February 2014 by SMCMA

S A N M AT E O C O U N T Y February 2014

S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 3 Issue 2

Physician

I NS I D E

COSMETIC SURGERY FOR THE MALE PATIENT IN 2014 COSMETIC SURGERY FOR THE MALE PATIENT IN 2014 P. 7

IS THERE A MISPERCEPTION OF THE RISKS OF TONSILLEC TOMY? P. 11

WHAT IS YOUR LEGACY GOING TO BE? P. 13

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SMALL GROUPS (2–50) Does ACA require me to offer health insurance or pay a penalty? Is your plan grandfathered? Does it satisfy ACA metal tier standards? If not grandfathered, does the new plan include the level of beneﬁts you want? No RAFs, new age bands, 19 rating territories, new family component rating D;M <EH (&'* Determine if eligible for employer tax credit through Covered California SHOP exchange Keep or consider employer provided coverage for employee morale, retention and recruitment strategy If no employee coverage, assist employees with meeting the individual mandate by directing them to Covered California Individual Exchange marketplace Comply with Employer notice requirements of October 1, 2013 for all new hires

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S A N M AT E O C O U N T Y

Physician Editorial Committee Russ Granich, MD, Chair Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

SMCMA Leadership

February 2014 / Volume 3, Issue 2 Columns Reconciling Evidence-Based Algorithms with Clinical Judgment ................ 4 Niki Saxena, MD

Amita Saxena,, MD, President; Vincent Mason, MD, President-Elect; Michael Norris, MD; SecretaryTreasurer; Gregory C. Lukaszewicz, MD, Immediate Past President Alexander Ding, MD; Manjul Dixit, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Susan Nguyen, MD; Michael Oâ&#x20AC;&#x2122;Holleran, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Feature Articles Cosmetic Surgery for the Male Patient in 2014 ............................................. 7 Sharon Clark, MD. FACS

Editorial/Advertising Inquiries

Is There a Misperception of the Risks of Tonsillectomy? ............................. 11

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Steve Kmucha, MD, JD, FACS

What Is Your Legacy Going to Be? ................................................................ 13 Ron Holt, DO

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

Of Interest New SMCMA Members .................................................................................. 17

ÂŠ 2014 San Mateo County Medical Association

Membership Updates, Index of Advertisers ................................................ 18

President’s Message by Niki Saxena, MD

Reconciling Evidence-Based Algorithms and Clinical Judgment

hen I was in medical school, clinical judgment was thought to be a valuable tool. Used alongside appropriate diagnostic testing, it allowed one to arrive at “the true diagnosis,” which would in turn lead to “the right treatment.” It was not always a precise system, and depending

on your skill or confidence level you might take a longer route to arrive at the diagnosis. There were also plenty of opportunities to make mistakes since one patient’s rales might be another patient’s rhonchi. Still, you took the clinical picture into account when diagnosing and treating a patient. In this era of value-based medicine, I’ve noticed a growing trend that places far more value on diagnostic test results and evidence-based algorithms than a practitioner’s judgment. That can be a good thing sometimes, but I wonder if it is the right approach to use all the time.

Last month one of my colleagues saw a three-year-old patient of mine and was pretty sure that he had pneumonia. We both agreed he needed a higher level of care, so we sent him off to a local emergency room. I fully expected him to be on his way to recovery at his follow-up visit the next day, but when I walked into the room, he looked awful! Mom had taken him to the ER and he had received a complete workup: his labs were all normal, his chest x-ray was clear, and his oxygen level was great. He was given IV fluids but no antibiotics—his mom was told that because all of his tests were normal they did not feel he did not have a bacterial pneumonia and therefore did not need antibiotics. My first thought was, “Okay, I guess we were wrong , but I’m glad we sent him for a more thorough work up. We need to reassess our diagnosis.” But when I examined him, I could hear rales during his

“ “

4 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

lung exam loudly and clearly. The kind of rales that in my medical school days would be labelled as a classic finding of probable bacterial pneumonia. And here is where I had a mini crisis of faith. How could I be sure that he really had a bacterial pneumonia? All the science was against me: normal labs, normal chest x-ray, and normal oxygenation….but clinically he looked awful. What should I do? What evidence should I believe? I decided to treat him with an IM antibiotic and kept him in the office for a couple of hours as we worked on rehydrating him orally. I sent him home reluctantly, and I am not ashamed to admit I did not sleep well that night….what if I had guessed wrong? What if I just gave my patient an unnecessary treatment that was not supported by the facts? How could I justify my actions? And yet…I had heard what I had heard and those were rales. The next day a different

Do right. Do your best. Treat others as you want to be treated. — Lou Holtz Too often reason deceives us ... but conscience never deceives. — Jean-Jacques Rousseau

child bounced into my office. His fever had broken, he was asking for food again and his mom and I both hugged each other in relief. It would be all too easy to play Monday morning quarterback and criticize how someone else took care of my patient. That is not what I want to do; I know the doctors in the emergency room took his case seriously, I know they did a thorough workup, and I know they provided the most current standard of care. What really struck me was how difficult it can be to reconcile your clinical judgment with evidence-based medicine, especially when the two don’t agree. I doubted what I heard, and in turn was not sure about what to do, because the test results were not consistent with the diagnosis made by using clinical skills alone. We all recognize that resources are finite, and mistakes are not an

option. We want to be democratic in our healthcare system and give every patient the same level of care. Evidence-based algorithms allow us to navigate symptoms by laying out a more objective path to follow. We can collect unambiguous data, we can standardize the diagnostic approach, and we can anticipate more predictable patient outcomes with fewer clinical errors. But what happens when we do everything right but a patient still falls through the cracks? Have we allowed our clinical judgment muscle to atrophy to the point where we no longer recognize when we need it to help us think outside the algorithm box? Is there a way to fold in the less quantifiable clinical judgment into existing algorithms? But how do we define clinical success? By following an evidence-based algorithm at the

expense of alleviating a patient’s suffering? Is there even room for clinical judgment if a physician’s compensation is directly connected to how well he or she utilizes resources and follows evidence-based algorithms? How can we create an environment that supports the use of clinical skills as a legitimate component of healthcare? I know there are no easy answers, but shouldn’t these questions be part of our current healthcare reform conversations? Maybe the real question is how do we foster competence and confidence in our clinical diagnostic skills and clinical judgment? Studies are starting to show that utilizing those skills can help us choose tests wisely, and to know when to follow an algorithm and when to take a detour. And that can mean all the difference to our patients. ■

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 5

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Please display this fact sheet in your office to help educate your patients about the imporance of upholding MICRA. Need more copies? Contact us at (650) 312-1663 or smcma@smcma.org.

by Sharon Ann Clark, MD, FACS

In 1875, painter Gustave Caillebotte startled the Parisian art world with his painting Les Raboteurs de Parquet (“The Floor Planers”). Léon Bonnat, an artist trained in the classical tradition of the Greco-Roman concept of the godlike features of man and known for his powerful religious paintings, had taught Caillebotte. The expectations of others were for figures more similar to Michelangelo’s David. Surprisingly, Caillebotte painted three shirtless male workers on hands and knees, planning the varnish off a wooden floor in a bourgeois apartment. Critics found Caillebotte’s realistic portrayal of the working class disrespectful of man. Writer Louis Énault said, “I only regret that the artist did not choose his types better... The arms of the planers are too thin, and their chests too narrow... may your nude be handsome or don’t get involved with it!”1

Caillebotte’s painting survived the initial criticisms and now hangs in Paris’s Musée D’Orsay, a national treasure. Just as attitudes about art have changed over the past 100+ years, so have society’s perceptions about masculinity and the ideal. Ten years ago Sharon Waxman’s article in The New York Times drew attention to this major shift: “Once upon a time…the American leading man had a square jaw, a glinty gaze and an imposing physique. The new generation of Hollywood’s young leading men are soft of cheek, with limpid stares and wiry frames.”2 Appreciation of a youthful, handsome appearance is nothing new, but the growing perception of such a look as a requirement for success has lead to a significant increase in the demand for cosmetic surgery procedures among men. According to InvestorsInsight.com, (01/29/2014), only 71.8 percent of working men have a job or are looking for work. That is a huge decline from 80 percent in 1970. At the same time, female labor increased from 43 percent in 1970, to 58 percent in 2000, then fell to 54.9 percent at the end of 2013. Male workers were the hardest hit by the Great Recession that began in late 2007, when nearly seven million people were unemployed for longer than six months. Approximately 68 percent of the men who lost jobs have found new employment, compared to 91 percent of the women. A study from the Washington, D.C.-based public policy institute Third Way Think Tank found that “…men are falling behind women in acquiring the necessary job skills to keep pace in the global economy. Over the last three decades the labor market trajectory of males in the U.S. has turned downward along four dimensions: skill acquisition; employment rates; occupational stature; and real wage levels.”3

Pictured above: Les raboteurs de parquet (“ The Floor Planers) by Gustave Caillebotte, oil on canvas, 1875.

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 7

he top five cosmetic procedures for men, from 1997 to 2011, were: 1. 2. 3. 4. 5.

Rhinoplasty Eyelid Surgery Liposuction Breast Reduction Facelift

For the man of today in search of a job, appearance matters more than ever before. Statistics from the American Society for Aesthetic Plastic Surgery show that the entire percentage of procedures, regardless of gender, increased 197 percent between 1997 and 2011. During that same time period, the number of cosmetic procedures for men increased by 127 percent. The top five surgical procedures for men were liposuction, treatment of enlarged male breasts, eyelid surgery, facelift, and rhinoplasty. The period between 1997 and 2012 showed an additional 106 percent increase in the number of procedures for men. Of interest, otoplasty, i.e., sculpting of the ear, was added to the top five procedures. The attention to the ears may reflect an increase in the shaving of the hair, which has the advantage of hiding male pattern baldness.4

the neck. For contouring of the face, men seek rhinoplasty and chin implant or advancement to achieve a manly balance. With today’s casual work attire, rather than business suits, men seem to seek more liposuction of flanks with love handles as well as treatment for gynecomastia (large breasts). The postoperative recovery after body-contouring procedures is easier for men to camouflage than after facial surgery and makes

Blepharoplasties, i.e., eyelid surgeries, are the most common facial surgical rejuvenation procedures for men, with the greatest improvement for the least recovery time. The procedure can help the trial lawyer appear sharp in the courtroom. It rejuvenates the fireman or pilot, looking fatigued after years of squinting in the sun: he appears alert and able to handle emergencies. Men often desire a lift of the neck rather than the full facelift, which includes

them immediately happy with the decision for surgeryto give the man improved self-esteem. One of my most memorable adolescent male patients beamed after his liposuction for nondietary fat of gynecomastia: thanks to the insight of his pediatrician, this depressed young man could play on the “skins” against the “shirts” of the intramural basketball teams and thrive both academically and socially in a

competitive public high school environment with nearly invisible peri-areaolar scars. The availability of technology and the popularity of social media has heightened the emphasis on physical appearance. The saturation of every one with images from cell phones makes it more difficult to define and to value the core traits of an individual. It is especially interesting that even websites focused on professional networking and job searching, such as LinkedIn, feature photos of its members. While much has been written on the obsession about body image amongst females, it is only more recently that scholars are looking at this same phenomenon in males. In their 2000 book, The Adonis Complex: The Secret Crisis of Male Body Obsession, by Harrison G. Pope, Jr., M.D. et al, the authors describe some of the lengths men will go to in the pursuit of physical

For today’s man who applies for a job, appearance matters more now than ever before.

8 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

perfection, including eating disorders, obsessive workouts, steroid use, and more.5 As we look around San Mateo County, there is no shortage of gyms and health clubs. This coincides with an increase in body dysmorphic illnesses: a society where males, as well as females, no longer know when their bodies have a balanced appearance of health. Eating disorders are much more prevalent

now in men. I was saddened recently when a young man presented for liposuction after his significant weight loss: he was quite orange from having subsisted on a diet of carrots for many months, misinterpreted his lax skin as apparent fat, and did not know how to look at himself any more without confusion. The good news is that scholars are now studying masculinity in all its complexities. R. W. Connell argued, in his 1995 book, Masculinities, that there is no such thing as a single concept of masculinity.6 Some universities now include an academic field of Men and Masculinities.7 Other universities worry that this will cause conflict with the feminist studies. As Peg Tyre observes, in the 2004 Task Force in Gender Equity in Education, the state of Maine studied the problems boys face in school: “Gender equity ensures that boys and girls are given the necessary supports to achieve the same standards of excellence. Equity acknowledges that boys and girls may need different supports to achieve these outcomes.”8 Time will see how the disciplines in different academic institutions study these sociological, psychological, and economic issues. Stanford University recently changed its program in Feminist Studies to be more inclusive: The Program in Feminist, Gender, and Sexuality Studies emerged to offer an inter-disciplinary Ph.D. minor.9 Changes can be seen in issues affecting cultural perceptions of men, and physicians from pediatrics to geriatrics, from surgery to psychiatry, need to try to help each patient succeed in his navigating the changing challenges of sense of self-worth. Perhaps the easiest way to illustrate this change is to look at Agent 007, James Bond. The New York Times published an article in 2012, “More Men Are Taking a Size 007,” by David

Colman. In it, the author talks about Sean Connery’s Dr. No, in which Ursula Andress increased the sale of bikinis fifty years ago. He then wrote: “And since men are the new women, it only makes sense that for Casino Royale, the 2006 reboot of the 007 series, a different blond came in out of the Caribbean. That is, Daniel Craig as Bond himself, who in a pair of short, tight Grigio Perla swim trunks caused a splash in the otherwise placid pool of men’s swimwear, effects of which are still reverberating.”8 There is no question that the character of Bond has also changed over the years, to a more conflicted and existential individual. Daniel Craig’s Bond

he himself values when it comes to his appearance and presentation. The modern man will be happy with surgery if the need is his own goal and not the attempt to fit a temporary image in the media. There is no question that people feel a greater pressure to appear younger and more attractive in the face and body since most people perceive escalating competition with the younger population in the work force. One need look no further than Fortune’s “40 Under Forty.” The message from Homer’s The Odyssey showed us that it was the climb up the mountains of life that mattered and made the

We physicians need to be sure that we listen carefully to the individual goals of the male patients and realize that these are every bit as complicated, varied, and unique as those of the female patients. The possible needs of the male patients are changing rapidly and merit careful analysis over time. appears to be a man trying to sort out his emotions and demonstrate the internal grim conflicts more openly than previous actors’ interpretations.10 It is interesting that, on his day off before the final of the Australian Open 2014, the Swiss champion Stanislas Wawrinka had attended a James Bond Exhibit in Melbourne. The reporter asked which Bond he liked best, and he answered Pierce Brosnan.11 Most would agree that Brosnan’s Bond had a more gentlemanly affect, whereas Craig gives more the appearance of the hard working Olympic athletes of today. The key point is that today’s male needs to express carefully what

individual special. The scars were symbols of victory. But now men want to appear more youthful and display less evidence of the passage of time. We physicians need to be sure that we listen carefully to the individual goals of the male patients and realize that these are every bit as complicated, varied, and unique as those of the female patients. The possible needs of the male patients are changing rapidly and merit careful analysis over time. For the plastic surgeon, the patient will be happiest if he achieves his own realistic expectation from the surgery. For example, upper and lower eyelid

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 9

blepharoplasties can rejuvenate the eyes so that the patient looks rested. But the clock is not turned back exactly, for even the bone of the orbits decreases with maturity. What occurs is a rejuvenation of the soft tissue; however, one also becomes aware of the change in the orbital skeletal anatomy and the decrease in certain types of fat. The patient may not fully understand what the difference is between the present and the past youthful photographs. Time spent on patient education on how to see and understand the facial features offers lasting benefits. It is a very real change in the background appearance before surgery that makes it impossible to truly turn the clock back. The patient as well as the doctor needs to see that a different clock is created and starts ticking from the date of surgery. Until the early scars fade, the male patient needs guidance and encouragement to use cover-up makeup wisely. This education will diminish his concerns and speed up the return to work after facial surgery. Many people feel the rapid passage of time very intensely. Self-esteem diminishes each day something is not achieved. The difficult search for a job may make some men choose surgery with an unresolved inner conflict about procedures not fully understood. The secret for the physician remains to not merely hear the patient but rather to listen to the specific needs of the patient in this complex and changing society. The technical challenges of treatment vary with chronologic and biologic age and individual anatomy. The selection of the best cosmetic procedure and the safest treatments for each male patient at this special time of his life offers the greatest reward for the patient who seeks the care of the aesthetic plastic surgeon. Just as Caillebotte saw the beauty in the “reality” of his floor planers (a reality his critics deemed “vulgar”) today’s patient can learn to find confidence in his own mirror’s reflection if he maintains a sense of his true inner self. ■

NOTES 1.

Wikipedia contributors, “ Les raboteurs de parquet,” Wikipedia, The Free Encyclopedia, http:// en.wikipedia.org/wiki/Les_raboteurs_de_parquet.

Sharon Waxman, “Hollywood’s He-Men Are Bumped by Sensitive Guys,” The New Your Times, The Arts, July 1, 2004.

Gary Halbert. “Why Male Workers Are Disappearing in America.” InvestorsInsight.com, January 29, 2014.

American Society for Aesthetic Plastic Surgery, “Celebrating 15 Years of Trustworthy Plastic Surgery Statistics,” New York, American Society for Aesthetic Plastic Surgery, March 20, 2012. “Cosmetic Procedures Increase in 2012,” New York, American Society for Aesthetic Plastic Surgery, March 12, 2013.

Harrison G. Pope, Jr., M.D., Katharine A. Phillips, M.D., Roberta Olivardia, Ph.D., The Adonis Complex: The Secret Crisis of Male Body Obsession. New York, The Free Press, Simon & Schuster, Inc., 2000.

R.W. Cornell, Masculinities. Sydney: Allen and Unwin, 1995.

Wikipedia contributors, “Men’s Studies,” Wikipedia, The Free Encyclopedia, http://en.wikipedia.org/wiki/ Men%27s_studies.

Peg Tyre, The Trouble With Boys: A Surprising Report Card on Our Sons, Their Problems at School, and What Parents and Educators Must Do. New York: Crown Publishers, 2008,.284-286.

Catherine Zaw, ”Feminist, Gender, and Sexuality Studies now offer interdisciplinary Ph.D. minor.” The Stanford Daily, October 30, 2013.

10. David Colman, “Trading Up: More Men Are Taking a Size 007, The New York Times, Fashion & Style, July 12, 2012. About the Author Sharon Ann Clark, MD, FACS, Board Certified by the American Board of Plastic Surgery, is an Active Member of the American Society of Plastic Surgery and of the American Society of Aesthetic Surgeons. She has a private practice in San Mateo.

11. Manohla Dargis, “Renewing a License to Kill and a Huge Movie Franchise,” Movie Review of Casino Royale (2006), The New York Times, November 17, 2006. 12. Greg Bishop, “Wawrinka Savors Advance to Australian Open Final,” The New York Times, Sports Section, January 25, 2014.

IS THERE A MISPERCEPTION OF THE RISKS OF TONSILLEC TOMY?

by Steve Kmucha, MD, JD, FACS The lay press has well-publicized a recent tonsillectomy in the local community that was associated with postoperative complications that ultimately resulted in a devastating outcome. Soon after that sentinel event, medical experts were quoted suggesting an average rate of serious or life-threatening complications after tonsillectomy with an incidence of approximately 1:25,000 operations.

onsillectomy remains a common operation, with approximately 737,000 procedures performed annually in the U.S. The two most common indications for tonsillectomy include sleep-disordered breathing and recurrent tonsillitis. These indications have changed from being a surgery performed primarily for recurrent infections in the 1970s to a surgery performed more commonly for sleep-disordered breathing today. A large number of recent clinical trials and medical reports have repeatedly confirmed that adenotonsillectomy improves quality of life, behavior outcomes, quality of sleep and polysomnographic findings, especially in children with documented obstructive sleep apnea. Relatively minor surgical complications such as minor hemorrhage, soft tissue injuries, abnormal taste, TMJ dysfunction and others are well-recognized and reported following tonsillectomy. Prior analyses of post-tonsillectomy malpractice claims has documented that hemorrhage is a predominant cause of mortality following tonsillectomy. Based upon data from the 1970s, total post-tonsillectomy mortality has been estimated at between 1:16000 and 1:35000. A 2009 European study documented a post-tonsillectomy mortality rate again of approximately 1:16000. Therefore, post-tonsillectomy mortality appears unchanged over more than 4 decades of monitoring and numerous studies/reports despite significant improvements in surgical technique, surgical

technology, anesthesia equipment and monitoring and an intense system-wide focus on surgical quality and patient safety. Perioperative arrhythmiae, cardiac death and other anesthesia complications are also associated with tonsillectomy surgery. A 2008 malpractice claims review documented that when monetary awards were paid to plaintiffs associated with perioperative or postoperative tonsillectomy claims, monetary awards against anesthesiologists were more frequent and higher than against otolaryngologists. The role of obstructive sleep apnea in tonsillectomyrelated malpractice claims remains somewhat controversial. With an increase in obesity, with an increase in the diagnosis of sleep apnea, with an increase in ambulatory surgeries, otolaryngologists and anesthesiologists would appear to be increasingly exposed to new areas of liability. Also, with the shift in the indications for tonsillectomy from recurrent infections in the 1970s to treatment of sleep apnea more recently, it would appear that both otolaryngologists and anesthesiologists are similarly being exposed to increasing liability when treating this growing population of patients with documented sleep apnea. For those patients without documented sleep apnea, only formal polysomnography (PSG) can provide such

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 11

documentation; due to the (geographic and financial) inaccessibility of PSG for many patients, such a study may not be available. As there are no clinical metrics that diagnosis OSAS other than PSG, a diagnosis based on patient reporting, family reporting and other clinical symptoms alone may under-diagnose a significant proportion of patients with true OSAS. While most otolaryngologists and anesthesiologists are familiar with postoperative post-obstructive “flash”

Tonsillectomy-Related Malpractice Awards, 1984-2012 There were 242 claims, 98 of which (41%) were fatal. Median age of plaintiffs: 8.5 years Primary causes of fatal claims were related to: • surgical factors (39.8%) • anesthesia-related factors (26.7%) • Post-operative opioid-related factors (16.3%) Primary causes of non-fatal claims were related to: • surgical factors (70.1%) • anesthesia-related factors (22.2%) • Post-operative opioid-related factors (4.2%) Sleep apnea was recorded as co-morbidity in 17 fatal and 15 non-fatal claims. Opioid-related claims had the largest awards for both fatal ($1,652,892) and non-fatal injuries ($3,484,278). Anesthesia and opioid-related claims, though fewer in number than surgical claims, are associated with larger median monetary verdicts. Monetary claims paid for non-fatal injuries was higher than those for fatal injuries. This is likely related to the ongoing medical expenses required to care for these injured individuals and the continued emotional trauma.

received less opioid doses after tonsillectomy than black children, white children had higher numbers of opioidrelated adverse events. The most commonly reported opioids associated with post-tonsillectomy claims were codeine, morphine, fentanyl and meperidine. Despite its well-known efficacy and safety problems, codeine remains one of the mostly commonly prescribed opioids for home pain management after adenotonsillectomy in the US likely due to cost, availability and perceived safety. Black box warnings were issued in 2013 by the FDA against the use of codeine following tonsillectomy in children. Ultra-rapid metabolizers of codeine have greatly enhanced rate of conversion of codeine to morphine in the blood stream rapidly increasing the possibility of morphine toxicity with associated respiratory depression and death. These risks are not limited to codeine but are associated with all other opioids. Many otolaryngologists have already switched to protocols which maximize analgesia provided by non-opioids administered on a scheduled basis (choosing medications which do not simultaneously increase the risk of bleeding such as acetaminophen) while reserving the lowest effective dose of opioids not dependent upon pathways present in “ultrametabolizers” on a limited and as needed basis such as hydromorphone, oxycodone and morphine with detailed safety instructions to parents and patients about potential side effects and appropriate use. Many studies suggest less pain and postoperative nausea is associated with a pre-operative dose of dexamethasone; a recent 2014 report suggests that significant variations persists around the US in the use of perioperative antibiotics, dexamethasone and analgesics. ■ References

pulmonary edema that often occurs after tonsillectomy in a patient with OSAS, some studies also suggest that the frequent episodes of hypoxemia associated with OSAS result in increased opioid sensitivity of mu-receptors such that a normal dose of opioid can be a relative overdose in patients with OSAS. Posttonsillectomy complications also appear to be more commonly associated with OSAS in younger children. The obvious fact that smaller children have smaller and more difficult airways is another important factor. Another recent report published in Pediatrics in 2012 documented that while younger white children

12 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

Subramanyam R et al. Paediatr Anaesth 2014 Jan 13, pp 1-9. About the Author Steve Kmucha, MD, JD, FACS, is board certified in otolaryngologyhead and neck surgery and in the subspecialty of ear, nose and throat allergy. He also holds a law degree specializing in health and healthcare law.

WHAT IS YOUR LEGACY GOING TO BE?

physicians we are all highly educated and trained to help heal others from physical and emotional ailments. Each one of us has unique knowledge, skills, experiences and/or abilities, which can be used to help others. We all have abilities to make the world a better place. For most of us, the practice of medicine can lead to a fulfilling life while earning a comfortable living. Each of us can decide how much money we make based on the amount of our life we are willing to sacrifice. But what if there is something in addition to the practice of medicine where one can make an equal, and possibly more substantial, impact on the communities we serve? My article today is about the ways in which community service can impact society and us. I want to share my personal journey of how I got involved with community service. I hope my story will encourage each of you to follow your heart, both inside and outside of the office â&#x20AC;&#x201C; even when it leads you off the well-worn path. My journey was heavily influenced by the experience of growing up as a gay person in the conservative Midwest. Several years into my employment as a TPMG psychiatrist at Kaiser South San Francisco Medical Center, I felt like something was missing in my life. I allowed this nagging sense of emptiness to speak to me and struggled to open my heart and mind to what has become a deep calling. Outside of my full-time work as a psychiatrist, I began to focus my energy on helping those who were being bullied. People can be bullied for many different reasons.I began to speak out publicly for those who were being bullied on the basis of their sexual orientation or gender identity. When I was growing up in Nebraska, I was bullied for being gay. I was not only bullied by my classmates, but also by my own father. I knew that I never wanted any child to go through what I had been through. There is a small but growing body of research that shows lesbian, gay, bisexual, and transgender (LGBT) youth are at higher risk for many psychological issues due to the prejudice, rejection, discrimination, and stigma against them. Compared to their heterosexual peers, LGBT youth are at higher risk for suicide attempts, mental health issues, and substance abuse. The pathway of my community service started 14 years ago at my undergraduate college, Wayne State College, which is located in rural northeast Nebraska. Having been a closeted gay student-athlete at Wayne State in the 1980s, I knew from personal experience the challenges that gay students must face. I wanted to help students, both gay and straight, have a better understanding of how bullying impacts education and how homophobia damages everyone. My first community service talk was in 2000 in front of about 12 students in a psychology class at Wayne State College. I was a guest speaker talking on the FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 13

topic of LGBT issues and civil rights. I remember how difficult it was to prepare for my talk as there was little scientifically based LGBT information on the Internet in 2000. It took tremendous courage to speak publicly about being gay in rural America, a topic I certainly avoided when I was a Wayne State student and athlete. There was a heavy presence of religious conservatives in the room that day who openly voiced the stance that homosexuality was an “abomination,” even as they proclaimed to “love the sinner but hate the sin.” Hearing that language again brought back feelings of when I was growing up as a closeted individual in Nebraska. Although that first presentation in 2000 was not a positive experience, it did reinforce the need for education on this topic. I pressed on, and over the

to learn more about LGBT health. Unfortunately, I realized that I was vastly unprepared and overwhelmed. That experience profoundly motivated me to never be so unprepared again. Over the course of 2009, I took a website design class and developed a website (audacityofpride.com). I also put together PowerPoint presentations that highlighted the scientific-based information regarding LGBT issues, including the biological theories of gay sexuality, LGBT healthcare, and LGBT suicide reduction. During these years, as I became more open to the possibilities, greater opportunities presented themselves to me. I was invited to speak to more and more people at larger audience groups in the Midwest. Unfortunately, since I had been using my personal vacation time to give

Dr. Holt created a website, audacityofpride, com, above, to raise awareness of the impact of homophobia on Lesbian, Gay, Bisexual, and Transgender (LGBT ) youth. years, have been able to speak at other regional Midwestern colleges educating students on LGBT issues. I emphasized that homosexuality is a normal variant of human sexuality. My goal was to reach out to those closeted LGBT youth who were in the audience and might be struggling with their identity, just as I did in the 1980s. In 2008, I expanded my talks to include LGBT health. My first medical audience was to a group of medical students at my alma mater medical school. The presentation was an extracurricular activity sponsored by the alumni association and was conducted during the students’ lunch hour. Since it was held on a Friday at noon, with no classes scheduled for the students afterward, I anticipated maybe 30 students would attend. However, more than 250 students crammed the small auditorium style classroom. They were eager 14 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

these presentations, I found that I was running out of vacation time. But with the tragic suicides of several gay youth that made national headlines in 2009 and 2010, I made the conscious decision to reduce my official paid work hours. This of course meant I would take a pay cut, but I was allowed to work unpaid hours, which could then be accumulated as additional paid time off days from the clinic. This afforded me the opportunity to have the necessary time off in order to travel back to the Midwest. As more tragic suicides occurred the following year, I felt a pull and took a second pay cut in order to expand the outreach. In the fall of 2011, I met a young videographer named Toan Lam who traveled back to Nebraska with me in order to produce a short video describing my community service work. (This video can be found on the main page of my website). Toan’s video was released

on YouTube in 2012. Within an hour after it was released, I received the following email from a 17-yearold Canadian teenager: “Good evening. I am a young gay male. I have not been at any of your conferences, but I did see your video on YouTube and would like to personally thank you! I wish someone like you came and told me that being gay is okay a lot sooner than I found out. I told my mother I was gay at 15, and I have been living alone since then, working full time - all because I was gay. Something so small can really change the way people view you! So thank you very much for helping, and educating others on this problem of gay hate. I really do appreciate it!” Just a short time later, I received a message through my Twitter account. This was from an eighth grade female who wrote: “Because of you, I’m not afraid to show my inner self anymore. Half of the eighth grade knows I have a girlfriend. Thank you.”

I have a deep conviction that we as physicians are here to help those who, for various reasons, are not yet able to help themselves; I believe that we are called upon to give a voice to those who can’t speak for themselves. Each day brings with it new opportunities to save or alter a life through our compassion, mentoring, and education. In his 2005 Stanford commencement speech, Steve Jobs said: “Have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.” It is my hope that by sharing my journey into community service, each of you will find the spark within you to follow your heart and intuition to make the world a better place. ■

About the Author I am deeply moved each time I receive messages like these. Over the years, there have been hundreds of comments that are posted on my website (under presentations tab) from youth and physicians who describe how my community service has impacted them. Whenever I read these comments, I am reminded just how important community service really is. Although volunteerism often does not bring material wealth, it often brings something which is much more valuable. In fact, I have come to believe that community service brings more wealth than money ever could.

Ron Holt, DO, is a practicing psychiatrist at Kaiser South San Francisco Medical Center. He is passionate about ending bullying and suicide, enhancing the knowledge of medical providers regarding LGBT healthcare and educating the public about the consequences of homophobia. He travels the country educating others on LGBT issues to help provide a safer and more understanding society for all.

Dr. Ron Holt has presented over 125 presentations to various audiences, including students, community groups, educational and medical conferences, and medical practitioners. Here is a small seletion of feedback he’s received: “Your discussion today went a long way toward helping educate my mother...I just wanted to tell you how impressed I was with your lecture. You didn’t hold back during the Q & A session, and seeing that you were an intelligent, out gay professional made me very proud of you...thank you for having the courage to speak today.” “The most important thing I learned today is sexual orientation is not a choice—sexual behavior is. I have told three of my friends that I am bisexual. It was probably the hardest thing I have ever done but I am glad I did it. I don’t have to be scared anymore. I didn’t know there was a difference between sexual orientation and sexual behavior.” “Dear Dr. Holt: I was a student at Wayne State six years ago when I attended one of your lectures. I remember what you said about “the first thing you say” when a family member or friend tell you they are gay, because they will remember those words forever. My grandson told me last year (with tears in his eyes) that he was gay. I was the first one he told and the only one (we’re very close). Your words were screaming in my ears! I told him I didn’t care and that I loved him and I always will. He was so relieved...Thank you again.” “I am very thankful for the opportunity to meet Dr. Holt and to listen to him and the other speakers present their information on homosexuality. I think it has helped me to become even more open minded about people who are different from me. All of the information that I received is helping me to become a better mother, teacher and citizen.”

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 15

“ We listen to policyholders. We provide solid advice and offer real-time solutions to real-time problems.” Loss Prevention Senior Representative Kathy Kenady

Service and Value MIEC takes pride in both. For nearly 40 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with policyholders to keep premiums low. Added value:

Average Dividend as % of Premiums

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Past five Years

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16 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

MIEC Owned by the policyholders we protect.

NEW SMCMA MEMBERS

Urmila Bajpai-Pillai, MD *RHU/S San Francisco

Natasha h Brasic, MD *DR/S San Francisco

Christine Chen, MD h h OBG/S San Francisco

Rhona Chen, MD h h *GS/S San Francisco

Marc Chinn, MD *PD/S San Francisco

Charles Everett, MD *PUD, *CCM, *IM/Burlingame

Toby Frescholtz, MD OBG/Redwood City

Sarah Gallager, MD *IM/S San Francisco

Daniell Guenin, MD *EM/Burlingame

Parisa Kashkouli, hk l MD *IM/S San Francisco

Hester Lee, MD *OPH/S San Francisco

Christine h Picco, MD OBG/Redwood City

Jennifer Rhee, MD *IM/S San Francisco

Heather h San Miguel,l MD *IM/S San Francisco

Vishal h l Sidhar, dh MD *DR/S San Francisco

Dariusz Tarasewicz, MD *OPH/S San Francisco

Welcome! Jocell yn Thein Jocelyn Thein, h MD *D/S San Francisco

Elena Torello, MD *IM/S San Francisco

* Board-certified by the American Board of Medical Specialties

FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 17

Reform School: The Affordable Care Act and Physician Survial Strategies San Mateo County Medical Association 777 Mariners Island Blvd., #100, San Mateo

Wednesday, March 12, 2014 Registration: 6:15 P .M. * Program: 6:30-7:45 P.M.

Hundreds of pages of regulations are spewing out of Washington, DC, now that the Patient Protection and Affordable Care Act is the law of the land. These regulations will affect the daily practice of medicine for years to come. Consultants are making a fortune trying to read the tea leaves. Some, even high-level politicians, are predicting a “train wreck” in the implementation of the ACA. So, what are doctors to do? The first piece of advice when crafting a strategy is: Get to a safe place. But, with all the upheaval in health care, it is very difficult to know where that safe place is for physicians. This presentation will outline four ways for physicians to get to the safest place possible: 1.

Creating Unity: There is safety in numbers, as well as strength. Learn how physicians can increase their bargaining power by joining forces with each other.

Forming patient alliances: The support of loyal patients is one of a physican’s greatest assets. Learn how tapping into patient goodwill can increase physician bargaining power and improve patient care.

Aligning with Other Providers: Learn how forming the physican-patient alliance before entering into a business relationship with a provider can help ensure equal bargaining power for physicians.

Creating Gain-Sharing Arrangements: Every physician knows which diagnoses and conditions could be treated more efficiently and cost-effectively. Learn how gainsharing arrangements can provide incentives for physicians to cooperate in providing less wasteful care.

Presenter Charles Bond, JD, is a principal of Physicians’ Advocates, a law firm in Berkeley. He writes on health law, medical economics, practice management, physician employment, hospital-physician agreements, and health policy. This program is free to SMCMA members, but space is limited and advance registration is recommended. Light refreshments will be provided. Please RSVP to (650) 312-1663 or sgoecke@smcma.org.

The following SMCMA members have recently retired from practice: Sein Aye, MD Amita Bhandari, MD Gloria Chang, MD

SMCMA Member Information Update Please note: The 2014 SMCMA Membership Directory included outdated information for Andra Batlin, MD. Dr. Batlin’s correct information is as follows:

Tracy Zweig Associates INC.

REGISTRY

PLACEMENT

FIRM

Physicians Nurse Practitioners Physician Assistants

Andra Batlin, MD/*IM 1860 El Camino Real, Suite 321 Burlingame, CA 94010 552-8180 Fax: 552-8199 We apologize for any confusion.

Index of Advertisers The Magnolia of Millbrae ............................................. Inside Back Cover Marsh .....................................................................................Inside Front Cover Medical Insurance Exchange of California (MIEC) ............................ 16 NORCAL ............................................................................. Outside Back Cover Tracy Zweig Associates .................................................................................. 18 For advertising information, please call (650) 312-1663.

18 SAN MATEO COUNTY PHYSICIAN | FEBRUARY 2014

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FEBRUARY 2014 | SAN MATEO COUNTY PHYSICIAN 19

777 Mariners Island Boulevard, Suite 100 San Mateo, California 94404

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NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our ďŹ rst priority. Visit norcalmutual.com, call 877-453-4486, or contact your broker.

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