March 2015 by San Francisco Marin Medical Society

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

IMAGING 3.0

THE NEW FACE OF RADIOLOGY

Radiation Safety Patient-Centered Care Advances in Breast Imaging

Plus: Highlights from the SFMS Annual Gala

VOL.88 NO.2 March 2015

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IN THIS ISSUE

SAN FRANCISCO MEDICINE March 2015 Volume 88, Number 2

Imaging 3.0 FEATURE ARTICLES

MONTHLY COLUMNS

9 What Is Imaging 3.0? The New Face of Radiology Geraldine McGinty, MD, MBA, FACR

Membership Matters

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President’s Message Roger S. Eng, MD, MPH, FACR

13 Improving Safety: Better Imaging Safety for Better Patient Care Nathaniel E. Margolis, MD 15 Patient-Centered Care: What Does This Mean for Radiology Patients? Jennifer L. Kemp, MD

17 Supercomputers in Radiology: What Do We Need in Order to Take Watson to the Clinic or Bedside? Eliot Siegel, MD

20 Advances in Breast Imaging: Mammography and Much More Bonnie N. Joe, MD, PhD

30 Medical Community News 34 Upcoming Events

OF INTEREST 22 SFMS Annual Gala 32 SFMS Student Activism: UCSF Medical Students Champion CMA Priority Bills at State Capitol Robert Orynich, MS1 33 Take Tobacco Out of Baseball

Welcome New Members PHYSICIANS Daniel P. Choi, MD | Internal Medicine Mimansa Geere, MD | Pathology Eli F. Merritt, MD | Psychiatry Ruchi Puri, MD | Obstetrics and Gynecology Trudy K. Singzon, MD | Family Medicine Melissa Slivka, MD | Pediatrics Stacy Joan Uybico, MD | Radiology RESIDENTS Benjamin A. Laguna, MD | Radiology STUDENTS Daniel Harrison Copeland Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Champions Access to Care for All San Franciscans; Assemblymembers David Chiu and Phil Ting to Coauthor Legislation for MediCal Reimbursement Increase

out California at this annual event. SFMS/CMA Lobby Day is an excellent opportunity to learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands-on experience in the practical aspects of physician advocacy. This one-day event includes education sessions on effective advocacy and lobbying techniques, briefings on legislative issues currently before Congress from CMA’s Government Relations team, and meetings with Senator Mark Leno as well as Assemblymembers David Chiu and Phil Ting. The event is free to all members. Visit http://www.sfms. org/events/lobby-day.aspx for event details and registration.

SFDPH Health Advisory: Measles Update SFMS is part of the CMA-led “We Care for California” coalition for increased Medi-Cal reimbursements. In order to ensure that Californians have real access to care, the coalition is advocating for a permanent increase of Medi-Cal rates to Medicare levels. SFMS leaders met with Senator Mark Leno as well as Assemblymembers David Chiu and Phil Ting in February to discuss accessible health care for all Medi-Cal patients. A recent study by the California Healthcare Foundation found fewer than 50 primary care physicians per 100,000 Medi-Cal enrollees, below the federal guideline of 60 to 80. Medi-Cal pays approximately half of what Medicare pays for the same services. For a primary care visit, a physician receives $16 from Medi-Cal as compared to $45 from Medicare. Assemblymembers Chiu and Ting have joined in the fight to increase Medi-Cal reimbursement rates to ensure that patients have real access to real care. They agreed to coauthor a bill to increase Medi-Cal rates after meeting with SFMS.

3/25: SFMS Member Networking Mixer

Networking is ranked as one of the most valuable services provided by SFMS. To realize the full power of networking, SFMS will co-host a series of networking events with the Cooperative of American Physicians that will help members connect in a relaxed, no-agenda format aimed only at networking. It’s a great way to meet fellow SFMS members from the local community and share your experiences. The next mixer is scheduled for March 25. Please note that this is a member-only event. Additional information is available at http://www.sfms.org/Events.aspx.

Become a Champion of Medicine, Participate in the 4/14 SFMS Lobby Day

Join SFMS for the CMA Legislative Leadership Conference on April 14 in Sacramento. Members have a unique opportunity to gain advocacy training and network with colleagues through4

California has been experiencing a measles outbreak, with at least fifty-nine confirmed cases of this airborne, highly contagious disease. Although no measles cases have been reported in San Francisco residents in 2014 or so far in 2015, a Contra Costa County resident rode BART to San Francisco and worked in San Francisco February 4–6, 2015, during his/her infectious period. Measles should be considered in patients presenting with fever and morbilliform or maculopapular rash. Suspected measles cases should be reported immediately to the SFDPH Communicable Disease Control twenty-four-hour line at (415) 554-2830. Please visit http://bit.ly/1vw9YMT for the SFDPH clinician guide.

Member-Only ICD-10 Transition Resources

With less than a year until the October 1, 2015, implementation date for ICD-10, physicians should be evaluating the readiness of their practices to transition to the new code set. SFMS/ CMA members have exclusive access to tools to help physicians and their practices prepare for ICD-10 at http://bit.ly/1zMnXsE.

Open Payments Database Available for Physician Review

The Open Payments database is available to physicians to review records provided by drug and medical device companies. The Open Payments database is part of the Physician Payments Sunshine Act, a provision of the Affordable Care Act. Drug and medical device manufacturers are required to report their financial interactions with licensed physicians, including consulting fees, travel reimbursements, research grants, and other gifts. Any payments, ownership interests, and other “transfers of value” will be reported to CMS for publication in the online database. In June, 2014 payment data and updates to 2013 data will be published. SFMS encourages physicians to register for the Open Payments portal to review and dispute any incorrect data. Physicians should be aware that there is a two-step registration pro-

SAN FRANCISCO MEDICINE MARCH 2015 WWW.SFMS.ORG

cess for the Open Payments program. Step 1 requires physicians to register at the CMS Enterprise Portal, a step many physicians may have already completed as the gateway enables access to a number of other CMS programs. Step 2 is to register in CMS’s Open Payments system.

SFMS Members Meet with Mayor Ed Lee

On January 26, the San Francisco Medical Society joined with the Hospital Council of Northern and Central California to sponsor a reception for San Francisco Mayor Ed Lee. A large number of physicians and members of the Hospital Council were in attendance to hear the Mayor’s remarks on the contributions of the health sector to the San Francisco economy.

California Lawmakers Announce Bill Tightening Vaccination Rules

In light of the recent measles outbreak in California, State Senators Richard Pan and Ben Allen introduced legislation that aims to increase the number of vaccinated children in California. The proposed legislation will abolish an exemption from the mandate that children get vaccinated before they enter school if it conflicts with their parents’ personal beliefs. SFMS applauds Senators Pan and Allen for their efforts for a healthier California. SFMS has previously endorsed AB 2109, which became law in 2012. AB 2109 requires a parent or guardian seeking a personal belief exemption from school immunization to first obtain a document signed by a licensed health care practitioner.

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 has sent out email 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 2014 directory, or if your information is outdated, we encourage you to update your directory entry by contacting SFMS at ayoung@sfms.org or (415) 5610850 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 2015 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) 5610850 extension 200.

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Family Medical Practice for sale. East San Francisco Bay, CA—Multidiscipline practice serving the Asian community. Revenue over $1 million. Multi-language staff; buyer doctor must be fluent in one Chinese dialect. EMR; high profit margin; seller will train buyer in proprietary systems. $682,000. Real estate also available. info@PracticeConsultants.com. (800) 576-6935. www.PracticeConslutants.com. WWW.SFMS.ORG

March 2015 Volume 88, Number 2 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Stephen Askin, MD Erica Goode, MD, MPH Payal Bhandari, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, 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 Coordinator Ariel Young

BOARD OF DIRECTORS Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, 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

Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

MARCH 2015 SAN FRANCISCO MEDICINE

Enhancing Our Network for PatientCentered Care

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PRESIDENT’S MESSAGE Roger S. Eng, MD, MPH, FACR

Reimagining Radiology Radiology is in the midst of a major evolution, if not revolution. I know it sounds dramatic, but it’s true. And as physicians who order imaging studies, you should know how this transition will impact you and your patients. That’s why we’ve dedicated this issue of San Francisco Medicine to the American College of Radiology’s (ACR) Imaging 3.0TM campaign—the strategy radiologists nationwide are following as they evolve from a volume-based to a valuebased model of care. To appreciate where radiology is headed, it is helpful to understand how it got to where it is today. Radiology saw a multitude of technological innovations during the past two decades, making radiologists more effective in diagnosing diseases and increasing efficiency in communicating these results to clinicians. However, with each technological breakthrough came the complexity of managing multiple imaging modalities and imaging systems—leading radiologists away from their traditional consultative roots. Soon radiologists began spending most of their time interpreting imaging exams and self-editing reports, and almost no time consulting with referring physicians and patients. But as payment systems and patient expectations shift to a focus on value over volume, radiology is evolving to meet the changing landscape. Instead of spending all of their time in their reading rooms, radiologists are engaging more directly with referring physicians and patients to provide exceptional care. Imaging 3.0 is guiding radiologists through this transition and helping them demonstrate their value as integral members of the health care team. The articles in this issue highlight the various components of Imaging 3.0 and provide further detail about the metamorphosis that radiology is currently undergoing. Additionally, each article explains how these changes will impact not only radiologists but also referring physicians and patients. I invite you to spend time with each of the articles, but for now I want to draw your attention to a few that are particularly central to understanding this new era of radiology. At the top of the list, “What Is Imaging 3.0?” provides an overview of the ACR initiative. In her article, Geraldine McGinty, MD, MBA, FACR, reflects on the history of radiology and the current state of the profession. She then explains how the culture of radiology is being reimagined to meet the demands of contemporary medicine. As McGinty points out, radiologists are reinventing themselves as consultants in patient care by working directly with referring physicians and patients to deliver the highest-quality care possible. WWW.SFMS.ORG

Building on the idea of radiologists as partners in care, “Patient-Centered Care: What Does It Mean for Radiology Patients?” describes the steps that radiologists are taking to provide personalized medicine. In the article, Jennifer L. Kemp, MD, shares some of the specific strategies that radiology practices are adopting to enhance the patient experience. These efforts include providing exceptional customer service, establishing direct-to-patient consultation services, and promoting technologies that allow patients to access their imaging reports online. At the heart of both Imaging 3.0 and patient-centered care is patient safety. In “Improving Safety: Better Imaging Safety for Better Patient Care,” Nathaniel E. Margolis, MD, describes the risks of excessive radiation exposure and what radiologists are doing to ensure they get the best images possible with the lowest doses possible. These efforts include working with referring physicians to help them select the most appropriate imaging exam based on a patient’s clinical scenario and participating in dose registries that encourage low-dose efforts by allowing radiology practices to compare their dose levels to regional and national values. Margolis also responds briefly to a recent Consumer Reports article, which focuses on the dangers of excessive radiation exposure but fails to mention the steps that radiologists are taking to limit radiation dose and unnecessary exposure to patients. The final article I want to point out isn’t specific to Imaging 3.0, but it provides a glimpse into the type of innovative work that is happening in radiology and other areas of health care today. In “Supercomputers in Radiology: What Do We Need in Order to Take Watson to the Clinic or Bedside?” Eliot Siegel, MD, explores how the supercomputer that bested Jeopardy champs Ken Jennings and Brad Rutter is improving health care by helping physicians identify treatment options. While it’s too early to know exactly how Watson’s cognitive computing technology will influence medicine, it’s logical to suspect that its impact will be significant. Connect with Dr. Eng via Twitter @RogerEngMD or send him an email at reng@sfms.org.

MARCH 2015 SAN FRANCISCO MEDICINE

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Imaging 3.0

WHAT IS IMAGING 3.0? The New Face of Radiology Geraldine McGinty, MD, MBA, FACR As a medical specialty, radiology’s goal is to deliver all of the imaging care that is valuable and necessary and none that is not by working in concert with referring

physician colleagues, patients, and other members of the health care team. To help it get there, the American College of Radiology (ACR) has launched Imaging 3.0, a blueprint for the future of radiology. But to understand where radiology is going, it is necessary to reflect on the profession’s past and critically assess its present.

In the Beginning

Remember when radiology “films” were produced on actual film and reports were typed on paper and mailed? Now dubbed Imaging 1.0, this era of radiology lasted from the advent of the X-ray in 1895 until the 1990s. Those were the days of the radiology file room, when a referring physician who wanted to review the images with a radiologist had to ask for the images to be retrieved and when a lost film could mean a significant delay in decision making. But there were many positive aspects to the Imaging 1.0 era. The radiology reading room was a place where the radiologist and other members of the health care team would meet. There they would talk to one another directly and use all of the information at their disposal, limited as it might have been, to achieve the most accurate diagnoses and most effective treatment plans for their patients.

A Technology Explosion

The late 1990s saw an explosion of technological innovations, including new modalities, digital imaging equipment, and enhanced picture archiving and communications systems (PACS). Radiology entered the Imaging 2.0 era as these technologies became mainstream, and soon patients began to benefit from the exquisite anatomic and physiologic details that the latest imaging technology provided. Additionally, advanced image storage and transmission capabilities gave radiologists the ability to access and interpret images remotely from any location. However, as much as technology can improve communication, it can also hinder real human connections. That has been the unexpected downside of the Imaging 2.0 era. As technology made radiologists more productive, they began spending an increasing amount of time reviewing images and producing reports and significantly less time in consultation with referring physicians and patients. As a result, radiologists missed opportunities to support referring physicians and help them understand the nuances of the incredibly detailed images, how to manage the incidental findings, and even how to choose the most appropriate imaging exams to answer their clinical questions. WWW.SFMS.ORG

Additionally, a health care payment system that incentivized volume and was neutral on value and outcomes inevitably led radiologists to focus more on productivity than on making connections with referring physician colleagues and patients. The value of the imaging care provided by radiologists was linked purely to their productivity in the payment system. So it’s not surprising that as the health care conversation has turned toward value, radiologists have not been considered as part of the solution—in fact, they have often been accused of being part of the problem.

The Future Is Now

To overcome these issues, the ACR has launched Imaging 3.0, a road map that guides radiologists and encourages them to reestablish themselves as integral members of the health care team by demonstrating the value they bring to the continuum of patient care. Closely aligned with the Radiological Society of North America’s Radiology Cares campaign, Imaging 3.0 requires a cultural change in radiology. Radiologists who have focused exclusively on volume and productivity are challenged to make time to provide consultation to their referring physician colleagues and connect with patients. Already, radiology practices across the nation are making the transition. The ACR has compiled a library of case studies, available at http://bit.ly/1vTIrAH, that showcases how groups are successfully embracing this new era of care and what these efforts mean for referring physicians and patients. While the journey is different for each practice, those that have begun the evolution are already reaping the benefits. Some groups, like Radiology Associates of Canton, Inc., in Canton, Ohio, have increased collaboration with their health systems, while other groups, like Radiology, Inc., in Mishawaka, Indiana, have positioned themselves as key members of their hospital leadership. Additionally, the ACR has collected inspiring stories from practices that are providing patient consultations and departments that are teaching their residents how to deliver bad news to patients. The Imaging 3.0 library also features stories like the one from Golden Gate Radiology, headed by San Francisco’s own Roger S. Eng, MD, MPH, FACR, which is combining technology with collaboration and consultation to improve care. While each practice is taking a different approach to Imaging 3.0, two things are consistent among them: The professional satisfaction of their radiologists and staffs has never been higher and their relationships with their referring physicians and patients have never been stronger.

Continued on page 11 . . .

MARCH 2015 SAN FRANCISCO MEDICINE

Working together, the San Francisco Medical

TOP

REASONS

To Join SFMS and CMA

PRACTICE MARKETING ASSISTANCE

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

MEMBER-ONLY ACCESS Gain full access to the SFMS website for guidelines, reports, and a variety of tools and resources to help you navigate the ever-changing health care environment. Members also receive exclusive admission to our private networking socials and the Annual Gala.

Promote your practice through our customizable physician member page on SFMS’ website, printed Member Directory, and networking mixers.

LEGISLATIVE ADVOCACY: Ensure physicians have a voice and remain in control of medicine this year and in years to come. By speaking as a united voice, SFMS/CMA exert a powerful influence on health policy and public health issues at the local, state, and national levels.

IMPROVING COMMUNITY HEALTH Spearhead community health issues in San Francisco including Hep B Free, anti-tobacco legislation and education, formation and continuation of the Healthy San Francisco program, advocacy on reproductive and end-of-life issues, and much more.

EXPAND YOUR NETWORK Grow your professional network and referral list by networking with peers, established physicians, and health care leaders across the state at SFMS events and online communities.

PROTECTING MICRA SFMS and CMA work diligently to protect the Medical Injury Compensation Reform Act (MICRA), spearheading a successful campaign to defeat Prop 46 in the 2014 Election. Prop 46 would have dramatically altered MICRA by making it easier to file lawsuits against health care providers, increasing health care costs, reducing access to care and ultimately generating more legal fees for lawyers.

CAREER CENTER Discover new employment opportunities through the annual SFMS Career Fair. This member-only event connect SFMS physicians with recruiters from San Francisco Bay Area hospitals, medical groups, and community clinics.

STAY CONNECTED Stay up to date on vital health care issues that affect San Francisco physicians with online and print media – San Francisco Medicine journal, SFMS News e-Newsletter, and SFMS blog.

COMMITMENT TO THE PROFESSION

PRACTICE MANAGEMENT ASSISTANCE Resolve contracting, billing, and payment problems with one-on-one assistance from CMA’s team of practice management experts.

Your support of the SFMS and CMA through membership affirms your commitment to the medical profession and ensures physicians remain in control of medicine this year and in years to come.

PLEASE JOIN OR RENEW YOUR MEMBERSHIP TODAY JOIN ONLINE AT www.sfms.org/Membership/JoinNow/MembershipJoin

RENEW YOUR MEMBERSHIP ONLINE AT www.sfms.org/membership/pay-dues-online

CONTACT SFMS AT (415) 561-0850 or membership@sfms.org

What Is Imaging 3.0? Continued from page 9 . . .

Imaging 3.0 Informatics To achieve the objectives of Imaging 3.0, practices are using advanced informatics solutions. For instance, radiologists are encouraging their referring physicians to use clinical decision support tools, such as ACR SelectTM, which uses the ACR’s Appropriateness CriteriaTM to rank the appropriateness of imaging exams at the point of order. Radiologists are also working with referring physicians directly to answer their questions about imaging appropriateness and guide them toward the right imaging exams. These efforts significantly reduce the chances of inappropriate imaging. Many radiology practices are also embracing their highvalue futures by participating in the ACR Dose Index RegistryTM, a data registry that allows practices to compare their dose levels to regional and national values. Radiologists’ goal is to achieve the best images possible at the lowest dose possible, while answering the clinical question at hand. These efforts ensure that patients are exposed to as little radiation as necessary to achieve quality images. Practices are further achieving the goals of Imaging 3.0 and enhancing the patient experience by implementing tools such as online scheduling and patient portals. These tools allow patients to take greater control of their health care and help ensure that patients remain at the center of care.

Value-Centered Advocacy

Another component of Imaging 3.0 involves advocating for health care payment policy that aligns with value-based imaging care. Imaging has been subject to numerous reimbursement cuts in the last eight years, but radiologists are encouraging payers and policy makers to refrain from making additional cuts and to instead focus on value-centered plans. As a result of radiologists’ advocacy efforts, legislators passed the Protecting Access to Medicare Act of 2014 (PL 11393), which requires the use of clinical decision support tools for advanced imaging of Medicare patients in 2017. Radiologists hope that this legislation will be the first step toward eliminating the onerous preauthorization process that many private payers currently impose. Another important payment policy decision that aligns with high-value imaging care was the decision by Medicare to cover screening for lung cancer with low-dose CT scans. The ACR worked with multiple stakeholders, including other physician specialty organizations, national advocacy organizations like the American Cancer Society, and, most important, patient-advocacy groups, to champion a robust lung cancer screening program for those patients who need it most. Radiologists are delighted that Medicare’s proposed decision largely reflects the program that the ACR and its collaborators had recommended.

Ready for Reform

By meeting the objectives of Imaging 3.0, radiologists are aligning with the Triple Aim of health care reform. Radiologists are improving population health through new and improved screening programs, enhancing the patient experience by leveraging advanced technology and emphasizing the importance of WWW.SFMS.ORG

in-person connections, and reducing overall costs by using their expertise of the imaging armamentarium to ensure that the most appropriate imaging is performed for each clinical situation. While change is often difficult, radiologists are using Imaging 3.0 as a guide to not only position themselves for the future of medicine but to also serve as leaders on the path to holistic, value-focused care. And they are excited to partner with their referring physician colleagues along the way.

Geraldine McGinty, MD, MBA, FACR, is a practicing radiologist, expert in health care payment policy, and a strong supporter of innovative health care companies and new payment models for health care. She is currently on the faculty at Weill Cornell Medical College in New York City. She received her medical training at National University in Ireland, completed her residency at the University of Pittsburgh, and performed her fellowship in women’s imaging at Massachusetts General Hospital. She also completed her MBA at Columbia University. Dr. McGinty is chair of the American College of Radiology’s Economics Commission and is on the medical advisory boards of several innovative health care companies, including FairHealth, OpenDr, and Wellthie. She recently joined the Board of the Industrial Development Agency of Ireland.

Antibiotic Resistance and Agriculture: A Decade of SFMS Advocacy Paying Off? In early March, McDonald’s corporation announced they would be phasing out purchase of chicken meat raised with the routine use of antibiotics. Also, national legislation was introduced, co-authored by our own Senator Dianne Feinstein, to curtail such use. Longterm, routine, low-level use of antibiotics in meat production has long been suspected, and now confirmed, as a contributor to bacterial resistance to antibiotics. In fact, up to 80% of all antibiotics produced are used in this manner. In 2001, the SFMS hosted an invitational conference on this concern, co-chaired by former UCSF Chancellor Philip Lee, MD and resulting in multiple publications and a policy statement urging more prudent use that was adopted by both the CMA and AMA. This new position was national news and helped spur a concerted, ongoing movement to reign in agricultural overuse which may now finally be yielding some results. The Feinstein Prevention of Antibiotic Resistance Act would require the Food and Drug Administration (FDA) to withdraw its approval of medically important antibiotics used for disease prevention or control that are at a high risk of abuse. It is supported by the Infectious Disease Society of America, among other medical and public health groups. “Antibiotic resistance is one of the biggest public health threats we face and we need a comprehensive response to preserve the effectiveness of antibiotics,” Feinstein said. —Steve Heilig, MPH MARCH 2015 SAN FRANCISCO MEDICINE

RADIATION SAFETY

EXPOSURE ASSOCIATED WITH COMMON PROCEEDURES

Information derived from a table on RadiologyInfo.org.

Imaging 3.0

IMPROVING SAFETY Better Imaging Safety for Better Patient Care Nathaniel E. Margolis, MD After X-rays were discovered in 1895, radiologists began to better understand the potential risks associated with this new medical technology. In early

experiments, scientists subjected animals to X-rays for five to twenty minutes, resulting in 100 times the dose typically used for diagnostic imaging, to gain greater insight into how exposure to ionizing radiation might impact humans. Imagine their concern when the animals emerged with shrunken limbs and bald spots. Clearly, something had to be done to protect humans from a similar fate, so radiologists began recommending the “least amount of X-ray exposure for the desired diagnostic or therapeutic task.”1 Today, this concept is known by the acronym ALARA—as low as reasonably achievable—and is the guiding principle that radiologists and medical physicists have used to approach radiation safety for the past century. While the concept is not new, recent events have put the spotlight on ALARA.

Recent Radiation Studies

As imaging technology has advanced during the past twenty-five years, the number of imaging studies performed using radiation has increased significantly. In response, several recent studies have addressed the potential for radiation from medical imaging to increase patients’ risk of cancer. For instance, in 2005, the National Institute of Environmental Health Sciences (NIEHS) concluded that 55 percent of the general population’s exposure to radiation comes from low-dose medical studies, while 43 percent comes from natural sources such as radon. Citing studies that have linked radiation exposure to leukemia, thyroid, breast, lung, and other cancers, NIEHS added X-ray radiation from imaging studies and gamma radiation from nuclear medicine to its list of known human carcinogens. Around the same time, the National Academies released BEIR VII, a report espousing a “linear no-threshold” model of radiation risk. The model indicates that the risk of cancer increases in a linear fashion as radiation dose increases. The model concludes that even the lowest levels of radiation may be carcinogenic, but exposure to low doses of radiation are expected to cause only a small number of cancers. Finally, in 2007, the New England Journal of Medicine published an article by David J. Brenner, PhD, DSc, and Eric J. Hall, DPhil, DSc, introducing the notion that CT scans are a significant carcinogen. Brenner and Hall estimated that 0.4 percent of all cancers in the United States could be attributed to CT scans. However, these estimates are only theoretical, because they were extrapolated from studies of atomic bomb survivors living in Hiroshima and Nagasaki who received extremely high radiaWWW.SFMS.ORG

tion doses—five to twenty times that of a single abdomen/pelvis CT—all at once.

Ionizing Radiation in Imaging

While ionizing radiation may carry risks, it is important to keep the benefits of medical imaging in mind. All medical imaging studies, even those that use ionizing radiation, allow physicians to detect diseases at an early stage, opening the way for expeditious treatment and good patient outcomes. In many instances, medical imaging reduces the need for surgery and saves lives. The important thing is to educate patients about the different types of medical imaging and their potential risks. In medical imaging, X-rays, CT scans, and nuclear medicine studies all involve ionizing radiation, while ultrasound and MRI do not. Most patients do not know which exams use radiation. In fact, a recent survey of nearly 5,500 patients at MD Anderson Cancer Center, in Houston, Texas, revealed that only 36 percent of patients know that CT exposes them to ionizing radiation, while 30 percent think MRI involves radiation. In diagnostic imaging, the way human tissue interacts with X-rays creates the images. Depending on its density, some tissue absorbs the X-rays, causing the image to appear white, while other tissue allows the X-rays to penetrate it, causing the image to “blacken.” In nuclear medicine, the patient consumes a radiopharmaceutical, either orally or intravenously, and the radiation is then detected outside of the patient, creating the image. The lower the radiation dose in any imaging modality, the lower the image quality. Therefore, radiologists must balance diagnostic image quality and radiation dose. Of all of the diagnostic modalities, CT requires the highest radiation dose—fifty to 500 times that of a single chest X-ray—because it involves multiple X-ray exposures fused together to form slices. For instance, an abdomen/pelvis CT scan with a dose of 10 milliSieverts is the equivalent of approximately 500 single chest X-rays, each with a dose of 0.02 milliSieverts.

Effects of Radiation Exposure

The effects of radiation exposure fall into two categories: deterministic and stochastic. Deterministic effects are those with a “determined” dose threshold. Examples include skin burns, hair loss, and sterility. Although a few cases of hair loss from CT perfusion studies of the brain have been well publicized, they were later found to be caused by operator error. The radiation dose known to cause deterministic effects is 100 to 1,000 times the typical dose used in CT studies. Stochastic effects describe the risk of developing cancer from ionizing radiation, for which no threshold is thought to ex-

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Improving Safety Continued from previous page . . . ist. The risk depends on the amount of exposure. For instance, the risk of developing cancer from one abdomen/pelvis CT is estimated to be 0.1 percent. However, no definitive cause-and-effect relationship between radiation used for diagnostic purposes and the development of cancer has been identified. Still, we must operate under the assumption that even the low doses of radiation used in diagnostic imaging may be harmful, and we must always strive to achieve ALARA. Ultimately, the benefit of the diagnosis must outweigh the risks. With that in mind, two patient populations warrant particular discussion: children and pregnant women. Atomic bomb studies show that children are approximately ten times more sensitive to radiation-induced cancers than middle-aged adults, for two reasons. First, the effects of radiation have more time to manifest in children, and second, children’s tissue is more radiosensitive. This heightened radiosensitivity appears to level off at around age thirty. Studies of pregnant women have shown that high doses of ionizing radiation can leave a fetus with deterministic effects, including chromosomal abnormalities, neurologic deformities, and growth retardation. The fetus is at greatest risk during the second to fifteenth weeks of gestation. The mother may not know she is pregnant during this time, so it is current practice to screen all women of childbearing age for pregnancy before administering tests that require ionizing radiation. Despite the possibility of deterministic effects at high-radiation doses, no harmful effects have been shown for fetal doses of less than 50 mGy—the equivalent of approximately two abdomen/pelvis CTs. Therefore, the American College of Obstetrics and Gynecology recommends informing women that “X-ray exposure from a single diagnostic procedure does not result in harmful fetal effects.”

Reducing Exposure

Referring physicians can help reduce radiation exposure by avoiding unnecessary repeat exams and by choosing radiationfree imaging modalities. For example, ultrasound is often the best imaging test for pregnant women and children because it uses no radiation. Upper right-quadrant pain and other clinical scenarios also lend themselves to ultrasound because things like gallstones are more visible with ultrasound than with radiography or CT. Referring physicians can use the American College of Radiology’s (ACR) Appropriateness CriteriaTM, accessible at www.acr.or/ac, and/or consult their partnering radiologists to decide which exams are best for patients. If CT is necessary, the radiologist can reduce the dose by governing the scanner’s radiation output. A trade-off between image quality and radiation dose always exists, but dramatically decreasing the radiation dose can still accomplish the clinical task in some cases. Examples include low-dose chest CT for lung cancer screening and low-dose abdomen/pelvis CT for detection of renal stones. Radiation dose can also be decreased by scanning only the area of interest and by limiting the use of multiphase CT. 14

The radiology community is committed to reducing and researching radiation dose. In fact, the industry’s leading professional organizations have partnered to create Image Wisely, a campaign for lowering radiation dose in adult medical imaging. The Image Wisely website, www.imagewisely.org, offers resources for radiologists, referring physicians, medical physicists, and patients. A similar campaign called Image Gently, www.imagegently.org, focuses on low-dose efforts for children. Additionally, many radiology practices are participating in the ACR’s Dose Index RegistryTM, which allows them to compare their dose levels to regional and national values—encouraging low-dose efforts nationwide.

Is Risk Exaggerated?

Although radiation dose is a concern, some medical professionals feel that radiation fears from imaging are overstated. Articles like the one entitled “The Surprising Dangers of CT Scans and X-rays,” published online by Consumer Reports in January, only incite concerns about radiation exposure. The Consumer Reports article focuses on the potential dangers of radiation exposure without mentioning any of the dose-reduction efforts underway. In 2012, the American Association of Physicists in Medicine issued a statement urging patients not to forgo medically necessary diagnostic imaging because of perceptions that it may be harmful. Although the risk of radiation exposure remains controversial, we must assume that even small doses of radiation used for medical imaging can increase the risk of cancer. To this end, radiologists and their physician partners must work together to use ionizing radiation only when necessary. When used appropriately, radiation doses from medical imaging can be made ALARA—as low as reasonably achievable.

Nathaniel E. Margolis, MD, is a breast imaging fellow at the New York University (NYU) School of Medicine. A summa cum laude graduate of the Sophie Davis School of Biomedical Education and the NYU School of Medicine, Dr. Margolis pursued a diagnostic radiology residency at NYU and was appointed chief resident. During his residency, Dr. Margolis launched an initiative in which radiology residents gave imaging safety presentations to residents in other specialties. The American College of Radiology (ACR) featured the project in an Imaging 3.0 case study. He served as the communications officer for the ACR Resident and Fellow Section and the vice president of the American College of Medical Quality Student and Resident Section.

Reference Oestreich AE. RSNA centennial article: ALARA 1912: “As low a dose as possible” a century ago. Radiographics. 2014 SepOct; 34(5):1457-60.

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Imaging 3.0

PATIENT-CENTERED CARE What Does This Mean for Radiology Patients? Jennifer L. Kemp, MD Radiologists, like other physicians, become doctors because they care about patients and want to have a positive impact on their lives. And, while radiologists

have always focused on providing the highest-quality imaging exams and reports, today they are more dedicated than ever to partnering with referring physicians and other members of the health care team to provide more patient-centered care. For patients, this translates not only into increased access to imaging reports and more direct consultation with radiologists but also to fewer repeat and duplicate imaging exams and lower radiation doses. Radiologists’ commitment to providing patient-centered care represents a significant change in the way they practice. During the past twenty years, radiologists have become more efficient and productive thanks to faster imaging technologies, increasingly sophisticated picture archiving and communication systems (PACS), and innovative teleradiology platforms. As their efficiency has improved, radiologists’ workloads have increased, requiring them to spend longer hours in their radiology reading rooms. With little downtime, radiologists have become less visible to patients at a time when these same technological advances have led patients to expect increased communication with their health care providers. Most patients want to receive their imaging results as soon as they are available, and many want to receive those results directly from their diagnosing radiologists. Additionally, many patients would like the opportunity to talk with their radiologists directly. But above all, patients want personalized care that demonstrates that their health care system and providers are concerned about them and their experiences as individuals. These demands will likely grow as patients begin accessing their radiology reports through Web-based patient portals. To address these trends, radiologists are improving all aspects of the patient experience with the support of the industry’s leading professional associations. In 2012, the Radiological Society of North America (RSNA) formed a steering committee to encourage radiologists to focus more on patient-centered radiology. Subsequently, the committee developed Radiology Cares, a campaign to assist radiologists in becoming more patient centered. RadiologyCares.org provides tool kits, practice resources, and PowerPoint presentations that enable and empower radiologists to better enhance the patient experience in their practices. Additionally, the RSNA has partnered with the American College of Radiology (ACR) to launch an online patient resource called RadiologyInfo.org. The site contains information about nearly 200 procedures, exams, and diseases that radiologists in diagnostic and interventional radiology, nuclear medicine, and WWW.SFMS.ORG

radiation therapy address. It also includes information about preparing for specific exams and what patients can expect during their evaluations. When it comes to radiology, referring physicians and radiologists may think that patient-centered care simply means that radiologists convey imaging results directly to patients. While this can be a component of patient-centered care, there is more to the approach. Providing patient-centered care means doing everything possible to enhance the patient experience throughout the continuum of radiological care. To accomplish this, radiologists and their staffs must consider the patient’s perspective before, during, and after the examination. For radiologists, patient-centered care begins when a referring physician first considers ordering an imaging exam. To help referring physicians determine which exams are the safest and most appropriate for answering specific clinical questions, radiologists are more available than ever for direct consultations. Additionally, referring physicians are encouraged to consult clinical decision support systems, such as ACR SelectTM, which is based on the ACR Appropriateness CriteriaTM, to rate the appropriateness of imaging exams at the point of order. When referring physicians consult with a radiologist directly and/or a clinical decision support system, patients are significantly less likely to receive inappropriate or unnecessary imaging exams. In turn, their chances of needing repeat exams and being exposed to unnecessary radiation decreases. Once an imaging exam is ordered, the radiology practice is responsible for ensuring that the patient experience is pleasant. This begins with scheduling the exam, which should be as seamless as possible and should include instructions about how the patient should prepare for the exam, where the patient should park, and what the patient should do to check in upon arrival. At the office, the patient will find that the registration and waiting room are optimized for the patient-centered world. This means that the office is not only clean and safe but also that the decor is comfortable and that extras such as magazines, coffee, Internet access, and a children’s play area are provided. When the patient enters the examination area, the radiology technologist or radiologist performing the exam personalizes the experience by greeting the patient and explaining in detail how the procedure will unfold. He or she also addresses any questions the patient may have before beginning the exam. During the exam, the person performing the study continues to demonstrate patient-centered care by keeping the patient informed as he or she makes adjustments to obtain the appropriate images. Once the exam is completed, the person who performed the study will tell the patient when and how he or she can expect to

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Patient Centered Care Continued from previous page . . . receive the findings after the radiologist interprets the images. An increasing number of institutions are now allowing patients to access their imaging reports through online patient portals. In many cases, the reports are posted to the patient portal a day or more after the exam, giving referring physicians time to review the findings before the patient has access to the report. Some referring physicians appreciate the delay because it gives them time to prepare, should the patient call with questions about the findings. Giving patients access to their imaging reports allows them to take greater control of their health care, answering a growing desire in contemporary medicine. Patients who have questions about their imaging reports are encouraged to contact their referring physicians, but radiologists are also available for patient consultations. In fact, radiology practices across the country are now establishing formal direct-to-patient consultation services—meeting a demand that is driven by patient preferences. Most patients appreciate having the opportunity to speak with their radiologists directly. The interactions allows them to get to know the people behind the names on their imaging reports and ask questions that may be beyond their referring physicians’ expertise. But even if radiologists do not interact directly with patients, they are always available to consult with referring physicians about imaging appropriateness and exam findings and to answer any other questions. For patients, this ensures that their interests remain the health care team’s top priority.

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While many radiology practices are implementing the aforementioned patient-centered strategies, not every group can adopt them all at once, and not all groups will take the same approach to achieving patient-centered care. Still, one thing is certain: All radiologists are committed to working with referring physicians to improve the patient experience. For patients, this means they can take comfort in knowing that when they undergo an imaging exam, their referring physicians and radiology teams have just one thing in mind: them. Jennifer L. Kemp, MD, is a private practice diagnostic radiologist in Denver, Colorado. She is chair of the Radiological Society of North America’s patient-centered radiology steering committee. She has served as chair or vice chair of the Department of Radiology at Rose Medical Center since 2004, and in 2010, she received the Rose Physician Humanitarian Award. Dr. Kemp currently serves on several committees to aid in diagnosis and prevention of lung and colon cancer, including the Colorado Cancer Coalition Lung Cancer Task Force, American College of Radiology Colon Cancer Committee, HealthOne Lung Cancer Physicians Workgroup, and HealthOne Complex GI Physician Workgroup. She received her undergraduate and medical degrees from the University of Kansas and completed her residency training at the University of New Mexico, where she was chief resident and resident of the year. She completed a fellowship in body imaging at the University of Colorado.

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Imaging 3.0

SUPERCOMPUTERS IN RADIOLOGY What Do We Need in Order to Take Watson to the Clinic or Bedside? Eliot Siegel, MD “I, for one, welcome our new computer overlords.”—Ken Jennings after being thoroughly crushed by Watson on Jeopardy! and, in turn, borrowing from Simpsons TV personality Kent Brockman’s self-serving homage to a “master race of space ants”

I had just finished a presentation on the next generation of “intelligent” CT contrast injectors at the

Venetian Hotel in Vegas in February 2011 when hundreds of incoming texts, e-mails, and calls started flooding in, from the U of Maryland hospital PR staff, The New York Times, Washington Post, PBS, Time magazine, and countless others. IBM’s Watson Deep Q/A had just thoroughly trounced Ken Jennings and Brad Rutter, the world’s most accomplished human Jeopardy! players, and had announced that the next step was to work with me to bring the “know-it-all” system to medicine. Although I had been collaborating with IBM for quite a few months to explore opportunities and challenges in medicine, I had no idea that they would make such a public announcement of the grant and our collaboration at the end of the Jeopardy! match. Thousands of messages started pouring in from all over the world from pre-meds, medical students, and practicing physicians. They ran the gamut, from “This is the best thing to happen to medicine in 100 years” to “You are destroying the practice of medicine” to “Well, I guess they won’t need doctors anymore, should I still plan to go to medical school?” to “Cyberdyne Systems Skynet has arrived.” My response in 2011 was that Watson was promising but akin to a really well-read second-year medical student who had memorized much of the medical literature but had little in the way of clinical common sense, experience, or sense of proportion or judgment. The challenge was to try to provide Watson with quantitative analytic and data mining tools that would actually make it useful in diagnosis and treatment, along with the data itself. Just as humans are equipped with the ability to discern patterns and analyze data, an “artificial intelligence” program designed to assist in diagnostic and treatment decision support would need these skills as well. Additionally, it would need the equivalent of “experience” that physicians typically get on the wards, in the clinic, etc. Just like a second-year medical student who believes he has every disease he reads about in the textbooks, Watson has virtually no data or experience to separate the zebras from the horses.

“To Err Is Human” . . . Do Physicians Actually Need Help from Computers to Make a Diagnosis or a Treatment Plan?

Graber et al., who advocate for computer diagnostic assistance, estimated that 75 percent of diagnostic errors were reWWW.SFMS.ORG

lated to “cognitive factors” and outnumber other medical errors by 2 to 4 times. A recently published study at Hopkins suggested that more than 40,000 patients die in ICUs in the U.S. each year due to diagnostic errors. Cognitive errors such as “anchoring bias” (being stuck on an initial impression), “availability bias” (tendency to jump to a conclusion based on a recent incident such as a physician’s recent missed diagnosis) and “satisfaction of search” (not continuing to look for additional findings, diagnoses after coming up with one relatively obvious diagnosis) are common to humans but are not characteristic of computers. The fact that humans and computers make different types of errors strongly suggests that the two can work together synergistically to reduce serious errors and their consequences.

What Are the Potential Benefits of Watson in Medicine?

Benefits include much faster input of data (Internist I from the early 1980s, for example, could take more than ninety minutes to provide input to the software) from a source such as the EMR. Another benefit would be that it is a non-“brittle,” flexible system that is not based on a series of rules such as “if-then” statements but can be constantly updated by downloading the latest literature, guidelines, etc. A third is the lightening-quick parallel processing used to analyze a question, generate candidate responses, and evaluate those responses within three seconds for Jeopardy! Watson also provides a graphical interface that allows a physician to drill into the reason it picked a particular answer and also display its level of confidence in the various possibilities.

What Are the Limitations of Watson for Diagnosis and Treatment?

Since the software was optimized for the specific Jeopardy!

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Supercomputers in Radiology Continued from page 17 . . . answers and questions, it uses techniques such as word juxtaposition (how often words appear in association with one another), popularity, semantic relatedness, type classification, geography, etc., which are not particularly applicable in medical diagnosis. The Jeopardy! approach assumes that the input is always accurate and there is only one correct answer, rarely the case in medicine. Also, the Deep Q/A software is not designed to perform complex statistical analysis or data mining from a large database such as a clinical trial or electronic medical record. Even more critically, the vast majority of data required to give Watson “experience” and “practical knowledge” is not available to Watson developers but is locked up in clinical trial raw data that is typically not shared except for research purposes or, alternatively, is locked in electronic medical records that are typically not available in a machine-intelligible, structured fashion and are difficult to de-identify, especially free text, which represents 90 percent of the entire patient record and is unavailable due to privacy/security concerns and regulations.

So How Far Has Watson Come Since 2011?

IBM has, in the past few years, also collaborated with other academic institutions on projects that mainly focus on education and improved searching of the medical literature, the electronic medical record, or a specific database such as Memorial Sloan Kettering’s cancer and MD Anderson’s leukemia databases. A program called Watson Paths, for example, has been developed and is being tested by students at the Cleveland Clinic for assistance in clinical problem-based learning. In the realm of diagnostic imaging, IBM has created the “Medical Sieve” project, which they describe as an “ambitious, long-term, exploratory grand-challenge project to build a nextgeneration cognitive assistant with advanced multimodal analytics, clinical knowledge, and reasoning capabilities that is qualified to assist in clinical decision making in radiology and cardiology.” However, despite the progress, the Watson software still has quite a few challenges before it can be widely used in medical decision support to answer questions that I would like to ask it, such as: • What is the most common diagnosis for a patient with a maculopapular rash, arthritis, and a fever, for example, according to the medical literature, in San Francisco overall, or at San Francisco General hospital? How about in patients who are HIV positive? What if the fever is over 103 degrees? How about in a child? • What is the best statin, antihypertensive, anticoagulant medication, etc., for treatment in a specific patient given his/her history, genomic characteristics, other medications, family history, etc.? In order to be able to answer questions such as these, the Deep Q/A software, which is really good at natural language processing and searching though data, needs to be combined with sophisticated analytic and database mining software, the electronic medical record needs to be “cleaned” up in such a way that it can be made machine intelligible, and we need to have a standard semantic (meaning) mapping among multiple EMR’s and institutions and need to index and make raw data from clinical trials readily available to a medical algorithm such as Watson. Additionally, we need to allow systems such as Watson to either WWW.SFMS.ORG

mine multiple sources of fragmented patient records from multiple hospitals and clinics or move toward a patient-controlled health record or more universal subscription to patient healthinformation exchanges. We will need to solve the new computer-age dilemmas of how to determine when a computer is able to provide better diagnosis than our subspecialty experts (since they are our current gold standard, who will be medico-legally responsible for errors committed by computers that may on the whole be safer than humans but occasionally make really catastrophic mistakes) and how one can ever test analytic software for decision support that is an order of magnitude more sophisticated but also exponentially more difficult to debug and test. This doesn’t mean that we have to wait too long for all of these to happen. Huge databases, such as the VA’s VINCI database of more than 32 million patients (including blood samples on a million veterans) and the United Kingdom’s CPRD (Clinical Practice Research Database) of more than 10 million outpatients, are available to researchers within those enterprises for data mining. The VA, for example, is working with Watson to provide data from VINCI that includes patient medications, ICD9 diagnostic codes, laboratory values, and progress notes in the development of medical data mining and decision support tools. If I had to create a time line for progress in “artificial intelligence” in medicine in the next twenty years, I would guess that we will see the following: in the next three years, tools that synthesize and summarize the EMR and act as “spell checkers” for red flags such as a patient without a diagnosis of diabetes on diabetic medications; in the next five to ten years, wide use of clinical-decision support systems using a combination of patient lab, clinical, and genomic information; and in the next five to fifteen years, sophisticated image pattern-recognition systems for radiology and pathology.

Conclusion

So we have a bit of time before we can look forward to medical “overlords,” and when this occurs it will undoubtedly arrive in phases and will provide tools that work collaboratively with physicians and other health care providers to improve disparity of care, patient safety, diagnostic accuracy, and patient outcomes. So if you’re pre-med, don’t drop out but rather prepare for a future that looks very promising, and look forward to a close working relationship with a new generation of intelligent assistants.

Dr. Eliot Siegel (pictured on page 17 reviewing images from Watson) is professor and vice chair of Research Information Systems at the University of Maryland School of Medicine, Department of Diagnostic Radiology; and chief of Radiology and Nuclear Medicine for the Veterans Affairs Maryland Healthcare System, in Baltimore, Maryland. He is the director of the Maryland Imaging Research Technologies Laboratory and has appointments as professor of Bioengineering at the University of Maryland College Park and as professor of Computer Science at the University of Maryland Baltimore County campus. Dr. Siegel was recently appointed to serve on the National Library of Medicine’s Board of Regents. MARCH 2015 SAN FRANCISCO MEDICINE

Imaging 3.0

ADVANCES IN BREAST IMAGING Mammography and Much More Bonnie N. Joe, MD, PhD When most people think of breast imaging, they think only of mammography. While mammography re-

mains the mainstay of breast imaging, this subspecialty area of radiology has evolved rapidly and substantially during the past several decades to include several other advanced technologies that aid in the detection and diagnosis of breast diseases. Ultrasound and MRI have also become standard components of breast imaging practices, along with breast interventional radiology. As breast imaging technology has evolved, so has the role of the breast imaging radiologist. In the past, breast imaging radiologists simply interpreted images and provided reports to referring physicians. But today’s breast imaging radiologist is an integral part of a multidisciplinary team caring for patients with breast cancer and other breast health issues.

The Advent of Mammography Screening

In the 1960s, radiologists performed mammography exams using general-purpose X-ray tubes with little or no compression and captured the images onto direct-exposure films, similar to chest X-rays. Images were low in contrast and areas of tissue close to the chest wall appeared “white” due to underexposure. By modern standards, the diagnosis quality of these direct-exposure film images would be inadequate. In the 1970s, mammography advanced significantly with the introduction of screen-film mammography. This enhanced technology made imaging faster, required lower radiation dose, and provided greater contrast, making it easier to “see through” breast tissue. Improvements in screen-film technology and the establishment of dedicated mammography units during the 1980s and ’90s made mammography images increasingly better. As the technology improved, mammography screening for breast cancer also became more common thanks to two primary factors. First, the results of multiple randomized and controlled trials demonstrated the effectiveness of mammography screening to reduce breast cancer mortality. And second, the development of effective preoperative image-guided wire localization techniques made it easier to obtain a tissue diagnosis for suspicious lesions detected at mammography.

Regulating Mammography

As mammography became more widely used and breast cancer was categorized as a significant public health threat, concerns about variations in mammography quality across the country grew. After numerous quality issues were uncovered, a series of Congressional hearings were dedicated to mammography. As a result, the U.S. Congress enacted the Mammography Quality Standards Act in 1992, imposing uniform mammography standards nationwide. 20

In addition to providing high-quality images and interpretations, breast imaging radiologists must communicate their findings and recommendations clearly to referring providers to ensure comprehensive patient care. To help breast imagers convey their findings, the American College of Radiology created and maintains the Breast Imaging Reporting and Data System (BI-RADS®), a structured reporting language for breast imaging. BI-RADS contains three important components: a lexicon of descriptors, a reporting structure that includes final assessment categories and management recommendations, and a framework for data collection and auditing. Increasingly, these categories and descriptors are based on supportive scientific evidence. For example, the BI-RADS Category 3: Probably Benign Finding is validated by robust literature that shows that periodic surveillance imaging is safe and effective for the management of specific findings with a less than 2 percent chance of malignancy, thus avoiding unnecessary biopsy.

Digital and 3-D Mammography

In the early 2000s, breast imaging experienced another significant advancement with the introduction of digital mammography. While digital mammography is performed the same way as analog from the patient’s perspective, the machine uses electronic signals to produce images that can be read on computers rather than X-ray film. Most radiology practices in the United States now use digital mammography because it provides better image quality, with improved tissue contrast, than traditional analog film (see Figure 1). Studies have shown that digital mammography is particularly better than film mammography for dense breasts, as well as for younger patients, who tend to have denser breasts than older women. Digital mammography also has the added benefit of lower radiation dose compared to traditional analog mammography. Building off of standard digital mammography, digital breast tomosynthesis (DBT) is a promising new technology that acquires multiple low-dose mammographic projections through the breast. DBT has been shown to reduce false-positive findings and improve the detection rate of invasive cancers. Hence, DBT has been called “a better mammogram” and may become the standard for mammographic screening once more vendors obtain the proper approvals to offer the technology.

Breast Ultrasound and MRI

But mammography is not the only tool breast imaging radiologists use to detect and diagnose breast diseases. Breast ultrasound is often performed contemporaneously with mammography in the diagnostic setting to evaluate breast lesions.

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Adding ultrasound to mammography for better characterization of breast masses improves diagnostic specificity and reduces the number of benign biopsies. Ultrasound has also been used for whole-breast screening and has the demonstrated ability to detect small cancers that are clinically and mammographically occult in women with dense breasts. However, several challenges limit the adoption of ultrasound as a common screening method, including operator dependence, physician time to perform the study, and a high rate of false-positive biopsies. Another tool breast imaging radiologists use to detect abnormalities in breast tissue is MRI. Breast MRI is considered the most sensitive imaging technique for detecting breast cancer; therefore it is being used increasingly on patients who are at high risk for the disease. The technology is also frequently used to monitor treatment response to neoadjuvant chemotherapy, since studies have shown that breast MRI has clinical utility for predicting recurrence-free survival and pathologic complete response. While breast MRI is highly sensitive, it is supplemental screening and should not be used alone. Instead, breast MRI should be used in addition to mammography as some cancers are actually undetectable with MRI but visible with mammography. Breast MRI is not recommended for screening women who have an average risk for breast cancer due to a high rate of false-positive biopsies. Advances in MRI technology and the addition of newer techniques such as diffusionweighted imaging may help improve the specificity of breast MRI.

Breast Interventions

In the past, management of a mammographically detected but clinically occult suspicious lesion was problematic because it was difficult to excise a nonpalpable lesion. Often the surgeon would resect a large portion of the breast quadrant to ensure removal of the lesion. But the development of mammographically guided needle-localization techniques has allowed more precise excisions, with more conservation of normal breast tissue. Needle localizations can be performed under mammography, ultrasound, or MRI guidance, depending on the needs of the patient and the breast surgeon. The development of image-guided percutaneous breast biopsy has expanded the role of the radiologist in managing breast WWW.SFMS.ORG

imaging patients further. Rather than localize a suspicious mammographic finding for a breast surgeon to excise, the radiologist can now obtain a sample directly and provide a tissue diagnosis. Expediting the diagnosis in this way decreases morbidity and improves cosmesis for the patient, and it decreases health care costs for society. Given its benefits, image-guided percutaneous biopsy is currently considered the “first-line” approach for tissue diagnosis, while breast surgical excision is reserved for cases not amenable to an image-guided biopsy or for cases where additional tissue is warranted to ensure adequate sampling after initial image-guided biopsy.

A Critical Practice

Breast imaging has come a long way from the days of direct-exposure films and rampant quality concerns. Breast imaging radiologists now have more tools at their disposal and are more integrated into patient care than ever before. As additional technological innovations are achieved and breast imaging radiologists continue to advance their expertise, mammography and other imaging techniques are expected to remain central to early detection efforts—leading to even lower mortality rates.

Bonnie N. Joe, MD, PhD, is chief of women’s imaging in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco (UCSF) and coleader of the department’s breast imaging research interest group. She received a PhD in electrical engineering and bioengineering from Carnegie Mellon University and an MD degree from the University of Pittsburgh. She completed residency and fellowship training at the Mallinckrodt Institute of Radiology and additional breast imaging training at UCSF. Dr. Joe serves on the editorial board for RSNA News and is a Core Exam Committee member for the American Board of Radiology. She was also the editor for the 2013 edition of Magnetic Resonance Imaging Clinics of North America: Breast Imaging and chaired the American College of Radiology’s 2014 National Conference on Breast Cancer in Phoenix, Arizona. She is a fellow of the Society of Breast Imaging.

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Immediate Past President Lawrence Cheung passing on the gavel to incoming President Roger Eng.

Celebrating 147 Years of Physician Advocacy and Camaraderie More than J200 and influential o i nphysicians the stakeholders in the medical community joined San Francisco Medical Society in on the SFMS Annual Gala festivities on Janua sary w30, e g2015. r a t eHeld f u l lat y the a cAsian know dge Artl eMuseum, the event year as the t h e marked s u p p oSFMS’s r t o f 147th these only physician association that advocates for dedicated partners

physicians across all specialties and their patients in San Francisco. Attendees were able to network with colleagues, meet SFMS leaders, and enjoy a private viewing of the museum’s collection galleries. A special lion dance by the internationally renowned Leung’s White Crane Martial Arts School was performed to celebrate the installation of Roger Eng, MD, as the 2015 SFMS President. SFMS would like to thank our members, sponsors, and special guests Senator Mark Leno, Senator Richard Pan, Assemblymember David Chiu, Supervisor Eric Mar, Supervisor Scott Wiener, and CMA President Luther Cobb, MD, for their support of the event and of the SFMS. Left: 2015 SFMS officers: Gordon Fung, Editor; Kim Newell, Secretary; Roger Eng, President; Man-Kit Leung, Treasurer; Lawrence Cheung, Immediate Past President; Richard Podolin, President-Elect

Assemblymember David Chiu thanking SFMS for championing accessible health care for all Californians

GOLD SPONSORS

S I LV E R S P O N S O R S Chinese Hospital Medical Staff • Mercer

BRONZE SPONSORS 22

SAN MEDICINE MARCH A . LFRANCISCO . Nella & Comp a n y 2015 L L P • G o l d e n G a t e R a d i o l o g y • J o h n M a a WWW.SFMS.ORG , M.D.

Pictured above: Guest enjoy a lovely evening at the Asian Art Museum. Right: Paul and Ashley Turek Bottom right: Jerry Arellano and Maria Ansari Bottom left: (clockwise) Ryan Padrez, Amy Whittle, Jesse Nishinaga, Meghan Gould, Kate Padrez All photos courtesy of the Asian Art Museum of San Francisco and Ginger Tree Photography.

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UCSF medical students enjoying the event

Above: Calvin So, Winnie Tong, Lisa Tang Left: Dawn Ogawa, Pratima Gupta, Charles Binkley, David Kemp

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Right: Ernie Khirallah, vice president of Marketing and Corporate Communications for the Cooperative of American Physicians, thanks SFMS for leading the fight to defeat Prop 46 in the 2014 Election. Bottom right: CMA President Luther Cobb and Senator Richard Pan with SFMS board member Katherine Herz Bottom left: Supervisors Eric Mar and Scott Wiener present Lawrence Cheung with a proclamation and certificate of honor on behalf of the San Francisco Board of Supervisors in recognition for Dr. Cheung’s public health advocacy efforts, including the Soda Tax Initiative.

Physician leaders from Chinatown’s medical community: Randall Low, Collin Quock, Richard Pan, Roger Eng, Raymond Li, L. Eric Leung, Justin Quock, Edward Chow, Lawrence Cheung, Dexter Louie

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Congratulations, Fifty-Year Members! Mark Oscherwitz, MD Dr. Mark Oscherwitz started his practice in internal medicine at Mt. Zion in 1963. He became active in organized medicine soon after, serving on the SFMS Delegation to the CMA House of Delegates, as SFMS president in 1983, and as a CMA trustee. Dr. Oscherwitz also served on the committee that purchased the 1409 Sutter mansion that was the SFMS headquarters until 2006. He currently lives a mostly quiet life filling out forms and trying to practice internal medicine. Dr. Oscherwitz received his medical degree at the University of Cincinnati and completed his medical training at UCSF Mt. Zion and Boston Medical Center. Left: Roger Eng with fifty-year member Mark Oscherwitz

John Fletcher, MD After completing an internship at the University of Oregon, Dr. John Fletcher practiced medicine for two years in the Navy aboard several destroyers before completing his residency in Portland and a fellowship in gastroenterology at Massachusetts General. He returned to San Francisco to practice medicine with his dad, a fellow internist and SFMS member, who was then chief of medicine at Saint Francis. Dr. Fletcher later joined with Morris Noble and relocated to 3838 California. He served on SFMSâ&#x20AC;&#x2122;s Chronic Illness and Aging Committee for ten years and on the editorial board for three years. Although he retired on October 1, Dr. Fletcher continues to teach the next generation of physicians at CPMC, SFGH, and UCSF. Left: Roger Eng with fifty-year member John Fletcher

Eric Wang, Fung Lam, Man-Kit Leung

Sheila and Michael Rokeach

SAN FRANCISCO MEDICINE MARCH 2015 WWW.SFMS.ORG

Stephen Pinney and Aissatou Haman

Kory and Elizabeth Stotesbery

Lion dance performance provided by internationally renowned Leungâ&#x20AC;&#x2122;s White Crane Martial Arts School

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Todd May, Stephanie Wu, Harris Goodman

MARCH 2015 SAN FRANCISCO MEDICINE

Left: Keith Loring, Mary Lou Licwinko, Senator Mark Leno Below: Ingrid Lim

Steve Walsh, Eli Merrit, Kristin Razzeca, John Sikorski

Sarah Zoogman and Matthew Diamond

SAN FRANCISCO MEDICINE MARCH 2015 WWW.SFMS.ORG

Gala

Join the San Francisco Medical Society as we gratefully acknowledge the support of these dedicated partners

PRESENTING SPONSOR

P L AT I N U M S P O N S O R S

GOLD SPONSORS

S I LV E R S P O N S O R S Chinese Hospital Medical Staff • Mercer

BRONZE SPONSORS A.L. Nella & Company LLP • Golden Gate Radiology • John Maa, M.D.

MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD

Physical pain touches virtually every patient, regardless of condition or diagnosis. Anesthesiologists are central to the care we provide at Dignity Health Saint Francis Memorial Hospital, whether they are easing cancer-related pain; administering anesthesia to a patient undergoing surgery; or performing peripheral nerve blocks in orthopedic procedures, such as joint replacement surgeries, to significantly alleviate patients’ post-op pain. In the last few years, we have had the pleasure of welcoming three remarkable anesthesiologists to our Saint Francis family. Dr. Calvin Lew joined the Department of Anesthesiology at Saint Francis in July 2013. He completed his residency at Stanford University Medical Center in 2013. In addition to caring for patients at Saint Francis, Dr. Lew also sits on the hospital’s Perioperative Council and Surgery Scheduling Committee. Dr. Nate Ponstein has been an anesthesiologist at Saint Francis since August 2012. He completed his residency at Stanford University in 2011 and then went on to complete an additional one-year fellowship in regional anesthesiology and acute pain medicine. He has advanced training in regional anesthesia techniques with a focus on ultrasound-guided peripheral nerve blocks; placement of continuous perineural catheters in inpatient and outpatient settings; and overall optimization of acute, postoperative pain management. Dr. Ponstein helped introduce the “adductor canal” nerve block at Saint Francis for patients undergoing total knee arthroplasty. Dr. Michael Wahlers has served Saint Francis as an anesthesiologist since May 2012. He completed his residency at Tufts University and Baystate Medical Center and has previous experience delivering anesthetics for office-based oral surgery and outpatient surgical cases. Dr. Wahlers is well versed in procedures such as intraoperative transesophageal echocardiography and thoracic epidural placement and management, as well as peripheral nerve blocks and multimodal pain-management techniques. 30

St. Mary’s

Robert Weber, MD

For the second consecutive year, Dignity Health St. Mary’s Medical Center has received the Distinguished Hospital Award for Clinical Excellence from Healthgrades, the leading online resource for comprehensive information about physicians and hospitals. This honor recognizes St. Mary’s as among the top five percent of more than 4,500 hospitals nationwide for clinical performance, demonstrating better-than-expected-quality care. St. Mary’s is one of only 261 hospitals in the nation to receive the Distinguished Hospital Award for Clinical Excellence in 2015. For patients undergoing treatment for at least twenty-one common conditions and procedures at these hospitals, this translates to a statistically significant lower likelihood of death or complications when compared to all other hospitals. This award is one of several accolades our hospital has received by Healthgrades for quality care and service. For instance, we recently received Healthgrades five-star ratings for services provided in heart failure, esophageal/stomach surgeries, and respiratory failure. Part of providing outstanding service is ensuring that our patients are cared for in the safest, cleanest environment possible. This means taking proper precautions and steps toward preventing hospital-acquired infections (HACs). St. Mary’s was the topperforming hospital in San Francisco and one of the best in California in an assessment on medical errors by the federal government. In the assessment by Medicare, hospitals nationwide were ranked on a score of 1 to 10, with 10 being the worst, on different types of HACs. St. Mary’s received a score of 2.325. As much as we are honored to be nationally recognized for the care we provide, one thing is certain: Such praise is a result of the teamwork and dedication of our physicians, nurses, and staff who consistently deliver compassionate, high-quality health services for those who come through our doors.

CPMC

Edward Eisler, MD

Dr. Fan, who is CPMC’s chairman of Obstetrics and Gynecology, delivered the very first Bay Area baby of 2015. Following the birth of little girl Fiona Liang at exactly midnight, Dr. Fan and Fiona’s parents were flooded with media requests for interviews. Local media flocked to the occasion with television stations KNTV, KPIX, KGO, and KRON covering the blessed event along with two radio stations, the Asian press, and various other media outlets. In 2013, more than half of all babies born in San Francisco were delivered at CPMC. Dr. Chris Kagay recently assumed the role of chair of the Department of Radiology. Many thanks to Dr. Kirk Moon for his service as chairman during the past thirteen years. Dr. Aditi Mandpe has also assumed the role of chair of the Department of Otolaryngology. Thank you to Dr. Tom Engel for his service as chairman during the past ten years. Dr. Hsiao was recently recognized by Operation Access with its “2014 Champion Award.” Operation Access is a nonprofit organization that connects people in need of care or treatment and who are in distressed circumstances, with some of the most skillful physicians and medical experts in the Bay Area. Over the past three and a half years, CPMC Surgeon Dr. Katherine Hsiao has performed twenty-one free procedures for disadvantaged women in San Francisco. The procedures—which include removal of fibroid tumors as well as partial and full hysterectomies—are donated and have helped women gain access to expertise and equipment they otherwise would not have been able to afford. Dr. Hsiao donates her fees for Operation Access patients and CPMC donates operating time, anesthesia, equipment use, and many other services. This year, CPMC physicians have thus far donated forty-eight operating room surgeries, seven minor procedures, and fourteen specialist evaluations through Operation Access.

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Kaiser

Maria Ansari, MD

Continually improving and offering the best patient care possible is our primary goal at Kaiser Permanente. To that end, we are constantly assessing and refining the radiology services at our medical centers, in both our hospitals and outpatient clinics. Recent initiatives include improved access to imaging by offering patients same-day appointments for everything from X-ray and ultrasound to CT and MRI. Our integrated system and use of technology enables providers to order and schedule imaging tests for patients before they even leave the office, thus expediting the process and, hopefully, helping reduce at least one component of our patients’ anxiety. Similar to our other services, our members can choose to have their studies in the medical center of choice. For example, if a member has a primary care provider in San Rafael but works in San Francisco, they can book imaging appointments or drop in at whichever facility is most convenient. Turnaround time for reporting of imaging studies is rapid (usually same-day), and this allows our clinicians to make quick decisions about care while reducing anxiety about results for our members. Some cases are highly specialized, such as subsets of neuroimaging. In cases like this we leverage the expertise in our organization so that the specialist with the most appropriate expertise may read the image, no matter where he or she is located. All of our imaging results are available through our electronic health record system, so images are available immediately at any medical center and for doctors working remotely. Finally, we continue to make significant strides in improving our breast imaging services for our members. This includes same-day mammogram appointments for a member who is here for another reason but is also due for a mammogram. Additionally, we provide same-day diagnostic mammography, ultrasound, and, in many cases, biopsies for symptomatic patients. WWW.SFMS.ORG

SPMF

Bill Black, MD, PhD

At Sutter Pacific Medical Foundation, ultrasound diagnostic testing has provided excellent care for pregnant mothers and babies—in utero and after birth. High-frequency ultrasound, which uses sound waves to create images of the fetus, is a safe technology that doesn’t use radiation and allows a physician to monitor fetal development. SPMF physicians recommend an ultrasound in the first and second trimesters of pregnancy. Women with high-risk pregnancies may have them more frequently. Our maternal-fetal specialists perform hundreds of ultrasounds every week in offices in Santa Rosa, Greenbrae, San Francisco, and San Mateo. Our skilled team includes Carl Otto, MD; Denise Main, MD; Regina Arvon, MD; MingKun Zhou, MD; and Yvonne Cheng, MD. “We can see an incredible amount of anatomy on the fetus and can detect structural abnormalities, even in the first trimester,” says Dr. Otto. “There are also certain physical changes indicating a risk for chromosomal abnormalities.’’ Sonograms, the images produced by ultrasound, are used to confirm a viable pregnancy; determine the gestational age of the baby to confirm a due date; check for multiple pregnancies; and examine the placenta, uterus, ovaries, and cervix. Physical abnormalities making the fetus at risk for disorders such as Down’s syndrome can also be detected. Neural tube defects and other severe or lethal abnormalities can be seen. These are difficult diagnoses, but it is better to inform a woman and her family early, so they can decide whether to continue the pregnancy. Heart defects, gastrointestinal blockages, and other nonlethal abnormalities can also be detected. Ultrasound can identify rare conditions like twin-to-twin transfusion syndrome, where identical twins share the vascular system in the placenta, or Rh disease, an incompatibility between blood types of mother and fetus that can lead to anemia in the fetus. These conditions require complex treatments.

SFVAMC

C. Dianna Nicoll, MD, PhD, MPA

The San Francisco VA Health Care System (SFVAHCS) has acquired the first ultrahigh field strength MRI scanner at any VA facility nationwide, and the most advanced MRI system on the West Coast. Generating a field strength of 7 tesla, it is 150,000 times stronger than the earth’s magnetic field and more than twice as strong as the best available MRI scanners used for patient care in hospitals and imaging centers. Named the Magnetom 7T, this scanner can vary its magnetic field more strongly and rapidly than older 3T and even 7T models. The combination of ultra-high field strength and gradient performance produces images of the human body faster and with much greater detail than has previously been possible. Currently dedicated to biomedical research use, Magnetom 7T can image the living human brain at a spatial resolution of much less than 1 millimeter in all three dimensions. It can perform functional imaging (fMRI) of activity in the whole brain in less than a second. A multidisciplinary team of investigators at the SFVAHCS, U.C. Berkeley, Harvard, and Duke Universities were recently awarded one of the first research grants from the National Institutes of Health as part of the Presidential Brain Research through Advancing Innovative Neurotechnologies Initiative. The goal of the project is to further improve the speed and spatial resolution of fMRI as well as tracking white matter connections between brain regions to better understand human brain circuitry. Progress in deciphering the human brain’s activity and circuitry should lead to revolutionary new diagnostic tools and potentially new therapies for autism, attention-deficit hyperactivity disorder, traumatic brain injury, epilepsy, posttraumatic stress, schizophrenia, major depression, Alzheimer’s disease, and Parkinson’s disease. By being among the first to adopt ultra-high field MRI, the SFVAHCS will help blaze the trail to the next generation of medical imaging technology.

MARCH 2015 SAN FRANCISCO MEDICINE

SFMS STUDENT ACTIVISM UCSF Medical Students Champion CMA Priority Bills at State Capitol Robert Orynich, MS1

From left to right: Iris Jovel, Walker Keenan, Assemblymember Rob Bonta, Robert Orynich, Rachel Ekaireb, Zachary Wettstein, Julie Wu, Brian Shaw, Amy Ton, and Aaron Chin Nine UCSF medical students missed class on February 25 to spend the day in Sacramento calling for

the elimination of California’s vaccine exemption loophole, additional and ongoing state budget support for graduate medical education, and an increase to Medi-Cal provider reimbursement rates. “As students, I think we often feel limited in how much we can help patients because, after all, we’re still learning. Having the chance to advocate for patients’ needs by pushing legislation that can help address these needs was really incredible. This was my first time lobbying, and I was amazed at how highly valued our opinions are as future doctors. It was very empowering,” said first-year medical student Rachel Ekaireb. The California Medical Association (CMA) hosted these physicians-in-training in Sacramento and arranged for this opportunity to advocate for the students’ future patients and for the medical trainings programs that would meet those patients’ needs. After a morning workshop at the CMA headquarters, students met with Senator Dr. Richard Pan, Assembly Health Committee Chair Rob Bonta, and staffs from Assemblymembers David Chiu and Phil Ting’s offices to discuss upcoming legislation that impacts public health and access to care in San Francisco. The group of UCSF medical students lobbied in favor of: • SB 227 (Pan): This bill will require that only children who have been immunized for various diseases, including

measles and pertussis (whooping cough), be admitted to a school in California. The bill will also require schools to notify parents of immunization rates at their child’s school. If this legislation is passed, California will join thirty-two other states that do not allow parents to opt out of vaccination requirements using a personal belief exemption. • State budget: The doctors-in-training called for additional and ongoing funding from the California Health Data Planning Fund to the Song-Brown Program to support the training of more primary care physicians in underserved areas. • SB 243 (Hernandez)/ AB 366 (Bonta): These bills will repeal the 10 percent across-the-board cut to Medi-Cal provider reimbursement rates, enacted during the height of the Great Recession, and increase the reimbursement rates to be equivalent to Medicare rates. While each office showed support for group’s three main appeals, the future physicians know the importance of meeting with legislators early and often in order to ensure the passage of legislation key to ensuring a healthy state. The students look forward to continuing their advocacy in both Sacramento and back home in San Francisco. Robert Orynich is a first-year medical student at UCSF and a student liaison to the San Francisco Medical Society board of directors.

SAN FRANCISCO MEDICINE MARCH 2015 WWW.SFMS.ORG

TAKE TOBACCO OUT OF BASEBALL SFMS Joins Supervisor Mark Farrell to Propose Tobacco Ban Legislation

The San Francisco Medical Society joined San Francisco Supervisor Mark Farrell (District 2) at Moscone Baseball Fields in late February to introduce a legislation to eliminate the use of all tobacco products—including smokeless tobacco—at all baseball venues and city athletic fields in San Francisco. The event received media coverage from news outlets including the San Francisco Chronicle, KTVU/FOX News, and Sports Illustrated. The SFMS and the California Medical Association will be working closely with the “Knock Tobacco Out of the Park” campaign to promote tobacco-free baseball and provide visibility to the issue of smokeless tobacco in baseball. Smokeless tobacco is a

dangerous, addictive product that contains at least twenty-eight cancer-causing chemicals. SFMS President Roger Eng, MD stated, “Chewing tobacco is a dangerous substance that has no place near our nation’s children and no place in our national pasttime.” The International Agency for Research on Cancer (IARC) and the Department of Health and Human Services′ National Toxicology Program have concluded that smokeless tobacco is a known human carcinogen. IARC has concluded that smokeless tobacco causes oral cancer and pancreatic cancer. Smokeless tobacco use is also associated with precancerous lesions in the mouth or leukoplakia, gum recession and disease of the gums, and tooth decay. In addition, there is reason to worry that smokeless tobacco use by young persons may serve as a gateway to cigarette smoking, this nation’s leading preventable cause of premature death and disease. Even as cigarette use continues a steady decline among youth, smokeless tobacco use has remained troublingly steady. Each year, about 535,000 kids ages 12 to 17 use smokeless tobacco for the first time. SFMS is calling on the local health care community as well as all San Franciscans to support Knock Tobacco Out of the Park. The proposed legislation will make the game of baseball safer for our kids, safer for the players, and safer for the future. To get involved in the effort, please contact membership@sfms.org or follow #TobaccoFreeBaseball on Twitter.

April 14, 2015 SFMS/CMA LOBBY DAY Sheraton Grand Sacramento

• LEARN about legislative issues affecting medicine • FOSTER relationships with state legislators • GAIN hands on experience in the practical aspects of physician advocacy

www.sfms.org/events/lobby-day.aspx

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UPCOMING EVENTS 3/24 Seminar: Mastering the Art of Disclosing an Unexpected Outcome 6:00 p.m.–9:00 p.m. | Saint Francis Memorial Hospital. *Note new event date.* | When an unexpected outcome occurs, a discussion explaining what happened can help prevent a negative patient response, improve patient trust, and reduce the risk of a lawsuit. Skillful physician communication and early disclosure of unintended outcomes can benefit all parties, including patients, doctors, health care systems, and insurers without compromising meritorious defenses. SFMS members receive complimentary registration for Medical Insurance Exchange of California (MIEC)’s effective communication seminar. The workshop is facilitated by Denise Davis, MD, UCSF associate clinical professor of medicine and a fellow of the American Academy on Communication in Healthcare. Please email rochellel@miec.com for registration information. Complimentary dinner is provided from 6:00 p.m. to 6:30 p.m. 3/25 SFMS Member Networking Mixer 6:00 p.m.–8:00 p.m. Networking is ranked as one of the most valuable services provided by SFMS. Connect with local physicians and meet SFMS leaders in a relaxed, no-agenda format aimed only at networking! RSVP is required. Please visit http://www.sfms.org/Events.aspx for event details and to RSVP. Wine/beer and hors d’oeuvres will be provided by SFMS.

4/14 SFMS Lobby Day/Legislative Leadership Conference 9:00 p.m.–4:00 p.m. | Sheraton Grand Sacramento | Join SFMS for the annual CMA Legislative Leadership Conference at the State Capitol. The SFMS/CMA Legislative Leadership Conference is an excellent opportunity to learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands-on experience in the practical aspects of physician advocacy. This oneday event includes education sessions on effective advocacy and lobbying techniques, briefings on legislative issues currently before Congress from CMA’s Government Relations team, and afternoon meetings at the Capitol with legislators and their staffs. The event is free to all members. Please contact SFMS at membership@sfms. org or call (415) 561-0850 to register for the event as part of the SFMS delegation. 5/1 Hospital Council Innovation Symposium Crowne Plaza Foster City/San Mateo | Physicians, hospital administrators, and medical executives are invited to imagine, envision, and experience the future of health care at the third annual Innovation Symposium. From Google Glass to 3-D printed organs, new technologies can provide the means to be more efficient, accurate, and effective while helping to improve our performance as care providers. Innovative health care leaders, clinicians, and vendors will share their visions and ideas about how technology is changing the delivery of care. Please contact Lisa Brundage O’Connell at loconnell@hospitalcouncil.net or (925) 746-0728 for event details and registration information.

5/29-31 Western Health Care Leadership Academy Loews Hollywood Hotel | The 18th 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. Visit http://www.westernleadershipacademy.com for event details.

SAN FRANCISCO MEDICINE MARCH 2015 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 Voya® 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 designed to remain level for 10 or 20 full years* • Benefit amounts that never change during the level term period 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. Sponsored by:

Underwritten by: ReliaStar Life Insurance Company, a member of the Voya® family of companies

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 60 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.

Our cancer experts shed light. You’re never in the dark. CPMC brings nationally-recognized cancer experts to our community, including our programs for melanoma led by Dr. Mohammed Kashani-Sabet and gynecologic oncology by Dr. John Chan. We take pride in providing timely access to our expert physicians, and personal follow-up with a patient’s primary or referring physicians means you’re always informed. Comprehensive cancer care at Sutter Health’s CPMC. It’s another way we plus you.

cpmc.org/cancer