvals unmatched in the history of neurology. Recently approved medications dimethyl fumarate, teriflunomide, and fingolimod are all associated with significant reduction in MS relapse rates and have comparable if not greater effectiveness as compared to traditional therapies such as interferon agents or glatiramer.

Monoclonal antibodies such as alemtuzumab, via IV five-day infusion monthly and currently under review, shows great promise compared to established standards. Monthly natalizumab IV infusion is remarkably effective and FDA approved. All of these new agents, especially those with a long half-life, are being closely monitored for the emergence of complications such as treatment-related PML (progressive multifocal leukoencephalopathy) as was seen in JC virus antibody-positive patients receiving natalizumab. At least four other agents are also in the pipeline with fully enrolled phase III trial results to be released once or twice per year. Vitamin D has been the subject of great interest given the low adverse side-effect risk of supplementation. For each increase of 10 ng/mL in 25-hydroxy vitamin D levels of patients with multiple sclerosis, there is a 15 percent decrease in T2 white matter abnormalities and a 32 percent decrease in gadolinium-enhancing brain lesions. Clinical relapse rates correlate as well. Vitamin D appears to be a remarkable disease-modifying therapy, yet the role of clinical supplementation is under study. Everyone knows that MS prevalence is higher in certain latitudes, generally without sun exposure. Higher milk or vitamin D intake during pregnancy decreases MS risk of offspring by 38 percent.

IV TPA for stroke has been standard therapy since 1996, with the treatment window of three hours from the onset of stroke symptoms, proposed to four-and-a-half hours by 2009.

Tertiary care with endovascular or intra-arterial TPA therapy in 2013 received a setback due to the inability to improve functional outcomes by three negative studies, regardless of the apparent success of the procedures. More to come.

The practice of neurology continues to evolve at a rapid pace due to innovation and motivation to care for our aging population. The intellectual satisfaction among neurologists is high, yet the professional satisfaction is at an all-time low due, in part, to government compliance mandates and reimbursement rates in nonprocedural neurology. The trend of postgraduate neurology residency education is not keeping up with demand. My hope is that we can reverse these trends before all of the Boomer generation becomes of Medicare age.

Donald Conrad Kitt, MD, was born and raised in San Francisco.

He has been in private practice as a neurologist since 1988, on the neurology faculty at UCSF since 1990, and on the clinical faculty at SF General since 1995. He is a longtime SFMS member and has served on the board of directors. He has worked as a consulting neurologist for St. Mary’s and CPMC, where he is also chief of neurology and a leading member of its Neuroscience Institute. He also serves as a neurology consultant to three major league baseball teams, including the SF Giants. He is a fellow of both the American Academy of Neurology and the American College of Physicians and has received the Charles A. Noble Jr. Teaching Award from the CPMC Department of Medicine, the President’s Award from the UCSF Association of Clinical Faculty, and the J. Elliott Royer Award in Neurology.

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

Specialists Share the Latest Trends

LESS IS MORE The Trend Toward Subdividing Obstetrics and Gynecology Lily Tan, MD In 1908, Henry Ford revolutionized the automobile industry with the debut of his Model T. It wasn’t a

unique style, superior components, or advanced technology that made the Model T rapidly outsell every other automobile in its day. It was the fact that it was a solid vehicle offered at an unusually affordable cost, and that it came with a high degree of standardization and therefore reliability. Prior to the Model T, cars were produced in their entirety by individual craftsmen working by hand to assemble each vehicle from start to finish. The skill and knowledge required to create a single car were reflected in the length of time required for its production and its resultant high price tag. By implementing a team approach, Ford was able to break down the car manufacturing process into discrete areas that could be readily mastered. Team members focused solely on their areas of expertise. Working together, they were able to rapidly manufacture cars in a reliable fashion, significantly driving down production costs and revolutionizing the transportation industry by making cars affordable to the masses.

Ob/gyn physicians are finding similar advantages to breaking down their wide scope of practice into more discrete subcategories. Focusing on an area of special interest or skill allows for higher levels of mastery within this narrower scope. This increases proficiency and improves patient outcomes. The vast field of ob/gyn already offers physicians the ability to subspecialize in a number of areas, including maternal-fetal medicine, gynecologic oncology, reproductive endocrinology and infertility, urogynecology, and pelvic pain. Increasingly, however, generalist ob/gyns have begun essentially subspecializing within their own practices to focus on one specific area in their field. The days of the full-scope ob/gyn physician appear to be limited as they are increasingly replaced with narrower-scope hospitalists, laborists, gynecologic surgeons, or clinic-only physicians.

This trend toward fractionating the field of ob/gyn is increasingly supported by the medical literature and by outcomes analyses. A Committee Opinion issued in June 2010 by the American College of Obstetrics and Gynecology, for example, supports the trend toward ob/gyn hospitalists as mutually beneficial to both patients and physicians. An ob/gyn hospitalist may provide inpatient consultations and patient care, see emergency room patients, and provide obstetric care. An even narrower subdivision of hospital-based care yields the laborist, who solely tends to the needs of the obstetric patients on the labor and delivery suite.

Obvious benefits of employing a hospitalist or laborist include having 24/7 in-house availability of a physician who is working a shift, rather than calling in a physician who is already busy in clinic, in the operating room, or, even worse, during offhours. Traditionally, ob/gyn physicians are expected to balance a full work day in the clinic, scheduled elective surgeries, and the WWW.SFMS.ORG

care of patients who present to the hospital at any hour, day or night, in labor or with gynecologic emergencies. This lifestyle easily leads to physician fatigue, which may negatively impact patient care as well as family and personal lives due to its inherent unpredictability. Having hospitalists attend to the in-house patient care not only improves the quality of life of the referring ob/gyn, it also expedites patient care and improves clinical outcomes. One study of twenty-four busy hospitals presented at the Society for Maternal-Fetal Medicine’s annual meeting in 2013 showed that using the laborist model resulted in 15 percent fewer labor inductions, reduced maternal length of stay, and led to a 17 percent reduction in preterm labor. Other studies confirm that hospitalists employing full-time laborists report lower cesarean section rates, lower maternal morbidity, and decreased health care costs.

Gynecologists who choose to practice with a focus on surgery reap similar benefits in terms of improvement in schedule predictability and lifestyle, as well as enhanced patient care. Common sense dictates that the more a surgeon operates, the more proficient he will become. This is now supported by multiple studies showing greater efficiency and lower complication rates for higher-volume surgeons compared to their lower-volume peers. A study by the Columbia University Medical Center analyzed outcomes for 77,109 patients from 500 hospitals throughout the U.S. Patients operated on by high-volume gynecologic surgeons were 31 percent less likely to experience an operative injury. The medical complication rate was also reduced by 24 percent, transfusions by 28 percent, and ICU admissions by 46 percent. Not surprisingly, multiple other studies confirm patient benefits of being operated upon by high-volume surgeons compared to low-volume surgeons: shorter operative time, shorter hospital stays, lower complication rates, and decreased cost.

Psychology studies abound demonstrating the detrimental effects of multitasking on productivity and expertise. Expertise results from focus. Narrowing the scope of practice within the wide field of ob/gyn improves efficiency, enhances patient safety, and increases provider satisfaction. After all, as the saying goes, the jack of all trades is master of none.

Dr. Lily Meiyu Tan, a native San Franciscan, served as a member of the San Francisco Medical Society Board of Directors from 2006 to 2012. She enjoyed a full scope ob/gyn practice from 1999 to 2006, providing services at CPMC, St. Francis Memorial, and Chinese Hospitals. Currently, she serves as director of Minimally Invasive Gynecologic Surgery at Kaiser Permanente in San Francisco, where she specializes in advanced laparoscopy and robotic surgery. Her narrowed scope of practice allows her time to enjoy raising her five children and practicing martial arts.

MARCH 2014 SAN FRANCISCO MEDICINE

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Specialists Share the Latest Trends

A MODERN PARADIGM Collaborative Care for Psychiatric Illness in Primary Care Weston Scott Fisher, MD, and James Bourgeois, OD, MD “Coming together is a beginning; keeping together is progress; working together is success.” —Henry Ford

As health care systems face increased fiscal and performance pressures to provide evidence-based ser-

vices for a growing patient population with increasingly limited resources, new and creative models of care must emerge.

Among these models, collaborative care between mental health and systemic medical care is becoming the new paradigm for providing the highest-quality and most cost-effective treatment for our patients.

Collaborative care is a model that provides mental and behavioral health care in the general medical outpatient setting. It goes beyond previous models of psychiatric and general medical integration. In the earlier integrative models, mental health professionals (MHPs) (e.g., psychiatrists, psychologists, social workers, and other mental health providers) might share office space with their systemic medicine colleagues and consult with one another from time to time. However, in such models, MHPs typically had their own panel of patients and had little to no involvement with the remaining patients seeing general medical clinicians, and they typically did not use a single integrated medical record system. With collaborative care, systemic medical and mental health providers are organized into a cohesive team working together to take care of a common panel of patients. Psychiatrists, other physicians, nonpsychiatrist MHPs, nurses, clerical staff, and ancillary staff all function as part of a team, each working to their highest degree of training to support the health and well-being of their patients.

By definition, a collaborative care model includes three main elements: 1) systematic psychiatric assessment (with the typical use of standardized rating instruments); 2) the use of nonphysician care managers to perform longitudinal symptom monitoring, interventions, and coordination of care; and 3) stepped care recommendations provided by mental health specialists (Huffman JC, 2013). Unlike previous colocated models, collaborative care uses nonpsychiatrist MHPs, who are often specially trained psychiatric nurses, as central figures in treating patients. Psychiatrists develop standardized, evidence-based protocols for psychiatric treatment that empower primary care providers to manage more of their patients without psychiatric referral. Psychiatrists also review population data (such as panel-based information from the entire clinic or multiple clinics) to aid in screening for mental illness and tracking treatment progression. This can be done with serial application of standardized rating instruments. Meanwhile, nonpsychiatrist MHPs in a collaborative care model use evidence-based, standardized psychotherapeutic techniques and WWW.SFMS.ORG

collaborate with medical providers regarding psychopharmacological interventions. The nonpsychiatrist MHPs and primary care providers both receive supervision from the psychiatrists for complex cases.

Did you know that there are an average of only 14.1 psychiatrists per 100,000 U.S. citizens (Lohr K, 1996)? An added benefit of the collaborative care model is that it allows one psychiatrist to care for a much greater number of patients. Her or his attention can be divided equitably by the thoughtful use of a system in which every professional works “at the top of his or her license.” The role of the psychiatrist becomes that of a director, saving their individual patient interaction for only the most complex cases requiring their level of advanced training and expertise.

Studies that have looked at this model have consistently demonstrated its benefits. Cost effectiveness studies have shown that, at worst, this model is cost neutral, and more often it is shown to be less costly than traditional models (Katon WJ, 2008). Studies have also shown that treating a patient’s mental illness in the primary care setting leads to more effective treatment (DA, 2010) (Unützer J, 2002). Additionally, patients’ systemic medical outcomes are more likely to improve with increased access to mental health services in the primary care clinic (Rollman BL, 2009) (Pyne JM, 2011). In many cases, the MHPs focus not only on the specific mental health concerns of their patients but also on the management of systemic medical conditions (for example, in using psychotherapeutic techniques in enhancing compliance and self-management). This has generally shown better results than focusing on one area alone.

The Affordable Care Act (ACA) has catalyzed an increasing emphasis on overall wellness of patients rather than the traditional fee-for-service structures as part of providers’ incentive plans. In the past, collaborative care has struggled with finding ways to generate revenue in traditional funding models, despite its improved cost effectiveness. New accountable care organization (ACO) fee structures are being designed with the goal of facilitating providers’ ability to work together in collaborative models in order to enhance patients’ functional outcomes.

Thus, providers’ reimbursement will be based on keeping “panels” of patients well. As we enter this new era, cost-effective models such as collaborative care may well prove attractive to administrators designing ACOs. The bulk of the development for collaborative care has occurred in primary care settings. However, this model, with modifications, is applicable across a broad range of medical settings. This is likely to be especially true in medical specialties where there is known to be a high rate of psychiatric comorbid-

Continued on the following page . . .

MARCH 2014 SAN FRANCISCO MEDICINE

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A Modern Paradigm Continued from the previous page . . . ity. Increasingly, obstetrician/gynecologists, infectious disease/HIV specialists, and organ transplant services are inviting psychiatrists and other MHPs into their clinics to help collaborate on patient care. For health care in America, collaborative care truly is the wave of the future. It’s time to work together.

Weston Fisher, MD, is a fourth-year resident psychiatrist at the University of California, San Francisco. In his final year of training, he is serving as chief resident for Program Development and has focused his work on systems leadership and quality improvement. He completed medical school at Pennsylvania State University (2010).

James Bourgeois, MD, is a clinical professor for the Consultation-Liaison Service at UCSF Medical Center in San Francisco. He completed his residency in psychiatry from Wright State University (1993) and is certified by the American Board of Psychiatry and Neurology in psychiatry (1995, recertified 2004) and psychosomatic medicine (2005).

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References 1. Roy-Byrne P et al. Delivery of evidencebased treatment for multiple anxiety disorders in primary care: A randomized controlled trial.

JAMA. 2010; 303 (19):1921–1928.

2. Huffman JC et al. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: A publication by the Academy of Psychosomatic Medicine Research and Evidence-Based Practice Committee. Psychosomatics. 2013; 13 (00175-8):0033– 3182.

3. Katon WJ et al. Population-based care of depression: Team care approaches to improving outcomes. Journal of Occupational and Environmental Medicine. 2008; 50 (4):459–467.

4. Lohr K et al. The nation’s physician workforce: Options for balancing supply and requirements. Washington: Institute of Medicine, National Academy Press. 1996.

5. Pyne JM et al. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Archives of Internal Medicine.

2011; 171 (1):23–31.

6. Rollman BL et al. Telephone-delivered collaborative care for treating post-CABG depression: A randomized controlled trial. JAMA. 2009; 302 (19):2095–2103.

7. Unützer J et al. Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA. 2002; 288 (22):2836–2845.

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Specialists Share the Latest Trends

A REVIEW OF NEUROSURGERY Trends on the Rise Brian T. Andrews, MD, FACS, FAANS The practicing neurosurgeon currently has multiple areas where there have been at times exciting and at other times alarming new pieces of information to relay to our patients. Grabbing the headlines in recent years have

been the risks of multiple concussions among professional football players, leading to the potential for early dementia due to chronic traumatic encephalopathy (CTE). Indeed, this was identified long ago among professional boxers (dementia pugilistica) and can occur among athletes in a variety of sports, such as soccer and motor racing. Of more common concern are concussions to pre-high school, high school, and collegiate athletes in football, soccer, and other sports. Guidelines have been developed for the definition of concussion, and advice has been developed for withdrawal from play and return to play after a concussion. In many parts of the country, baseline computerized cognitive testing is being performed on young student athletes and used to help guide return to play after concussion—even to guide return to regular classroom activities and intensive studying. It is very likely that most college and professional athletes in at-risk sports have had vast underrecognition of the number of and severity of concussions they have had over time, and there is probable genetic diversity to the likelihood of developing CTE. One of the most important factors that influence prognosis after severe head injury is the development of increased intracranial pressure (ICP). Elevated ICP that cannot be controlled correlates to extremely poor prognosis, so in recent years there has been enthusiasm for more early use of decompressive craniectomy, which is effective in lowering ICP. Recent studies, however, do not show improved functional survival with this treatment when compared to best medical management of ICP, and there is substantial concern that many survivors are left with very poor neurological function.

Thus, the future of this surgical technique in the treatment of severe head injury remains unknown. Similarly, decompressive craniectomy is being used for large ischemic infarctions of the brain when there is life-threatening brain swelling, particularly in patients younger than sixty-five years of age. Here the data are more encouraging that the technique may help both survival rates and functional recovery. When there is cerebellar infarction or hemorrhage, early surgical decompression can be a lifesaving technique.

The surgical exposure of anterior skull base tumors have advanced with the use of transnasal endoscopic techniques, allowing for improved ability to remove tumors arising from the pituitary gland and adjacent structures. So-called extended endonasal techniques are now being used for many tumors of the anterior skull base, such as meningiomas that historically would have been treated with craniotomy. Similarly, transcranial tumor surgery has been refined with the use of image-guidance systems that allow smaller and more accurate craniotomy site selection and aid the surgeons in determining their location within the brain as they WWW.SFMS.ORG

navigate to the lesion site. This can be combined with cortical and subcortical electrophysiologic mapping of the brain to determine areas of eloquent function. When working in the dominant hemisphere, awake craniotomy for speech mapping has become a standard technique. All of these methods are now used to optimize more complete removal of intrinsic brain tumors such as gliomas while minimizing the risk of a postoperative neurological deficit.

It has been clearly shown that more complete removal of such tumors improves the prognosis for survival.

Neurosurgeons have increasingly been working with radiation oncologists using techniques of stereotaxic radiosurgery to treat a multitude of conditions, including metastatic tumors of the brain; benign tumors, such as vestibular schwannomas; pituitary tumors; and functional conditions, such as trigeminal neuralgia and epilepsy. These methods have now extended to the spine, where benign tumors can be treated safely and effectively without open microsurgery. Functional neurosurgery has advanced with the increasing use of implanted electrodes placed in precise regions, where stimulation safely negates activity, to treat movement disorders such as Parkinson’s disease, severe tremor, dystonia, and refractory depression and obsessive-compulsive disorders. In all of these situations, there can be dramatic reduction in the severity of symptoms.

In epilepsy, electrical mapping of the brain can allow neurosurgeons to resect epileptic foci with accuracy to reduce or eliminate seizures. In some cases, removal of the corpus callosum reduces seizures that involve both hemispheres. Recent work has been done in developing implanted pacemaker-like devices that can detect seizure onset and halt seizures from developing. Finally, the area of spinal surgery has advanced with the use of minimally invasive techniques to treat common problems such as disc disease, spinal stenosis, and spinal tumors throughout the length of the spinal canal.

Spinal surgery is most effective when treating symptoms of compression of the spinal cord and nerve roots. Increasing attention is also being paid to restoring total spinal alignment in both the frontal and sagittal planes, and more effective methods for correcting deformities such as spondylolisthesis and scoliosis have been developed.

The use of artificial discs has now been proven more effective in some cases than fusion surgery in treating disc disease in the cervical spine. This is not the case in the lumbar spine, however, where the use of artificial discs to treat refractory back pain remains controversial. Indeed, the use of spinal instrumentation for the treatment of back pain itself remains widespread and overused in this country, and it is only sometimes effective. Unless very carefully selected for surgery, most patients with back pain alone are best treated with a structured rehabilitation program and pain management.

Brian T. Andrews, MD, is chair of the Department of Neurosciences at California Pacific Medical Center in San Francisco.

MARCH 2014 SAN FRANCISCO MEDICINE

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Specialists Share the Latest Trends

CANCER IMMUNOTHERAPY An Integral Part of Future Treatments?

Bertrand Tuan, MD Science, the official publication for the American Association for the Advancement of Science, announced on December 20, 2013, that its choice for Breakthrough of the Year was cancer immunotherapy. To put this in perspective, Science magazine’s

choice for Breakthrough of 2012 was the discovery of the Higgs boson, the so-called “God particle,” which may be able to explain how all matter in the universe, including life, exists.

However, in contrast to the Higgs boson, cancer immunotherapy is already taking credit for beating down life-threatening cancers: The six-year-old girl with acute lymphoblastic leukemia in her second relapse, near death after infusion of genetically engineered T-cells, currently healthy and in remission; the seventy-two-year-old engineer from Maryland with progressive metastatic kidney cancer who had disappearance of disease a year after his last dose of an experimental antibody aimed at unleashing T-cells previously emasculated by his tumor; and the retired police officer with metastatic lung cancer to his chest wall with continued shrinkage of his tumor eight months after his last dose of antibody therapy all were subjects of front-page stories in the New York Times in late 2012 and 2013.

Cancer therapies attempting to exploit the body’s natural tendencies to fight back invading viruses, bacteria, and tumors date back to the late 1890s, and a century later they were extensively researched and promoted for renal cell cancer and malignant melanoma. How is today’s cancer immunotherapy different?

It has been recognized for centuries that rare patients with advanced tumors who survived life-threatening bacterial infections such as erysipelas had shrinkage or even disappearance of their tumors. William Coley, MD, a prominent New York surgeon of the early twentieth century, developed a concoction of streptococcal and staphylococcal bacterial toxins named, appropriately, Coley’s toxins, which again induced the rare remission in sarcoma patients.

In the 1970s and 1980s, Steven Rosenberg, MD, brought interleukin-2, a growth factor for T-cells, to market with a current FDA approval for treatment of patients with metastatic melanoma and renal cell cancer. IL-2 therapy is rigorous, requiring monthly cycles with common complications of hypotension, capillary leak, fevers, rashes, and intensive care.

However, up to 6 percent of IL-2 patients will have durable remissions and can be considered cured of this metastatic malignancy.

This new cancer immunology focuses on T-cells, the lymphocytes that, along with B-cells, fight off microbial infections. However T-cells are also responsible for the anticancer 18

immune surveillance going on continuously in our bodies; organ transplant patients have a high incidence of skin cancers due to inhibition of their T-cell surveillance by anti-rejection immunosuppressive drugs. Instead of using IL-2 to stimulate T-cells, dissection of T-cell antitumor activity over the past twenty years has focused on three “brakes” abolishing antitumor activity: CTL4 (cytotoxic T-lymphocyte antigen 4), PD-1 (programmed death 1), and PD-L1,2 (programmed death ligand 1 and 2).

Ipilumimab (Yervoy) is a bioengineered monoclonal antibody inhibiting CTL4 approved by the FDA in 2012 to treat patients with metastatic melanoma. It is the first agent to actually prolong overall survival for treated patients, with some patients remaining in remission for years following four monthly treatments. Antibodies to PD-1 have also resulted in sustained responses for up to 20 percent of renal cell, melanoma, lung cancer, and ovarian cancer patients. Exciting news from November 2013 at the World Lung Cancer Conference in Sydney using antibodies to PD-L1 demonstrate a higher rate of sustained responses in smokers as opposed to nonsmokers. Toxicities of these therapies range from life-threatening diarrhea and pituitary failure to pneumonitis and rash. All of these agents can take months before evidence of response, and many durable responders had growth of tumors initially on therapy only to manifest a complete remission later on.

Recent work started at the University of Pennsylvania involves inserting genes into T-cells to recognize and attack lymphoma and leukemia cells expressing the B-cell CD19 antigen. Durable remissions have been seen in multiple relapsed chronic lymphocytic leukemia and lymphoblastic leukemia patients. Some patients have had cytokine storms of fevers, hypotension, and respiratory failure successfully treated with the anti-IL6 antibody tociluzumab used for rheumatoid arthritis.

Dr. David Minor is the principal investigator at CPMC for trials integrating ipilumimab for adjuvant therapy of resected melanoma and, in combination with an oncolytic virus, injected into patients with metastases. Dr. Alan Kramer recently was involved in a trial for lung cancer patients treated with chemotherapy versus a PD-1 antibody, which recently closed due to rapid accrual. Dr. Ari Baron, whose previous trials at CPMC treated prostate cancer patients with ipilumimab, is leading a soon-to-open trial of the anti-PD1 antibody nivulomab in combination with ipilumimab for patients with metastatic colorectal cancer.

In my opinion, cancer immunotherapy is not just a trend in oncology; it will be an integral part of our future treatment

Continued on page 22 . . .

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

Specialists Share the Latest Trends

ORAL SEX AND THROAT CANCER The Rising Rate of HPV-Related Oropharyngeal Cancer Man-Kit Leung, MD “Can I get throat cancer from oral sex?” is a question an increasing number of patients have been asking me. Ever since actor Michael Douglas last summer

suggested that his base of tongue cancer was linked to cunnilingus, there has been growing public awareness and concern about the association of sexually transmitted infections and throat cancer. Indeed, the rate of oropharyngeal cancers related to the sexually transmitted human papillomavirus (HPV) has been on the rise and represents an emerging threat in the field of otolaryngology—head and neck surgery.

What Is HPV?

HPV is a double-stranded DNA virus that commonly infects epithelia of skin and mucosa in the genital area. The virus is transmitted by skin-to-skin contact during sexual intercourse. HPV infection is the most common sexually transmitted disease in the U.S. In fact, according to the CDC, HPV is so common that nearly all sexually active men and women will get at least one strain of the virus at some point in their lives.

Fortunately, over 90 percent will clear the infection within two years without sequelae, most without ever knowing they were infected. Moreover, most strains of HPV do not cause cancer. In fact, the vast majority of HPV-related head and neck cancers is associated with just one particular strain, HPV-16.

In some cases, however, infection with certain high-risk strains of HPV, such as HPV-16, can persist and induce cancer.

In these cases, viral DNA integrates into the DNA of the host epithelial cells, causing the expression of oncogenes. The resulting oncoproteins, E6 and E7, bind to and inactivate two tumor-suppressor proteins, p53 and pRB, which play critical roles in regulating the cell cycle. With p53 and pRB inactivated, infected epithelial cells can undergo malignant transformation into cancer cells. HPV infection has been shown to cause virtually all cervical cancers and most anal cancers, as well as vaginal, vulval, penile, and oropharyngeal cancers.

An Emerging Threat

Did you know that HPV-positive oropharyngeal cancers increased by 225 percent from 1988 to 2004? In contrast, HPV-negative throat cancers declined by 50 percent during the same time period. According to the same study, the percentage of oropharyngeal cancers associated with HPV rose dramatically from 16.3 percent during 1984 to 1989 to 71.7 percent during 2000 to 2004. If current trends continue, the study authors contend that the annual incidence of HPV-positive oropharyngeal cancers is expected to outnumber that of cervical cancers by 2030.1 Current data from the CDC estimates that approximately 8,400 new cases of HPV-related WWW.SFMS.ORG

oropharyngeal cancers are diagnosed each year in the U.S. Similar recent studies have shown a changing demographic in those diagnosed with throat cancers. In contrast to HPV-negative oropharyngeal cancers, which are mostly seen in older men with a history of smoking, drinking, and poor oral hygiene, HPV-positive cancers are found in younger, nonsmoking, and nondrinking adults with a higher number of lifetime sexual partners.2 Fortunately, despite presenting at more advanced initial stages, the prognosis for patients with HPV-positive cancers has been shown to be better than that for patients with “traditional” oropharyngeal cancers caused by smoking and drinking. In a study with a median follow-up time of more than three years, patients with HPV-positive tumors had a risk of progression that was 72 percent lower and a risk of death that was 79 percent lower than patients with HPV-negative tumors.3 The authors conclude that the improved outcomes in HPV-positive cancers may be explained, at least in part, by enhanced sensitivity to chemotherapy and radiation, raising the possibility that these tumors may require less aggressive treatment regimens.

So, what do I tell my patients who ask me about the risk of getting throat cancer from oral sex? My response is that yes, there is a risk of developing oropharyngeal cancer if you are infected with a high-risk strain of a virus that is sexually transmitted. However, most people have already been exposed to the virus and the vast majority of people clear the infection without ever knowing it. Even if you are infected with a highrisk strain of HPV, there is currently no known intervention that can prevent the infection from causing cancer. My best advice is to use protection such as condoms and dental dams during sexual intercourse, to consider HPV vaccination for those under twenty-six years old, and to seek prompt medical attention if you develop symptoms of throat cancer, such as difficulty swallowing, persistent sore throat, or a lump in the throat or neck.

Man-Kit Leung, MD, is a board-certified otolaryngologist— head and neck surgeon in private practice with SF ENT Medical Group and a current officer of SFMS. He attended UCSF medical school, trained at Stanford for residency, and at Harvard Medical School for rhinology fellowship. He is a fellow of both the American Academy of Otolaryngology—Head and Neck Surgery and the American Academy of Otolaryngic Allergy. He is fluent in Cantonese and Mandarin and has offices in San Francisco’s Chinatown and Nob Hill neighborhoods. He continues to teach as adjunct clinical faculty in the Stanford University School of Medicine Department of Otolaryngology—Head and Neck Surgery. In his spare time, he enjoys spending time with his twin toddlers. References on page 22.

MARCH 2014 SAN FRANCISCO MEDICINE

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Specialists Share the Latest Trends

ULTRASOUND GUIDANCE Many Uses for Interventional Pain Procedures Justin McKendry, MD Ultrasound guidance for interventional pain procedures is a rapidly growing field. There are increas-

ing numbers of published articles describing the technique, as well as workshops to train practitioners.

Ultrasound has several advantages over traditional nerve blocks.

Ultrasound is precise. It enables direct visualization of the targeted structure. Nerves, muscles, vessels, tendons, and tissue planes are visible with ultrasound. Traditional targeting of these structures is blind, depending upon the target’s relation to palpated landmarks or bony landmarks visualized with fluoroscopy.

Ultrasound enables expeditious diagnosis and treatment. Direct visualization of the targeted structure

eliminates questions of “missed” blocks. This diminishes unnecessary repeat procedures. Direct visualization and precise procedures maximize the clinical benefit of the block.

Ultrasound is safer. Direct visualization of nerves and vessels lessens incidence of inadvertent needle injury to nerves or injection into vessels. Direct visualization of the pleura when performing ultrasound-guided intercostal nerve blocks makes a pneumothorax less likely.

Ultrasound is less painful. Traditional nerve blocks frequently use “nerve finders” that electrically stimulate the nerve as the needle comes near. Direct visualization of the nerve lessens the use of painful “nerve finders.”

Ultrasound eliminates ionizing radiation exposure. Traditional nerve blocks frequently use fluoroscopy to

identify bony landmarks or CT to identify the targeted structure. Ultrasound visualization of the target can eliminate the need for fluoroscopy or CT. There are no known harmful effects of standard ultrasound imaging.

Ultrasound is portable. Unlike fluoroscopy or CT, the procedure can be done at the patient’s bedside.

Ultrasound is less expensive than a fluoroscopic or CT-guided procedure. An ultrasound machine is

composed of a console and transducer. The image is viewed and modified on the console. The transducer is placed on the patient and produces the sound waves. Ultrasound uses high-frequency sound waves to create an image of the inWWW.SFMS.ORG

ternal organs. The sound waves are produced in the transducer. An electric current is sent through crystals within the transducer; these crystals vibrate, creating sound waves. The sound waves pass through the body, where they are reflected, refracted, scattered, or absorbed. The waves reflected back to the transducer are converted into electrical signals that create the ultrasound image visualized on the console. The ultra in ultrasound indicates that the frequency of the sound waves is above the frequency audible to the human ear.

Transducers are straight-edged (“linear”) or rounded (“curvilinear”). The straight-edged probes are used for most nerve blocks. The curvilinear probes are lower frequency and allow for visualization of deeper structures. Transducers have adjustable frequencies. The higher the frequency, the better the image quality. The lower the frequency, the deeper the penetration. Color Doppler allows visualization of flow. The flow can be arterial, venous, or injection of fluid from the needle. Red Doppler color flow indicates flow toward the transducer. Blue color Doppler flow indicates flow away from the transducer.

The performance of an ultrasound-guided nerve block begins with proper patient and operator positioning. The patient should be in a comfortable position. The operator’s hands, needle, transducer, and ultrasound screen are in a straight visual line. The skin is disinfected. The transducer is sheathed with a sterile plastic cover. The target is visualized on the ultrasound screen. The needle is inserted and continuously visualized as it is advanced toward the target. Performance of an ultrasound-guided nerve block requires precise knowledge of the anatomical structures visualized and targeted, as well as those to be avoided.

Interventional pain procedures performed with ultrasound guidance include the following:

• For greater and lesser occipital nerve blocks, ultrasound allows avoidance of injection into the occipital artery.

Precise identification of the nerves allows for a smaller injectate volume. Traditional, larger volumes of anesthetic injected into the scalp are painful.

• Stellate ganglion blocks are used to treat sympathetically mediated pain in the arm, head, and upper chest. Ultrasound guidance allows avoidance of the vertebral, carotid, and perforating thyroid arteries.

• Brachial plexus block within the interscalene groove targets the brachial plexus at the level of the roots and results in anesthesia of the shoulder and clavicle. This is useful for

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Ultrasound Guidance Continued from the previous page . . .

Cancer Immunotherapy Continued from page 18 . . .

surgical and postoperative anesthesia.

• Supraclavicular brachial plexus block provides anesthesia for the entire arm beneath the shoulder. Ultrasound guidance lessens the risk of pneumothorax and injection into subclavian vessels.

• Axillary nerve block targets the terminal branches of the brachial plexus. This block is useful for upper limb surgeries.

• Intercostal nerve blocks are useful for intercostal neuralgia, broken ribs, and painful rib metastasis. Ultrasound guidance allows precise targeting of the intercostal nerve and lessens the risk of pneumothorax.

• Femoral nerve blocks can be used for knee surgeries including knee arthroscopy, anterior cruciate ligament repair, and total knee arthroplasty.

• Ilioinguinal and iliohypogastric ultrasound-guided blocks are useful for surgery as well as diagnosis of lower pelvic wall pain.

• Lateral femoral cutaneous nerve ultrasound-guided blocks diagnose and treat lateral femoral cutaneous nerve entrapment or meralgia paresthetica. Ultrasound visualizes the nerve, while traditional technique relies on bony landmarks.

• Piriformis injections allow precise targeting of the piriformis muscle. They are used to treat piriformis syndrome, which is a painful compression of the sciatic nerve.

of cancer patients and promises to be transformative. In addition to the significant advances over the twenty-five years I have been in training and in practice, which include monoclonal antibodies, targeted tyrosine kinase receptor inhibitors, antiangiogenesis agents, and a plethora of chemotherapy, immunotherapy offers the hope of sustained remission for advanced epithelial cancer patients who, until now, would inevitably die of their metastatic disease. The trick will be in identifying which patients will benefit from this, dare I say, potentially curative therapy.

Ultrasound guidance for surgical and interventional pain procedures is a rapidly expanding field. It enables visualization and precise targeting of structures, which facilitates successful blocks and lessens the risk of complications.

Justin McKendry is chief of the Interventional Pain Clinic, Kaiser San Francisco. He is boarded in internal medicine, anesthesia, and pain medicine.

Oral Sex and Throat Cancer Continued from page 19 . . .

References 1. Chaturvedi AK, Engels EA, Pfeiffer RM et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011; 29:4294–4230.

2. Gillison ML, D’Souza G, Westra W et al. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J. Natl Cancer Inst. 2008; 100:407–420.

3. Fakhry C, Westra WH, Li S et al. Improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst. 2008, Feb 20; 100(4):261–9.

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Dr. Bertrand Tuan has practiced hematology and medical oncology at CPMC as part of Pacific Hematology-Oncology Associates since 1994. He was born and raised in the East Bay and after obtaining a biophysics degree at Cal was awarded his MD in 1985 at the Albert Einstein College of Medicine of Yeshiva University in the Bronx. His residency training was at Boston City Hospital, with fellowship training at Massachusetts General Hospital and Brigham and Women’s Hospital. He is a member of the American Society of Clinical Oncology and the American Society of Hematology. His clinical interests include treatment of lung, ovarian, lymphoma, and hepatobiliary malignancy patients, and he has an ongoing interest and practice in coagulation disorders.

References

1. Breaking through cancer’s shield. New York Times. October 14, 2013.

2. In girl’s last hope, altered immune cells beat leukemia.

New York Times. December 9, 2012.

3. Horn et al. Fifteenth World Conference on Lung Cancer (WCLC). Abstract M18.01 (MPL-3280A). October 29, 2013.

4. Ribas A. MD, PhD. Tumor immunotherapy directed at PD-1. N Engl J Med. 2012; 366:2517–2519. June 28, 2012.

SFMS Weighs in on HIV Prevention via Needle Exchange On February 26, SFMS President Lawrence Cheung had this lead letter printed in the San Francisco Chronicle—as noted, SFMS was an early leading voice in favor of this intervention: Regarding “Expiring law reopens debate on clean needles” (cover, Feb. 24), needle/syringe exchange programs have a long history in San Francisco and have been shown to be effective in reducing transmission of disease without increasing drug abuse or other exposure. In fact, although some local physicians at first opposed such efforts, the evidence that they can even encourage drug users to access drug treatment convinced the San Francisco Medical Society to get both the California and American Medical Associations to support these programs. As your story notes, the evidence has continued to build that letting pharmacists dispense clean needles is useful. We thus commend Assemblyman Ting for his legislative efforts to continue and expand such efforts. —Lawrence Cheung, MD, SFMS President

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

Specialists Share the Latest Trends

HOSPITAL MEDICINE Advancing Patient Safety, Care Quality, Communication, and Cost Christopher Moriates, MD Hospital medicine may be the fastest-growing specialty in the history of American medicine, but that

does not mean that everyone knows what a hospitalist really does. In a rapidly changing medical world, the core competencies for hospitalists continue to evolve briskly. Most hospital physicians now do much more than simply take care of adult patients admitted to the hospital. Hospitalists are increasingly expected to take leading roles in advancing patient safety, quality improvement, and health care value—defined roughly as quality divided by costs. Many hospitalists are now “specializing” in the work of process improvement and system redesign. As the New York Times asserted, “Medical experts have come to see hospitalists as potential leaders in the transition to the Obama administration’s health care reforms.”1 Indeed, both the Centers for Medicare and Medicaid (CMS) chief medical officer and President Obama’s nomination for the next surgeon general are both hospitalists.

But hospitalists do not only lead from Washington, D.C.; those of us at the bedside are also integral in this revolution to transform health care and create hospitals that are safer, more efficient, and less wasteful places for our patients to receive care.

“Only the people who give the care can improve the care,” Dr. Donald Berwick, former administrator for CMS, has said.2 And with more than 30,000 hospitalists practicing in the U.S., it is clear that hospitalists are increasingly “the people who give the care,” at least for patients admitted to a hospital.

Although many hospitalists over the past decade have improved care by tackling quality improvement and patient safety initiatives, hospitalists are now increasingly setting their sights on communication, patient satisfaction, and decreasing costs by cutting out waste. Some of these efforts are driven by federal policies of the Affordable Care Act. Under the new law, hospitals are penalized for readmissions and certain medical errors. In addition, Medicare reimbursements are also now tied to patient satisfaction. As hospital administrators scramble to ensure they meet these new metrics, hospitalists are clearly on the front lines of efforts to address these issues.

At the University of California, San Francisco (UCSF) Medical Center, hospitalists have introduced and led programs aimed at improving communication and health care value. With so many clinicians now simultaneously taking care of patients during a hospitalization, one study showed that less than 25 percent of hospitalized patients could name anyone when asked to identify the physician in charge of their hospital care.3 To combat this problem, our hospitalist group created “face cards” featuring a picture of the physician and a brief description of their role and training background (think baseball cards for doctors). The program has been met enthusiastically by both patients and physicians and has now been adopted by the Medical Center to be rolled out to all departments.

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We have also created initiatives focused on defraying medical costs primarily by decreasing unnecessary services. Did you know that currently up to 30 percent of all health care spending in the U.S. may be wasted?4 On a national scale, this is money that takes away from other national priorities such as education, infrastructure, business, research, and useful health programs.

Hospitals are a primary source of these unsustainable health care costs. At UCSF, we recently created a High-Value Care program within our Division of Hospital Medicine. The program uses financial data to identify areas with clear evidence of waste in the hospital and then ensures that interventions are based on a high standard of current evidence and that they improve the quality of care. We pair interventions with evidence-based cost awareness education to drive culture change. The group identified six ongoing projects during the first year, targeting unnecessary transfusions, certain lab tests, telemetry, gastric stress ulcer prophylaxis, repeat inpatient echocardiograms, and nebulizer bronchodilator therapies. Preliminary data for our inaugural projects are encouraging, with nebulizer treatment rates decreased by more than 50 percent on the pilot medical unit.5 The High-Value Care program is proving to be a successful hospitalist-led mechanism to promote improved health care value and to further engage clinicians in this effort. We have heard from other hospitalist groups around the country that are developing similar programs at their medical centers. There have been many advances in the evidence-based clinical practice of hospital medicine, but some of the most significant progress in recent years is likely due to hospitalists’ commitment in improving care processes and systems for our patients.

Christopher Moriates, MD, is with the Division of Hospital Medicine, University of California at San Francisco.

References 1. Gross J. New breed of specialist steps in for family doctor. The New York Times. http://www.nytimes.com/2010/05/27/us/27hosp. html. Published May 26, 2010.

2. Berwick DM. The moral test. 2011. Available at http://www.ihi.org/ knowledge/Pages/Presentations/TheMoralTestBerwickForum2011Keynote. aspx.

3. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009; 169(2):199–201. doi:10.1001/archinternmed.2008.565.

4. Institute of Medicine. Committee on the Learning Health Care System in America. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, D.C.: National Academies Press; 2012.

5. Moriates C, Novelero M, Quinn K, Khanna R, Mourad M. “Nebs no more after 24”: A pilot program to improve the use of appropriate respiratory therapies. JAMA Intern Med. 2013. doi:10.1001/jamainternmed.2013.9002.

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SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

Specialists Share the Latest Trends

ULTRASOUND IN THE ED Rise in Emergency Department Use Aparajita Sohoni, MD Did you know that ED physicians use ultrasound for nerve blocks and joint aspirations/injections?

The rise in the use of ultrasound at the bedside in emergency departments (EDs) by emergency physicians (EPs) in the last twenty years is a well-known fact. But did you know the extent to which EPs are being trained to use ultrasound technology? Now hailed as the “stethoscope of the future,” ultrasound in the ED has extended from simple FAST exams and bedside ECHOs to nerve blocks and joint aspirations/injections.

Using ultrasound guidance, certified EPs can rapidly identify and introduce a local anesthetic around a nerve, thereby providing precise anesthesia targeted to a specific injury or procedural need. All that without running into side effects or the dreaded inadequate coverage that often results from parenterally administered medications. While you may be used to ED practitioners doing ultrasound-guided radial, median, and ulnar nerve blocks, and possibly also brachial plexus blocks, these represent only the beginnings. More advanced ultrasound practitioners are also getting comfortable with the superficial cervical plexus block for placement of internal jugular central lines, or pain relief from the clavicle fracture, not to mention ear lobe abscesses. Abdominal wall abscesses can be drained with a precisely placed transabdominal plane (TAP) block. And say good-bye to painful injuries or procedures in the leg or foot with artful blocks of the femoral, sciatic, tibial, common peroneal, and/or posterior tibial nerves.

Ultrasound guidance is also increasingly being used for diagnosing the presence of a joint effusion and, when present, to guide arthrocentesis and joint injections. For example, appropriately trained providers can use ultrasound to determine whether an ankle is swollen because of fluid accumulating in the joint or simply due to swelling of overlying soft tissue. Ultrasound guidance can make arthrocentesis of the ankle, knee, hip, and shoulder a stress-free and rapid procedure, with good visualization of surrounding vascular and nerve structures. Real-time guidance of the needle into the joint has also opened up the realm of accurate joint injections—such as steroid injections into the hip—as valid treatment options that the EP can provide (in appropriate patients). Lastly, ultrasound-guided shoulder joint injections are an effective option for shoulder dislocations. After having had an anesthetic agent directly injected into the dislocated joint, the patient often feels complete relief and self-reduces the joint.

The uses of ultrasound in the ED are definitely on the rise. The draw of ultrasound is not only the increased safety—for both patient and provider—but the increased efficacy of nerve blocks and procedures when performed with realWWW.SFMS.ORG

time guidance. EPs who are trained in ultrasound provide a valuable service to their emergency departments and patient communities.

Aparajita Sohoni, MD, is an emergency physician at California Pacific Medical Center. She completed medical school at Stanford University and residency in emergency medicine at Alameda County Medical Center—Highland Hospital. She also completed a fellowship in ultrasound at Highland Hospital in 2011. Her areas of interest include nerve blocks, ultrasound education, and evolving pediatric applications. She teaches ultrasound courses to emergency medicine groups in California, at national conferences, and internationally.

Learn how your business tax will be changing.

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2014 SAN FRANCISCO MEDICAL SOCIETY

Annual Gala Annual Dinner Sponsors 2014 San Francisco Medical Society

JOIN THE SFMS AS WE GRATEFULLY SUPPORT OFjoined THESE DEDICATED PARTNERS More than 170 physicians and influentialACKNOWLEDGE stakeholders in the THE medical community in on the SFMS Annual Gala festivities on January 16, 2014. Held at the Asian Art Museum, the event marked SFMS’ 146th year as the only physiTHANKS AND ACKNOWLEDGMENTS TO inSPONSORS cian association that advocates for physicians across all specialties and their patient San Francisco. Attendees were able to network with colleagues, meet SFMS leaders, and enjoy a private viewing of the Asian Art Museum’s collection galleries.

SFMS would like to thank our members, sponsors, and special guests Senator Leland Yee, Supervisor David Chiu, Supervisor Scott Wiener, and CMA President Richard Thorp for their support of this event and SFMS. Left: 2014 SFMS officers from left to right: Richard Podolin, secretary; Gordon Fung, editor; Shannon Udovic-Constant, immediate past president; Lawrence Cheung, president; Man-Kit Leung, treasurer; Roger Eng, president-elect.

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Immediate past president passing on the gavel to incoming president Lawrence Cheung.

Supervisor David Chiu addressing gala attendees

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SAN FRANCISCO MEDICINE

Chinese Hospital Medical Staff Mercer Sutter Health CPMC MARCH 2014 WWW.SFMS.ORG

Pictured above: guest enjoy a lovely evening at the Asian Art Museum.

Right: Roger Eng and Linda Tang Bottom right: Lawrence Cheung, Mary Lou Licwinko, Senator Leland Yee Bottom left: Jennifer Do, James Chen, Vanessa Kenyon All photos courtesy of: the Asian Art Museum of San Francisco and Deborah Welsh Productions

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UCSF students Daniela Maristany, Sarah Cheng, Erin Duralde with physician mentors Gary Chan and James Constant

Above: Liyun Li, Isabelle Ryan, Michael Moores, and Rachel Shu Left: George Fouras, Liz Ziemann, Shannon UdovicConstant

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SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

On behalf of the SFMS Board of Directors, we wish to acknowledge and give special thanks to Dr. H. Hugh Vincent for representing SFMS so diligently as CMA Trustee from 1997-2003 and AMA Delegate from 1996-2013, as well as SFMS President in 1992.

Right: Hugh Vincent, MD, was recognized for his dedication to organized medicine and seventeen years of service as the SFMS representative to the AMA Bottom right: Payal Bhandari and Albert Peng Bottom left: Supervisor Scott Wiener and John Maa

SFMS past and present presidents from left to right: Shannon Udovic-Constant, Michael Rokeach, William Goodson, Hugh Vincent, Toni Brayer, Lawrence Cheung, George Fouras, R. Dennis Collins, Stephen Walsh, Charles Wibbelsman

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Left to righ: Leslie Preger, Wayne Fung, and Richard Bohannon

Congratulations Fifty-Year Members!

The SFMS honored three fifty-year members at the Annual Gala, Richard Bohannon, Wayne Fung, and Leslie Preger. These physicians have made tremendous commitments to provide quality health care for the San Francisco community. The SFMS extends our sincere and heartfelt thanks to these members for their devotion to provide accessible and quality health care in San Francisco, and for their continued support of the local medical society. The SFMS is honored to have had these outstanding physicians as member for the past half of a century.

Leslie Preger, MD

Dr. Leslie Preger was board certified in “Radiology” in 1964 when Radiology included Diagnostic Radiology as well as Radiation Therapy and Nuclear Medicine. He also board certified in radiology in Dublin at the Royal College of Surgeons of Ireland and in London at the Royal College of Radiologists. During his distinguished career, Dr. Preger chaired the Radiology Clinical Faculty at UCSF, served as a member of the UCSF Radiology Department committee and as an occasional member of the UCSF Executive Committee.

Wayne E. Fung, MD

Dr. Wayne E. Fung is a board certified Ophthalmologist. He became interested in Ophthalmology while being trained to be a flight surgeon

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in the U.S. Air Force. He completed his residency at the then Pacific Presbyterian Medical Center, San Francisco, and fellowships in retinal surgery at Washington University in St. Louis and the University of Miami. Dr. Fung began his practice at the California Pacific Medical Center in 1968 and continues to serve in the Department of Ophthalmology at CPMC to this day. Dr. Fung was selected to be the personal Ophthalmologist of President Chieng Ching Quo, President of Taiwan, from 1980 to 1988 and made 35 round trips during those 8 years. Other highlights of his long and illustrious career include serving as President of the Retina Society from 1991 to 1993 and being awarded the Life Achievement Award of the American Academy Of Ophthalmology in 2012.”

Richard A. Bohannon, MD

Dr. Richard Bohannon has been on the medical staff at CPMC for the past 50 years, practicing internal medicine and medical oncology.

He served for a decade on the National Board of the American Cancer Society, as well as President of the California Division of the American Cancer Society. Other highlights of his career include serving as President of the Association of Northern California Oncologists and as a member of the Board of Trustees of the SF Conservatory of Music for 23 years. He is still hoping to have golf score that matches his age.

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Kathleen Jordon and Harris Goodman

Ashley and Paul Turek

Leslie and Robert Purchase

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Justin Quock and John Umekubo

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Shannon Udovic-Constant is presented with California State Assembly proclamation by Walt Donner, field staff for Assemblymember Phil Ting

CMA Senior Vice President Janus Norman

Man-Kit Leung, Gary Chan, Andrew Snyder, Robert Waters

Lisa Tang and Robert Mithun

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SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

2014 SAN FRANCISCO MEDICAL SOCIETY

Annual Gala Annual Dinner Sponsors 2014 San Francisco Medical Society

JOIN THE SFMS AS WE GRATEFULLY ACKNOWLEDGE THE SUPPORT OF THESE DEDICATED PARTNERS

THANKS AND ACKNOWLEDGMENTS TO SPONSORS

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Chinese Hospital Medical Staff Mercer Sutter Health CPMC

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Roof, Eidam & Maycock, LLC

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Special thanks to Saint Francis Memorial Hospital for providing meeting space and parking for the 2014 SFMS board meetings.

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MEDICAL COMMUNITY NEWS UCSF

Michael Gropper, MD

SFVAMC

Diana Nicoll, MD, PhD, MPA

SUTTER PACIFIC MEDICAL FOUNDATION Bill Black, MD, PhD

Other than skin cancer, prostate cancer is the most commonly diagnosed cancer among men. According to the Centers for Disease Control and Prevention, after lung cancer, prostate cancer is the leading cause of cancer death among American men.

More than one-third of these patients receive androgen deprivation therapy (ADT).

The goal of this treatment: to reduce the levels of testosterone and dihydrotesterone in the body, causing the cancer to shrink or grow more slowly. In many patients, ADT also improves the effectiveness of radiation therapy.

While androgen deprivation therapy (ADT) is an extremely effective treatment for prostate cancer, it causes various side effects related to decreased testosterone levels, including fatigue, hot flashes, decreased libido, and decreased erectile function. It is also associated with weight gain, loss of muscle mass, and an increased risk of diabetes.

Historically, the focus has been primarily on the treatment of the cancer itself, while management of side effects has taken a back seat. The new UCSF STAND (Supportive Therapy in Androgen Deprivation) Clinic, however, is one of the first of its kind that provides comprehensive care to prostate cancer patients who have started hormone therapy.

This approach represents an important and, until recently, unmet need for patients.

Through screening and intervention aimed at preventing treatment-related morbidity, many side effects of ADT can be effectively addressed, prevented, and treated. For example, hot flashes can be helped by treatment with certain antidepressants. There are several different drugs available to prevent and treat osteoporosis. Depression can be addressed through medication and counseling. Exercise and nutrition counseling can also help reduce many side effects, including fatigue, weight gain, and loss of bone and muscle mass.

For more information about the STAND Clinic, visit www.ucsfhealth.org/clinics/ stand.

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Bone formation is an ongoing process.

Even after skeletal maturity, bone is in a constant state of rebuilding, with old bone replaced by the formation of new bone. Skeletal health depends on this process, and in the setting of injuries—a broken bone, for example—these bone-remodeling pathways are beneficial and come into play to heal injuries.

Sometimes, however, this normal process is disrupted, leading to either failure of bone healing or to excess bone formation.

Excess bone formation where it is not necessary—often in the muscles or around joints— is called heterotopic ossification. This excess bone formation can lead to pain, joint stiffness, and loss of function, and, once formed, it can currently only be removed surgically.

Heterotopic ossification, which traditionally was thought to be a rare occurrence, has become an increasingly important issue in the veteran population who had service in Iraq and Afghanistan. Research has shown an association of heterotopic ossification with blunt muscle trauma, as well as with spinal and head trauma, which are common among injured veterans. Those who now survive severe skeletal injuries caused by improvised explosive devices, because of more timely and sophisticated medical care than was available in prior conflicts, may develop heterotopic ossification. Currently the treatments for heterotopic ossification are limited, involving surgery after its formation, medications with side effects, or radiation therapy.

At the San Francisco VA Medical Center, we have active research programs involved in elucidating the pathways for heterotopic ossification, using injury models that are relevant to these multisystem combat injuries.

As we learn more about the mechanisms for excess bone formation in heterotopic ossification, we hope to be able to devise therapies to prevent its development after severe traumatic injuries.

Liver disease, especially chronic hepatitis C (HCV) and non-alcoholic fatty liver disease (NAFLD), is increasing in prevalence in the United States. Sutter Pacific Medical Foundation (SPMF) hepatologists and liver transplant surgeons manage all manner of liver disease and their sequelae. HCV and NAFLD are forming an increasingly sizeable fraction of the diagnoses they see. The CDC estimates about 3.2 million people in the United States have chronic HCV. Dr. Raphael Merriman, SPMF Hepatologist, points out that due to increases in diabetes and obesity, “NAFLD has emerged as the most prevalent liver disease in the U.S., affecting 17 percent to 30 percent of the population.” He reminds us that “NAFLD represents a histologic spectrum extending from simple steatosis or excess fat alone to necroinflammation with variable degrees of fibrosis, such as nonalcoholic steatohepatitis, to frank cirrhosis.”

Treatment for the conditions is evolving.

Dr. Robert Osorio, SPMF surgeon, and Chairman of the California Pacific Medical Center Barry S. Levin, MD, Department of Transplantation, notes that, “with new therapy for HCV available, it is now more important that all patients be evaluated by a hepatologist or gastroenterologist for treatment of HCV.” Dr. Merriman cited the “numerous therapeutic clinical trials ongoing for NAFLD and its variants, with the NIH FLINT trial showing promising preliminary data using the farnesoid X receptor (FXR) agonist obeticholic acid.” SPMF treatment for these conditions includes liver transplant. Dr. Osorio points out that “HCV is currently the most common indication for transplant, and more NAFLD patients are being transplanted.”

Dr. Merriman agrees. “While cirrhosis and HCC associated with NAFLD are currently the third most common indication for liver transplantation in the U.S., within a decade it will become the dominant indication.” Dr. Merriman and his hepatologist colleagues see patients at twelve different locations in northern California and Nevada, including a dedicated NAFLD clinic in San Francisco. Dr. Osorio and team perform about seventy liver transplants annually.

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

CPMC

Edward Eisler, MD

Dr. Martin Brotman, Sutter Health’s senior vice president of education, research, and philanthropy, has announced his plans to retire at the end of 2014, after a career spanning decades of leadership in patient care, medical education, health care administration, philanthropy, and community leadership. In his remaining year with us, Dr. Brotman will focus primarily on the Sutter research enterprise and graduate medical education. Dr. Brotman has been part of the San Francisco health care fabric since the mid-1960s, when he began practicing gastroenterology and internal medicine—a practice he maintained for more than forty-five years.

A special interest in health care administration led Dr. Brotman to serve as CEO of California Pacific Medical Center in 1995, and from 2009 to 2011 he oversaw Sutter Health’s West Bay Region. In 2012, the San Francisco Business Times named Dr. Brotman a “Hero in Health Care” for his lifetime contributions to our industry.

Congratulations to Dr. Lawrence Feld, who has been appointed acting chair, Department of Anesthesiology. Dr. Feld assumed the role previously held by Dr. Edward Eisler, who was elected chief of staff. Dr. Oded Herbsman will replace Dr. Eisler as chair of the Quality Improvement Committee.

Dr. Aravind Mani will lead CPMC’s Project RED (Re-Engineered Discharge) training program, which is designed to help hospitals reengineer their discharge process. A collaboration between the Agency for Healthcare Research and Quality (AHRQ) and Boston University, the program employs a variety of tools that hospitals can use to ensure that patients have adequate support to manage their transition from hospital to home. The target audience identified for the project will be patients at highest risk for readmission. A risk assessment model is being developed for implementation of a pilot program to be launched at the Pacific campus in March 2014.

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SAINT FRANCIS

ST. MARY’S

Robert Harvey, MD

Robert Weber, MD

For doctors and patients alike, the publication last month of results from a long-term Canadian study on the role of mammograms in reducing breast cancer deaths only added opacity to the issue’s already muddy waters.

As experts continue to argue all sides of the whens, whys, and wherefores of breast imaging, it can be difficult for physicians to figure out a firm position.

To this end, St. Mary’s offered a seminar in February designed to shed a little light on the subject for primary care physicians. Radiologist David Priest, MD; surgeon Pamela Lewis, MD; and internal medicine specialist Diana Hilbert, MD; tackled the topic of when to use whole breast ultrasound, tomosynthesis, and MRI in breast screening. While their panel did not specifically address the use of mammography, it did provide physicians with guidelines on when and whether to take imaging to the next level.

The symposium included a discussion by our new genetic counselor Julie Mak on how to identify patients at risk of breast cancer who might benefit from genetic counseling and testing.

We also offered a multidisciplinary discussion on surviving cancer and late-term side effects, which I led along with radiation oncologist Sara Huang, internal medicine specialist Ruth Marlin and oncology nurse navigator Cheri Goudy.

St. Mary’s Medical Center—like every other health care provider in the nation and beyond—can’t settle the debates that are raging over breast cancer diagnosis and treatment. But we are proud to have a role in sharing the best information available, and providing a forum where physicians bombarded with conflicting reports don’t have to grapple with them alone.

For the next six months, Saint Francis Memorial Hospital is offering our orthopedic surgeons a chance to delve a little deeper into the world of robotic technology and provide their patients with a more accurate and less invasive alternative to knee replacement surgery.

Our Total Joint Center has contracted with Blue Belt Technologies to offer its handheld robotic surgery system—called the NavioPFS—through August. We are excited about this arrangement, which makes Saint Francis the only hospital in the region to provide access to this technology.

Both patients and surgeons stand to benefit from this system, which was FDA approved last year. The robotics-assisted technology allows motion sensors to capture movement and bone structure images, which are then mapped by computer, providing surgeons with far more accurate information needed to align knee implants. Since partial knee replacement preserves healthy ligaments, bone, and cartilage often lost in total replacement procedures, patients benefit from less post-op pain and quicker recovery.

We encourage interested physicians in the community to participate in education and training for this unique opportunity. Expanding our comfort level with robotic technologies will only help us as the field of orthopedic surgery continues to be revolutionized. *** Before I conclude, I wanted to take a moment to extend my gratitude and best wishes to Tom Hennessy, who served as Saint Francis’s president and CEO for eight years. We all wish him success and enjoyment in his retirement. During his tenure, Tom’s strength of character and focus was a guiding light for our hospital, our patients, community, and staff, and we are very grateful for his service to Saint Francis.

I’d also like to welcome aboard Dr. Hugh Vincent, who will serve as our interim president and CEO until a permanent replacement is selected.

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To make an appointment, call us at 1-888-393-4483 or visit www.bloodcenters.org 36

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

San Francisco Medical Society Advocating for Physicians and Patients The San Francisco Medical Society (SFMS) has been a champion for community health issues since its inception in 1868. As the only medical association in San Francisco representing the full range of medical specialties and interests, many projects and activities that have begun here have gone on to have implications for the state and the nation. Beyond the broad and deep resources devoted by the CMA to representing physicians in the halls of state politics and in providing many useful practice management resources, here are some highlights from the SFMS community health agenda.

SFMS Community Health Activities

Universal Access to Care: SFMS leaders have long advocated

that every San Franciscan should have access to quality medical care, with ongoing, vigilant efforts to preserve programs and prevent cuts in Medi-Cal reimbursement. Our representatives served on the Mayoral Task Force that designed the Healthy San Francisco program, and SFMS joined in the lawsuits to preserve that program as well.

SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s.

Anti-Tobacco Advocacy: SFMS advocates were in leadership

roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies.

HIV Prevention and Treatment/Hepatitis B: The SFMS

was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more. SFMS is a partner in the Hep B Free program in San Francisco and in educating physicians and patients on prevention and treatment of hepatitis B.

Schools and Teen Health: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards; it provides ongoing medical consultation to the SFUSD school health service.

In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent.

Environmental Health: SFMS’s many efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures.

Reproductive Health and Rights: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medically indicated services.

WWW.SFMS.ORG

End-of-Life Care: SFMS leaders have developed numerous

policy and educational efforts to improve care toward the end of life, including promulgation of the Physicians Orders for LifeSustaining Treatment medical order.

Rebuilding and Preserving San Francisco General Hospital: SFMS spokespersons took a lead in both advocating for

full funding of the seismic rebuild and acting on the mayoral committee to advise where and how that would best occur.

Blood Supply: SFMS has long been a partner of the Blood Centers of the Pacific and continually seeks to help increase donations there.

Organ Donation: SFMS has been a leader in seeking improved donation of organs to decrease waiting lists due to the shortage of organs, via education and new polices regarding consent and incentives for organ donation.

Operation Access: SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds.

Drug Policy: SFMS has been a leader in exploring and advocat-

ing new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration. We were integral in the development of the CMA’s landmark report on decriminalization and regulation of cannabis.

Medical Ethics: SFMS has developed and promulgated forwardlooking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public.

Partnerships: SFMS works closely with many local specialty and health organizations, such as the San Francisco Department of Public Health, San Francisco Emergency Physicians Association, San Francisco Pediatric Council, San Francisco Community Clinic Consortium, West Bay Hospital Conference, Chinese Community Health Care Association, and others.

“I was an SFMS member for almost fifty years until I retired and always saw them as an important and often progressive voice in organized medicine on many crucial issues.” —Philip R. Lee, MD, UCSF Chancellor Emeritus and U.S. Secretary of Health “The SFMS helped save the Haight Free Clinic from the start, and I’ve been a loyal member ever since. So much of state and national impact has come from here and the SFMS has helped in many ways.” —David Smith, MD, founder, Haight-Ashbury Free Medical Clinics SFMS: An advocate for physicians and their patients MARCH 2014 SAN FRANCISCO MEDICINE

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PUBLIC HEALTH UPDATE

UPCOMING EVENTS

ELECTRONIC CIGARETTE ROULETTE

3/18 CME Program: Bioethics Education Forum Brain Death is Death: Determining Death Using Brain Criteria March 18, 6:00 p.m. to 7:30 p.m.

California Pacific Medical Center—PAC Campus RSVP for this event is required. Please contact Antonio at (415) 600-1647 or krugera@sutterhealth.org.

Steve Heilig, MPH San Francisco prides itself on staying “ahead of the curve” on healthrelated policies. This has especially been true with respect to tobacco – from banning use in restaurants and businesses to many other healthy advances. But we’ve already fallen behind on regulating “electronic cigarettes”, or e-cigs, and it’s time for our officials to catch up.

Our board of supervisors is now considering regulating e-cigs to bring them in line with regular tobacco products – allowing use of them only where tobacco is used, restricting where they can be sold, a requiring a tobacco permit for sale. This is actually a conservative proposal – the European Union just approved e-cig rules that would also ban all advertising, limit nicotine content, and require graphic warnings on all e-cig products. Many other cities, including even Los Angeles, are ahead of San Francisco in this regard as well.

Why is regulating e-cigs important? E-cig advocates hold that these nicotine delivery devices are mostly intended to help tobacco smokers quit. Such positive “harm reduction” use does occur – and the proposed regulations would not deter such use in any way.

However, real concerns about e-cigs are growing. As with tobacco, carcinogens, other toxins, and addictive substances such as nicotine are present in e-cigs, and not only users but others are exposed via second-hand “vapors.” Even more troubling, use among young people – many who are not tobacco smokers – is rapidly rising. Use by teens has doubled recently, with e-cigs increasingly feared to be initiating youth into smoking. Heavy e-cig advertising focused on youth is rampant.

All of this is really no surprise, as the big tobacco companies have been heavily investing in e-cig products and using their wellknown tactics to promote these products. Dr. Jonathan Fielding, director of the Los Angeles Department of Public Health says “We don’t want to risk e-cigarettes undermining a half century of successful tobacco control.” The California Medical Association holds that e-cigs should be regulated like tobacco (below).

Thus, San Francisco Supervisors are well-advised to follow the lead of other nations and cities and a growing professional consensus that e-cigs need much stricter regulation. And they’d be equally well-advised to question anybody opposing such regulations regarding their links to the e-cig and tobacco industries as well. Clearing the smoke – even if it’s called “vapor” – in such proceedings is always a good idea.

CALIFORNIA MEDICAL ASSOCIATION, 2011 Regulation of Electronic Cigarettes

Authors: George Fouras MD, Tomas Aragon MD, Steve Heilig MPH

RESOLVED, that the CMA will support policies that prohibit the use of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids in those places where smoking is prohibited by law, and that will require a tobacco permit for the sale or furnishing of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids.

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3/24: Soda Tax Measure Medical Community Town Hall Meeting March 24, 6:00 p.m.

Morrissey Hall at St. Mary’s Medical Center, 2250 Hayes Street

4/11-13: Western Health Care Leadership Academy (formerly known as the California Health Care Leadership Academy) April 11-13, 2014 San Diego Convention Center The 17th Annual Western Health Care Leadership Academy continues its mission of providing information and tools needed to succeed in today’s rapidly changing health care environment. Hear from the experts and leaders of change, and attend a comprehensive slate of practice management seminars and workshops to position your practice for success. Topics include leadership development, ACA implementation, ICD-10 transition, and practice management. Former Secretary of State Hillary Rodham Clinton is confirmed to give the keynote address. Visit http://www.westernleadershipacademy.com/ for event details.

4/22: Legislative Leadership Conference/Lobby Day Join SFMS for the CMA Legislative Leadership Conference on April 22 in Sacramento. Members have the unique opportunity to participate in advocacy training and network with colleagues throughout California at this annual event.

This year, to better facilitate meeting with legislators, the agenda has been restructured to provide members with both morning and afternoon appointments to meet with their elected representatives.

The meetings are scheduled and coordinated by local county medical societies.

This event is offered at no cost to SFMS members. Plan to join more than 400 physicians, medical students and CMA Alliance members who will be coming to Sacramento to lobby their legislative leaders as champions for medicine and their patients.

Please email SFMS at membership@sfms.org or call (415) 5610850 if you would like to attend this event.

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.

• March 19: Should I Join an ACO? | 12:15 p.m. to 1:15 p.m.

• March 26: Physician Practice Options: Self Employed vs. Group Affiliation | 12:15 p.m. to 1:15 p.m.

• April 23: Surviving Covered California: What Physicians Need to Know | 12:15 p.m. to 1:15 p.m.

• April 30: Stage 2 Meaningful Use/2014 Edition: What You Need to Know | 12:15 p.m. to 1:15 p.m.

SAN FRANCISCO MEDICINE MARCH 2014 WWW.SFMS.ORG

A financial safety net for you—

AND THE ONES YOU LOVE 10- AND 20-YEAR LEVEL TERM LIFE No matter where you are in life, SFMS Group Level Term Life Insurance benefits can be an affordable solution to help meet your family’s financial protection needs.

Mercer and SFMS leveraged the buying power of your fellow members to secure dependable and affordable life insurance benefits at competitive premiums from ReliaStar Life Insurance Company, a member of the ING family of companies.

With quality life insurance benefits extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plans.

As a member, you can conveniently help protect your family’s financial future with the Group 10-Year and 20-Year Level Term Life Plan.

It features: • Benefits up to $1,000,000 • Rates that are level for 10 or 20 full years* • Benefit amounts that never change provided premiums are paid when due

See For Yourself: Get more information about your Group 10-Year and 20-Year Level Term Life Plans, including eligibility, benefits, premium rates, exclusions and limitations, and termination provisions by visiting www.CountyCMAMemberInsurance.com or by calling 800-842-3761.

Underwritten by:

Sponsored by:

Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

65409 (3/14) Copyright 2014 Mercer LLC. All rights reserved.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 90 days’ advance written notice.

The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

EXPERTS INSPIRED BY TECHNOLOGY, STILL PICKING UP THE TELEPHONE At Sutter Health’s California Pacific Neuroscience Institute, our team is at the leading edge of technology and research. Our neurosurgery team uses a new technique to remove pituitary tumors and reduce the risk of complications such as CSF leakage.

Additionally, our center was the largest enroller in the clinical trial of a new deep brain stimulator device for epilepsy, recently approved by the FDA. Like all our experts at CPMC, we communicate to build relationships, so we can return patients to your care in a state of better health. It’s one more way we plus you.

cpmc.org/cpni