June 2012 | Volume I /No. 5
A Publication of the San Mateo County Medical Association
Coming Soon... Walk with a Doc July 14, 2012 A San Mateo County Medical Association community event that brings together physicians and community residents to walk together and discuss healthy living.
A former employee sued me for wrongful termination.
What do I do now? You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. SMCMA members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are: • A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of
your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations. • If a member seeks Helpline advice on an employee termination which later results in a claim, there is
a 50% reduction of the member’s EPLI deductible for that claim. • Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors. • EEO compliance training for managers/supervisors. An internet-based training program, compliant with
California law, provides supervisors with sexual harassment training. • A low, minimum premium of $1,500 annually. • Wage and Hour Defense Coverage.
For more information on these important benefits, and the special SMCMA First-Time Buyers program, please contact Marsh at 800-842-3761 or email us at CMACounty.Insurance@marsh.com. Sponsored by:
59810 (6/12) ©Seabury & Smith, Inc. 2012 • 777 S. Figueroa St., Los Angeles, CA 90017 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance@marsh.com
d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #SL0633005 • AR Ins. Lic. #245544 • 800-842-3761
SMCMA services
SMCMA Educational Opportunities The San Mateo County Medical Association frequently offers educational programs for physicians and their staff, either webinar or in-person format. These programs contain a tremendous amount of value in terms of improving your practice’s bottom line. This month alone, the San Mateo County Medical
Care (June 14), Physicians and Implementing a Billing Compliance Program - A
San Mateo County Physician
Practical Perspective for a Physician’s Office (June 26). If you haven’t registered
June 2012
for a SMCMA educational seminer, please do so today!
Vol. I / No. 5
Association hosted three webinars - HIPAA and Meaningful Use (June 12), Delivering and Billing for Preventive Care - An Untapped Opportunity for Primary
We carefully select faculty that have extensive experience and a long history working with medical practices on topics that range from customer service in a medical office, Medicare updates and issues, running a medical practice, coding and much more!
Table of Contents President’s Message..........................5 Executive Report................................7
We are in the process of planning our Fall 2012 slate of programs and are
Active Access.....................................8
looking for feedback in terms of what educational topics would be of interest to
Obscure Gastrointestinal Bleeding.............................................9
you and your practice. So far, we are planning a program on marketing a medical practice, additonal practice management as well as billing courses. Do you have an idea for an educational program? Let us know what courses we should be offering by contacting smcma@smcma.org or (650) 312-1663. In the mean time, you can check the SMCMA website for a calendar of educational programs available at www.smcma.org/events.
Breast Tomosynthesis: 3D Mammography.................................10 My Mission of Palliative Care...................................13 SMCMA Nominating Committee Report............................17 Membership Update and Classified Ads..................................18
SAN MATEO COUNTY PHYSICIAN | page 3
LIFE INSURANCE
DISABILITY Protecting the rights of all policyholders to be treated fairly and in good faith.
Unfortunately, the same insurer that readily accepts your premium dollars may not be so eager to pay benefits. Pillsbury & Levinson lawyers pursue insurance bad faith litigation on behalf of doctors and their patients in coverage disputes. We seek compensation for our clients’ financial losses, as well as punitive damages and attorney’s fees. We have collected hundreds of millions of dollars in policy benefits for clients throughout California in all types of insurance matters.
415.433.8000 | 888.433.8335
pillsburylevinson.com
Lo n g -T e r m C a r e
president’s message
Practicing Medicine in a Digital Age By gregory Lukaszewicz, MD
An editorial in a recent issue of General Surgery News titled ,“HAL” caught my eye, as any reference to the murderous computer in Stanley Kubrick’s classic 1968 film 2001, A Space Odyssey, would. The author of the editorial, a vascular surgeon in Southern California, lamented what he predicted would lead to the ultimate demise of his career. It would not be failing eyesight, an uncontrolled tremor, a degenerative neurologic disorder or cancer. Rather, it would be…the electronic health record or EMR. For the author of the editorial and perhaps for many physicians, the EMR is fraught with issues beyond simply learning and navigating a complex new technology. These problems include the cost of the system to the individual physician (as well as society as a whole); the vast amount of data that is generated and the difficulty of obtaining information that is essential without having to wade through countless meaningless details; the transformation of nurses and even physicians into data enterers rather than care givers; and the (further) loss of physicians’ autonomy and authority. Beyond these concerns, it appears that what the author is truly anxious about is how the EMR is yet another example of the radical changes that are taking place in the medical profession which he has known, loved and practiced for a number of years. Though I can certainly sympathize with the author’s viewpoint. However, as one who has used an EMR for a number of
years now, I personally feel that the benefits, from the standpoint of the individual user and patient, far outweigh the difficulties in learning to use it. I am not, by any means, a technology junkie (I have resisted buying a smart phone or iPad, lack a Twitter or Facebook account, prefer music played on a record player to an MP3 player) and it was, and continues to, be difficult and even painful at times to learn to navigate the EMR. However, I could not imagine going back in time to the paper charts that were used when I started my career over a decade ago. The ease of communication with my colleagues and patients, the security of knowing that my orders are being transmitted and read as I have written them, the ability to quickly search a chart and find the patient’s past medical and history, knowing that any study I order will arrive in my inbox in a timely manner are all invaluable pros of the EMR. There is an additional aspect of the EMR, beyond the benefits to individual physicians and their patients - the ability to collect large amounts of data from a public health perspective. A recent story on NPR regarding fracking illustrates this point. Fracking is the process of injecting large volumes of water, sand and chemicals into shale rock to release oil or natural gas. Though the process has been around since the 1950s, it has only come into widespread use over the past decade. However, a number of concerns about the environmental and health risks associated with fracking have been
raised at an anecdotal level, but which have yet to be examined with any type of rigorous data analysis. In Pennsylvania, fracking is being used to develop the Marcellus Shale which is believed to contain huge reserves of natural gas. Over the last several years, roughly 5000 wells have been drilled and thousands more are planned. However, stories are emerging from people living near the gas wells of chemical and gas contamination in the local water supplies and an increase in illnesses such as asthma and skin conditions. In order to examine these health questions, epidemiologists are using the electronic medical records of the Geisinger Health System, which cares for over two million Pennsylvanians and whose electronic health record system goes back about ten years, several years before fracking started. By focusing on one condition such as asthma, epidemiologists can examine the records of a large population, including visits to the emergency department, primary care physicians and pulmonologists, emails and phone calls, pharmacy records and the results of pulmonary function tests to see if there is an increase in the rates or severity of asthma complaints since fracking became widespread. In addition, the data and resulting conclusions will hopefully be neutral and untainted by ideology or political bias so as to present an accurate picture of the health risks of fracking. We are clearly living in the midst of the digital continued on page 17
SAN MATEO COUNTY PHYSICIAN | page 5
page 6| San Mateo county physician
EXECUTIVE REPORT
SMCMA Kicks Off “Walk with a Doc” Program By sue u. malone
Next month, SMCMA will commence a new community service project, “Walk with a Doc” fitness regimen. Our first event will be held on Saturday, July 14 at the Sawyer Camp Trail. Staying healthy can be a walk in the park, literally. And if your patients are talking with a doctor, all the better. Walk with a Doc is a free walking program for anyone who is interested in taking steps to improve their health. We all know walking is a great way to feel better and get healthy at the same time. Walk with a Doc is the brainchild of an Ohio physician, David Sabgir, MD, a cardiologist who initiated the program in his hometown of Columbus. SMCMA will recruit physicians who are willing to give up part of a Saturday to meet and walk with participants, for approximately 60 minutes. Initially, we are planning walks every other weekend at different trails and parks across the County. Fortunately, in San Mateo County we have a plethora of choices. The format for this activity would commence with a free blood pressure check for those walkers who choose to have the checks. Before taking off on a walk, a physician is asked to give a three to five minute talk about the
importance of physical activity. Other volunteers will be sought to register the walkers, obtain their written waiver of liability, make healthy refreshments available and offer a free pedometer to each participant. All of our volunteering medical experts will be asked to wear shirts or hats provided by SMCMA so that the walk personnel can be easily identified. With doctors support, we can offer a healthy opportunity for patients in San Mateo County to exercise and join in the fun. The pace and distance are self-determined by the walkers. As the program expands we believe participants will develop a new perspective on physicians and health care. SMCMA plans to encourage doctors to place flyers in their office waiting rooms announcing perhaps three months of scheduled walks at a time. The first walk will take place on the Crystal Springs Regional Tail starting at the Sawyer Camp trail starting at the 280 Freeway and Crystal Springs Reservoir. Other walks will be scheduled for downtown Half Moon Bay, sites such as Long Ridge and Coal Creek as well as other downtown walks that would start at the Historical Museum in downtown Redwood City.
We need doctors who will commit to part of a day, or multiple days in succeeding weeks and months. Each walker will be given a free blood pressure check, free pedometer, snacks, and a chance to talk with a doctor while walking. We will be contacting the San Mateo County Superintendent of High Schools and local and state legislators representing this County to place notices about the walks on their websites, as well as newspapers and other entities that will promote the walks. Posters will be designed for placement in doctors’ offices, hospitals and clinics announcing the “Walk with a Doc” dates and, of course, we will use social media. The SMCMA will be emailing/faxing further event details to members in the coming weeks. Be sure to keep a lookout for this correspondence. If you are interested in volunteering to walk with County residents and /or publicizing the scheduled “Walk with a Doc” events in your office with signage or through your office’s social media sites, please contact me at smalone@smcma.org or (650) 3121663. We hope to see you on July 14!
SAN MATEO COUNTY PHYSICIAN | page 7
Active Access -
Your Access Point to Free Physical Activity Opportunities in San Mateo County By Kristi Skjerdal, MPH The Active Access Initiative is a collaboration of San Mateo County, local recreation departments, and non-profit community partners representing 30+ organizations, which includes San Mateo County Medical Association. Our mission is to promote health and physical activity in the community by offering to and informing residents of free and low cost physical activity opportunities available in their city. These events cost $5.00 and under (many are free), will not require registration and an individual may attend as many events as he/she chooses. The goal of the Active Access Collaborative is to have multiple free offerings in each of the cities in the county with new activities added on a regular basis. Our website, smcactiveaccess.org, lists available activities in the community and includes special Active Zone events for some of the cities. The latter are those that are organized and hosted by member organizations of the Active Access collaborative. They may be held weekly or periodically by an individual organization or a group of organizations partnering together on an event, such as “Active Access Day in the Park.” The Active Access website offers a great referral source to help your patients embark on a more physically active lifestyle. Examples of Free/Low-Cost Events Featured on smcactiveaccess.org •
•
•
Pick-up basketball offered daily at San Mateo High School Gym - $4/adults, $3/youth (w/ school ID) A free running club gathers on the third Thursday of the month @ 6:30 pm at Sawyer Camp Trail. Sawyer Camp Trail Walk gathers
page 8| San Mateo county physician
every other Saturday @ 8:30 am - 3-5 mile walk along Sawyer Camp Trail. Walk takes approximately 1-1.5 hours. •
Hawaiian Outrigger Canoe Paddling gathers at 9:00 - 11:30 am at Coyote Point.
•
Bicycle Sundays @ 9:00 am - 3:00 pm on Canada Rd. in San Mateo. An easy ride for anyone...big hills, good shoulder, moderate traffic. Targets all ages.
•
Open gym volleyball on Saturdays from 10:00 am - 1:00 pm at San Mateo High School gym $4/adults, $3/youth (w/ school ID)
•
Morning walks daily at 9:00 am at Veterans Memorial Senior Center in Red Morton Park in Redwood City.
•
Diesel Fish Dragonboat Team meets on Saturdays @ 10:00 am - 12:00 pm at Bair Island Aquatic Center in Redwood City
On a national level, the National Physical Activity Plan is a comprehensive set of policies, programs, and initiatives that aim to increase physical activity in all segments of the American population. This work is a public-private collaboration that began in 2006 and culminated with its launch in 2010. Our efforts here in San Mateo County began in 2009 and have been moving full stream ahead ever since. In a 2009 Journal of Physical Activity and Health article by Gregory Heath, he wrote: “Public health agencies need to partner with community organizations, including schools, businesses, planning agencies, healthcare organizations, and recreation
agencies, to plan, promote, and coordinate efforts to increase physical activity. Critical functions of public health agencies in these efforts include insuring that strategies to reduce health disparities in physical activity are implemented, monitoring the effectiveness of physical activity programs, and evaluating and reporting on program effectiveness.” We know that San Mateo County and the Active Access Initiative are on the right path. Your role in Universal Health Promotion Benefits gained in participating in universal health promotion throughout the county far exceed the costs associated with promoting the Active Access program. The Active Access website provides an access point for community members to find convenient, accessible and low-cost opportunities that encourage them to become physically active; an effective strategy to promote health. The dual impact of physical activity and social connection blossoming in public parks and plazas “every day in every city” could potentially change social norms substantially. Physicians can encourage their patients to access the site and even direct them to specific activities to meet their physical activity needs. It should be noted, that a full assessment of the patient’s physical capabilities should be made either by the physician, counseling nurse, or trained lay person. We welcome information about programs and events. Find our website at smcactiveaccess.org Kristi Skjerdal, MPH is a Health Educator in Chronic Disease and Injury Prevention Program
Obscure Gastrointestinal Bleeding By Edward Onuma, MD, phd Obscure gastrointestinal bleeding is defined as bleeding from the gastrointestinal tract that persists or recurs without an obvious etiology after upper endoscopy, colonoscopy and radiologic evaluation of the small intestine. It can be further classified as obscure-overt and obscure-occult. Obscure-overt presents with visual evidence of bleeding, such as hematemesis, melena or hematochezia. Obscure-occult presents with hemoccult positive stool and is usually associated with iron deficiency anemia. Obscure gastrointestinal bleeding accounts for 5% of cases of patients with gastrointestinal bleeding, and in 75% of the cases the source of bleeding is found in the small intestine. In the remainder of the cases, the source is usually a lesion which was missed on the initial upper endoscopy or colonoscopy. Some commonly missed lesions on upper endoscopy include Cameron erosions, fundic varices, peptic ulcer, angioectasias, Dieulafoy’s lesion, and gastric antral vascular ectasia (GAVE). Some commonly missed lesions on colonoscopy are angioectasias and neoplasms.
The most common cause of small intestinal bleeding is angiodysplasia, accounting for 30 to 40% of cases. Angiodysplasias are dilated, thin-walled blood vessels lined by endothelium alone or endothelium with small amounts of smooth muscle. They are believed to develop because of intermittent, recurrent low-grade obstruction of submucosal veins which results in dilatation and tortuosity of the draining vessels. Forty to 60% of patients have more than one, and 20% of synchronous lesions are found elsewhere in the gastrointestinal tract. Other terms commonly used to describe the same lesion are arteriovenous malformation (AVM), angioectasia and vascular ectasia. Telangiectasia is a term used to describe lesions which are associated with a systemic or congenital disease (i.e. Osler-Weber-Rendu syndrome). Predisposing conditions for angiodysplasias are endstage renal disease, von Willebrand disease and aortic stenosis, however angiodysplasias may be found more commonly in these conditions because of the increased risk of bleeding associated with these conditions.
Etiology of Small Intestinal Bleeding
The second most common cause of small intestinal bleeding are small intestinal tumors/polyps (5 to 10% of cases). Small intestinal neoplasms are rare and account for 3% of all gastrointestinal neoplasms. Malignant small intestinal neoplasms include adenocarcinoma, carcinoid, lymphoma and sarcoma, with carcinoid recently becoming the most common. Benign small intestinal neoplasms include adenoma, leiomyoma and lipoma. Peutz-Jeghers syndrome and familial adenomatous polyposis syndromes are two hereditary polyposis syndromes that are associated with small intestinal polyps and malignancies. Melanoma is the most common metastatic neoplasm
The four most common causes of small intestinal bleeding are: angiodysplasia, small intestinal tumors/polyps, Crohn’s disease, and NSAID enteropathy. Less common causes include: Dieulafoy’s lesion, aortoenteric fistula, Meckel’s diverticulum, celiac sprue, pelvic radiotherapy, small intestinal varices, hemobilia, and hemosuccus pancreaticus. Patients younger than 40 years old usually present with Crohn’s disease, Meckel’s diverticulum, Dieulafoy’s lesion, celiac sprue or a small intestinal tumor. Older patients usually present with vascular lesions, celiac sprue, or erosions and ulcers related to NSAIDs.
to the small intestine. Crohn’s disease and NSAID enteropathy are associated with erosions and ulcerations of the small intestine. A Dieulafoy’s lesion is a dilated aberrant submucosal vessel which erodes the overlying epithelium in the absence of a primary ulcer. Endoscopically one may find active bleeding or a raised nipple (visible vessel). An aortoenteric fistula usually develops in the third and fourth portions of the duodenum and presents with a herald bleed, followed by massive bleeding resulting in exsanguination. Primary causes are atherosclerotic aortic aneurysm and infectious aortitis, and secondary causes include prosthetic abdominal aortic vascular graft, penetrating ulcers, tumor invasion, trauma, radiation therapy or foreign body perforation. A Meckel’s diverticulum results from incomplete obliteration of the omphalomesenteric duct, and half of the cases are associated with ectopic gastric mucosa. Bleeding results from ulceration within this gastric mucosa. Celiac sprue and pelvic radiotherapy can also be associated with erosions and ulcerations. Small intestinal varices are usually found at anastomosis sites and adhesions in patients with cirrhosis. Hemobilia is bleeding from the biliary tract and it can develop from hepatic artery aneurysms or from liver trauma (i.e. liver biopsy). Hemosuccus pancreaticus is bleeding from the pancreatic duct and occurs when a pancreatic pseudocyst in communication with the pancreatic duct erodes into an adjacent blood vessel. Radiologic Imaging In significant overt-obscure bleeding, a radionuclide scan can be obtained to localize the bleeding site to an area of the abdomen with an accuracy of 24 to continued on page 15
SAN MATEO MATEO COUNTY COUNTY PHYSICIAN PHYSICIAN || page page 9 9 SAN
Breast Tomosynthesis: 3D Mammography A Leap Forward for Breast Imaging By beth kleiner, MD Screening mammography has been in clinical use for over 30 years. It has been documented that this examination decreases mortality from breast cancer. From its earliest beginning to the current full field digital mammography (DM) there have been limitations . The sensitivity of digital mammography remains low, estimated to be 70% and recall rates for many centers remain above the target of 5-10%. It is accepted that one of the biggest limitations in detecting breast cancer relates to breast density. Cancers go undetected because overlapping dense tissue obscures the tumor. Overlapping tissue also results in unnecessary callbacks from screening. A new imaging technique called digital breast tomosynthesis (DBT) or 3D mammography has been developed to improve detection of cancers hidden by overlapping tissue and to more confidently determine when a density on a screening mammogram is due to overlapping tissue or is an abnormality, resulting in a decrease in unnecessary callbacks. DBT has been in use in Europe for several years. In March 2011 the FDA approved the first tomosynthesis mammography system for clinical use in the US. This article will briefly describe the technical aspects of breast tomosynthesis, its clinical performance, future potential and current drawbacks.
Breast tomosynthesis has been developed on the digital mammography platform. The DM unit is modified to obtain tomographic cross-sectional images or “slices” of a volume of tissue. Tissue is in sharp focus when it is within the plane of the section; tissue outside the plane is out of focus or “blurred”. The DBT mammography machine looks very similar to a DM unit. The tube moves in a 15 degree arc over the patient while the breast is compressed in the two standard mammography positions. These 1 mm tomographic slices of the entire breast volume are obtained during a single acquisition and single exposure. The radiation dose is equivalent to a single mammographic view (1). This examination is so similar to DM that many patients are unaware tomosynthesis has been performed. Currently the FDA has approved 3D mammography obtained with 2D mammography. European reports on breast tomosynthesis have been mixed. In 2009 Gennaro et al published a study of 200 diagnostic patients who underwent two view DM and one view DBT. The right and left breasts were evaluated separately. Although there was a trend to increased lesion conspicuity with DBT, it was not statistically significant and the authors concluded that one view DBT was equivalent to two view DM (2). A 2008 non-blinded study of 36 patients
with either a palpable abnormality or abnormal screening DM underwent additional single view DBT in the projection which least demonstrated the abnormality. If an abnormality was only seen on ultrasound, MLO only DBT was performed. In spite of the limitations of this study design it showed higher sensitivity for breast cancer detection for single view DBT than one or two view DM (3). Initial trials in the US have demonstrated that while some cancers are visible on DBT in both views, some may be seen only on the CC or MLO position (4). These results are similar to that of cancer visualization on DM. In the US the largest multicenter clinical trial evaluating the performance of DBT vs DM was sponsored by Hologic. These results were presented to the FDA for clinical approval of DBT. This non-peer reviewed study compared radiologists’ cancer detection rates and mammography recall rates using conventional DM plus DBT to rates when DM was obtained alone. The study evaluated 1,083 women from 5 centers which included both screening and diagnostic patients. Two view 2D and two view 3D (DBT) images were obtained. Images were randomly selected for review by 12 radiologists. Individual and mean ROC curves were generated. 2D plus 3D increased sensitivity for cancer detection (BIRADS 4 & 5) from 66% to 76% and improved specificity of
noncancers (BIRADS 1-3) from 84% to 89%. A mean reduction in recall rate(BIRADS 0) of 45% was observed (5). Other studies have shown an increase in specificity but not a statistically significant increase in sensitivity. In 2007 Poplack et al reported results of 98 women who were recalled from screening mammography. Using an early prototype unit and evaluating images in an unblinded manner, the authors reported a 40% reduction in what would have been recalled if DBT had been the initial examination performed but no significant improvement in cancer detection (6). This study did not include screening patients, however.
mammography to DM can be performed. There are drawbacks to 3D mammography. On the technical side, these imaging data sets are large and additional storage capacity is needed. Reading of the 3D studies currently requires a proprietary work station as most of the current PACS reading stations do not support 3D mammography. These examinations consist of many more images than a standard four view screening mammogram. Therefore, they require more of the radiologists time to interpret. Currently, insurance companies do not reimburse at a higher rate for 3D examinations.
Approximately 37 million screening mammograms are performed in the US each year. If DBT can reduce the call back rate from 15% to 6% 2.2 fewer women would be called back, resulting in significant cost savings as well as reducing the emotional toll associated with a “false positive” screening mammogram.
The FDA approved clinical use of DBT only when accompanied by a DM examination. Patients currently undergo both a 2D and 3D mammogram. The dose of the combined examination is equivalent to film screen mammography but higher than that of 2D alone. It is currently possible to reconstruct a 2D mammogram from the volumetric data obtained during the 3D examination which has been called a “synthetic mammogram”. Initial work in this area has shown promise with equal sensitivity comparing DM with the synthetic mammogram but a loss in specificity (8). This is an area of active research.
Most early reports indicate a trend toward improved sensitivity of DBT over DM and one large non peer reviewed trial indicates a statistically significant improvement in breast cancer detection in the screening population. Of the centers that participated in the Hologic trial, none returned their 3D unit to the manufacturer and all of the centers were planning to increase their number of DBT units. Hopefully a trial similar to DMIST which compared film screen
In summary, breast tomosynthesis represents the first true advance in breast imaging in 25 years. All early studies have demonstrated a significant reduction in callback rates from screening. More studies are needed to demonstrate a significant increase in breast cancer detection but initial results are encouraging. The downsides of 3D mammography are being addressed by the manufacturers and it is likely that solutions will come quickly.
Gur et al reviewed 125 examinations evaluating the right and left breast as separate exams. Using a combination of 2D and 3D the authors showed a statistically significant decrease in recall rate of 30% and a trend toward improvement in cancer detection which was not statistically significant (7).
References: 1.
Dobbins JT 3rd, Godfrey DJ. Digital x-ray tomosynthesis: current state of the art and clinical potential. Phys Med Biol 2003; 48:R65-R106.
2.
Gennaro G, Toledano A, diMaggio C, et al. Digital breast tomosynthesis versus digital mammography: a clinical performance study. Eur Radiol 2009; 20:1545-1553.
3.
Andersson I, Ikenda DM, Zackrisson S, et al. Breast tomosynthesis and digital mammography:a comparison of breast cancer visibility and BIRADS classification in a population of cancers with subtle mammographic findings. Eur Radiol 2008; 18:2817-2825.
4.
Rafferty E, Niklason L. Breast tomosynthesis: one view or two? Radiological Society of North America, annual meeting, 2006.
5.
Chakrabarti K, Ochs R, Pennello G, et al. FDA executive summary: meeting of the radiological devices advisory panel. Gaithersburg, MD:Food and Drug Administration, 2010.
6.
Poplak SP, Tosteson TD, Kogel CA, et al. Digital breast tomosynthesis: initial experience in 98 women with abnormal digital screening mammography. AJR Am J Roentgenol 2007; 189:616-623
7.
Gur D, Abrams GS, Chough DM, et al. Digital breast tomosynthesis: observer performance study. AJR Am J Roentgenol 2009; 193:586-591.
8.
Gur D, Zuley ML, Anello MI, et al. Dose reduction in digital breast tomosynthesis (DBT) screening using synthetically reconstructed projection images: and observer performance study. Acad Radiol. 2012 Feb; 19(2):16671
I would like to thank my colleague Dr. Susan Marks for integrating 3D mammography into our practice and for her contribution and support in preparing this article. Dr. Kleiner is a radiologist practicing in San Mateo.
SAN MATEO COUNTY PHYSICIAN | page 11
We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company
You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical professional liability program, including the Tribute Plan, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293. You can also visit us at www.doctorsagency.com.
www.thedoctors.com
3645_SanMateoCMAbulletin_Jun2012.indd 1
5/16/12 7:06 AM
My Mission of Palliative Care By aruna chinnakotla, md SMCMA will feature a regular column on how different SMCMA members chose their specialty. This is the first article for this regularly appearing column. Do you have an interesting story as to how you chose your specialty? Send it to us at smcma@ smcma.org. Articles need to be around 500-600 words. My own interest in palliative and hospice care was sparked by my brother’s death five years ago. My brother was just starting out in life, a young father at the time with a threeyear-old son, when he suffered from a massive Cerebro-Vascular accident. Unfortunate delays in the diagnosis of his stroke and in treatment resulted in brain herniation and in him being put on life support. He was unresponsive with fixed pupils, yet medical technology kept marching forth, denying his grave and terminal condition. Brain decompression was pressed upon the family even though the chances of mere survival were low, let alone a recovery leading to any kind of meaningful life. It was apparent that if he lived, and again I emphasize if he lived at all, he would be in a vegetative state for the rest of his days, being kept alive by tubes running into his body, and never being able to talk, walk, move, feed or wash himself. Is this a life anyone wants to live, an agonizing imprisonment in a body which is already gone and with the only relief from this existence being death? My brother was a fighter. His choice would have been to fight for his life, if there had been an option for him to have a life. His choice would never have been to become a vegetable and die a death by inches. Nor would he have tolerated the daily torture his parents and spouse would have faced caring for him and seeing him in this condition. I became involved in the treatment decisions and was disturbed by the
treating physicians’ turning a blind eye to the reality of my brother’s condition. Offering the family a full prognosis, discussing alternatives and helping them make valuable decisions in the heart of a medical crisis is a tremendous service we as physicians and healers are in a position to provide. In what was a tough personal call, I took the initiative and made the decision on behalf of the family to request that treatment be stopped and my brother be made as comfortable as possible. As a sister, my loss is huge and one that I will have to bear my whole life, but I derive comfort from preventing his turning into a vegetable. The aftermath of the decision was messy and involved medico-legal issues, flaring tempers of the physicians-in-charge, accusations of secondary gains I stood to inherit from his death, and a decision to perform an autopsy following his death minutes after my intervention. Something that will haunt our family forever is the fact that my father witnessed the autopsy and seeing this simply killed a part of him so that he has become a shell of the person he once was. He suffers from continued depression, has suffered through two cardiac attacks, and endures chronic overall malaise. There is no systematic help or guidance in India for grieving and my parents have neither overcome, nor moved out of the phase of intense, crushing grief, even five years after my brother’s death. The emotional toll on each one of us in the family has been enormous, crippling our ability to move forward with life to various extents. This scenario of relentless grief could have been very different and my parents could have learned to let go over time, if only we had had a system to help us grapple with our loss and which had addressed the process of dying and death (which in this case were a sad,
but foregone conclusion). My personal tragedy impressed upon me the need for physicians who excel not only in the practice of medicine, but in the administration of timely compassion. Physicians who help the families make important decisions free of guilt, with the aim of letting the dying person go in peace and harmony. I envision physicians holding hands, giving hugs, saying, “It’s alright, I will be here with you as you journey out of life. Just as your birth was, your death is a momentous experience and we will support you and your family with what resources we can”. Medicine goes beyond the treatment of disease and well into the essence of humanity; into the very milk of human kindness that one human being can give another. This is what hospice and palliative care is all about. This is what I practice now and it is an aspect of my profession I am very proud to be a part of. I can’t help but wish that this experience had come in time for me to help my brother die more peacefully, and in time to have helped my parents find the resources and people who could have supported them through a healing process. With our knowledge, we can make the crucial difference in whether someone is able to cope with death or not, whether the bereaved move forward in life or get stuck in a cycle of grief they don’t know how to break. I would like to quote Philippe Aries and end by saying, “Death should simply become a discreet, peaceful and dignified exit of a person from a helpful society. Without pain, suffering and ultimately, without fear.” Dr. Chinnakotla practices at the Kaiser in South San Francisco.
SAN MATEO COUNTY PHYSICIAN | page 13
Gastrointestinal Bleeding continued from page 9
91%. It can detect bleeding that is occurring at a rate of 0.1 to 0.5 ml/min, and patients can be scanned over a prolonged period of time if the bleeding is intermittent. However, it is a purely diagnostic test. Catheter-directed angiography can detect bleeding that is occurring at a rate of 1.5 to 2.0 ml/min. In order to minimize exposure to radiation and contrast, the bleeding site should first be localized with a radionuclide scan. Interventions can be performed, such as infusion of vasoconstricting medications or embolization. CT angiography involves thin collimation and rapid IV administration of contrast with acquisition of an arterial phase. It was shown in porcine studies to detect bleeding at a rate of 0.3 ml/min. It is a noninvasive and purely diagnostic test, but can be useful for identifying angiodysplasias and neoplasms. Compared to MR angiography, CT angiography has higher spatial resolution and a faster acquisition time, however it involves radiation and an iodinated contrast agent. Small bowel follow through (SBFT) involves the oral ingestion of dilute barium and serial abdominal images of the small bowel. In enteroclysis, a NG tube is inserted to the proximal small bowel and this is followed by injection of barium, methylcellulose and air. It is a double contrast study and superior to SBFT, however it is more uncomfortable for the patient. The yield for enteroclysis for obscure gastrointestinal bleeding is less than 20%, and it is used in settings where capsule endoscopy and enteroscopy are unavailable or contraindicated. In CT or MR enterography, large volumes of a low density oral contrast is used to distend the small bowel, and thin collimations are taken. In this manner, the small bowel wall and lumen can be better displayed. CT enterography provides better images compared to MR enterography, but involves radiation and an iodinated contrast agent. In a recent study comparing CT enterography and
capsule endoscopy in patients with obscure gastrointestinal bleeding, CT enterography was found to be more sensitive in detecting a small bowel bleeding source (largely because it detected more small bowel masses). Capsule Endoscopy Currently two wireless video capsules are available in the United States for imaging the small bowel, the PillCam SB2 (Given Imaging) and the EndoCapsule (Olympus). These capsules transmit two images per second for a total of 8 hours, with a resolution of 0.1 mm (which allows for visualization of individual villi). The study is performed by first attaching a sensor array to the patient’s abdomen. The patient then swallows the capsule and the images are transmitted to a recording device which is worn on the patient’s waist. At the end of the study the images are downloaded to a workstation and then read. The overall yield of capsule endoscopy is 55 to 70%. It is noninvasive and permits visualization of the entire small bowel, however it does not permit tissue sampling or therapeutic intervention. It is contraindicated in patients with gastrointestinal obstructions, strictures or fistulas because of the risk of capsule retention. In patients with swallowing disorders, esophageal strictures, esophageal diverticula or gastroparesis, it may be necessary to place the capsule endoscopically. Enteroscopy Push enteroscopy involves the passage of a pediatric colonoscope beyond the ligament of Treitz. Because of looping in the stomach and patient discomfort, the scope generally can only be advanced to the proximal 150 cm of the small bowel. The yield for identifying bleeding lesions ranged from 3 to 70%, with angiodysplasias being the most common lesion found. Tissue sampling can be performed as well as therapeutic maneuvers (i.e. cautery). Intraoperative enteroscopy involves the insertion of an endoscope through an enterotomy site, or per-orally and per-rectally during surgery. The surgeon telescopes the small bowel over the
endoscope and the entire small bowel can be evaluated in more than 90% of patients. The diagnostic yield ranged between 60 to 88%, however intraoperative enteroscopy has been associated with complications and deaths. Complications include serosal tears, avulsion of the superior mesenteric vein, ileus and perforation. Deep small bowel enteroscopy include double balloon enteroscopy, single balloon enteroscopy and spiral enteroscopy. In double balloon enteroscopy using the antegrade approach, the scope and over-tube are advanced into the duodenum. The balloon on the end of the over-tube is inflated, anchoring it in the small bowel. The scope is then advanced as far as it can and the balloon on the tip of the scope is then inflated, anchoring it in the small bowel. The balloon on the end of the over-tube is deflated, and the over-tube is advanced to the end of the scope. The balloon on the end of the over-tube is again inflated, and with both balloons inflated the scope and over-tube are gently withdrawn until resistance is met. In this manner, the small bowel is pleated onto the over-tube and loops are reduced. The balloon at the end of the scope is deflated, and the scope is again advanced as far as it can. This sequence is repeated until the scope can no longer be advanced. The double balloon enteroscopy can also be performed using the retrograde approach, and using both antegrade and retrograde approaches the entire small bowel can be examined in 42 to 86% of patients. In one large study the diagnostic yield was 78%, with ulcers and erosions being the most common findings. Tissue sampling can be performed as well as therapeutic interventions. Because of the length of the study and the potential for patient discomfort, it is commonly performed using general anesthesia. Single balloon enteroscopy uses the same push and pull technique with a single balloon on the overtube. Spiral enteroscopy uses rotational energy to pleat the small bowel by spinning an overtube with a spiral element at the tip. continued on page 17
SAN MATEO COUNTY PHYSICIAN | page 15
You are cordially invited to attend the
2012 Annual Meeting
San Mateo County Medical Association
THURSDAY, JUNE 28, 2012
MENLO CIRCUS CLUB 190 Park Lane, Atherton Hosted Reception: 6:30 p.m. • Dinner: 7:30 p.m.
Distinguished Service Award presented to
Edward A Hinshaw, Esq. Mr. Hinshaw has provided over 40 years of service defending physicians who have called on him to assist them in governmental entity defense, administrative defense, and medical malpractice defense. Mr. Hinshaw also spent significant time in Sacramento on behalf of physicians in the development of the MICRA legislation. He has truly been a friend to all doctors over his extensive legal career. --------------------------------------------------------------------------------------------------------------
RESERVATION FORM
Member & Spouse or Guest tickets x $50 per person Non-Member & Spouse or Guest tickets x $80 per person
$ $
Name_____________________________________Spouse or Guest___________________________________ Address________________________________________________________________________________________ Tel________________________________Email________________________________________________________ Credit card number__________________________________________________Expiration___________ 3 Digit Code_________________ Cardholder billing address if different from above____________________________________________________ Signature__________________________________________________________Date____________________________ Please send check or complete credit card information to: SMCMA, 777 Mariners Island Blvd., #100, San Mateo, CA 94404/Email: gcromosini@smcma.org
President’s Message continued from page 5
age. Whether all the changes taking place around us will prove as revolutionary to the development of humankind as the printing press, the Copernican Revolution or the industrial revolution, only history will be able to provide that answer. But the EMR, for better or worse, is here to stay and can, if used correctly, improve the care and safety of our patients, make our lives as physicians easier and improve our ability to recognize and potentially prevent or treat major public health issues.
Gastrointestinal Bleeding continued from page 17
Diagnosis and Management The diagnosis and management of obscure gastrointestinal bleeding can be challenging. Patients with obscure-overt bleeding should be considered for repeat endoscopic examination. Those with massive bleeding should undergo a radionuclide scan followed by catheterdirected angiography. If these are negative, the patient should undergo capsule endoscopy. Patients with obscure-occult bleeding with anemia should also undergo capsule endoscopy. Positive findings on these tests will direct further management (i.e. medical management, enteroscopy with cauterization, angiography with embolization, etc). If the capsule endoscopy is negative, CT enterography or repeating the capsule endoscopy should be considered, although the decision to pursue further testing should take into account the rate of blood loss and the presence of comorbidities. In some cases of obscure-occult bleeding, the cause may not be identified despite a thorough workup. In other cases, such as small intestinal angiodysplasia, the location of the lesion may not be easily accessible to endoscopic intervention, there may be multiple bleeding lesions, or the lesion may recur despite endoscopic therapy. These patients will require iron supplementation and periodic transfusion. Hormonal therapy with estrogen (with or without progesterone) may have efficacy in controlling bleeding from angiodysplasia in patients with von Willebrand disease, endstage renal disease and hereditary hemorrhagic telangiectasias. In patients with obscure-occult bleeding with no anemia or evidence of iron deficiency, further testing may not be necessary unless there is a concern for a specific cause of gastrointestinal bleeding. Dr. Onuma is a gastroenterologist practicing in San Mateo.
SMCMA Nominating Committee Report The 2012 Nominating Committee has proposed the following candidates to officer, board, and delegation positions. Nominations may also be made by members of the Association. These nominations are to be in writing, signed by 10 active members, and delivered in-person to the Association headquarters or by registered mail no later than June 20, 2012. Officers President-Elect: Amita Saxena, M.D. Secretary-Treasurer: Vincent R. Mason, M.D. Immediate Past President: John D. Hoff, M.D. The office of the President will be filled by Gregory C. Lukaszewicz, M.D. Board of Directors C.J. Kunnappilly, M.D. Board members continuing terms: Raymond Gaeta, M.D., Russ Granich, M.D., Edward Koo, M.D., Michael Norris, M.D. and Kristen Willison, M.D. Delegation Leslie Kim, M.D. Barry Oberstein, M.D. Gregory Lukaszewicz, M.D. Robert Reisfeld, MD Vincent Mason, M.D. Amita Saxena, M.D. James Missett, M.D. William Tatomer, M.D. Delegates continuing terms: Dirk Baumann M.D., John D. Hoff, M.D., Steven Kmucha M.D., Betty Lee, M.D. Alternate Delegates Gordon A. Brody, M.D. Mark Levsky, M.D.
Julie O’Callahan, M.D.
Alternate Delegates continuing terms: Edward Lipton, MD Nominating Committee John D. Hoff, M.D., Chair Dirk Baumann, M.D. Raymond Gaeta, M.D. Robert Jasmer, M.D. Leslie Kim M.D.
Edward Lipton M.D. Ori Melamud, M.D. Michael Norris, M.D. Barry Oberstein, M.D.
SAN MATEO COUNTY PHYSICIAN | page 17
Classified Ads
Editorial Committee
Burlingame Medical Building Location on El Camino, Burlingame; across from MillsPeninsula Hospital. Two office suites: 800+ square feet and 1700+square feet. Call Ted Baiz, (650) 703-7855.
Russ Granich, M.D., Chair Edward G. Morhauser, M.D Michael Stevens, M.D
Medical Office Space Available for Sublet Four exam rooms with running water and one MD office available for up to four days weekly. May be able to provide office staff if needed. Excellent location, opposite Peninsula Hospital. For details please contact Bonnie McGuire: Bonnilee@aol.com or 650-259-1480. Medical Office Space to Share Downtown San Carlos Dermatology office. Private rooms with shared reception area and waiting room. Ideal location for Medical/Paramedical practitioner. Ground floor with direct street access. Excellent visibility to a passer-by! Call Darlene (650) 591-8501 Medical Office to Share Downtown San Carlos medical office with large, bright, up to date waiting area. Great professional setting for satellite office or small practice. Three rooms available for dedicated use. Two are 10x10 with vinyl floors and built-in cabinets and sinks. One is 8x10, carpeted with built-ins. Additional 2 rooms a possibility. Shared use of waiting room, reception, bathrooms, and kitchen. Laurel St. at Morse. Call Leslie Weil, MD at (650) 654-2133. Place a classified ad for $40 for up to five lines for members and $75 for up to five lines for non-members. Contact SMCMA at (650) 312-1663 or smcma@smcma.org.
Tracy Zweig Associates INC.
A
REGISTRY
&
PLACEMENT
FIRM
Physicians
Nurse Practitioners Physician Assistants
Sharon Clark, M.D. Gurpreet K. Padam, M.D.
Sue U. Malone.............................................Executive Director Reina O’Beck..................................................Managing Editor
2011-2012 Officers & Board of Directors Gregory C. Lukaszewicz, M.D...................................President Amita Saxena, M.D...................................Secretary-Treasurer John D. Hoff, M.D...........................Immediate Past President Alberto Bolanos, M.D. Russ Granich, M.D. Edward Koo, M.D. Vincent Mason, M.D. Kristen Willison, M.D.
Raymond Gaeta, M.D. Robert Jasmer, M.D. C.J. Kunnappilly, M.D. Michael Norris, M.D.
David Goldschmid, M.D. ......................................CMA Trustee Scott A. Morrow........................Health Officer, San Mateo Co. Barry B. Sheppard, M.D. ..................AMA Alternate Delegate
Article Submission Members are always encouraged to submit articles, commentary and Letters to the Editor. Email your submission to the SMCMA Editorial Committee at smcma@smcma.org for consideration for publication in San Mateo County Physician. For editorial or advertising inquiries, please use the contact information provided below.
Editorial and Advertising Offices 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404 Tel (650) 312-1663 Fax (650) 312-1664 smcma@smcma.org www.smcma.org Acceptance and publication of advertising in San Mateo County Physician does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. SMCMA reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted.
Locum Tenens Permanent Placement V oice: 800-9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 41 FAX : 8 0 5 - 6 4 1 - 9 1 4 3 tzw e i g @ t r a c y z w e i g . c o m w w w. t r a c y z w e i g . c o m
Š Copyright 2012 San Mateo County Medical Association
Get More Support
Cynthia Carsolin-Chang, M.D. Hill Physicians provider since 2010. Uses Hill inSite, RelayHealth and Ascender for eligibility, eClaims processing, secure online communications, ePrescribing, eReferrals and preventive care reminders.
Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and secure online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,700 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group.
Get more information at www.HillPhysicians.com/Providers or contact: Bay Area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com
Hill Physicians’ 3,700 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt in.
SAN MATEO COUNTY PHYSICIAN | page 19
777 Mariners Island Boulevard Suite 100 San Mateo, California 94404 ADDRESS SERVICE REQUESTED
NUMBERS Callers assisted in 2011
is all it takes
24/7 phone access to live experts
25,000
1call
phone
AS YOU DO credentialing letters issued
22,800
THAT WORK
AS HARD
What is great service? For NORCAL Mutual insureds, just 1 phone call is all it takes for great service. That means calling during business hours and immediately reaching a live, knowledgeable, friendly expert. After hours, it means promptly receiving a call back from a professional qualified to help with your issue. No automated telephone tango. Questions are answered and issues resolved—quickly. We’re on call 24 hours a day, every day of the year. Great service brings you peace of mind. Great service 24/7. Hard-working numbers you can count on.
Call 1-800-652-1051 or visit norcalmutual.com Proud to be endorsed by the San Mateo County Medical Association.
Our passion protects your practice