November/December 2015 by San Francisco Marin Medical Society

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

THRIVING IN MEDICINE Don’t Just Survive;

Thrive!

BURNOUT

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

November/December 2015 Volume 88, Number 9

Thriving in Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Staying On Top Of Your Game: Don’t Just Survive; Thrive Linda Hawes Clever, MD

Membership Matters

President’s Message Roger Eng, MD, MPH, FACS

11 Surviving Burnout: A Tale from the Trenches Katherine Herz, MD

13 Lessons Learned: Turning Conflict into Positive Change Richard Podolin, MD 15 Maintaining Board Certification: Who is Thriving and Who is Surviving? Michel Accad, MD

19 Online Review Sites: How to Survive, Thrive, and Manage Your Reputation Ashley Porciuncula 20 HIPAA Compliance: How to Survive an Audit Kimbelee Snyder

21 New Health Care Laws: 2016 Laws of Interest to California Physicians 23 Professional Liability Insurance: Defining the Details Ronni Fan

24 Electronic Medical Records: Choosing the Best System for Your Practice Michael Blum, MD

25 Classified Ads

32 Medical Community News 34 Upcoming Events

OF INTEREST 9

SFMS Advocacy Activities

26 SFMS Election Results 26 Thank You SFMS Political Action Committee Contributors! 27 MIEC After Forty Years: Still Fulfilling Its Mission Robert Margolin, MD 29 In My Opinion: End Of Life Option Act A Major Step In Improving Care Steve Heilig, MPH 30 CMA House of Delegates Report

Editorial and Advertising Offices: 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

STUDENTS Johanna Burch Nicholas Rudolf Murphy Sonja Marie Swenson

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

San Francisco Health Commission Votes to Support SFMS-Endorsed “Screen at 23” Campaign

Advanced care planning: The final fee schedule includes two CPT codes to reimburse for advance care planning. It allows physicians to include end-of-life discussions as part of patients’ annual check-ups. Physician payments: The final rule includes a 0.5% overall increase in Medicare reimbursement in 2016 for all providers. Merit-Based Incentive Payment System: In the final rule, CMS has made changes necessary to begin implementation of the new Merit-Based Incentive Payment System for physicians and other practitioners, which will fully take effect in 2019.

Medical License Renewals May be Delayed in December

The San Francisco Health Commission voted unanimously to support a campaign to unmask the hundreds of thousands of hidden cases of diabetes among Asian Americans. The SFMS joins the National Council of Asian Pacific Islander Physicians and a growing list of medical and public health experts in endorsing the use of a body mass index (BMI) of 23 as a risk factor to consider for diabetes testing among Asian Americans. Several SFMS members provided testimony in support of the resolution at the October 20, 2015, Health Commission meeting (pictured above). The approved resolution aims to raise awareness and screening for diabetes at a BMI of 23 as a standard across the Department of Public Health through the San Francisco Health Network, and encourages its use across private and public health care settings. With this, San Francisco becomes the first U.S. city and county to encourage the adoption of these appropriate screening guidelines throughout its citywide health care system.

SFMS Releases Vaccination Public Service Announcement Featuring Musical Icon Graham Nash

“Teach your children” is the title of rock legend Graham Nash’s most-loved song, and also of the new SFMS video wherein he urges parents to fully vaccinate their children. Mr. Nash, of “America’s Beatles” Crosby, Stills, Nash & Young, graciously offers his words and classic music for this 45-second public message: “I vaccinated my kids and they’re all brilliant!” he says. The PSA can be viewed at http://bit.ly/1W2qS1S.

CMS Issues Final Rule for Medicare Coverage of End-of-Life Talks

Centers for Medicare and Medicaid Services (CMS) issued a final rule that will allow Medicare to reimburse physicians for end-of-life discussions with patients, effective January 1, 2016. Key policies finalized in the 2016 payment rule include: 4

The Medical Board of California is asking physicians who need to renew their medical licenses in the next few months to do so early to avoid delays associated with scheduled upgrades to the BreEZe online licensing system. Individuals holding a professional license with December 2015 or January 2016 expiration dates who wish to renew their licenses are strongly encouraged to renew as early as possible, preferably before the end of November 2015. The Department of Consumer Affairs will be transitioning additional boards and bureaus to BreEZe. This will require a temporary shutdown of all licensing processes for several business days, and could result in delays in processing initial license applications, license renewals, and name or address changes. Physicians can contact the medical board at (916) 2632382 or webmaster@mbc.ca.gov.

Victory on Antibiotic Misuse: SFMS-Sparked Campaign Prompts Healthy Regulations

Governor Jerry Brown signed the nation’s strictest regulations on the use of antibiotics in healthy livestock, a move lauded by public health and infectious disease experts. SB 27 will curb the overuse of antibiotics in livestock, which limits the effectiveness of the medicines in both animals and people and contributes to the spread of dangerous, drug-resistant superbugs. The law, which takes effect in 2018, requires medications given to livestock to be approved by a veterinarian. It also eliminates the availability of livestock antibiotics for over-the-counter sales. And therein lies yet another story of SFMS advocacy. Back in 2001, SFMS convened an invitational meeting of medical and public health leaders, chaired by UCSF Chancellor Emeritus Philip Lee, which resulted in new CMA and AMA policy urging the curtailment of antibiotics in food. Further advocacy pushed at least four national bills to make such use less damaging, as the evidence continued to mount that resistant strains were spreading from farms and feedlots to humans. SB 27 was heavily contested and was even initially opposed by CMA until it was revised. Dr. Lee and other luminaries then supported it, as did the California Vet-

SAN FRANCISCO MEDICINE OCTOBER 2015 WWW.SFMS.ORG

erinary Association, for the first time. The stringent new requirements will hopefully spread to other states and serve as the impetus for national policy.

SFMS Physician Networking Mixer a Success

Local physicians participated in SFMS’s October Networking Mixer at Sessions in the Presidio. Attendees took advantage of the opportunity to meet SFMS leaders and connect with colleagues from a wide range of specialties and practice settings. SFMS would like to acknowledge the Cooperative of American Physicians (CAP) for their support of SFMS and our networking mixer series. With great attendance and positive feedback from all, SFMS plans to organize similar social networking events in 2016. Please check the SFMS website or follow SFMS on Twitter (@SFMedSociety) for event details.

SFMS Members Meet with Supervisor Scott Wiener

November/December 2015 Volume 88, Number 9 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Maryann Hulsman, MCP EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young

Local physicians joined SFMS Immediate Past President Lawrence Cheung, MD, and the San Francisco Medical Society Political Action Committee, for a reception benefiting San Francisco Supervisor Scott Wiener’s candidacy for the California State Legislature to represent the 11th Senate District. Wiener is committed to protecting access to care for the patients of California and ensuring that our landmark Medical Injury Compensation Reform Act (MICRA) is not undermined through the legislative process. He has been an advocate of medicine, collaborating with the medical society on a variety of issues including the soda tax, vaccination, and preserving access to care and health safety nets in San Francisco. The event raised more than $11,000 for Wiener’s campaign.

Governor Signs Bill to Extend CURES Registration Deadline to July 2016

All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish, or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate) now have until July 1, 2016, to register to use the Controlled Substance Utilization Review and Evaluation System (CURES). SFMS and CMA worked to pass Assembly Bill (AB) 679 to extend the CURES registration deadline for six months. SFMS/CMA will continue to monitor the situation, communicate with the Department of Justice, and update members on progress. SFMS/CMA recommends that any physicians who need access to CURES not wait for streamlined registration and begin the process for registration as soon as possible. WWW.SFMS.ORG

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

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

THE SAN FRANCISCO MEDICAL SOCIETY REQUESTS

Gala THE PLEASURE OF YOUR COMPANY

annual

text

J an u a r y 29, 2016 • 6 : 30 PM - 9: 00 PM T he L e g i o n of Honor • 100 34th Ave, San Francisco Celebrate SFMS’ 148 years of physician advocacy and camaraderie, as well as the installation of Richard Podolin, MD as the 2016 SFMS President. Guests are treated to an exquisite reception with elegant hors d’oeuvres, libations, and exclusive access to the Legion of Honor ’s galleries.

Ticket Prices

Online

Mail-In/Phone

Early Bird

$95.00

$100.00

Regular

$105.00

$110.00

(RSVP by 12/31/15) (RSVP by 1/21/16)

Black-tie optional. RSVP Required.

For more information, go to www.sfms.org/Events/AnnualGala.aspx or contact SFMS at (415) 561-0850 x200

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

San Francisco Medical Society At Your Service 2015 began with MICRA’s preservation and the defeat of the trial lawyer-sponsored Proposition 46. In the wake, we thought SFMS and CMA might have a quiet year. Little did we know, 2015 would be one of the most active for the Society. Outreach is a key component of the SFMS. This year we hosted more events and engaged more community leaders, legislators, and health care organizations than any other time in recent history. Via SFMS networking mixers, online forums, Medicare reporting/ practice management workshops, and other events, local physicians were able to connect and share experiences with their colleagues. The SFMS Political Action Committee, under the capable direction of Chair George Fouras, helped elevate our physician voice in the local political arena. In 2016, SFMS PAC hosted political fundraisers for Mayor Ed Lee, Assemblymember David Chiu, and Supervisor Scott Weiner. All three are advocates of medicine, committed to preserving access to care and health safety nets in San Francisco. Both Assemblymember Chiu and Supervisor Wiener have publicly taken support positions on MICRA. Today we are considered a major player in health care issues in the city. The SFMS enjoyed its largest membership growth in decades, led by the addition of physicians working with the City and County of San Francisco. In the latter half of this year we welcomed 250 San Francisco Department of Public Health (SFDPH) physicians into the Society. SFDPH Director Barbara Garcia, in her October report to the Health Commission, aptly recognizes this shared alignment: “San Francisco Medical Society is one of the most progressive medical societies in the country. It has led efforts locally and state-wide on tobacco/e-cig regulation, sugar-sweetened beverage taxes . . . issues that are aligned with the SFDPH’s mission to protect and promote the health of all San Franciscans.” Your member dues continue to be used and managed wisely. The financial picture is as strong as it has ever been. Under leadership of Man-Kit Leung, Finance Committee Chair and incoming president-elect, your Society has repositioned the investment portfolio to increase non-dues revenue while decreasing costs. This significant change will assist SFMS to financially meet its objectives for many years to come. As camaraderie has become rarer in our profession it is— thankfully—thriving at SFMS. Here is but one example: at many organizations past presidents fade into the background, never to be seen again. However, at the SFMS there are at least six past presidents still playing active roles, big and small. Their dedication to this organization and volunteerism are truly inspirational. As my days as your president come to a close, I aspire to follow in their footsteps.

Public Health. The proud SFMS tradition of leading health care

policy continued in 2015. We engaged community stakeholders to educate and ally with areas of common interest. SFMS joined forces with the San Francisco Dental Society and UCSF to endorse the Children’s Oral Health Initiative to eradicate health disparities in childhood oral health and make San Francisco cavity-free. WWW.SFMS.ORG

In partnership with Supervisor Mark Farrell, the SFMSendorsed legislation to ban tobacco products from all baseball venues in San Francisco, including AT&T Park, was unanimously approved by the San Francisco Board of Supervisors in May. Working with Supervisors Scott Wiener, Eric Mar, and Malia Cohen, a trio of SFMS-endorsed sugar-sweetened beverage bills were signed into law by Mayor Lee in June. Through collaboration with the National Council of Asian Pacific Islander Physicians we have successfully persuaded the Health Commission to adopt the use of body mass index (BMI) of 23 as a screening guideline to consider for diabetes testing among Asian Americans. On the state level, SFMS’s longstanding policies in physicianassisted dying, POLST, and reimbursement for end-of-life counseling have become California law. Several of these victories were years in the making thanks to the hard of work of members and staff who have pursued these initiatives despite vigorous opposition within and outside medicine. CMA policy initiated by SFMS could not have been possible without our outstanding House of Delegates representatives, led by Delegation Chair Gordon Fung.

Physician Practice. Maintaining the physician right to advocate independently on behalf of patients is a core value in organized medicine’s DNA. SFMS and CMA took this to heart over the summer while legally and politically defending the rights of the Chinese Community Health Care Association when it was being threatened by a local health plan. We also successfully defeated health plan attacks to deny physicians ability to negotiate fair rates in hospital setting. AB533 would have given health plans and insurers all the power to determine what they should pay for physician services, with no transparency. This bill would ultimately result in a vast decline of providers able to provide services to consumers with PPO products. Looking to ensure the sustainability of medicine, SFMS continues to engage and work with UCSF medical students who are active participants of every board meeting. We collaborate with local residency programs to continue the cultivation of emerging leadership in organized medicine. None of this is automatic. Over fifty of your colleagues collectively donate hundreds of hours of their free time on behalf of the Society. Each of them believes in the good that the Society can create through collaborative effort. Moreover, accomplishing these goals would be impossible without our dedicated professional staff—Jessica, Posi, Steve, Ariel, and Mary Lou. We are all indebted to their service. There is much work to do. Together we have and will continue to make a difference. Thank you for giving me the opportunity to serve in 2015. Connect with Dr. Eng via Twitter @RogerEngMD or send him an email at reng@sfms.org. NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

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SFMS ADVOCACY ACTIVITIES SAN FRANCISCO MEDICAL SOCIETY, AN ADVOCATE FOR PHYSICIANS AND THEIR PATIENTS As the only medical association in San Francisco to represent the entire spectrum of medical specialties and interests, the San Francisco Medical Society (SFMS) has been a champion for community health issues since its inception in 1868. Our policymaking efforts through collaborations with medical and political leaders, as well as articles in our award-winning journal have given us a reputation for being influential far beyond San Francisco. The SFMS agenda and activities continue to focus on the community and the following areas of involvement:

MEDICAL LIABILITY PROTECTION: The CMA and SFMS were instrumental in passing California’s landmark Medical Injury Compensation Reform Act (MICRA), which saves virtually every doctor many thousands of dollars annually in liability premiums, and saves hospitals and health systems much more. We have successfully defeated repeated attacks on MICRA by trial lawyers throughout the years, including the 2014 victory over Proposition 46. SFMS understands that MICRA must be preserved to avoid increased health care costs paid by consumers, state and local government entities, and taxpayers—with resulting decreased access to care. UNIVERSAL ACCESS TO CARE: With ongoing, vigilant efforts to preserve programs and prevent cuts in Medi-Cal reimbursement, SFMS leaders have long advocated that every San Franciscan should have access to quality medical care. We successfully stopped deep cuts in physician reimbursement, averting a scheduled 24% Medicare rate cut in 2014. SFMS additionally joined in the lawsuits to preserve the Healthy San Francisco program, a curriculum designed by those (including our own representatives) serving on the Mayor’s Task Force. SFMS advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s. ANTI-TOBACCO ADVOCACY: SFMS advocates were instrumental in the banning of tobacco smoking in San Francisco restaurants, an accomplishment that was ahead of the rest of the state and nation. SFMS advocated for many policies, including ever-stronger protections from secondhand smoke, higher taxes on tobacco products, and the removal of tobacco products from pharmacy settings. SFMS later signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies, and helped set local and state policy on electronic cigarettes. HIV PREVENTION AND TREATMENT/HEPATITIS B: Having been among the first to push for legalized sy-

ringe exchange programs, appropriate tracking and reporting processes, optimal funding, and more, the SFMS was, naturally, at the center of medical advocacy for solid responses to the AIDS epidemic. SFMS is a partner in the Hep B Free program in San Francisco and helps educate physicians and patients on the prevention and treatment of hepatitis B. SUGAR TAXATION AND HEALTH: SFMS has long been on record combatting overconsumption—and marketing—of sugar and soda, especially where young people are concerned. To help prevent and battle obesity and other associated WWW.SFMS.ORG

ills, SFMS has not only endorsed the broad coalition, but is also at the forefront of it, hoping to institute a landmark local tax on soda with revenue marked for health needs. We have authored policy on this issue for the California Medical Association as well. SCHOOL AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service. SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent. END-OF-LIFE CARE: SFMS leaders have developed numerous policy and educational efforts to improve care toward the end of life, including promulgation of the Physicians Orders for Life-Sustaining Treatment (POLST) medical order, and most recently succeeded in having CMA make what the San Francisco Chronicle termed “a humane shift” on physician-assisted dying. ENVIRONMENTAL HEALTH: SFMS’s many efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health, and advocating for reduced exposure to mercury, lead, and air pollution. REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for woman’s reproductive health and choice, including access to all medicalindicated services. BLOOD SUPPLY: SFMS has long been a partner and sponsor of the Blood Centers of the Pacific, and continually seeks to help increase donations there. ORGAN DONATION: SFMS has been the vanguard in seeking improved donation of organs to decrease waiting lists and deaths due to the shortage of organs through educating the public and proposing new policies regarding consent and incentives for organ donation. OPERATION ACCESS: SFMS is a founding sponsor of this local organization which provides free surgical services to the uninsured, and has provided office space, volunteers, and funds. DRUG POLICY: SFMS has been a leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, “treatment on demand”, and treatment instead of incarceration. We were integral in the development of CMA’s landmark report on decriminalization and regulation of cannabis, and now on Gavin Newsom’s cannabis policy commission. MEDICAL ETHICS: SFMS has developed and promulgated forward-looking policies and approaches regarding end-oflife care, patient directives, physician-assisted dying, nonbeneficial treatment, and other topics of interest to patients, physicians, policymakers, and the general public. PARTNERSHIPS: SFMS works closely with many local specialty and health organizations such as the San Francisco Department of Public Health, San Francisco Emergency Physicians Association, San Francisco Pediatric Council, San Francisco Community Clinic Consortium, West Bay Hospital Conference, Chinese Community Health Care Association, and others. NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

Thriving in Medicine

STAYING ON TOP OF YOUR GAME Don’t Just Survive; Thrive Linda Hawes Clever, MD New Zealand is more than kiwis and lamb chops. Recently, researchers there have made landmark contributions to the field of “flourishing.” They identified and analyzed measures that define this felicitous state of being that include positive relationships, engagement, meaning, and self-esteem. In 2001, Eric Weiner et al. outlined five practices that can lead to flourishing1. They include: • Having strong relationships • Having an active religious and/or spiritual life • Taking care of yourself • Liking your work • Feeling that you can play the hand that’s dealt you

Starting at the top, family and friends are usually the strongest relationships. Family tends to mean kin. Who are friends? They are people who will be with you when they would rather be anywhere else. A more pointed definition: “A friend is someone who will take you in, in the middle of the night, when you are running away.” Not many colleagues, neighbors, fellow committee members, or buddies would do that, so sustaining healthy friendships should be high on your to-do list. My family has found that one great way to help friendships flourish is to put your next date on the calendar before you say goodbye after the current one. Religion and spirituality overlap, of course. Rabbi Eric Weiss notes that religions name their awe (the Buddha, the Prophet, Zoraster, Jesus) and usually have protocols and ceremonies. Spirituality is that transfixing wonder about the world: babies are born with fingernails! Monarch butterflies fly to Mexico and back! This deep wonder brings a certain peace that you don’t need to struggle to explain, and you don’t need to understand these mysteries. Lives buoyed by a strong sense of religion and/ or spirituality require, in part, knowing and living your values. Your values are the basis of your judgments about what is good and bad, right and wrong. Shared values hold groups and families together. Deliberate conversations with yourself, your family, and your work colleagues about values help clear the air and solidify bonds. Living your values brings meaning and joy; that’s flourishing! Taking care of yourself often means doing what you tell your patients: moderation, healthy food, exercise. You keep immunizations up to date in order to save your patients and children. You get professional help if you need it; curbstone consults on yourself may be the start of the process, not the end. You make sure you play enough and have plenty of fun. As Stuart Brown, MD, said, “The opposite of play is not work—it is depression.”2 Although work can be rewarding in many ways, it is not always heaven. To put a finer point on your reflections: Do you en10

joy the people around you and do they respect you? Do you have enough space, mentoring, and opportunities to learn, teach, and think? Think location and systems in place; decide if your passions are satisfied and your talents are well-used. Another set of questions that could reveal the state of your whole life was formulated by the late cultural anthropologist, Angeles Arrien, PhD: • When did you last sing? • When did you last dance? • When did you stop being enchanted by stories? • When were you last comfortable in the sweet territory of silence? If you feel more pinched than enthusiastic, consider a change or exit plan. The fifth quality of people who are at the top of their game is being able to play the hand that’s dealt them, even if it’s a bad hand. This does not mean having unbridled optimism. This means having the conviction that you can make it through no matter what. Relying on your resources—experiences; intelligence; allies and other contacts; sense of humor and spirit—you can recover. Sometimes you may have to lower your expectations. If that doesn’t work, consider lowering your standards. (I’m not entirely kidding. The house doesn’t have to be broomclean; just make sure the health department isn’t called. . .). Any time of year is a great time to be at the top of your game. You want to have the energy and wits to contribute, accomplish, celebrate, and, well, play! This is an especially good time of year to flourish.

Linda Hawes Clever, MD, MACP, is an internist and is founder and President of RENEW, a not-for-profit aimed at helping devoted people maintain (and regain) their enthusiasm, effectiveness and purpose. She is a member of the National Academy of Medicine for which she chairs a standing committee and serves on the Board of Health Sciences Policy. She is also Clinical Professor of Medicine at UCSF and founding Chair of the Department of Occupational Health at California Pacific Medical Center. Dr. Clever is author of The Fatigue Prescription: Four Steps to Renewing Your Energy, Health and Life. She likes walks, good conversations, and good cookies. She is a longtime SFMS member and serves on the editorial board for San Francisco Medicine.

References

1. Weiner, E.L., G.R. Swain, et al., A qualitative study of physicians’ own wellness-promotion practices. West J Med 174(1): 19–23. PMCID: PMC1071222 2. BeWell @Stanford. https://bewell.stanford.edu/why-we-needplay.

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

Thriving in Medicine

SURVIVING BURNOUT A Tale From The Trenches Katherine Herz, MD A year ago I was on staff at what I believe to be hands-down the best health care organization in California. I had lovely

medical assistants with whom I enjoyed spending my days. I used state-of-the-art electronic medical records that allowed me to see emergency department notes, order medications, and review lab results with ease. I had incredibly smart colleagues and specialists with whom I felt grateful to consult and to whom I was confident making referrals. I had the best benefit package in the industry and I cared for a wonderful group of patients. It wasn’t enough. While burnout has no formal definition, it is generally recognized as a triad of emotional exhaustion, relational distancing, and a sense of voided achievement. Every burnout story is unique, and any individual experience can be discounted as peculiar and therefore a statistically unreliable example. Dismissing burnout as an outlier phenomenon certainly makes for more comfortable water-cooler work environments. Recent data, on the other hand, suggest I’m not terribly remarkable. A 2012 study published in the Archives of Internal Medicine revealed significantly higher rates of burnout among practicing physicians than among other US workers. 1 As quoted in the New York Times: “We’re not talking about a few individuals who are disorganized or not functioning well under pressure; we’re talking about one out of every two doctors who have already survived rigorous training,” said Dr. Tait D. Shanafelt, the lead author of the study and a professor of medicine at the Mayo Clinic in Rochester, Minn. “These numbers speak to bigger problems in the larger health care environment.” 2 A few important if not impertinent questions have thus nagged at me in recent years.

Are you really working too hard? My colleagues knew I was struggling. At one point a friend with administrative clout looked into the numbers. Maybe I simply carried an unusually high patient load. It turned out I had on average eighteen visits per day. Did I really think that was too many patients to see, she wondered? I was stunned by the meager sum to which my daily efforts amounted. Why did my life feel so different than that number implied? Was I really addressing only a fraction of the needs I felt drew my attention on a regular basis? Investigating this discrepancy between recognized contribution and perceived effort sheds light on the clash between new-age drivers of medical practice and a stubborn old-time professional model that is churning through its workforce.

Do you measure up? Medicine is increasingly a measure-driven business. I am a big fan of data, as I suspect most physicians are. We WWW.SFMS.ORG

have devoted ourselves to a profession that hinges on evidence. That being said, what you measure matters. The average of eighteen patients per day was presented as an indication of every day reality. But what does an average really signify? The answer is very little in the absence of information about distribution and variance. Median number of patients would better reflect a physician’s “expected” office visits if that were the concept aimed for. Presenting daily workload as a sum of patients who attended clinic also begs the question of what it means in this day and age to “see” a patient. The proliferation of tools for digital communication has allowed patients the convenience of virtual appointments. We provide telephone visits and video visits, neither of which “counted” toward measured workload. We field emails from patients who increasingly expect a rapid reply, encounters also excluded from official output assessments. Even a full count of patients “touched” per day underestimates true workload if we are also expected to review labs, consults, hospitalization, and emergency department records.

Isn’t coordinated care more efficient? Health policy experts promote a laudable “triple aim” of lower cost, higher quality, patient-centered medical care. The triple-aim is a hoped-for win-win-win, rewarding patients, physicians, and national accountants. Resource-intense encounters are an obvious target for making progress toward the triple aim. Emergency room visits and hospital stays are both costly and risky. The longer a patient stays, the greater the expense, and the more likely are unnecessary tests or procedures, hospital-acquired infections, or other complications. As we push patients out of high-acuity settings, we demand more from our outpatient system. If we hope to avoid the most resource-intense stays altogether, still more will be required from outpatient teams. Studies of so-called “medical home runs”—primary care clinics whose most complicated patients achieve disease management sufficient to lower morbidity and avoid hospital and emergency room visits—reveal common features. They have tightly coordinated teams whose members have clear roles and who insist on rigorous pursuit of treatment goals. These clinics are, in their own way, highly resource-intensive.3 It turns out that gains from such coordinated care are not readily “monetizable,” at least not in the short run, and not for patients who have chronic conditions but are not the most ill outliers. Payment schemes that have grown as a method to achieve more “rational” care by paying one fee for the care of one person—as opposed to paying per blood count or per well visit or per CT scan—have Continued on the following page . . .

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

Surviving Burnout Continued from page 13 . . . therefore failed to accrue the savings that might push businesses to ensure this care coordination works well.

Why don’t you take on an administrative role? In fact,

recent changes in the business environment of health seem to be pushing outpatient teams in a direction opposite from thoughtful and efficient care of sick people. Implementation of the Affordable Care Act (ACA) brought millions of new patients into the U.S. health system. Clinical organizations faced great uncertainty, and the best tried to strategize their approach. I was impressed with my organization’s studied method, using surveys to help figure out how we could continue to do well and grow despite increased competition. The curious result of our organization’s investigation was to focus on features of the outpatient experience most valued by healthy people. People prefer neat and tidy spaces, frictionless transactions, and the ease of being seen at their convenience. It turns out that people who need only rare medical attention assess quality predominantly by these features. The subjective assessment of quality, in turn, determines enrollment. And we need relatively healthy people to buy into our system in order to finance care for the sick and maintain our margins. The administrative focus therefore became one of attracting and keeping low-frequency users of our system. We needed more appointments available per day so that people could be seen when they wanted. We needed to answer all emails that arrived by 5pm within the same calendar day to impress everyone with our service. We needed to call back every patient who made it through our phone triage no matter how much time had been set aside—or not—for this work. We should also be clearing out our “inbox” of test results, copied charts, and messages from colleagues on a daily basis. We were told in no uncertain terms to do more with less or risk economic annihilation. Every department was tasked with brainstorming ideas to ensure our organization’s future. We targeted interventions that would appeal to low-frequency users without incurring significant cost or organizational disruption. A recent incident provided my group’s inspiration. An unsightly spill had been noted in our hallway. Environmental services had been called, but two days later the spill remained. Why didn’t we just clean up such messes ourselves? Were we above a little dirty work? “Scan the room. Pick it up. Throw it away. Wipe it down,” became the new departmental cheer. Descriptions of modern medical practice often include battlefield analogies. Studies of physician burnout indicate that “frontline” workers are at highest risk.4 We motor through the office visits, the phone calls, the emails, and the in-baskets, making sure everything is “doned” by the end of the day. This task-mastering routinely takes nine continuous hours of rapid-fire cognitive switching. What we can’t manage under this load is anything beyond the most basic medical problems. An ear infection can be covered. A first-presentation reactive airways disease with moderate respiratory distress and borderline oxygenation will require two to three hours in clinic and throw the whole day off, stretching those nine hours to ten or eleven. Structural incentives therefore push that patient away from pediatricians and back to the emergency department. I was trained to uncover rare diseases, help families navigate 12

decisions, and manage both acute and chronic medical conditions. The exigencies of the healthcare marketplace have re-defined my role as one of triage. Simple problems remain with me; complex problems get referred out. This leads to both cognitive dissonance and dissatisfaction. Our administration encourages us with language to “do the right thing” for our patients, to take extra time to puzzle out clinical conundrums, explain risks and benefits of intervention with thoroughness and patience, review the rationale for chronic treatments instead of just handing over a prescription. Going the “extra mile” in these ways is key to our professional satisfaction. It also requires hours of unpaid overtime. The “you’reonly-seeing-eighteen-patients-per-day” job description not only systematically underestimates widgets of medical production but also clearly values those units over the exercise of our expertise. To practice medicine anywhere near professional capability requires perpetual over-extension.

Can’t you “make it work?” For most people, life in the trenches

cannot be sustained. One solution is to “lean out” by reducing number of hours worked. At last count, eighty percent of my group worked part-time. No full-time clinician had children at home. Another survival strategy is to take on administrative work. In a group famous among policy experts for its innovative approach to care, this seems a potential outlet for creative thinking about systems improvement. Given business-model constraints, however, wellintentioned administrative approaches proved so limited as to be risible. (Is that purple gloves for patients and tawny ones for trash?) We turn to the spiritual meaning of our work for further inspiration and energy. Mindfulness experts encourage us to sit in silence, to appreciate the beauty and peace of nature, to remember what drew us to medicine in the first place. Pause before each encounter, we are told, to make sure you connect with that higher calling. This isn’t a problem that for me eighteen deep breaths would solve. At its heart lies a string of fundamental questions. What is the modern health production function? How do we measure output? How do we value it? What role does quality play? And importantly for the profession of medicine, is there a role for thinkers in this system? I am committed to finding workable answers to these questions that advance our patient care and our profession — and that will allow me to do more than just survive as a physician. Katherine Herz, MD, is a general pediatrician. She graduated with a BA in economics from Princeton, received her MD from and completed residency training at UCSF, and earned a Master of Science in Health Services Research during an Agency for Healthcare Research and Quality Fellowship at Stanford. She is an SFMS board member and delegate to the CMA.

References 1. Arch Intern Med. 2012;172(18):1377-1385. doi:10.1001/ archinternmed.2012.319 2. “The Widespread Problem of Physician Burnout,” by Pauline Chen, 8/23/2012 3. “American Medical Home Runs” by Arnold Milstein and Elizabeth Gilbertson, Health Affairs, doi: 10.1377/hlthaff.28.5.1317 Health Aff September/October 2009 vol. 28 no. 5 1317-1326 . 4. Arch Intern Med. 2012;172(18):1377-1385. doi:10.1001/ archinternmed.2012.319.

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

Thriving in Medicine

LESSONS LEARNED Turning Conflict into Positive Change Richard Podolin, MD Nine years ago, St. Mary’s Medical Center went through a period of hostility between the organized medical staff and the hospital administration, end-

ing with the removal of the hospital president. Now, as economic pressures increasingly and paradoxically favor both alliance and competition between hospitals and physicians, are there lessons from our unhappy experience that can help independent physicians thrive? During the aforementioned president’s early years at St. Mary’s, he enjoyed wide support. He was young, energetic, and approachable. He engaged physicians in strategic planning and developed goals in a collaborative process. The relationship between the physicians and the president did not start to deteriorate until well into his tenure. Changes were made to service lines without consulting or notifying the department chairs. A physician who had opposed the president in Medical Executive Committee (MEC) deliberations found he was no longer able to renew his office rental agreement. Memos from the Chief of Surgery about quality issues were left unanswered. Critically, the president “closed” the Department of Anesthesiology, turning it into a contracted service, but was then unwilling to finalize a contract with a new anesthesiology group. The quality of the service, now staffed by a parade of locum tenens, declined precipitously, and the medical staff was compelled to act. Our first lesson was about the power of association. Once we determined collectively to address the problem, the sense of impotence we had experienced as individuals dissipated. Physicians who had considered leaving now became fully engaged. We learned that we had unanticipated allies, particularly among the physician leadership of contracted services. Every action had the unanimous support of the MEC, including the chairs of both the open and the contracted departments. This negated the easily anticipated claim of the administration that the opposition was just “a small group of disgruntled physicians.” We avoided mobilizing physicians beyond the leadership, however, because we knew some supported the president and we did not want to polarize the community. We realized that we needed legal advice, so we engaged an attorney who had successfully defended medical staffs in conflicts with hospital administration. From him, we learned our second lesson: physicians have no “right” to be treated well, or even respectfully, by hospital administration, but Title 22 of the California Code of Regulation requires that a hospital have an MEC “responsible to the governing body for the adequacy and quality of the care rendered to patients.” Since the administration had failed to alleviate the critical quality problems in our operating room and anesthesiology service, we had a responsibility to petition the Board for corrective action. WWW.SFMS.ORG

Unfortunately, I had failed to prepare the Board for the action the MEC was about to take. This was my most regrettable error. As chief of staff, I delivered the quality report at each Board meeting. Reluctant to “air dirty laundry” in this more public setting, I had not conveyed the severity of the quality concerns, or the degree to which the hospital president was losing the support of the medical staff leadership. Consequently, when the MEC petitioned for his removal, the members of the Board felt blind-sided and angry. We were fortunate that the Board nonetheless undertook a careful and impartial investigation of our claims. It took more than a year, but ultimately we had a new president who worked collaboratively with the medical staff. A contract stabilizing the Department of Anesthesiology was swiftly finalized, and we have since enjoyed excellent anesthesiology services. We are on a journey of continuous quality improvement, but we are again taking that journey together. Dignity Health has recently introduced new initiatives, including clinical integration and co-management, which further align independent non-employed physicians with the hospital and promote physician-administration collaboration. Briefly, clinical integration is a legal arrangement that allows a hospital and independent physicians to collaborate on improving quality and efficiency, and in return the participating independent physicians can collectively negotiate with payers for more favorable rates. Co-management is an arrangement in which physician and the hospital co-manage a service line. The physicians become actively engaged in improving quality and efficiency for the hospital, and in exchange receive management fees and incentives for achieving defined targets. There will always be tensions between hospital administration and medical staff. Even when our goals are aligned, our priorities may differ. But our experience made one thing eminently clear: the best interests of our hospital, our physicians, and— most importantly—our patients, are served when the hospital and physicians work together collaboratively and with mutual respect. Richard Podolin, MD, is a cardiologist based at St. Mary’s Medical Center, where he has been chief of the medical staff. He is a longtime SFMS member and is the 2016 SFMS President.

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

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Thriving in Medicine

MAINTAINING BOARD CERTIFICATION Who is Thriving and Who is Struggling? Michel Accad, MD Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career. Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise. To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise. In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated. At the heart of the discontent are changes implemented by the American Board of Medical Specialties (ABMS) and its affiliate organizations, which have made the MOC process considerably more time-consuming and costly. MOC is no longer a matter of taking an examination every ten years. Instead, doctors must enroll in a program of continual online testing that may also include practice review activities, whereby physicians are asked to document their participation in some quality improvement intervention and monitor the impact of this intervention on patient care. To give a sense of the effect of the new changes, a recent study conducted by UC San Francisco and Stanford investigators has estimated that under the latest MOC rules implemented by the American Board of Internal Medicine (ABIM), physicians will be spending on average over $23,000 (in money and time) every ten years simply to maintain their certification status.1 In the last five years, physicians across specialty and around the nation have become increasingly vocal in their criticism of these onerous requirements. The rebuke against board-certifying organizations has been widespread, intense, and, at times, acrimonious, leading a Newsweek journalist to report on what he called an “ugly civil war” in American medicine.2 The intensity of the resistance is explained not only on the basis of the added requirements, but also because board certification is now widely mandated as a condition for hospital staff privilege or for employment in large medical organizations. As a result, physicians are now obligated to do an activity which, until recently, was a voluntary exercise. Initially, the anti-MOC movement was primarily a grassroots effort of disgruntled physicians. In 2010, the New England Journal of Medicine sponsored an online survey about the new MOC requirements, and 63 percent of physician respondents expressed their opposition.3 Following that survey, physicians shared their frustration via dedicated websites and on social media.4 Since then, the movement has grown into a powerful WWW.SFMS.ORG

challenge to the ABMS, striking several blows against the established order. The first blow came with an online petition launched by Scripps Clinic cardiologist Paul Teirstein. The petition gathered 19,000 signatures, 6,000 of which were “pledges of non-compliance” with the MOC requirements. Following this petition, Teirstein enrolled a group of well-respected academic physicians to form the National Board of Physicians and Surgeons (NBPAS), an organization that would verify a doctor’s continued medical education efforts and issue renewal certificates through a much less onerous process. (Note: NBPAS certificates require an initial ABMS certification.) A spate of debates followed these moves, both online and in prestigious medical journals, bringing to the fore some of the problems that the grassroots effort had been calling attention to over the last few years. An important question raised by the MOC controversy concerns the apparent lack of data to support its more onerous requirements. This point was openly advanced by Teirstein in a videotaped debate that occurred at the winter meeting of the Association of Professors of Medicine. The debate put him in opposition to Richard Baron, CEO of the American Board of Internal Medicine (ABIM), and to Lois Nora, CEO of ABMS, and was followed by a number of journal editorials where the question was examined further.5 Another aspect of the debate has concerned possible financial improprieties by the board-certifying organizations. Some physicians have examined the publicly available financial statements of ABIM and have called attention to the way the earnings from MOC have been used. Given the sharp increase in certification costs over the last few years, these allegations added fuel to the discontent and put board organizations in a defensive position. Adding their voice to those of practicing physicians, a number of professional societies have also been critical of the MOC programs. Specialty groups, like the American College of Rheumatology, and state medical societies, like the Washington Medical Association, have issued statements supporting alternative pathways for board certification, such as the one offered by NBPAS. And if that weren’t enough pushback, ABMS is also dealing with a 2-year-old legal action initiated by the Association of American Physicians and Surgeons (AAPS) which alleges that the burden of recertification amounts to a restriction of trade on physicians. The courts have not issued a ruling on this claim, but recent testimony by physicians who have been denied hospital privilege for failing to fulfill MOC requirements may bolster the charge, especially now that the high cost of MOC has been docu-

Continued on page 17 . . .

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Maintaining Board Certification Continued from page 15 . . . mented in a peer-reviewed academic journal. So what are physicians who aspire to thrive in their practice to do in the face of so much controversy? At the rate things are evolving, there is no easy answer to that question. Earlier this year, and in response to the discontent, ABIM suspended or scaled back some of its more controversial MOC requirements. It also recently issued a lengthy task force report that sketches other possible changes to come. One the side of the “rogues,” NBPAS is garnering increased support. According to the NBPAS website, the organization has already attracted well over 2,000 applicants and has been recognized as a legitimate board-certifying entity by a small but growing number of hospitals.6 Prudence would dictate that if a physician’s certificate is on the cusp of expiring, he or she should follow current board rules to ensure renewal, particularly if board certification is a prerequisite for employment. Otherwise, it might make sense to watch the situation unfold: ABMS organizations could deliver on their promise to make the MOC process less onerous, or alternative pathways for board certification, such as the one offered by NABPS, could become more widely recognized. In either case, MOC may soon become less burdensome for the already over-burdened physician. This will be a welcome change for physicians who of late have become more accustomed to struggling than to thriving. Michel Acaad, MD, is a cardiologist in San Francisco. He is an SFMS member and serves on the editorial board for San Francisco Medicine.

References

1. Sandhu AT, Dudley RA, and Kazi DS. A Cost Analysis of the American Board of Internal Medicine’s Maintenance-of-Certification Program. Ann Intern Med 2015;163(6):401-408. 2. Eichenwald, K. The Ugly Civil War in American Medicine. Newsweek. March 10, 2015. Available online at http://www. newsweek.com/2015/03/27/ugly-civil-war-american-medicine-312662.html (Accessed October 31, 2015) 3. Kritek PA, Drazen JM. Clinical decisions: American Board of Internal Medicine maintenance of certification program – polling results. N Engl J Med 2010;362:e54-e54 4. Examples of such physician-led websites include http:// www.nomoc.com and http://www.changeboardrecert.com/ 5. The videotape can be found at https://nbpas.org/debateon-maintenance-of-certification/ (accessed October 31, 2015) 6. https://nbpas.org/nbpas-update/ (accessed October 31, 2015)

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Thriving in Medicine

ONINE REVIEW SITES How To Survive, Thrive, and Manage Your Reputation Ashley Porciuncula In the digital age we live in, doctor-patient communications don’t end when the patients steps out the door. People are constantly connected, socially and profession-

ally, and the medical field is no exception. Now more than ever, patients are reviewing their doctors online, rating their experiences, and writing personalized testimonials about their visits on sites like Yelp, HealthGrades.com, Vitals.com, ZocDoc, and others. The results from a survey conducted by Dimensional Research emphasize the value of a good review. 90% of participants were swayed by positive reviews while 86% were swayed by negative reviews. Just as consumers rely on testimonials when making a purchase, potential clients consider prior patients’ feedback when choosing a doctor. Because online reviews are playing a bigger role in guiding decisions, doctors need to make that monitoring and evaluating their online presence a priority in order to manage and improve their practice’s reputation.

Assess and Take Control

First things first: take stock of your existing Internet presence. Search for the name of your practice as well as the names of your staff and doctors to get a full picture of what people are saying about you. Some of the more popular websites for pre-existing client-made profiles, comments, and ratings are HealthGrades.com, Vitals.com, RateMDS.com, ZocDoc.com, Yelp, Google Reviews, and Facebook. Remember, it’s not possible to simply opt out of being reviewed. When creating your profiles, use it as an opportunity to shape the perception of your practice. By uploading brand elements, a description, a welcome message, and other information about your practice, you are taking the first step to controlling how your practice is viewed. Once setting up your profiles, examine all client-written reviews and see whether you can make any immediate changes to your practice to improve how it’s managed.

Encourage Positive Reviews

There are a number of ways to encourage patients to leave positive feedback: add links to your profiles on your practice’s website and in emails, follow up on appointments with an email asking patients to rate their experiences, post flyers advertising where patients can find your practice’s profiles online, and, of course, provide your best services. Some practices even set up Wi-Fi in the office to make leaving a review easy before or after an appointment. Day to day, don’t be a stranger to your patients. Engage with them online through social media to show that you pay attention to their needs in and out of the office. They will be more likely to write a review if they think you will read and respond to it. Setting up social media profiles may sound unnecessary and WWW.SFMS.ORG

time-consuming for some practices, but once they are up and running you will soon see their benefits. When you do get a positive review, reach out to the patient and thank them privately. A personal touch goes a long way in the office and online. Do not post your own or make patients write them for you. Reviews should always be optional. In fact, you can be liable for false reviews.

When Bad Reviews Happen

Even if you have an A+ relationship with your patients, few physicians are exempt from ever receiving a bad review. If you receive negative feedback, read it and then walk away to reflect for a while—a few hours or even a day. Then you can craft a polite and professional response instead of an impulsive one. Once you have taken time to write your response, reply to the user directly through the website, publically when possible, but do not acknowledge the patient is your patient. When writing a public response, remember that any and all personal patient information must be emitted to comply with HIPAA laws. The CMA legal department recommends the following: “Our practice takes patient concerns seriously. Federal laws preclude us from responding to [a] patient[’s] concerns publicly. If you are our patient, please contact our office directly at [your contact] so we can address your concerns confidentially.” Remember that negative reviews will happen, but your overall reputation will shine through. As long as you have positive reviews to balance it out, your reputation will not suffer.

Monitor and Maintain Future Reviews

Be patient. A good profile requires time. As reviews accumulate, trends will emerge and the average rating will become consistent and more accurate. Dedicate a specific person to regularly monitor all of your profiles. The office manager is usually the best person for this position. When setting up your profiles, you can opt to receive notifications when new reviews are added. You can also set up Google Alerts to send you an email whenever Google Search finds something new about you or your practice. If your practice is small or there is not someone on your team who can handle the added work, there are professional consultants that can set up and monitor your profiles and social media campaigns. These service providers will be able to personalize a system that works for your practice and takes the stress off you and your team.

Ashley Porciuncula is a branding, logo, and Website designer, blogger, and social media consultant to physician practices. www. plcpracticewebsites.com.

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

Thriving in Medicine

HIPAA COMPLIANCE How To Survive an Audit Kimbelee Snyder The use of health information technology continues to expand in health care. Although these new tech-

nologies provide many opportunities and benefits for consumers, they also pose new risks to consumer privacy. Because of these increased risks, the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) include national standards for the privacy of protected health information (PHI), the security of electronic protected health information, and breach notification to consumers. The Office of Civil Rights (OCR) is responsible for enforcing the HIPAA Privacy and Security Rules. OCR will conduct HIPAA compliance audits in 2016, and it is recommended that all covered entities begin preparing for these audits. Audits will cover hospitals, health care providers, health plans, and business associates. The OCR HIPAA Audit program reviews each area of security for an organization. An audit protocol has been established by OCR and is organized around modules, representing separate elements of privacy, security, and breach notification. The combination of these multiple requirements may vary based on the type of covered entity selected for review. Specifically: • The audit protocol covers Privacy Rule requirements for: (1) notice of privacy practices for PHI, (2) rights to request privacy protection for PHI, (3) access of individuals to PHI, (4) administrative requirements, (5) uses and disclosures of PHI, (6) amendment of PHI, and (7) accounting of disclosures. • The protocol covers Security Rule requirements for administrative, physical, and technical safeguards. • The protocol covers requirements for the Breach Notification Rule. Electronic health records have resulted in the need to implement reasonable and appropriate security measures to protect against anticipated threats to the security and integrity of PHI. HIPAA requires covered entities to evaluate risks and vulnerabilities in their databases, applications, and systems that contain PHI. Privacy and security assessment of paper records must also be assessed. Even if an electronic health record system is HIPAA-compliant, a security risk assessment must be done for the entire covered entity.

How to Ensure HIPAA Compliance

Providers should have a professional security risk assessment completed by a certified HIPAA specialist. The HIPAA specialist will assess the areas listed below and note any areas of non-compliance. A mitigation plan will be provided to outline steps needed to mitigate areas of risk. The security risk assessment should be re20

viewed yearly. If a provider is participating in the Electronic Health Records (EHR) Incentive Program, a security risk assessment is a requirement in order to receive incentive payments. A security risk assessment includes the following areas:

Administrative Safeguards

• Security Management Process • Assigned Security Responsibility • Workforce Security • Information Access Management • Security Awareness and Training • Security Incident Procedures • Contingency Plan Evaluation • Business Associate Contracts

Physical Safeguards

• Facility Access Controls • Workstation Use • Workstation Security • Device and Media Controls

Technical Safeguards

• Access Control • Audit Controls • Data Integrity • Person or Entity Authentication • Transmission Security

Organizational Requirements

• Business Associate Contracts • Organization Documentation Updates (i.e., Notice of Privacy Practices, Authorizations)

Penalties for Non-Compliance

Penalties for non-compliance with HIPAA rules can cost a health care organization anywhere from $100,000 to $2,000,000. A practice was posting patient clinical and surgical appointment information on a non-secure web site, and OCR found they did not have adequate policies and procedures in place. The practice was fined $100,000, which appears to be average for a small practice breach of PHI. OCR also required the practice to adopt a corrective action plan within 30 days or pay an increased fine. One other action that OCR has taken is to add those providers found non-compliant to the yearly audit review list. If a provider is receiving meaningful use incentive payments and they are non-compliant, they are required to refund incentive payments received and they are subjected to a yearly meaningful use audit.

Continued on page 22 . . .

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

Thriving in Medicine

NEW HEALTH CARE LAWS 2016 Laws of Interest to California Physicians

Governor Brown spent four weeks up to his October 11 deadline working on deciding the fates of the over 650 bills sent to his desk by California legislators. Below is a list of the most important bills pertaining to the practice of medicine and/or impacting physicians. All laws are effective January 1, 2016, unless otherwise specified.

Approved Healthcare-Related Legislation

AB 637 - Expanded Role of NPs and PAs on POLST Assembly Bill (AB) 637 authorizes as valid the completion and signature on the Physician Orders for Life Sustaining Treatment form (POLST) by a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician. The bill stemmed from a SFMS resolution and was a CMA-sponsored piece of legislation.

AB 679 – CURES Prescriber Enrollment

All California-licensed physicians authorized to prescribe, order, administer, furnish, or dispense Schedule II, III, or IV controlled substances must be registered to access the Controlled Substance Utilization Review and Evaluation System (CURES), as required by California Health and Safety Code Section 11165.1. AB 679 extends the current deadline for enrollment with the Department of Justice to access information contained in the CURES database from January 1, 2016, to a new deadline of July 1, 2016.

SB 277 – Public Health and Safety: Vaccinations

Legislation championed by SFMS, CMA, and Senator Richard Pan, MD, Senate Bill (SB) 277 eliminates the personal belief exemption from school vaccination requirements, barring parents from skipping their children’s school-required immunizations unless they have a medical exemption from a physician. Students may obtain a written medical exemption to vaccinations from a licensed physician (MD or DO) that includes the following information: • That the physical condition or medical circumstances of the child, which may include family medical history, are such that the required immunization(s) is not indicated • Which vaccines are being exempted • Whether the medical exemption is permanent or temporary • The expiration date, if the exemption is temporary

SB 299 – Medi-Cal: Provider Enrollment

SB 299 grants an exemption from notarization requirements for any Medi-Cal provider that choose to enroll electronically. It also mandates the Department of Health Care Services to collect an application fee for continued enrollment. WWW.SFMS.ORG

AB 1177 – Primary Care Clinics Written Transfer Agreements AB 1177 requires primary care clinics to directly send with each patient at the time of transfer all medical records and pertinent information related to the patient’s transfer (or in the case of an emergency, as promptly as possible). Medical records should include current medical findings and a brief summary of the treatment provided prior to the patient’s transfer. The bill removes the current requirement that all clinics must have a hospital transfer agreement in place as a condition of licensure.

AB X2-15 – End of Life Option Act

AB X2-15 enacts the End of Life Option Act, authorizing an adult who meets certain qualifications and who has been determined by his or her attending physician to be suffering from a terminal disease resulting in death within six months to request and obtain a prescription for a drug that the individual may self-administer to end the individual’s life. The bill makes the participation of a physician providing care to a qualified patient seeking an aid-indying drug entirely voluntary, and establishes procedures and reporting processes, as well as provides the necessary forms required for both medical records and reporting to the State Department of Public Health. AB X2-15 will not go into effect until 90 days after the extraordinary session on health care is adjourned, which is projected to be in January 2016 at the earliest and November 2016 at the latest. The bill has a sunset date of January 1, 2026.

SB 337 – Physician Assistants

SB 337 requires physicians and surgeons supervising PAs to review a minimum of 5% of the medical records of patients treated by the PA within 30 days of the date of treatment. It also authorizes a PA, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient or to transmit an order to furnish medication or a medical device. SB 337 also prohibits a PA from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the PA has completed an education course that covers controlled substances and that meets approved standards. All PAs who are authorized by their supervising physicians to issue drug orders for controlled substances will need to register with the United States Drug Enforcement Administration (DEA). The act requires that the medical record of any patient cared for by a PA for whom a PA’s Schedule II drug order has been issued or carried out be reviewed, countersigned, and dated by a supervising physician and surgeon within seven days.

Continued on the following page . . .

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

New Health Care Laws Continued from the previous page . . .

HIPAA Compliance Continued from page 20 . . .

SB 643 – Medical Marijuana Legislative Packet

Breach Notification

SB 643 sets standards for physicians and surgeons prescribing medical cannabis. It also requires the Medical Board of California to prioritize investigative and prosecutorial resources to identify and discipline those who improperly recommend excessive cannabis to patients for medical purposes or do so without a good-faith examination. Many of the new standards will take effect in January 2018.

A breach is anything that comprises the privacy and security of PHI. Any use or disclosure of PHI without permission is presumed to be a breach unless a covered entity can demonstrate low probability that PHI was comprised. An assessment is required that includes the following: the nature and extent of the breach, indication of the unauthorized person who used the PHI, explanation of whether the PHI was acquired or viewed, and description of the extent the risk to PHI was mitigated. Reporting based on the following requirements is also required:

SB 658 – Automated External Defibrillators (AED)

SB 658 provides an exemption from civil liability for a physician and surgeon or other health care professional that is involved in the selection, placement, or installation of an AED.

SB 738 – Pupil Health: Epinephrine Auto-Injectors: Liability Limitation

SB 738 prohibits an authorizing physician and surgeon from being subject to professional review, being liable in a civil action, or being subject to criminal prosecution for the issuance of a prescription or order, pursuant to these provisions, unless the physician and surgeon’s issuance of the prescription or order constitutes gross negligence or willful or malicious conduct.

This bill summary is provided courtesy of the Cooperative of American Physicians, Inc., with the assistance of Capitol Advocacy, a full-service government relations company based in Sacramento. This is not a complete list of all health-related legislation recently passed and is not intended as a substitute for legal advice provided by a retained attorney in any particular medical situation.

Individual Notice – individuals should be notified of the

breach right away (no later than 60 days following the breach) by first-class mail or email. If the covered entity has insufficient information to contact individuals, a notice must be posted on their website OR in major print or broadcast media where individuals reside.

Media Notice – If more than 500 residents of a state are impacted by a breach, the covered entity must use media notification and notify the individuals impacted. This should be done right away and no later than 60 days following the breach.

Notice to the Secretary – All breaches impacting PHI of 500 or more individuals must be reported to the Secretary of Health and Human Services right away, and no later than 60 days following the breach. If less than 500 individuals are impacted, the covered entity may report on an annual basis but no later than 60 days after the end of the calendar year. Summary

Lumetra is pleased to offer discounted pricing to members of the San Francisco Medical Society Security Risk Assessment and Mitigation Plan Normal rate $1,250 SFMS rate $1,100

Policy and Procedure Manual Normal rate $1,250 SFMS rate $1,100 The pricing above does not include travel and mileage to a provider site. A custom quote for training practice staff, at a discounted hourly rate, is available upon request. For more information or to sign up, please contact SFMS at membership@ sfms.org or (415)561-0850 x200.

Breaches of PHI are becoming more and more common. Physician practices and medical organizations are losing millions of dollars from fines paid when breaches of PHI happen. Some of these breaches involve the use of unencrypted email with PHI attached, stolen laptops, unauthorized users accessing PHI, and cyber-attacks. Providers can mitigate risk of a breach by following HIPAA rules and putting safeguards in place. Although it is difficult to prevent theft of a laptop, for instance, a process can be put in place to help ensure that this has a small chance of happening. With the onset of ever-changing digital health information, it is critical to be compliant with HIPAA Privacy and Security Rules. As OCR begins conducting more audits, it is recommended that providers complete a security risk assessment, plan for mitigating any risk identified, document policy and procedures, and train staff. Kimbelee Snyder is Vice President, Informatics Services at Lumetra Healthcare Solutions. Lumetra has been awarded a grant from Medi-Cal to help providers with their EHRs and quality measures. Lumetra’s team includes experienced Certified HIPAA Privacy and Security Experts who helps providers ensure that they are compliant with all regulations impacting PHI.

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

Thriving in Medicine

PROFESSIONAL LIABILITY INSURANCE Defining The Details

A necessary cost of being a physician is professional liability insurance, sometimes known as medical malpractice insurance, which protects the physician from

liability associated with wrongful practices resulting in bodily injury, medical expenses, and property damage, as well as the cost of defending lawsuits related to such claims. There are two basic types of malpractice insurance—occurrence or claims-made.

Occurrence, Claims-Made, Tail Coverage

An occurrence-based policy provides insurance against incidents that occur during the term of the policy, regardless of when the claim is made. A claims-made policy covers the insured for any incidents that occur during the policy period, as long as the claim for the incident is also filed during the policy term. If you cancel or don’t renew a claims-made policy, you will have no insurance for any claims first reported afterward unless you buy additional coverage, commonly called “tail coverage.” Tail coverage extends your policy protection for late reporting of claims. Tail insurance is generally a onetime payment and the cost is based on a multiple of the mature premium, generally around 175% to 250%. If a physician decides to change employment, wants to continue practicing medicine, and requires a new malpractice policy, tail insurance will be required to continue coverage for all incidents that may have occurred under the old policy. Many claims-made policies offer “free” tail coverage for death, disability, or permanent retirement. If the insured cancels his or her policy and moves to another insurance carrier, a prior acts (or “nose”) policy may also be purchased, and this functions similarly to tail coverage. Under this scenario, the new company takes the retroactive date from the old policy and endorses it onto the new policy. The price for prior acts coverage is usually similar to the price of tail coverage, if not a little greater. Whereas a claims-made policy premium will start low and gradually build up over five years, the premiums for occurrencebased policies are priced at a mature level from day one. Even after hitting mature rates, a claims-made policy is almost always less expensive than an occurrence-based policy. For this reason, most physicians purchasing their own insurance will opt for claims-made policies, especially if they plan on staying in the same practice for the remainder of their career. Most hospitals and facilities carry occurrence-based policies, so often when a physician is employed by a hospital system he will be provided occurrence-based insurance. If a physician is considering hospital employment, either he will need to pay for tail or prior acts coverage or negotiate this as part of his new employment. If the physician decides to leave hospital employment at a later date, under an occurrence-based policy WWW.SFMS.ORG

Ronni Fan

he can do so without needing to purchase any tail coverage. For this reason, an occurrence-based policy can be appealing to a physician entering into an employment contract with a hospital system, knowing that if he leaves this employment and changes policies there will be no need to purchase tail insurance.

What Are The Limits of Liability?

The limits of liability are the maximum amount that the company will pay on your behalf to each claim (called the “per claim” limit) and the total amount available for all claims reported during the policy period or year (called the aggregate limit). Most carriers offer several choices of limits of liability, beginning at $1 million per claim/$3 million annual aggregate.

What’s Covered…And What Isn’t?

Medical malpractice insurance covers a range of expenses associated with defending and settling malpractice suits; it also pays damages if you’re found liable. Covered costs include: • Attorneys’ fees and court costs • Arbitration costs • Settlement costs • Punitive and compensatory damages • Medical damages In addition to facing medical liability claims, medical practices also face risks associated with cyber liability and regulatory requirements, such as compliance with the Health Insurance Portability and Accountability Act (HIPAA). Physicians may want to consider purchasing separate cyber liability insurance or seeking a malpractice policy that covers these types of exposures.

Ronni Fan is an underwriter for the Medical Insurance Exchange of California (MIEC). MIEC is a not-for-profit physician-owned professional liability insurance carrier, founded in 1975 by SFMS and five other Northern California county medical societies when commercial carriers withdrew from the medical malpractice insurance market. SFMS exclusively endorses MIEC’s medical liability insurance program for its members. For more information, visit http://www.sfms. org/membership/membership-benefits/miec.aspx.

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

Thriving in Medicine

ELECTRONIC MEDICAL RECORDS Choosing the Best System for Your Practice

Driven initially by Federal financial incentives and now by increasingly stiff penalties, EMRs have changed

from a “nice to have” to a “must have” for today’s clinical practices. Unfortunately, EMRs can be complex, costly technologies even for practices with dedicated information system capabilities. For small group and individual providers, choosing and implementing an EMR can be an overwhelming undertaking. The good news is that certification requirements for the vendors and newer technologies have removed some of the difficulty and risk associated with selecting and implementing an EMR in your office. Once viewed as clinical saviors that help improve quality, consistency, and safety while reining in runaway costs, EMRs are now vilified as electronic taskmasters that suck the life out of clinicians while causing new types of errors and facilitating fraud in billing and documentation. Some of the market leaders’ reliable, high-performing platforms are labeled “obsolete” and incapable of delivering a contemporary computing experience. The EMR has essentially been painted with most of the ills of the current healthcare system. Still, a reasonably successful implementation of an EMR typically brings powerful benefits to patient care that are typically not discussed, yet rarely denied. The elimination of handwriting is surely the most obvious, and the ubiquitous access to the chart is probably next. How quickly we forget struggling to decipher the handwriting of our peers and the hundreds of thousands of medication errors due to poor handwriting. How much time do we save by the ability to instantly access a patient’s chart from most anywhere on the planet? How many errors and misdiagnoses have we avoided by simply having access to the patients’ data? Even little things like immediate access to the medication list and recent labs while refilling medications is far more efficient than it was with the paper chart. Also, the timeliness of communications is greatly improved – when I complete a visit, my consultation note is instantly available to the patient’s PCP who they may be seeing later in the day. Previously, it took days to weeks for a letter to get to the PCP, if ever. What is often missing from this narrative is the distinction between the larger, more complex enterprise EMRs used by hospitals, health systems, and large practices and the lighter weight, more contemporary systems used by smaller practices. These systems are designed for practices that have far less computer sophistication and resources. By using contemporary “cloud based” platforms, they eliminate the need to implement computer servers, databases, and data interfaces in the office, markedly reducing the complexity, cost, and risk of the implementation. With cloud based systems, the servers exist in large, secure, professionally managed data centers, and are protected 24

Michael Blum, MD

from man-made and natural disasters. Also, they are redundant in case of hardware failure and regularly backed up to avoid data loss and the attendant financial and regulatory risk. One of the most compelling features of these cloud-based systems is that the software is supported by the vendor and updated on a regular basis. While there may be some updates needed in workflows within the office, the lion’s share of the upgrades are done by the vendor in their data center (the cloud), dramatically reducing effort and risk for the practices. In this model, a practice always has access to the latest version of the EMR software and the vendor handles the hassles of EMR software updates, security (you still need to secure the user IDs and passwords), and backup. Before EMR certification was required, there were literally thousands of vendors in the marketplace. By 2013 the number was down to around 600 vendors. In the hospital/health system marketplace, the top ten vendors control over 95 percent of the market. However, in the ambulatory practice space, there is much more variety and, as of 2014, the top ten vendors only controlled 65 percent of the market. It is important to realize that the EMR changes both the provider’s clinical experience and the provider-patient interaction. Several studies have demonstrated the amount of time, some of it net-new, that providers now spend interacting with the EMR and some studies have suggested that a portion of that time would previously have been spent engaging with patients. Some of the numbers are disturbing—50 percent of a visit spent typing in the EMR, thirty seconds before interrupting the patient to enter data, two hours spent answering emails from the patient portal, completing clinic notes at 2:00 a.m., etc. So, if you are evaluating an EMR for your practice there are several important things to consider: 1. Implementation and support will be much easier and faster with a cloud-based, software as a service (SaaS)-based EMR. As discussed above, keeping the servers and software out of your physical space reduces costs, speeds implementation, and simplifies upgrades. Practice Fusion and athenahealth are two well-known systems that have championed this approach. 2. Assess total cost of ownership when evaluating systems. Some vendors charge less for software licenses but have greater implementation, hardware costs, or maintenance costs. Be sure to assess the annual, five-year, and ten-year costs. It is not easy to replace a thoroughly integrated EMR, so you need to look at the long-term. Also, some systems use a “free-mium” model where there is little to no software license, but you may need to accept advertising or agree to let the vendor access your clinical data so they can anonymize, aggregate, and sell it. Make sure you are comfortable with the associated risks. Include Federal penalties for non-compliance and PQRS reporting in your cost analysis.

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

3. Assess the usability for you and your partners! You will be spending a lot of time with the EMR, so make sure the data input is intuitive and consistent with your work-flow. You may need to do some redesign to gain efficiency, but avoid systems that require wholesale change. Most importantly, talk to your peers who have the EMR you are considering and make sure they use it like you intend to. Better yet, go watch them work for half a day. Make sure the system is well deployed in your specialty—there is a great deal of variability depending upon the amount of focus a vendor has applied to a clinical domain. If you are expecting to use speech recognition with the EMR, find someone already doing it with that EMR and watch them to see how accurately and seamlessly it works. You will be surprised how much you learn about the EMR and how different it may be from the sales and marketing pitch! 4. Try to get a sense of the patients’ reaction to the EMR and the patient portal. 5. Once you have your short list of vendors, go online and review the ratings and customer comments. Implementing an EMR can be a rewarding experience for the practice and your patients. Enjoy the process and good luck!

Michael Blum, MD, is the associate vice chancellor for informatics and a cardiologist at UCSF. He specializes in the care of patients with coronary artery disease, congestive heart failure, valvular heart disease, and preventative cardiology. In addition, Dr. Blum applies his expertise in technology as the chief medical information officer at UCSF Medical Center.

New Book: Suicide Risk in the Bay Area In October, Eli Merritt, MD, published a book entitled Suicide Risk in the Bay Area: A Guide for Families, Physicians, Therapists & Other Professionals. Two books in one, Suicide Risk in the Bay Area combines a suicide prevention resource directory, containing over 300 Bay Area resources, with a step-by-step guide on how to assess, manage, and talk about suicide risk. Renée Binder, MD, President of the American Psychiatric Association, who wrote the foreword, states emphatically that this book “deserves to be on the desk of every mental health professional who lives and works in the Bay Area.” Further praise from leaders in the field can be found below. Throughout Suicide Risk in the Bay Area, the message is clear: Talk About It. The Introduction offers anecdotes from Dr. Merritt’s psychiatric practice, and the book proceeds with many tips and checklists to help readers to talk about suicide risk with patients, colleagues, friends, and family. The resource directory collects hotlines, mobile crisis units, suicide prevention trainings, and other crucial resources from all regions of the Bay Area. The book is available for sale on Amazon, with discounts on bulk orders available by contacting Dr. Merritt directly at info@merrittmentalhealth.com. WWW.SFMS.ORG

SFDPH Physicians Granted Membership in the SF Medical Society “San Francisco Medical Society (SFMS) is one of the most progressive medical societies in the country. It has led efforts locally and state-wide on tobacco/e-cig regulation, sugar-sweetened beverage taxes, reimbursement for end of life counseling, promoting childhood vaccinations, and many other issues that are aligned with the SFDPH’s mission to protect and promote the health of all San Franciscans.” —Barbara Garcia, San Francisco Director of Public Health In recognition of this alignment, starting this year, all SFDPH physicians will automatically receive a membership in the SFMS/ CMA unless they choose to opt out. SFDPH will cover full dues for all of its employed physicians; there will be no out-of-pocket cost for the individual physician. On a leadership level, SFDPH has had a longstanding connection with SFMS: Commissioner Pating and Todd May, CMO for SFGH, are both current board members, and SFDPH regularly attends the annual SFMS Career Fair. Starting next year SFHN will be contributing a regular column in San Francisco Magazine.

Renew Your Commitment to Medicine; Renew Your SFMS Membership Today 2015 membership renewals are right around the corner! Make sure you continue to receive the benefits of SFMS and CMA by renewing your membership. There are three easy ways to renew your dues again this year: 1. Mail/fax in your completed renewal form when you receive it in the mail. 2. Renew online at www.sfms.org with your credit card. 3. Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415)561-0850 or membership@sfms.org.

Classified Ads Medical/Neurological Office Space (Lower Nob Hill) Shared medical office space available immediately. All services provided including office, labs, examining rooms, bathroom and answering service capabilities. Flexible schedule to suit tenant. Please contact us at email: jgoldstein@sfcrc.org; phone: (415) 279-6952.

New SFMS Member Benefit: Discounted Tickets to the California Academy of Sciences SFMS members and their practice staff can enjoy a 15% savings off admission tickets to the California Academy of Sciences via our exclusive eTicket program. Members can go to www.calacademy.org/etickets2 and enter sales code “sfms” to take advantage of this member discount. NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

SFMS ELECTION RESULTS

SFMS POLITICAL ACTION COMMITTEE CONTRIBUTORS 2015

2016 Officers One-year term President-Elect: Man-Kit Leung, MD Secretary: John Maa, MD Treasurer: Kimberly L. Newell, MD Editor: Gordon L. Fung, MD, PhD, FACC, FACP

2015 President-Elect, Richard A. Podolin, MD, FACC, automatically succeeds to the office of President. 2015 President, Roger S. Eng, MD, MPH, FACR, automatically succeeds to the office of Immediate Past President.

Board of Directors Seven elected for three-year term 2016-2018 Charles E. Binkley, MD Katherine E. Herz, MD, MS Todd A. LeVine, MD, MS Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD, MPH Winnie Tong, MD

Nominations Committee

Four elected for two-year term 2016-2017 Mabel A. Chan, MD Alice Hm Chen, MD David T. Duong, MD, PhD Dawn D. Ogawa, MD

American Medical Association Delegate Two-year term 2016-2017: Robert J. Margolin, MD

American Medical Association Alternate Two-year term 2016-2017: Gordon L. Fung, MD, PhD, FACC, FACP

Young Physicians Section Delegate Two-year term 2016-2017: Shoshana R. Ungerleider, MD

Young Physicians Section Alternate Two-year term 2016-2017: Mark A. Schrumpf, MD

Delegation to the CMA House of Delegates Two-year term 2016-2017: Delegates Ameena T. Ahmed, MD, MPH Charles E. Binkley, MD Roger S. Eng, MD, MPH, FACR Katherine E. Herz, MD, MS Man-Kit Leung, MD* *Automatically serves in his capacity as SFMS President-Elect Alternates George A. Fouras, MD Keith E. Loring, MD Stephanie Oltmann, MD Judy L. Silverman, MD Daria L. Thompson, MD, MPH (Resident) 26

Tomas J. Aragon, MD, PhD* Richard A. Bohannon, MD Amy N. Bossen, MD Andrew F. Calman, MD, PhD* James M. Campbell, MD Richard L. Caplin, MD* Paul B. Carlat, MD Gary L. Chan, MD* Kenneth D. Chan, MD Lawrence C.C. Cheung, MD, FAAD, FASDS* Clifford F. Chew, MD Edward A. Chow, MD* Roger S. Eng, MD, MPH, FACR* Thomas L. Engel, MD Stephen E. Follansbee, MD George A. Fouras, MD* Benjamin L. Franc, MD* Steven H. Fugaro, MD* Gordon L. Fung, MD, PhD, FACC, FACP* Erica T. Goode, MD William H. Goodson, III, MD Brian Grady, MD* Pratima Gupta, MD Katherine E. Herz, MD* Thomas M. Jackson, MD Howard B. Kleckner, MD Eric R. Kwok, MD Man-Kit Leung, MD* Elizabeth M. Lewis, MD Ronel L. Lewis, MD Raymond K.Y. Li, MD Ingrid T. Lim, MD* Keith E. Loring, MD* Randall Low, MD John Maa, MD* Robert J. Margolin, MD* Kimberly L. Newell, MD* Stephanie Oltmann, MD* Heyman Oo, MD Pacific Gynecology & Obstetrics Medical Group Ryan Padrez, MD* Richard A. Podolin, MD* Cynthia A. Point, MD* William T. Prey, MD* Winchell W. Quock, MD Dean L. Rider, MD Michael H. Rokeach, MD* Michael C. Schrader, MD, PhD* Rachel H.C. Shu, MD* Lorraine H. Smookler, MD Dennis Song, MD, DDS James E. Storm, MD Peter W. Sullivan, MD Lisa W.Y. Tang, MD* Winnie Tong, MD Shannon Udovic-Constant, MD* John I. Umekubo, MD Charles J. Wibbelsman, MD Joseph W. Woo, MD*

* SFMS Board and/or PAC Board member/consultant SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

MIEC AFTER FORTY YEARS Still Fulfilling Its Mission Robert Margolin, MD In 1975, six county medical societies in Northern California—Alameda-Contra Costa, San Francisco, Marin, So-

lano, Shasta-Trinity, and Siskiyou—joined together to form the Medical Insurance Exchange of California (MIEC). MIEC was the first doctor-owned professional liability insurance company in California and was formed as a result of the “malpractice crisis” where every commercial insurance carrier abandoned individual and group malpractice insurance programs. Medical societies were invited to join MIEC because:

“The alternative insurance offers made by companies in the field are few and unreliable; because they require extremely high premiums and permit carriers to “whipsaw” them higher; because they deprive the medical profession of any control over costs, ratemaking, losses, income, underwriting, coverage, interpretations of contracts or management of the risk; because ownership by the profession provides potential for economies and for solution by medicine of the medical aspects of the malpractice problem.” The founders of MIEC thought they needed 1,500 physicians to make it a viable insurer. However, on August 1, 1975— the date MIEC was officially launched—only 800 physicians had applied for coverage. MIEC’s board and supporters took a leap of faith to provide physicians with a dependable professional liability insurance program and by the end of August there were over 1,100 physicians insured. Within a year the number climbed to 1,600. Recognizing its value, MIEC was invited by other state medical societies to offer coverage to their members—Idaho in 1977, Alaska in 1978, and Hawaii in 1981. Physicians have benefited greatly from MIEC’s commitment to the medical profession. In addition to being the first doctorowned insurance company in California, MIEC pioneered many innovations for physicians’ professional liability coverage and risk mitigation, including: • Efforts to educate physicians on minimizing exposure to malpractice risks. This includes studying claims histories to identify causes for major claims and adopting policies to prevent those causes. • Reduced rates for new doctors, and doctors in part-time practice. • A policy to protect retiring, disabled, or deceased from additional costs for tail coverage. • Medical society committee peer review of pending claims for invaluable insight and to ensure fair treatment of physicians facing malpractice actions. • Coverage that includes indemnification for countersuits and cost of legal defense against attacks on physicians’ medical licenses. • “No fault” emergency medical payments for care provided to patients. WWW.SFMS.ORG

Fulfilling the promise to give unused premiums back to physicians, MIEC declared the first dividend to policyholders in 1979. In its twentieth year MIEC had over 5,100 policyholders, a surplus of $101 million, and had paid back policyholders $115 million in dividends. At the end of its thirtieth year MIEC had assets of $332 million, a surplus of $108 million, and had distributed dividends of more than $218 million. This year MIEC celebrates its fortieth anniversary. It has returned over $400 million in dividends and continues to be one of the most financially secure professional liability carriers in the country. Moreover, it applies a nonprofit approach to providing professional liability insurance coverage to policies for medical groups so that they may work hand-in-hand with MIEC to minimize risk and reduce costs associated with professional liability. As a company owned by policyholders, MIEC continues to be the ultimate consumer-driven insurance company. Additionally, as part of a commitment to the medical profession and its relationship with sponsoring medical societies, last year MIEC was a strong supporter—financially and in the commitment of organizational resources—in the successful campaign to defeat trial lawyers’ anti-MICRA Proposition 46. As members of the MIEC Board of Governors, we are pleased to continue the long tradition of commitment to serving the medical profession and working side-by-side with our medical societies to make professional liability insurance as affordable and secure as possible while promoting the highest standards of care and patient safety. MIEC continues a zero-profit tradition to the benefit of the medical profession, other health care professionals, and the patients we serve. It remains a shining example of what physicians can do collectively to enhance the practice of medicine and improve patient care.

Robert Margolin, MD, has been an SFMS member for thirty years. He is a past president, a recent CMA trustee, and our current delegate to the AMA. He practices primary care medicine and is vice chief of staff at CPMC and he is also a member of the MIEC Board of Governors.

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

RECEIVE MORE THAN $6,000 A YEAR IN SAVINGS AND SERVICES, INCLUDING:

FOR $3 A DAY, SFMS/CMA MEMBERS

SFMS/CMA Member Benefit

Value

Patient referral service via SFMSâ&#x20AC;&#x2122; phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $200 Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . . . . . . *$150 reimbursement and practice operation issues . *value hourly rate with a practice management consultant Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Special member rate for AAPCâ&#x20AC;&#x2122;s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session Discounted registration for the Western Leadership Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20 HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100 with other physicians at the point of care 15% off temper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . $162 .75 30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000 *based on average savings

30% off on Epocrates products, including Epocrates Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50 Up to 10% discount on life insurance through Mercer Health & Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $400 and effective coding/billing strategies, including our exclusive value-based payment model workshop with CMS Region IX Administrator in May 2015 . For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

IN MY OPINION End Of Life Option Act A Major Step In Improving Care Steve Heilig, MPH Californians have just won a right that we all hope we will never need to use: The right to physician-assisted dying. Governor Jerry Brown signed California’s End of Life Option Act in October after what was clearly deep consideration; he concluded, “In the end, I was left to reflect on what I would want in the face of my own death. I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.” These are wise and compassionate words, and Brown also noted that he had talked with many of his close advisors and personal friends, including his doctors, and that he remains a practicing Catholic; but he brought his perspective down to that of the patient, and many of us are grateful to him for that. This was a hard-fought battle over decades that uncomfortably pitted smart and well-intentioned people against each other, but times have changed and a strong majority of Californians now support a legal option for physician-assisted dying (PAD). Physician-assisted dying is, in fact, a relatively rare occurrence even where legal; it is part of a spectrum of overdue efforts to improve care at the end of our lives. Such care has improved where assisted dying has been legalized, and it can here as well. So, to borrow from a slogan in the abortion debate, the work begins to make this right a “safe, legal and rare” one—but one available when truly a last resort. Medicine as an organized profession has long been opposed to legalizing assisted dying and thus, until this year, defeated any attempts to legalize it. But presented by the SFMS with strong evidence that a majority of physicians had become pro-choice on this issue, that professional medical ethicists were far from uniform in opposing PAD and many support the option, and that carefully developed laws in other states were working as intended to prevent abuses, the CMA’s leadership voted to become neutral on the bill and allowed it to advance at last. It was a strong majority vote at CMA, so much so that it surprised even many supporters there. An attempt to later turn back the clock on this position at the CMA annual meeting in October met with resounding rejection as well. For those strongly opposed to this option, of course, all will have the option not to request assisted dying. And the strict guidelines will make any such deaths among the most scrutinized of all, preventing coercion or other problems. In fact, most people with a terminal disease—the only ones who can request such a hastened death—will not follow through with that request. The irony observed by many who care for dying patients is that reassuring such patients that they will not be abandoned in this regard can actually lengthen their final days, with less fear and distress, as having some sense of control is a crucial issue. It is no accident that this right has been legalized due to a huge effort partly arising from San Francisco, and this new law is a tribute to thousands of AIDS, cancer, and other patients from our city who worked to make it become reality. There has been a moving outWWW.SFMS.ORG

pouring of support by those who worked before to make this policy change, including a number of leading physicians who have said “I’d given up on this happening in my lifetime.” Some confessed to becoming very emotional, thinking of all the patients in the past who had died without this option. It has been a real lesson in the importance of evidence and perseverance…and compassion guiding policy. What is crucial now is that the health care, legal, and other professions continue to work on everyone’s behalf so that the best possible care is available to all; that each of us document our wishes in already available advance health care directives, living wills, and the newer Physician Orders for Life-Sustaining Treatment (POLST) forms; that the “Palin Death Panel Amendment” to Obamacare be reversed so that more discussions about end-of-life-care planning will take place and be reimbursed; and that access to good hospice care be expanded. And as a culture, we need a more open, compassionate, practical approach to talking about mortality and providing care for all of us at the end of our lives. A number of efforts are already underway to see that the new law is optimally implemented and monitored. With such progress, the need for active assisted dying can be minimized. But alas, there will most likely always be a relatively few but tragic cases where suffering remains unrelieved, and this new right to die then becomes, in fact and practice, a part of what real healing can mean.

Steve Heilig is co-editor of the Cambridge Quarterly of Healthcare Ethics and a staff member of the San Francisco Medical Society. An earlier version of this piece appeared in the San Francisco Chronicle.

GOVERNOR BROWN SIGNS “ASSISTED DYING” BILL

California became the sixth state to legalize physician-assisted dying, after many previous failed efforts. In signing the bill which becomes law January 1, Brown noted in a very personal letter:

October 5, 2015 | To members of the California State Assembly, ABx2 is not an ordinary bill because it deals with life and death. The crux of the matter is whether the State of California should continue to make it a crime for a dying person to end his life, no matter how great his pain and suffering. I have carefully read the thoughtful opposition materials presented by a number of doctors, religious leaders, and those who champion disability rights. I have considered the theological and religious perspectives that any deliberate shortening of one’s life is sinful. I have also read the letter so those who support the bill, including heartfelt pleas from Brittany Maynard’s family, the Archbishop Desmond Tutu. In addition, I have discussed the matter with a Catholic Bishop, two of my own doctors and former classmates and friends who take varied, contradictory and nuanced positions. In the end, I was left to reflect on what I would want in the face of my own death. I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others. —Sincerely, Edmund G. Brown, Jr.

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

CMA HOUSE OF DELEGATES REPORT Gordon Fung, MD, PhD, and Steve Heilig, MPH broad coalition in favor of conserving these crucial medications for human use. New SFMS policy also further increases pressure to help achieve these ends (see page right).

Reimbursement for end-of-life counseling: This is a national development, pushed by the AMA after the CMA and then the AMA adopted policy advanced by SFMS to reverse the “Palin Death Panel Amendment” to the American Care Act (ACA) prohibiting such payment. The new Medicare codes become operational in January.

MEDICAL POLICY-MAKING 2015: BATTING 1000 AT THE CMA ANNUAL MEETING The annual CMA meeting of its elected house of delegates (HOD) took place in mid-October. With over

400 delegates and others in the room, the debates can be contentious, and the old adage that making policy is like making sausage—not something advisable to observe—can come to mind. But the results are important in the real world of clinical and public health practice. Below are four quick but crucial examples from just the past year.

Physician Aid-In-Dying (PAD): Legalized via the Governor’s signature, this would not have happened as long as CMA remained opposed, and their “neutrality” was finally obtained via SFMS advocacy at the HOD and beyond, after many years of such attempts. At the October HOD meeting, there were multiple attempts to reverse the CMA position back to opposing PAD, despite the California law already having been passed. The backlash to these attempts resulted in a stronger endorsement of neutrality, along with a call for strong liability protections for physicians who do or do not elect to hasten a patient’s dying. With more explicit wording “That CMA remain neutral on physician aid in dying for terminally ill patients who have the capacity to make medical decisions.”

POLST expansion: A bill allowing trained nurse practitioners and physician assistants to “POLST” (physician orders for life-sustaining treatment) patients, a position that is supported by UCSF research and physician experience, passed just six months after the SFMS had CMA change its opposing position to support—again, after multiple attempts. Antibiotic Resistance: Governor Brown signed the nation’s strictest limits on use of antibiotics in agriculture. The fact that the SFMS pushed this policy for over a decade helped spark a 30

This year, the scope of subjects addressed in resolutions was as broad as usual. The SFMS delegation brought ten policy resolutions to the CMA HOD for deliberation and approval was achieved in all cases. The SFMS delegation supported a number of other resolutions as well, including some from UCSF medical students, all with similar success. Delegates are asked to vote for prioritization of adopted resolutions after the HOD meeting, and some of the SFMS resolutions received high ranking. In addition to the PAD issue, our resolution on medication costs, entitled “Regulation of Pharmaceutical Marketing and Pricing”, received a high priority. It states: “[That] CMA supports the authority for the Secretary of the Department of Health and Human Services to negotiate contracts with manufacturers of covered Medicare Part D drugs; and that CMA support[s] eliminating the Medicare prohibition on drug price negotiation.” This could be very important in the coming battles to contain pharmaceutical costs. Likewise, our resolution entitled “Support for Public Funding of Family Planning Services” mandates that CMA supports full funding of Title X Family Planning Services; and that CMA support that actions related to abortion and fetal tissue research be based on scientific evidence, rather than politics. Since the HOD met while Republican presidential candidates were making severe pronouncements on this topic, the policy had high relevance. With marijuana policy also on the political front burner, we proposed “Regulation and Labeling of Cannabis Products,” which was adopted. It reads, “That CMA urges the development of strict labeling guidelines and regulations ensuring accuracy in ingredients and potency of all marijuana products sold as medical or recreational products; and that CMA urges that strict regulations regarding sales and marketing of marijuana products be implemented, in line with existing regulations for alcohol and tobacco.” Following a front-page New York Times story about how aggressively U.S. business interests still market tobacco overseas, we submitted this resolution, which was also adopted: “Challenging the Pro-Tobacco Actions of the U.S. Chamber of Commerce.” It reads, “[That] CMA strongly objects to any pro-tobacco efforts by the United States Chamber of Commerce in other nations and calls on the United States Chamber of Commerce to immediately halt all advocacy efforts on behalf of tobacco com-

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

panies; and that CMA urges conscientious companies that are members of the U.S. Chamber of Commerce to call for an end to all pro-tobacco efforts within the organization, and if necessary, quit their membership to protest such anti-health efforts.” An online petition by resolution co-author John Maa, MD, had over 6,000 signatures by the beginning of the HOD.

Other SFMS resolutions which were adopted and are now CMA policy included:

Sales and Marketing of Powdered Alcohol Products: “That CMA support a ban on the sale of powdered alcohol until powdered alcohol is evaluated for potential health and societal impacts by an established health research entity; and that CMA support a ban on the sale of powdered alcohol absent the development of regulatory controls to protect the public health, including regulations on sales, marketing, product placement, packaging and warning labels.” Many other states have banned such products and California should catch up and join them.

Encouraging Foodstuffs Produced without Use of Medically Important Antibiotics: “That CMA encour-

ages bulk purchasers of foodstuffs, including restaurant chains, school and hospitals, to adopt policies encouraging procurement of foodstuffs from food animals raised with no medically important antibiotics except when given on a therapeutic basis by a licensed veterinarian with an established veterinarian-client-patient relationship”

Opposing Prolonged Solitary Confinement: CMA supports limiting the use of long-term solitary confinement of inmates and ending the practice of solitary confinement of minor inmates, due to the profound psychological suffering it causes; and CMA supports physicians and other health care professionals who advocate for their patients to be removed from or not to be housed in such “Security Housing Units.” Recognizing that such practices are counterproductive and inhumane, state authorities are already reducing solitary confinement; this resolution encourages that and more. Another SFMS resolution urging banning of the death penalty was not accepted for review, but that is being challenged.

Restrictions and Regulation of Sugar-Sweetened Beverages: CMA supports measures that restrict retail or vend-

ing machine sales of sugar-sweetened beverages within hospitals, clinics, or food service outlets that operate in space owned by licensed health care facilities; and CMA supports adoption of sugarsweetened beverage regulations that require warning labels on product advertising, restrict ads on public property, and restrict public agencies from buying sugar-sweetened beverages.

Housing First to Eradicate Homelessness: CMA supports efforts by coalitions seeking to eradicate homelessness in California that use successful, evidence-based models. CMA has offered to lend health expertise to organizations such as Housing First, which focuses on helping individuals and families access and sustain permanent rental housing as quickly as possible while offering a variety of services that promote housing stability and individual well-being. (This was one of a number of resolutions from UCSF medical students, who also had great success with their roster of resolutions.) In addition to all this, the SFMS-produced forty-second public service announcement supporting childhood vaccination— titled “Teach Your Children” and featuring Graham Nash, author of the iconic song of that title—kicked off one of the days of the HOD. The PSA garnered both itself and State Senator Richard Pan, MD, champion of vaccinations, a standing ovation. (The PSA is now on the SFMS website.) “What a way to start the day,” said the CMA’s speaker of the HOD, Ted Mazer, MD. New procedures for CMA policymaking, including the operation of the HOD, now make policymaking more accessible all year round. Any SFMS/CMA member can author a policy resolution; if you have an idea regarding any topic relevant to medicine or public health, join us! One never knows how big the impact can be!

Improved Medical Response to Childhood Bullying:

CMA encourages physicians to consider peer bullying in any screening for adverse childhood experiences that they provide to California youth, and recommends that quality screening tools and referral resources be made available to clinicians wherever needed and appropriate; and CMA supports efforts that encourage local education agencies to adopt policies that prohibit student discrimination, harassment, intimidation, and bullying, and to train school personnel in compliance with such policies. WWW.SFMS.ORG

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

California Pacific Medical Center (CPMC) is pioneering a first-of-its-kind earthquake technology in North America at our Van Ness and Geary hospital to ensure it remains fully operational after a major seismic event. The first U.S. application of earthquake technology that was perfected in Japan—viscous wall dampers—was just installed at the Van Ness and Geary site. It’s a unique component of the hospital seismic damping system and reduces seismic accelerations during an earthquake, which in turn reduces overall stress on the building superstructure and infrastructure. Viscous wall dampers replace other seismic isolators, such as base isolation bearings, rubber isolators, etc. This technology has been used in Japan and refined over the last 20 years to provide a greater level of protection to buildings during an earthquake. CPMC recently unveiled its newest private-label ambulance Monday--a colorful and kid-friendly neonatal and pediatric intensive care vehicle. The custom-designed ambulance, operated by ProTransport-1, is branded solely for CPMC use. The new ambulance has a custom external and internal wrap designed to create a pleasant atmosphere for the tiniest and most acute patients. The ambulance has custom features that make it a mobile intensive care unit: the vehicle is equipped with GoogleGlass capabilities for live video and audio streaming, allowing the transport team to communicate directly with hospital staff. It also has high-speed Wifi and an entertainment system with video streaming to help reduce stress for the child. The CPMC liver transplant team participated in the 2015 San Francisco Liver Life Walk. The CPMC team had about 75 walkers—the largest group in the walk—and raised $10,000, which will benefit the American Liver Foundation. These funds were the largest donation in the history of the Liver Life Walk Northern California, which dates back to 2002. CPMC participants included patients and families, liver transplant physicians, staff, and their families. 32

SFVAMC

Diana Nicoll, MD, PhD, MPA

Methicillin-Resistant Staphylococcus Aureus (MRSA) has been an ongoing health care challenge. In the early Twentieth Century, Staphylococcus aureus became notable for causing significant world-wide morbidity and mortality. The introduction of Penicillin G in 1941 was a major breakthrough in the treatment of Staphylococcus aureus. Two more significant advancements in treatment were the introduction of Vancomycin, a glycopeptide antibiotic, in 1956 and Methicillin, the first semisynthetic anti-staphylococcal Penicillin, in 1961. In the early 1980s, due to the use of Penicillin, Vancomycin, and Methicillin, reports surfaced of community-acquired MethicillinResistant Staphylococcus Aureus (CA-MRSA). CA-MRSA primarily affected younger individuals. Hospital-acquired MRSA emerged in the 1990s, with infections found at multiple body sites. From 1988 until 2003 there was a steady increase in the prevalence of MRSA in the United States. In response to the impact of unregulated antibiotic use on multi-drug resistant organisms, in 1997 the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America published guidelines for antimicrobial stewardship, for the optimal selection, dosage, and duration of treatment with antimicrobial agents. In 2007, the Department of Veterans Affairs issued an initiative to implement an evidencebased “MRSA bundle” to decrease the prevalence of community- and hospital-acquired MRSA. In response, the San Francisco Veterans Affairs Health Care System (SFVAHCS) employs a robust antibiotic stewardship program as part of this bundle, including active surveillance for colonization (nares screening), hand hygiene, environmental cleaning, contact precautions, and patient/family education. The MRSA bundle at the SFVAHCS focuses on inpatient, outpatient, and inpatient psychiatric care. From 2005 to present there has been a steady decline in community-acquired and hospital-acquired MRSA. Adherence to the MRSA bundle, focus on nares screening for colonization, and vigilance with environmental cleaning will ensure a continued decline in the prevalence and transmission of MRSA.

Kaiser Permanente Maria Ansari, MD

At The Permanente Medical Group (TPMG) we recognize that professional satisfaction and personal health and wellness are essential ingredients in providing the best quality, service, and access to our patients. And we believe that supporting our physicians is the right thing to do. We work to design programs so that our physicians can remain hearty and resilient in the current era of medical practice. In fact, physician wellness is one of the core pillars of our organizational strategy. To this end we have a wide range of programs and support systems for our physicians. Many of our efforts promote collegiality; we know that when we know each other, the work goes better, and our patients feel it. There was a time when the “doctor’s lounge” was a place where physicians lunched and also came to discuss cases. These days most of us spend our lunches at our desks, and so TPMG has created regular physician social lunches, many with no agenda, to recreate the old doctor’s lounge. We are expanding our mentoring program to continue throughout the entire career cycle, recognizing that physicians need support along the way to rediscover the meaning, purpose, and joy of their work. We also realize, as a recent RAND Corporation study looking at physician burnout illuminated, that physicians are happiest when they feel they are giving the best possible care to their patients. To realize this goal, an internal innovation team aims to increase our ability to provide exceptional care by doing process improvement. This focus considers not only efficiency, but also how to create the best care experience for both patients and providers. We have many other programs which support the personal health of our physicians, assist with desktop workflows, sustain emotional and spiritual health, and maintain a connection to community. Wellness is really a symphony of solutions. In all of this we aim to be the best place to work as a physician.

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

Saint Francis Robert Harvey, MD

As health care services and technologies evolve, the physicians, nurses, and staff at Dignity Health Saint Francis Memorial Hospital remain at the forefront of innovation through the addition of new physicians, facilities, and technologies. We are pleased to welcome Susan Anzalone, MD, as medical director of our Multiple Sclerosis Infusion Center. Our three-chair infusion center—one of the only centers dedicated exclusively to treating MS patients—is designed to help patients stay comfortable and relaxed. The Saint Francis Orthopedic Institute named Robert Purchase, MD, as medical director of Shoulder Surgery. Widely recognized as an expert in complex and revision shoulder arthroplasty, he treats all types of shoulder disease, from arthroscopic repair of rotator cuff tears to revision reverse total shoulder replacements. Combined with our award-winning Sports Medicine program, the Orthopedic Institute offers one of the most comprehensive orthopedic care programs in San Francisco. Response to Saint Francis’s CyberKnife and da Vinci robotic surgery has been very strong. In addition to radiation oncologist Alexander Geng, MD, who joined the San Francisco Cyberknife staff in July, demand for both gynecologic and urologic da Vinci procedures has be so great that our team has been joined by Curtis Ross, DO, a fellowshiptrained robotic urologic surgeon. Finally, construction is well underway for our expanded 16-bed Bothin Burn Center. Expected to open early next year, the $16 million unit on the fifth floor will be the largest in Northern California. In addition to state-ofthe-art life support, monitoring equipment, and ultrasonic hydrotherapy, the center will feature spacious treatment rooms designed to maximize patient comfort and facilitate care, a patient gym, an operating room, and dedicated pediatric treatment rooms. Thanks to Bothin Burn Center Medical Director Jeffrey DeWeese, MD, assisted by Richard Grossman, MD, for his leadership during this process. These important additions enable us to provide even better care to our patients as well as more options and support for our physicians, nurses, and staff. WWW.SFMS.ORG

St. Mary’s

Robert Weber, MD

Since its founding in the 1850s, Dignity Health St. Mary’s Medical Center has been deeply invested in San Francisco. Through community grants, sponsorships, and participation in events that advance community health, we are committed to partnerships that improve quality of life for all who live and work here. These events also engender camaraderie among our staff and help forge new relationships. It turns out they’re also a lot of fun. St. Mary’s team members recently stepped up and out to support three events that significantly impact our community. On September 19 and 20, St. Mary’s was a major sponsor of the 2015 San Francisco International Dragon Boat Festival, at which staff volunteered and members of our Asian Physician Advisory Committee formed a team in the highly competitive boat races. Now in its twentieth year, the festival and races drew 60,000 Bay Area attendees and 140 racing teams to Treasure Island for two days of dragon boat racing and Asian arts and cuisine. Also in September, the American Heart Association Heart Walk, (which counts Dignity Health as a sponsor) saw the participation of more than eight St. Mary’s Medical Center teams, including Team Care Transition, Team Cardiac Rehab, and Team Rehab Services. Members of the St. Mary’s community volunteered and raised funds with the goal of building healthier lives that are free of cardiovascular diseases and stroke. Special Olympics Northern California is also a beneficiary of St. Mary’s support. Along with our colleagues at Dignity Health St. Francis, we participated in the Bridge to Bridge run on October 4, which benefits Special Olympics Northern California. Participants chose between 5- and 12-kilometer routes, beginning at the foot of the Bay Bridge and continuing as far as the Golden Gate Bridge. Special Olympics Northern California provides athletic opportunities to more than 22,000 children and adults with intellectual disabilities, instilling the confidence to succeed in life through 184 competitions in 12 different sports. It’s a great feeling to know that this organization at which so many of us dedicate so much of our time has team members with such a profound commitment to making life better for our entire community.

SPMF

Bill Black, MD, PhD

At Sutter Pacific Medical Foundation, providing personalized care to each patient is a high priority. An equally important goal is providing comprehensive services to the larger population we serve while improving the health of communities. Improving the health of populations is an important driver of our model of care, and it is exciting to see that taking shape. We are planning new care centers in fast-growing areas of San Francisco so that patients will have better and more convenient access to physicians, medical services, and hospitals. In 2016, new care centers will open in the SOMA neighborhood at 55 Second Street near Market Street and in the Mission neighborhood at 899 Valencia Street, close to California Pacific Medical Center’s St. Luke’s campus. We are piloting innovative models of care. Our primary care physicians located at 1580 Valencia Street now have psychiatrists working in the same clinic, another step at integrating care for patients who may need primary care and mental health services. “We are enhancing the patient experience so there is less delay in care, less uncertainty about how a person can access his or her care team,” said Jonathan Lee, MD, a primary care physician who works at 1580 Valencia Street. “As our patients’ health improves, the health of [the] community we serve will improve as well.” In the bigger picture, the structure of the Sutter Health medical foundations brings together hundreds of doctors throughout Northern California and encourages them to collaborate and exchange best practices. Our doctors use the Sutter Health EHR (electronic health record), which leads to efficiencies and improvements in patient care. By creating systems of care that are more accessible, more timely, and of the highest quality, individuals will achieve better health, as will the population as a whole. In this, we are committed to the health needs of all the communities we serve and to San Francisco overall.

NOVEMBER/DECEMBER 2015 SAN FRANCISCO MEDICINE

UPCOMING EVENTS 12/16 Webinar: Meaningful Use – 2015 and 2016 Modified Rules | 12:00 p.m. to 1:00 p.m., CMA webinar Learn about the Center for Medicare and Medicaid Service’s recent changes to the Electronic Health Record Incentive Program, with a focus on 2015 and 2016 meaningful use, at this complimentary webinar for SFMS members. This presentation will help providers and their staff assess whether they have met meaningful use for program year 2015 and are prepared to meet meaningful use in 2016. To register, visit http://www.cmanet. org/events/detail/?event=meaningful-use-2015-and-2016modified-rules.

1/28/2016: Society of Physician Entrepreneurs Quarterly Meeting | 6:30 p.m. to 9:00 p.m., San Mateo

County Medical Association Office | The Society of Physician Entrepreneurs (SoPE) San Francisco Bay Area Chapter invites you to their quarterly meeting. SoPE help physicians and health care workers expand their careers by looking into consulting, incorporating cutting edge technology, starting up their own company, or joining a large corporation. The event is open to all physicians and dinner will be provided. For more information, visit http://bit.ly/1NxrIyd.

1/29/2016: SFMS Annual Gala | January 29, 6:30 p.m. to 9:00 p.m., Legion of Honor | Celebrate SFMS’s 148 years of physician advocacy and camaraderie with many of San Francisco’s most influential stakeholders in the medical community! The 2016 Annual Gala will be held at the iconic Legion of Honor. Guests will be treated to an exquisite reception with elegant hors d’oeuvres and libations. Richard Podolin, MD, will be installed as the SFMS President. Network with colleagues, meet SFMS leaders, and enjoy a private viewing of the Legion of Honor’s collection galleries. Please note this is a member-only event. Gala tickets will go on sale December 2015. 3/3 - 4/2016: Development Disabilities: An Update for Health Professionals| March 3 to 4, 2016, UCSF | The

15th annual interdisciplinary conference celebrates maximizing potential for individuals with developmental disabilities, offering a unique update for primary care and subspecialty health care professionals and others who care for children, youth, and adults with developmental disabilities and complex health care needs. The 2016 conference continues to cover topics across the lifespan on a broad range of developmental disabilities. For more information or to register, visit http://www.ucsfcme.com/2016/ MOC16001/info.html.

We are the SF Health Network High-quality healthcare that enables all San Franciscans to live vibrant, healthy lives. We offer a full range of care: ■ ■ ■ ■ ■ ■ ■

pre-natal and pediatric primary and specialty medicine dentistry hospital care skilled nursing and rehabilitation substance abuse treatment mental health services

Our network includes: ■ ■ ■

14 neighborhood clinics San Francisco General Hospital Laguna Honda Hospital and Rehabilitation Center

SFGH and UCSF have been partners since 1872, making SFGH one of the nation’s top academic medical centers.

www.sfhealthnetwork.org

SAN FRANCISCO MEDICINE NOVEMBER/DECEMBER 2015 WWW.SFMS.ORG

CMA/San Francisco Medical Society sponsored Health Insurance Program

It’s the time of year to look at your off-exchange health insurance options for 2016! Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2016. The open enrollment period for individual and family plans starts on November 1, 2015. Many practices have open enrollment periods for small groups on December 1, 2015 or January 1, 2016. Did you know that you can get the right insurance though the CMA/San Francisco Medical Society sponsored Medical program with Mercer? If you are just covering yourself, or if you’re covering your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget. All of the health plans offered outside of the health insurance exchange are available. It doesn’t matter if your current coverage is “Grandfathered,” “Grandmothered,” or already ACACompliant and Platinum, Gold, Silver or Bronze, Mercer can help you determine what’s best for you. Call today at 800-842-3761 or visit www.CountyCMAMemberInsurance.com.