May 2012

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

The Healing Team Common Specialties Explained What Does an Occupational Therapist Do? When Should You Get an Ethics Consult?

How Are Nutritionists Trained?

How Can a Social Worker Support Your Patients?

When Is a Psychologist’s Expertise Needed?

Photos from Legislative Leadership Day

VOL. 85 NO. 4 May 2012

MIEC Belongs to Our Policyholders!

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IN THIS ISSUE

SAN FRANCISCO MEDICINE May 2012 Volume 85, Number 4

The Healing Team FEATURE ARTICLES

MONTHLY COLUMNS

14 The Interdisciplinary Team: Why Medicine Is Best as a Team Sport Shieva Khayam-Bashi, MD

4 Membership Matters

16 Sharing the Care: Team Building in Primary Care Amireh Ghorob, MD, and Thomas Bodenheimer, MD

18 Clinical Ethics Consults: The ABCs William Andereck, MD, and Steve Heilig, MPH 19 Occupational Therapists: The Profession Defined Tiffany Tang, OTD, MBA

20 Geriatric Specialists: Providing Comprehensive Care for Older Adults Helen Kao, MD

7 SFMS Advocacy Activities: Legislative Leadership Day 9 Executive Memo Mary Lou Licwinko, JD, MHSA 11 President’s Message Peter J. Curran, MD

13 Editorial Gordon Fung, MD, PhD 32 Hospital News 33 Classified Ad

21 Nurse Practitioners: Enhancing Specialty Practice and Patient Care Mary J. Wong, MSN, ANP-BC

34 In Memoriam Nancy Thomson, MD

24 Social Workers: Support for the Primary Care Team Alice B. Aronow, LCSW, and Karen McCarthy Xavier, LCSW

31 Health Policy Perspective: Book Reviews Steve Heilig, MPH, and John Maa, MD

22 Nutritionists: The Role of Nutritional Professionals on the Healing Team Carol Ceresa, MHSL, RD

25 Psychologists: The Role of Psychologists in Medical Practice Randall B. Smith, PhD 26 Physical Therapists: Providing Support in Rehabilitation Sabrina Yee, PT

27 Office Staff: Administrative Support for the Healing Team Debra Phairas

28 Acupuncturists: Understanding Traditional Chinese Medicine Daniel Jiao, DAOM, LAc, DiplAc, CH & OM (NCCAOM)

29 Team Model for HIV Care: Integrated Teams at Kaiser Permanente Stephen Follansbee, MD Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

OF INTEREST

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members Physicians Advocate for Immunization Bill Package at 2012 Lobby Day More than 400 physicians, including SFMS members, participated in CMA’s Lobby Day on April 17 at the State Capitol.

The SFMS group, represented by leadership as well as at-large members, met with Senator Mark Leno, Assemblywoman Fiona Ma, and legislative aides for Senator Leland Yee and Assemblyman Ammiano.

The group advocated heavily in support of the CMA Immunization Bill Package (AB 2109, AB 2064, SB 1318), Medicare/Medi-Cal reimbursements, and the reinstatement of the CURES program in the California Department of Justice budget. Photos and details from the event can be found on page 7.

SFMS would like to thank the participants for championing the cause of San Francisco physicians and their patients.

We hope to bring an even larger group to Sacramento for Lobby Day 2013.

HealthShare Bay Area Health Information Exchange Update

Eighteen Bay Area health care organizations will be founding members of the region’s first community health information exchange (HIE) program, HealthShare Bay Area (HSBA). HSBA began as a grassroots community initiative and was formed under the auspices of the San Francisco Medical Society Community Service Foundation. It will provide a secure, safe, and interoperable method for exchanging patient health information among providers of care and patients in the San Francisco Bay Area. Read a message about HSBA from the SFMS Executive Director on page 9.

CMS e-prescribing Backlog Reduces Fees to Physicians Despite Hardship Exemptions

California physicians are reporting that they’re seeing a reduction in 2012 Medicare payments for a failure to prescribe enough electronically in 2011, despite the fact that these physicians have filed hardship applications to the Centers for Medicare & Medicaid Services (CMS). CMA is working with CMS to build clarity over whether penalties will apply to physician reimbursement rates going forward and to ease confusion over the process in the future. For now, there is no official appeals process for the e-prescribing penalty program.

However, CMS has expressed a willingness to work with individual physicians on concerns with the payment adjustments.

For more information, visit http://bit.ly/HIhZTi.

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San Francisco Medicine May 2012

SFMS Unveils New Website SFMS now has a new presence on the Internet with the recently revamped www.sfms.org. The new site features a physician finder tool and customizable physician page for each SFMS member; a rotating flash marquee on the home page to promote key benefits, upcoming events, and news; a New Advocacy section that includes guest blogging and/or updates from AMA and CMA; a more robust Membership section with full integration with the SFMS member database to enable online application, renewal, event registration, and member information updates; commenting capability to promote two-way communication and better user engagement; and integration with Issuu to read SFM in e-magazine format. Check out the new www.sfms.org and update your profile today!

2012 Medicare eRx Payment Adjustment Update

SFMS has put together a list of updates to clarify common issues CMS has heard from physicians and other health care professionals regarding the Medicare Electronic Prescribing (eRx) Incentive Program and the 2012 eRx payment adjustment. Visit http://bit.ly/GYEWR6 for more details.

Supreme Court Concludes Hearings on Federal Health Reform Law Case

The Supreme Court concluded three days of oral arguments in the lawsuit challenging the federal health reform law in late March. The debate focused primarily on the conwww.sfms.org

May 2012 stitutionality of the Affordable Care Act, with emphasis on the individual mandate question and whether Congeress is allowed to force states into expanding Medicaid. More details and audio recordings of the oral arguments can be found at http://bit.ly/HiQUYB. The high court is expected to release its decision in late June 2012.

Volume 85, Number 4 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

Complimentary Webinars for SFMS Members

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

June 6: A Manager’s Guide to Lowering Practice Costs • 12:15 p.m. to 1:15 p.m.

June 20: Writing Effective Appeals • 12:15 p.m. to 1:15 p.m.

SFMS Seminar: Creating a “Director of First Impressions”

May 18, 9 am – 12 pm. Creating a positive first impression is essential to the success of a medical practice. Excellent telephone manners and patient relations techniques are key elements in creating and maintaining that positive first impression. This half-day practice management seminar will provide valuable training for both front and back office staff to handle patients and tasks professionally and efficiently using superlative customer service skills. Interactive role playing and a listening skills quiz are used to demonstrate wrong and right ways to interact with patients. $95/each for SFMS/CMA members and their staff ($85 for each additional attendee from the same office); $150/each for nonmembers.

Please contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260, for more information.

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EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD Sashi Amara, MD SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Lauren Estrada

BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Arti D. Desai, MD Roger S. Eng, MD Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD

CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

May 2012 San Francisco Medicine

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San Francisco Medicine May 2012

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SFMS Advocacy Activities Legislative Leadership Day: A Health and Medical Advocacy Day in Sacramento

April 17 was a gorgeous day in Sacramento—sunny but not

too hot, lush vegetation in the Capitol gardens—a terrible day to have to spend indoors. But it was worth it!

Attendance from across the state was impressive, with dozens of medical students and residents joining their somewhat grayer colleagues. San Francisco was well represented both by SFMS leadership and those beginning their training and careers.

We were fortunate to hear directly from Attorney General Kamala Harris and Governor Jerry Ralph Fenn, MD; Jessica Kuo, MBA; Melissa Lorang, MD; Assemblywoman Fiona Ma; Brown about the issues affecting Michael Rokeach, MD; Andrew Calman, MD; George Fouras, MD; Peter Sullivan, MD California health policy and budgets over the next year. Although there was much unpleasant news, at least it was presented in about how to speak on a particular topic. I thought to myself, “Oh, an informed and balanced manner. And the bad news reinforced good, they’re not all perfect at this already. Maybe I can speak up.” how crucially important it is for physicians to lobby and network By the third office, I was ready to present the case for continuwith their legislators and remain politically engaged. ing to fund the CARES program, which is a database containing We had productive meetings with our state senators, asall the controlled substance prescriptions fill by patients at every sembly members, and staff. It was particularly enlightening to pharmacy (other than the VA) throughout the state. I was even discuss Medi-Cal and health budgets with Senator Mark Leno, prepared with a clinical example. who chairs the Senate Budget Committee. His frustration with An unexpected opportunity arose for me to watch part of a some aspects of the Governor’s plans was palpable. So all in all a committee hearing on AB 2109. If passed into law, it would regood day, even if not all the news was good. quire that parents seeking a “personal belief” exemption for vac —Andy Calman, MD cines meet with a health care provider to discuss the risks and Chair, SFMS Political Action Committee benefits. Parents would still be able to refuse to vaccinate but

would no longer be able to do it by simply signing a form at school.

What seemed to me to be a straightforward bill that will better I headed to my first CMA Lobby Day full of curiosity protect children from preventable communicable diseases was and wonder. Having never met a politician, I was reminded being aggressively attacked. Hoards of antivaccinationists from of the anxious excitement of an adolescent hoping to meet a faall over the state were bused to Sacramento to speak against the mous celebrity. Listening to Attorney General Harris and Goverbill. A favorite description of the bill was “unconstitutional,” and nor Brown was both inspiring and humbling. After Jerry Brown’s many parents came parading their children in front of the microspeech I was ready to vote for any tax increase he would throw phone with rehearsed lines about being “vaccine injured.” In a my way, but on the salary of a resident, that is probably easier year where we had the most cases of measles in fifteen years, with to fully endorse. I was impressed by the turnout of physicians, one out of three needing hospitalization, this was shocking to me. residents, and medical students, easily filling a large hall.

But it helps me understand why legal and policy change is so It was easy to get lost in the various wings of the Capitol slow in our country, and why many physicians don’t take the time Building. I was tempted to wander its beautiful historic areas to advocate for change or for our patients. Luckily I have the oppoand learn more about its history, but being prompt for an apsite reaction, and I’m ready to advocate harder for change with evpointment was emphasized most in what we were taught about ery opportunity I get. Now I am excited, instead of nervous, about how to lobby. On entering the first office, belonging to Senator going to Washington, D.C., on May 11 to lobby for children’s menYee, I was happy to stay quiet and listen to other members of tal health issues. Thank you, CMA and SFMS, for this experience. the SFMS speak about funding concerns, senate bills, and assem —Melissa Lorang, MD bly bills with ease, knowledge, and confidence. It was reassuring SFMS Resident Member to see one physician give constructive feedback to a colleague www.sfms.org

May 2012 San Francisco Medicine

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San Francisco Medicine May 2012

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Executive Memo Mary Lou Licwinko, JD, MHSA

SFMS Becomes Health Information Exchange Founding Member After working on developing a health information exchange for San Francisco and the East Bay for more than two years, the San Francisco Medical Society joins with eighteen health care organizations to announce the founding of the exchange.

The development of the exchange, now called HealthShare Bay Area (HSBA), was led by SFMS members Arieh Rosenbaum, MD; Amy Berlin, MD; and John Muir Health HIPAA/HIE Project Manager Dave Minch, all of whom devoted their expertise and countless hours to making the exchange a reality.

In a recent conversation, HSBA Board Chair Dr. Rosenbaum cited the participation of the SFMS as a major factor in the successful development of HSBA. “The San Francisco Medical Society has played a critical role in the success of HSBA, through its business guidance and its generous administrative support, as well through the incorporation of HSBA into its 501(c)(3) Community Service Foundation. Without SFMS, it is unlikely HSBA would be where it is today.”

The following organizations are the eighteen founding members of the region’s first community health information exchange (HIE) program, HealthShare Bay Area (HSBA): Alameda-Contra Costa Medical Association, Alameda County Community Health Center Network, Alameda County Medical Center, Brown & Toland Physicians, California Pacific Medical Center, Glide Health Services, Haight Ashbury-Walden House, Hill Physicians Medical Group, John Muir Health, John Muir Physician Network, Lyon-Martin Health Services, Mission Neighborhood Health Center, North East Medical Services, St. Anthony Medical Clinic, San Francisco Department of Public Health, San Francisco Medical Society, South of Market Health Center, and Women’s Community Clinic.

The HealthShare Bay Area HIE will provide a secure, safe, and interoperable method for exchanging patient health information among providers of care and patients in the San Francisco Bay Area.

In the coming weeks, the founding members will form a governing board for the HIE. The board will then contract with a vendor that will provide the technical infrastructure for the exchange. The chosen technology will operate according to robust data privacy and security standards.

The governing board will also be tasked with securing additional funding for HSBA. The HIE’s four-year, $11 million start-up and operating cost will come primarily from the founding members’ participation fees. Additional federal and private grants will be sought to supplement expenses as HSBA develops. New members joining the exchange in the coming months will provide additional revenue. www.sfms.org

HealthShare Bay Area began as a grassroots community initiative. In August of 2009, the California eHealth Collaborative brought together various San Francisco parties interested in creating a health information exchange within the city. This meeting was precipitated in large part by the passing of the American Reinvestment and Recovery Act (ARRA), which allocated $20 billion for the deployment of health information technology. The ARRA also calls for medical organizations to participate in HIEs. In March of 2010, a governing committee was formed under the auspices of the San Francisco Medical Society Community Service Foundation. A similar movement was also underway in the East Bay with the the Alameda-Contra Costa Health Information Organization. That fall, the San Francisco and East Bay groups joined forces. In April of 2011, the effort officially became HealthShare Bay Area.

Mary Lou Licwinko, JD, MHSA, is executive director of the SFMS.

May 2012 San Francisco Medicine

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PRESIDENT’S MESSAGE Peter J. Curran, MD, and Steve Heilig, MPH

Taxing Tobacco: Clearing the Smoke What is the leading cause of preventable morbidity and mortality in the nation? Tobacco.

What is one proven way to reduce that harm and mitigate associated economic costs?

Taxing tobacco, and using the money for tobacco-related research and other health-oriented purposes. If only it were that simple. Actually, it is conclusively shown that higher tobacco taxes reduce use and provide funds for preventive and treatment efforts, but getting such taxes implemented is the complicated part. We call that “politics.”

Last year, the SFMS brought the following policy to the CMA, under the authorship of CMA trustee and former SFMS president Robert Margolin, MD:

Whereas, the coalition supporting CRCA is led by the American Cancer Society, American Lung Association in California, American Heart Association, Campaign for Tobacco-Free Kids, Stand Up to Cancer, and Livestrong; with CMA absent thus far; now be it

Whereas, the California Cancer Research Act (CRCA) qualified for California’s next statewide ballot after its supporting coalition submitted over 600,000 verified voter signatures; and Whereas, cigarette smoking and other uses of tobacco remain the leading causes of cancer in California, and a leading cause of many other life-threatening health problems, including heart disease and emphysema; and Whereas, California’s cigarette tax is currently 87 cents per pack (with an equivalent tax on other types of tobacco products) and is levied on cigarette distributors who supply cigarettes to retail stores; and the CRCA would increase the existing excise tax on cigarettes by $1 per pack effective 90 days after its passage; and Whereas, the state-mandated independent analysis of the CRCA indicates that it would have the following major impacts: increase in new cigarette tax revenues of about $855 million annually by 2011–12, declining slightly annually thereafter, for various health research and tobacco-related programs; increase of about $45 million annually to existing health, natural resources, and research programs funded by existing tobacco taxes; and increase in state and local sales taxes of about $32 million annually; and Whereas, the funds would be allocated thus: 60% provide grants and loans to support research on prevention, diagnosis, treatment, and potential cures for tobacco-related diseases such as cancer and heart disease; 15% to provide grants and loans to build and lease facilities and provide capital equipment for research on tobacco-related diseases; 20% for tobacco prevention and cessation programs administered by the California Department of Public Health (DPH) and the California Department of Education; 3% allocated to state agencies to support law enforcement efforts to reduce smuggling, tobacco tax evasion, illegal sales of tobacco to minors, and to otherwise improve enforcement of existing law; and 2% deposited into an account that would be used to pay the costs of tax collection and expenses of administering the measure; and

cigarette taxes to raise revenues to support research focused on detecting, preventing, treating, and curing cancer, heart disease, emphysema, and other tobacco-related diseases and to finance prevention programs.

SUPPORTING THE CALIFORNIA CANCER RESEARCH ACT San Francisco Medical Society

www.sfms.org

RESOLVED: That CMA support the concept of increasing

This policy was adopted, and CMA is now in support of Proposition 29, along with a long list of health organizations. On the opposing side? The tobacco industry, of course, but in many guises. Here is just one example of one of its “front groups”: “Paid for by No on 29—Californians Against Out-of-Control Taxes and Spending. Major funding by Philip Morris USA and R.J. Reynolds Tobacco Company, with a coalition of taxpayers, small businesses, law enforcement, and labor.” The “coalition” mentioned consists of a variety of interests bought and paid for by tobacco funds—even associations like the California Hispanic Chambers of Commerce have unfortunately been bribed with tobacco funds. Tobacco funds are paying for $15 million in television ads alone, and much more for anti-Proposition 29 propaganda, much of it recycled from previous specious arguments.

California now ranks thirty-third among states in taxing tobacco. Clearing the tobacco-funded smoke to get California voters to see the wisdom of Proposition 29 will not be easy. But we agree with the Sacramento Bee, which recently editorialized that, despite some reluctance about the initiative process in general, “the potential benefits of raising the tobacco tax outweigh the uncertainties posed by Prop. 29 governance. And that’s the bottom line. To discourage smoking and save lives, California must again raise the tobacco tax. It must again overcome the specious arguments and hired guns of the tobacco barons.” Vote yes on Proposition 29.

May 2012 San Francisco Medicine

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San Francisco Medicine May 2012

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EDITORIAL Gordon Fung, MD, PhD

Team Approach to Medical Care One of the hottest topics in health care reform is the concept of medical teams that can serve a community. The main push for this concept is that there is an impending (or current, according to many) shortage of primary care and specialist physicians to care for the American public.

There has been a push to train more “physician extenders,” which are usually physician assistants (PAs) or advanced nurse practitioners (NPs), and some are even doctors—RNs, PhDs, or DNSs (Doctors of Nursing Sciences). These are nurses with advanced training, perhaps with education in administration or a specialization in clinical practice for, say, heart failure or pacemakers or primary care or family medicine.

Some think-tank groups feel that the practice of medicine needs to keep up with the times, delegating to some of these practitioners or allowing them to practice what their training indicates, including diagnosing and providing treatment for common, uncomplicated ailments as well as taking care of advanced chronic illnesses once diagnoses are made. There is data in the medical literature to support the idea that clinics and hospital services that use PAs and NPs, clinical pharmacists, physical therapists, medical social workers, and a whole host of other providers have at least as good outcomes as totally physician-run practices—in some cases, better outcomes in areas such as diabetes management or heart failure management. Hence the leap to the thought that medical teams—usually headed by physicians—can serve larger numbers of people and portions of the community than the limited number of actual physicians can. This is of special concern given the coming onslaught of patients expected as the baby boomers reach the age of retirement and higher medical need. Thus the development of the patient-centered medical home (PCMH), with its goal of expanding coverage to a community with decreased costs, since the costs of allied health professionals would be less than that of a similar-size group of physicians.

Here is one fact that needs to be considered: Medical teams are not new to practice of medicine. Since the development of hospitals and simple to complex surgeries or medical emergencies, there have been teams—the surgical team composed of the surgeon, the surgical scrub nurse, the recording nurse, the anesthesiologists, the patient-transport person, and everyone else involved in preoperative evaluation and postoperative care. When you add up all the team members involved with one patient going through a surgical procedure, it’s no surprise that the cost of medical care is so high. In medical emergencies there are usually ICU teams, code-blue teams, and rapid response teams, to name a few. Each of these teams is run by a physician or, in the inpatient setting, by a senior nurse, and includes a host of others including pharmacists, lab personnel, anesthesiologists, and technicians. The main difference between these teams and outpatient teams is that the main focus of inpatient teams is the single patient undergoing a procewww.sfms.org

dure, or the critically ill patient who needs the focused attention of the entire team.

The teams were established by experts who reviewed the problem and determined the necessary skills of each team member, outlining the roles and specific tasks for each member to carry out in order to address the crisis or have a successful surgical outcome. In fact, during my training for advanced cardiac life support (ACLS), we physician members were taught that the best team member knows every team member’s role and responsibilities and can switch from one to the other as long as it is within the scope of the person’s practice. But these ideal team members also recognize that, in an emergency, the Good Samaritan Act will protect those who can perform emergency procedures that might be outside of one’s usual practice. This could mean a pharmacist could start an IV line in a code blue situation, or the RN could run the code, which includes interpreting the cardiac rhythm and ordering specific treatment for the patient, depending on his or her interpretation of the ECG. The main difference in these medical teams versus the types of medical teams being discussed in the first paragraph is the focus of the team. In the inpatient setting, the whole team is focused on one patient at a time to get over the acute crisis or procedure through recovery. In the outpatient setting, the team is focusing on many patients, including the health of the overall community.

So can we learn something, from the range of work done by inpatient medical/surgical teams to those in the outpatient setting? I think that it would be important to say right up front that, given the difference in the actual focus of each team, not everything about inpatient teams will be applicable to the outpatient setting.

The one thing that is crucial to any team, though, is that everyone needs to be aware of the roles and responsibilities of every team member in order to have an effective, successful team. So we have tried to amass “The Team” and have members give us some idea of their training and their roles in the team setting. As you will see, there are more team players than we have been able to put into this single issue. However, we did try to get as many as possible. Knowing the team members is only the first step toward having an effective, successful team.

The next steps include training to work together as a team and having practice runs and simulated situations to learn from We hope this issue gets the process started.

May 2012 San Francisco Medicine

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The Healing Team

The Interdisciplinary Team Why Medicine Is Best as a Team Sport Shieva Khayam-Bashi, MD

I played on the varsity tennis team in high school.

It was challenging and fun, but I must admit that I usually felt lonely on the court. The game and its out-

come depended entirely on me and my own performance. In junior high and elementary school, I played on volleyball, basketball, and softball teams, and I recall that these games were a lot more fun. Those games depended on the way that our teammates played together, not on my performance alone.

Like most physicians, I was trained in medical school and residency to be strong, capable, and mostly independent. As growing physicians, we learn to depend on our own skills and work ethic, and we rarely learn to ask for help. But as we gain more experience, we understand that there are limits to our own abilities and knowledge, and there are many times when we need to ask for assistance from our colleagues.

No matter what our specialty, sometimes we need to ask for consultations from other specialists in medicine—surgeons, dermatologists, radiologists, cardiologists, gynecologists, pediatricians, and many others. We also ask for consultations from other disciplines when needed—from nurses, nutritionists, social workers, pharmacists, physical and occupational thera14 15

San Francisco Medicine May 2012

pists, speech therapists, chaplains, to name a few. I believe that the best physicians are those who know when to ask for help in order to serve their patients’ needs best.

When we ask for help, it usually comes in the form of a “consultation”—that is, the ambulatory patient goes to an appointment scheduled with our colleague and returns with a written note summarizing our colleague’s recommendations.

Or, in the hospital setting, our colleague consults on the patient’s care and writes a consultation note in the chart. Too often, there is a vital piece to the process that’s missing—that is, a direct, interpersonal communication that includes the patient, the primary physician, and the consulting clinician.

Though usually helpful medically, this process of sending the patient for consultation can feel divisive to the patient’s feeling of wholeness. Since consultants are being asked to address only a specific problem, and since they do not really know the whole person, the patient may be left feeling less personalized and less whole. The referring primary physician, too, can feel isolated from the opportunity to have a dialogue about the patient whom she knows so well.

The solution to this problem is to find a way in which the www.sfms.org

various clinicians and patients can actually meet in person to discuss each patient’s care together. In this way, they can share various perspectives, communicate clarifying points, and then make the most appropriate decisions to provide the patient with the best care. This is the fundamental principle that is motivating more clinicians to change their practices to involve an “interdisciplinary team” (IDT) model of care.

Interdisciplinary teams are an integral basis for care in many settings, including but not limited to hospice and palliative care, geriatric medicine, integrative medicine, chronic disease management, intensive care units, and skilled nursing facilities. There is much in the medical literature that supports the concept that good interdisciplinary communication leads to improved patient and family satisfaction, decreased length of stay and hospital costs, improved clinical management, higher patient wellness scores, and enhanced clinician/ staff satisfaction.

I am fortunate enough to work in a skilled nursing facility (SNF), as the medical director and attending physician. In the setting of an SNF, it’s required that we meet regularly with an interdisciplinary team to allow for information exchange, patient education, care planning, and team decision making.

We meet formally once each week to discuss each patient’s care and plans. We include the patient and any family members who wish to attend, as well as the physician, nurse practitioner, nursing staff, medical social workers, activity therapists, physical and occupational therapists, pharmacist, nutritionist, chaplains, and ombudsman. At various times, we also include the patient’s primary care provider from the community and any specialty physicians. And sometimes our therapy dog attends as well.

The benefits of having interdisciplinary team meetings are enormous.

Prior to the patient’s entering the room, each discipline takes a moment to share what his/her perspective and experience with the patient has been. In this shared time and place, I have the advantage of learning in much more depth about all the varied aspects of my patient’s life and experience—her diet, appetite, and nutritional intake; pertinent housing and income situation; her social, relational, and family issues; her functional status and mobility, wound care, and pain issues; her ability to think and process clearly; her emotional, psychiatric, and spiritual concerns; and her use of medications, with any drug interactions and side effects. Then the patient and family enter, and for approximately ten to twenty minutes we review her care, answer questions, provide education, and together come up with new plans and goals.

The beauty of these meetings is that each discipline/ team member has a unique perspective and relationship with the patient, and we have a scheduled time and place to communicate and address issues. Invariably, patients and families enter these meetings feeling positively overwhelmed by the sheer size of their team of clinicians—all in the same room together—who actively care for them. After introductions one day, a patient cried out happily, “You all are my team?! Well, I must be doing all right, then!” www.sfms.org

These meetings, as a formal process, are not only helpful to the patient—they are invaluable to the team members as well. Each team member feels that her perspective is valued and respected, and that the sum of all of our expertise and caring leads to the patient’s best healing and wellness.

Though we meet weekly in a formal IDT meeting, we also meet daily in more informal ways to discuss our patients. This usually occurs during our daily morning report, in which we discuss, more briefly, the issues that need more immediate attention. The same effects are seen in both improving the patient’s care and in allowing individual team members perspectives to be heard and valued.

The most important net result of these informal and formal interdisciplinary team meetings is that the patients get more thorough and complete care. The other effects of the process are that there is a much greater sense of satisfaction among all of the team members: The process promotes respect for one another’s expertise and a clear sense of collaboration and collegiality in our shared work. And more, it promotes a feeling of camaraderie and support for one another, which sustains our own sense of provider wellness and ability to continue in this challenging daily work. The IDT practice is useful in the both the ambulatory and inpatient care settings.

Its foremost initial requirement is an organizing leader who makes the approach a priority.

In a prior community clinic practice, I led weekly interdisciplinary team meetings in which the clinicians, practice manager, social workers, pharmacist, and medical assistants met with certain patients who were especially challenging medically or socially. We learned much about the patients in these meetings, and we always came away with greater compassion and understanding, a new and unified plan for the patient’s care, and a greater sense of support for each other and meaning in our work. More and more, inpatient teams are working as interdisciplinary teams as well, and they report similar effects for patients, families, and team members. The only issue of concern cited is the need for creating adequate time to allow for team rounding. While there is indeed a required investment of time, the rewards are tremendous for everyone involved.

Babe Ruth once said, “The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime.” Medicine is most efficacious, least lonely, and most fun when seen and practiced as a team sport. When we care for our patients as an organized and cohesive interdisciplinary team, there are no losers. Everybody wins.

Shieva Khayam-Bashi, MD, is an assistant clinical professor at UCSF School of Medicine and is also director of the shortterm skilled nursing facility at San Francisco General Hospital.

She is also a member of the San Francisco Medicine Editorial Board.

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The Healing Team

Sharing the Care Team Building in Primary Care Amireh Ghorob, MD, and Thomas Bodenheimer, MD Primary care is a team sport. But building successful teams has proven to be difficult. Forming a

dream team is not as simple as thrusting individuals into a group. In order to engage all team members equally, everyone must agree upon the old adage, “There is no ‘I’ in ‘team.’”

For primary care practices to build great teams requires the introduction of several changes into those practices. We call the new team model Share the Care.

Share the Care is both a paradigm shift and a concrete implementation strategy. The paradigm (culture) shift transforms the practice from “I” to “we.” “I” refers to the lonedoctor-with-helpers model, in which the clinician assumes all responsibility, makes all decisions, and delegates tasks to other team members, whose job is to assist the clinician. The language “delegating tasks from doctor to team” suggests that team-building means less work for the doctor and more work for others. Nonclinician team members often resist such delegation. In contrast, the “we” paradigm means reallocated responsibilities, not only tasks, so that all team members share responsibility for and contribute meaningfully to the health of their patient panel. The patient panel is the team’s panel, not the physician’s panel.

What is the difference between delegation of tasks (“I with helpers”) and Share the Care (“we”)? The list of key team characteristics to implement Share the Care are colocation, concrete goals agreed upon by all team members, mapping team work flows, training, regular team meetings, ground rules, and—most important of all—standing orders.

Colocation means that all team members, including clinicians, work together in one space, allowing for easy minuteto-minute communication. Clinicians in colocated practices learn to value working side by side with other team members.

Specific team-created goals allow nonclinician team members to take responsibility for the health of a patient panel. Examples of goals are increasing the percent of appropriate patients receiving colorectal cancer screening from 25 percent to 75 percent by January 1, 2013, or reducing the percent of diabetic patients with HbA1c > 9 from 20 percent to 10 percent by July 1, 2012.

Work flow mapping involves the entire team creating a step-by-step diagram of each primary care process, for example refilling prescriptions or performing panel management (ensuring that all patients receive all evidence-based preventive and chronic care services). Mapping work flows determines the division of labor within the team and indicates how team members interact with each other. The exercise of mapping work flows is in itself a team-building process.

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sponsibilities is evident. Following-up initial training with booster sessions plus mentoring and feedback keep team members’ skill set sharp and up to date. Regular team meetings can provide opportunities for booster sessions; daily huddles organize the day’s work. For communication and decision making, teams need ground rules—such as who makes decisions, what the expectations are for coming to meetings on time, and how is feedback given when a team member is uncooperative—to encourage team cohesion and team spirit.

Perhaps the most essential characteristic of a Share the Care team is need for physician leaders to create standing orders that empower nonclinician team members to assume patient-care responsibilities. Without standing orders, all responsibility and all decisions remain with the clinician.

In a number of high-performing primary care practices, RNs have standing orders to treat—without clinician involvement—positive strep or chlamydia cultures or urinary tract infections in uncomplicated patients. Medical assistants in some practices use standing orders to give routine pediatric and adult immunizations without checking with the clinician.

Other practices adopt standing orders that empower RNs or MAs to refill hypertensive or cholesterol medications for wellcontrolled patients without involving the clinician. Without standing orders, teams cannot share the care.

If team-based care is so difficult, why have teams at all?

Two compelling reasons come to mind. First, given the large panels of most primary care practices, inevitable due to the primary care clinician shortage, clinicians cannot do everything expected of them. It would consume eighteen hours per day for a primary care physician without a team to provide high-quality chronic and preventive care to a panel of 2,500 patients, which is close to the average panel size for U.S. primary care. A team is needed to share chronic and preventive care because the physician cannot do it alone. Secondly, the team is needed to increase capacity for patient encounters in order for a primary care practice to deliver patient-centered access. With a well-functioning team, RNs, pharmacists, and medical assistants trained as health coaches and panel managers can substantially increase the capacity to provide chronic and preventive care, thereby improving access.

Sharing the care requires change on the part of physicians.

Some resist the idea; four main reasons are at play, three of which are valid. First, nonclinician staff may not have the proper training to take on new responsibilities; second, they may not feel accountable for providing high-quality care; www.sfms.org

and third, they may not have time to assume new roles. The fourth, an invalid reason, is that some physicians believe that “only I can do it.” This fourth reason is best addressed by solving the first three: making sure nonclinician staff are well trained in new roles, building in accountability by arranging that clinicians always work with the same nonclinician team members, and analyzing work flows to ensure that everyone has the time and resources needed to do their new jobs well.

If these barriers are overcome, many physicians will come to enjoy sharing the care.

Amireh Ghorob received her MPH degree at Columbia School of Public Health and has been working as a project director and director of training at the Center for Excellence in Primary Care at the University of California, San Francisco.

She has trained hundreds of people in the United States and Canada in health coaching; among the trainees are low-income patients with diabetes who have become health coaches for other patients with diabetes. Health coaches assist people with chronic disease to acquire the knowledge, skills, and confidence to better self-manage their disease.

Thomas Bodenheimer attended Harvard Medical School and finished his internal medicine residency at UCSF. He worked as a full-time primary care internist in San Francisco’s Mission District for thirty-two years, ten years at community health centers and twenty-two years in private practice. He is currently a professor of family and community medicine at UCSF.

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3/20/12 4:0317 PM May 2012 San Francisco Medicine

The Healing Team

CLINICAL ETHICS CONSULTS The ABCs William Andereck, MD, and Steve Heilig, MPH Hospital ethics committees (ECs) have been increasingly common since the 1980s, when a Supreme

Court case stated that each hospital and other health organization should have some mechanism to help deal with ethical issues. This was codified into accreditation standards, and, true to form, most hospitals formed committees. ECs vary widely in form and function, but official guidelines for such committees have specified three primary roles: policy development, clinical education, and case consultation. Consultation is where most medical staff members might encounter an EC at their hospital. The ethics consultation process varies among hospitals, so we can speak primarily about how things occur at CPMC/Sutter Health; your results may vary.

What is an ethics consult and why might I need one for a case? Sometimes there are different values repre-

sented by patients, surrogates, or other medical providers that come in conflict with the goals of care as envisioned by the attending physician. We can all live with differences of opinion, but there are times, particularly in an emotion-laden experience like a hospitalization, when differences can become more intense. Other times a physician just wants some advice on a troubling situation.

Who can call a consultation? When ethics committees were first established, this tended to be a physician-only option, but in many hospitals that has broadened. At all the Sutter West Bay Hospitals, anyone involved in the care of a patient may request a consultation—the patient and his or her surrogates, physicians, nurses, social workers, and consultants. Physicians and nurses request most consults, although we receive requests from social services and case managers as well. Last year 14 percent were anonymous, and 8 percent came from patients.

Who will conduct the consultation? Most of our requests for consultation are received on our confidential hotline, which is posted on the hospital floors. The committee chair or our bioethicist, Ruchika Mishra, PhD, contacts the requestor for information about the case. The attending physician is then contacted for additional information and perspective on the case.

After an initial evaluation, three methods of evaluation can occur. If the case is relatively straightforward, and not contentious, the clinical ethicist or the chair can complete the evaluation and recommendation. When consultations involve more difficult issues or legal implications, a subcommittee of three members of the EC conducts the consultation. Finally, if the issue is not time sensitive, the committee will discuss it at its monthly meeting.

What is the consultation process? In almost all cases,

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ables, such as the presence of an advance directive. In most cases, a family/medical team meeting is scheduled about forty-eight hours after the consult is received. In the meantime the clinical ethicist, or subcommittee member, explores the competing moral values in the case, from the viewpoint of each person involved. The bioethics literature is reviewed and legal and hospital policies are consulted.

The process is part mediation, part information providing, part emotional support, and part exhortation to action. In most cases, by the time the meeting arrives, a skilled ethics consultant is able to help navigate the moral problems and agree to a course of action based on the goals of care identified in the ethics consultation. An effort is made to discuss the recommendations verbally with both the consult requestor and the attending physician before a formal note is placed in the medical record documenting the recommendations. Like any other consultation, all EC recommendations are advisory. The entire EC meets monthly and reviews the details and recommendations made in each case.

What are the most common types of cases seen in ethics consults? We have conducted more than 750 ethics

consultations at CPMC alone since the committee got started, and we now are on pace to conduct about 100 a year. We find that most of our consultations cluster into four categories: requests for nonbeneficial or “futile” treatments; patients who are incapacitated and have no one to represent them in medical decision making; and the “hateful patient”—the abusive, noncompliant individual who thwarts his or her own care with self-destructive behavior. The fourth category we now refer to as “uncoordinated care.” These cases often involve a lack of trust between patients and their caregivers due to frequent change of physician personnel. They also include disagreements among the medical team, or teams, which leads to dysfunctional decision making resulting from unclear goals.

A good ethics committee, and consult, constitutes a prime example of how a team approach can work. Multiple disciplines are involved, with the aim of providing the broadest perspectives to the primary clinicians caring for a patient. In our experience, once a physician avails him or herself of this service, either by request or default, initial skepticism about the approach often gives way to gratitude for the assistance offered. In fact, sometimes physicians and others who resisted a consult at first become our biggest fans—even to the point where we feel the need to dissuade them from calling at the slightest provocation!

Dr. Andereck is codirector of the Program in Medicine and Human Values (PMHV) at Sutter West Bay, longtime chair of the CPMC ethics committee, and former editor of San Francisco Medicine. Steve Heilig is with both the SFMS and the PMHV. www.sfms.org

The Healing Team

OCCUPATIONAL THERAPIST The Profession Defined Tiffany Tang, OTD, MBA The occupational therapist (OT) probably is one of the more obscure members in the health care team.

Many patients, including some health care providers, don’t really understand what occupational therapy is about. According to the American Occupational Therapy Association executive board (1976), occupational therapy is defined as “the therapeutic use of work, self-care, and play activities to increase development and prevent disability. It may include adaptation of task or environment to achieve maximum independence and to enhance the quality of life.” In its simplest terms, occupational therapy practitioners help people across the lifespan participate in the things they want and need to do, through the therapeutic use of everyday activities (occupations).

What does It take to be an OT? Occupational therapy practitioners can be credentialed as occupational therapists (OT) or as occupational therapy assistants (OTA); they are educated in science as well as in liberal arts. Besides physiology, kinesiology, anatomy, and pathology, occupational therapy education also includes study of human development, psychology, sociology, and anthropology. These educational focuses are the ones that set occupational therapy apart from physical therapy. The entry-level education for an occupational therapist can be either a master’s or doctoral degree, whereas the entry-level education for an occupational therapy assistant is an associate degree. Both OTs and OTAs must complete a supervised fieldwork program during their studies and pass a national certification exam; most states also require continuing education courses to be taken to maintain licensing.

What do OTs do? Occupational therapists (OTs) help people

of all ages improve their ability to perform tasks in their daily living and working environments. They work with individuals who have conditions that are mentally, physically, developmentally, socially, or emotionally disabling. They also help them develop, recover, or maintain daily living and work skills. Occupational therapists help clients improve their basic motor functions and reasoning abilities and also compensate for permanent loss of function. Occupational therapists assist clients in performing activities of all types, ranging from using a computer to caring for daily needs such as dressing, cooking, and eating. Physical exercises may be used to increase strength and dexterity, while other activities may be chosen to improve visual acuity and the ability to discern patterns. For example, a client with short-term memory loss might be encouraged to make lists to aid recall, and a person with coordination problems might be assigned exercises to improve hand-eye coordination. Occupational therapists are also skilled in the design and fabrication of custom orthoses (splints) to protect an injured or healing body part, prevent or decrease deformity, support weak muscles, or facilitate www.sfms.org

function. Occupational therapists also use computer programs to help clients improve decision making, abstract reasoning, problem solving, and perceptual skills as well as memory, sequencing, and coordination—all of which are important for independent living.

In addition, occupational therapists are often skilled in psychological strategies such as cognitive behavioral therapy; they may use cognitive therapy especially when introducing people to new strategies for carrying out daily activities, such as activity pacing or using effective communication strategies.

Patients with permanent disabilities, such as spinal cord injuries, cerebral palsy, or muscular dystrophy, often need special instruction to master certain daily tasks. For these individuals, therapists demonstrate the use of adaptive equipment, including wheelchairs, orthoses, eating aids, and dressing aids. They also design or build special equipment needed at home or at work, including computer-aided adaptive equipment. They teach clients how to use the equipment to improve communication and control various situations in their environment. Some occupational therapists treat individuals whose ability to function in a work environment has been impaired. These practitioners might arrange employment, evaluate the work space, plan work activities, and assess the client’s progress. Therapists also may collaborate with the client and the employer to modify the work environment so that the client can succeed at work.

Where do OTs practice? Occupational therapy practitio-

ners work in a wide variety of settings, including schools, hospitals, subacute rehabilitation facilities, nursing facilities, outpatient clinics, home health, hospice, assisted-living facilities, academic settings, mental health, and private practice.

As occupational therapy’s goal is to enhance the individual’s participation in activities of daily living, some occupational therapy practitioners have entered into other emerging practices in recent years, such as life skills training, health and wellness, productive aging, work and industry, and case management—areas that involve in improving and enhancing one’s quality of life. With our health care dollar shrinking and health care reform fast approaching, higher accountability will be demanded by payers. In order for occupational therapy to remain an important player in health care, the profession has been stepping up its efforts to embrace evidence-based practice to show that health care dollars spent on occupational therapy services are worth the cost.

Tiffany Tang, OTD, MBA, has been an occupational therapist for more than twenty years. She is also a certified hand therapist, certified ergonomic assessment specialist, and certified functional capacity evaluator. She is currently the lead occupational therapist at the CPMC Davies Campus outpatient occupational therapy department.

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The Healing Team

GERIATRIC SPECIALISTS Providing Comprehensive Care for Older Adults Helen Kao, MD Geriatricians are far more than just physicians who “take care of older adults.” Most physicians care

for older adults because our nation’s population is aging. This is accompanied by an increasing burden of complex chronic medical conditions; with these conditions come variable disability and dependency. Just as pediatricians care for patients at the beginning of their lives, geriatricians care for patients approaching the end of their lives. We pride ourselves on being both realistic and passionate about caring for patients who require expertise in the complex issues related to this phase.

Geriatricians specialize in the care of older adults who have concerns about aging, face physical or cognitive impairments, and, in the case of many, despite the many advances in medicine, grow increasingly frail and disabled. Such impairments and concerns may include confusion; changes in mood or behavior; depression or anxiety; memory loss; increasing weakness, weight loss, disability, or frailty; falling and trouble walking; bowel or bladder incontinence; issues regarding driving safety; questions about or problems with medications; need for more caregiving help, or becoming homebound; concerns about elder abuse, neglect, and capacity; questions about home safety and one’s ability to remain independent; and concerns about advanced financial or health care goal planning.

Geriatrics is less defined by a specific age cutoff; rather, it is about caring for patients who are “slowing down” as part of their aging process. A core philosophy of geriatrics is to emphasize and address how and what a patient feels because of his or her medical conditions (e.g., fatigue, dizziness, loss of “spunk”), rather than to primarily focus on global quality measures that drive traditional chronic care management for younger adults (e.g., glucose and cholesterol levels, blood pressure goals, etc.). We are particularly attuned to how we, and the interdisciplinary teams with whom we collaborate, can and should modify “usual care” to fit our patients’ needs and priorities. Additionally, because geriatricians often care for the frailest of the frail, especially in the increasing number of house-calls practices, the integration of geriatrics and palliative care is particularly salient.

The practice of a geriatrician is unique in that we are specialists and generalists at the same time. Rather than narrowing our scope of care to a specific organ system or disease state, our practice focuses on the way that medical conditions coexist and interact with our patient’s environments, psychosocial stressors, and physical abilities to enhance or impede independence, comfort, and quality of life. Specifically, we focus on critically evaluating the full spectrum of patients’ conditions and treatments and the impact they have on patient (and caregiver) function and quality of life; addressing the interaction between our patients and their family/caregivers and their environment; applying our 20 San 21 SanFrancisco FranciscoMedicine Medicine May May2012 2012

skills to helping patients navigate physical and cognitive decline; and working intensely with multidisciplinary providers beyond medicine (e.g., nurses, social workers, rehabilitation specialists, and others) in a team approach.

Additionally, because geriatricians train throughout the spectrum of care settings (clinics, inpatient hospitals, nursing homes, patient homes, and in-home or residential hospices), we are uniquely trained to understand the complex infrastructure of care settings; to understand how care processes function in each clinical setting, and how transitions of care can be optimized between them. Our expertise in the clinical settings traversed by most frail older adults—nursing facilities, home-based care, and hospice— allows us to better collaborate with care teams at each stage to optimize patients’ function and quality of life.

Geriatricians can serve dual roles as primary care providers and specialty consultants. Because there will never be sufficient numbers of geriatricians to provide primary care for our nation’s aging population, geriatricians frequently serve in consultative and educational capacities to provide accessible geriatrics expertise to our health care colleagues in the community. Our expertise is best suited to help primary care and specialty physicians with the care of complex elders: for example, in the management of psychological and behavioral manifestations of dementia; or assessment, evaluation, and care planning for patients experiencing precipitous functional or cognitive declines (the ones often labeled “failure to thrive”). Patients who are homebound, or completely bedbound, can be referred for home-based geriatrics consults or can be offered transition to a house-calls practice.

We geriatricians welcome referrals from our colleagues who care for older adults with geriatric syndromes (such as falling, incontinence, or vision or hearing impairment), complicated dementia, or functional impairments. We aim to help our peers care comprehensively for older patients and their caregivers to optimize symptom control, independence, and quality of life for older adults and to decrease suffering of both patients and their families.

The field of geriatrics touches on the vast scope of human experience. As such, this work is immensely rewarding professionally and personally. Despite the shortage of geriatricians in the country, for those of us who have found our calling in this unique practice, it comes as no surprise to us that geriatricians regularly rank their career satisfaction highest among all physicians. In collaborating with our peers to care for the frailest patients, we hope to improve the quality of life of our patients and their families.

Helen Kao, MD, is an assistant professor of medicine and geriatrics at UCSF. She is also medical director of Geriatrics Clinical Programs, including UCSF Housecalls and the Geriatrics Transitions, Consultation, and Comprehensive Care practice (GeriTraCCC), which she founded in 2010. www.sfms.org

The Healing Team

NURSE PRACTITIONERS Enhancing Specialty Practice and Patient Care Mary J. Wong, MSN, ANP-BC I work with an attending who raised three boys, and his hobbies revolve around sports. All his analo-

gies of life and patient care are sports oriented. He has taught me that in many sports, it is teamwork that builds character and wins games. Being a nurse practitioner (NP) in a specialty practice, especially cardiology, requires a lot of teamwork.

The NP is a lot like the point guard on a basketball team. The point guard doesn’t have to be the star to be a critical member of the team, but the player knows what is happening all over the court and distributes the ball to the scorers in the right place and at the right time.

The role of an NP was initially established in the 1960s to fill a void in primary health care providers in underserved areas. The role has since evolved and has been used in many areas including primary care, specialties, schools, clinics, and hospitals. There are currently more than 16,000 NPs in California and 140,000 practicing NPs in the U.S. The basic training of an NP requires a master’s degree, doctoral degree, or equivalent. The NP is trained to function independently to diagnose and treat acute and chronic conditions. NPs work under standardized protocols in the state of California. The protocols are agreed upon between the supervising physician(s) and the NP. The NP also adheres to the standards set by the State Board of Nursing. NPs have prescriptive privileges that may differ depending on the state one is practicing in. I received my master’s degree at the University of Pennsylvania and completed a post-master’s NP program at UCSF. My own personal training is enhanced through continuing education courses through the American College of Cardiology, Heart Rhythm Society, and cardiac device manufacturers, as my particular areas of interest are in cardiac arrhythmias, heart failure, and heart rhythm devices.

I have worked for more than ten years in a cardiology practice comprised of four cardiologists and two NPs. In my practice, the NPs provide specialized care to patients and often bridge the gap between the patient and physician. I was initially hired in 2001 as a provider to patients who would otherwise have had to be rescheduled when the cardiologist/ interventionist would need to leave abruptly to tend to an acute MI or other urgent procedure in the hospital. I was able to step in and see these patients whose care would otherwise be delayed. My typical work day includes fielding questions regarding anticoagulants/antiplatelet agents and pacemaker/defibrillator patients needing anything from MRIs to surgery. I see patients for post-procedural and surgical followup, chronic cardiology problems such as heart failure and atrial fibrillation, and urgent appointments—chest pain, arrhythmias, or anything else deemed urgent by the patient or www.sfms.org

another health care provider. My expertise allows the patients to be seen and assessed quickly and triaged.

Are patient’s happy with care from an NP? A metanalysis of eleven randomized control trials and twenty-three observational studies found patients were more satisfied with care from an NP and no differences in health status were found (Horrocks et al 2002). In addition, NPs have been shown to decrease the overall health care cost as well as generate revenue. A study compared hospitalizations, medical costs, and patient satisfaction before and after the introduction of an NP in a heart failure clinic. The number of yearly hospitalizations decreased from 2.8 to 0.7 with a decrease in total yearly medical cost of $131,175 (Cintron et al 1983).

If a patient feels uncomfortable seeing me and would rather see his or her physician, we try to accommodate those wishes even though the most expeditious way to get to the physician may be through the NP. Sometimes patients are reluctant to see an NP because of their lack of knowledge and familiarity with NPs and their skill level. However, most patients, once they have worked with an NP, are just as comfortable with the care given. Patients often share details of their life and health with me that they are uncomfortable sharing with their physician. Some patients perceive my role as less threatening than that of the doctor, and thus they feel more open to sharing.

It’s important to keep the patient in mind when implementing an NP into a practice. My goal as an NP is to care for patients competently and efficiently. The use of a team approach is essential to providing the best care for the patient.

If the patient’s attending is in the office and has a moment when the patient is seeing me, I try to get him or her to come into the exam room so I can provide information about the patient. Patients are reassured in these brief encounters that their doctors are aware of their conditions and agree with the plan, which does wonders to decrease patients’ anxieties.

As demands increase on physicians, incorporating an NP in the practice may be the answer to meet the needs of the patient efficiently, competently, and cost effectively. I am lucky to work in collaboration with some incredibly smart, talented, and caring cardiologists. My training and my length of experience in my specialty area make me uniquely qualified to care for these patients, but when questions or problems arise, I don’t hesitate to consult with my physician team.

Mary Wong, MSN, ANP-BC, is a cardiology nurse practitioner at Golden Gate Cardiology and a clinical preceptor for UCSF NP students.

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The Healing Team

NUTRITIONISTS The Role of Nutritional Professionals on the Healing Team Carol Ceresa, MHSL, RD The role of nutrition in health and illness, although constantly evolving, is well established. The nutrition

professionals, registered dietitian, and dietetic technician, registered (working under the supervision of the dietitian) have a wide variety of roles across the continuum of care to both support healthy eating behavioral changes and to provide effective intervention—specifically, medical nutrition therapy (MNT) for specific medical diagnoses and conditions. Just as there are physician generalists and specialists, there are generalist registered dietitians and specialized dietitians. The specialty dietitians include board-certified dietitians for pediatrics, geriatrics, renal, oncology, diabetes, and nutrition support (enteral and parenteral nutrition).

Examples of selected practice areas and the role of nutrition professionals on the healing team in my work setting, the San Francisco VAMC, are as follows:

Ambulatory Care

Diabetes Education/Treatment: Interdisciplinary diabetes management includes RD/CDE (registered dietitian, certified diabetes educators). Eighty-six percent of veterans enrolled in the SFVAMC “Living Well with Diabetes” program have shown a significant reduction (achieving an A1c level of <7.0%) of hemoglobin A1c levels, which improves quality of life and greatly reduces risk of diabetes complications.

Weight management/bariatric surgery: RDs work with

empowering and enabling patients to take charge of attaining and maintaining a healthy weight—and, if need be, they provide guidance and assistance to support them through a process of longterm eating and lifestyle changes related to bariatric surgery and gastric reduction.

General surgery: Before and after selected significant surgeries, nutrition referrals are made by surgeons to insure optimal nutrition intake and status before surgery as well as during the recovery and healing phase.

Specialty clinics (renal, dialysis treatment, liver, heart failure, endocrine, GI/inflammatory bowel disease, Parkinson’s clinic, etc.): Referrals are made by

the health care team for predialysis patients with the goal of deferring or delaying dialysis. Nutrition intervention and education are critical for patients receiving dialysis and for many other special medical conditions that have resulted in altered labs, weight, and GI tolerance.

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Home care: The RD working with the home care teams works with primarily frail, elderly patients and their families and caregivers to insure that they are consuming sufficient quantities and quality of food and nutrients to maintain strength, feel healthy, and manage chronic or acute disease.

Primary care clinics: In the primary care setting, dietitians work collaboratively with team members to insure a case management approach to addressing patient- or team-surfaced problems. Food and eating behaviors interrelate to many of the action plans recommended by the team for improved patient/client health. Drop-in nutrition clinics, nutrition telephone clinics, nutrition clinics by videoconferencing, and shared medical appointments are all constructs for effective, healing health care in team/ patient-centered care.

Health promotion: DTRs and RDs provide health promotion and disease prevention in nutrition-focused programs, including a healthy cooking class to support healthy eating behavior changes.

Food-drug, nutrient-drug education: The RD works closely with the pharmacist to ensure that patients receive appropriate, timely education about selected medications with significant risk, such as anticoagulants, insulin, hypoglycemic agents, corticosteroids, cholesterol lowering medications, etc.

Inpatient

Acute care: Studies have consistently shown that up to 65 percent of hospital patients are malnourished or at nutritional risk. Malnutrition is a large, hidden component of quality and cost challenges in all health care. Multidisciplinary awareness and collaboration is key to improving patient outcomes. Joint Commission expects that every patient admitted to acute care is screened for nutrition problems (by nursing or other health care team members); nutrition consults are entered by physicians to have the dietitian address identified problems, such as significant weight loss and food allergies/intolerances. Nutrition education needs to enable patients to self-manage their diet and nutrition status and, in some cases, to assess, recommend, and monitor nutrition support (tube feeding/enteral nutrition or parenteral nutrition), both while in the hospital and, sometimes, following discharge. The DTR assists dietitians with aspects of the nutrition care process and performs the NCP for selected patients, such as heart-healthy education following cardiac bypass surgery, or sodium-controlled nutrition education for patients with congestive heart failure. www.sfms.org

CLC, or Community Living Center (skilled nursing): Every resident admitted to the CLC , by national OBRA mandate, receives a comprehensive nutrition assessment, nutrition care planning, and monitoring.

Studies show that for every $1.00 spent on nutrition screening and intervention, at least $3.25 are saved (Nutrition Screening Initiative Nutrition in the Elderly, www.aafp.org).

See also Nutrition and Healthy Aging in the Community: Workshop Summary, www.nap.edu/catalog.php?record_id=13344.

The Nutrition Care Process

Step 1: Nutrition Assessment—A systematic method for obtaining, verifying, and interpreting data needed to identify nutrition-related problems and their causes and significance. It is an ongoing, dynamic process that involves initial data collection, continual reassessment, and analysis of the patient/client’s status compared to specified criteria.

Step 2: Nutrition Diagnosis—A critical step between nutrition assessment and intervention. The purpose of nutrition diagnoses language is to describe nutrition problems consistently, so that they are clear within and outside the profession. The standardized language enhances communication and documentation of nutrition care, providing a minimum data set and common data elements for future research.

Step 3: Nutrition Intervention—Uses specific actions to remedy a nutrition diagnosis problem. Planning and implementation are two interrelated components.

Step 4: Monitoring and Evaluation—Quantifies progress made

by the patient/client in meeting nutrition care goals. Nutrition care outcomes, the desired results of nutrition care, have been defined and measured compared to patient/client progress.

Qualifications of a Registered Dietitian

A registered dietitian is a food and nutrition expert who has met academic and professional requirements including: A bachelor’s degree with course work approved by the Academy of Nutrition and Dietetics Accreditation Council for Education in Nutrition and Dietetics (ACEND). Course work typically includes food and nutrition sciences, food service systems management, business, economics, computer science, sociology, biochemistry, physiology, microbiology, and chemistry; completion of an accredited, supervised practice program at a health care facility, community agency, or food service corporation; successful completion of a national examination administered by the Commission on Dietetic Registration; completion of continuing professional educational requirements to maintain registration.

What Services Do RDs Provide?

The majority of registered dietitians work in the treatment and prevention of disease (administering medical nutrition therapy, working as part of a medical team), often in hospitals, HMOs, private practice, or other health care facilities. In addition, a large number of registered dietitians work in community and public health settings and academia and research. A growing number of www.sfms.org

registered dietitians work with food and nutrition industry and business, journalism, sports nutrition, corporate wellness programs, and other nontraditional work settings.

What Is a Dietetic Technician, Registered?

A dietetic technician, registered, often works in partnership with registered dietitians and screens, evaluates, and educates patients; manages and prevents diseases such as diabetes and obesity; and monitors patients’ and clients’ progress. DTRs work in settings such as hospitals and clinics, extended-care facilities, home health care programs, schools, correctional facilities, restaurants, food companies, food service provider organizations, public health agencies, government and community programs such as Meals on Wheels, health clubs, weight management clinics, and wellness centers. DTRs have met one of the following criteria to earn the credential: (1) Completion of a two-year associate degree granted by a U.S. regionally accredited college or university, completion of dietetic technician program requirements in an ACEND-accredited program, successful completion of a national written examination administered by the Commission on Dietetic Registration (CDR), and completion of continuing professional educational requirements to maintain registration (2) Completion of a baccalaureate degree granted by a U.S. regionally accredited college or university or foreign equivalent, completion of an ACEND-accredited DPD program, completion of an ACEND-accredited dietetic technician supervised practice, passage of a national written examination administered by CDR, and completion of continuing professional educational requirements to maintain registration

How RD Services Can Help Your Practice

RDs provide a nutrition assessment, determine the nutrition diagnosis, determine and implement a nutrition intervention, and then, in subsequent visits, monitor and evaluate the patient’s progress. Nutrition education for disease prevention and nutrition counseling for chronic conditions provided over a series of visits are essential components of a comprehensive health care program.

Medical nutrition therapy provided by RDs can improve a patient’s health and well-being and increase satisfaction levels through decreased hospitalizations and reduced prescription drug use. Medical nutrition therapy improves patient outcomes and quality of life and lowers health care costs. Medicare covers outpatient MNT provided by registered dietitians for beneficiaries with diabetes, chronic renal insufficiency/end-stage renal disease (nondialysis renal disease), or post-kidney transplant.

Many other private insurance companies also cover MNT services for a variety of conditions and diseases. The Institute of Medicine identifies registered dietitians as qualified professionals for nutrition therapy. According to IOM, “the registered dietitian is currently the single identifiable group of health-care professionals with standardized education, clinical training, continuing education, and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy.”

Carol Ceresa, MHSL, RD, is clinical nutrition section chief at the San Francisco VA Medical Center.

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The Healing Team

SOCIAL WORKERS Support for the Primary Care Team Alice B. Aronow, LCSW, and Karen McCarthy Xavier, LCSW The Department of Veterans Affairs (VA) recognizes the importance of a patient-centered approach and is implementing a patient-aligned care team (PACT) model. The core team consists of a provider (physician or nurse

practitioner), registered nurse, vocational nurse, and clerk. Other support professionals include a social worker, dietitian, occupational and physical therapist, psychologist, and pharmacist.

How Does a Social Worker Fit into a PACT?

A PACT can be implemented in a community physician’s office through referrals to independent social workers or having a provider group employ a social worker for their patients. Social workers prepare for a health care career through training: a twoyear master’s degree with a focus on human development and two practical internships in hospitals, clinics, or social agencies. Their expertise lies in their ability to assess a patient in his or her own environment, evaluating mental status, family situation, finances, housing, employment, functional status, resources, legal issues, strengths, and ability to plan. From this assessment the social worker can help develop a care plan with other PACT members.

How Can a Social Worker Help?

Ideally, there would be a social worker for every two PACTs, serving about 2,400 patients. In practice, the provider might work with a social worker on a referral basis, to help with progressive, debilitating illness, including dementia; need for increased home support; noncompliance related to inadequate psychosocial support; future care and placement planning; caregiver support/respite/family stress; abuse and neglect; benefits and finances; and advance directive education.

Example: Social Work in the Management of Dementia

A dementia patient presents unique challenges. Beyond diagnostic and medical treatment issues, a primary care provider is faced with deciding whether the patient is safe at home. This is where the social worker can help. Social workers assess how a patient is functioning in the community and what his or her support system looks like. They may contact family members, a building manager, neighbors, and any home health professionals who are involved. They can address safety concerns, evaluate for self-neglect, and involve Adult Protective Services when indicated.

Much of the social worker’s role is to identify who constitutes the patient’s support system and work with those contacts to activate them so they will provide any supervision and support the patient needs. Social work interventions address both family and community resources. Social workers look to the community to provide help in the home, home-delivered meals, transportation alterna-

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tives, adult day care, medication reminders, and support groups.

They access resources according to a patient’s income, savings, and eligibility factors.

Family involvement: To begin, the social worker joins the primary care provider, nurse, and other available team members in a family meeting to equip the family to cope with the situation and plan for the future. The family hears from the team what they can realistically expect will be the course of the patient’s future functioning, and it gives the team permission to intervene. The social worker plans future meetings with the family and concerned friends to educate them about strategies and resources for patient care. Acknowledging the strain family caregivers experience, the social worker can link them to respite programs and caregiver resources for support groups and classes. The social worker can provide counseling around role change, loss, and grief and can continually monitor a patient and family, assuring that they’re connected with resources. If a patient is admitted to a hospital, the social worker can communicate with the inpatient social worker or discharge planner about the patient’s history and situation and be involved as an advocate for the family in developing an appropriate discharge plan. If there’s a change in living situation, the patient and family can turn to the social worker again for assistance with that transition.

Social worker/team interaction: Social workers work in-

dependently but not in a vacuum. Frequently they’ll report back to the PACT about the patient’s status and any needed assistance, such as medical or rehabilitation information to support applying for benefits or programs, or testing to determine appropriate level of care. If they observe behavioral or physical changes, they may recommend reassessment. When it becomes clear that a patient needs out-of-home placement, the social worker can advise on options. When the patient is unable to manage his funds or make decisions, the social worker may be the one who knows about the change and alerts the team to the possible need for a conservatorship evaluation.

It takes a village . . . or, if not a whole village, at least a team, to provide comprehensive outpatient care, especially when a primary care provider has a large panel of patients and limited time to spend with each one during the office visit. The team members— including the social worker—can pool their expertise and extend the scope of the medical practitioner so the needs of the whole patient are addressed.

Alice B. Aronow, LCSW, is assistant chief of social work service at the SFVAMC. Karen McCarthy Xavier, LCSW, is supervisor of ambulatory care social work at the SFVAMC. www.sfms.org

The Healing Team

PSYCHOLOGISTS The Role of Psychologists in Medical Practice Randall B. Smith, PhD Psychologists are licensed by California to practice independently. In addition to completing a PhD/PsyD, two

years of predoctoral and postdoctoral clinical training are required before taking the board examination for licensure. Psychologists have specific training with regard to general scientific methodologies, psychopathology, the clinical evaluation process, psychotherapy, and psychological/neuropsychological testing. There are, broadly speaking, four primary areas of specialization that are relevant to practicing physicians. These include clinical psychology, neuropsychology, health psychology, and medical-legal (forensic) psychology.

Clinical psychologists focus on treating individuals, couples, and families with demonstrable psychopathology, such as affective disorders, adjustment disorders, PTSD, maladaptive patterns of behavior, and a variety of other functional problems that physicians often observe independent of, or concomitant with, medical problems that prompt patient appointments. Of course, the pharmacologic treatment of significant affective disorders must be provided by a psychiatrist or a knowledgeable physician of another specialty. The treatment provided by psychologists involves some form of psychotherapeutic intervention, most commonly cognitive-behavioral therapy (CBT) or psychoanalytic psychotherapy.

Some, but not all, psychologists also have specific expertise in administering, scoring, and interpreting cognitive and psychological test measures. If a referral is made for such services, the physician should ensure that the psychologist is very familiar with the uses and misuses of test data, knowledgeable about a broad array of test measures, familiar with sophisticated validity measures used to clarify whether full effort has been put forth on tests of maximal performance, and adept at differential diagnosis.

Although there are many forms of therapy that may be used by psychologists, the two most common forms are cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy. CBT focuses on immediate adaptive difficulties, underlying dysfunctional and unrealistic beliefs, and the development of more realistic coping resources. This treatment is often time limited, goal directed, and focal in nature. There is less attention paid to elucidating an individual’s formative years.

Psychoanalytic psychotherapy focuses on the adverse impact of events and trauma from an individual’s formative years on their development and functioning during adult life. Understanding the psychogenetic underpinnings for current dysfunctional attitudes, beliefs, emotions, and behavior is thought to be essential to developing a new understanding of self and others and to enabling a better overall level of resilient adaptation. The patient’s specific relational idiosyncrasies with the therapist are viewed as important information about psychological structures and are used to facilitate an understanding of adverse effects of early psychologiwww.sfms.org

cal traumas and difficulties in adapting. This treatment is often an open-ended and relatively long-term process.

Neuropsychology is a second specialization area that involves the careful coordination of a thorough history and mental status examination with a broad array of specific cognitive, neuropsychological, and psychological test measures. Such an evaluation process is used to assess sensory input and behavioral output in relationship to such problems as traumatic brain injuries, dementia form disorders, toxic substance exposures, hypoxia/anoxia, and a wide variety of other conditions that can result in disruption to cognitive processes. Such services are often used by neurologists and rehabilitation medicine specialists. These evaluations are often lengthy, involving an interview process of two to three hours, followed by administering, scoring, and interpreting an array of tests that might take five to eight hours. In the context of using sophisticated validity measures to make sure that a full effort was put forth throughout the examination process, test data can provide detailed and accurate information about an individual’s adaptive resources and functional limitations. Domains that may be covered in a general evaluation include a patient’s capacity for attention, concentration, selective attention, divided attention, constructive inhibition of an overlearned response set, working memory, short-term and delayed memory, visuomotor functioning, processing speed, and various “executive” capacities. The level of detail derived from such testing far exceeds what can be obtained via a simple mental status examination. In addition to its use in providing great detail about an individual’s present status, such data can serve as a basis for assessing changes in functioning over time, something particularly relevant in disorders that may be progressive.

Psychologists who specialize in the area of health psychology often work in conjunction with specific hospital and medical center departments. In such circumstances, the accumulated literature clearly points to the importance of psychological and emotional variables in terms of the outcome of medical treatment, surgery, and other interventions. Health psychologists have developed specific assessment methodologies and treatment protocols for dealing with the psychosocial variables that are considered to be relevant to prognoses for improvement and recovery.

Given the significant comorbidity of many medical and psychiatric problems, physicians are strongly encouraged to develop familiarity with an array of psychologists and psychiatrists who are best suited to their professional needs. The names of such individuals can be obtained through professional societies or from trusted colleagues.

Randall B. Smith, PhD, is a clinical psychologist and neuropsychologist who practices in San Francisco. In the past, he was the director of outpatient psychiatry at CPMC and is now in full-time private practice.

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The Healing Team

PHYSICAL THERAPISTS Providing Support in Rehabilitation Sabrina Yee, PT Physical therapists are health care professionals who specialize in the treatment of neuromusculoskeletal conditions. They can also address impairments and

dysfunction in the cardiovascular/pulmonary and integumentary systems of the body. Physical therapists are experts in movement and exercise.

They treat patients of all ages in the inpatient, outpatient, industrial, and home settings. The goals of physical therapy are focused on helping patients reduce pain and improve or restore mobility. In addition, they are involved in ergonomics, injury prevention, and wellness services as well as activities that promote health and fitness.

Physical therapists are required to complete a graduate degree—either a master’s or clinical doctorate—from an accredited education program. The curriculum is built on the basic sciences, behavioral sciences, and clinical sciences, including examination, intervention, medical screening, diagnostic imaging, clinical decision making, and pharmacology. Currently, 96 percent of professional physical therapist education programs offer the doctor of physical therapy degree. This entry-level doctoral degree fulfills the profession’s need to expand the breadth and depth in educational preparation. All physical therapists advance their knowledge base through annual continuing education, as required for state licensure. Some pursue postgraduate residency and fellowship programs. Also, the American Board of Physical Therapy Specialties (ABPTS) offers board certification in eight specialty areas of clinical practice: cardiovascular and pulmonary, clinical electrophysiology, geriatrics, neurology, orthopaedics, pediatrics, sports, and women’s health.

Physical therapy is indicated for people with neuromusculoskeletal conditions. In the inpatient setting, therapists frequently treat patients who are not at their prior level of functioning or who need evaluation of their functional mobility and ability to return home safely. Not all inpatients are appropriate for physical therapy. For example, if patients are confused and unable to follow instructions, physical therapists cannot teach them new skills. In the outpatient setting, therapists may work with the elderly who are weak, people who have joint pain, and people who have balance problems, among many other situations, for referral. If a patient is looking for a therapist, the “Find a PT” tab at MoveForwardPT.com allows a search of a national database of physical therapist members of the American Physical Therapy Association. It also identifies American Board of Physical Therapy Specialties (ABPTS) board-certified specialists. Also, local hospitals have outpatient clinics. Patients should check that their insurance will cover outpatient services at the clinic before starting.

At the first visit, physical therapists begin with a thorough evaluation that includes patient history, observation, examina-

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tion, and special tests. By gathering the objective and subjective facts and noting the signs and symptoms, physical therapists determine what’s causing the patient’s problems and design a proper treatment plan with time-specific goals. Outpatient physical therapists may routinely update the physician about the patient’s progress before a follow-up visit and again every thirty days.

From the evaluation to each treatment, physical therapists screen for conditions that are outside the scope of physical therapy practice. Red flags are warning signs that physician referral may be needed. They may include symptoms that “seem out of proportion to the injury or when the symptoms persist beyond the expected time for that condition.” Physical therapists have been receiving additional training on how to distinguish between “activity-related mechanical disorders, which respond to physical therapy interventions, and nonmechanical ones, which require referral for further medical evaluation.” The red flag screening leads to the result of either treat, treat and refer, or refer only.

Physical therapists can aid physicians by being an additional set of eyes and ears for any new signs and symptoms. Due to the longer encounter time with the patient, therapists may gather information that the patient did not tell the physician or that may have changed since the last physician appointment. Therapists can provide feedback to physicians with respect to improvement in mobility or, on the other hand, limitations in progress, but with attention to specific patient complaints that may assist physicians in pursuing the next step.

Physicians can aid physical therapists by writing physical therapy prescriptions that include safety precautions (weight-bearing limitations, joint range of motion limitations) and specific protocols, if indicated. The best way to improve the working relationship with physical therapists is to learn more about your local physical therapists and to maintain open channels of communication.

In my setting in a hospital-based skilled nursing facility, I feel fortunate to be a part of a multidisciplinary team where there is mutual respect for each member’s contribution. We work closely and have open lines of communication to facilitate the patient’s recovery. Whether in the inpatient or the outpatient setting, physical therapists can contribute their training and knowledge in improving the movement, activity, and health of our patients.

References

Goodman CC, Snyder TE. Differential Diagnosis in Physical Therapy, third ed. Philadelphia: W.B. Saunders Co. 2000; 57.

Richardson JK, Iglarsh ZA. Clinical Orthopaedic Physical Therapy. Philadelphia: W.B. Saunders Co. 1994; 140.

Sabrina Yee PT is a Level III physical therapist at the California Pacific Medical Center Skilled Nursing Facility. www.sfms.org

The Healing Team

OFFICE STAFF Administrative Support for the Healing Team Debra Phairas Many physicians have never worked at any other job than medicine or been exposed to a corporate environment with human resources training or a team-building culture. Medical school training, in-

cluding Grand Rounds, is an exercise in humiliation in which a physician is often disciplined or criticized in front of peers.

This molds an excellent physician but is poor training in how to manage your staff and meld them into a cohesive team. Patients want a “pilot-copilot” type of atmosphere in the medical office, where the physician and staff treat each other with respect, compliments, and a harmonious style of working together. It is very important for the physician owner/manager to “praise in public, reprimand in private” with your staff.

Attributes of good working relationships include identification of and commitment to the largest set of common goals appropriate to the coworkers’ respective roles, mutually agreed-upon goals, mutual trust and respect, shared norms and expectations, and respect for individual differences and tolerance for diversity of views.

As the owner/manager of the practice, it is the boss’s job to ensure that each staff member understands that he/she contributes to the overall success of the organization and that each person works with fellow members of the organization to produce results. Even though the staff member is in a frontdesk, back-office, or billing position and has a specific job function, that staff member is unified with other staff members to accomplish patient-care delivery. Therefore, when a new staff member comes into the practice, orientation to other positions needs to occur. That staff member should shadow the other positions to understand how each interrelates to the whole. This will prevent “us” versus “them” finger-pointing and blaming.

It’s recommended, for example, to have the front-desk position sit with the billing position so the biller can actually show how errors in inputting demographic information slows the billing effort and requires do-over work on the biller’s part. The billers should also sit at the front desk to understand how hectic this can be, with its many interruptions. Together they should work on the process steps in the revenue cycle so that both staff members understand that they are both responsible for the ultimate outcome, which is the physician being paid in a timely manner.

Establish the expectation that all staff members need to excel in all three areas of performance in order for continued employment and a raise. These three areas are the ability to perform the job description tasks effectively; superlative customer service to the patient; and a demonstrated team-player mentality when working with other staff, the manager, and the physician. www.sfms.org

Hold regular staff meetings that are problem-solving and team-oriented in tone and spirit. Emphasize the importance of the team to problem-solve to get to the root cause of office-flow problems and to encourage creative brainstorming for solutions.

Corporations spend time and money on their staff to foster a team atmosphere. As a business owner, it is important to interact with your staff and show them you’re willing to be a part of the team as well. There are many low-cost ways to accomplish team spirit. These include potlucks, cooking contests (such as chili cook-offs or dinners where you break into teams to prepare recipes), manicure parties, mid-morning surprise latte breaks, holiday decorating contests, costume contests, and charitable projects accomplished as a team. In fact, the practice can create a team-spirit committee with a budget, and they can come up with ideas pertinent to your staff.

Building successful teams also requires a willingness to change old habits and patterns. Ask yourself: Are you willing to reward creative innovation instead of maintaining the status quo?

Are you willing to risk losing staff who may be great with patients but are terrible team players? Are you willing to allow staff to be empowered to try new ideas and solve problems? If so, you are on your way to creating an effective team at your practice!

Meeting Ground Rules

We have listed below a set of ground rules that we are committed to following in all employee meetings to ensure that the meetings are productive and smooth.

• Only one person may speak at a time. When someone is speaking, everyone else in the meeting will listen respectfully and sincerely and try to understand the other person’s needs and interests.

• We will commit to keeping discussion on topic and focused.

• Questions will be used for the sole purpose of gaining clarity and understanding.

• We will all commit to challenging opinions we do not agree with without attacking the individual who expresses them.

• The raising of voice or the use of derogatory or abusive language will not be permitted.

• We will only discuss items predetermined on the meeting agenda.

• Should any of these meeting ground rules be violated, the meeting will be immediately terminated.

Debra Phairas is president of Practice & Liability Consultants, a nationally recognized firm specializing in practice management and malpractice prevention. She regularly holds seminars for SFMS members on various aspects of practice management.

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The Healing Team

ACUPUNCTURISTS Understanding Traditional Chinese Medicine Daniel Jiao, DAOM, LAc, DiplAc, CH & OM (NCCAOM) Traditional Chinese Medicine has more 5,000 years of history and has been effective in the treatment of all kinds of ailments. Throughout his-

tory, countless people have relied on TCM to treat sickness, maintain health, and prevent the onset of illness. TCM has a unique system of viewing the human body and the various ailments that plague the human population, both physiologically and energetically, and carries with it an immense amount of information and experience in treatment, attaining sometimes miraculous results.

TCM is a holistic medicine, which means it focuses not on part but on the whole of the human body, including the emotional and physical aspects and taking into consideration people’s interaction with nature. It also advocates nutrition and exercise as important components in maintaining good health. Its core is differential diagnosis and treatment principles tailored to the individual’s unique needs.

One important part of Traditional Chinese Medicine is acupuncture, which is widely used in the United States as a therapeutic method of treatment, with growing influence among the general population. The theory of acupuncture is based on the understanding of a system that governs the flow of qi in the human body. Qi can be understood as a life force that determines whether or not a person is healthy. When the qi is balanced and freely flowing, the person is health; when there is a blockage of qi or pathological changes in the body, the person falls ill. Based on this understanding, acupuncture works to regulate qi, which circulates the blood and strengthens the body’s organ systems.

In TCM theory, if there is blockage, then pain will develop. Therefore the pain is an indication that there is something wrong with the body’s internal systems. This may be due to invasion of external evils (in TCM they are referred to as the Six Evils) or internal imbalances (in TCM, the Seven Emotions). When energy (qi) circulates, then these evils, regardless if they are external or internal, can be resolved.

The World Health Organization has recognized acupuncture for certain conditions: upper respiratory tract infections (such as acute sinusitis, the common cold, acute bronchitis), eye disorders (acute conjunctivitis, cataracts, etc.), gastrointestinal disorders (including gastroptosis, acute and chronic gastritis, constipation, diarrhea), neurological and musculoskeletal disorders (headaches and migraine, trigeminal neuralgias, facial palsy, etc.), reproductive and gynecological conditions (such as PMS, dysmenorrhea, impotence, infertility), and mental and emotional problems (including stress, anxiety, depression, insomnia).

Acupuncture can be used to treat a myriad of conditions.

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Generally it is safe, when administered by a properly trained practitioner. Practitioners in the United States usually must be licensed by the NCCAOM or the California Board of Acupuncture, and they must have, at minimum, a master’s degree in Traditional Chinese Medicine. Should the Western practitioner find a condition suitable for treatment by acupuncture, he or she can refer the patient to a TCM practitioner, who will then assess the condition and determine the treatment.

As part of integrative medicine, in the practice of TCM, we often have to refer patients out to see their family doctors and specialists (in internal medicine, gynecology, orthopedics, etc.) for various medical examinations in order to get a fuller picture of the individual’s health as well as to attain a diagnosis and possible treatment plan from the Western perspective.

When the patient is referred to those of us who are TCM practitioners, we will perform a thorough history intake with which to plan a suitable treatment program. We also decide the most appropriate treatment modalities, including acupuncture, Chinese herbal medicine, therapeutic massage, nutrition consultation, recommendations for exercise, and so on.

For physicians who want more information about acupuncture as a treatment method, the Mayo Clinic has a description; and books about acupuncture and Traditional Chinese Medicine include Acupuncture: A Comprehensive Text (Eastland Press, Seattle) and A Manual of Acupuncture (Journal of Chinese Medicine Publications).

Daniel Jiao, DAOM, LAc, DiplAc, CH & OM (NCCAOM), has received training in both Eastern and Western medicine.

He graduated from Beijing University of Traditional Chinese Medicine (TCM) in China. He holds a doctorate in acupuncture and oriental medicine and a master of science degree in TCM from the American College of TCM. Jiao was the chief instructor of oriental medicine in the Medical Acupuncture program at Stanford University, in addition to teaching in the Department of Health Sciences at California State University at Long Beach.

Jiao is currently the chair of the Department of Herbal Medicine and professor at the American College of Traditional Chinese Medicine, where he also serves as a supervisor at the school’s teaching clinic. He is also an acupuncturist at the Chinese Hospital Excelsior Health Service.

www.sfms.org

The Healing Team

TEAM MODEL FOR HIV CARE Integrated Teams at Kaiser Permanente Stephen Follansbee, MD Providing the width and breadth of services necessary to care for more than 2,400 HIV patients at Kaiser

Permanente San Francisco is not possible without the coordinated efforts of a well-integrated care team. The Kaiser Permanente medical model of linked primary and specialty care, with connections to community organizations and outside services, is designed to create highly efficient and patient-centered care.

The HIV Adult Primary Care Clinic, familiarly known as the “HIV Module,” is composed of eighteen physicians and nurse practitioners who are specialists in HIV care; thirteen medical assistants who are labor partners; and eleven licensed professionals including nurses, pharmacists, a behavioral mental health therapist, a clinical health educator, nutritionist, physical therapist, and chronic-condition nursing care specialist. Supported by two HIV-specific benefit coordinators and a program assistant, they provide care with measureable HIV-specific outcomes that can be tracked and compared to other organizations. These outcomes include the percentage of patients taking HIV treatment, percentage of those treated with undetectable viral loads, percentage with CD4 counts over 200 (considered the break point for an AIDS diagnosis) and over 350, percentage screened and immunized against hepatitis B if appropriate, and percentage screened for hepatitis C. Results are independent of background demographics. Thus, women and men have equally successful outcomes in each area and men of color have equally successful outcomes to white men of non-Hispanic ethnicity. In addition, our HIV patients are at increased risk for other conditions, such as diabetes mellitus, coronary artery disease, hypertension, and depression. Success in treating these conditions is also determined through the larger monitoring programs for these other conditions.

The success of this model of care was acknowledged at the recent Center for Medicaid and Medicare Care Innovations Summit in Washington, D.C., in January 2012. This prompted Kaiser Permanente to issue the KP HIV Challenge at the national level.

The crux of the HIV Challenge (kp.org/hivchallenge) is to challenge other private health care providers, and public and community health clinics, to increase the number of HIV-positive people getting effective treatment by sharing Kaiser Permanente’s tool kit of clinical best practices, provider and patient education materials, mentoring, training, and health IT expertise.

Physician consultants in dermatology and psychiatry are available “on the spot” for urgent questions and evaluations, as well as initiation of therapy for our HIV-infected members. Other medical and surgical subspeciality consultants are available by phone for immediate assistance and a same-day visit if appropriate, as is the model of care for all Kaiser Permanente members.

Clinicians at Kaiser Permanente San Francisco have initiated www.sfms.org

more than 500 courses of nonoccupational post-HIV exposure prophylaxis. This process involves 24/7 access by phone for infectious diseases consultation and follow-up appointment booked online with an HIV program coordinator to answer additional questions, confirm adherence to the twenty-eight-day treatment course, and encourage follow-up HIV testing.

HIV-related research is conducted through the Clinical Trials Unit (CTU), in existence for more than twenty-five years. The program offers members an opportunity to participate in studies of new medications for the treatment of HIV, as well as for associated conditions such as hepatitis C. In addition to physicians, the CTU staff is comprised of nurses, research assistants, and pharmacists.

All of this is possible due to coordinated efforts and tools at the team’s disposal, principally Kaiser Permanente’s fully integrated electronic medical record, known as KP HealthConnect. Through this system a provider can view a patient’s chart, review notes from previous encounters in nearly every department, e-mail communications from the patient to previous providers, and scan lab and imaging results, all while assessing medication orders and hospital and emergency room visits before seeing the patient.

New Kaiser Permanente members, or members newly diagnosed with HIV, are referred to the HIV program coordinators for intake. This process involves a two- to three-hour appointment, which includes review of the services available both within Kaiser Permanente and in the community. Referrals can be initiated and members are then offered a choice of primary care providers from whom to receive their care. Staff in the various specialty areas, including dietitian, pharmacy consultant, behavior and emotional support staff, physical therapist, and anal cancer screening staff, have schedules that can be directly booked by medical assistants. The coordinator is able to schedule one or multiple appointments, send secure messages to providers prior to seeing the patient, and share relevant information.

Other unique aspects of our approach to HIV care include an HIV Advisory Board that meets bimonthly, offering an opportunity for providers and both HIV-infected and uninfected patients to share experiences, exchange information, and answer relevant questions from both sides of the care perspective. By including patients on the advisory board, we as providers can modify and adjust critical aspects of HIV care as suggested by those who are on the receiving end.

The HIV provider team itself meets weekly over the lunch hour to present and review cases, share best practices, and review literature and updates from international meetings. Visiting colleagues and community partners from the University of California at San Francisco (UCSF), San Francisco General Hospital (SFGH), and community-based organizations broaden the understanding

Continued on page 33 . . .

May 2012 San Francisco Medicine

29

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San Francisco Medicine May 2012

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HEALTH POLICY PERSPECTIVE Book Reviews Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs Maureen Bisognano and Charles Kenney Jossey-Bass, a Wiley imprint, 2012 In the late 1980s, Don Berwick and a group of visionary quality improvement champions founded the Institute for Healthcare Improvement (IHI) to reduce medical error and promote efficiency in the American health care delivery system. In nominating him to the post of Medicare administrator in 2010, President Obama cited Dr. Berwick’s dedication to “improving outcomes for patients and providing better care at lower cost.” These ideals reflect the three pillars of the IHI mission, known as “The Triple Aim: Better Care for Individuals, Better Health for Populations, and Lower Per Capita Costs.” In their new book, current IHI President and CEO Maureen Bisognano and health care journalist Charles Kenney present seven case studies from innovators across the country who have improved access to primary care, enhanced the care of chronic illnesses, harnessed employer purchasing power to improve quality, and prioritized quality over the quantity of care delivered. Of particular interest to San Francisco Medicine readers will be the valuable lessons learned at Kaiser Permanente (the development of the Value Compass and medication safety programs) and by Pittsburgh surgeon Anthony Digioia (who redesigned the orthopedic perioperative process through a patient-centered approach).

Many of the proposed solutions are intuitive and adaptable.

Physician readers will gain a better understanding of the important perspectives and roles of hospital administrators and patient safety leaders in implementing these solutions. A recurring theme of the book is the critical role of visionary leaders in catalyzing institutional change, which raises the question of how an institution should respond if effective leadership is unavailable. Others may wonder whether the innovations are sustainable, as a price tag for these pilot efforts is not presented. Smaller hospitals may be challenged to marshal the considerable time, energy, and resources to test these innovations, which could result in dissatisfied patients accustomed to the prior model. The legal risks that may arise from undesirable patient outcomes while a new system is implemented must also be contemplated, although they are not highlighted in the book.

Some might argue that the Triple Aim is unachievable without a better definition of patient expectations and responsibility, or establishing limits to the amount of care that can be provided.

In the final chapter, “No Excuses,” Bisognano and Kenney highlight the importance of teamwork, communication, coordination, and standardization to achieve a “culture of safety,” perhaps best reflected in the remarkable improvements in the aviation industry described in an interview with Captain Sully Sullenberger. Time will reveal which of the seven innovations will endure and merit national dissemination, leading our nation’s health care system to a better future through fulfillment of the Triple Aim.

Power, Politics, and Universal Health Care: The Inside Story of a Century-Long Battle Stuart Altman, PhD, and David Shactman Prometheus Books, 2012

There’s a sad old joke in health policy circles: A big-shot policy wonk, who worked to get a good universal health coverage plan in place, dies and goes to heaven where, due to his good intentions, he is granted an audience with God. “Nice try anyway,” says God. “Any questions?” The health reformer says, “Yes—it’s too late for me, but when will America have universal health care at last?”

“Not in my lifetime,” God replies.

Stuart Altman told that joke recently at UCSF, where he was giving a talk to debut his new book. The joke could have been about his own life so far. A health official under Presidents Nixon; Reagan; Clinton; Bush, Sr.; and Obama, he knows this history firsthand, and his book is a gold mine for political nerds, full of irony, scandal, and intrigue over seemingly bland technical proposals. “Alcohol, Sex, and Burglary: Health Reform Fails Again” is a typical chapter subheading (referring to strippers and Watergate). Various Kennedys, presidents, and other politicos abound. “Clinton Chooses Wrong” is his succinct heading for that failed attempt, a proposal he deems too complex, at 1,342 pages (about half of the current one).

Legislation has been likened to sausage—ugly to see being made. It’s all here: the prolonged traumatic birth of Medicare/Medicaid; the shifting allegiances of groups such as the AMA—from “apoplectic” to supportive on Medicare, and likewise on Obama’s plan—and many proposed, failed, or successful programs. Altman outlines their history, often as a direct witness, although he strangely refers to himself in the third person. His overriding message is that most everything comes down to fights about costs, and always has; and that health care is crucial, complex, and wholly vulnerable to political winds and chicanery. His final 100 pages cover “Obamacare,” with similar conclusions and chapters with titles such as “The Summer of Death Panels: The Truth, the Part Truth, and Nothing Like the Truth.”

Altman notes that the initial title for his book was Failure Again. At his UCSF talk, he reflected, “When I read and hear all the accusations of this current attempt at reform being ‘socialism’ or a ‘government takeover,’ I can’t help but be a little sick to my stomach. . . . Those of us who have worked and lived with these issues for decades just wonder, ‘What are they talking about?’ This is an incremental attempt; it’s not a revolution, it’s just evolution.”

But of course, we know how some people nowadays are even opposed to that.

—Steve Heilig, MPH

—John Maa, MD

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May 2012 San Francisco Medicine

31

HOSPITAL NEWS KAISER

Veteran’s

CPMC

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Rokeach, MD

At Kaiser Permanente San Francisco, our inpatient medical social worker team is one of the most important factors in the overall health and well-being of our hospital patients.

With a group of fourteen social workers on staff, focusing on areas such as geriatrics, maternal child health, and the emergency department, the team provides nonmedical assistance to patients and family members who are in distress or just trying to cope with an overwhelming situation.

Members of the social work team provide that extra support, often going above and beyond what is expected of them (including feeding pets or retrieving items from home) for patients for whom the medical staff cannot do everything due to competing priorities. Providing continuity of care, both when patients are in the hospital and after they have been discharged, is essential for ensuring that people remain healthy once they have left the medical center—and the social work team does just that.

Trained in bereavement and grief counseling, able to identify substance abuse indicators, and well versed in the signs of cognitive impairment, the inpatient social workers are able to address a myriad of situations across the care spectrum. Using a system theory approach, team members look at what systems influence a patient’s life and what the critical needs are, in order to help address stressors and provide resources.

A central goal of the social work team is that when patients are discharged, they are placed in the most appropriate setting for their health status and life circumstances.

Helping to ensure that patients are not unnecessarily readmitted to the hospital requires careful planning and concerted effort on everyone’s part—medical staff and otherwise.

Veterans of Iraq and Afghanistan with posttraumatic stress disorder (PTSD) and other mental health diagnoses were significantly more likely to be prescribed opiates for pain than were other veterans with pain, according to a study led by researchers at the San Francisco VA Medical Center (SFVAMC).

Veterans with pain and PTSD who received opiates were significantly more likely to receive higher dose prescriptions (two or more opiate prescriptions and concurrent prescriptions of sedative-hypnotics such as valium). They also were more likely to request early refills. All veterans who were prescribed opiates were also at significantly higher risk of serious adverse clinical outcomes, such as drug and alcohol-related overdoses or suicide and violent injury, with the risk being most pronounced for veterans with PTSD. To address the issue, the study authors recommend that the VA implement more broadly its current program of what lead author Karen Seal, MD, MPH, a physician at SFVAMC, called a multifaceted, integrated approach to simultaneously managing pain and PTSD. That approach would include the implementation of patient-aligned care teams (PACTs), which align primary care physicians with nurse care managers, mental health providers, pharmacists, and social workers.

For patients presenting to primary care with pain, PACTs are important in the provision of better coordination of care. Patients requiring more intensive treatment can access multidisciplinary specialty pain management and cognitive behavioral therapy, which are provided at most VA medical centers.

The VA is making strides to discourage the overuse of opiates in favor of antiinflammatory medications, physical therapy, exercise, relaxation techniques, and complementary alternative medicine such as acupuncture. The study of 141,029 veterans who served in Iraq and Afghanistan from 2005 through 2010 appears in the March 7 issue of the Journal of the American Medical Association.

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San Francisco Medicine May 2012

Congratulations to Dr. Ronald Elkin, who has been appointed medical director of Critical Care Quality and Education. For many years, Dr. Elkin has been a strong advocate for quality improvement in the ICU, particularly for improvements regarding sepsis care.

He brings a wealth of national experience in teaching physicians and nurses best practices in critical care medicine. Dr. Elkin will work with Dr. Christopher Brown, medical director of Critical Care, over the next year to develop a quality improvement plan for the ICUs at the St. Luke’s, Pacific, and Davies campuses.

Areas of improvement that they will address include patient mobility, sedation scoring, delirium reduction, alcohol withdrawal, glucose control, and sepsis resuscitation strategies.

Please welcome Dr. Elkin in his new role as we advance the care of our critically ill patients.

A warm welcome to our newest medical staff members: Drs. Monica Bhargava (pulmonary/critical care medicine), Vinona Bhatia (medical oncology), Douglas Chin (plastic surgery), Donald Park (ophthalmology), Navdeep Singh (critical care/ICU), and Lowell Wetter (general surgery).

This past February, Single Sign-On (SSO) began rolling out at the Pacific Campus. SSO will allow physicians, with a single tap of their badge, to have access to all the major hospital applications they use without needing to separately log in to each. Only a single user name/password combination will be necessary. Overall, this should save physicians a huge amount of time and frustration. The rollout activities—which involve installation of new card readers at each work station—will steadily progress across all four campuses over the next six months as follows: California Campus (May 7), Davies Campus (June 20), and St. Luke’s (August 7). If you may have questions, please email Arieh Rosenbaum at rosenba@sutterhealth.org.

www.sfms.org

HOSPITAL NEWS

HIV Care continued from page 29 . . .

St. Mary’s

Saint Francis

Francis Charlton, MD

Patricia Galamba, MD

Health care is the ultimate team endeavor. The breadth and depth of knowledge and expertise in so many diverse fields has naturally led to greater and greater specialization.

It is increasingly true that we know more and more about less and less, particularly in a metropolitan hub such as the one we live and practice in. Optimal patient care depends upon our ability to know what resources are available to us on the health care bench, and to know when to call them into action. Enlisting the right help at the right time requires not only prompt action but also relationships and systems in place that enable us to respond appropriately, and sometimes emergently.

Health care needs can arise without warning at any hour of any day, and many patients require around-the-clock care. We all must depend on many others to provide care to our patients for myriad reasons. The health care team functions at its best if all members communicate in a timely, efficient, and collegial fashion. Respectful interaction among all the members of the team, recognizing each of their individual contributions to the joint effort, is essential for successful outcomes. We depend on the specialized input from innumerable disciplines to achieve our goals.

It is true that the physician sees himself as the captain of the team, and rightfully so.

However, it is incumbent upon us to remember that every member of the team plays a crucial part and performs a critical function, whether it be excising a malignant tumor, disinfecting the room so that the patient doesn’t contract C dif or MRSA, or preventing bedsores by cleaning and turning a patient.

Winning teams are notable for their ability to work together toward a common goal. None of us can do it alone.

Happy spring! In this season of rebirth and renewal, I would be remiss if I didn’t mention our name change. Saint Francis has been a member of Catholic Healthcare West since 1993. In January, our system was renamed Dignity Health. As described by the Dignity Health’s board of directors, “This new name and structure change reflects who we are and what we stand for. Dignity is embedded in our culture.” Along with the name change comes a restructuring of governance that will position Dignity Health to succeed in this changing health care environment. For us at Saint Francis Memorial Hospital, it will be business as usual. These changes will not impact our operations, policies, or mission. The hospital will remain a non-Catholic hospital, following our Statement of Common Values and commitment to the overall health of the communities we serve.

Other changes are also taking place here at Saint Francis. In March we began demolition of 15,000 square feet of space for a new and improved Bothin Burn Center. As the only verified acute burn center in San Francisco, we have outgrown our existing space, and the demands on the unit require an expansion and total upgrade. The new center will jump from ten beds to sixteen (twelve private rooms and two semiprivate) and will include a new and improved day room for patients and family interaction, as well as a state-ofthe-art surgical suite and overhead lifts for patients. The project is expected to be completed by June 2013, and you’ll hear more from us as we get closer to the grand opening.

Kudos and thanks to the philanthropic Saint Francis Foundation for playing a key role in helping to support the cost of this project and others in the pipeline.

of HIV care within the larger context of the City.

The HIV team is fortunate to have a robust relationship with an extensive network of community and safety net providers within San Francisco, as there are many issues facing patients with HIV outside of our medical facility. The working partnerships between the team and such organizations as the Asian and Pacific Islander Wellness Center and the Positive Resource Center are part of the overall care provided to patients. Several providers sit on the boards of community organizations, where they offer valuable technical assistance and other resources to help ensure stable services within the broader population.

Finally, the work that our HIV benefits specialists perform on behalf of our patients cannot be overemphasized.

Since employment and steady benefits for many patients are often items of ongoing uncertainty, the benefits specialists must be well versed in the complex rules and regulations determining coverage.

Despite all of our progress, challenges for HIV providers remain. Any integrated model must still account for the time and energy involved in managing and coordinating the care for the multiple conditions associated with aging and with HIV infection. In time-constrained settings with reimbursements from third-party payors hinging on performance in non-HIV-related areas of considerable importance (such as diabetes, hypertension, smoking cessation, and cancer screening), it is not always clear that provider organizations can recognize the time and resources necessary to manage HIV care from an integrated specialty and primary care perspective.

Stephen Follansbee, MD, is director of HIV services, Kaiser Permanente San Francisco. He is a longtime member of the SFMS and former president.

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May 2012 San Francisco Medicine

33

In Memoriam Nancy Thomson, MD

Charles Epstein, MD Charles J. Epstein, MD, a leading researcher, educator, and clinician the field of genetics, was born September 3, 1933, in Philadelphia and passed away in Tiburon on Tuesday, February 15, aged 77, after a prolonged struggle with pancreatic cancer. He graduated summa cum laude in chemistry from Harvard in 1955, then graduated first in his class at Harvard Medical School in 1959. He married his classmate, Dr. Lois Epstein, in 1956. The couple moved to San Francisco in 1967, where he joined the faculty of UCSF as chair of the medical genetics division.

Charles Epstein established genetic screening and counseling clinics around the state of California, providing the model for many such clinics around the world. He became a professor of biochemistry and pediatrics in 1972 and was named director of UCSF’s human genetics program in 1997. His gene dosage effect hypothesis formed the basis for a broad array of medical genetic research.

Working with his wife, he produced the first mouse model to be used in Down syndrome research, one of his major fields of study.

He received multiple awards and honors for his work. He served as president of the American College of Medical Genetics and the American Society of Human Genetics, both of which recently presented him with lifetime achievement awards. He also served as president of the American Board of Medical Genetics. Most recently, Epstein chaired both the Scientific Advisory Board and Board of Trustees of the Buck Institute on Age Research, which has established an annual lecture series in his name.

A cellist, lover of travel, gardener, and craftsman, Charles Epstein had many passions and pursuits beyond his professional career.

He is survived by his wife, Lois; his four children, David, Jonathan, Paul, and Joanna, and their spouses; and six grandchildren.

Washington University in 1953; interned at Barnes Hospital; and had residencies in pathology at UCSF Barnes Hospital, St. Louis, and Massachusetts General Hospital in Boston. In 1964, Dr. van Ravenswaay began residencies in dermatology at UCSF and trained as assistant registrar at Saint John’s Hospital for Diseases of the Skin in London. He returned to a position in dermatology at Kaiser Permanente in San Francisco in 1967, becoming a dermatologist at Kaiser Terra Linda.

During his years there, he was instrumental in establishing the Mohs Clinic for cancer surgery, was an associate clinical professor in dermatology at UCSF, and served as lieutenant colonel in the U.S. Army Reserve. He was board certified in pathology, dermatology, and dermatopathology, retiring from Kaiser Permanente in 1987 as chief of the San Rafael Kaiser Dermatology Department.

Theodore van Ravenswaay, MD

Theodore van Ravenswaay, MD, longtime physician and resident of Tiburon, passed away peacefully on March 8, 2011, at Kaiser Hospital at age 83. He is survived by his wife, Nancy van Ravenswaay, and their children and grandchildren.

He received his medical degree from 34

San Francisco Medicine May 2012

Leonard Daniel Rosenman, MD Leonard Daniel Rosenman, MD, was a brilliant and skillful surgeon who relished “the opportunity for a thousand love affairs” with the patients he cared for during his fifty years in practice. An avid student of philosophy, literature, languages, and history, he devoted his retirement to the translation of the seminal European surgical texts of the Middle Ages into English from archaic Italian and French. His encyclopedic knowledge and passionate joy in sharing it served as a marvelous pre-Google search engine for his family, friends, and colleagues. He was a devoted husband to Helen, his beloved wife of sixty-nine years, who died last year.

Matt Dickstein

Business Attorney Representing Medical Practices Since 1994 * Medical Corporations * Stark & Kickback / Regulatory Compliance * Employment & Contractor Agreements * Breakaway Physician Competition * Buying & Selling a Practice * Hospital – Group Contracts * Leases for Medical Offices * Multi-Discipline Practices Idea of the Month: I went on a diet, swore off drinking and heavy eating, and in 14 days I had lost exactly two weeks. – Joe E. Lewi1s 39488 Stevenson Pl. #100 Fremont, CA 94539 510-796-9144 mattdickstein@hotmail.com mattdickstein.com www.sfms.org

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