July/August 2018

SAN FRANCISCO MARIN 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 A R I N M E D I CA L S O C I E T Y

HEARTENING PROGRESS: What’s New in Cardiology?

Hypertension Tension Preventing Heart Disease Adversity and Cardiovascular Disease Exercise and Sudden Death Congenital Heart Disease Cardio-Oncology Surgical Advances PLUS: Artificial Medical Intelligence AMA Policy Report Safe Injection Centers CURES . . . and more!

Volume 91, Number 5 | July/August 2018

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE July/August 2018 Volume 91, Number 5

HEARTENING PROGRESS: What’s New in Cardiology?

FEATURE ARTICLES

OF INTEREST

10 How Low Should We Go in the Blood Pressure Limbo?

Binh An P. Phan, MD

9

14 Tackling Adversity and Cardiovascular Disease

Jonathan Z. Butler, PhD, MDiv, and Michelle A. Albert, MD, MPH

31 Safe Injection Site in San Francisco Would Address Drug Use and Discarded Needles

John Maa, MD, and Steve Heilig, MPH

12 Is ASCVD Truly a Preventable Disease?

Carlin S. Long, MD

16 Preventing Sudden Death in Athletes and the Healthy

Byron K. Lee, MD

18 A Rising Tide of Adults with Congenital Heart Disease!

Anushree Agarwal, MD, and Ian S. Harris, MD 20 Cardio-Oncology: What Can a Cardiologist Offer to Combat the “Emperor of All Maladies”?

Rajni Rao, MD

22 Demystifying Artificial Intelligence: Present and Future Applications to Medicine

Geoff Tison, MD, MPH 24 Burning Platforms in Healthcare Delivery: A 2018 Cardiovascular Clinician’s Perspective

Ralph G. Brindis, MD, MPH, MACC, FAHA, FSCAI 26 Cardiac Surgical Advances: Minimizing Risk and Invasiveness for Maximum Return

Glenn Egrie, MD

MONTHLY COLUMNS

2

Membership Matters

5

President’s Message: Healthcare Reform via Ballot Initiative: Bad Prescription John Maa, MD

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Editorial: Heartening Progress: What’s New in Cardiology?

Gordon Fung, MD, PhD

Not Your Father’s AMA Lawrence Cheung, MD

28 SFMMS Advocacy Activities

32 Are You Ready to Check CURES?

Katherine Boroski

34 Health Policy Report: The Unfinished Work of Achieving Universal Coverage

Sandra R. Hernández, MD, MPH 35 Children Detainees Must Be Reunited with Their Families

Theodore M. Mazer, MD

2018 SFMMS General Membership Meeting Wednesday, September 12, 2018 | 6:00–7:45 pm Golden Gate Yacht Club, San Francisco

Calling all SFMMS members: Join SFMMS at our General Meeting to meet SFMMS leadership and to learn firsthand the issues SFMMS and CMA are advocating for on behalf of physicians and their patients in San Francisco, Marin, and California. Dinner will be provided.

Register at www.sfmms.org/events.aspx.

13 Upcoming Events 35 Classified Ads

37 Welcome New Members!

37 Community News: Kaiser Permanente

Maria Ansari, MD 37 Advertiser Index

SAN FRANCISCO

MARIN MEDICAL SOCIETY

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

MEMBERSHIP MATTERS Celebrating 150 Years of SFMMS History

Leading Health Organizations Filed Statewide Soda Tax Measure for 2020 On July 2, 2018, a ballot measure to protect public health through a state soda tax was filed for the 2020 ballot by two of California’s leading healthcare provider organizations — the California Medical Association (CMA), representing 43,000 California physicians, and the California Dental Association (CDA), representing 27,000 California dentists. This announcement came four days after the multi-billion-dollar soda industry held the state of California hostage with a dangerous ballot threat that jeopardized the fiscal outlook of local governments, forcing the state to preempt local authority and pass an unprecedented 12-year moratorium on any local soda tax. Read more at http://bit.ly/2NZflPC.

SFMMS Opposes Child Separation Practices at Border

When the 1906 San Francisco earthquake struck, it ignited devastating fires and destroyed over 80% of the city.

Medical society members in San Francisco and Marin remained united and got to work delivering high-quality medical care to the community, including bringing medical services to earthquake refugees camped at Forest Meadows at Dominican College in Marin.

The SFMMS leadership unanimously voted to oppose the child separation actions, with many in the physician leadership noting that they themselves, their parents, and many of their patients were immigrants and that the practice serves little practical purpose. The negative health consequences of childhood traumatic events disrupt the natural development of a growing brain and body, and increase the lifetime risk for heart problems, cancer, diabetes and stroke. The negative effects on the family and community are far-reaching and long-lasting. SFMMS board member, Dr. Heyman Oo, recently spoke at the Families Belong Together rally in San Francisco, attended by several SFMMS members, to underscore the harm this separation can cause.

Watch the video at http://bit.ly/2LosvY8 and read the SFMMS statement at http://bit.ly/2mnEGpP.

The 1910 Flexner Report called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research.

Nearly 200 medical schools fell short of the standard and either merged or were closed outright. San Francisco’s medical schools were found to be adequate and the report led to improvements in their clinical curricula. With its medical schools and large number of hospitals, San Francisco had become the medical center for all of California.

In 1927, the first issue of the medical society journal

was published, and has been in continuous publication ever since. Today, the award-winning San Francisco Marin Medicine journal is distributed to over 4,000 and is an essential resource for the Bay Area’s medical community.

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SAN FRANCISCO MARIN MEDICINE JULY/AUGUST 2018

Marin pediatrician and SFMMS board member Heyman Oo, MD, SFMMS board liaison and SF Public Health Officer Tomas Aragon, MD, and SFMMS President John Maa, MD. WWW.SFMMS.ORG

Public Health Policy Should Not Be a Political Bargaining Chip CMA President Ted Mazer, MD, recently wrote a thoughtful op-ed on why public health should be a non-partisan issue. This excellent piece (http://bit.ly/2Lp1uR2 ) touches on a number of issues SFMMS has endorsed over the years. We are pleased and proud of the CMA for speaking out forcefully about the separation of immigrant children from their parents, interference with encouraging breastfeeding, and sugary-drink taxes. The SFMMS has long been a strong voice within the CMA to bring public health issues such as these to the forefront, and we applaud the CMA’s leadership on these very important issues.

Read president Mazer’s most recent editorial on the immigrant children issue on page 31 of this issue.

CMA Saves Medical Groups Millions in Workers’ Comp Premiums

In 2016, the California Legislature passed a bill (AB 2883) that changed the definition of “employee” for the purposes of workers’ compensation coverage, setting an arbitrary 15 percent ownership threshold to be able to exempt owner/employees from such coverage. Unfortunately, the bill required many owners of medical corporations to pay drastically increased workers’ compensation insurance premiums for coverage they neither needed nor wanted. To assist affected medical groups and corporations, the CMA sponsored a law (SB 189) to once again allow appropriate coverage exemptions for owners. As a result of the new law, physician owners of professional corporations will be able to exempt themselves from workers’ compensation coverage — regardless of the percentage of ownership. This will result in premium savings for individual medical groups ranging from hundreds to hundreds of thousands of dollars. Read more at http://bit.ly/2zXARS3.

State Budget Includes 10 New CPT Codes Eligible for Supplemental Tobacco Tax Payments

Governor Jerry Brown recently signed a $139-billion California budget for the 2018–2019 fiscal year. The budget continues the Administration’s commitment to using the Proposition 56 tobacco tax funding to provide supplemental payments for Medi-Cal providers, with $500 million in tobacco tax funds allocated to improve provider reimbursement through supplemental payments. The total funding for provider payments is approximately $1.3 billion. DHCS plans to allocate the tobacco tax funds to increase payments for a total of 23 CPT codes, which includes 10 new preventive CPT codes. Read more at http://bit.ly/2uJpk2u.

CMA’s Health Law Library Updated with 2018 Content

CMA On-Call — the CMA’s online health law library — has been updated with 2018 content. One of CMA’s most valuable member benefits, the health law library contains nearly 5,000 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. The searchable online library contains all the information available in the California Physician’s Legal Handbook (CPLH), an annual publication from CMA’s Center for Legal Affairs. CMA members can access On-Call documents free at www.cmanet.org/cma-on-call. Members also have access to the CMA legal information line, which provides members with information and resources about laws and regulations that impact the practice of medicine. For assistance, call CMA’s member help center, (800) 786-4262 or e-mail legalinfo@cmanet.org.

(Continued on page 6) WWW.SFMMS.ORG

July/August 2018 Volume 91, Number 5 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Linda McLaughlin EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Erica Goode, MD, MPH Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President John Maa, MD President-Elect Kimberly L. Newell Green, MD Secretary Benjamin Franc, MD, MS, MBA Treasurer Brian Grady, MD Immediate Past President Man-Kit Leung, MD SFMMS 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 Erin Henke Membership Coordinator Ruben Pambid SFMMS BOARD OF DIRECTORS Charles E. Binkley, MD Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen Kumar, MD Michael K. Kwok, MD Raymond Liu, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD Michael Scahill, MD, MBA Monique D. Schaulis, MD Michael C. Schrader, MD, PhD, FACP Dennis Song, MD Jeffrey L. Stevenson, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo , MD

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PRESIDENT’S MESSAGE John Maa, MD

Healthcare Reform via Ballot Initiative: Bad Prescription In 2014, over $63 million was spent by both sides on Proposition 45, which sought to grant the California Insurance Commissioner the authority to reject health insurance rate increases. Prop. 45 was defeated by a margin of 59 to 41.

The same year, nearly $73 million was spent by both sides

on Proposition 46, which sought to change the medical liability system in California. Prop. 46 was defeated by a margin of 67 to 33. In 2016, over $128 million was spent by both sides on Proposition 61, which sought to limit what California state agencies pay for medications. Prop. 61 was defeated by a margin of 53 to 47.

One might anticipate that defeats like these would deter proponents from using the ballot initiative process again to attempt healthcare reform. But in November 2018, California voters will decide the fate of Proposition 8, which seeks to “fix” dialysis in California. This measure could likely prove to be the costliest ballot measure in California history. The proposition will set severely low limits on what insurance companies are required to pay for dialysis care, which may not cover the costs of providing care, and may force many dialysis clinics to reduce services or close. The National Kidney Foundation opposes Prop. 8, as does the CMA and the California NAACP. The SFMMS has also joined the coalition “Patients and Caregivers to Protect Dialysis Patients.”

The uniquely complex American construct of healthcare evolved over decades. Meaningful healthcare reform must be a thoughtful and careful process. A mistake of the past has been to propose a solution before fully understanding the problem in healthcare delivery, and jumping into the middle of a complex conversation rather than starting at the beginning. Over the past half-century, most attempts at reform have been largely unsuccessful, and perhaps some of these efforts have instead contributed to the challenges we now face. The future health of Californians should not be placed at unnecessary risk, and comprehensive reform cannot be achieved through a ballot measure drafted by one special interest without proper vetting, which selectively chooses what to present to the voters.

Contrary to CMS data showing that California dialysis clinics outperform on quality of care when compared to the rest of the nation, the proponents of Prop. 8 have criticized quality of care to justify the initiative. But the proposition is being promoted

by United Healthcare Workers West as part of a broader unionorganizing strategy. It is unclear how any issues related to quality of care will be made better by cutting reimbursement, and limiting the ability of dialysis clinics to meet federal Pay for Performance mandates and state quality reporting requirements.

Certainly it will not be beneficial for patients with renal failure if their neighborhood dialysis clinic closes and it becomes more difficult to receive dialysis treatment.

This debate should be closely watched by proponents of a WWW.SFMMS.ORG

single-payor healthcare system. In 1965, President Lyndon Johnson signed the Social Security Amendments of 1965, which created Medicare as federal health insurance for the elderly. In 1972, President Richard Nixon signed an amendment that expanded coverage to those with end-stage renal disease, with reimbursement rates established by Medicare. In that regard, dialysis care provides insights into how a single-payor system might operate, and also the resulting challenges that remain unsolved.

Another key concern is what might be the unintended consequences of the measure. Reduced payment will likely stifle innovation and research. The impact will be felt most by patients, with fewer facilities to receive care, longer distances to travel for treatment, and less availability for appointments. The clinical consequence may be more cardiac and pulmonary events from electrolyte and volume abnormalities, hospital readmissions, complications of hyperkalemia, and an increased use of in-hospital dialysis through the emergency room for patients who cannot access care elsewhere. All of these would also entail increased costs, of course.

As we seek to redesign the American healthcare delivery system, we should recognize that we are likely only at the beginning of an endeavor that will require decades to complete. Perhaps the key principle that will transform the existing money-driven medical system is to consider healthcare as a public good. In the end, we will likely identify ways to reform our society as a whole. Similar to the flaws with Prop. 45, Prop.

46, and Prop. 61, Prop. 8 fails to consider the larger landscape of health reform, and to balance the larger perspectives of all stakeholders involved.

Medical specialties most directly impacted by the debate over Prop. 8 are nephrology, kidney transplant, interventional radiology, and urology, but many of our patients could be adversely affected, and our whole system as well. Prop. 8 would also set a bad precedent for other services. Please encourage your colleagues, patients, hospital staff, and fellow voters to vote No on Prop. 8, and also let us know if you would like to help with the No on Prop. 8 campaign.

Dr. John Maa attended UC Berkeley and Harvard Medical School, completing his surgery residency at UCSF, and also completed a fellowship at the UCSF Institute of Health Policy Studies and has been president of the Northern California chapter of the American College of Surgeons. He is the chief of the Division of General and Acute Care Surgery at Marin General Hospital and on the medical staff of Dignity-St. Francis Hospital.

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(MEMBERSHIP MATTERS, continued from page 3)

Take the AMA 2018 CLRPD Survey Annually, the American Medical Association’s (AMA) Council on Long Range Planning and Development (CLRPD) solicits input on topics or issues that may be related to the current AMA agenda and those that the AMA may need to address in the future. The primary purpose of the stakeholder input process is to identify important healthcare issues related to the practice of medicine and the healthcare environment and obtain feedback from physician and medical student leaders. To complete the survey by August 31, 2018, visit http://bit.ly/2uGoLXh.

Sign Up to Receive Marin Public Health Newsletter

Stay up to date on public health issues of importance to Marin County residents and providers by signing up for the Public Health Newsletter published monthly by the Marin Department of Health and Human Services. To sign up, simply send an email to LRogers@marincounty.org. Visit http://bit.ly/2L1Swgh to view past newsletters.

CMA Launches the Next Generation of Its Brand and Website

The CMA recently launched a new website, including powerful recruitment and engagement tools to keep CMA at the forefront of an ever-changing healthcare landscape. The website functionality, design and content strategy have been reimagined for easier, more intuitive navigation and loaded with a suite of digital tools that will help you get the most from your membership. Highlights of the new website include a simplified CMA/county login process, the ability to choose preferences

for custom content and personalized alerts, mobile responsive design for interacting on mobile devices, a Grassroots Action Center for tracking all of CMA’s advocacy efforts, discussion forums, legislative tracker, newsroom, and much more! Visit www.cmadocs.org.

SFMMS Members Enjoy 15% Discount at California Academy of Sciences Did you know that SFMMS members enjoy a 15%% discount on tickets to the California Academy of Sciences? In the Academy’s newest major exhibit, Giants of Land and Sea, science becomes sensory as you explore Northern California’s natural wonders through a variety of interactive experiences. Ascend through an ancient redwood interactive, feel a jolt in an earthquake, roll through a fog room, and more! Use code “sfmms” to save 15% on tickets at www.calacademy.org/etickets2.

Be on the Lookout for the 2018–2019 SFMMS Membership Desktop Reference

SFMMS’ annual member pictorial directory includes San Francisco and Marin physician members with their practice address and phone number. The directory also includes physician lists by specialty as well as a reference list of local health organizations and services. With a circulation of 1,400 and used by many physicians and office staff on a daily basis, the directory proSPECIALTIES vides a great opportunity for IN physician members to receive GREATEST NEED referrals and grow their network.

One free copy of the directory TODAY INCLUDE: is mailed to all member physicians.

Dermatology

SPECIALTIES IN Family Practice SPECIALTIES IN GREATEST NEEDNEED GREATEST Gastroenterology/Hepatology TODAY INCLUDE: TODAY INCLUDE: Dermatology

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Gynecology Gastroenterology/Hepatology

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Oncology

Infectious Diseases

Gynecology Orthopedics Internal Medicine’ Neurology

We need your help as ambassadors of The MAVEN Project to recruit stellar physician volunteers in all specialties including primary care Pediatrics Oncology Infectious Diseases and pediatrics. Please reach to your Project friends and colleagues Ambassador Be Aout MAVEN Recruitment (general and specialty) about MAVEN Project’s flexible, convenient, and meaningful Orthopedics We need your help as ambassadors of The MAVEN Project to recruit Internal Medicine’ Neurology volunteer opportunities. stellar For more information, direct potential physician volunteers in all specialties including primary care Pediatrics physician volunteers to fill outpediatrics. an onlinePlease inquiry form them and colleaguesPulmonology and reach outor to have your friends contact the Director of Physician Engagement, Jill Einstein, MD at about MAVEN Project’s flexible, convenient, and meaningful Oncology(general and specialty)

volunteer opportunities.

For more information, direct potential jeinstein@mavenproject.org or 617-641-9743 x713.

Be A MAVEN Project Recruitment Ambassador physician volunteers to fill out an online inquiry form or have them

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contact the Director of Physician Engagement, Jill Einstein, MD at help as ambassadors of The MAVEN Project to recruit jeinstein@mavenproject.org 617-641-9743 x713.

PHYSICIA N VOLUNTE ER INQ UorIRY FORM

We need your stellar physician volunteers in all specialties including primary care Pediatrics 6 SAN FRANCISCO MARIN MEDICINE JULY/AUGUST 2018 and pediatrics. Please reach out to your and colleagues P H YSfriends I C I AN VOLUN TE E R IN QUIRY F OR M (general and about MAVEN Project’s flexible, convenient, and meaningful

WWW.SFMMS.ORG

specialty)

EDITORIAL Gordon Fung, MD, PhD

HEARTENING PROGRESS: What’s New in Cardiology?

Ever since 1911 when the CDC began reporting the leading causes of death in the U.S., cardiac disease has been No. 1

and continues to the present (except for 1918, when the leading cause of death was the Russian flu with its devastating toll on the U.S. population). This put the burden on the specialty of cardiology, which was formally established in 1948 to spearhead research and practice to reduce the morbidity and mortality of heart disease. Over the past 30 years, there has been a significant reduction in the incidence of heart disease and heart-related deaths, but it remains the leading cause of death not only in the U.S., but also in all developed nations.

The reduction in cardiac deaths has been attributed to multiple improvements in our approaches. These have included a comprehensive focus on acute management of cardiac events with patient education about warning signs of heart attacks and public education about CPR, in addition to regional management of EMS, where collaboration of STEMI centers with credentialing organizations ensures ongoing quality-improvement strategies and reduces delays to effective patient treatment.

Along with ongoing research and practice into optimal medical management of the acute coronary event, and treatment with percutaneous coronary intervention or bypass surgery with adjunctive therapy, the development of the secondary prevention to reduce the recurrence of these cardiac events has led to further decreases in cardiac mortality.

Some of the lessons learned over the last 50 years show that prevention is the key to reducing cardiac morbidity and mortality. Autopsy and accidental death studies have demonstrated that cardiovascular diseases begin in the very young with evidence of atherosclerotic changes in the aorta. So the development of cardiac risk factors and focusing on risk-factor reduction and emphasizing lifestyle changes has been key to the study and development of strategies to focus on primary prevention. To me, the most important lesson of the past 50 years has been that treating cardiac disease is not limited to a specific subspecialty; but a public health approach with education, and a community strategy to encourage the culture of healthy diet and exercise as a part of normal, healthy living to prevent cardiac disease.

In this issue, we emphasize some of the newer prevention strategies recently published by the American Heart Association with the American College of Cardiology and related health organizations. First were the new Hypertension Guidelines of WWW.SFMMS.ORG

October 2017. Dr. Binh Ahn Phan of the SF Department of Public Health discusses the new changes and the impact on population health. The second and related important question is, “Is cardiac disease truly a preventable disease?” At UCSF there is a Center of Cardiovascular Disease Prevention, now under the direction of Dr. Carlin Long, devoted to addressing this question. There is significant concern that “stress” and ethnicity can lead to cardiovascular disease. This has long been suspected but poorly studied. Dr. Michelle Albert, director of the NURTURE Center, collaborates with Jonathan Butler, PhD, in describing the center’s research of that issue.

We all prescribe exercise where appropriate or we should — and for many of us, sports is the main avenue of exercise activity; the AHA and ACC have long held that screening with ECG and echocardiograms are not indicated for the general public or young athlete to prevent cardiovascular death. Dr. Byron Lee discusses this issue in preventing sudden cardiac death in the athlete.

With the longer term improvement in congenital heart disease survivability into adulthood, there has developed a shortage of trained adult cardiologists and internists to manage these patients as they age. A new subspecialty of cardiology has been developed at major training sites as the Adult Congenital Heart centers. Drs. Anushee Agarwal and Ian Harris have kindly agreed to educate us on this new service to the community. Another new subspecialty of cardiology that has developed over the past few years is cardio-oncology, dealing with the increasing integration of cardiotoxic and chemotherapeutic agents that have adverse effects of cardiomyopathy or myocarditis. Dr. Rajni Rao introduces us to this area and its approaches. With the explosion of all these new areas of study, there has also been an awareness of increased data in all forms. How to identify relevant valid data and study it with the use of artificial intelligence — which has been felt to be the hope of smarter analysis — is addressed by Dr. Geoff Tison.

Finally, virtually any changes in the healthcare field must consider the major player of the government agencies and policy.

The common goal of physician involvement has been advocacy for health policy based on scientific evidence more than any other factor. Dr. Ralph Brindis, past president of the ACC and current professor in the UCSF Institute of Health Policy, shares his experience and thoughts for this continued approach.

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CURES Duty-to-Consult Mandate Takes Effect October 2 Effective October 2, 2018, physicians must consult California’s prescription drug monitoring database (the Controlled Substance Utilization Review and Evaluation System, or CURES) – before prescribing Schedule II, III or IV controlled substances.

When Must I Consult CURES?

Physicians must consult the database before prescribing controlled substances to a patient for the first time and at least once every four months thereafter.

Save the Date:

Free CURES webinar with the California Department of Justice on 8/22.

Register at cmanet.org/events.

For More Information CMA CURES webpage: cmanet.org/cures CURES website: oag.ca.gov/cures

Not Your Father’s AMA While the American Medical Association (AMA) may conjure images of a stodgy old boys’ club with conservative values in some people’s mind, I would challenge that the House of Delegates at the AMA is significantly more progressive than most people think.

Gender neutral bathrooms and kids camp (for us young delegates) are now regular features. Women and minorities make up a significant number of senior leadership. Dr. Barbara McAneny was inaugurated as the 2018 AMA President and Dr. Patrice Harris was elected to be the first African-American woman as the President-Elect. The Speaker of the House is in the capable hands of Dr. Susan Bailey. One worthy note is that our very own Dr. Jack Resneck, Vice-Chair of Dermatology Department at UCSF, was re-elected to the Board of Trustees and is now the Chair of the Board of Trustees.

Most importantly, a host of progressive recommendations from various AMA Councils as well as resolutions submitted by delegates were adopted by the HOD as official AMA policy. I have included ones that are of interest to the SFMMS. Gun Control The media immediately picked up on the dramatic policies adopted with a Washington Post headline article, “Frustrated AMA adopts sweeping policies to cut gun violence.” Here are some highlights: 1. Amend Policy H-145.993, “Restriction of Assault Weapons,” by addition to read as follows: “Our AMA supports appropriate legislation that would restrict the sale and private ownership of inexpensive handguns commonly referred to as ‘Saturday night specials,’ and large clip, high-rate-of-fire automatic and semi-automatic firearms, or any weapon that is modified or redesigned to operate as a large clip, high-rate-of-fire automatic or semi-automatic weapon and ban the sale and ownership to the public of all assault-type weapons, bump stock and related devices, high capacity magazines and armor piercing bullets.” (Passed by an overwhelming 80% of HOD.) 2. Require the licensing of owners of firearms including completion of a required safety course and registration of all firearms. (New policy passed by an overwhelming 70% of HOD.) 3. Support local law enforcement in the permitting process in such that local police chiefs are empowered to make permitting decisions regarding “concealed carry,” by supporting “gun violence restraining orders” for individuals arrested or convicted of domestic violence or stalking, and by supporting “red-flag” laws for individuals who have demonstrated significant signs of potential violence. In supporting local law enforcement, we support as well as the importance of “due process” so that decisions could be reversible by individuals petitioning in court for their rights to be restored. (New policy passed by an overwhelming 80% of HOD.) 4. Bans of sales of firearms and ammunition from licensed and unlicensed dealers to those under the age of 21 (excluding certain categories of individuals, such as military and law enforcement personnel). Passed unopposed.

WWW.SFMMS.ORG

Lawrence Cheung, MD

5. Oppose “concealed carry reciprocity” federal legislation that would require all states to recognize concealed carry firearm permits granted by other states and that would allow citizens with concealed gun carry permits in one state to carry guns across state lines into states that have stricter laws.

Physician Assisted Dying

Council on Ethical and Judicial Affairs (CEJA) Report #5: Study Aid-In-Dying as End-of-Life Option/The Need to Distinguish “Physician Assisted Suicide” and “Aid in Dying.” The recommendations from CEJA and the reference committee was to not amend the Code of Medical Ethics and that the AMA will continue to uphold policies against physician assisted dying (PAD). Dr. Ted Mazer (CMA President) gave a moving testimony on the floor of the HOD and argued that many notions that we had previously believed in as unethical have shifted with the change in time and culture.

Specifically, he compared PAD to the notion of abortion as unethical many decades ago and that the medical profession has now embraced it. The HOD then voted to refer this report back for further study and possible change in the AMA position on PAD. This is a very significant win for the SFMMS, CMA and the PacWest.

Single Payer

Resolution 108 (from the MSS) “Expanding AMA’s Position on Healthcare Reform Options” specifically asks the AMA to rescind Policies H-165.844 and H-165.985; amend Policy H-165.888 by deletion to remove “1(B) Unfair concentration of market power of payers is detrimental to patients and physicians, if patient freedom of choice or physician ability to select mode of practice is limited or denied. Single-payer systems clearly fall within such a definition and, consequently, should be continue to be opposed by the AMA. Reform proposals should balance fairly the market power between payers and physicians or be opposed;” and amend Policy H-165.838 by deletion to remove “12. AMA policy is that creation of a new single-payer, government-run healthcare system is not in the best interest of the country and must not be part of national health system reform.” Due to the highly complex nature of this, the HOD agreed with the reference committee to refer this for study. AMA’s position on single-payer may or may not change with the report and this is worth watching.

Cost Sharing

One other resolution of interest is Resolution 707, “Health Plan Payment of Patient Cost-Sharing,” which is a CMA resolution. It asks that our AMA urge health plans and insurer to bear the responsibility of ensuring physicians promptly receive full payment for patient copayments, coinsurance and deductibles.

This was referred by the reference committee to be studied by the Council on Medical Services.

A summary report from our PacWest delegation is available and the complete actions of the HOD is available at https://www.amaassn.org/about/business-ama-house-delegates-2018-annual-meeting

Dermatologist Lawrence Cheung is an SFMMS past-president and chair of the SFMMS delegation to the CMA. JULY/AUGUST 2018

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What’s New in Cardiology

How Low Should We Go in the Blood Pressure Limbo?

The evolution and current controversy surrounding hypertension management Binh An P. Phan, MD

The diagnosis and treatment of elevated blood pressure has been in constant evolution over the past century. In the 1940s, high blood pressure was believed by many physicians to be a compensatory mechanism needed to maintain normal blood flow to vital organs in the face of age-related narrowing of arteries. This erroneous theory on the origins and proposed benefits of elevated blood pressure led to the use of the term “essential hypertension” and explained why medical providers during that time elected not to treat high blood pressure. Epidemiologic research since that time has documented a consistent link between increasing blood pressure and a higher risk of developing cardiovascular disease, particularly myocardial infarction and stroke. Results from large randomized placebocontrolled trials starting in the 1960s demonstrated that lowering blood pressure using various pharmacologic agents was associated with a reduction in cardiovascular events.

Based upon the growing data on the harms of elevated blood pressure and benefit of treatment, the National Heart, Lung, and Blood Institute (NHLBI) convened the first Joint National Committee (JNC) in 1977 to provide guidelines on the detection and management of hypertension. In the past 30 years as the JNC released periodic updates and new guidelines, idefinition of hypertension and recommended optimal blood pressure goals has been in continuous flux. JNC 1 in 1977 primarily focused on abnormalities in diastolic blood pressure (DBP) to define hypertension, and diagnosed abnormal DBP as anything greater than 90 mmHg. The third report from JNC in 1984 defined hypertension using a systolic blood pressure (SBP) threshold of 160 mmHg in addition to a DBP of 90 mmHg. A decade later, JNC 5 lowered the threshold of hypertension diagnois to anyone having a blood pressure equal to or greater than 140/90 mmHg. JNC 7, released in 2003, recommended having an even lower blood pressure threshold for treatment of 130/80 mmHg in people with diabetes or chronic kidney disease. JNC also labeled anyone in the general population who had a SBP between 120 and 139 mmHg or a DBP between 80 and 90 mmHg with the term pre-hypertension.

The prior JNC guidelines had defined these blood pressure levels as being normal.

Despite the stepwise decrease in the blood pressure levels used to define hypertension over the past four decades, there 10

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has been an absence of clinical trial data to support the concept that targeting progressively lower blood pressure would lead to better clinical outcomes. On the contrary, there have been historical clinical trials that have shown no cardiovascular benefits in aiming for a lower systolic blood pressure target of 120 mmHg as compared to a target SBP of 140 mmHg in patients who have diabetes or chronic kidney disease. Recently, the SPRINT trial was the first large, randomized, controlled study to document the cardiac benefits of lowering blood pressure below the JNC target of 140/90 mmHg. The SPRINT trial randomized over 9,300 people with increased cardiovascular risk to a standard systolic blood pressure target of 140 mmHg, or a more aggressive target of 120 mmHg. SPRINT excluded individuals with diabetes or a history of stroke. After approximately three years of follow-up, the intensively-treated group achieved an average SBP that was 14 mmHg lower than the standard group and this resulted in a 25% reduction in cardiovascular events.

Buoyed in part by the results of the SPRINT trial, the 2017 national blood pressure guidelines released by the American College of Cardiology (ACC)/American Heart Association (AHA) lowered the definition of hypertension to 130/80 mmHg. They recommended starting pharmacologic therapy in high-risk individuals with blood pressure above 130/80 mmHg who had elevated 10-year risk of cardiovascular events of more than 10%. Based upon this new threshold, 30 million more adults in America, who previously were considered to have normal blood pressure, now carried a diagnosis of hypertension, and approximately 10 million of those adults were recommended to start on medical treatment.

Controversy erupted immediately after the release of these new guidelines. Some people raised concerns about the inappropriate weight given to the SPRINT trial in the development of the guidelines and the push for more aggressive goals. They cited the previously negative blood pressure trials as support against adopting lower blood pressure goals. Other people critiqued the recommendation by the ACC/AHA to use a calculated cardiovascular risks score to guide who would be needed to start on pharmacologic therapy. The SPRINT trial did not use such a risk score to determine blood pressure targets or treatment.

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Additionally, there were questions made on the potential harms associated with aggressively lowering SBP below 120 mmHg; particularly in elderly patients. In the SPRINT trial, intensive treatment was associated with significant increases in symptomatic hypotension, electrolyte abnormalities, and acute kidney injury. Many providers favored a more personalized approach to hypertension management that included individualized blood pressure goals rather than having a single target for the entire adult population as endorsed by the ACC/AHA. Citing some of these issues, many providers and some professional health organizations, including the American Academy of Family Physicians, elected not to endorse the new guidelines.

As the definitions of hypertension continue to evolve and the controversy of national guidelines persist over the past century, other critically important issues related to awareness and compliance with hypertension management have surfaced and may play greater roles in impacting healthcare. Recent national surveys have shown that approximately 25% of people with a diagnosis of hypertension were left untreated and only 50% of people treated with medical therapy had adequate control of their blood pressure. While these levels have slowly improved over the past several decades, there remains a substantial portion of the population that is not adequately treated and at significant risk for developing cardiovascular events. While the answer to the question of how low we should go for blood pressure management may be far from being resolved, the importance of improving patient compliance and control is clearly apparent now. Perhaps the act of encouraging people to participate in the limbo of blood pressure treatment may be as important as determining how low they need to go.

Older patients need wiser care.

Binh An P. Phan, MD, is an Associate Professor of Medicine at UCSF. He is an attending cardiologist at Zuckerberg San Francisco General Hospital where he serves as the Director of Inpatient Cardiology Services. He is also the Associate Program Director of the UCSF Cardiology Fellowship Program.

1868 2018

Anniversary

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11

What’s New in Cardiology

Is ASCVD truly a preventable disease?

Carlin S. Long, MD

“The report of my death was an exaggeration.”

—Mark Twain, May 1897 Is it premature to claim we are rid of the growing risk of atherosclerotic cardiovascular disease?

How did we get such a notion?

In 1978, the National Heart, Lung, and Blood Institute held a meeting in Bethesda that soon became known as the “Decline Conference.” The meeting’s discourse centered on the 20% decline in cardiovascular deaths during the prior decade.

Although there was no final consensus about the cause, the reduction in CHD deaths coincided with efforts to educate Americans about smoking, diet, and other CHD risk factors.

There had also been many changes in medical care during that time period, such as the advent of dedicated coronary care units, the development of high-quality and safe coronary bypass surgery, a concerted effort on control of hypertension, and the passage (and implementation) of Medicare and Medicaid legislation in 1965.

Ten years later, in 1988, the NHLBI convened a follow-up workshop where data from the Atherosclerosis Research in Communities effort (a National Institutes of Health study of four cohorts from different communities in the U.S.) and a similar effort from the World Health Organization (39 centers in 26 countries — MONICA) allowed for a robust comparison of international trends in CHD mortality. This data confirmed an accelerated decline of CHD in the United States in the 1980s, with rates falling 4% each year. Once again, whether this was due to prevention strategies or improved medical care/delivery was the topic of much debate and little consensus.

In 1999, Simon Capewell, a Scottish cardiologist and one of the first epidemiologists in this niche published his review of CHD deaths prevented between 1975 and 1994. His model demonstrated that 36% of deaths prevented could be attributed to decreased smoking, 10% to acute coronary care, and 9% to treatment of hypertension. He concluded that “risk factor reductions and modern treatments contributed almost equally” to the reduction — 40% treatment, 51% prevention.

So far, so good. The trends identified in these reports were 12

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favorable and very encouraging for future reductions in CHD morbidity and mortality. However, upon closer examination, did the trends expose a more complex picture?

Breaking down the data revealed there was a leveling off of the mortality rate figures, showing the rate of decline in CHD deaths slowing from 4% in the 1970s to 3% in the 1980s. A study of subgroups uncovered that this slowing seemed more prevalent in men aged 35–54, where the rate of decline fell from 6.2% in the 1980s to 0.5% in the 2000s. This latter statistic was reported in 2007 in an article entitled “Coronary Heart Disease Mortality Among Young Adults in the U.S. From 1980 Through 2002: Concealed Leveling of Mortality Rates.”

What caused this unexpected deceleration in the rate of CVD deaths? Finger-pointing concentrated on the worrying surge of obesity in America and its downstream consequences of hypertension and diabetes. Coupled with poor eating habits, Americans were suffering from a general lack of physical activity. Statistics revealed only about one in five Americans got the AHA recommended levels of aerobic exercise. By 2012, 45% of U.S. deaths were attributed to heart disease, stroke and type 2 diabetes.

Fast-forward to 2018 when, despite the American Heart Association report that from 2005 to 2015 the annual death rate attributable to coronary heart disease declined 34.4% (actual deaths declined 17.7%), the rate of death from high blood pressure increased by nearly 11%, and the actual number of deaths rose by almost 38% — up to nearly 79,000 by 2015. As most of the readers of this publication are acutely aware, guidelines published last November redefined high blood pressure as a reading of 130/80 from the prior standard of 140/90. In one fell swoop the percentage of U.S. adults with high blood pressure jumped from 32% under the old definition to nearly 46%. How this will affect the reporting of deaths attributable to hypertension alone is likely to be unfavorable.

Heart disease (including coronary heart disease, hypertension, and stroke) remains the No. 1 cause of death in the U.S. and is clearly the costliest, with an estimated direct and indirect cost of $204.8 billion (average annual cost 2013 to 2014). As such WWW.SFMMS.ORG

it has been, and must remain, on our radar as physicians as the number one target for risk mitigation. But can we take one step further and ask if atherosclerotic disease is, in fact, preventable in the same way that childhood illnesses like measles, mumps and rubella have now become “preventable?”

Before I give my answer, first allow me to take a minute to

introduce myself to the San Francisco Marin Medical Society audience. I am the new Director of the UCSF Center for Prevention of Heart and Vascular Disease, taking over from Dr. William Grossman, who established the center in 2008. Although I spent my “formative years” in the UCSF system, training in internal medicine and cardiology and then serving as junior faculty (1982 to 1998), I left for 20 years to be the Chief of Cardiology at Denver Health Medical Center. Now that I have returned to the UCSF Division of Cardiology, my vision for the Prevention Center is to design a comprehensive program that will address all facets of cardiovascular health.

Although our Center places a strong emphasis on maximizing reduction for risk factors over which we have the greatest control (lifestyle, blood pressure, cholesterol, and diabetes), we are bringing some additional “cutting edge” tools to the process of risk assessment and incorporating newer prognostic factors.

These include novel circulating biomarkers that reflect reverse cholesterol transport (prebeta-1 HDL), and others that address underlying immune/inflammatory damage. Additionally, we are focusing on DNA mutations seen in bone marrow-derived cells (cells with “clonal hematopoiesis of indeterminate potential” or CHIP). Patients who present with these mutations have been shown to have a four-fold increase in heart attack and stroke compared with those who did not carry these mutations.

This latter finding reflects our Prevention Center’s increasing appreciation, in the importance of genetics in cardiovascular disease and the clustering of risk apparent with a number of both known and currently unknown genes.

So, the answer to the question, “Is ASCVD preventable?” is a qualified “maybe.” Innovative therapies may hold a key to a new downward trend we are all hoping to achieve. Stay tuned.

In the meantime, I encourage you to get behind the American Heart Association’s recent campaign of “Life’s Simple 7” (Manage Blood Pressure, Control Cholesterol, Reduce Blood Sugar, Get Active, Eat Better, Lose Weight, Stop Smoking) as we hope for the day when heart disease is finally deposed from the top of that mortality list!!

Carlin S. Long, MD, is Professor of Medicine and Cardiology at UCSF. Dr. Long received his internal medicine and cardiology training at UCSF from 1982 until 1989. He was recently recruited from the University of Colorado, where he had served as the Chief of Cardiology at Denver Health Medical Center from 1998 until 2017. He is currently the Director of the UCSF Center for Prevention of Heart and Vascular Disease.

UPCOMING EVENTS State of the Art in Addiction Medicine |August 30– September 1, 2018 | Hilton San Francisco Union Square The California Society of Addiction Medicine’s annual conference is designed for physicians and other healthcare professionals who seek an advanced level of knowledge about the latest scientific and clinical advances in addiction medicine. For more information or to register, visit http://bit.ly/2LhWf90.

SFMMS General Membership Meeting September 12, 2018. 6:00 to 7:45 pm | Golden Gate Yacht Club, San Francisco

Calling all SFMMS members: Join us for our General Meeting on September 12. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMMS leadership and to learn firsthand the issues SFMMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and Marin. Details and registration is available at https://www.sfmms.org/events.aspx. For more information, contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

2018 Network of Ethnic Physician Organizations (NEPO) Summit | September 13-15, 2018 | Westin Pasadena The 2018 Network of Ethnic Physician Organizations (NEPO) Summit will be held September 13-15 in Pasadena. This year’s theme, Building the Best You: Celebrating the Joy of Medicine, will address issues of physician burnout and provide solutions to create a culture of wellness and physician well-being. The three-day summit is an innovative educational event for physicians, public health professionals, healthcare advocates and community leaders that offers policy and best practices for reducing health disparities, building diversity in the workforce and increasing cultural competency in clinical care.

Visit http://bit.ly/2Lr0AmU for more information.

CMA Presidential Gala | October 13, 2018 | Sacramento Convention Center

The incoming CMA president will be recognized at the Presidential Gala, which includes a cocktail reception, dinner and exciting entertainment. For more details including hotel and attire, visit http://tinyurl.com/y7gbxala.

2018 CMA House of Delegates | October 13-14, 2018 |

Sacramento The House of Delegates convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues. Policies adopted by the House are implemented by the Board of Trustees, which also deals with the many interim policy issues that arise between annual sessions. Visit http://bit.ly/2zOYv2J for more information.

2018 West Coast Minority Women Professionals (MWP) Conference | October 27, 2018 | Oakland Asian Cultural Center

This year’s theme is “We are Family,” and the one-day seminar will focus on providing our attendees with the tools for success and showcasing endurance from prominent women of color or other disadvantage. Visit http://bit.ly/2LsuNlE for more information.

SAVE THE DATE: 2019 SFMMS Annual Gala: Friday, January 25, 2019 | Cavallo Point, Sausalito WWW.SFMMS.ORG

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13

What’s New in Cardiology

Tackling Adversity and Cardiovascular Disease Jonathan Z. Butler, PhD, MDiv, and Michelle A. Albert, MD, MPH Introduction The biology of adversity and health remains a relatively untapped domain of research that interweaves molecular/ genetic biomarker science, multi-modality imaging (e.g brain MRI and cardiac ultrasound), and social determinants of health (SDH) with the evaluation of various types of adversity (e.g. cumulative psychosocial stress) to address evidentiary gaps in health outcomes such as cardiovascular disease (CVD) onset, progression and outcome. Thus, the CeNter for the StUdy of AdveRsiTy and CardiovascUlaR DiseasE (NURTURE Center) is an interdisciplinary, translational research center seeking to perform exploratory and interventional scientific research to understand the “biology of adversity” and its impact on health, particularly cardiovascular health.

Specifically, the goal of the NURTURE Center is to understand the psychosocial underpinnings and neurological correlates of cardiovascular conditions such as high blood pressure, heart attacks, type II diabetes mellitus, and heart failure. The overarching objective is to develop precision-based behavioral and therapeutic implementation strategies for at-risk individuals and populations across the lifespan. Key domains of interest include cumulative psychosocial stress, reproductive and childhood adversity, neuro-cardiovascular health and interventional science. While drug and technological advances have resulted in declines in cardiovascular mortality and morbidity, large gaps remain in longevity and adherence to recommended cardiovascular therapies based on exposure to adversity regardless of social, economic or demographic characteristics.

For the purposes of this piece, the focus will be on psychological stress (stress) as a form of adversity. Whereas, everyone experiences various forms of psychological stress throughout life, most stressful experiences are healthy or tolerable stress.

Healthy and tolerable forms of stress are typically anchored by good social support. However, toxic stress, i.e., stress associated with adverse experiences and associated with chaos and lack of social support is the kind of stress that results in disease.

Socioeconomic status and race/ethnicity are strong correlates of adversity related toxic stress. The potential mechanism through which stress results in disease is outlined in Figure 1.

Adversity and Childhood

Adverse childhood experiences (e.g., traumatic events such as physical or emotional abuse, death of a caregiver, socioeconomics) are closely linked to chronic disease in adulthood, affecting all racial/ethnic groups living in the United States.1 For example, among 84, 837 children participating in the National Survey of Child Health, approximately 50% of them were exposed to at least one adversity, and 23% were exposed to two or more adversities. Moreover, children from all racial/ethnic groups of 14

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Lifecourse Adversity Psychosocial Stress

(e.g. financial, neighborhood, discrimina=on)

Gene=cs + Epigene=cs Brain

Hypothalamic Pituitary Axis

Sympathe=c Nervous System

Inflamma=on

• Accelerated aging • Metabolic perturba=ons • Vascular Changes (e.g. endothelial dysfunc=on, hemodynamic)

Allosta=c Load Cardiovascular Disease + Other Health Outcomes + Well-Being

Figure 1. Poten=al Me through which Life=m Influences CVD and Ot Outcomes

Butle

Figure 1. Potential Mechanisms through which Lifetime Adversity Influences CVD and Other Health Outcomes.

lower socioeconomic status were more likely to have two or more adversities than children with higher socioeconomic status.2 For children, particularly those from U.S. minority groups, there remains critical need to study determinants of advantaged educational and health outcomes beyond the first two years of life when the brain is rapidly developing.3 However, arguably more important is an understanding of how potential interventions such as organized sports activities and mentoring interact with adverse and other childhood experiences to influence educational and health outcomes. Additionally, little is known about the social and biological embedding of adversity in an intergenerational context, and further, how the latter interfaces with promotion of supportive relationships and interactions between children from different socioeconomic backgrounds. Thus, in a WWW.SFMMS.ORG

collaborative effort between a novel sports camp (DiverseCity — founder, Mike Fratangelo) and the NURTURE Center (intended to promote meaningful interaction between children ages 9–12 from different socioeconomic backgrounds through sports and science education), we have launched DiverseCity Health.

DiverseCity Health intends to longitudinally evaluate intergenerational social, behavioral, biological and psychosocial factors that potentially impact chronic CVD risk and educational outcomes. Unique features of this program include the pairing of children from diverse socioeconomic backgrounds, shared athletic and educational experiences including self-efficacy, leadership and cardiovascular health teaching among the children.

Additionally, geographic heterogeneity related to Diverse-City sites (e.g., Pittsburgh, Pa.) presents the potential opportunity to assess both children and caregivers and to assess other sociodemographic characteristics besides socioeconomic status. The pilot DiverseCity Health program was initiated at the NURTURE Center, Division of Cardiology, University of California, San Francisco in the summer of 2017.

Adversity and Adults

Adversity is also associated with obesity and cardiovascular disease.4 Indeed, individual (e.g., physical activity, income, employment) and neighborhood-level (e.g., crime, built environment) constructs affect obesity risk.5 However, the specific mechanisms through which they confer risk are unclear. Risk may be affected via different pathways including neurological, psychological, behavioral, and biological pathways. Moreover, it remains unknown how these individual- and neighborhood-level indicators interact with each other independently or jointly to dictate risk. Furthermore, certain U.S. minority groups including blacks and Hispanic/Latino individuals are disproportionately affected by overweight/obesity and socioeconomic disadvantage. For example, in San Francisco, overweight/obesity prevalence is 53.9% with higher rates in blacks and Hispanics (74%) versus whites (45%).6 Nationally >33% of adults with income less than $15,000/year versus 25% of those with incomes greater than $50,000/year are obese. Furthermore, differential poverty rates by race/ethnicity exist in SF (white, 7.5%; black, 25%; Hispanic, 17%; Asian 9%), and the unemployment rate is typically twofold greater in nonwhites than whites.7 Thus, understanding the pathways through which these factors impact obesity is a critical step toward the development of evidence-based, effective interventions. Hence, in collaboration with the YMCA in San Francisco, our work in NURTURE seeks to incorporate social determinants of health into clinical trials aimed at obesity and cardiovascular risk reduction using a precision public health approach targeting socioeconomic status.

Thus, by focusing on interventional science related to

adversity and cardiovascular disease, the goal is to untangle fundamental mechanisms involved in the interactive roles of adversity defined by social disadvantage and cumulative psycho-social stress on biological risk, well-being and health outcomes across the life course. Hence, the mission at NURTURE is to improve educational and cardiovascular health through innovative research and interventional science that combines biological mechanisms of adversity with social determinants WWW.SFMMS.ORG

of health globally. The vision is “Advantaged health and wellbeing for all by dismantling the effects of adversity across the life-course.”

References

1. Boylan, J.M., Jennings, J.R. & Matthews, K.A. “Childhood Socio2.

3.

4.

5.

6.

7.

economic Status and Cardiovascular Reactivity and Recovery Among Black and White Men: Mitigating Effects of Psychological Resources.” Health Psychol (2016). doi:10.1037/hea0000355.

Slopen, N., Shonkoff, J.P., Albert, M.A., et al. “Racial Disparities in Child Adversity in the U.S.: Interactions With Family Immigration History and Income.” American Journal of Preventive Medicine. 2016; 50(1): 47-56.

Fox, Sharon E., Levitt, Pat, Nelson III, Charles A. “How the Timing and Quality of Early Experiences Influence the Development of Brain Architecture” Child Dev. 2010; 81(1): 28-40.

Adler, N.E. “Disadvantage, self-control, and health.” Proc National Academy Science U S A. 2015;112(33):10078-9. doi: 10.1073/pnas.1512781112. PubMed PMID: 26261315; PMCID: PMC4547272.

Baum A., Garofalo J.P., Yali A.M. “Socioeconomic status and chronic stress. Does stress account for SES effects on health?

Ann N Y Acad Sci. 1999; 896:131-44. PubMed PMID: 10681894.

Harder+Company for San Francisco Department of Public Health. Community Health Status Assessment: City and County of San Francisco. 2012. 1-189.

Silicon Valley Institute for Regional Studies. Poverty in the San Francisco Bay Area. 2015. 1-23.

Dr. Butler is a Research Postdoctoral Fellow in the CeNter for the StUdy of AdveRsiTy and CardiovascUlaR DiseasE (NURTURE Center) University of California, San Francisco, Division of Cardiology, Department of Medicine. His research focus examines the pathways from social determinants of health to cardio-metabolic health. He serves on the Sugary Drinks Distributor Tax Advisory Committee for San Francisco.

Dr. Michelle A. Albert is a cardiologist and Professor of Medicine at the University of California in San Francisco (UCSF). She is the founding director of the UCSF CeNter for the StUdy of AdveRsiTy and CardiovascUlaR DiseasE (NURTURE Center), Division of Cardiology and President-Elect of the American Heart Association Greater Bay Area Board of Directors.

University of California at San Francisco NURTURE Center 400 Parnassus Avenue, AC-16 Box 0369 San Francisco, CA 94143-0369 Jonathan.butler@ucsf.edu Michelle.albert@ucsf.edu

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15

What’s New in Cardiology

Preventing Sudden Death in Athletes and the Healthy Byron K. Lee, MD

On March 4, 1990, Loyola Marymount University basketball

player Eric “Hank” Gathers collapsed during a game, and died.

The crowd in the arena was stunned. At the time, Gathers was considered the best college player in the country. After leading the nation in scoring and rebounding, he was just months away from becoming a first-round draft choice and NBA star. Could this tragedy have been prevented? Three months before, Gathers fainted during a game and underwent a full medical evaluation.

Despite extensive testing, his 6-foot, 7-inch frame now lay lifeless. Did the doctors miss something? Did the medical profession fail him?

Fainting is one of most common reasons patients go to the emergency room or see their primary care doctor or cardiologist. Often, the cause of fainting can be determined with a careful history. Fainting during a blood draw and preceded by a prodrome of lightheadedness and diaphoresis can be confidently diagnosed as vasovagal syncope. However, fainting is sometimes unexplained even after a very detailed history. Dealing with unexplained fainting can be frightening for clinicians who don’t want to miss a condition that can cause sudden death. In dealing with unexplained syncope, it’s helpful for all practitioners to be familiar with the main causes of sudden death.

Sudden Death for 35 Years Old and Over

For patients 35 and over, the main cause of sudden death is overwhelmingly coronary artery disease (CAD). This can be due to an old myocardial infarction (MI) scar leading to ventricular tachycardia or an acute MI that triggers ventricular fibrillation.

St. Louis Cardinals pitcher Darryl Kile was nearly 35 years old when he did not show up for a game. He was later found dead in his hotel room. Autopsy showed that had died of an acute MI. He had 90% stenosis of two of his coronary arteries. It’s believed that Kile had a genetic predisposition to early coronary artery disease since his father died of an MI in his forties. For unexplained fainting in this age group, it’s important to consider CAD and possibly order an exercise treadmill test, nuclear perfusion scan, or cardiac catheterization.

Sudden Death for Under 35 Years Old

For patients under 35, the most common cause of sudden death is hypertrophic cardiomyopathy (HCM). In HCM, the myocardial cells are disordered and interspersed with scar, 16

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increasing the risk of ventricular tachyarrhythmias. Gathers was diagnosed with HCM before he died on court. Modern guidelines would have recommended that he get an implantable cardioverter defibrillator (ICD). There was an external defibrillator at courtside. Reportedly, he did not get defibrillated immediately since the first responders thought it would be inappropriate to shock him in front of the crowd. Instead, defibrillation attempts were delayed until he could be moved to the side. By then, he could not be resuscitated. Most likely, he was too acidotic to regain sinus rhythm. HCM can often be picked up by electrocardiogram (ECG), which can show very high voltages and T wave abnormalities. However, this diagnosis is usually made

by Echo. In some instances, the hypertrophy in HCM is patchy rather than circumferential, and cardiac MRI is necessary to make the diagnosis.

After HCM, the next most common causes of sudden death in the young are commotion cortis and coronary anomalies. Commotio cordis is an ill-timed blow to the chest during the T-wave (ventricular repolarization) that triggers ventricular fibrillation.

This claims the lives of a few little league baseball players every year. An astute clinician among the fans who witnesses fainting after a baseball impacts the chest can potentially save a life by recognizing commotio cordis, starting CPR, and calling for immediate defibrillation. In contrast, coronary anomalies are difficult to recognize. They can sometimes be picked up by Echo, but more commonly cardiac MRI or CT is necessary to make the diagnosis. There may be no symptoms until the patient dies suddenly due to plaque rupture in an anomalous coronary artery supplying entire left ventricle. “Pistol” Pete Maravich played an entire NBA career before dying suddenly at age 40. Autopsy showed he had a single coronary artery supplying blood flow to his entire heart.

ECG Screening to Prevent Sudden Death

Since sudden death can occur in otherwise healthy individuals without preceding symptoms or signs of heart disease, there has been interest and debate about whether screening ECGs should be done. Many of the diseases that can cause sudden death have characteristic ECG findings such as in HCM, Long QT Syndrome, and Brugada’s Syndrome. Several countries already operate large scale ECG screening programs often focused on athletes or young people. Although a few of these countries WWW.SFMMS.ORG

report success in decreasing the incidence of sudden death with screening ECGs, the U.S. has yet to embrace this approach. The American Heart Association (AHA) has maintained that an ECG screening program in the U.S. would be too costly and lead to too many false positives. However, there has been publication of several cost-effective analyses that have supported the use of ECG screening in the U.S.

Mastering Tough C Mastering Tough Conversatio Mastering Tough Conversat SF Bay Area Region SF Bay Area Regional Courses: Fall 2018 Mastering Tough Conversations Mastering Tough Conversations SF Bay Area Regional Courses:

UCSF PlaySafe Cardiac Physicals Program

Although the AHA has not supported nationwide ECG screen ing, they have not specifically discouraged local grassroots ECG screening programs that are typically run by volunteers. In this setting, the ECGs are nearly free. This tilts the cost-effectiveness balance, making ECG screening now a sensible approach.

For the past 10 years, we have run the UCSF PlaySafe Cardiac Physicals Program for high school athletes in the community. Most local high school athletes need a medical clearance

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Oakland, CA D formed 3,255 ECGs and 191 Echoes. We have found the followand disciplines who care for seriously ill patients6, are2018 October 23, 2018 October 23, 2018 December December 6, a2018 We believe We believe effect ive, effect empathic ive, empathic and ho nest and ho conversations nest conversations between between a clinician, clinician, ing: 8 Wolff Parkinson’s White patterns, 6 Long QT or borderline 8:00 AM – of4:30 PM 8 encouraged to attend, as are postgraduate trainees in patient patient and their and family their are family the are cornerstones the cornerstones of patient-centered patient-centered care. care.

October 23, 2018 December 6, 2018 Palo Alto, CA Oakland, CA Long QTs, 2 frequent premature ventricular contractions, 5 right 8:00 AM – 4:30 PM 8:00 AM – 4:30 PM the health professions.

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17

What’s New in Cardiology

A Rising Tide of Adults with Congenital Heart Disease!

Anushree Agarwal, MD, and Ian S. Harris, MD

As the growing ACHD population is expected to continue to live

[Dr. Agarwal] When I was a child, my younger brother had a syncopal episode that led to the diagnosis of bicuspid aortic valve stenosis, and he needed an urgent aortic valvuloplasty.

Although this fascinated me — and made me want to become a doctor and a cardiologist — it was not until my general cardiology fellowship training that I became interested in pursuing a career in congenital heart disease (CHD). Until then, I always assumed that congenital heart defects are esoteric conditions, and within the arena of pediatric cardiology. As I trained in cardiology, I was surprised to learn that there is now an entirely new field of adult congenital cardiology (because these patients are surviving longer) but very little literature exists on the problems faced by them and their management approaches. I found a mission — an opportunity to contribute in an area that is rapidly flooding our practices but still has so many unknowns!

Congenital heart disease is the most common type of birth defect in humans. Due to the extraordinary advances in medicine, patients with CHD/ACHD have become one of the fastest growing populations within adult cardiology. Overall, it is estimated that ~1.6 million adults in the United States are now living with CHD, a figure that is expected to increase by about 5 –10% annually. Furthermore, the profile of this patient population is also changing, due not only to advancing age, but also to improved survival of patients with complex anomalies. Healthcare for the increasing ACHD population requires careful planning for their specialized needs in all settings (inpatient and outpatient) and is more expensive than care for adults without CHD. In addition to their cardiac problems, these patients frequently have neurological/psychological issues, pulmonary limitations, hepatic abnormalities, renal dysfunction, hematologic problems, and endocrinopathies. Their abnormal cardiac

physiology also often creates special challenges regarding pregnancy and delivery. Common age-related acquired comorbidities such as hypertension, coronary artery disease, depression and dementia are important predictors of mortality and health resource utilization in these patients. Hence, we are seeing a rising tide of a challenging population with health problems related both to sequelae of CHD and to aging.

Overall, these patients require a comprehensive team approach that involves not only frequent regular outpatient evaluations with specialists in CHD but also care from providers with experience managing the interaction between CHD and typical adult-onset comorbidities.

The specialized center often serves as the medical “home” for this population of patients and visits are considered a measure of quality of CHD care.

Unfortunately, there have been significant gaps in access to care for these patients, and particularly, patients transitioning from pediatric to adult specialists often suffer fragmented and inconsistent care, which may coincide with loss of insurance.

Data from the Netherlands show that adults with CHD have 3.6-fold higher odds of facing barriers to obtaining insurance and increased premiums. To meet these challenges, tremendous efforts have been made globally to improve the access to care and understand the clinical needs of these patients, and specifically in domains of clinical, education, research, and community collaborations. Accredited training opportunities are now available for pediatric and adult cardiologists; multicenter research collaborations have been created, like the Alliance for Adult Research in Congenital Cardiology; and patient/provider collaborative organizations such as the Adult Congenital Heart Association and the International Society of Adult Congenital Heart Disease have initiated major global initiatives. Funding

longer and face challenges of

acquired conditions, providers who may not be familiar yet

with the management of these patients will see them more

frequently in outpatient and inpatient settings.”

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for research through various federal and non-federal organizations has also improved, especially in the U.S. Together, these initiatives have created a roadmap for the advanced training of physicians in ACHD and the building of centers of excellence designed to provide comprehensive care to this unique population of patients. There is now an initiative to build a national registry to understand the natural history and track outcomes of these patients.

The Bay Area is home to a long tradition of excellence in congenital heart care. The UCSF ACHD program is one of the oldest and largest ACHD programs on the West Coast, and is at the forefront of all the advances in the field — clinically, in education, and in research. We have a comprehensive multidisciplinary team of surgeons, interventionalists, electrophysiologists, imaging experts, geneticists and specialized board certified ACHD cardiologists, dedicated to care for these challenging patients.

Furthermore, we have established one of the first programs of its kind in the nation — a very unique “Pregnancy and Cardiac Treatment” that provides a standardized team-based approach to heart disease in women in every aspect of their child-bearing from pre-conception to postpartum, in collaboration with highrisk obstetrics/perinatology and anesthesiologists. In addition to providing care in San Francisco, we are creating a “hub and spoke” model of ACHD care to reach out to our patients and collaborate with physicians in the community, and have already established our outreach clinics in Modesto, Salinas, the East Bay and soon in Santa Rosa while having ongoing collaborations with the ACHD programs at Kaiser, CPMC, and Stanford.

Anu Agar wal, MD, is Assistant Professor of Medicine and an adult congenital cardiologist at the University of California School of Medicine. She is board certified in internal medicine, cardiology, echocardiography and adult congenital heart disease. She specializes in noninvasive cardiology and treats adult patients with congenital heart disease, including those who are pregnant. She performs outcomes research aimed to reduce mortality, morbidity, and to improve the functional status of these patients. She has been using large data methodology to help understand the healthcare needs of this patient population.

Ian S. Harris, MD, is Associate Professor of Medicine and Director of the Adult Congenital Cardiology Program at the University of California School of Medicine. He is board certified in internal medicine, cardiology, and adult congenital heart disease. He has a research background in basic cardiovascular developmental biology, and specializes in the care of adults with congenital heart defects and in cardiovascular genetics.

The UCSF ACHD program is also dedicated to teaching

the future generation in becoming competent in managing these complex patients, and offers a two-year advanced fellowship in ACHD to physicians who have completed clinical training in either adult or pediatric cardiology. I am fortunate and humbled to be the first trainee out of this contemporary training pathway.

We at UCSF are also actively involved in research to help understand the clinical profile and healthcare needs of these patients.

We are using “big data” approaches to obtain accurate population-based estimates of the rate of comorbidities and healthcare utilization to help understand how care should be structured, to guide, for example, specific training in acquired age-related comorbidities. These population-based approaches are aimed at helping policymakers allocate resources appropriately to provide the most cost-efficient care to improve clinical outcomes of these patients. Moreover, UCSF is one of the leaders in the efforts to create a prospective long-term national registry for these patients. We are poised to make the Bay Area a national leader in ACHD care, education and research.

As the growing ACHD population is expected to continue to live longer and face challenges of acquired conditions, providers who may not be familiar yet with the management of these patients will see them more frequently in outpatient and inpatient settings. As such, increased overall awareness in the community of the needs of the ACHD population will help improve care for them. The onus of continuing the success stories of the surgical and technical innovations now relies on providing the optimal, efficient care aimed at improving the quality of care and longevity of the rapidly growing and aging ACHD population.

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What’s New in Cardiology

Cardio-oncology: What can a cardiologist offer to combat the “Emperor of All Maladies”?

Rajni Rao, MD “ . . . The story of cancer . . . is the story of patients who struggle and survive, moving from one embankment of illness to another. Resilience, inventiveness, and survivorship — qualities often ascribed to great physicians — are reflected qualities, emanating first from those who struggle with illness and only then mirrored by those who treat them. If the history of medicine is told through the stories of doctors, it is because their contributions stand in place of the more substantive heroism of their patients.” ― Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer “Minutes are myocardium; seconds are sarcomeres.” ― William Grossman, speaking about the importance of acting quickly in acute myocardial infarction

I’ll be quite honest. I had started my medical training at the

other MGH (Massachusetts General Hospital) on the oncology ward, caring for people submitting themselves to the cruelty of bone marrow transplant sometimes with what seemed like an ineluctable ambition for living based on slim or even nonexistent odds, subjecting their bodies to all forms of pain. With this limited view, I regarded oncology as a sad field, presided over by a special strain of physicians — big-hearted people with infinite kindness, dark circles under the eyes and faintly glowing halos

over their heads. It was the quickly decisive, high-tech, commonsense field of cardiology that attracted me to medicine. I later realized that these presumptions were myopic and that these two fields are importantly linked for me and most importantly, for many of our patients.

My view of medicine changed when my father, who had lived with Crohn’s disease almost his entire adult life, began having recurrent small bowel obstructions refractory infusions of adalimumab and necessitating urgent surgery. The surgeon had opened the abdomen and found invasive small bowel cancer. Chemotherapy, IR procedures, and 14 hospitalizations and nine months later, he succumbed. Along the way, we had gotten to know an entire team of people, with names, emails, cell phones. Nurses who called us to check-in before we had to call them. Doctors who contacted us as soon as they heard a result.

Appointments made for us. Chaplains, social workers, massage therapists, counselors, group sessions, symptom-management specialists. People to help us park, obtain a wheelchair, home nursing, etc. A team-based style of care not often seen in other types of medical practices. Information given, considered, and shared decisions to be made by patient and physician. I couldn’t quite grasp what made my father want to battle the disease so determinedly against any reasonable odds and with so much suffering. But I later began to notice similar characteristics in

Table 1. Common cardiovascular considerations of cancer therapies

20

Treatment

Example

Cardiovascular Effect

Anthracyclines

Doxorubicin

Dose-dependent cardiomyopathy

Radiation

Esp. of chest

Myocardial dysfunction, valvular degeneration, acute pericarditis, constrictive pericarditis

Her2 inhibitors

Trastuzumab or Herceptin

High rate of cardiomyopathy esp. in combination with anthracyclines

VEGF inhibitors

Bevacizumab or Avastin

Systolic and diastolic hypertension

Small molecule (tyrosine kinase) inhibitors

-ib drugs such as sunitinib, imatinib, dasatibib, nilotinib, etc.

• Vascular events (TIA, PAD, MI), often in patients with atherosclerotic risk factors • Hypertension • Pulmonary hypertension • Cardiovascular dysfunction • Arrhythmias (atrial fibrillation)

Immunomodulatory drugs

Thalidomide, lenalidomide

Venous thromboembolic disease, myocardial infarction, stroke, hypertension

Immunotherapy

Checkpoint inhibitors

Case reports of autoimmune myocarditis; still uncertain CV safety profile

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Table 2. Suggested responsibilities of a cardio-oncologist Ongoing cardiovascular management of baseline CV conditions for a cancer patient Preoperative assessment for cancer surgery, including weighing of risks and benefits of coronary interventions and dual antiplatelet therapy vs. pursuing cancer treatment Management of postoperative complications including atrial fibrillation, acute coronary syndrome, hypertension Assessment of risk prior to potentially cardio-toxic chemotherapy Careful echocardiographic evaluation of possible LV dysfunction Management of treatment-related hypertension, cardiomyopathy, vascular events Assistance with management of polypharmacy and side effects of multiple cardiac and other drugs Collaboration with oncology and primary care, IR, surgery, radiation oncology; enhanced communication for shared decision-making Establish a patient-centered practice with excellent communication, considering the use of traditional office visits or electronic communication, video or telehealth visits, physicians and allied health professionals Familiarize oneself and stay current on updates on oncology treatments and cardio-oncology trials

my patients referred to me by oncologists — they were often well-informed, driven, savvy consumers of their healthcare, who needed something from me so that they then could then move on to the real business of the day: fighting cancer. They needed facilitation of their care, not more roadblocks on a road that is already riddled with roadblocks. However, what is cardiooncology? Is it not just the practice of cardiology in patients who happen to have cancer?

Perhaps. But even before getting into checkpoint-inhibitor mediated myocarditis and trastuzumab cardiomyopathy (Table 1), perhaps the primary role of the cardio-oncologist (Table 2) is philosophical, to mainly facilitate, to ferry patients from point A to point B, whether that be a pre-op evaluation or chemotherapy or surgery, or even just getting them through some minor hypertension, and all along the way working with our oncology colleagues as a polyglot learning their ever-changing language of drug combinations that will inform our understanding of cardiotoxicities.

We began our carcinoid heart disease center at UCSF by problem-solving with oncologists, who are the ultimate barristas, trying to craft the perfect personalized solution for a given patient with a rare neuroendocrine tumor. We began to learn best practices, employ n-of-1 trials in our patients, and when evidence not in supply, craft a solution individually. This sometimes means careful timing of double heart valve surgery prior to liver debulking treatment, and other times meant designing a palliative transcatheter pulmonic valve replacement hybrid procedure in those too frail for surgery. It may mean the most inelegant treatment of hypertension, with multiple short acting drugs in low doses all on sliding scales, for patients with disabling paraneoplastic dysautonomia. After we rolled out our Epic EHR, we soon started receiving the MyChart messages from our patients with breast cancer within minutes of them completing their screening echocardiograms on trastuzumab — “could you please tell me my ejection fraction?” It doesn’t take long for patients to realize that so much hinges upon that number, and any delay we have in answering their email leaves them hanging, WWW.SFMMS.ORG

not knowing if the life-altering medication would have to be halted for cardiotoxicity. From these patients, we have learned another cardio-oncology prerogative: be creative, responsive, flexible, and available, because to quote Sid Mukherjee again, “All cancers are alike but they are alike in a unique way.”

Cardio-oncology, or oncocardiology as it is also called, represents the intersection of the two fields and the cardiovascular care of cancer patients because of unrelated coexisting disease states or to manage the cardiovascular effects of cancer treatment. It is a growing field because CV disease and risk factors are common and there is an explosion of new targeted cancer treatments that have or may have CV side effects (Table 1).

What we can adopt, whether or not we choose to formally practice cardio-oncology, is a version of the patient-centered care our oncology colleagues provide. They have developed teams with various expertise to help patients and their familyies navigate the complexities of cancer treatments, multiple appointments, cost, and emotional and social issues. They have learned how to make themselves available to patients and how to take a well-informed patient and put him or her in the driver’s seat. And this is what our cancer patients should rightly expect from all their physicians.

Dr. Rajni K. Rao is Associate Professor of Medicine at UCSF, and is a cardiologist with special interests in non-invasive cardiology. Rao received her undergraduate degree from Harvard University and her medical degree from UCSF. She completed her internship at the Massachusetts General Hospital and returned to UCSF for her internal medicine residency and cardiology fellowship. She served as chief cardiology fellow and completed advanced training in echocardiography at UCSF. She has received numerous awards including two recognizing her as a distinguished educator.

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What’s New in Cardiology

Demystifying Artificial Intelligence: Present and Future Applications to Medicine Geoff Tison, MD, MPH In the past couple of years, the term “Artificial Intelligence”

seems to be almost everywhere we look. Artificial Intelligence, or “AI,” is advertised as being used to help do everything from driving your car to selling your next pair of shoes. Even in healthcare, AI is frequently invoked with fanfare, but often accompanied by little insight into what it actually is, what is possible, or how soon it will come. Certainly, our daily lives have been infused by technology, from the internet to smartphones, and much of it does seem “intelligent,” so much so that sometimes we forget that there is no human on the other side. For example, Lyft tells you when your ride is coming and when you’ll arrive at your destination, interspersing several pickups and dropoffs along the way.

Google not only gives you a list of webpages related to your query, which can be spoken or typed using natural language, but may answer your question directly or even recommend a book to further your understanding. But healthcare is complex, its data is nuanced and medicine is different — or is it? In this article, I will outline some of the basics underlying AI and begin to describe ways in which it may impact the medical field.

So what does AI actually refer to and how “intelligent” is it really? In common parlance, the term AI is often used loosely.

But from an algorithmic perspective, modern references to AI usually indicate efforts that use a collection of algorithms that fall under the category of machine-learning algorithms. What makes these types of algorithms different from those that came before them is that they possess the ability to learn patterns from large amounts of data without explicitly being given rules that describe how to interpret that data. Combined with recent advances in computing, these algorithms tend to be flexible enough to accept raw, unprocessed data as inputs, without the need to summarize the data or extract a hand-picked subset of the data for interpretation. This has opened the door to analyzing data in ways not even conceivable just over a decade ago, such as analyzing every pixel across an entire image (and the interactions between them) to identify a breed of dog, or interpreting the series of images in a video to self-drive a car.

Importantly, the way that these algorithms are developed usually requires large amounts of example data that have been annotated for the task of interest. For example, one could provide many pictures of different dogs that have been labeled with their specific breeds or hours of video with labels for street signs, delivery trucks or pedestrians. Thus, while these algorithms have become quite adept at increasingly complex tasks for which they are trained — spurring predictions that robots may soon replace doctors — current algorithms do less well for novel tasks involving data that are substantially different from those for which they were trained. For example, an algorithm that has been trained to interpret brain MRIs for specific tumors may not perform well for other types of tumors, or even for T2-weighted MRI images of the same tumors. This has led some to caution that there is no real intelligence in present artificial intelligence — at least not yet. So, while there are certainly limits to what can currently be achieved by applying AI techniques to medicine — robots will not be doing our jobs anytime soon— there are just as certainly many substantial gains that are solidly within reach given our current capabilities that can potentially improve the lives of our patients and our work as physicians. As physicians, we can help by working with AI experts (either researchers or in partnership with companies) to identify the applications of AI to medicine that can most impact patient care and to highlight the clinically relevant problems that these algorithms, even with their limitations, are best positioned to solve.

Similar to other fields in which AI has made the largest strides, such as voice or image recognition, the large potential for AI in medicine is enabled in large part by the widespread digitization of medical data that has occurred over the past couple decades. From radiology “films” to electrocardiogram tracings, we have all witnessed the large-scale migration of medical data to digitized formats, and this provides the raw fuel with which to train AI algorithms. But just like other raw materials, this digitized medical data requires appropriate processing

We applied deep neural networks to data collected passively from

the Apple smartwatch, namely raw heart rate and step-count . . . [and] used this data to detect

atrial fibrillation with high accuracy when compared against electrophysiologist-confirmed ECGs.”

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before it can be used to develop machine-learning algorithms.

Specifically, most algorithms require annotations of this data for every disease that the algorithm is designed to identify. So for radiographs, we would want to provide annotated examples of lung nodules, pneumonias, cancers, etc. And since these all come in many locations, shapes and sizes, we would want to ensure that the examples we use to train the algorithms are similarly varied. For medical applications, physicians are often required to provide the annotations in a format that the algorithms can process. In many cases, this proves to be the rate-limiting step to obtaining adequate amounts of data to train medical AI algorithms. But especially as the clinical systems that physicians use to interpret medical data for clinical purposes evolve, it may be possible to design systems that record clinical diagnoses in such a way that they can also provide annotations for AI training, removing the need for additional annotation by physicians.

Due to the recent advances of AI in the fields of image recognition and computer vision, image-recognition tasks in medicine have been the first to demonstrate progress by AI, and this will likely continue to be the case in the near future. In late 2016, a group led by Gulshan, et. al. published one of the first largescale efforts of AI applied to medicine in JAMA: The Journal of the American Medical Association. They used a machine-learning algorithm known as a deep neural network to detect diabetic retinopathy from retinal fundus photographs, showing high sensitivity and specificity when compared to interpretations by board certified ophthalmologists. Similar work has been published detecting various subtypes of skin cancer from dermoscopy images with similar performance to dermatologists, corroborating that machine learning algorithms can perform well for medical image recognition tasks if provided the right amounts of training data. Not surprisingly, more recent work has come out for radiologic tasks, and we can expect progress on similar tasks in the near future. Beyond image recognition, machine-learning algorithms enable interpretation of raw data from multiple simultaneous sources in ways not previously possible. This capability offers promise to begin integrating the copious amounts of data being produced daily in our digital lives for medical applications, such as data from our smartphones, smart watches, activity trackers, connected health devices and beyond. In work published earlier this year in JAMA Cardiology by our lab at UCSF, we applied deep neural networks to data collected passively from the Apple smartwatch, namely raw heart rate and step-count data. In the main validation experiment, we used this data to detect atrial fibrillation with high accuracy when compared against electrophysiologist-confirmed ECGs. And in early exploratory work, we demonstrated that there is signal to detect some additional prevalent diseases such as hypertension or possibly even diabetes.

In its current state, modern AI algorithms have greatly expanded what types of data can be processed and what kinds of tasks can be tackled. And we’ve seen just the tip of the iceberg for how it can be applied to medicine. However, for all the advances that have been made, modern AI still relies heavily on humans to identify appropriate and discrete tasks and to hand-hold algorithms through their development by providing examples of what is normal versus diseased. Applications of AI can and almost certainly will begin to assist us in medical tasks, likely working under the hood first by providing assistance in WWW.SFMMS.ORG

the form of preliminary interpretations or early warnings. Certainly, many of us have experienced efforts toward “decision support” in the past, with varying degrees of success. And modern AI will undoubtedly experience similar obstacles as it matures, particularly for medical applications. But as evidenced by its already highly visible (or if successful, invisible) impact on our daily non-medical lives, modern machine-learning algorithms represent a paradigm shift in algorithmic evolution, so there is reason to believe that medicine stands to benefit significantly if AI is applied appropriately. As experts not only of pathophysiology, but also the idiosyncrasies of healthcare delivery and the social/psychological realities of patients, physicians are going to be central in guiding AI applications in medicine. It is only with the input and guidance from physicians that we can ensure that AI is applied toward applications that are clinically relevant and in ways that can realistically integrate into the healthcare delivery system to improve the work we do with patients—work which, especially in this era of AI, will continue to be as important as ever.

Geoff Tison, MD, MPH, is a faculty member in the Division of Cardiology at UCSF. His clinical research focuses on cardiovascular prevention with an emphasis on machine learning and artificial intelligence applications to cardiology and medicine.

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What’s New in Cardiology

Burning Platforms in HealthCare Delivery: A 2018 Cardiovascular Clinician’s Perspective Ralph G. Brindis, MD, MPH, MACC, FAHA, FSCAI

With the continued fluidity occurring in U.S. healthcare

reform, there are substantial challenges confronting clinicians in their pursuit of the practice of medicine. Some of the important “burning platform” issues facing cardiovascular (and all) professionals include: • Implementation of the Quality Payment Program created under the Medicare and Children’s Health Insurance Program (CHIP) Reauthorization Action (MACRA).

• The continued shift toward a value-based health system that is driving more clinicians toward participation in alternative payment models (APMs). Knowing how and when to participate in an APM poses significant challenges for all physicians navigating the APM landscape.

• The onerous burden of prior authorization requirements for tests, procedures and medications.

In response to the U.S. healthcare reform challenges, the American College of Cardiology (ACC) healthcare advocacy priorities focus on: 1) creating a value-driven healthcare system; 2) ensuring access to care and cardiovascular practice stability; 3) promoting the use of clinical data to improve care; 4) fostering research and innovation in cardiovascular care; and 5) preventing cardiovascular disease and improving heart health. Importantly, the ACC also advocates for the “Fourth Aim” amendment to the Institute for Healthcare Improvement’s “Triple Aim”— now the Quadruple Aim. This new additional “aim” focuses on the caring of the clinician by taking steps to increase clinician wellness and reduce burnout, all in service of improving the quality of healthcare delivery.

Several important programs that impact the Quadruple Aim, including the Quality Payment Program, alternative payment models and prior authorization reform, are examined in detail, along with some innovative efforts to foster improved cardiovascular care.

Quality Payment Program (QPP)

The Centers for Medicare and Medicaid Services (CMS) is continuing implementation of the previously established Quality Payment Program in an effort to move care from volume to value, albeit with noteworthy changes in philosophy under the Trump administration. The ACC has encouraged legislators to exercise oversight of the Quality Payment Program implementation and to streamline requirements for EHR use by supporting 24

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H.R. 3120, a bill to reduce the volume of future EHR-related significant hardship requests. Other “asks” are to ensure consistency of EHR requirements across care settings and to facilitate smooth transition to new payment models by relying on clinician feedback, removing barriers, and aligning new requirements with existing regulations. The interested practitioner can find a user-friendly, personalized, interactive primer on the QPP and the Merit-Based Incentive Payment System (MIPS) at http:// www.acc.org/macra/index.html

Alternative Payment Models (APMs) The continued transition from a health system focused on volume to one focused on value is driving clinicians toward alternative payment models (APMs). Understanding APMs and knowing how and when to participate poses significant challenges for clinicians, including the need for appropriate staffing and capital capacity, practice redesign, management of regulatory burdens, and managing the uncertainties of reimbursement. ACC’s APM Framework guidance web portal http:// www.acc.org/tools-and-practice-support/advocacy-at-theacc/health-policy-issue-center/alternative-payment-modelframework is focused on four categories: 1) organizational readiness; 2) clinical practice transformation; 3) reporting and analytics; and 4) financial risk. Under each category, the Framework offers a series of questions that introduce concepts that practitioners should consider when evaluating their potential participation. For example, the “Organizational Readiness” section walks through considerations related to approaches to value-based payment strategies, external partnerships, workforce, and other key elements. Completing the “Practice Transformation” section assesses your clinical care redesign capabilities prior to APM participation. Practices can explore key considerations regarding their reporting and analytics infrastructure, including integrating EHR, claims, and payer supplied data, under the “Reporting and Analytics” category.

The APM Framework is intended to cover all forms of valuebased payment arrangements, including accountable care organizations, bundled payment programs, global or population payments, and/or other government and commercial valuebased arrangements. Alternative payment models are here to stay. The more prepared that practices, clinicians and administrators are for this reality, the greater the chances of succeeding in these programs.

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Prior Authorization Reform Prior authorization takes time away from direct patient care, adds cost to the delivery of care, and requires additional staff to process and follow requests. The ACC has urged payers and prior authorization contractors to modify their requirements and criteria to be more transparent, be based on ACC’s Appropriate Use Criteria (AUC), and be less burdensome on providers. ACC state chapters have lobbied local state legislators and Insurance Commissioners on behalf of patients to improve transparency, efficiency, and validity of the prior authorization process.

ACC’s Prior Authorization Reporting Tool (PARTool) http:// www.acc.org/PARTool was developed to collect data on inappropriate request denials for cardiovascular testing and procedures by insurers and prior authorization vendors, serving as a process to monitor and identify inconsistent denials by region, payer, prior authorization vendor and modality. Launched in 2017, the PARTool has already collected more than 500 reports of prior authorization experiences from 36 states. Catalogued by insurer and benefit manager, these data shed light on the too often clandestine process of peer-to-peer review. Early data demonstrate that two-thirds of denials are based on payer guidelines, with very few citing AUCs. Furthermore, 45% of encounters required more than 30 minutes and 74% required more than 10 minutes of time to complete the process, while 60% of encounters resulted in procedural delays due to the prior authorization process.

A coalition led by the AMA focused on Prior Authorization unites a broad range of healthcare industry stakeholders, including physicians, hospitals, medical groups, patients, and pharmacists. This coalition has developed a set of principles to allow easier access to certain drugs, tests and treatments recommended by their healthcare providers. The principles seek to ensure prior authorization requirements are clinically valid and evidence-based; maintain continuity of care; are transparent and fair; allow patients timely and efficient access to drugs and treatments; and clearly articulate alternatives and exemptions.

The need for standardization is an important element to ease the burdens on physicians and practices navigating distinct prior authorization processes that differ among payers.

The ACC further recommends “gold-carding” to reduce prior authorization burden. This concept encourages a “glide path” for payers or contracted benefit managers authorizing requests for tests and treatments from exemplary providers or practices that demonstrate compliance with established AUCs and clinical guideline recommendations. The ACC also promotes the concept of transparency and communication through a requirement that payers make publicly available to consumers their rates of allowed and denied procedures. Established, online standardized prior authorization tools and criteria for providers and their practice staff are also encouraged to ensure both improved transparency and efficiency in the prior authorization process.

Such examples of prior authorization reform support the “Quadruple Aim” by removing barriers to care, promoting evidencebased best practices, and improving patient satisfaction.

Recent National Legislation Affecting Cardiovascular Healthcare The Bipartisan Budget Act of 2018 was passed by Congress and signed by President Trump in February. The bill WWW.SFMMS.ORG

includes a provision expanding access to cardiac rehabilitation, allowing physician assistants, nurse practitioners and clinical nurse specialists to supervise cardiac, intensive cardiac and pulmonary rehabilitation programs. Though the provision will not be implemented until 2024 for budgetary reasons, this will provide CV patients with increased access to rehabilitation proven to reduce the risk of future cardiac events.

Additionally, the Budget Act includes four more years of funding for the CHIP. Congress has now approved a decade of stable funding for this vital program that provides extensive health benefits and coverage to nearly nine million children across the U.S. The bill also creates a temporary transitional payment, for critical services associated with Medicare Part B infusion drugs (beginning January 2019). This payment ensures that our most fragile patients do not experience a gap in care while CMS works to finalize a permanent services payment within the 21st Century Cures Act, scheduled for January 2021. The temporary and transitional payments will allow cardiac patients to continue home inotropic infusions as part of palliative, end-of-life care or as a bridge to cardiac transplantation. The budget bill contains several other important policies, including the repeal of the Independent Payment Advisory Board and a provision providing technical amendments to the Merit-Based Incentive Payment System within the Quality Payment Program, consistent with the Quadruple Aim.

Clinical Data to Foster Research, Innovation and Timeliness for CV Care

The ACC continues to strongly advocate the fostering of innovation and research through increased funding for the NIH, the FDA, and the CDC. Improvement in health information technology through improvement in EHR interoperability/usability along with promoting standards and certification are a necessary cornerstone along with insuring electronic data privacy and security. Proactive regulation of digital and mobile health tools will become increasingly important. Adequate funding and support is necessary for the implementation of the 21st Century Cures Act, the incorporation of Unique Device Identifiers (UDI) in patient records and databases, and in the development of a National Device Evaluation System (NEST). The FDA is actively promoting the use of Real World Evidence (RWE) for more timely and accurate drug and device assessments not only for post-market surveillance, but also for evaluations of safety and efficacy of current and new, innovative, if not “disruptive,” CV devices. The FDA, CMS, industry, payers, purchasers, hospitals, clinicians and patients are increasingly utilizing the National Cardiovascular Data Registry (NCDR) for evidence generation, clinical outcomes data reporting and public health surveillance.

The STS/ACC TVT Registry™, through its collection of RWE, has enabled the FDA to approve and broaden new indications for TAVR, such as “valve-in-valve,” alternative vascular access, and earlier approval of new device iterations. These accomplishments occurred years before formal randomized clinical trials could have been completed and at approximately one-fifth the cost, allowing device technology to become available to clinicians and patients much earlier in the CV product life cycle.

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What’s New in Cardiology

CARDIAC SURGICAL ADVANCES: Minimizing Risk and Invasivness for Maximum Return Glenn Egrie, MD

Cardiac surgery is a unique discipline in the medical world.

It is one of the newest fields of medicine, only becoming a specialty with training programs in the 1960s. Operating on the heart was limited to emergency trauma procedures that were usually fatal. Through the 1940s–1960s, the early heart surgeons performed a limited number of operations, such as closed commissurotomy, in which a valve narrowed by rheumatic heart disease was opened by the surgeon placing his finger through the beating heart! Not until the development of the heart-lung machine in the 1960s did the modern specialty of cardiac surgery become possible and give surgeons the tool to repair a wide range of pathologies including abnormal heart valves, blockages of the coronary arteries, congenital heart defects, and perform heart transplantation. One of the earliest heart-lung machines was developed here in our community, and was used by one of the pioneer surgeons in cardiac surgery, Frank Gerbode, at CPMC (formerly Presbyterian Hospital).1 Innovation has been a hallmark of cardiac surgery and has allowed surgeons and scientists to develop safe and reproducible mechanical solutions to numerous structural congenital and acquired heart diseases. The biggest systemic change in cardiac surgery has been the shift from isolated departments of surgeons to service lines, where teams of doctors across specialties (called heart teams) collaborate to treat cardiovascular disease. Surgeons, cardiologists (and their subspecialties), interventional cardiologists (proceduralists), vascular surgeons, electrophysiologists, and others work together to treat diseases with medicines, catheterbased procedures, and surgeries.

This team-based approach is clearly evident in the two most common types of cardiovascular diseases surgeons treat: coronary artery disease (CAD) and valvar heart disease. CAD is caused by atherosclerotic blockage of the vessels that supply oxygen to the heart muscle. It is a tremendous problem in the United States, killing over 370,000 people annually. Treatment of acute ischemia (heart attacks) and chronic angina involve both catheter-based procedures performed by the interventional cardiologist and surgeries. Through many large clinical trials, the best practices have been developed so heart teams can individually assess each patient and decide which procedures are

best for them. New ways to combine catheter-based procedures with less invasive surgeries are being studied. Within hybrid operating rooms, catheter-based interventions and surgery are used together to treat blocked coronary arteries. Stents placed via catheters are used to open some blockages while robotic assisted surgery is used to bypass others. This capitalizes on benefits of each approach to minimize risks and hasten recovery.

In the past five years, a significant paradigm shift in heart disease treatment has been the treatment of aortic stenosis, an acquired narrowing of the aortic valve. Aortic stenosis affects 1 in 8 people by the age of 75 in the United States, and aortic valve replacement is the second most common cardiac operation performed after bypass surgery. Formerly, this was only treatable with open-heart surgery, but with the introduction of transcatheter aortic valve replacement (TAVR), over 50% of all eligible patients can now be treated non-surgically. TAVR deploys a new prosthetic valve inside of the existing aortic valve with the heart still beating, and in most cases, while the patient remains awake. Most patients can go home the day after the procedure with easier physical recovery since there is no open incision. This revolutionary approach was initially trialed in elderly or very ill patients at high risk for complications from surgery.

The outcomes showed superior results to either medical therapy or surgery. Trials extending over two years comparing TAVR and surgery in patients at intermediate risk for complications have shown non-inferiority in mortality and complications between the procedures.2 These results have now led to these devices being used in lower risk and younger populations of patients.

Advances in device design have led to smaller and better equipment, reducing complications such as strokes and the need for pacemakers. The durability of these devices remains a question, especially in younger patients. In the future, the development of bioengineered valves with regenerative properties might improve durability allow for growth of the valve.

The use of transcatheter devices for other valves is also being investigated. The MitraClip is an FDA-approved device for treating mitral regurgitation in elderly and high-risk patients.

The Melody valve is being used to treat pulmonary valve problems in adults born with congenital heart disease. Patients with

Formerly, [aortic stenosis] was only treatable with open-heart

surgery, but with the introduction of transcatheter aortic

valve replacement (TAVR), over

50% of all eligible patients can

now be treated non-surgically.�

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Post-op photo of one of Dr. Egrie’s patients demonstrates size and location of incision for a minimal-access mitral valve repair.

severe tricuspid regurgitation are a challenging group, as this disorder can cause very serious complications and our ability to predict who is at greatest risk is not very accurate. The use of transcatheter devices to treat this problem is being studied and holds great promise. There are several transcatheter valves that are entering trials for mitral valve replacement. The use of transcatheter valves for the management of failing bioprosthetic (animal or tissue) valves has been studied and in the past year has been approved by the FDA to treat failing aortic and mitral valves in patients deemed high-risk for complications due to surgery. The short-term results of this approach are very favorable, and will continue to be tested in younger and lowerrisk patients. This strategy has led to a shift in how heart team doctors make recommendations for which valve type a patient should use. The use of bioprosthetic valves for younger patients has increased with the expectation that many of these patients will be able to receive a transcatheter valve when the surgical valve degrades. This has led to a reduction of the number of mechanical valves being used, which requires patients to take coumadin, an anticoagulant with a long-term risk of bleeding complications.

A large number of cardiac procedures can be performed via smaller incisions, rather than traditional full sternotomy (division of entire breastbone), or without the use of a cardiopulmonary bypass machine. These approaches can reduce blood usage, complications, postoperative pain, and recovery time.3 The majority of mitral valve procedures can now be performed via a small incision under the right breast, with or without WWW.SFMMS.ORG

robotic assistance. Aortic valve procedures are done through a small incision on the right anterior chest, without dividing the breastbone. Many coronary artery bypass procedures can be performed without the heart-lung machine, and primarily with the use of arteries for the bypass grafts, which often has better long-term results. Aortic aneurysms (enlarged vessels) now have transcatheter stent options for repair in addition to the traditional surgical approach. Often we will treat the aneurysms with both open surgery and stents at the same procedure to reduce complications and recovery time.

Minimization of incisions and surgical invasiveness has also extended to the treatment of heart arrythmias (irregular heart rhythm). Atrial fibrillation, the most common arrythmia, often requires an ablation procedure to eliminate when medication treatments are not sufficient. However, in certain patients with continuous atrial fibrillation, catheter-based ablation procedures tend to be unsuccessful. Surgical ablation is more effective in these situations; however, surgery is more invasive and has greater risks of complications. Hybrid procedures that combine transcatheter ablation and lesser invasive limited surgical ablation of the external portions of the heart are being conducted.

Early results show a higher percentage of patients with return to normal rhythm than catheter-based procedures, and lower morbidity than full surgical ablation.

Mechanical circulatory support of patients with failing hearts from cardiomyopathy has seen rapid growth. Implantable ventricular assist devices (VADs), for long-term support, have been developed as small, highly reliable machines that allow patients to restore themselves to fully functional, vibrant lifestyles. VAD therapy has nearly achieved the same short- and long-term survival rates as transplantation, which has been the gold standard therapy for the failing heart. Advances such as a transcutaneous power delivery system, making the machines completely internalized, are in development and will give patients even greater freedom to return to all of life’s activities.

Cardiac surgery has evolved very rapidly in its relatively short history, with the cardiac surgeon now integrated into a heart team of doctors. The goal of the heart team is to develop a multi-disciplinary approach for cardiovascular disease to improve the durability of procedures, reduce invasiveness of operations, minimize risks, and return patients to the best possible quality of life.

1. Historical perspectives of The American Association for Thoracic Surgery: Frank Gerbode (1907-1984); December 2013 Volume 146, Issue 6, Pages 1317–1320.

2. Surgical or transcatheter valve replacement for intermediate risk patients. N Engl J Med 2017; 376:1321-1331.

3. Minimally invasive mitral valve surgery. Interv Cardiol. 2018 Jan;13(1):14-19. doi: 10.15420/icr.2017:30:1.

Dr. Glenn Egrie is a thoracic and cardiac surgeon in San Francisco, California and is affiliated with multiple hospitals in the area, including California Pacific Medical Center

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MARIN MEDICAL SOCIETY

SFMMS ADVOCACY ACTIVITIES A History of Advocating for Community Health

As the only medical association to represent the entire spectrum of medical specialties, modes of practice, and interests of physicians in San Francisco and Marin, the San Francisco Marin Medical Society (SFMMS) has been a champion for community health issues since its formation in 1868.

ENSURING ACCESS TO CARE

With ongoing vigilant efforts to preserve programs and prevent cuts in Medi-Cal reimbursement, SFMMS leaders have long advocated that everyone should have access to quality medical care. SFMMS joined in the lawsuits to preserve the Healthy San Francisco program, an ultimately successful battle that went all the way to U.S. Supreme Court. SFMMS advocated for, and has provided assistance to, community-based organizations including the Haight-Ashbury Free Medical Clinics, San Francisco Free Clinic, Marin Community Clinics, Operation Access, and many others where members have donated medical care and treatment for the uninsured and underserved.

ANTI-TOBACCO ADVOCACY

SFMMS was a loud voice for cracking down on tobacco promotion and use and supported the early 1990s ban on smoking in San Francisco restaurants, a landmark policy that spread nationwide. SFMMS has also advocated for stronger protections from secondhand smoke, higher taxes on tobacco products to provide additional funding to Medi-Cal, and the removal of tobacco products from pharmacies. In 2017, SFMMS supported a ban on flavored tobacco products adopted in San Francisco that is now being fought hard by the tobacco industry.

HIV PREVENTION AND TREATMENT/ HEPATITIS B

Having been among the first to push for legalized syringe exchange programs, appropriate tracking and reporting processes for clinical data, optimal funding, and more, SFMMS has been at the center of advocacy for responses to the AIDS epidemic since the 1980s, including drafting several resolutions that would evolve into CMA and AMA policies as well as statewide ballot initiatives. SFMMS continues to be a partner in the Hep B Free program in San Francisco.

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SUGAR-SWEETENED BEVERAGES

SFMMS has long been on record combatting overconsumption and marketing of sugar and soda, especially to young people. To help prevent and battle obesity, diabetes, heart disease, and other associated diseases, SFMMS endorsed the SF vs. Big Soda coalition and supported the landmark local tax on sugar-sweetened beverages, approved by voters, with revenue slated to help fund programs to prevent or reduce the consequences of consumption of sugar-sweetened beverages.

ANTIBIOTIC RESISTANCE

SFMMS leaders have presented at national meetings and contributed to policy on antibiotic resistance, including the AMA’s first statement on antibiotic overuse and agriculture.

SCHOOL AND TEEN HEALTH

SFMMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and has worked on improving school nutritional standards.

VACCINATION ADVOCACY AND EDUCATION

In response to increased outbreaks of vaccine-preventable diseases in the Bay Area and across the state, the medical society emerged as a leader in supporting policy to increase school vaccination rates. Through education about the safety and efficacy of vaccines and support of legislation that eliminated personal belief exemptions from required childhood vaccines, vaccination rates have increased significantly since 2012. SFMMS has authored several resolutions for the CMA, including a resolution allowing minors to receive vaccines to prevent STIs without parental consent.

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END-OF-LIFE CARE

SFMMS leaders have developed numerous policies and educational efforts to improve care toward the end of life, including publishing guidelines on medical futility or non-beneficial treatments that have been widely adopted by regional health systems. SFMMS was one of the early adopters of Physician Orders for Life-Sustaining Treatment (POLST) in California and has been active in the local community coalition to ensure successful use of the form and the important conversation that goes along with completing the medical orders contained on the form. As medical and public opinion evolved, SFMMS became neutral on the option of physician-assisted dying and advocates for physicians and patients to exercise their own judgment as part of the patient-physician relationship.

REPRODUCTIVE HEALTH AND RIGHTS

SFMMS has been a champion of reproductive choice for women, including supporting the use of RU486 and the medical termination of pregnancy. SFMMS continues to be a state and national leader in advocating for women’s reproductive health and choice, including access to all medicalindicated services.

ENVIRONMENTAL HEALTH

Among SFMMS’s many environmental health efforts are 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.

GUN SAFETY/DOMESTIC VIOLENCE INTERVENTION

SFMMS has contributed to the national debate on gun safety, including ending censorship and allowing physicians to discuss gun safety with their patients. The medical society published guidelines on domestic violence screening and intervention for physicians and other clinicians that were widely distributed and well received by clinicians citywide; the society was cited in the Journal of the American Medical Association as one of the best such resources.

DRUG POLICY AND OPIOID SAFETY

SFMMS 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” policy that supports immediate entry into drug treatment for those requesting it, and treatment instead of incarceration. SFMMS was integral in the development of CMA’s landmark report on decriminalization and regulation of cannabis. In collaboration with the public health department, SFMMS has helped develop guidelines for safe opioid prescribing that have been adopted in primary care settings.

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Tobacco Regulation The FDA recently issued three Advance Notices of Proposed Rulemaking (ANPRMs) as part of its agency-wide initiative to address tobacco and nicotine regulations. The intention of the comprehensive initiative is to place addiction at the center of its approach, encouraging innovative developments to render delivery mechanisms less harmful to users and ensuring that the FDA has the proper scientific and regulatory foundation to efficiently and effectively implement the Family Smoking Prevention and Tobacco Control Act. These notices focused on: 1) the development of a standard for the maximum level of nicotine permitted in cigarettes, proposing to reduce the level of nicotine currently allowed in tobacco products to a minimally addictive or non-addictive level; 2) industry’s inclusion of flavors, including menthol, in efforts to address the use of tobacco products and smoking cessation, while seeking information on how flavors attract youth to tobacco use and exploring regulatory restrictions on the sale and distribution of flavored tobacco products; and 3) obtaining feedback and scientific data on the public health impacts and appropriate regulatory status of premium cigars. The ACC enthusiastically supports this initiative, but has concerns that the FDA has delayed deadlines for filing applications of e-cigarettes and cigars until 2021–2022. It is also concerning FDA has not set deadlines for the actual review process itself, therefore continuing the U.S. population exposure of these harmful tobacco/nicotine products.

As reflected by these multiple policy and regulatory issues present in our current healthcare environment, fulfilling the vision of a Quadruple Aim will require activism among professionals committed to improving the delivery of healthcare, while also recognizing the potential challenges in implementation and our own accountability. Healthcare professionals need to advocate for our patients whether it be promoting tobacco regulation or fostering innovation in cardiovascular research and clinical care delivery.

Dr. Brindis is a Clinical Professor of Medicine at the University of California, San Francisco and serves on the affiliate faculty of the Philip R. Lee Institute of Health Policy Studies at UCSF. He presently is the Senior Medical Officer, External Affairs, for the ACC National Cardiovascular Registry. Dr. Brindis was the President of the American College of Cardiology (ACC) from 2010 to 2011 and the Senior Advisor for Cardiovascular Disease for the Northern California Kaiser Permanente Medical Group from 2003 to 2012. He received his undergrad education at MIT and has a Master’s Degree in Public Health from UCLA. He graduated from Emory Medical School and his graduate medical training was performed at UCSF as a Resident and Chief Resident in Internal Medicine and then as a Cardiology Fellow.

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A CONFERENCE ON THE TREATMENT OF SUBSTANCE USE DISORDERS

STATE OF THE ART IN ADDICTION MEDICINE Highlights • The U.S. Surgeon General (invited) and Faye Zenoff of the Center for Open Recovery • Responding to the Opioid Epidemic: The Cutting Edge of Science and Treatment • Putting Addiction Medicine into Practice: Integration into Systems • Psychoactive Medicine or Malady?

• Beyond Nature & Nurture: Social Determinants of Addiction and Health

August 29September 1, 2018

• The Addiction Practitioner’s Survival Guide: Tools and Perspectives for Success

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Earn up to 25.5 AMA PRA Category 1 Credits™

Register now at csam-asam.org

Safe Injection Site in San Francisco would address drug use and John Maa, MD, and Steve Heilig, MPH discarded needles Reprinted from San Francisco Chronicle, July 22, 2018

Back in the 1980s, a deadly new virus exploded in San Francisco. The response to the HIV epidemic from all fronts in San Francisco has become legendary, and a model for the world. Innovative efforts proved essential, even if at the time they might have seemed outrageous or even illegal. Now we face another epidemic, that of opioid drug abuse.

This problem has long been with us, but it has now

exploded around the nation. There are more American deaths from overdoses in just one year than in the entire Vietnam War. At the San Francisco Addiction Summit last month at UCSF, speakers from the East Coast warned that this epidemic is a “hurricane” heading our way. It’s truly an emergency on many levels — public health, humane treatment, economic and more.

San Franciscans and visitors to our city already see the fallout on our streets — human bodies, alive or barely, syringes and needles strewn about, feces and urine. Tourists, businesses and residents complain in various ways. As with the homelessness problem — with which the drug problem overlaps — solutions appear elusive.

One proposal is for safe injection sites — facilities where drug users can go to inject without fear of arrest, violence, robbery or other problems of living on the street. Sites where used needles are disposed of properly rather than discarded publicly, thereby also keeping the streets cleaner. Drug users can assess medical care and treatment more easily as well. Mayor London Breed unveiled a demonstration of such a site in the Tenderloin on Sunday. Similar facilities are already open elsewhere in the world, such as Canada and Europe, but San Francisco would be the first American city to do so.

The obstacles are legion, but the two most prominent are very reminiscent of the debate over needle exchange three decades ago. As soon as it became clear that HIV was being transmitted via shared needles, activists looked to other nations where exchange programs were already in place. They decided to begin operations here — illegally, as it was against the law to hand out injection equipment.

Some were outraged that this was being done, but experience and research soon began to show that: 1) Needle exchange programs worked to interrupt disease transmission, as intended, and 2) Such programs garnered contact and trust among addicts, many of whom finally decided to seek drug treatment. This latter point helped to convince addiction experts, who were initially opposed to needle exchange programs as “enabling” drug use, to support the programs.

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A police officer checks on the well-being of a man lying on the pavement at United Nations Plaza. San Francisco may become the first in the U.S. to open a safe injection site. PHOTO: PAUL CHINN / THE CHRONICLE

Local public health officials declared an “emergency” to allow operation without prosecution. Eventually the San Francisco Medical Society, California Medical Association and the American Medical Association all supported these programs, as did the National Academy of Sciences. It is now long established that they work, legal or not, even though some politicians and citizens have never quite come to support them.

Reducing addiction, crime, taxpayer costs and public nuisance are positive goals. Locating the sites within existing clinics strongly reduces “NIMBY” concerns as well.

Now, again, we face an emergency that warrants an emergency response. Having evaluated the evidence and the need, the board of directors of the San Francisco Marin Medical Society voted unanimously in 2017 to support piloting safe injection sites here, and were soon joined by the AMA. San Francisco has long taken many innovative approaches to health issues, and it is time to do so once again. We commend Mayor Breed and our public health leaders for seeking to implement this important effort.

John Maa is a surgeon and president of the San Francisco Marin Medical Society.

Steve Heilig, a member of the society staff, co-chaired the San Francisco Addiction Summit and was an early needle exchange volunteer.

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Are you ready to check CURES? Starting October 2, all physicians must consult database before prescribing controlled substances

Katherine Boroski

Effective October 2, 2018, physicians must consult California’s prescription drug monitoring database (the Controlled Substance Utilization Review and Evaluation System, or CURES) —— prior to prescribing Schedule II, III or IV controlled substances. 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 must be registered to use CURES. Because of the critical importance of adequate technical

support for physicians who will have to rely on CURES as a part of their prescribing workflow, the California Medical Association (CMA) negotiated into the final legislation a requirement that the mandate could not take effect until the California Department of Justice (DOJ) certified that the database was ready for statewide use and that the department had adequate staff to handle the related technical and administrative workload.

On April 2, 2018—two years after the law was enacted—DOJ finally certified that CURES was ready for statewide use. The certification began a six-month transition period, with the dutyto-consult taking full effect on October 2, 2018.

What Physicians Need to Know

Under the new mandate, physicians must consult the database prior to prescribing controlled substances to a patient for the first time, and at least once every four months thereafter if that substance remains part of the patient’s treatment. Physicians must consult CURES no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient.

The law provides, however, that the requirement to consult CURES would not apply if doing so would result in the patient’s inability to obtain a prescription in a timely manner and adversely impact the patient’s conditions, so long as the quantity of the controlled substance does not exceed a five-day supply.

Physicians are also not held to this duty to consult when prescribing controlled substances to patients who are: • Admitted to a facility for use while on the premises; • In the emergency department of a general acute care hospital, so long as the quantity of the controlled substance does not exceed a seven-day supply; • As part of a surgical procedure in a clinic, outpatient setting, health facility or dental office, so long as the quantity of the controlled substance does not exceed a five-day supply; or • Receiving hospice care.

In addition, there are exceptions to the duty to consult when access to CURES is not reasonably possible, CURES is not operational or the database cannot be accessed because of technological limitations that are beyond the control of the physician.

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CMA Fights for CURES Protections CMA worked closely with the bill’s author and other stakeholders to reach mutually agreeable language, which was reflected in the final version of the bill (SB 481, Lara). Among the negotiated amendments are liability protections related to the duty to consult the database and changes to ensure that health-care providers can meet the requirements under state and federal law to provide patients with their own medical information without penalty. The bill also clarifies that healthcare providers sharing the information within the parameters of HIPAA and the Confidential Medical Information Act, including adding the CURES report to the patient’s medical record, are not out of compliance with the CURES statute.

Save the Date: CURES Webinar with DOJ on 8/22

CMA will be cohosting a live CURES webinar with DOJ on August 22, 2018. The webinar will be free to all interested parties. Registration will open soon at cmanet.org/events.

For More Information

For more information, see CMA On-Call document #3212, “California’s Prescription Drug Monitoring Program: The Controlled Substance Utilization Review and Evaluation System (CURES).” On-Call documents are free to members in CMA’s online resource library at www.cmanet.org/cma-oncall. Nonmembers can purchase documents for $2 per page.

Additional Resources:

• CURES website: oag.ca.gov/cures • CURES FAQ: oag.ca.gov/cures/faqs • Medical Board CURES webpage: mbc.ca.gov/cures • CMA CURES webpage: cmanet.org/cures • CMA Safe Prescribing webpage: cmanet.org/safe-prescribing

CMA will continue to provide educational resources and work with DOJ to ensure a smooth implementation of the new requirement. Physicians who experience problems with the CURES database should contact the DOJ CURES Help Desk at (916) 227-3843 or cures@doj.ca.gov.

Katherine Boroski is Senior Director of Communications for the California Medical Association.

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CMA publishes safe prescribing resources for physicians

New report shows California’s progress addressing opioid crisis

The California Medical Association (CMA) has published a members-only resource page to provide physicians with the most current information and resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction and overdose.

The page includes two CMA white papers on opioid prescribing, links to CMA’s health law library resources on the topic, the Medical Board of California’s “Guidelines on Prescribing Controlled Substances for Pain,” a listing of continuing medical education courses and webinars on pain management and safe prescribing, as well as the latest information on the state’s prescription drug monitoring database.

Members can find the page at cmanet.org/ safe-prescribing.

The American Medical Association (AMA) recently issued a new report documenting how California’s physician leadership is advancing the fight against the opioid crisis. The report found a statewide decrease in opioid prescribing, as well as an increase in the use of California’s Controlled Substance Utilization Review and Evaluation System (CURES) database, number of physicians trained and certified to provide patients with buprenorphine for the treatment of opioid use disorder, and naloxone access. California also saw two consecutive years of decreases in prescriptionrelated opioid deaths and surpassed the national average for prescription decreases between 2014 and 2017.

“This report demonstrates that California physicians have made significant strides against the opioid crisis by expanding access to effective treatments for substance use disorders,” said California Medical Association (CMA) President Theodore M. Mazer, M.D. “CMA will continue to lead the nation in implementing effective solutions to reduce opioid abuse and ensure that patients have timely access to medically necessary treatment.”

For more details on the report visit end-opioid-epidemic.org.

CMA saves medical groups millions in workers’ comp premiums As of July 1, 2018, physician owners of professional corporations will be able to exempt themselves from workers’ compensation coverage—regardless of percentage of ownership—resulting in significant premium savings.

In 2016, the legislature changed the definition of “employee,” requiring owners with less than a 15 percent ownership to have workers’ compensation coverage. Because of this law, some medical groups were forced to pay drastically increased workers’ compensation insurance premiums for coverage they neither needed nor wanted.

To assist affected medical groups and corporations, the California Medical Association (CMA) sponsored a law (SB 189) to once again allow appropriate coverage exemptions for owners. This will result in premium savings for individual medical groups ranging from hundreds to hundreds of thousands of dollars.

All owners of medical corporations must act now to take advantage of this significant savings opportunity.

Learn more about SB 189 and how it affects your medical group at cmanet.org/sb189.

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Health Policy Report

The Unfinished Work of Achieving Universal Coverage After the Affordable Care Act (ACA) passed, California boldly embraced the opportunity to dramatically increase the number of Californians who have health coverage.

The progress made in our state has been enormous. As a result of the ACA, more than five million people have gained health insurance, and we have cut in half the share of California’s population that remains uninsured. Even with that progress, three million Californians lack health coverage. For the time being, they will not be seeing any relief. Despite strong political momentum, a thriving economy, and a significant budget surplus, the governor and the California legislature finalized a budget for the next fiscal year that provides no direct help to Californians who are ineligible for coverage.

Given what it means for a person to live without health insurance, it is regrettable that state policymakers missed this opportunity to expand coverage. I believe that our goal of universal coverage has enduring importance, and that California is positioned to make additional gains in the foreseeable future.

The Human Cost of Being Uninsured

The negative effects of living without health insurance are well known: stress, undiagnosed disease, delayed care, medical debt, lost days at work and school, and early and avoidable deaths. In California, those who are most likely to be uninsured are undocumented, low-income, and Latino. Even though 68% of low-income undocumented adults are employed, they earn low wages in jobs without health insurance benefits. We also know that affordability is the top reason that people who are eligible for health plans through Covered California lack insurance. (Of note, I am a member of Covered California’s board of directors.) In a state struggling with widespread economic inequality, we must stay focused on the lack of access to health care as one of the biggest inequities.

The demographics of the uninsured hew closely to the lines of race and income.

The governor and the legislature could have crafted a budget funding the expansion of Medi-Cal eligibility to include undocumented low-income young adults and seniors. They also could have increased subsidies that would make Covered California health plans more affordable. The final budget does neither.

All state budgets are a product of compromise and tradeoffs.

They are never perfect. Still, this year’s budget will have very human consequences — at least in the short term. In California, too many of our brothers and sisters will experience avoidable illnesses and die at a younger age because they cannot afford health insurance. That is what makes universal coverage such an urgent goal.

The Path Ahead

While there has been vigorous debate about how California can establish universal coverage, the common ground on both sides of the debate reveals widespread support in our state for reaching that goal. Favorable voter sentiment drove unprecedented activity in universal coverage throughout this legislative session. Health coverage has also been one of the top issues for candidates and 34

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Sandra R. Hernández, MD, MPH

voters in this election campaign season. Together, we must carry that momentum forward into the next phase of state policymaking — and there are opportunities.

Despite the disappointments in the final budget, the spending plan does map out new potential pathways to universal coverage.

The budget includes $5 million for a new, independent council to study how the state can get to universal coverage, building on the work legislators did this year to develop policy solutions. That includes the Assembly’s recent Select Committee on Health Care Delivery Systems and Universal Coverage, which recommended important short- and long-term steps to achieving universal coverage. The budget also directs Covered California next year to present to the legislature options for improving affordability in the individual market.

Both measures will help to ensure continued dialogue around coverage expansion. For the millions among us who remain uninsured — people we encounter as we move through our daily lives — we must be prepared to take full advantage of this opportunity.

It is worth noting that the budget uses part of this year’s surplus to boost programs that directly help low-income Californians. The budget includes emergency aid to help local governments address homelessness, increased funding for cash assistance to help lift lowincome Californians out of poverty, and funding to expand eligibility for the state’s earned income tax credit. The budget also includes money to strengthen California’s healthcare workforce, which is necessary to expand access and make healthcare more affordable.

The Finish Line Is Near

Thanks to the ACA, California is closer than ever to making sure all our residents are covered. It took advocates, policymakers, and communities decades of persistence to get our state this far. It’s heartening that the finish line is within sight, but close is not good enough for the three million Californians who remain without coverage and access to care. For them, we must remain resolute in our determination to cross the finish line and cover everyone.

Dr. Sandra R. Hernández is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also co-chaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco, an innovative health access program for the uninsured. Sandra is an assistant clinical professor at the University of California, San Francisco, School of Medicine. She practiced at San Francisco General Hospital in the AIDS clinic from 1984 to 2016. She was appointed by Governor Jerry Brown to the Covered California board of directors in February 2018. Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government, and is a longtime SFMMS member.

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Children Detainees Must be Reunited with their Families

CLASSIFIEDS North East Medical Services North East Medical Services is one of the largest community health centers in the United States targeting the medically underserved Asian population in San Francisco. They are searching for an Associate Medical Director with at least 2 years clinical and leadership experience. Candidate must be Board Certified/ Board Eligible Family Medicine or Internal Medicine.

Cantonese and/or Mandarin language skills preferred.

This position is approximately 50% clinic, 50% administrative. For more information please contact Galen Roberts: groberts@jordansc.com (636) 542-8310.

and Given Access to Proper Healthcare Theodore M. Mazer, MD The federal government’s recently enacted “zerotolerance” policy of enforcement of immigration has

sparked widespread outrage and condemnation from healthcare providers, for medical reasons. Like the American Medical Association and many others, the California Medical Association (CMA) opposes the administration’s detention and separation of an estimated 2,300 immigrant children from their families and expresses concerns about the irreparable and lasting physical and mental health consequences of this policy.

Recent reports detail the effects of what family separation can do to these children, including irreparable harm to lifelong development by disrupting a child’s brain architecture, toxic stress, depression, post-traumatic stress disorder and heart disease. The American Academy of Pediatrics recently stated that forced separation of children from families is child abuse. A June 2018 report on the Department of Homeland Security’s detention practices in the facilities that house these children in Texas depict children facing sexual assault, harassment, lack of legal representation and inadequate medical and mental healthcare.

This reported lack of transparency at detention facilities, and allegations of improper medical treatment, including forcibly giving children a range of psychotropic drugs, is unacceptable.

And while President Donald Trump issued an Executive Order to end the forced separation of immigrant families, the order created no process for the reunification of families, leaving many of them stuck in limbo while courts and bureaucrats attempt to track down their parents and guardians. U.S. District Judge Dana Sabraw in San Diego recently ordered the Trump Administration to reunite families because “the executive order included ‘subjective’ standards for separating minors from their parents and the government has only stated it will reunite children with their families for removal from the country.”

This kind of indefinite detention of children — even when accompanied by their families — is not a viable or healthy solution.

As physicians, we have an obligation to ensure that everyone in California has access to medical care provided by qualified healthcare providers. We also have a solemn obligation to identify threats to the health and welfare of the public — especially children.

The health of these children should not be a partisan issue.

Children’s lives are at stake. We urge our member physicians, other healthcare practitioners and the public to continue advocating for a quick and sensible resolution to this unnecessary public health crisis.

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Dr. Mazer is President of the California Medical Association.

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THE STRENGTH TO HEAL

and the opportunity to practice on the leading edge.

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You may also earn many financial benefits, including a $220,000 signing bonus and student loan repayment.

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SAN FRANCISCO MARIN MEDICINE JULY/AUGUST 2018

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welcome new members!

Jeffrey Jonathan Devido, MD | Neurology John Wadsworth Fisk, Jr., MD | Family Medicine Tony Abraham Joseph, MD | Emergency Medicine Brian Joo-Taek Lee, MD | Pediatric Anesthesiology Joseph Andrew Mollick, MD | Medical Oncology Sahar Naderi, MD | Internal Medicine Sanup D. Pathak, MD | Anesthesiology Mitesh G. Popat, MD | Family Medicine Kirsten Elise Salmeen, MD | Obstetrics and Gynecology Jeffrey James Sasser-Brandt, MD | Family Medicine Kristen Cadden Swann, MD | Emergency Medicine Jessica Anne Tashjian, MD | Anesthesiology Shan Wen, MD | Internal Medicine Pediatrics Lisa Wu, MD | Emergency Medicine Nejat Zeyneloglu, MD | Internal Medicine Maria Petrick, MD | Allergy and Immunology Juline Caraballo-Fonseca, MD | Allergy and Immunology Louis Yang, MD | Ophthamology

STUDENTS Christopher Cai, ANP Anna Elise Feiss Amy Ransohoff

1868 2018

Anniversary

Advertiser Index CMA AB 3087 Thank-You. . . . . . Back cover CMA CURES Duty-to-Consult .

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COMMUNITY NEWS KAISER PERMANENTE

Maria Ansari, MD At Kaiser Permanente San Francisco, we focus primarily on prevention and overall cardio-

vascular risk reduction. However, our cardiac program provides exceptional care for those who develop heart disease.

Our clinicians work collaboratively to identity risk factors and enroll members in the Preventing Heart Attacks and Strokes Every day (or PHASE) program.

PHASE helps us to prevent and treat patients with chronic heart conditions through a combination of medication and lifestyle changes. We also provide Health Education classes that help make the necessary lifestyle changes possible.

This focus on prevention is one of the reasons Kaiser Permanente Northern California has seen heart disease rates among members decline faster than in the rest of the United States. According to an article published this year in American Journal of Medicine, heart disease death rates among adults aged 45 to 65 fell by 48.3% in 3.2 million Kaiser Permanente members from 2000 to 2015, compared to a 23.6% decline nationwide.

And while our comprehensive and integrated approach to care prevents a significant portion of cardiovascular disease, when someone does develop heart disease, we have state-of-the-art care in San Francisco to diagnose and treat complex situations.

Our interventional cardiologists provide care to patients referred from all over Northern California and their high-volume practice consistently achieves excellence. For example, our PCI-related mortality is nationleading, and our complication rates are well below national benchmarks, particularly with regards to bleeding and need for transfusions, contrast nephropathy, and stroke. We also offer advanced therapies for structural heart disease and are a lead enroller in national trials for TAVR and Mitral-clip to treat aortic stenosis and mitral regurgitation through minimally invasive approaches.

Vital Talk Courses. . . . . . . . . . . . . . . . . 17 WWW.SFMMS.ORG

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Presorted Standard U.S. Postage

San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

PAID

San Dimas, CA Permit No. 410

Thank You You Thank Physician Physician Members!

Members!

We Defeated AB 3087 We Defeated AB 3087 In May 2018, the California Medical InAssociation May 2018, the California Medical (CMA) announced the Association announced theBill 3087 resounding(CMA) defeat of Assembly resounding defeat of Assembly 3087 (Kalra) – dangerous legislationBill that would (Kalra) – dangerous legislationof that would have created a commission unelected have created a commission of unelected political appointees empowered to political appointees to care arbitrarily cap ratesempowered for all health arbitrarily forhospitals all healthand care services cap in allrates clinics, services in all clinics, hospitals and physician practices in California. physician practices in California.

Thousands of physician members Thousands physician members contactedof their legislators because contacted their legislators because AB 3087 would have: AB 3087 would have: ∙ Decimated California’s health care ∙ Decimated California’s health care delivery system. delivery system. ∙ Disrupted care and limited choice for ∙ Disrupted care and limited choice for millions of California patients. millions of California patients. ∙ Caused 175,000 health care workers to ∙ Caused 175,000 health care workers to lose their jobs. lose their jobs. ∙ Forced hospitals to close and pushed ∙ Forced hospitals to close and pushed health care providers into early retirement. health care providers into early retirement. ∙ Caused a “brain drain” of talented ∙ Caused a “brain drain” of talented medical students and residents fleeing medical students and residents fleeing California for more ideal working conditions.

California for more ideal working conditions.

wanttotothank thank each you your "I"Iwant each ofof you forfor your support and dedication to CMA. support and dedication to CMA. WeWe couldnot nothave have dealt this bill such could dealt this bill such a a resoundingdefeat defeat without the united resounding without the united voices of our physician members. voices of our physician members.

Together,we westand stand taller and stronger."

Together, taller and stronger."

CMA President –– CMA President Theodore Mazer, M.D. Theodore M.M. Mazer, M.D.

Jointhe theFight Fightto toProtect ProtectMedicine Medicine Join

Yourvoice voiceisiskey keytotoour oursuccess. success.All Allyou youneed need the desire make Your isis the desire toto make animpact, impact,and andCMA CMAwill willgive giveyou youthe therest. rest.Join Join CMA's Physician an CMA's Physician AdvocateProgram Programtoday! today!Learn Learnmore moreatat cmadocs.org.

Advocate cmadocs.org.