January 2014 by SMCMA

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

Physician

I NS I D E

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 1

OBSTRUCTIVE SLEEP APNEA AND CARDIOVASCULAR DISEASE: The Importance of Getting Your Z’s

PHYSICIAN PROFILE: DEBRA MATIT YAHU, MD Mother-daughter team are changing women’s lives in Kenya

HONORING THE PLACE WHERE THE LIGHT DWELLS: Palliative care physician learns from her patients every day

SHOULD MY DAUGHTER GO INTO MEDICINE? Nine out of ten doctors would not recommend medicine to their kids

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INDIVIDUALS Guaranteed issue coverage, 19 rating territories, new family component rating D;M <EH (&'* Is your plan grandfathered? Which ACA metal tier do you want? Do you qualify for a subsidy through the Covered California Individual exchange? Decide to comply with individual mandate or pay the penalty – greater of $95 ($285 per family) or 1% of household income Determine if you want to buy on or off exchange Critical to evaluate provider networks before making a change Evaluate formularies to make sure new insurer covers your medications

SOLE PROPRIETORS If you are a sole proprietor or partnership without any non-spouse W2 employees, ACA considers you individuals and no longer eligible for group coverage. If you have non-spouse employees, provide coverage or obtain other group coverage waivers If no non-spouse employees, determine if subsidy eligible for Covered California Individual plans Decide to comply with individual mandate or pay the penalty – greater of $95 ($285 per family) or 1% of household income Determine if you want to buy on or off exchange Critical to evaluate provider networks before making a change Evaluate formularies to make sure new insurer covers your medications

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

SPONSORED BY:

CLEAR ANSWERS TO YOUR QUESTIONS ARE A CLICK OR PHONE CALL AWAY. www.CountyCMAMemberInsurance.com or 800-842-3761 to speak with a Mercer Client Advisor.

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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

Columns President’s Message Having the Difficult Conversations ................................................................ 4 Niki Saxena, MD

SMCMA Leadership 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 O’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

Editorial/Advertising Inquiries 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. 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.

Executive Report Still Don’t Know Whether You Are a Covered California Provider? .............. 6 Sue U. Malone

Feature Articles Obstructive Sleep Apnea and Cardiovascular Disease: The Importance of Getting Your Z’s ............................................................... 7 Samir Thadani, MD

Physician Profile: Debra Matityahu, MD Mother/Daughter Team Are Changing Women’s Lives in Kenya ................. 10 SMCMA Staff

Honoring the Place Where the Light Dwells: Palliative Care Physician Learns from Her Patients Every Day ............................................ 13 Shoshana Helman, MD

Should My Daughter Go Into Medicine? ...................................................... 14 Christian Serdahl, MD

Of Interest New SMCMA Members .................................................................................. 12 Covered California FAQs for Physicians ....................................................... 16 Membership Updates, Classifieds, Index of Advertisers ............................. 18

President’s Message by Niki Saxena, MD

Having the Difficult Conversations

appy New Year, everyone! I am writing this column sitting in a lovely flat in the Notting Hill section of London. As a reward for being on call over the Christmas holiday I got to take some time off in January. After some thought I decided I would just pretend to

move to London for a week, and thanks to VRBO and the magic of the internet I can now enjoy what life is like for “someone who lives here.” Today I went on a walking tour of the Marylebone area, home to the famous Harley Street physicians. Even in this land of socialized medicine there exists a separate system for those who can afford it. While there are plenty of supporters for democratic and egalitarian medicine here in Britain, there is one fact they reluctantly acknowledge: that level of national coverage comes at a price. Under national health insurance, you can’t get any medical service, at anytime,

anywhere or any place. Coverage for all can exist because resources are carefully considered, some would even say rationed, and sometimes people have to wait. Worse yet, sometimes people are denied. I can’t help but think of the seismic shift that is taking place in America’s healthcare system, and what that will mean over time. It’s going to take a sea change in the culture and ethos of how we practice medicine and access healthcare, never mind the nuts and bolts of how we will pay for it. How much money do we spend on healthcare in the United States? An unsustainable amount, that’s how much. Our GDP runs the risk of being crippled by increasing healthcare spending rates. We have one of the most expensive systems in the world, yet, according to a January 2013 article by Atlantic Monthly (based on 2008 WHO data) the U.S. was in last place for health rankings comparing 17 developed countries (Japan was at the top). It’s an astonishing

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statistic that many of you may already know: approximately 90 percent of the money spent by Medicare for a beneficiary is spent during the last six months of life. There is a growing movement to try and bend that cost curve by encouraging clinicians to have discussions about end-of-life care with patients before it becomes an issue. I have heard the talks and, on an abstract level, I completely agree. It’s when things become personal that those conversations become difficult. Now, I come from an East Indian family that is very traditional in some ways, and very forwardthinking in others. This past holiday season my father pulled me aside. “Niki,” he said, “you are our eldest child. It is your duty to carry out my wishes for what I want done when I am gone. And it is my duty to discuss those things with you.” I am ashamed to admit it, but my immediate reaction was panic. How could this be happening? How did we both age to the point where these conversations were necessary?

We don’t see things as they are, we see them as we are. — Anaïs Nin It takes as much energy to wish as it does to plan. — Eleanor Roosevelt

But really, it’s not the medical details that made me uncomfortable; it was the realization that, interspersed with these conversations would be conversations that we both had been putting off for quite some time. How does one make peace with all those life details that would never be “fixed”? I’d always thought, “There will be plenty of time to discuss these things later.” Well, as my father likes to say, “That time has come.” If we both plan well, someday my father will pass on comfortably with a minimum of pain. And while I don’t know how I will cope with the pain of his passing, I know that what we do now can enable him to finish his journey in comfort and with dignity.

This topic came up at our board meeting in December, and there was an outpouring of similar stories from other members. Several folks were generous in sharing their past experiences, resources they had found, what was helpful, and what was not. The overwhelming theme was “don’t be afraid. This is something you need to do and we can help.” Dr. Russ Granich, the chair of our editorial committee and a palliative medicine expert, also offered his perspective on the topic after years of helping patients and families through end-of-life issues. Bottom line? There is no “wrong way” to talk about these issues—the only mistake would be in not talking about them at all. It made me think of the adage “physician, heal thyself,” only in my case it was

more like “physician, take thine own advice.” So, after my vacation I will go home, set aside my personal fears and make the time to have those conversations with my father. You could argue this isn’t just about respecting his wishes, it’s about doing my part to participate responsibly in our healthcare system. I know there are lots of people who have walked this path as well and who are willing to help. Who knows? That may be part of what it takes to help change the culture of how we access healthcare in this country: by having those very difficult but vital conversations with our loved ones. ■

2014 STEPPING UP TO LEADERSHIP PROGRAM MARCH 6-8, 2014 LOEWS CORONADO BAY HOTEL, SAN DIEGO The Stepping Up to Leadership program was created by the Institute for Medical Quality and the PACE Program at the University of California at San Diego in response to a commonly expressed need for better, more practical hands-on training for medical staff leaders. The program made its debut in 2011 with a program emphasizing communications skills and addressing issues of disruptive and impaired professionals. The 2014 conference will cover all of the original content, with an added emphasis on aligning the needs of medical staffs and hospitals and helping both work together effectively. The 2014 conference will feature keynote speaker Nancy Dickey, MD, family practitioner and the first female president of the American Medical Association; Barbara Paul, MD, Senior Vice President and CMO of Community Health Systems in Nashville, Tennessee; Greg Abrams, Esq., an expert in legal issues confronting medical staff leaders; Carol Havens, MD, President of the California Academy of Family Physicians; and others. For more information, call Leslie Iacopi at 415-882-5167 or visit www.imq.org/Education/ConferencesWorkshopsWebinars.aspx.

JANUARY 2014 | SAN MATEO COUNTY PHYSICIAN 5

Executive Report p byy Sue U. Malone

Still Don’t Know Whether You Are a Covered California Provider? SMCMA has previously sent out information to members to assist them in finding out if they are listed as participating in one of the health plans that offers health coverage in San Mateo County through Covered California. Below is contact information for the

provider relations department of the four plains (aside from Kaiser Permanente) that are offering coverage in our county. If it is verified that you are in a Covered California network, then be sure and inquire about the terms of your participation, i.e., reimbursement rates, opt-out provisions, and so on. You can also use these numbers if you decide you would like to participate in the program. By the way, I am told that Health Net is the only one of the four plans that has not reduced its reimbursement rate to providers participating in its network. You should also check your participation status through the Covered California provider directory. There are two ways to do this. The Covered California site will list your name and contact information if a participating health plan lists you as in a particular network.

Go to www.coveredca.com/ hbex/stakeholders/providerdirectory/. Click on one of the health plans offering a network in San Mateo County. An Excel spreadsheet will open. Click on the provider link at the bottom of the Excel page. When the provider list appears, use your mouse to highlight the “Last Name Provider” column, then click on “Find and Replace” on the top toolbar. Enter your last name to search. If your name is not common, you should find it without a problem; however, if you have a common last name you will have to scroll through a lot of names, as the entire statewide list for a particular health plan will pop up.

Another way to see if you are listed as a health plan provider requires you to complete several questions, as if you are applying for insurance. 1. 2. 3.

Go to www.coveredca.com. Click “Apply Now” and then the “Preview Plans” link. Answer some general questions—I suggest something along the lines of: income at $30,000; one person in household, age 60. Click “See My Result.” At the bottom of this page, click again on “Preview Plans.” Go to

the bottom of this screen and click the link that says “Find Your Doctor.” Type in your Name and hit the Search button. If you are identified by one of the health plans as in their network, your name will pop up. Then click on your name to see your listing.

By the way, there may be something incorrect in your listing, so this will give you an opportunity to have the information corrected. Unfortunately, up to this point you still cannot identify which health plan lists you are a provider. To learn this piece of information, continue with the application process by clicking “Choose a Plan” at the bottom of the page “Choose a Plan.” The plans in which you participate will show a gray checkmark box. A gray minus-sign indicates that you do not participate in the plan. A warning: there may be more than one doctor in the state with the same first and last name, so double check to make sure you are reviewing your listing. Frankly, it is probably easier to work through your health plans; however, you should go through the Covered California website to make sure your listing accurately identifies your address, board certification, languages, and so on. ■

Anthem Blue Cross Network Relations: 855-238-0095 Networkrelations@wellpoint.com

HealthNet of California

Blue Shield of California Provider Services: 800-641-7761

Chinese Community Health Plan

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Provider Services: 800-641-7761 Provider_services@healthlnet.com

Provider Services: 415216-0088, x2806

nocturia; depression; and awakening with chest pain. The STOP-Bang questionnaire is an eight-item questionnaire that asks about snoring, tiredness, observed apneas, blood pressure, BMI (more the 35), age (more than 50), neck circumference (more than 16 inches or 40 cm), and gender (male). A score of three or more has a sensitivity and specificity of 84 percent and 56 percent respectively, for the diagnosis of OSA using an apnea hypopnea index (AHI) threshold of more than five events per hour (mild OSA), and a sensitivity and specificity of 93% and 43%, respectively, for an AHI more than 15 (moderate to severe OSA).

OBSTRUCTIVE SLEEP APNEA AND CARDIOVASCULAR DISEASE: The Importance of Getting Your Zâ&#x20AC;&#x2122;s

Systemic Hypertension

by Samir Thadani, MD

Obstructive sleep apnea (OSA) involves obstruction of the upper airway resulting in apneas and hypopneas. It is the most common sleeprelated breathing disorder with prevalence amongst adults in this country of at least 15% in men and 5% in women. The key risk factors for OSA are obesity, male gender, older age, and craniofacial and upper airway abnormalities. Additional risk factors include family history, smoking, and nasal congestion.

OSA is associated with increased risk of systemic hypertension as well as cardiovascular (CV) disease, including coronary heart disease (CHD), cardiac arrhythmias, heart failure, cardiomyopathy, and pulmonary arterial hypertension. In order to prevent the progression of these diseases, it is important to understand the clinical features of OSA and the link with specific risk factors and CV diseases so that an appropriate diagnosis can be made and early therapy can be initiated. Clinical Features OSA most commonly features daytime sleepiness and loud snoring. Other associated symptoms include awakening with a sensation of choking, gasping, or smothering; moodiness or irritability; lack of concentration;

A number of studies have shown that hypertension is more common among people with OSA than those who do not have OSA, even after adjusting for possible confounders. Research has also demonstrated that increased severity of OSA (i.e., higher AHI) corresponds with both a higher likelihood of hypertension overall as well as resistant hypertension requiring at least three anti-hypertensive medications. In total, about 50 percent of OSA patients are hypertensive and about 30 percent of hypertensive patients also have OSA. It is believed that the elevation in blood pressure (BP) is secondary to activation of the sympathetic nervous system due to apnea-related arousals and/or hypoxemia. Additionally, recent evidence has demonstrated that the renin-angiotensinaldosterone system may play a

JANUARY 2014 | SAN MATEO COUNTY PHYSICIAN 7

he STOP-Bang questionnaire is an eight-item questionnaire that asks about snoring, tiredness, observed apneas, blood pressure, BMI (more the 35), age (more than 50), neck circumference (more than 16 inches or 40 cm), and gender (male). role in OSA-related hypertension. In fact, since hyperaldosteronism and OSA have been shown to occur together, patients with resistant hypertension being evaluated for one condition may benefit from an evaluation of the other condition. Finally, reduced slow wave sleep, which is associated with OSA, may result in impaired vascular function and increased sympathetic activity. Treatment of OSA with continuous positive airway pressure (CPAP) has been shown to result in a reduction is systemic BP. Although the overall impact of CPAP on BP reduction is small, a larger impact is seen in those with more severe OSA, difficult-to-control hypertension, and better CPAP compliance. Taken together, the above evidence suggests a need for more screening for OSA in the population of patients with resistant hypertension. Coronary Heart Disease The prevalence of OSA in people with CHD is approximately 30-60 percent Amongst men hospitalized for an acute myocardial infarction (MI), the prevalence is as high as 70 percent In the Sleep Heart Health

Study (SHHS), where more than 6,000 people were followed for over eight years, the risk of CHD-related death in men was 70 percent higher in those with an AHI of 15 or more compared to those without OSA. Other studies have shown that MI may be associated with worsening of sleep-disordered breathing. These data are not surprising given the association of OSA

The presence of Coronary Heart Disease, particularly in men, should warn clinicians that screening for OSA may be indicated.

with a number of cardiovascular risk factors including decreased high density lipoprotein (HDL) and increased C-reactive protein (CRP), homocysteine, and blood glucose. Recurrent hypoxemia causes the release of vasoactive substances, such as endothelin, that may result in vasoconstriction that persists for hours. Interestingly, endothelin levels fall after four hours of CPAP therapy.

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The presence of CHD, particularly in men, should warn clinicians that screening for OSA may be indicated. This is particularly important since patients with OSA who are treated with CPAP have a lower incidence of fatal and non-fatal cardiovascular events compared to those with untreated severe OSA. Cardiac Arrhythmias Multiple studies have demonstrated that atrial fibrillation (AF) and nonsustained ventricular tachycardia (NSVT) are more prevalent in individuals with OSA than in those who are unaffected. Conversely, amongst patients with AF, the prevalence of OSA is high (estimates range from 32 to 82 percent). In one study, a paroxysm of AF or an episode of NSVT was 18 times more likely within 90 seconds of an apneic or hypopneic event compared to normal breathing. Another study showed that the diagnosis of OSA increased the risk of recurrent AF after radiofrequency catheter ablation by about 25 percent. Patients who have untreated OSA and AF and are cardioverted into sinus rhythm are twice as likely to have recurrent AF compared to those with treated OSA. Additionally, due to activation of the cardiac vagal system, OSA is also associated with bradycardia and asystole during sleep as well as bradyarrhythmias during waking hours. In one study, the prevalence of OSA amongst patients with pacemakers was almost 60 percent. This raises the question of whether some patients being referred for pacemaker implantation would benefit from first being screened and treated for OSA.

Conversely, patients who already have pacemakers may also benefit from increased screening. Based on the above evidence and the fact that CPAP has been shown to suppress many nocturnal arrhythmias, any patient observed to have nocturnal arrhythmias should be evaluated for OSA. Additionally, patients with recurrent daytime arrhythmias that are resistant to therapy and with some risk factors for OSA should be considered for screening. Heart Failure/Cardiomyopathy It is well known that OSA as well as central sleep apnea can be complications of heart failure (HF). The prevalence of OSA in patients with HF is between 10 percent and 35 percent. Additionally, more than half of all patients with OSA have diastolic dysfunction, which improves with CPAP therapy. Recently, OSA has been shown to be a risk factor for developing HF. Men in the SHHS cohort with severe OSA, after adjusting for potential confounders, were 60% more likely to develop HF compared to those without OSA. The most likely mechanisms by which OSA contributes to HF is through increased sympathetic activity and elevated BP, particularly elevated nocturnal BP,

which is thought to play a bigger role in the development of left ventricular hypertrophy compared to BP during wakefulness. Finally, studies have shown that OSA is common in patients with hypertrophic cardiomyopathy and may play a role in increasing the burden of AF in these individuals. It is still unknown as to whether CPAP therapy can improve outcomes in this population.

Conclusion Significant evidence demonstrates that OSA is linked to numerous cardiovascular risk factors and contributes to the pathogenesis of heart diseases, particularly in men. Thus, clinicians need to be vigilant about recognizing and screening at-risk patients for OSA such that prompt therapy can be initiated to mitigate the burden of this disease. â&#x2013;

Pulmonary Arterial Hypertension Patients with OSA have frequent episodes of increased pulmonary artery pressure during sleep. Additionally, it has been shown that OSA may be associated with mild pulmonary arterial hypertension (PAH) in patients with both nocturnal and daytime hypoxemia (e.g., those with chronic lung disease). The likely mechanism of OSA-induced PAH is thought to be hypoxemia, which can cause an increase in pulmonary artery pressure. What is unknown is whether nighttime hypoxemia alone is sufficient to induce daytime PAH. Regardless, patients with OSA who have PAH have lower survival rates compared to OSA patients without PAH. CPAP therapy has been shown to decrease pulmonary artery pressures in patients with OSA, particularly in those with PAH.

About the Author Samir Thadani, MD, is a cardiologist with Kaiser Permanente Medical Group in South San Francisco. A graduate of NYU School of Medicine, he is boardcertified in internal medicine and cardiovascular disease. His cardiology interests include preventive cardiology, multi-modality imaging, adult congenital heart disease, and the appropriate use of medical technology to improve outcomes.

References 1. Peppard PE, Young T, Barnet JH, et al. Increased Prevalence of SleepDisordered Breathing in Adults. Am J Epidemiol 2013. 2. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812. 3. Monahan K, Redline S. Role of obstructive sleep apnea in cardiovascular disease. Curr Opinion Cardiol 2011; 26:541-547. 4. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol 2008; 52:686â&#x20AC;&#x201C;717. 5. Porthan KM, Melin JH, Kupila JT, et al. Prevalence of sleep apnea syndrome in lone atrial fibrillation: a casecontrol study. Chest 2004; 125:879.

PHYSICIAN PROFILE: DEBRA MATITYAHU, MD Mother-daughter team are changing women’s lives in Kenya

by SMCMA Staff

hen Redwood City gynecologist Debra Matityahu spent a month in western Kenya in late 2010, she found she couldn’t turn away from the stories. Rather, it was one story, told by different young women, with different details, but the central themes were the same—trauma and pain, loss and grief, betrayal, humiliation and hopelessness. The women were patients of Dr. Hillary Mabeya, who had founded the Gynocare Fistula Center—a nongovernmental organization in Eldoret, Kenya, providing reproductive health services to women, in 2010. The women had come to Gynocare and Eldoret’s Moi Referral Hospital for fistula repair surgery. Obstetric fistula is a childbirth injury that affects women almost exclusively in third-world countries. When carried out by a trained provider with the proper resources, the repair surgery boasts success rates of more than 90 percent, but, in places like Kenya, there are few, if any, such resources to help these women. There are two kinds of obstetric fistula: Vesicovaginal (VVF), occurring between the vagina and the bladder, and recto-vaginal (RVF), occurring between the vagina of the rectum. Both are typically the result of a prolonged obstructed labor when a woman is unable to deliver safely and cannot access a cesarean section. The constant pressure of the baby’s head against the mother’s pelvic bone causes the flesh to necrose, leaving a hole. The fistula can also be caused by violent sexual assault. The physical and psychological damage that follow the trauma is hard for most people to even imagine. The baby almost always dies. With VVF, the fistula allows the continuous involuntary discharge of urine

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into the vaginal vault. RVF can allow both flatulence and feces to escape through the vagina, leading to recurrent vaginal and urinary tract infections. The social aftermath is often more severe than the physical effects. Returning home, childless, leaking urine and/or feces, they are often abandoned by their husbands and rejected by their entire families. They are isolated, stigmatized, and essentially discarded. Their stories are laced with despair.

“The women on the waitlist for the Stepping Forward program have more to gain than our kids do with an admission to Harvard. To see the difference in their lives from just learning to sew is almost mindboggling.” Debra Matityahu, MD

atityahu, her husband, and their children Arielle and Jake, were in Kenya for one month, as part of a ten-month trip around the world. Husband Amir Matityahu, MD, an orthopaedic surgeon at San Francisco General Hospital, was participating in a prestigious fellowship that would also take them to Germany, Israel, South Africa, China, and Japan. While they were in Kenya, Debra Matityahu would assist Dr. Mabeya at the Gynocare Fistula Center. Dr. Mabeya had become the

first specialized fistula surgeon in the region in 2003. His wife, Carolyne Mabeya is a social worker at the center. As the women recovered from their surgeries, they were interviewed by Dr. Matityahu, and her daughter Arielle, then eleven years old. With the help of a translator, they heard stories from girls like 15-year-old Priscillah, who became pregnant after a rape and was kicked out of her mother’s home. She was taken in by her grandmother who, believing it would reduce Priscillah’s “sin,” convinced the girl to submit to Female Genital Mutilation (FGM) while pregnant. After three days of labor at home, she was finally taken to a hospital, near death with a dead baby inside her. She developed a fistula during delivery and her body was so badly damaged that she will never be able to have children. Another woman, Emily, developed a RVF during the birth of her first child. She and her husband returned home, unable to afford proper medical treatment, and managed to have three more children over the years. Then her husband disowned her; she and their children were chased from the family home by her husband’s relatives. Emily lived with her fistula for eleven years before she learned of Gynocare and received surgery. Opposite page: Dr. Debra Matityahu and daughter Arielle are reunited with Priscillah in June 2013. They originally met Priscillah in 2010 when she was 15, recovering from major surgery to repair her fistulas. Priscillah was the first recipient of a scholarship to return to school,. This page, from top: Arielle and Priscillah; Joness at her sewing machine; Ann showcasing some of the shopping bags she created in the Stepping Forward program. All photos courtesy of Debra Matityahu, MD.

Another common thread in the stories was the desire to go to school, to be able to learn a trade and earn a living. Lack of funds was the common obstacle. While Dr. Matityahu listened, rapt, to each woman’s story, Arielle wondered, “Why do you keep interviewing girl after girl?” she asked “It’s the same story again and again. That’s just what happens here.” That didn’t sit well with Dr. Matityahu. Even after a month assisting Dr. Mabeya with fistula

repairs, she had to ask herself, “What am I doing for the women here? Am I making any lasting difference?” When Arielle learned that was all that stood in the way for these girls was approximately $24 for a uniform and school supplies, she was shocked. She went to her mother and said, “Just give me $24. We could do so much here for so little.”

ack home in Los Altos, Arielle started their nonprofit organization, A Little 4 A Lot, to raise funds to help women recovering from fistula repairs return to school or learn a trade. She created a website and Facebook page, got her friends involved, and raised funds by selling T-shirts she created at her school’s holiday craft fair at Egan Middle School. She recorded a 30-second commercial that was played on her school’s TV station. She even used the occasion of her bat mitzvah to publicize the work of A Little 4 A Lot and encourage donations. Dr. Mabeya and his wife, Carolyne, have also been an integral part of the work. A Little 4 A Lot administers three programs. The Scholarship Fund enables girls to return to primary and secondary school and is currently sponsoring six girls. Priscillah, the teenager who became pregnant through rape, was the first scholarship recipient. The Stepping Forward Program teaches skills to help the women learn a skill and achieve some financial independence. Currently, there are eight women who have been put through the program, learning to sew and learning computer skills with old laptops that have been donated and shipped to the center. The Microloan Program allows the graduates to purchase their own sewing machines. Emily, the woman who was disowned by her husband, was the first student in the program. Amongst other items, Continued on page 17

JANUARY 2014 | SAN MATEO COUNTY PHYSICIAN 11

NEW SMCMA MEMBERS

Amy Ak Akers, MD A *N/Burlingame

Christopher Bonzon, MD ristoph h er Bonzon *PMR/Redwood City

Chang, Mina Ch h ang MD IM/Redwood City

Robert Rob b ert Detch, Det ch h MD *ORS/Burlingame

Diana Droubi, MD D/Redwood City

Andrea Harzstark, MD ON/Redwood City

Lisa Hladik, MD *IM/Burlingame

George Huang, MD U/Redwood City

Samantha h Krawitzky, k MD FM/Redwood City

Karen Lee, MD *N, SLM/Menlo Park

Judy Liu, MD IM/S San Francisco

Zoe Martinez, MD *PSY/San Bruno

Welcome! Susan Thorne, MD FM/Redwood City

* Board-certified by the American Board of Medical Specialties

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HONORING THE PLACE WHERE THE LIGHT DWELLS: A Palliative Care Physician Learns from Her Patients Every Day

by Shoshana Helman, MD Victor* is a fascinating gentleman. He was diagnosed with relapsing progressive multiple sclerosis almost 20 years ago, and is now a quadriplegic from this disease. He goes out in public regularly in his wheelchair in an effort to normalize his disability. One of his goals in life is to “help others understand that someone in a wheelchair is just a regular person.” I first met Victor in the hospital after he had survived a cardiac arrest. After several weeks of right upper quadrant pain, his family finally was able to talk him into being seen in the Emergency Department. He was admitted on Christmas day with an abdominal abscess and sepsis, likely due to a ruptured diverticula; he went into cardiac arrest soon after he arrived at our Kaiser Permanente Redwood City Medical Center.

future, given how well he has recovered after the dramatic interventions that saved his life.

Curious about his ability to face such challenging personal circumstances for so many years with what appeared to be equanimity, I asked about his life philosophy. He said, “About seven or eight years ago, the phrase popped into my head, ‘I honor the place in you in which light dwells’ when I was meeting people. Soon after that first appeared, the word ‘I’ no Victor stated that he longer made sense to me. I can’t did not recall the “two explain it other than to say that ‘I’ didn’t fit, or didn’t have meaning or three minutes that any more. The phrase then changed, I was dead.” As he and this is what I hear in my heart described the love and every day now: ‘We honor the place in you in which the entire universe appreciation he felt dwells. We honor the place in you for the surgeon who which is of love, of truth, of light and of peace. And, when you are in “saved my life,” he was that place in us, and we are in that tearful and radiant all place in you, We Are One. Amen.’”

Victor stated that he did not recall the “two or three minutes that I was at the same dead.” As he described the love and appreciation he felt for the surgeon who “saved my life,” he was tearful and radiant all at the same time. He described a newfound appreciation for life and for all the people around him. His gratitude infused every sentence he shared and he talked about feeling like he was “bleeding love” all the time now. As a palliative care physician, I was there to inquire about his treatment goals, symptom management needs, choice of a healthcare agent, and the like. Victor considers himself lucky to have little pain or other symptoms on most days. And he is very willing to undergo another attempt at CPR if needed in the

time.

I was struck by just how close this language is to one definition I had heard of the term Namaste (a common greeting in certain Eastern cultures). Several websites I found reflected this description - Namaste: “I honor the place in you in which the entire universe dwells. I honor the place in you, which is of love, of truth, of light and of peace. When you are in that place in you, and I am in that place in me, we are one.” Victor was curious about that connection, having heard the term before but not recalling having learned Continued on page 17

* Victor gave permission to use his name and publicly provided details of his medical condition.

JJANUARY A NU NUAR AR R Y 201 2014 14 | S SAN AN M MATEO ATEO C COUNTY O U NT NTY Y PH PHYSICIAN H Y SICIAN 13

SHOULD MY DAUGHTER GO INTO MEDICINE?

by Christian Sendahl, MD It may come as a surprise to many folks not in the medical field that most medical doctors these days are not recommending a career in medicine to their children. According to recent studies of career satisfaction published in 2012 by The Doctors Company, the nation’s largest malpractice insurer, nine out of ten physicians would not recommend medicine to their college kids. One question everyone should ask is, what does this mean for the future of medicine? My wife and I are both physicians in our early 50s, and we have one daughter who just started college. She has naturally expressed some interest in medicine, so we asked ourselves how we felt about medicine as a career for her. Together we compared notes and surprisingly agreed on the following list in favor of and against medicine as a career choice.

Top Reasons to Become a Physician

acumen is what sustains many of us as we plod along, wondering who our next patient will be. 2. Medicine will provide a stable financial career. There will always be sick people who will need doctors to care for them and, thus, no shortage of work, The ability of the patients to pay for physicians has been eroded by the huge escalation in pharmaceutical costs and insurance company profit margins, but in the end, there will still be a need for good physicians.

1. Opportunity to help others.

3. Opportunity to be self-employed.

Although this is perhaps the most obvious, I think it is also the most important. In medicine, at the end of the day, you don’t have to think very hard about who you helped. This is not so easy in other professions where one is confined to a cubicle and a computer screen. Professions that directly help others, such as being a minister, a school teacher, a policeman, a nurse, or a physician, offer a daily opportunity for kindness.

I am in private practice and truly enjoy running my own business and controlling my own schedule. I get to hire and fire my own employees and give other people meaningful jobs with full benefits. My wife, on the other hand, has spent 23 years at a large medical group functioning essentially like an employee. She has no control over her schedule and frequently gets told she needs to work harder to keep her present salary. Her staff is unionized and she has little control over their productivity and their patient care skills.

The simple act of helping others is at the core of all medical care. The doctor-patient relationship is a sacred one, but no more sacred one than a teacherstudent relationship or the pastoral relationship a minister has with one of their congregation. The non-monetary benefit of directly helping others is a daily reward for the practicing physician. The ability to cure and treat with one’s own hands and diagnostic 14 SAN MATEO COUNTY PHYSICIAN | JANUARY 2014

It is getting hard to stay in private practice as many physicians jump to become employees of hospitals coupled with insurance groups. Even if there were a remote chance of being self-employed, I would highly recommend medicine as a career choice. The ability to work harder and make more money, rather than being

paid a salary and being told to work harder to justify your salary, seems like a no-brainer to me. Running a medical practice is not rocket science, and there are always professionals out there to help you stumble your way through the business side of medicine. 4. You can do other things besides medicine with an MD. Most of us practicing physicians fail to realize that we do have other choices besides actually seeing patients and doing surgery. Teaching in a medical school or university is also possible. There are positions with state and federal governments that favor those applicants with a medical degree. Opportunities arise as a medical expert in the legal world. It may be easier to get financing to start a new business in some health care related venture if one has an MD. With some additional training in business and management, many non-practicing physicians find employment with HMOs, insurance companies and medical groups in various roles as a medical director. In short, it would not be a waste of time and money if someone graduated from medical school but decided not to practice medicine!

STOP

Top Reasons Not to Become a Physician

On the flip side, why is that so many physicians are not recommending medical school to their collegeaged kids? 1. It takes a long time to get through medical school and residency, and it is expensive. To get a job as a physician, it takes four years of undergraduate training, four years of medical school, and three to seven years of residency, depending on your specialty. About 50 percent of specialities decide to do a fellowship, which can last from one to five years. That is a lot of time spent before beginning a medical practice! The American Medical Student Association predicts that by 2020, the average debt for graduating medical students will be $300,000. The increased cost of medical education has significantly outpaced the increases in income for the average physician. These increases continue to shape specialty choices with higher indebted students usually choosing a more lucrative profession. Advice to our daughter: If you can finish residency with less than $150,000 in debt, choose whatever specialty you wish. If you owe $300,000, don’t choose family practice or pediatrics

and expect to pay off your student loans in less than ten years. 2. Doctors are increasingly viewed as “providers” and not “healers.” The delivery of health care in America has become a business, a big business. HMOs, insurance companies, and hospitals now call physicians “providers” and consider us “cost centers.” Quality is no longer considered the most important attribute by the largescale physician employers, but rather how many patients can one provider see in a single day. Hiring as few providers as absolutely necessary to get the work done seems to be the norm in large HMOs. Productivity standards can be harmful to the doctorpatient relationship if the “provider” has only minutes to discuss a patient’s medical condition. Physician “extenders” is a common term for physician assistance and nurses who are now charged with filling the gaps that exist in our current health care systems. Many patients now do not get the luxury of even seeing a physician during their doctor appointments. Expect these gaps to widen as the population ages and more people enter the system through the Affordable Care Act. 3. Most new doctors will be employees of large health care systems and not private practitioners. These health care systems have to function as businesses and, as such, need to operate with a profit margin. This means paying physicians as little as possible for the services they provide while persuading them to work harder. These health care systems shift costs by paying primary care physicians above-market rates and various surgical specialists below-market rates. Employee physicians can be fired for failing to follow a set practice pattern. Most new physicians seem to want both the security of practicing in a large group and the lifestyle of working “9 to 5,” leaving time for family and recreation. The ideal of being your own boss as a physician is an ideal that will likely be much harder to attain for the next generation of physicians. 4. New regulations are making medicine less efficient. The current amount of waste in hospital-based medical care is abominable. I estimate that nearly $500 of eye drops are wasted after each cataract surgery I do in the hospital-based ambulatory surgery center due to poorly written laws. Continued on page 17

JANUARY 2014 | SAN MATEO COUNTY PHYSICIAN 15

COVERED CALIFORNIA FAQS FOR CLINICIANS & THEIR STAFF What Is Covered California? Covered California is the new marketplace where Californians can compare and purchase health coverage. Through Covered California, many patients will be eligible for financial assistance to help pay their premiums and even co-pays. Individuals and small businesses can compare different health insurance companies and learn whether they qualify for premium assistance and tax credits. Californians will also be able to find out if they are eligible for low-cost or no-cost health coverage through Medi-Cal. Legal California residents, except for currently incarcerated individuals and legal minors, are eligible to buy insurance through Covered California. How will Covered California impact my practice? The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage. Small and medium-sized physician practices with 50 or fewer employees are also eligible to participate in the Small Business Health Options Program (SHOP). Which patients are eligible for subsidies to purchase coverage? Premium assistance is available to individuals and families who meet certain income requirements and do not have access to affordable, adequate health insurance through their employers. Eligibility for premium assistance is based on family income and the number of people in the family. The size of the premium assistance is calculated on a sliding scale, with those who make less money getting more financial assistance. Individuals with incomes up to $45,960 and a family of four with an income up to $94,200 may be eligible for premium assistance.

actual income. A patient may be held accountable for any excess subsidies received when filing that year’s taxes. For this reason, patients should immediately report any changes in income to Covered California that may impact the amount of premium assistance, such as changing jobs, losing a job or receiving a promotion. Will my Covered California patient be able to continue to see me? You will have to be contracted with a Covered California plan and your patient will have to select that plan. Each health insurance plan has a specific list of doctors and hospitals that are considered innetwork providers for covered services. Directories of doctors and hospitals will be available at www.CoveredCA.com. Patients should be advised to verify with the individual plan that a particular doctor’s or hospital’s services will be covered under that plan. Covered California is providing a searchable online directory so that patients can see which health plan networks contain a particular doctor or hospital. How can a patient apply for Covered California Coverage or Medi-Cal? Open enrollment will continue until March 31, 2014, but patients must enroll in a plan by December 15, 2013, for coverage to begin January 1, 2014. In subsequent years, open enrollment will run from October 15 through December 7. Patients can apply for a Covered California health insurance plan online at www.CoveredCA.com or by calling (800) 300-1506. In-person assistance is also available from Certified Enrollment Counselors in many communities. Patients can be directed to their nearest Certified Enrollment Counselor by calling (800) 300-1506. How much should patients expect to pay out of pocket for health care services? Patients’ co-pays and deductibles will vary based on the plan that is selected.

How will federal premium subsidies work? Federal premium assistance is only available when enrolled in a health plan through Covered California, and it is paid directly to the health plan in which the patient is enrolled. Premium assistance will be adjusted at the end of the benefit year based on the patient’s 16 SAN MATEO COUNTY PHYSICIAN | JANUARY 2014

This information was compiled from the CMA brochure, “Covered California FAQs for Clinicians and Their Staff.” Find the complete brochure, which includes information about patient premiums and standard benefit designs by tier, please visit www.smcma.org/coveredca.

DEBRA MATITYAHU, MD

HONORING THE PLACE WHERE THE LIGHT DWELLS

continued from page 11

continued from page 13

they sew colorful tote bags that are sold in the United States to raise funds to bolster the program and help more women. The Matityahus returned to Kenya in June 2013 to visit old friends and see how far they had come. Son Jake, now eleven, got involved with the interviewing. Indeed, the effort was a family affair: In the fall of 2013, Dr. Amir Matityahu helped to organize and rode in a mountain bike event to raise funds for A Little 4 A Lot. Thanks to the efforts of the family, and others, more women who had previously given up hope will be able to tell a new story: one of empowerment, perseverance, and independence. ■ To learn more and find out how you can get involved, please visit www.alittle4alot.com.

its definition. He mentioned that “Love, Truth, Light and Peace” are words he lives by and repeats them to himself all day long. He was as radiant discussing these things as he’d been when recounting his near-death experience. I don’t suppose it matters whether this is an eternal truth which has a way of finding itself into the hearts and ears of those who are listening, or whether it is something he heard one day and liked. All I know is that I prefer Victor’s version best. And I hope to face my own challenges in life with even half the courage he’s shown. Meeting people like Victor is what makes work as an inpatient palliative care physician beautiful. ■

About the Author Shoshana Helman, MD, is Chief of Palliative Care at Kaiser Permaente in Redwood City. Before joining Kaiser, she launched inpatient Palliative Care programs at two hospitals in San Jose. A graduate of UCSF School of Medicine, she is board-certified in internal medicine.

SHOULD MY DAUGHTER GO TO MEDICAL SCHOOL? continued from page 15 The transition to electronic medical records (EMR) is another sensitive area for physicians. It is estimated that a practice that adopts EMR will suffer a productivity loss of 30 percent during the first year of implementation. These EMRs are costly and seem to have a short lifespan as the electronic medical highway tries to become interconnected, a goal that seems to be several generations away and mission of dollars in the future.

Insurance billing complexity seems to increase exponentially, further reducing the amount of time your doctor has to spend with you. Witness the new ICD-10 (replacing the ICD-9), which has 68,000 billing does in order to get paid. Using this data, insurance companies can get even more information about you, such as exactly how you fell and broke your leg.

The Affordable Care Act places a premium on the patient experience with a physician and not on the actual quality of care they provide. Doctors now spend precious time looking at results of patient surveys rather than at the patient’s medical condition.

I gave my daughter a cautious thumbs-up about a career in medicine while my wife gave her a thumbs-down! This is not so surprising, since my wife and I rarely agree on anything. In the end, our daughter will do what she chooses, and she won’t disappointed

The bottom line for our daughter?

in whichever path she follows, as long as she finds something she has a passion for and tries to graduate from college in four years. After all, what 18-year-old does what their parents tell them anyway? ■ About the Author Christian Serdahl, MD, is an ophthalmologist practicing in Sacramento. This article was originally published in the January/February 2014 issue of Sierra Sacramento Valley Medicine.

JANUARY 2014 | SAN MATEO COUNTY PHYSICIAN 17

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