S a n M at e o C o u n t y
November/ December 2015
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
Physician H appy H olidays
IN S ID E
Volume 4 Issue 10
In support of annual screening mammography
2015 legislative victories
Actions of the 2015 House of Delegates
CMA/San Mateo County Medical Association sponsored Health Insurance Program
It’s the time of year to look at your off-exchange health insurance options for 2016! Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2016. The open enrollment period for individual and family plans starts on November 1, 2015. Many practices have open enrollment periods for small groups on December 1, 2015 or January 1, 2016. Did you know that you can get the right insurance though the CMA/San Mateo County Medical Association sponsored Medical program with Mercer? If you are just covering yourself, or if you’re covering your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget. All of the health plans offered outside of the health insurance exchange are available. It doesn’t matter if your current coverage is “Grandfathered,” “Grandmothered,” or already ACACompliant and Platinum, Gold, Silver or Bronze, Mercer can help you determine what’s best for you. Call today at 800-842-3761 or visit www.CountyCMAMemberInsurance.com.
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S a n M at e o C o u n t y
Physician Editorial Committee Russ Granich, MD, Chair Judy Chang, MD Uli Chettipally, MD Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor
November-December 2015 - Volume 4, Issue 10 Columns President’s Message: The House of God....................................................... 5 Michael Norris, MD
SMCMA Leadership
Executive Report: See you in 2016.............................................................. 7
Michael Norris, MD, President; Russ Granich, MD, President-Elect; Alexander Ding, MD, SecretaryTreasurer; Vincent Mason, MD, Immediate Past President
Sue U. Malone
Alex Lakowsky, MD; Richard Moore, MD; Michael O’Holleran, MD; Joshua Parker, MD; Suzanne Pertsch, MD; Xiushui (Mike) Ren, MD; Sara Whitehead, MD; Douglas Zuckermann, MD; Dirk Baumann, MD, AMA Alternate Delegate; Scott A. Morrow, MD, Health Officer, County of San Mateo;
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. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.
Feature Articles In support of annual screening mammography. . .................................... 9 Harriet Borofsky, MD
2015 legislative victories. . ...................................................................... 11 Shannon Goecke
Actions of the 2015 House of Delegates. . .............................................. 12 CMA Staff
Walk with a Doc: Thanks for a great year. . ............................................. 13 Shannon Goecke
Of Interest Membership updates, index of advertisers..........................................14
© 2015 San Mateo County Medical Association
On the cover: “The Skating Minister” by Henry Raeburn - http://www.nationalgalleries.org/object/NG%202112. Licensed under Public Domain via Commons - https://commons.wikimedia.org/wiki/File:The_Skating_Minister. jpg#/media/File:The_Skating_Minister.jpg.
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4 SAN MATEO COUNTY PHYSICIAN | NOVEMBER-DECEMBER 2015
President’s Message
The House of God I recently re-read The House of God, a satirical novel published in 1978. It details the intern experience of a young doctor at the House of God, patterned after Boston’s Beth Israel Hospital. The author is Samuel Shem, pen-name of psychiatrist Dr. Stephen Bergman. Like the novel’s protagonist, Roy Basch, the author spent his internship at the House of God.
Michael Norris, MD President
Roy is a graduate of the Best Medical School (BMS=Harvard) and has landed a prized slot at the prestigious institution of healing. There he meets his mentor, the Fat Man, a medical resident who preaches the Rules of the House of God. There are 13 rules, including number 6: “There is no body cavity that cannot be reached with a #14 needle and a strong right arm.” As Roy proceeds though his year, he also learns Rule number 13: “The delivery of medical care is to do as much nothing as possible,” for he discovers that many of his elderly patients actually do better without numerous tests and interventions, while his younger patients will often die despite all his efforts.
The passing of the torch...
The novel depicts the sleep deprivation, the housestaff camaraderie, the relationships with the nursing staff (often sexual). There are passages that are laugh-out-loud funny, yet others portraying housestaff isolation, depression, and even suicide. I first read this book in the late 1970s, as a general surgical resident. All of my fellow residents read it, and we would often quote the wisdom of the Fat Man. The broad satire seemed, at the time, to miss the truth by only a small amount. Bergman wrote this book in part to protest the inhumanity of the graduate medical education process of the time. As Chuck, another intern, wonders, “How can we care for patients, man, if ’n nobody cares for us?” The interns see the flaws in the system, in the delivery of medical care, and try to change it, ultimately by opting out. Protagonist Roy Basch, like Bergman, goes into psychiatry. Many young doctors loved The House of God because it resonated with their own experiences during their internship training, but many senior physicians found it offensive. A movie was made of the novel in 1984, starring Tim Matheson as Roy Basch, but it was considered too dark and never released in theaters, though it was shown on HBO a few times, mostly as filler in non-peak hours.
Many young doctors loved The House of God because it resonated with their own experiences during internship training, but many senior physicians found it offensive.
Re-reading the book after 36 years made me a little nostalgic for the young me, those days and nights spent in the hospital. Yet I can now see, as an “older” doc, how it can also be accused of casting the medical profession in a negative light. ■
NOVEMBER-DECEMBER 2015 | SAN MATEO COUNTY PHYSICIAN 5
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Executive Report
See you in 2016 When the SMCMA (then called the San Mateo County Medical Society) held its first official meeting in 1905, there were just 16 physician members, and they agreed to meet five or six times per year to discuss the latest developments in medicine. Seldom more than ten physicians were able to attend these meetings.
Sue U. Malone Executive Director
Our membership has grown since then, as have the number of opportunities for physicians to connect with their peers. Our social networks in particular have changed dramatically in the past few decades. Before the internet, we wrote letters, made phone calls, and met people face-to-face. Today, individuals can get professional information and advice on a million different topics via online discussion groups, 24/7, from anywhere in the world; and establish new professional contacts by clicking a button on a website or an app, instead of picking up the phone and asking a shared acquaintance to make an introduction. But our online relationships and activities should augment our offline ones, not replace them. There’s no substitute for face-to-face interaction. That was clear on the evening of December 3, 2015, when the SMCMA held a physician networking mixer for its members at TasteVin Wine Bar & Bistro, a warm and intimate venue in downtown San Carlos. The event was generously sponsored by the Cooperative of American Physicians. We had the pleasure of seeing forty of our members from a variety of practice areas, some long-term members and some brand-new ones that evening. Feedback from guests was extremely positive. While the association hosts an elegant annual gala every June, this was the first more casual mixer we’ve had in a while. We want to thank everyone who was able to join us. Based on your feedback, we look forward to providing more social events and other opportunities to connect, face-to-face, in 2016. We hope to see you there. ■
When the SMCMA held its first official meeting in 1905, there were just 16 physician members, and they agreed to meet five or six times per year to discuss the latest developments in medicine.
NOVEMBER-DECEMBER 2015 | SAN MATEO COUNTY PHYSICIAN 7
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8 SAN MATEO COUNTY PHYSICIAN | NOVEMBER-DECEMBER 2015
IN SUPPORT OF ANNUAL SCREENING MAMMOGRAPHY Last month in JAMA, the American Cancer Society (ACS), a highly influential organization in cancer care policy in the United States, revised its breast cancer screening recommendations to align itself in the direction of the United States Preventative Task Force (USPTF) and the current trend toward considering harms over benefits/ stress and anxiety due to false positive results over value of lives saved; while at the same time, acknowledging the undisputed fact that annual screening mammography, starting at age 40, reduces mortality from breast cancer. by Harriet Borofsky, MD These new guidelines are intended for average-risk women and raise the age to begin annual screening from 40 to 45, increase the interval between screening from annual to biennial at age 54, but maintain an individual woman’s right to access annual screening mammography starting at age 40. How insurance carriers, which are currently mandated to cover screening mammography annually starting at age 40, will react to these guidelines, and the impact this may have on women’s decision to be screened and ultimately on women’s health, is yet to be determined. As we clinicians face increasingly complex discussions with our patients about benefits versus harms of mammography, in light of these conflicting, confusing and ambiguous screening guidelines, the following facts should be considered: 1. It is appropriate to screen for breast cancer. Breast cancer meets established criteria for population-based screening: it is the most common cancer in women worldwide, it is a leading cause of premature mortality in women, and it is progressive. The majority of breast cancers are sporadic and most women diagnosed have no known risk factors, other than gender and age. Early detection is an opportunity to decrease chance of metastatic spread, decrease morbidity and mortality, and increase surgical and medical treatment options. 2. Proof of benefit of mammographic screening is well established. Eight randomized controlled trials (RCTs) have confirmed a 23%-44% mortality reduction in women invited to be screened versus those not invited to be
screened. In fact, since mammographic screening programs began in the 1990s, the mortality from breast cancer, which had been unchanged in the preceding 50 years, has declined by 30% across all age groups. 3. Screening mammography benefits women in their 40s. Breast cancer incidence increases linearly with age, starting at age 35. Approximately 20% of all breast cancers diagnosed are in women in their 40s, who tend to have more aggressive tumors and greatest potential productive years of life. Observational studies in assessing the benefits of mammography in women in their 40s estimate mortality reduction from screening ranging from 20% to 40%. 4. Annual screening mammography intervals detect earlier stage tumors. Recent analysis by the Breast Cancer Surveillance Consortium (BCSC) comparing annual vs. biennial screening found that the proportion of tumors that were stage IIB or higher and larger than 15 mm was greater for biennial screening than annual screening in all women, especially those premenopausal. 5. Screening has led to a paradigm shift in management of early stage breast cancer. The majority of breast cancers diagnosed today are mammographically-detected, early stage tumors. This has led to less invasive surgical procedures, such as sentinel lymph node biopsy in lieu of axillary breast dissection, increased radiation therapy breast radiation, and endocrine therapy in lieu of chemotherapy for many women.
Artwork: “Weiblicher Halbaktby” (“Woman Half-Clothed”) by Vlaho Bukovac, 1922, [public domain], via Wikimedia Commons NOVEMBER-DECEMBER 2015 | SAN MATEO COUNTY PHYSICIAN 9
6. Improvements in screening mammography and core needle biopsy techniques have minimized the “harms” of false positive mammograms. Screening mammography is not a perfect screening test. Sensitivity is inversely related to breast density and, in our medical audit data, ranges from 94% in fatty breast tissue down to 71% in extremely dense tissue. False negative results may lead to a false sense of security and delay in diagnosis. Approximately 10% of women screened will be recalled for additional evaluation; , of those, only 2%-5% will be diagnosed with breast cancer. False positive results may lead to biopsies, most of which are benign. Digital breast tomosynthesis, an advanced application of digital mammography, has markedly improved overall accuracy of mammographic screening, decreasing the recall rate by 15-30% and increasing breast cancer detection by 30%-50%. Minimally invasive core needle biopsies have replaced surgical excisional biopsies, providing safe, well tolerated, effective tissue diagnoses with prompt results.
Did I remember to renew my SMCMA membership?
7. Multidisciplinary teams of breast specialists minimize the potential harms of “overtreatment.” Breast cancer is a heterogeneous disease occurring in women of varying ages, values, lifestyles and co-morbidities. Targeted, individualized treatments, based on specific tumor characteristics and recurrence risk assessment, along with patients’ personal preferences, tolerance for risks and goals are now the standard approach to management. Screening mammography has had an undeniable, overall significant and positive impact on the health and lives of countless of women. The Mills-Peninsula Women’s Center remains committed to providing the highest quality of care dedicated to the early detection and diagnosis of breast cancer, while striving to recognize and minimize the stress and anxiety associated with the screening process; including utilizing important new technologies to minimize false positives, scheduling patients promptly for recalls and biopsies, and discussing results with patients directly to answer their questions and concerns and involve them in follow-up decisions. Based on the current evidence and over two decades of clinical experience, the Breast Tumor Board at Mills-Peninsula, a multidisciplinary team of breast specialists, agrees that the benefits of mammographic screening far outweigh the harms. We continue to support and recommend annual screening mammography for all women, ages 40 and above.
About the author Harriet Borofsky, MD, is medical director of breast imaging at Mills-Peninsula Women’s Center, the first of its kind in the region to provide expert diagnosis, treatment and education for health issues that are specific to women. She attended Brown University and Harvard Medical School.
10 SAN MATEO COUNTY PHYSICIAN | NOVEMBER-DECEMBER 2015
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2015 LEGISLATIVE VICTORIES Your SMCMA/CMA membership enables us to take action and influence policy on the issues that affect you. No other organization at the state and local level provides such comprehensive legislative services on behalf of all physicians. Here is just a small sampling of our legislative achievements of 2015. For more comprehensive information about the 2015 legislative session and 2016 health laws of interest to health care professionals, please visit smcma.org/advocacy/state-advocacy.
Keeping children safe—Passing Senate Bill 277 In early 2015, the U.S. experienced a large, multi-state measles outbreak linked to Disneyland, and a traveler who became infected overseas with measles and visited the amusement park while infectious. The outbreak sickened 147 people in the U.S., including 131 in California. Soon after, State Senator Richard Pan (D-Sacramento) introduced Senate Bill 277, which requires almost all California schoolchildren to be fully vaccinated in order to attend public or private school, regardless of their parents’ personal or religious beliefs. From its inception, the bill was met with opposition and controversy, but we continued to fight to protect our communities from preventable infectious diseases. Governor Brown signed SB 277 on June 30, 2015, making California one of only three states that permit only medical exemptions as legitimate reasons to sidestep vaccinations.
Protecting patient safety—Defeating the Scope of Practice Bills In 2009, a review of 381 cases at the VA Palo Alto Health Care System revealed that eight veterans had suffered “significant” vision loss, and another 23 suffered progressive vision loss, after optometrists there had ignored requirements to refer glaucoma patients to an ophthalmologist so that their so their glaucoma treatment could be appropriately monitored by a physician specialist. Senate Bill 622, introduced by Ed Hernandez (D-West Covina), in February 2015, would have expanded the scope of practice of optometrists to include the ability to perform laser and scalpel surgeries with only minimal education, training, and supervision requirements. Optometrists simply do not have the training, education, or experience to provide these services. Facing pressure from SMCMA and others, the author withdrew the bill in July 2015.
of supplementary procedures with little additional training including scalpel surgeries, laser surgeries and intraocular injections. SB 622 was scheduled to go before the Senate Business and Professions Committee in July but was pulled at the request of the author. Another scope bill, SB 538, introduced by Block (D-San Diego) would have allowed naturopathic doctors (NDs) to prescribe Schedule V drugs and drugs that are not classified on the DEA schedule, without physician supervision. SB 538 also would have modified under what circumstances an ND may order diagnostic imaging studies and dispense, administer, order, prescribe, provide or furnish devices and durable medical equipment. SB 538 failed in the Assembly Appropriations Committee in August.
Protecting access to care—Defeating Assembly Bill 533 Assembly Bill 533 was introduced to prevent consumers from receiving surprise bills when seeking care at an in-network facility, but it would have caused problems to the health care delivery system much more significant than those it aimed to solve. Introuced by Rob Bonta (D-Oakland), AB 533 would have transferred negotiating power to the health plans at the expense of physicians, requiring non-contracted physicians/providers to accept the “average contracted rate”—as determined by the health plan—when performing services in a contracted or “in-network” facility. In so doing, AB 533 would have eliminate incentives for health plans to provide fair contract terms to physicians and discouraged hospital-based and on-call specialists from accepting PPO patients. After countless hours of lobbying and passionate debate at the State Capitol, the measure was defeated on the floor of the State Assembly in September—the final act taken by the Legislature in 2015.
A separate scope of practice bill, SB 622, also authored by Senator Hernandez, would have allowed optometrists to perform an array NOVEMBER-DECEMBER 2015 | SAN MATEO COUNTY PHYSICIAN 11
Extending the CURES deadline—Passing Assembly Bill 679 CURES (Controlled Substance Utilization Review and Evaluation System) is a national online database that allows providers access to patients’ prescription records for controlled substancesto help monitor for prescription misuse, abuse or diversion. CURES evolved from California’s triplicate prescription program, created in 1940 to monitor schedule II controlled drugs including morphine, oxycotin, and methadone using duplicate prescription pads. In 1996 CURES was established as a pilot project by the California Board of Pharmacy. The Pain Treatment and Drug Diversion Prevention Act of 2003 made CURES a permanent program. However, a Los Angeles Times investigation in 2012 found that less than 10 percent of doctors, pharmacists and other eligible providers actually had signed up to use CURES. In 2013, SB 809 required health practitioners who
prescribe or dispense narcotics to subscribe to CURES by the end of 2015, but the endeavor has been plagued by technical problems with the database and an onerous registration process for users. SB 809 required the California Department of Justice (DOJ) to identify and implement a streamlined application and approval process for CURES registration, which was seen as essential to meeting the January 1, 2016, registration deadline. DOJ has not issued a definite date for when streamlined registration will be available, so we pursued an extension. AB 679, authored by Travis Allen (D-Huntington Beach) and signed by the Governor in October, will allow the Department of Justice to roll out is automated registration process and protect doctors from being disciplined by the Medical Board of California during the system roll-out. ■
ACTIONS OF THE 2015 HOUSE OF DELEGATES More than 500 California physicians convened in Anaheim October 16-18 for the California Medical Association’s (CMA) 2015 House of Delegates (HOD), the association’s annual meeting. Below are highlights of the actions taken at this year’s meeting. All actions of the House can be found at at www.smcma.org/advocacy/cma-hod.
Tobacco (Res. 107-15): Strongly objects to pro-tobacco efforts by the U.S. Chamber of Commerce in other parts of the world and urges all conscientious companies that are members of the Chamber to either take similar action or quit their membership to protest such anti-health efforts. Public Health Funding (Res. 112-15): Urges state health and legislative officials, through the state budget process, to develop a plan to repair California’s public health infrastructure and funding for prevention services. Biomedical Careers (Res. 609-15): Supports pipeline programs targeting underrepresented minority and disadvantaged students to help increase ethnic minority physicians in medically underserved areas. Implicit Bias Training (Res. 610-15): Support studies of the impact on patient care of “implicit bias” and supports the inclusion of implicit bias training in medical school curriculums and CME programs. HSA Limits (Res. 411-15): Supports increasing dollar amounts eligible for tax-free deposit into a health savings account to cover a greater proportion of an enrollee’s potential out-of-pocket costs in a high-deductible health plan. Hospital Affiliation Requirements (Res. 402-15): Opposes the health plan practice of requiring physicians to maintain a hospital affiliation in order to contract with the plan. Many physicians, for a variety of reasons, no longer physically practice in a hospital setting; requiring them to have hospital privileges at an in-network facility to contract with a health plan unfairly penalizes physicians whose practices do not require interaction with a hospital, and potentially reduces access to care for patients. Administrative Burdens (Res. 404-15): Supports a requirement that each health plan provide a single comprehensive information resource (telephone or online) that can address all inquiries related to benefit eligibility, provider plan participation and service pre-certification. Powdered Alcohol (Res. 104-15): Encourages an established health research entity to evaluate powdered alcohol products for potential health and societal impacts. The resolution also calls on CMA to advocate for the development of regulatory controls for powdered alcohol products similar to those for liquid alcohol products, including regulation on sales, marketing, product placement, packaging and warning labels. ■
12 SAN MATEO COUNTY PHYSICIAN | NOVEMBER-DECEMBER 2015
WALK with a DOC Many thanks for a successful year! Walk with a Doc is a free program of the San Mateo County Medical Association Community Service Foundation that aims to encourage physical activity in people of all ages and fitness levels. Members of the community walk side-byside with volunteer physicians, who can answer their health-related questions along the way. Walks take place on Saturday mornings at some of our county’s most picturesque public spaces. Our WWAD program was launched in 2012 and has grown steadily each year. This has been our most ambitious year yet, with 30 walks at 15 different locations, from East Palo Alto to Daly City. The feedback from walkers has been overwhelmingly positive. Here are some of their comments: “ It is really worthwhile; it motivates us to walk in good company.” “ I love the experience. I enjoy speaking with professionals. Thank you so much for caring and crewing the events.” “ It’s a great idea, inspiring folks who at times need a little social encouragement to walk. It’s also a safety feature for someone like myself, who wants to recover and get moving again, knowing that, if I have a problem, there is a doctor nearby. “ This success of this program depends on our volunteer physicians, and we would like to thank the members who walked with us this year: Aruna Chinnakotla, MD Pamela Carrington- Tribble, DO Emily Hu, MD Eshwar Kapur, MD Eva Liu, MD Vincent Mason, MD Suzanne McKell, DO Michael Norris, MD Sharon Ou, MD Dennis Park, MD Josh Parker, MD
Adekemi Oguntala, MD Niki Saxena, MD Wendy Smith, MD Srirat Sritulanonda, MD Lizabeth Staniotes, MD Elizabeth Watson, MD Barbara Weissman, MD Sara Whitehead. MD Kristen Willison, MD Pearl Wu, MD Wendy Zeng, MD
Many thanks, also, to our Walk with a Doc program sponsors:
NOVEMBER-DECEMBER 2015 | SAN MATEO COUNTY PHYSICIAN 13
SMCMA welcomes new members
RETIREMENTS The following SMCMA member has recently retired from practice:
Edward Fischer, MD
Diana Divanji, MD Obstetrics & Gynecology Burlingame
Whitney Landa, MD Child Psychiatry, Psychiatry Redwood City
Oloruntoyin Falola, MD *Dermatology Burlingame
Shenghua Lang, MD Internal Medicine Daly City
In Memoriam Kent Barber, MD August 7, 2015 Stanley Lann, MD May 23, 2015 Frederick Schaaf, MD June 1, 2015
Umesh Gheewala, MD *Internal Medicine, Pediatrics Burlingame
Frederick Mugler Jr., MD January 19, 2015
Kiki Lwin, MD Geriatric Medicine, Family Medicine Redwood City
Richard Myler, MD October 9, 2015 Robert Sieling, MD August 24, 2015
Correction to the July/August 2015 issue of San Mateo County Physician Jimmy Kakkanad, MD *Pediatrics Foster City
It has come to our attention that the July/August issue incorrectly listed one of our members as having retired. *Board-certified
Please be informed that DR. RICHARD B. BRAUNSTEIN has NOT retired from practice. We apologize for any confusion. Dr. Braunstein’s information is as follows:
INDEX OF ADVERTISERS Cooperative of American Physicians........................ Inside Back Cover The Doctors Company....................................................................................... 6 Institute for Medical Quality............................................................................ 8 The Magnolia of Millbrae................................................................................. 4 Mercer.....................................................................................Inside Front Cover NORCAL.............................................................................. Outside Back Cover Tracy Zweig Associates................................................................................... 14
14 SAN MATEO COUNTY PHYSICIAN | NOVEMBER-DECEMBER 2015
RICHARD B. BRAUNSTEIN, MD Board-certified in Ophthalmology San Carlos Eye Care 750 El Camino Real, San Carlos, CA 94070 Phone: 650/596-1999; Fax: 650/596-1987 Email: rbraunstein@comcast.net
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