San Francisco Medicine, November 2011 issue. Medicine for the Later Years of Life.
VOL. 84 NO. 9 November 2011 SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y MEDICINE fOr thE LatEr YEars Of LIfE CARe OptIONS FOR OlDeR ADultS IN SAN FRANCISCO TrainingClinicianstoWorkwithAgingPopulations Nutrition for Longevity tHe lAteSt IN KNee ReplACeMeNt Decision Making at end of life tHe pOlSt FORM CMA House of Delegates " As your MIEC Claims Representative, I will serve your professional liability needs with both steadfast advocacy and compassionate support." Senior Claims Representative Michael Anderson Service and Value MIEC takes pride in both. For over 35 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we've partnered with policyholders to keep premiums low. Added value: n Zero-profit carrier with low overhead n Dividends with an average savings on premiums for 2011 of 40.4%* For more information or to apply: n www.miec.com n n Call 800.227.4527 Email questions to firstname.lastname@example.org * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.) MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 � www.miec.com SFmedSoc_ad_06.17.11 MIEC Owned by the policyholders we protect. IN THIS ISSUE Medicine for the Later Years of Life FeAtuRe ARtICleS 10 Healthy Aging and Wisdom: Moving through the Later Years with Grace SteveWalsh,MD 12 Care for Older Adults: Community Based Health Care and Supportive Services DavidWerdegar,MD,MPH 15 Training Clinicians: Building a System for an Aging Century AnnaChang,MD;ElizabethChur;HelenKao,MD;Suzanne Kawahara,MBA;BrieWilliams,MD 17 From Biologics to Bionics: The Future of Knee Replacement KevinR.Stone,MD 19 Nutrition for Longevity: Eating Well into the Later Years EricaGoode,MD,MPH 21 The Deadly Triangle: Depression-Alcohol-Grief DavidPating,MD 23 Decision Making for End-of-Life Care: The San Francisco POLST Coalition JeffNewman,MD,MPH;SteveHeilig,MPH;andFrancesWu,MS 24 Aging and Accentuating the Positive: Collected Quotes LindaHawesClever,MD 25 Treating Cancer in the Elderly: A Personal Perspective JustinP.Quock,MD,FACP 26 Nonbeneficial Treatment: SFMS Effort Serves as Model for State Policy WilliamAndereck,MD,andSteveHeilig,MPH SANFRANCISCOMEDICINE November 2011 � Volume 84, Number 9 MONtHlY COluMNS 4 Membership Matters 7 President's Message GeorgeFouras,MD 9 Editorial GordonFung,MD,PhD 28 Hospital News 29 Classified Ads OF INteReSt 6 CMA House of Delegates and Foundation Gala Photos 30 2011 CMA House of Delegates Report StephenFollansbee,MD,andSteveHeilig,MPH In between pages 22 and 23 you will find the pink POLST (Physician Orders for LifeSustaining Treatment) form. This form, printed on bright pink paper to be clearly visible in a patient's medical record, indicates which types of life-sustaining treatment he or she wants in the event that he or she cannot communicate. To learn more about this form and the efforts to have a POLST form for every patient, read about the San Francisco POLST coalition on page 23. Editorial and Advertising Offices: 1003 A O'Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: email@example.com Web: www.sfms.org Advertising information is available by request. MEMBERSHIP MATTERS a sampling of activities and actions of Interest to sfMs Members The SFMS delegation, along with hundreds of California physicians, convened in Anaheim in October for the 2011 CMA House of Delegates. The CMA HOD is an annual conference where all fifty-three California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine, and patient care, as well as to elect CMA officers. sfMs Member honored at CMa house of Delegates; sfMs Delegation scored Big Wins SFMS members with an iPad, iPod Touch, iPhone, and any Android-based phones and tablets receive a free subscription to DocBookMD! DocBookMD is a smartphone platform designed by physicians for physicians, providing a HIPAAcompliant way for physicians to connect, communicate, and collaborate within their local medical community and across the nation. This tool--selected as one of the top 50 iPad apps for physicians--has been embraced by primary care physicians and others seeking quick consults and pharmacy contacts. To enjoy complimentary access to DocBookMD, all you need is your six-digit SFMS/CMA member ID after downloading the app at the iTune or Android store. Connect and Communicate with Local Physicians on Your smartphone Go to http://wp.me/pBDEx-r7 to view a short list of notable policies approved at this year's HOD. There is also a full write-up of the event on page 30 of this issue, and several more photos on page 6. Many SFMS-submitted resolutions--including coverage of contraception as a health insurance benefit, regulation of e-cigarettes, opposition to legal prohibition of circumcision, and study of presumed consent for organ donation--were well supported by delegates across the state and incorporated into CMA policy. The CMA also awarded to SFMS member David R. Pating, MD, the 2011 Gary S. Nye, MD, Award for Physician Health and Well-Being. Dr. Pating is a psychiatrist and chief of addiction medicine at Kaiser Permanente in Northern California. The Nye award is given annually to a California Medical Association member who has made significant contributions toward improving physician health and wellness. Please join the SFMS in congratulating Dr. Pating on receiving this prestigious award! 5 4 San FranciSco Medicine noveMber 2011 David Pating, MD, receives award SFMS would like to thank our 1,400-plus members for their support of the local medical society this year. Because of your support and participation in organized medicine, SFMS continues to be the preeminent physician organization championing the cause of physicians and their patients as we face the many challenges of these changing times. Please take a moment to renew your support of SFMS by remitting payment for your 2012 dues today. There are three easy ways to renew your dues this year: � Mail/fax in your completed renewal form. � Renew online using your credit card at www.cmanet.org. � Enroll in the EasyPay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or firstname.lastname@example.org. The October Physician Wine Mixer at Monroe SF was well attended by resident and physician members. More than half of the attendees were first-timers! Networking is ranked as one of the most valuable services provided by SFMS. To realize the full power of networking, SFMS will continue to host a series of networking events that will help members connect in a relaxed, no-agenda format aimed only at networking. Please check the SFMS blog at http://sfmedicalsociety.wordpress.com/ for details of upcoming mixers. sfMs Networking Events Pledge Your Commitment to Medicine and renew Your Membership today hhs releases final regulations for aCOs The Department of Health and Human Services (HHS) www.sfms.org CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events. November 16: Top Ten Ways to Save Your Practice Money � 12:15 p.m. to 1:15 p.m. and 6:15 p.m. to 7:15 p.m. December 7: Medicare 2012--Final Rules � 12:15 p.m. to 1:15 p.m. December 14: Individualized Treatment for Patients with Diabetes, presented by the CMA Foundation � 12:00 p.m. to 1:00 p.m. On November 1, 2011, Cigna will change the claim filing time limit for contracted providers from 180 days to 90 days. Those impacted will be notified in writing of any changes and will receive an amendment to their agreements or will be contacted by a Cigna representative. When Cigna is the primary insurance, claims must be received within 90 days of the date of service. When Cigna is secondary, claims must be received within 90 days of receipt of the Explanation of Payment from the primary payer. The change also applies to health care professionals whose Cigna contract includes GWH-Cigna business. SFMS members requiring reimbursement assistance, please contact (888) 401-5911 or email@example.com. released its long-awaited final rule for Medicare-accountable care organizations (ACO) in mid-October. Key changes in the final rule include the following: � Providers will be able to participate in an ACO and share in savings with Medicare without risk of losing money. � The number of quality measures that ACOs will have to meet to qualify for performance bonuses was reduced from 65 to 33. � The ACOs will be told upfront which Medicare beneficiaries are likely to be part of their system. � Community health centers and rural health clinics will be allowed to lead ACOs. Please follow SFMS on Twitter (@SFMedSociety) for news and updates about ACOs. November 2011 volume 84, number 9 EditorGordon Fung, MD, phD ManagingEditorAmanda Denz, MA CopyEditorMary VanClay EDITORIALBOARD EditorGordon Fung, MD, phD ObituaristNancy thomson, MD Stephen Askin, MD erica Goode, MD, MpH toni Brayer, MD Shieva Khayam-Bashi, MD linda Hawes Clever, MD Arthur lyons, MD peter J. Curran, MD Stephen Walsh, MD Cigna reduces Claim filing time Limit to 90 Days SFMSOFFICERS PresidentGeorge A. Fouras, MD President-Elect peter J. Curran, MD Secretary lawrence Cheung, MD TreasurerShannon udovic-Constant, MD ImmediatePastPresident Michael Rokeach, MD SFMSEXECUTIVESTAFF ExecutiveDirector Mary lou licwinko, JD, MHSA AssistantExecutiveDirectorSteve Heilig, MpH AssociateExecutiveDirectorfor MembershipDevelopment Jessica Kuo, MBA DirectorofAdministration posi lyon MembershipAssistant Jennifer Suh CMa Webinars Learn how to improve patient education and compliance in your practice. SFMS is partnering with the Alameda-Contra Costa County Medical Society to offer a free webinar on health literacy and its effects on patient safety and physicians' liability exposure. The webinar will be held on November 15 from 12:30 p.m. to 1:45 p.m. Register at https://www. accma.org/Learning/UpcomingPrograms.aspx. sfMs/aCCMa to host Complimentary health Literacy Webinar BOARDOFDIRECTORS Term:Jan2011-Dec2013 Jennifer H. Do, MD Benjamin C.K. lau, MD Man-Kit leung, MD Keith e. loring, MD terri-Diann pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD Term:Jan2010-Dec2012 Gary l. Chan, MD Donald C. Kitt, MD Cynthia A. point, MD Adam Rosenblatt, MD lily M. tan, MD Shannon udovicConstant, MD Joseph Woo, MD Term:Jan2009-Dec2011 Jeffrey Beane, MD Andrew F. Calman, MD lawrence Cheung, MD Roger eng, MD thomas H. lee, MD Richard A. podolin, MD Rodman S. Rogers, MD saVE thE DatE The 2012 SFMS Annual Dinner will take place on January 19, 2012, at the Concordia-Argonaut Club in San Francisco. Our special guest speaker will be Anthony B. Iton, MD, JD, MPH, senior vice president of the California Endowment's Building Healthy Communities. Invitations will be mailed to SFMS members in midDecember. RSVP is required. For more information, contact Posi Lyon at firstname.lastname@example.org or (415) 561-0850 extension 260. www.sfms.org SFMS Annual Dinner: January 19, 2012 CMATrustee Robert J. Margolin, MD AMARepresentatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate noveMber 2011 San FranciSco Medicine 5 CMa house of Delegates and foundation Gala 2011 Top left: SFMS President-Elect Peter Curran, MD, chairs a committee (right). Top right: SFMS member Arti Desi, MD, addresses the group. Left: SFMS Member Robert Margolin, MD, (center) shares his comments. Photos by David Flatter. CMa house of Delegates Below, from left to right: Roger Eng, MD; Shannon UdovicConstant, MD; Keith Loring, MD; George Fouras, MD; Mary Lou Licwinko, JD, MHSA; Robert Margolin, MD; Leslie Lopato, MD; Elizabeth Andrews, MD; Joan Watson-Vincent, RN; Gordon Fung, MD; Hugh Vincent, MD; Peter Curran, MD; Dexter Louie, MD; Steve Heilig, MPH. Photo by Bre Thurston. CMa foundation Gala 7 6 San FranciSco Medicine noveMber 2011 www.sfms.org PRESIDENT'S MESSAGE George Fouras, MD reaching out to residents and the CMa house of Delegates The SFMS has accomplished much in the past month. In late September we held our second annual Career Fair. I was impressed at how much larger it was this year than last. Kudos to our membership director, Jessica Kuo, and her staff for all their hard work. Not only did we have more exhibitors this time but we also had more residents attending and looking for posts. A big thanks also goes to Ryan Johannesen (GME coordinator at CPMC) and to CPMC for their help in sponsoring the venue for the event. We are learning a great deal about hosting a career fair, and I suspect that next year's will be even better. In early October, we held another event for residents at Monroe SF in North Beach. This social mixer was sponsored by JoAnn Tracht-Rawson from MIEC. Residents were able to network and also meet members of the SFMS. As a result, we are encouraging the next generation of leaders to become more involved in organized medicine. As I write this column, I am sitting in the Disneyland Hotel Ballroom as a delegate for the CMA House of Delegates. I know that we mention the HOD often, but what this body accomplishes is truly impressive. In 2010, we passed a resolution that asked for a Technical Advisory Committee to make recommendations regarding the decriminalization and taxation of marijuana, and stating that the current drug policy of the U.S. and the State of California is a failed policy. Donald Abrams, David Pating, Steve Heilig, and I represented the SFMS on the TAC, and our final report was accepted by the Board of Trustees on October 14, 2011. The major recommendations coming from the report are that the use of marijuana should be legalized and regulated, that physicians should be removed from the role of gatekeepers for medical marijuana, and that marijuana's medical use is questionable and that marijuana must be rescheduled to Schedule II to allow more research on its potential medical uses. This was nothing short of explosive. A press conference is scheduled for Sunday, October 16, and as I write this I have no idea what the reaction is going to be. I do know, however, that it will be controversial and covered nationwide. Another recent accomplishment coming out of the HOD was a resolution authored by Charles Wibbelsman and Shannon Udovic-Constant, which asked for CMA to support legislation to allow minors to consent for preventive care for STIs (HPV and Hep B), in addition to postexposure prophylaxis. The resolution went on to the AMA House of Delegates as well. This has resulted in a bill passing the California legislature and now signed into law by Governor Jerry Brown. This year we have resolutions asking for the study and regulation of e-cigarettes, for the promotion of an "opt-out" www.sfms.org mechanism for organ donations to increase the supply of organs for transplantation, and for exposure of the deceptive practices by some pregnancy counseling centers. I will refer you to the report by Steve Heilig and the chair of the delegation, Stephen Follansbee, for a summary and outcome of these proposals. This is completely my own observation, but I would say that the SFMS has over the years had the largest number of members sitting on the reference committees that occur during the HOD. All resolutions are dealt with in reference committees, which hear testimony from delegates, digest available information, and refine the resolution either for acceptance or debate by the larger house. We consistently have a large presence on the reference committees and have chaired several of them. The net result is that the SFMS often brings the most resolutions to the HOD with the most important, controversial, and significant resolutions that end up shaping both state and national policy. In closing, I want to draw your attention to yet another example of the CMA's excellent work. Several years ago, the CMA filed an injunction against the State of California, which was proposing to cut MediCal rates by 10 percent across the board. It has now reached the U.S. Supreme Court, with arguments having been presented by CMA, and a decision is expected by the end of this term. At issue is the question of whether a private entity has standing to sue the State. This issue has the potential for broad ramifications, and we anticipate that the Court will hand down a narrow ruling that upholds our right to sue but constrains the scope. noveMber 2011 San FranciSco Medicine 7 Get More Support Luis Bonilla, 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. 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Get more information at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com 9 Hill Physicians' 3,600 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans San FranciSco Medicine noveMber 2011 in all regions. Medi-Cal in some regions for physicians who opt-in. www.sfms.org EDITORIAL Gordon Fung, MD, phD Medicine for the Phases of Life: the Later Years As I sit down to write this column, humankind has reached a population milestone: 7 billion people now live on planet earth. While this can partially be attributed to the exponential growth in the number of babies being born, we also have to recognize rising life span as a contributing factor. In his 2007 New Yorker article entitled "The Way We Age Now," Atul Gawande, MD, touches upon the changing demographics in our population: fort us here, it seems to not apply. Geriatrics as a specialty is not growing fast enough, for a number of reasons. Income in geriatric medicine and adult primary care is among the lowest in medicine. Additionally, as Gawande explains, caring for older adults is not appealing to many younger docs going into residency. "Mainstream doctors are turned off by geriatrics, and that's because they do not have the faculties to cope with the Old Crock," explains Felix Silverstone, a geriatrician. "The Old Crock is deaf. He has poor vision. His memory might be somewhat impaired. With the Old Crock, you have to slow down, because he asks you to repeat what you are saying or asking. And he doesn't just have a chief complaint--The Old Crock has fifteen." One certainty is that we will all age and eventually pass away. So will everyone we care about. The quality of care received by an older adult can make a huge difference in how enjoyable the final years are. Good medical care can mean more time living independently, more time being mobile, more time to enjoy the slower pace of the later years of life. "We are, in a way, freaks living well beyond our appointed time," Gawande says. "So when we study aging, what we are trying to understand is not so much a natural process as an unnatural one." And we are living well beyond our natural expiration dates because of our own resourcefulness. We in medicine have found so many ways to not only extend life but also to support good quality of life for years beyond what it has been for most of human existence. We now have to draw on our resourcefulness once more to deal with the unintended consequence of our successes: having a large population of older adults in need of specialized care. I hope this issue of the journal will spark thought and conversation among you and your colleagues on how we will adjust our profession to meet this growing need. noveMber 2011 San FranciSco Medicine 9 In this month's issue of San Francisco Medicine, we delve into the last of our "Medicine for the Stages of Life" series by exploring topics specific to the later years of life. First and foremost, a concern for the future of caring for this group is capacity. In their article, several members of the UCSF Geriatrics Division explain how they hope to prepare clinicians for what they refer to as the "Silver Tsunami" coming as the baby boomers age. "While there is an estimated need for 20,000 geriatricians to effectively care for our burgeoning population of older adults, there are about 7,100 board-certified geriatricians in the United States today," they write. While the basic idea of supply and demand should comwww.sfms.org For most of our hundred-thousand-year existence-- all but the past couple of hundred years--the average life span of human beings has been thirty years or less. . . . People died young. Life expectancy improved as we overcame early death--in particular, deaths from childbirth, infection, and traumatic injury. By the 1970s, just four out of every hundred people born in industrialized countries died before the age of thirty. It was an extraordinary achievement, but one that seemed to leave little room for further gain; even eliminating deaths before thirty would not raise overall life expectancy significantly. Efforts shifted, therefore, to reducing deaths during middle and old age, and, in the decades since, the average life span has continued upward. The result has been called the "rectangularization" of survival. Throughout most of human history, a society's population formed a sort of pyramid: young children represented the largest portion--the base--and each successively older cohort represented a smaller and smaller group. In 1950, children under the age of five were 11 percent of the U.S. population and those over eighty were 1 percent. In 2007, we had as many fifty-year-olds as fiveyear-olds. In thirty years, there will be as many people over eighty as there are under five. Medicine for the later Years of life Healthy Aging and Wisdom Moving through the Later Years with Grace Steve Walsh, MD "grow old with me! The best is yet to be, the last of life, for which the first was made."--robert Browning "The older I grow the more I distrust the familiar doctrine that age brings wisdom."--h. L. Mencken "As one ages, it is important to discern one's actual wisdom from possible delusions of wisdom."--David W. allen Coming of age recently in our cultural conversation is the subject of wisdom. New books, articles, and recent research are focusing interestingly and appropriately on this vital capacity, this adaptive virtue and inherent strength in many human beings. Winston Churchill once noted a paucity of wisdom in some quarters when he said, "It would be a great reform in politics if wisdom could be made to spread as easily as folly." Psychoanalytic researcher Erik Erikson viewed the capacity for developing wisdom as present early in each human life cycle, dependent for further development upon more or less successful resolution of each of eight major life-stage tasks, conflicts, or "crises." These are experienced by all peo11 10 San FranciSco Medicine noveMber 2011 San FranciSco Medicine noveMber 2011 ple from infancy to old age, as I spelled out in the September 2011 issue of San Francisco Medicine in the article "Erikson Revisited." There I described Erikson's eight stages, their specific conflicts, and each of the associated "ego strengths" developing epigenetically from favorable resolution of the earlier-stage "crises." In this issue we are focusing on matters in late life, and in this article on Erikson's eighth-stage task of the development of ego integrity and wisdom. The related conflict is with a sense of despair in the face of the inevitability of problems of aging and of eventual death. As with the seven previous lifestage tasks, successful resolution of this final major issue rests greatly upon favorable outcomes of earlier developmental www.sfms.org tasks. These related to the growth of trust, autonomy, initiative, industry, identity formation, and the capacity for intimacy. In midlife, productive contributions to the lives and growth of others (Erikson's "generativity versus stagnation" conflict), the "adaptive virtue" of a capacity for caring develops. This sets the stage for the further development of wisdom from a growing sense of ego integrity in later life. Erikson has defined wisdom as "detached concern with life itself, in the face of death itself." He states that wisdom in older people maintains and conveys to younger people "the integrity of experience, in spite of the decline of bodily and mental functions." This contributes to the oncoming generation's need "for an integrated heritage" while it "yet remains aware of the relativity of all knowledge." Matured judgment is seen as "the essence of knowledge freed from temporal relativity." If potency, performance, and adaptability may decline in the elderly, vigor of mind and "responsible renunciation" by some old people can lead to the ability to "envisage human problems in their entirety." This is one meaning of integrity. It "can represent to the coming generation a living example of the `closure' of a style of life." Erikson believes that such integrity and wholeness can "balance the despair of the knowledge that a limited life is coming to a conscious conclusion" and "can transcend the petty disgust of feeling finished and passed by." Here, wisdom and a sense of integrity in the elderly "cogwheels" with the developmental needs and tasks in younger generations, enhancing hope and meaning for all. The current president-elect of the American Psychiatric Association is Dr. Dilip Jeste, director of the Stein Institute for Research on Aging and professor of psychiatry at the University of California San Diego. Dr. Jeste has researched ancient and modern definitions of wisdom across cultures. Sources included the 2,500-year-old "Hindu Bible" the Bhagavad Gita, other philosophical and religious texts, and an extensive survey of modern experts on wisdom. The philosopher and theologian Thomas Aquinas said that, "Of all the pursuits open to men, the search for wisdom is most perfect, more sublime, more profitable, and more full of joy." diet and weight control--all of these slow aging and help the growth of wisdom. He has researched the "neurocircuitry of wisdom" as well, reviewing many neuroimaging studies from multiple researchers. A "balance" between prefrontal cortical and amygdala/limbic system activity is the common finding in the wise brain's functional imaging--not a surprising finding. Another research neuroscientist, Dr. Florin Dolcos, found functional MRI results which correlate with healthy older persons' "positivity bias--they can actually manage how much attention they give to negative situations so they are less upset by them." The older brain is still quite capable of "neuroplasticity," the ability to grow new neurons and synapses, with research demonstrating increased grey matter with specific activities using specialized areas of the cortex. Much of the literature on aging shows increased pattern recognition, improved judgment, intact and growing vocabulary with reading and writing, and preserved recognition and autobiographical memory in the elderly. I believe that our culture shows some evidence that the skills and wisdom of older people may be more appreciated and used in the next few years. There is remarkable convergence in all these views of what wisdom consists. Some of these qualities include a pragmatic experience-based knowledge of life, reflective and self-reflective capacities, effective dealings with uncertainty and ambiguity, valuing relativism and tolerance for the varying views/perceptions of others, emotional stability, prosocial attitudes, recognition of the need for multiple perspectives and the limits of knowledge, and allowing for compromise. Dr. Jeste believes that healthy aging promotes the growth of wisdom, which in turn contributes to healthy aging. A positive attitude, learning new skills, engaging with meaningful tasks and projects with others, mental and physical exercise, good www.sfms.org Healthy aging can make this quest nearly lifelong. Even slowed mentation and physical activity can aid the reflectiveness necessary for the growth of wisdom. Oliver Wendell Holmes, Jr., said, "To be seventy years young is sometimes far more cheerful and hopeful than to be forty years old." Searching for general and clinical wisdom adds pleasure to medical practice. We learn from those we serve, and in turn benefit them. This is professional and human mutuality at its best. Steve Walsh, MD, psychiatrist in private practice in Mill Valley and San Francisco. He is a clinical professor of psychiatry at UCSF. He is also a past-president of SFMS, former editor, and a member of the editorial board for San Francisco Medicine. noveMber 2011 San FranciSco Medicine 11 Medicine for the later Years of life Care for Older Adults Community-Based health Care and supportive services David Werdegar, MD, MpH Watercolor mock-up of the new Institute on Aging building The last thirty years have witnessed significant development of home- and community-based services for older adults --in which San Francisco has led the way in many respects. The Institute on Aging (IOA) is a good example. These developments reflect a transformation in attitudes about aging and greater understanding of the responsibilities entailed in provision of "long-term" health care. The primary motivation was to find alternatives to institutional care--which generally meant nursing home care. New models of service have been designed to allow the older adult--despite frailty--to continue living at home and in the community, to maintain familiar surroundings and cherished relationships, and to remain as independent as possible, with supportive help as needed. These developments received added impetus when a noteworthy U.S. Supreme Court decision (Olmstead, 1999) ruled, in essence, that segregation of patients in institutions, when community placement was possible, constituted a form of discrimination prohibited by the American Disabilities Act. The greatest impetus, looking forward, stems from the ur13 12 San FranciSco Medicine noveMber 2011 the Development of Community-Based services for Older adults A striking demographic change has occurred in the United States and most other developed nations: aging of the population. People are living much longer. Dr. Robert Butler, the father of modern geriatrics, called this "the Longevity Revolution" in his insightful monograph of the same title. Increased longevity has vast implications, many still unforeseen, for all aspects of society. We are only beginning to sense some of its challenges in health care. Aging of the population is especially evident in San Francisco, which has the "oldest" population of any major city in the United States. Approximately 20 percent of the population is 60 years or older (one out of every five residents of the City), and almost 15 percent are age 65 or older. Those percentages will increase. The fastest-growing segment of the population is actually those 85 years and older. Detailed demographic information is available in publications from the City's Department of Aging and Adult Services the aging Population of san francisco gent necessity of finding more economical approaches to the health care and social support of an aging population. www.sfms.org The Institute on Aging had its start in a small geriatric clinic on an upper floor of the old Mount Zion Hospital, with Dr. Larry Feigenbaum as its physician and Ms. Barbara Sklar its social worker and administrator. In 1985, aided by a grant from the Goldman Foundation, the geriatric program moved out of the hospital and into the community as a new nonprofit entity. Originally named the Goldman Institute on Aging, the name was later shortened to Institute on Aging, or simply "IOA," as it is now best known. A central program of the new IOA was an Adult Day Health Center, to which frail elderly patients could be brought by van to spend the day. There they would receive close nursing follow-up, social worker case management, occupational and physical therapy, nutritious meals, stimulating activities, and an opportunity to socialize with others of their age. This health center "home away from home" had the further advantage of allowing the patient's family the freedom to go to work or go about other activities with the peace of mind of knowing that the elderly relative was in a safe and caring environment. Patients were referred to the adult day health center by their primary care physicians, who continued to have overall responsibility for their medical care. The State provided support through the Medi-Cal program. To be eligible for care at the adult day health center, the patient had to be frail, with significant limitation in ability to participate unassisted in "activities of daily living" such as feeding, bathing, and using the bathroom. The center was designed to provide support to patients who might otherwise require nursing home care. Over ensuing years, a network of adult day health centers developed throughout San Francisco under the auspices of a number of other nonprofit agencies, such as Catholic Charities, Jewish Family and Children's Services, Self-Help for the Elderly, Kimuchi, and Bayview Hunter's Point, among others. In time the adult day health center became a major cornerstone of community-based care for the frail elderly. Moreover, it provided a model of day-time care that could be adapted for use in other community programs, such as Alzheimer's centers, social day programs, and PACE programs. (Ironically, it is not clear at this writing whether adult day health centers will continue to be funded under Medi-Cal. The program was cut in the Governor's budget, and various legislative efforts to sustain it were unsuccessful. It is therefore slated to terminate in 2012, unless lawsuits brought by advocacy groups result in its continuation.) IOA will continue its adult day program in modified form as a "social day program" requiring sliding-scale private payment or long-term care insurance. At about the time that the Mount Zion programs were getting their start, an important new community program named On Lok was founded in Chinatown by Dr. William Gee, a local (DAAS). That agency, under its director, Anne Hinton, has done an excellent job of analyzing the City's changing demographics and its resources for long-term care. Institute on aging Begins at Mount Zion hospital It is not possible to acknowledge the contributions of the many nonprofit agencies in San Francisco that are engaged in aging services. They all work "on the side of the angels," and IOA has collaborative relationships with many of them. Since IOA plays a unique role in the community, given the comprehensive range of its programs and services for older adults, it may be useful to describe them: Alzheimer's programs: In addition to the Adult Day Health Center and PACE programs singled out for detailed IOa services and Programs practicing dentist with a genius for health services. The On Lok model was much more comprehensive than the adult day health center, which nevertheless remained a core element of the program. On Lok added full geriatric primary care using an interdisciplinary team, home care, specialty consultation, and hospitalization if needed. Thus On Lok created the PACE Program, an acronym for Program of All-Inclusive Care of the Elderly. On Lok recently adopted the name Lifeways for its PACE programs. PACE is a capitated program funded by a combination of Medi-Cal and Medicare dollars. To be eligible, the patient must have both Medi-Cal and Medicare coverage. The individual must have a significant limitation in ability to conduct activities of daily living that would otherwise require nursing home care, similar to the requirement for adult day health centers. There are seven On Lok/Lifeways PACE centers in San Francisco. Two of them are operated by IOA in collaboration with On Lok; one is located in the new IOA Senior Campus building. Continued on the following page . . . On Lok and the PaCE Program Entrance to the new IOA building noveMber 2011 San FranciSco Medicine 13 www.sfms.org On Geary Boulevard near Arguello, where the Coronet Theater once stood, IOA has built new headquarters in collaboration with BRIDGE Housing, a leading nonprofit housing developer. The "Senior Campus" is an attractive six-story structure in which IOA uses the first two floors for many of its programs and offices, while BRIDGE uses the upper four floors for Care for Older Adults Continued from the previous page . . . description earlier, IOA maintains daytime programs for individuals with mild to moderate Alzheimer's disease or cognitive impairment of other etiologies. These programs provide structure, socialization, mental stimulation, recreation, and group support. The patients are often improved by this daytime experience away from home, and it gives their families some respite from caregiver responsibilities. IOA has two programs: the Irene Swindells Center at California Pacific Medical Center and the Libi and Ron Cape Alzheimer's Treatment Center in the new "Senior Campus" building. Care management: Care management by a skilled caseworker, usually a social worker, is often the key to enabling a client with chronic illness, frailty, forgetfulness, or whatever diminished functional capacity to continue to live in their own homes safely and comfortably. IOA offers such assistance through a number of care management programs, some funded by the state, some very helpfully by the City, and some by private pay. One, for example, is the Community Living Fund supported by DAAS and designed to help patients leave Laguna Honda and gain stable residence in the community, or to help avert unnecessary placement in Laguna Honda. Psychology services: These services include psychological evaluations and testing; ongoing counseling; and various support groups (for example, for caregivers, or for clients suffering loss and grief). IOA operates a well-known and venerable 24/7 telephone helpline called the Friendship Line for older adults who feel isolated, lonely, depressed, or in distress. Elder-abuse prevention: IOA coordinates a citywide elder abuse prevention program working with many participant city agencies and nonprofits. It conducts training programs for police, clergy, lawyers, bankers, other professional groups, and the public, who can all play an important part in preventing elder abuse. IOA joins with Adult Protective Services, the police department, and the District Attorney's office in a "Forensic Center" that seeks prosecutions in elder-abuse cases. Fiduciary services: Seniors often need trustworthy assistance in handling their financial affairs, whether simply to manage their checkbook and pay bills and taxes or more extensive assistance such as power of attorney, executor, or conservator. IOA offers such a service. Financial management may be coupled with social work support (care management) to assure most prudent use of the client's resources. Such services can prevent "financial elder abuse," an increasing problem. Home care: Assistance in the home, ranging from help with household cleaning and meal preparation to more extensive assistance with activities of daily living, may be all that is needed to enable the older adult avoid institutional care. IOA offers such services. Aided by grants from the Mount Zion Health Fund and the Bechtel Foundation, IOA and the Geriatrics Division of the UCSF School of Medicine are engaged in a planning process for a center that would provide consultation in complex geriatric cases and comprehensive care for selected patients. The center would combine the community-oriented strengths of IOA with the academic-medicine strengths of UCSF, offering a unique resource for comprehensive geriatric consultation and care. It would also provide unique opportunities in geriatric health professional education and health services research. (The collaborative project is also described by Dr. Anna Chang et al in her article in this issue of San Francisco Medicine.) 150 affordable apartments for seniors. Fifty-three of the apartments are designated for PACE program clients. Thus, the new Senior Campus represents a unique model of affordable senior housing combined with affordable health care and supportive services. The IOA portion of the building includes an auditorium and meeting rooms for educational activities, a studio for intergenerational arts programs, room for a health services research unit studying relationships between housing and health care, and ideal space for a Geriatric Consultation and Comprehensive Care Center. Plans for an IOa/UCsf Geriatrics Center the Institute on aging: (415) 750-4111 and online at www.ioaging.org. Dr. David Werdegar has been the president and CEO of the Institute on Aging since August 2002. Dr. Werdegar was a faculty member for many years at the UCSF School of Medicine, where he served as chair of its Department of Family and Community Medicine as well as associate dean for the School's programs at San Francisco General Hospital. In 1985, then-Mayor Dianne Feinstein appointed him director of the San Francisco Health Department, where he served, on leave, until 1991. He then returned to the University as a senior member of its Institute for Health Policy Studies. A year later, however, he was appointed head of the California Office of Statewide Health Planning and Development in Sacramento, where he served until 2002. references IOa's New "senior Campus" Alzheimer's/Dementia Expert Panel. San Francisco's strategy for excellence in dementia care. Department of Aging and Adult Services, City and County of San Francisco, 2009. Butler Robert N, MD. The Longevity Revolution. Public Affairs, New York, 2008. Center for the Advanced Study of Aging Services, UC Berkeley. Creating aging-friendly communities. Generations: Journal of the American Society on Aging. 2009; 33:2. Hinton, E Anne. Long-term care services in San Francisco (white paper). Department of Aging and Adult Services, City and County of San Francisco, 2006. Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Chapter 3: New Models of Care. The National Academies Press, Washington, D.C., 2008. www.sfms.org 14 San FranciSco Medicine noveMber 2011 Medicine for the later Years of life Training Clinicians Building a system for an aging Century Anna Chang, MD; elizabeth Chur; Helen Kao, MD; Suzanne Kawahara, MBA; Brie Williams, MD Mrs. Linda Lewis is an eighty-year-old woman who lived with her husband in Michigan until he passed away one year ago. Last December, she began to have trouble handling such routine activities as cooking and bathing. Her daughter, Nancy Mitchell, lives in San Francisco and became increasingly concerned. While she knew her onebedroom condominium with stairs was not ideal for her mother, Nancy decided to have her mother move in temporarily. Two weeks after moving to San Francisco, Mrs. Lewis fell. She later developed urinary tract infections and pneumonia for which she was hospitalized in February, April, and July. She no longer walks well, is slower in her thinking, and seems withdrawn. Nancy missed weeks of work to care for her mother and is worried about what to do next. The fault lines in our health care system are particularly detrimental for frail older adults with multiple comorbidities, cognitive impairment, and physical functional decline. They travel from clinic to clinic, from specialist to specialist, often receiving very good treatment for individual medical conditions. Many have extraordinarily committed and knowledgeable primary care physicians. However, the current system is sorely lacking in time and resources to attend to the way an individual's many medical conditions change one's ability to navigate day-to-day life and affect one's family. As the number of older patients grows, we need an integrated system of care to focus not only on older adults' medical conditions, but also on their cognitive, functional, and emotional well-being, and learning about what brings each older person meaning and quality in their lives. This information is key to determining a comprehensive care plan that achieves the delicate balance between maximizing benefit and minimizing harm. the Broken system: MOrE tests, Medicines, and appointments aren't the solution We face a crisis in the health care of older adults in this Aging Century. To address this crisis, we must focus on training future clinicians, and training them in new and effective health care systems. This year, the first of the baby boomers turned sixty-five, leading the "Silver Tsunami." The number of adults age sixtyfive and older will double between now and 2050, and the number of the oldest old, those eighty-five and older, will quadruple. This wave of aging will have tremendous impact on our health care system; today about half of physician visits are from patients aged sixty-five and older. Yet our fragmented health care system is illprepared to provide coordinated, quality care for older adults with complex conditions. the aging Century: What's the rush? There are not enough health care professionals trained to care for older adults with complex conditions. While there is an estimated need for 20,000 geriatricians to effectively care for our burgeoning population of older adults, there are about 7,100 board-certified geriatricians in the United States today. The number of geriatric medicine fellows has declined in the last decade, despite the growth in the population of very old people and studies demonstrating that geriatricians rank among the highest in physician career satisfaction. In a medical culture with an increasing technological focus, specializing in the care of older adults is less prestigious than choosing other specialties. C. Seth Landefeld, MD, chief of the UCSF Division of Geriatrics, says, "It's about the money. Outside academic medicine and large health care organizations, the payment system is broken. Geriatricians in practice often earn less than general internists, despite completing additional fellowship training. This is a problem." the training Gap: Who Will take Care of Me? Although physicians in almost every specialty care for a large number of older patients, geriatric training focuses on developing expertise in the approach to caring for older adults with complex conditions. There are three key elements in teaching the next generation of clinicians to care for older adults. First is determining an individual patient's goals and values to maximize quality of life within that framework. Terri Fried and colleagues at Yale reported in a New England Journal of Medicine study that three-quarters of older adults would not choose a treatment that would impair their function, even if it increased survival. Thus, we might begin with a focus on functional ability--whether patients can walk up a flight of stairs or bathe themselves--rather than on specific illnesses or the results of laboratory tests. A second element is using prognosis to guide decision making. A patient who has weeks or months of life may not benefit from a medication or procedure that will prevent disease in years or decades. If medicine cannot cure the illness, for example, we may offer the choice of fewer pills (with their inherent risk of side effects) and fewer lab tests in favor of coordinating our resources into helping the patient visit grandchildren. We may offer the choice of modified medical management of particular medical conditions in favor of more time playing bridge with friends. A third element is a holistic care plan developed in col- a Different approach to Care Continued on the following page . . . 15 www.sfms.org noveMber 2011 San FranciSco Medicine One important way to ignite passion for mastering the care of complex older adults is to create functional systems within which clinicians and their learners can work together. Learners often choose careers after carefully observing role models--teachers who have walked the road before them. They watch how we work, and whether we love our work. They witness the impact we have on our patients, and whether we change patients' lives for the better. To inspire future clinicians to excel in caring for older adults, we need a cadre of clinician-educators today who care and teach in comprehensive and integrated clinical systems. Training Clinicians Continued from the previous page . . . laboration with a team of health care professionals targeted to each patient's needs. Coordinated access to providers with expertise unique from the medical perspective helps physicians more effectively care for older adults with layers of medical, social, psychological, and spiritual challenges. A successful approach to care of the older adult requires a combination of each of these key elements in the development of a decision-making strategy in light of complexity. The focus on big-picture goals, maximizing function, and prioritizing quality of life guides each health care decision. The ability to hear a patient's fears and desires, and the communication skills to discuss issues such as death and family dynamics, enables a care team with an aging focus to develop individual care plans. Most older adults will not be cared for by geriatricians. Instead, geriatricians can partner with primary care physicians to provide recommendations on issues such as patients' living situations, safety, function, and prioritizing treatment recommendations from multiple specialists. While most students and residents will practice in other specialties, cultivating their skills in caring for this population is critical. addressing the training Gap ties or remaining in Nancy's home with additional support. A psychologist will evaluate her withdrawal and assess for depression, grief, or cognitive changes. The Center's team will help Mrs. Lewis' primary care physician by recommending a care plan that addresses these important issues, thus enabling her physician to more effectively optimize her well-being. We believe this new Center will provide the best care possible to older patients and their families and will serve as a sustainable model that can be disseminated to other communities. It will serve as a rich and functional clinical training arena for students, residents, and fellows. Through our work at the Center we can plant the seeds of commitment to outstanding care of older adults in future clinicians and leaders of our health care system. We invite you, our community colleagues, to collaborate with us and share your ideas, experiences, and challenges. We encourage students and residents to consider a richly rewarding career caring for older adults. We urge our patients and families to share stories from the inadequate system of today and to advocate for policy changes for a better system tomorrow. Creating new, effective, and patient-centered systems to care for our aging patients is an endeavor that requires us all to work together. Recruiting and training the next generation of clinicians with the skills to care for the approaching "Silver Tsunami" requires study of innovative approaches. These efforts have the potential to transform the way care is delivered to our older patients. Hopefully, our loved ones and we ourselves might enjoy rich lives; so, to paraphrase Flannery O'Connor, the lives we transform may be our own. Anna Chang, MD, is a clinician and an educator, and is associate professor of medicine in the UCSF Division of Geriatrics, Department of Medicine. Ms. Elizabeth Chur is a communications and grant-writing consultant. Helen Kao, MD, is a geriatrics and palliative care physician at UCSF and medical director of Geriatrics Clinical Programs. Suzanne Kawahara, MBA, is the deputy director of the Program for the Aging Century. Brie Williams, MD, is an assistant professor of medicine in the UCSF Division of Geriatrics, Department of Medicine. Dr. Williams is a clinician-researcher. The UCSF Division of Geriatrics pioneers innovations in geriatrics education, clinical care, and research that will build such systems in partnership with the Program for the Aging Century, directed by Dr. Landefeld and supported by the S.D. Bechtel Jr. Foundation. One project is the creation of an Aging and Wellness Center, which is being planned as a partnership between UCSF and the Institute on Aging (IOA), offering comprehensive care for older adults and scheduled to open in San Francisco in 2012. The Center, which will be located in the IOA's new Geary campus, will allow for integrated care of older adults that marshals community resources in one site. This includes UCSF geriatricians and a team of aging specialists, including mental health professionals, social workers, and nurses. At the Center, a patient and family such as Mrs. Lewis and her daughter might meet with multiple members of a geriatrics team to develop a comprehensive care plan. Their geriatrician will evaluate Mrs. Lewis's health and causes for her falls, and determine her goals. The social worker will discuss options for her living situation, such as board and care facili- Pioneering the future Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Chapter 3: New Models of Care. The National Academies Press, Washington, D.C., 2008. Fried, Terri R, MD; Bradley, Elizabeth H, PhD; Towle, Virginia R, MPhil; Allore, Heather, PhD. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002; 346:1061-1066. references 16 San FranciSco Medicine noveMber 2011 www.sfms.org Medicine for the later Years of life From Biologics to Bionics the future of Knee replacement Kevin R. Stone, MD Knee joint replacement for arthritis occurs more than 500,000 times per year in the United States. principles of the technique. When a patient presents with an arthritic or damaged cartilage surface inside the knee, we visualize the arthritic surface arthroscopically, create a fresh fracture in the arthritic area, and then harvest a plug of bone, cartilage, and underlying stem cells from the intercondylar notch of the femur. We take that plug out of the knee, smash it into a paste, and then impact the paste back into the freshly fractured area. Secondlook arthroscopy and biopsies of sixty-six of the first 125 patients we performed this procedure for demonstrated a range of repair tissues from purely fibrous cartilage to a mixture of fibrocartilage to hyaline-like cartilage. Subsequently published outcome studies reported that the type of repair tissue regenerated inside the knee did not affect the patient's improvement in pain or function over the course of the two-to-twelve-year follow-up; all three types of repair tissue led to functional improvement. Repairing the articular cartilage, however, is only one part of the story. It is necessary to provide a new shock absorber to protect the cartilage surface from further damage or reinjury. Traditional thinking was that a transplanted meniscus would not survive in an arthritic knee. Our data demonstrates that transplanted meniscus cartilage can survive in the arthritic knee for an estimated average of 9.9 years when the arthritic surface is treated with a cartilage paste graft or other cartilage repairstimulation techniques. This combination of meniscus cartilage replacement and articular cartilage repair provides both a new joint surface and necessary protection and shock absorption for the patient. Lastly, for joints that are both arthritic and unstable, donor ligaments can be obtained from tissue banks, sterilized, and imThe technology has provided wonderful pain relief for arthritic knees, especially for the elderly. However, it does not provide a normal knee, nor a truly athletic knee, and complications can be severe. Everyone knows both someone who worries about their new knee and someone who swears by it. Fortunately, the field is changing. At the Stone Clinic in San Francisco, we have developed a biologic knee-replacement program to repair arthritic knees in both the young and old by using a combination of the patient's own stem cells, donor meniscus cartilage, and donor ligaments. Long-term data and outcome studies of these techniques reveal a relatively high success rate, with 80 percent of the patients in a two-to-twelve-year outcome study demonstrating survival of the meniscus cartilage implants despite Grade IV severe arthritis, accompanied by a sustained improvement in average pain and function scores over the course of the study. This monograph will describe some of the progress made and the direction in which joint replacement is going. Until as late as 1950, the dominant opinion in orthopaedics was that the meniscus was the "functionless remains of leg muscle origins." It turns out the meniscus cartilage is a crucial component for both the shock absorption and the stability of the knee. Even the removal of relatively small portions of meniscus cartilage can lead to dramatically large increases in force concentration in the joint. These increases can lead to more rapid wear and tear in early traumatic arthritis. Millions of people have undergone removal of their meniscus cartilage after suffering an injury playing high school and/or college sports. Twenty or thirty years later, these same individuals present back in our offices asking, "Doc, isn't there a shock absorber you can put back in my knee? I lost my meniscus and have developed arthritis, but I want to continue to play sports." With meniscus damage and removal often comes articular cartilage damage. Articular cartilage (the weight-bearing surface of the joint) was long thought to be irreparable. Once damaged, surgeons believed it would always develop arthritic changes. This turns out not to be true. Studies have shown that repair processes can be stimulated both inside and outside the joint by exogenous stimulation. The combination of meniscus cartilage replacement with donor tissue and articular cartilage regrowth using various stimulation techniques has developed the basis for biologic joint replacement. In 1991, we developed a technique of cartilage paste grafting at our clinic. Using the patient's own stem cells, underlying bone, and cartilage, we create a paste of stimulatory articular cartilage repair material. The following steps illustrate the basic www.sfms.org Continued on the following page . . . Meniscus allograft transplantation using the threetunnel technique. noveMber 2011 San FranciSco Medicine 17 bot. By obtaining a preoperative CT of the patient's knee to generate a 3D model of the joint surface, we can position the partial joint replacement components on the virtual knee model before an incision is ever made. During the actual insertion, only a small incision is required. A burr is passed into the joint and used to shape the exact area where the new joint replacement components will be inserted. The joint replacement components are virtually guaranteed to be accurately aligned based on the computer projections. This revolutionary advance, similar to the way the da Vinci robot has revolutionized general surgery, has now made partial joint replacement an outpatient procedure in our hands. It can be performed in less than an hour, and patients can walk away from the surgical center immediately, on the joint itself. The MAKO robotic insertion techCartilage repair using the cartilage paste grafting technique. (A) Morselizing nique has dramatically expanded our inthe lesion to bleeding bone. (B) Harvesting of articular cartilage and cancellous bone from the intercondylar notch. (C) Manually crushing the graft into dications for joint arthroplasty, especially now that we see severe arthritis in both paste. (D) Impacting the paste graft into the morselized lesion. younger and older patients. We can offer them a procedure that has far less morFrom Biologics to Bionics bidity than a total joint replacement procedure itself. There are Continued from the previous page . . . several reasons that partial knee replacements feel more norplanted to provide ligament stability. This technique is effective mal to our patients. No ligaments need to be cut, and a minimal primarily for the ACL and PCL knee joint ligaments. The comamount of bone needs to be removed. This also translates into bination of ligament reconstruction, meniscus cartilage replaceless bleeding and shorter recovery times. We permit our patients ment, and biologic joint resurfacing has given active people an to return to full sports after partial knee replacements, although option to choose either an artificial joint of metal and plastic or we encourage them to avoid running and impact, as all artificial a biologic reconstruction using natural tissue. The advantages of materials will eventually fail. Partial joint insertion techniques biologic reconstruction are that it can be performed as an outwill continue to improve as technology permits increasingly patient arthroscopic technique and, once healed, it permits pagreater alignment and placement accuracy of the components. tients to return to full sporting activities. Biologic joint replacement techniques will continue to imOn the bionic side of the joint replacement story, additional prove as we migrate from regrowing new cartilage surfaces to progress has been made as well. Artificial joint surfaces have imreplacing entire cartilage surfaces. We believe this can be acproved. They now use costly polyethylene polymers to provide complished using preformed intact cartilage shells loaded with longer-lasting plastic trays and oxinium surfaces to provide rethe patient's own stem cells. We have started work in animals duced coeffients of friction. Today's artificial joints are inserted and now have several pigs running around with resurfaced cartithrough smaller incisions, disrupting less of the joint anatomy lage defects using grafts loaded with their own stem cells. If this and allowing a shorter hospital stay and quicker recovery. We works well in pigs (who, by the way, have not learned how to use permit our patients to return to full nonimpact sports with a tocrutches), we expect this will progress to human studies within tal joint replacement; however, most patients avoid running and a few years. note that their knees, while improved in pain, are not normal. The future is now. Patients do not need to live in pain nor Patients who present with unicompartmental bone-onrestrict their activities. The more active we can encourage and bone arthritis, either in the tibiofemoral or patellofemoral joint, facilitate our patients to be, the healthier and the longer they will have the option of a partial or unicompartmental joint replacelive. ment. At our clinic, we have performed partial joint replacements for the past twenty-three years. In our experience, patients who Kevin R. Stone, MD, is an orthopaedic surgeon at the Stone receive a partial joint replacement, where the components are Clinic and chairman of the Stone Research Foundation in San perfectly aligned, seem to have much longer and better outFrancisco. The clinic treats athletes and people with arthritis, with comes, whereas components that were slightly misaligned wore a focus on knee and shoulder injuries. The foundation conducts out more quickly and had less satisfactory outcomes. research in advanced surgical techniques and tissue regeneration In order to solve the problem of implant accuracy, we have for orthopaedic sports medicine. turned to a robotic joint-insertion technique using a MAKO ro19 18 San FranciSco Medicine noveMber 2011 www.sfms.org Medicine for the later Years of life Nutrition for Longevity Eating Well into the Later Years erica Goode, MD, MpH The group aged 65-plus is forecasted to grow to approximately 25 percent of California's population by 2025. As a society we have been somewhat dismisI've asked patients over many years what they fear about aging, and the top five are "losing my brain, my energy, my loved ones, my driver's license, my savings." Loss of any of the above at least indirectly impacts overall nutrition. Studies show increased illness and earlier mortality for those with cognitive impairment, for example. Depression plays a role as well. Patients don't generally wish to hear the minutiae of cell biology as it relates to nutrition. But they should know something regarding appetite and gut function, as well as the guidelines from the Harvard Pyramid and/or the USDA's Healthy Plate. And a complex topic like nutrition requires further details regarding selection of whole, unprocessed foods; an emphasis on fresh fruits and vegetables, whole grains, healthy proteins, and sensible amounts and types of oils; and the value of some amount of dairy foods (which can be managed even for most lactose-intolerant individuals). I use as my teaching guide the Harvard Pyramid; its newer version incorporates the USDA Plate. The Pyramid is particularly helpful, given its emphasis on exercise as the base of operations. The overall recommendation is that this age group (a) get some form of brisk walking or other cardiovascular exercise for at least 150 minutes per week, (b) use arm weights (5 pounds for women, 10 pounds for men for approximately 20 minutes twice a week) for arm toning and maintenance of vertebral mineralization, and (c) perform overall toning and balance exercises to avoid falls and fractures, as promoted by Tufts, Stanford, and other research groups. As people age, muscle mass tends to be lost, although, depending on levels of exercise, strength is maintained until about age 50. The Tufts University Jean Mayer USDA Human Research Center on Aging did scores of intriguing studies on this population and found that among 85-plus-year-olds, this sarcopenia of muscle translates into real compromise for many in terms of rising from a chair, climbing one flight of stairs, or walking a quarter mile. And as we know, when they fall, they die. Hip protectors are not the answer. � Emphasize a variety of whole foods and a relative minimum of sweet, salty, fried foods, many of which the food industry refers to as having "craveability" (not addiction) qualities, since our caveperson origins encouraged us to gorge on such tasty items as greasy mastodons and the like. � For vegetarians, I urge their use of whey or egg white because of the relative need for some increase in high- sive of this demographic, but this group includes humanity's collective memory. It is our job, as physicians and as a society, to assist them in remaining healthy for their remaining decades. There is a huge splay in overall energy and self-fulfillment in this group, the healthy individuals tending to feel much younger and more self-reliant than their years might suggest. Indeed, many are extremely healthy as they hit the threedigit mark. My own Auntie Peggy, who died at 101.4 years of age, retained all of her parts, except for mild forgetfulness and increasing emphasis on the quirky sides of her nature, until death. Likewise my father, who died at age 99. Both were remarkably healthy. They kept active, held jobs they loved, traveled, exercised, maintained normal weight, cooked and ate well, drank little, never smoked, and had rich lives full of friends, neighbors, hobbies, and fun. In contrast, their sedentary parents with unhealthy consumption habits--my beanpole grandma and overweight grandpa--both died in their late 60s. While this is merely anecdotal, it demonstrates what epidemiologists have determined over the past forty years, which is that some 50 to 60 percent of chronic illness in adults could be avoided if healthy lifestyles were embraced. If we think of this communally, it behooves us to assist people of all ages toward optimal health, since the economy may require longer working years of this group, and less reliance on home care, hospitalization, and social services. The elderly of either gender are at risk when a partner or spouse dies, or when caregiver burdens fall upon them. Financial constraints can lead to marginal nutritional status, even if those individuals were previously healthy. Furthermore, stress (a challenge for me may be a threat for someone else) can powerfully influence frequency, amount, and type of foods eaten, whether in response to feeling overwhelmed or because earlier patterns are reverted to. Many other factors can also be at play: sleep apnea, insomnia, and night eating; lack of exercise due to injury or retirement; and the simple weight gain that accumulates from menopause/andropause onward, as muscles lose bulk, strength, and power, often leading to less exercise and increased tendency to fall or suffer other physical setbacks. www.sfms.org Nutritional considerations for a prototypic, reasonably healthy older adult: Continued on the following page . . . 19 noveMber 2011 San FranciSco Medicine mend checking fasting serum levels; if your patient has GI abNutrition for Longevity sorption issues (especially post-bariatric surgery patients), Continued from the previous page . . . calcium, vitamin D, and often massive levels of other nutriquality BCAA protein to maintain muscle function, especially ents are required. This is best managed by an endocrinologist, if some weight loss is desired. These can be obtained from and these patients should be in long-term nutrition support organic, sustainable, and humane farm sources of cows and groups for a host of reasons. chickens. A list of wild fish that are not endangered and that Finally, several excellent monthly health newsletcontain limited or no mercury can be obtained online from the Monterey Bay Aquarium. ters, mostly from universities, are available for adults of all � Seek out organic versions of those items that virages, often with a particular emphasis on healthy aging and the broad spectrum of preventive health. Since many suppletually always have heavy residual pesticide and herments and health products are labeled "When in doubt, conbicide content, such as stone fruits and Florida sand-grown sult your physician," many of these nutrition and health questomatoes (see the "Dirty Dozen" on the Internet). tions would otherwise come to you. Older people in a senior � Eat a variety of colorful, fiber-rich foods; possihousing setting often have access to a library and some funds bly a small amount of red wine daily; a few supplements (see for such subscriptions. For those living with computers, onbelow); and green tea if desired, or, for many, coffee, either line subscriptions are available. caffeinated or water-processed decaf. I have alluded to sources of statements made, but for a � Find some form of activity that is safe, feasible, detailed reference list, you may e-mail me at goodee@sutterand condoned by your physician. If weight and/or former health.org. overuse and consequent lower-extremity problems (especially of the knee) are an issue, find a warm swimming pool Erica Goode, MD, MPH, recently retired as an internist at for laps, water aerobics classes, and especially water walking. the Institute for Health and Healing, CPMC. She is an associate This is often key to weight management and adequate exerclinical professor at UCSF. She received her BS and MPH degrees cise to balance the needed intake of calories and nutrients. in nutrition at U.C. Berkeley and worked as a public health nu� Avoid AM doses of proton pump inhibitors in tritionist in Washington, D.C. She completed her MD and resielderly stomachs, which often have less ability to digest. dency training at UCSF and Children's/CPMC, San Francisco. Dr. Most patients do fine with PPIs given after dinner. Efficient Goode is also on the editorial board of San Francisco Medicine. digestion requires gastrin, pepsin, and some acidity, and since GERD is most prominent as a nighttime issue, evening dosing is often sufficient. � Take any supplements with a meal or drink containing some oil or fat (such as vitamin D3 and fish oil), since these, as with fat, must be absorbed via INC. the lacteal system in the small intestine. A REGISTRY & PLACEMENT FIRM � For people in independent or assisted-living settings with inhouse food service, further challenges arise, especially if an outside food service contract is part of the mix. It may require Nurse Practitioners ~ Physician Assistants a physician's note to negotiate with the food service (a relative of the older person may need to help here) to assure that requests will be taken seriously. � Supplements that I recommend, for younger and older adults, include (as capsules, powders, and occasionally tinctures) a daily multivitamin with no more than 1 milligram of copper, daily fish oil to provide at least 500 milligrams each of the omega-3 acids EPA and Locum Tenens ~ Permanent Placement DHA, and calcium from food and supplements to provide at least 1,200 milligrams V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 per day as calcium citrate. My favorite is FA X : 8 0 5 - 6 4 1 - 9 1 4 3 calcium citrate liquid, either the MRM or ReViva brands. Both contain some magnesium citrate, vitamin D3, and more. email@example.com � At least 1,000 to 2,000 IUs of w w w. t r a c y z w e i g . c o m vitamin D3 per day, or more. I recom- Tracy Zweig Associates Physicians 21 20 San FranciSco Medicine noveMber 2011 San FranciSco Medicine noveMber 2011 www.sfms.org Medicine for the later Years of life The Deadly Triangle Depression-alcohol-Grief David pating, MD At age eighty-six, Mr. Beltramo passed quietly in the night, leaving his widow, Mary, alone for the first time in fifty-two years. Mary was a devoted spouse who kept house while raising two children, now grown and living on the East Coast. Mary was typically happy and enjoyed working in the garden, despite arrhythmias that brought her regularly to the clinic--creating ample opportunity to interact with medical providers. None of us had noticed that Mary was losing weight, looked tired, and missed every other appointment. ***** Depression-alcohol-grief: This is the deadly triangle of older adulthood, resulting in overall poorer health status and significantly higher suicide rates in older adulthood. While adults over sixty-five are only 12 percent of the population, they accounted for 16 percent of completed suicides in 2004. Of every 100,000 people aged sixty-five and older, 14.3 died by suicide in 2004, compared to eleven in 100,000 for the general population. Non-Hispanic white men had rates of 49.8 completed suicides per 100,000.1 In psychological autopsies, depression is the overwhelming predictor of completed suicides in older adults. Depression has a population-attributable risk (PAR) for suicide of 74 percent, which is the proportion of suicide that would be prevented if affective illness were eliminated from the population. Alcohol use, social isolation (PAR=27%), and chronic medical illness are the most significant other risks in decreasing impact. These relative risks must be weighed cautiously, since cohort studies of population-based risks, especially those related to baby boomers, predict that alcohol problems in this next generation of older adults will double by 2020. Lastly, the influence of depression and alcohol misuse in older adults is worsened by social isolation, especially the loss of a partner or loved one. For these reasons, our National Institutes of Health have taken great effort to institute nationwide screening for depression and alcoholism, now incorporated into standard HEDIS measures reported by health systems. Besides implementing universal screening, all of us should be encouraged to look after our older adults by carefully screening them for depression, alcohol, or suicide risks, particularly after they have suffered a loss. Three questions are will prove useful: 1) Have you had depressed, sad, or blue mood for two weeks or more? 2) Do you drink more than one drink a day or three drinks on any single occasion? 3) Do you ever have thoughts that you would be better off dead, or of hurting yourself in some way? A "yes" to any of these questions should trigger a warning and an essential reminder: Up to 75 percent of older www.sfms.org adults who complete suicide visited a physician in the month before death. What we want to avoid is having our patients attempt a "permanent solution to a temporary problem." Most depression, even in older adulthood, remits with treatment--typically antidepressants or psychotherapy. As physicians, we must overcome our common misconception that depression in older adulthood is normal--it is not. Similarly, although alcohol consumption decreases with age, we must understand that risky alcohol use and abuse in older adults is more common than imaginable: Among older adults ages seventy-five to eighty-five years, 27.1 percent of women and 48.6 percent of men exceed recommended drinking guidelines.2 For each of our recent widows or widowers who are depressed, alcoholic, or both, they walk a fine line of risk. Add to this basket a mix of comorbidities, and the picture may seem complicated. Fortunately, in terms of suicide, while chronic illness (such as cancer, cardiovascular disorders, HIV) does increase the risk for suicide, its predictive impact is more significant in younger and middle-aged adults. For seniors with chronic illness, depression appears to be the principal Continued on the following page . . . noveMber 2011 San FranciSco Medicine 21 The Deadly Triangle Continued from the previous page . . . mediator. Dementia alone does not seem to be predictive of suicide, while other sources of psychological distress--family fights and financial loss--may increase social isolation, which is predictive. Lastly, while only one in twenty-five suicide attempts are successful on average, among people over sixty-five, one in three attempts result in death. These deaths are usually well planned, and plans may go unnoticed due to isolation. I encourage all physicians to inquire about access to firearms, since 60 percent of completed suicides involve guns. From a public health perspective, allowing guns in households is a preventable source of unnecessary mortality.3 Rather than summarize the newest treatment protocols, such as IMPACT for older adult depression or SBIRT for alcohol misuse, I want to be brief so as to reinforce the main point: Please ask. Older adults will come to you--at least three out of four of them--before they take the final plunge. Ask them about depression, alcohol, or suicide. This is especially true for those of us in primary care, since only 6 percent of older adults will seek specialty mental health or substance abuse treatment. It's up to our internists, geriatricians, and family practitioners to make the play; the rest of us are a phone consult away. And keep handy the numbers of San Francisco's Suicide Prevention Hotline ( 781-0500), Friendship Line for the Elderly ( 971-0016), or the Family Services Agency of San Francisco ( 474-7310) as local resources. But first: Ask, before it's too late. 4 ***** Mary Beltramo passed away six months after her husband. The autopsy documented natural causes, but the report noted undigested prescription pills (Coumadin) in her stomach and low levels of alcohol in her blood. The family did not wish to pursue further investigation into the cause of death. Was this preventable? David Pating, MD, is a psychiatrist practicing at Kaiser San Francisco. He is past-president of the California Society of Addiction Medicine and a board member of San Francisco's Suicide Prevention, the nation's oldest prevention hotline. 1. Older adults: Depression and suicide fact sheet. NIMH, 2007. 2. Grella C. Older adults and co-occurring disorders. Alcohol & Drug Policy Institute, 2009. 3. Conwell et al. Risk factors for suicide in later life. Biological Psychiatry. 2002. 4. See http://www.apa.org/pi/aging/resources/guides/ depression.aspx for a comprehensive resource guide on suicide and depression in older adults. references National power. Local clout. No compromises. The Doctors Company protects California members with both. What does uncompromising protection look like? With nearly 55,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage. In addition, our 20,000 California members benefit from the significant local clout provided by our long-standing relationships with the state's leading attorneys and expert witnesses, plus litigation training tailored to California's legal environment. When it comes to your defense, don't take half measures. Get protection on every front with The Doctors Company. This uncompromising approach, combined with our Tribute� Plan that has already earmarked over $106 million to California physicians, has made us the nation's largest insurer of physician and surgeon medical liability. To learn more, call our Napa office at (800)352-0320 or visit www.thedoctors.com. We relentlessly defend, protect, and reward the practice of good medicine. Any Tribute Plan projections shown here are not intended to be a forecast of future events or a guarantee of future balance amounts. For a more complete description of the Tribute Plan, see our Frequently Asked Questions at www.thedoctors.com/tributefaq. A3203_SF Medicine.indd 1 9/28/11 10:55 AM 23 22 San FranciSco Medicine noveMber 2011 www.sfms.org Medicine for the later Years of life Decision Making for End-of-Life Care the san francisco POLst Coalition Jeff Newman, MD, MpH; Steve Heilig, MpH; and Frances Wu, MS "Oh, no, not another form!" is the understandably common reaction among clinicians when confronted with more paperwork. But the POLST (Physician Ortance in filling out the form for physician review. We have found that the process works best when physicians and nurses who know the patient identify readiness for the conversation and introduce the social worker as a member of the care team. Another site where palliative care in general and POLST in particular can be introduced is the Emergency Department. In a pilot program at CPMC (also supported by the Metta Fund), we demonstrated that consultation in the ED by the palliative care team leads to better symptom control and prevention of some hospitalizations. When the patient needs to be admitted during off-hours, arrangements are made for early inpatient palliative care consultation. We are making POLST documents available in the ED so that they may be considered by appropriate patients and brought to their primary physicians for the conversation. Although there are early adopters among office-based physicians, we appreciate the challenges of implementing POLST conversations in ambulatory care setting. As familiarity with POLST increases among patients and physicians, we expect opportunities to increase. Among patients with advanced illness and limited life expectancy, we recommend alertness to the teachable moment, when they may be ready to consider EOL decisions. Providing the POLST document and general instructions to appropriate patients may help them initiate discussions with family and advisors, before cognitive and medical decline further complicate decision making. POLST is not a panacea for all problems in palliative and end-of-life treatment decisions and care, but it can help. We hope you find it valuable--and, most importantly, that your patients do as well. Jeffrey Newman is director of the Sutter Health Institute for Research and Education (SHIRE) and adjunct professor for the Institute of Health and Aging at UCSF. Steve Heilig is on the SFMS staff and is coeditor of the Cambridge Quarterly of Healthcare Ethics. Frances Wu is a health services researcher at SHIRE and a doctoral student at the U.C. Berkeley School of Public Health. ders for Life-Sustaining Treatment) seems to be an exception. Also known as "that pink form," POLST has spread among physicians and other clinicians as a useful means of eliciting and documenting patient preferences for care, remaining with patients wherever they might be. From the emergency department to intensive or long-term care, the value of this is apparent. With a two-year grant from the Metta Fund and the California HealthCare Foundation, the San Francisco Medical Society is hosting the San Francisco POLST Coalition, tasked with helping increase awareness and use of POLST. While we are blessed with a wide range of end-of-life (EOL) resources in our community, many patients still do not receive timely palliative care and the opportunity to understand and decide among alternative medical approaches. POLST is designed for EOL patients and their designated decision makers to document their choices regarding CPR, intensity of medical interventions (in addition to comfort care), and artificial nutrition. The current version is printed here as a useful tear-out resource. A brief video, "Conversation about POLST," features a physician and patient and is available from the University of California at http://www.uctv. tv/search-details.aspx?showID=18360. The POLST document needs to be signed by a physician (or, in other states, an advanced practice nurse or physician's assistant). Many times the conversation about POLST is complicated by issues better addressed by other members of the health care team, including nurses and social workers, especially when there are complex family and cultural issues. Ideally, the conversation should involve you in decisions about the treatments you want if you get too sick to speak for yourself, broach the issue of how long you might have to live, discuss your spiritual or religious beliefs, discuss what dying might be like, discuss your feelings and details concerning the possibility that you may get sicker, and discuss the things in life that are important to you (Reinke, Moss, Engelberg, and Au). While most POLST documents are implemented in skilled nursing facilities, there are many opportunities in hospitals, medical offices, and other community sites. POLST champions and active programs have been identified at a variety of hospitals and other provider organizations, including Kaiser, CPMC, St. Mary's, Saint Francis, Laguna Honda, On Lok, and Jewish Home for the Aged. The San Francisco End-of-Life Coalition (sfeol.org) and the Institute on Aging provide training and liaisons for a wide variety of community-based practitioners. At CPMC, we explored the use of a dedicated social worker for POLST conversations involving the family, as well as assiswww.sfms.org For more detailed information about using POLST, from the California Medical Association: http://www.cmanet.org/about/ patient-resources/end-of-life-issues/physician-orders-for-lifesustaining-treatment resource Reinke LF, Moss BR, Engelberg RA, Au DH. Patient-clinician communication about end-of-life topics. Journal of Palliative Medicine. 2011; 14:923-928. reference noveMber 2011 San FranciSco Medicine 23 aging and accentuating the Positive My Great Auntie Verle used to say, "If [aging] is the worst thing that ever happened to you, it isn't very bad." It's true. We aren't starving in Somalia or homeless in Haiti. We are getting older--and that can be fraught--yet we're here. Studies show that elders, even ones with several disabilities, are happier and feel better than we physicians expect, perhaps because they compare themselves to others--they could be worse off--and they also lower their standards. Here is a collection of quotes I've heard recently: � When he was eighty-one, Henry Jones, emeritus professor of Radiology at Stanford, observed, "I'm feeling just great. Of course, if I had felt this way when I was seventeen, I would have called 911." � Retired San Francisco surgeon Leonard Rosenman, also eighty-one, said, "I'm perfect. At my age, `perfect' is three things: When you wake up in the morning, you realize you can breathe. When you open your eyes, you realize you can see. And you only hurt in two places." � John W. Gardner's mother, nearing 100, said to him, "The trouble with aging is that you just aren't as sharp. You get grumpy; you don't look as good." John said, "Oh, Ma, you have so much going for you--a great mind, a fine family, a pleasant place to live." She said, "John, I'm not talking about me; I'm talking about you!" � A colleague was moaning to his mother about turning fifty. She said, "You think you have problems! I'm the mother of a fiftyyear-old!" � Stanford Professor Herant Katchadourian noted, "I'm doing very well considering my highly reduced expectation." � Jing Lyman, noted activist for fair housing and women's rights, on her eightieth birthday said, "I'm doing fine--age-adjusted." linda Hawes Clever, MD Adapted from The Fatigue Prescription: Four Steps to Renewing Your Energy, Health and Life, by Linda Hawes Clever, MD. Viva Editions, Berkeley, California, 2010. SFMS MEMbErS: COnnECt And COMMunICAtE wItH LOCAL PHySICIAnS On yOur SMArtPHOnE FOr FrEE! For iphone, i pa d a n d android Mobilize your practice. Get DocBookMD today. � � � � Exclusive HIPAA-compliant network On-demand multimedia messaging Share images of X-rays, EKGs etc Fast look-up of local physicians and pharmacies DocBookMD is supplied at no charge to SFMS members thanks to MIEC. To register, go directly to your device to download DocbookMD from the iTunes App Store or Android Market. Then complete registration right on your device. You will need your SFMS member ID #. c o n n e c t c o m m u n i c a t e collaborate DocBookMD.com www.sfms.org 25 24 San FranciSco Medicine noveMber 2011 Medicine for the later Years of life Treating Cancer in the Elderly a Personal Perspective Justin p. Quock, MD, FACp Often enough, patients have asked me why I went into oncology. Rather than speak of experiences could not undergo radiotherapy because he was too weak to crawl onto the exam table and sit still for the treatment. He and his family were content with conservative management. The seventy-nine-year-old lady with a subdural hematoma and acute leukemia was recommended hospice due to her poor prognosis from the initial diagnosis of myelodysplastic syndrome, which had cytogenetic abnormalities. In addition, neurosurgery felt that her hematoma was located in a vascular area, hence postoperative around-the-clock platelet transfusions would be anticipated. The eighty-six-year-old liver cancer patient with cirrhosis who could not afford his medication was referred to the drug's pharmaceutical financial assistance program. And the seventy-nine-year-old with metastatic pancreas cancer was not offered chemotherapy because of his extensive weight loss. Another challenge I am seeing more frequently in treating the elderly is the delay in the treatment of cancer due to the Internet. With its increased use, our patients and their families are more knowledgeable about cancer treatments, but what is lacking is their working experience with that information. I enjoy explaining treatment management and options of therapy to help ease their anxieties, but after spending an extraordinary amount of time and hoping that I have won them over with a plan of care, they leave and do not return. I am glad that my patients and their family members are more educated, but with knowledge comes doubt, and rather than work with me on a plan of care, patients and family shop for a doctor with an answer they want to hear, rather than accepting the truth. Unfortunately for the patient, precious time passes and the opportunity to palliate or cure a disease is lost. An example is the seventy-four-year-old gentleman who lost fifteen pounds off his already thin build, whose primary care physician's preliminary work-up and CT scans suggested lymphoma. A neck node biopsy led to a diagnosis of a metastatic T-cell lymphoma, but given his significant weight loss and other poor prognostic indicators, I did not feel chemotherapy was appropriate; palliation with steroid therapy was prescribed. The family agreed--or at least I thought they did. Shortly thereafter, they sought a second opinion, and the same treatment plan was recommended. A third opinion then was obtained, and chemotherapy was rendered despite their initial desire against it. Although his follow-up is unknown, a month passed before a plan of care was accepted. Although treating cancer in the elderly does have its challenges, on the whole patients are treated and their lives are improved. And as the population ages, the intervention noveMber 2011 San FranciSco Medicine of chemotherapy toxicity and cancer-related deaths, I think of it as an opportunity to extend quality of life. Call me the perpetual optimist? As the patient population ages more and more, I am seeing people who have conquered previous malignancies; who are on treatment for chronic diseases such as hypertension , stroke, or diabetes; or who have survived a heart attack or prolonged complicated hospitalization from a nosocomial infection. Less frequently do I see the young or middle-aged individual with de novo acute leukemia, osteosarcoma, or familial polyposis with a new diagnosis of colon cancer (such cases are mainly seen on Board exams). Today's challenge for the modern oncologist, I believe, is to skillfully determine the most appropriate therapy that will promote the most quality of life without side effects causing an intolerable existence. In particular with the elderly, who have more comorbidities, the tightrope walk is challenging. For example, in the case of the wheelchair-bound eighty-year-old severe COPD oxygendependent patient who is not a surgical candidate but needs radiation for early stage lung cancer: Should I refer him to my radiation colleague for radiation therapy? Such treatment may compromise his breathing even more. The previously active seventy-nine-year-old lady who sustained a subdural hematoma after a fall and now has altered mentation, and who has blood and platelet transfusion-dependent myelodysplastic syndrome and is transitioning into acute myeloid leukemia and needs chemotherapy: Would decompression of her hematoma be prudent in the face of her down-trending platelet count? And what if she survives the surgery? Will she survive chemotherapy? And, ultimately, how long will she live? Or the eighty-six-year-old metastatic liver cancer patient with a cirrhotic liver from chronic hepatitis B who may benefit from a new oral medication but cannot afford the very high copayment. Or the seventy-nine-year-old patient who was, six months earlier, treated for both colon cancer and pancreas cancer only to now develop metastatic pancreas cancer and who has a thirty-pound weight loss. As oncologists, we are reminded that a patient's performance status, rather than age, is the guiding light in helping us make treatment decisions. I find this to be most useful in answering the question of whether or not to treat. For example, the above-mentioned eighty-year-old COPD male www.sfms.org Continued on page 29 . . . 25 Medicine for the later Years of life Nonbeneficial Treatment sfMs Effort serves as Model for state Policy William Andereck, MD, and Steve Heilig, MpH The modern medical ethics "movement" has had much to do with patient's rights and autonomy-- the right and responsibility to make treatment decisions in partnership with clinicians and to be able to reject what is not wanted. This arose at least The Process: To promote an atmosphere of respect and understanding, [the Medical Staff of ________ and ________ health care facility] adopt this Policy as a fair and explicit process for resolution of disagreements between physicians and Patients or their Legally Recognized Health Care Decisionmakers concerning the appropriateness of specific medical studies, Treatments, diagnostic procedures, or other interventions. This Policy is intended to facilitate communication and recognize and respect both shared values and areas of disagreement. Thorough communication with the Patient or Legally Recognized Health Care Decisionmaker at each step in the process is vital and each step in this process should be documented in the Patient's medical record. Working through the steps outlined in this Policy will often lead to resolution of the situation well before the final stages of this process are reached. responding to requests for Nonbeneficial treatment: CMa Model Policy Adopted by the CMA Board of Trustees, July 29, 2011 Introduction: Patients have the right to receive quality care, including medically effective and beneficial Treatment that meets the standard of care. However, physicians are not obligated to provide medical Treatments that are outside the standard of care, including Treatments that, in the physician's exercise of professional judgment, are not expected to benefit the Patient. When disagreements arise about a particular Treatment, all parties involved are best served by a fair and explicit process that acknowledges and respects the views of all parties involved in individual medical decision-making, Patient autonomy and dignity, as well as the rights and professional obligations of physicians and other members of the Medical Team. 27 26 San FranciSco Medicine noveMber 2011 in part as a reaction to decades, even centuries, of paternalism and "doctor knows best." But sometimes there is a limit, and sometimes doctor does know best, and sometimes there is a struggle. Since some important legal decisions and journal articles in the past few decades, medicine and hospitals have struggled with developing solid, humane, defensible policy on how to determine when treatments are being provided or contemplated that might be "futile" or "nonbeneficial." Many professional groups have issued statements affirming what the AMA holds: "Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients." That conviction has held even when challenged with legal action by patient surrogates unhappy with a determination that continued treatments would be nonbeneficial and would not be provided. More than a decade ago, the SFMS convened physician representatives from hospital ethics committees around the state and developed a model policy on this topic, published in the Western Journal of Medicine (and this journal). It has served some hospitals well and was useful in the formation of CPMC's policy, and more recently for the new California Medical Association "model policy" we present here. We print this policy as an example of a tested approach that has served clinicians well in a growing number of difficult cases. Step 1: Identify Nonbeneficial Treatment If a member of the Medical Team receives a request from a Patient or their Legally Recognized Health Care Decisionmaker ("LRHCDM") for a specific Treatment that, in his or her professional judgment, is Nonbeneficial, the particular Treatment in question should be clearly identified and the provision of the requested Treatment evaluated using the following steps. CMA Model Policy: Responding to Requests for Nonbeneficial Treatment Step 2: Communication within the Medical Team Members of the Patient's Medical Team should be advised of the requested Treatment and the Coordinating Physician should be notified. Team members' questions regarding the proposed Treatment should be discussed among the Team. Team consensus is desired as it is best that all Medical Team members move forward with a clear, common understanding of the Patient's goals of care and whether the requested Treatment is beneficial. Team member understanding and consensus is especially important in situations involving withholding or withdrawing life-sustaining Treatment. The Coordinating Physician should act to facilitate this consensus and resolve disputes. Step 3: Communication with the Patient/LRHCDM regarding the Treatment Plan The Medical Team will communicate the medical prognosis and Treatment plan to the Patient or LRHCDM with compassion and patience. The Coordinating Physician should attempt to reconcile differences between the treating Medical www.sfms.org Team and the Patient or LRHCDM and to negotiate solutions to disagreements directly. Staff should document this communication process in the medical record, including notes of explanation and discussion of Patient capacity for medical decision making, probable diagnoses, probable prognosis, Patient/LRHCDM desired Treatment plan, and Coordinating Physician recommended Treatment plan, as well as relevant alternatives. When the Treatment is not Life-Sustaining or CPR, the Coordinating Physician may decline to offer the Treatment at this point, while offering an additional medical opinion (Step 4). Step 4: Seek Second Opinion by Another Physician If disagreement persists between the Medical Team and the Patient/LRHCDM, seek consultation with another physician concerning the potential benefit of the proposed Treatment. If the Consulting Physician believes the Treatment is beneficial, transferring care of the Patient to another physician or health facility who agrees with the Patient/LRHCDM's requested Treatment should be considered and offered as an option to the Patient/LRHCDM. If the Consulting Physician believes the Treatment is Nonbeneficial, the Medical Team should communicate that second opinion to the Patient/LRHCDM and again attempt to reconcile differences and negotiate solutions. This communication process should be documented in the Patient's medical record. If disagreement persists, invoke other resources, such as the institution's Ethics Consultation Service. Step 5: Ethics Consultation Service If the Consulting Physician agrees that the Treatment is Nonbeneficial but the Patient or LRHCDM continues to demand the Treatment, the institution's Ethics Consultation Service or other appropriate body should be consulted. The Ethics Consultation Service should include a physician member who has not previously been involved in the care of the Patient. Step 6: Transfer of Care If the Ethics Consultation Service agrees with the recommendation of the Coordinating Physician as supported by the second opinion of the Consulting Physician, the Patient/ LRHCDM must be promptly informed, preferably in writing, that the Treatment will not be offered or will be withdrawn if the Patient remains at the institution following an opportunity to arrange transfer. Unless the Patient/LRHCDM does not desire transfer, the physician or institution shall assist in the transfer of the Patient to another health care provider or institution that is willing to comply with the Patient/LRHCDM's Treatment request. Until transfer can be accomplished, the Medical Team will provide continuing care to the Patient. In all cases, any appropriate pain relief and other palliative care should be continued. The Patient/LRHCDM may be notified of the ability to seek judicial review of the Treatment. Step 7: If Transfer of Care is NOT Possible or NOT Desired by the Patient/LRHCDM If the Ethics Consultation Service agrees with the Patient/ www.sfms.org LRHCDM and transfer of care is not possible, then Treatment must be continued by an accepting Medical Team identified by the Ethics Consultation Service. If the Ethics Consultation Service agrees with the recommendation of the Coordinating Physician, and transfer of care is not possible or not desired by the Patient/LRHCDM, the Patient or LRHCDM should promptly be informed that the Treatment will not be offered or will be withdrawn after a reasonable period of time for accommodation. This period of time is not longer than the time that it would ordinarily take for family to gather at the bedside. Relevant Legal Standards: This Policy is consistent with professional medical standards, professional medical-ethics standards, and California law. For a summary description of these relevant standards, see CMA On-Call Document # 0403: Legal and Ethical Principles Applicable to Requests for Medically Ineffective or Nonbeneficial Treatment. Dr. William Andereck is an internist at CPMC and chairs the ethics committee there. Steve Heilig is on the SFMS staff and is coeditor of the Cambridge Quarterly of Healthcare Ethics. A monthly meeting began at the SFMS more than a decade ago to bring a wide range of clinicians and other professionals together during lunchtime for presentations, discussions, and more about end-of-life issues. While no longer meeting at the SFMS, the group continues and is a recommended resource for those working with patients in hospice and similar settings. The San Francisco Bay Area Network for Endof-Life Care is now in its thirteenth year of monthly meetings that offer support, community, and education for those involved in delivering hospice and palliative care throughout the Bay Area. They meet the first Wednesday of each month from 11:30 a.m. to 1:30 p.m. for lunch, networking, and a speaker presentation. The coalition works to improve end-of-life care by increasing public awareness through education, by identifying and filling end-of-life needs in diverse communities, and by strengthening resources within our network of local providers (e.g., POLST implementation practices, caregiver support, etc.). Meetings are free and open to the public, and the membership includes a diverse array of physicians, nurses, social workers, mental health providers, chaplains, volunteers, and art/massage therapists, all of whom serve those in our Bay Area hospice and palliative care settings. For more information, please contact coalition Chair Nate Hinerman, PhD (firstname.lastname@example.org), or visit www.sfeol.org. Meeting location and speaker information can be found on the website. Feel free to pass along this information to anyone interested in end-of-life care. sfBa End-of-Life Nework noveMber 2011 San FranciSco Medicine 27 HOSPITAL NEWS KAISeR Robert Mithun, MD Saint Francis Patricia Galamba, MD CpMC Michael Rokeach, MD Our aging population is one of the most daunting challenges modern medicine will face over the next twenty years. Between 2000 and 2030, the number of persons over age 65 will have doubled and will account for nearly 20 percent of the population. While advances in general internal medicine (hypertension, diabetes, coronary artery disease) have extended life span and improved the function of older persons nationwide, as the population ages the prevalence of dementia, falls, fractures, and incontinence will also rise. Along with these issues comes the burden of frailty, a complicated and poorly understood process of gradual decline and debility. Frailty in older adults often demands a high level of care in nontraditional settings such as rehab, home-based care, and outpatient hospice. At Kaiser Permanente San Francisco, comprehensive geriatric care begins with high-quality primary care in the office. In addition to managing common chronic diseases, we are focused on falls risk assessment and prevention as well as avoidance of adverse drug events from medications deemed unsafe for older adults. We have a practice of talking about the risk of falls with senior patients and sending informational letters on the topic to their homes. We encourage patients to exercise and provide some specific exercise programs to decrease the risk of falling. We encourage people to decrease their fall risk at home by eliminating unnecessary cords and obstructions and by having proper lighting. Once a patient needs more intensive geriatric-oriented services, our Continuity of Care department focuses on finding just the right level of care. Multidisciplinary by definition, our continuum teams call on nursing case managers, nurse practitioners, geriatricians, and social workers to help patients navigate the care maze beyond the hospital and clinics. Our electronic medical record allows these conversations to be recorded and passed on, which helps us help our families when it comes to difficult decisions near the end of life. 29 28 Geriatric medicine has become of particular interest to me as I mature into my third decade as a family practitioner. I see patients of all ages, but because I have had the pleasure of caring for patients for almost thirty years, many are now older adults. Older patients have special needs, and they usually require more time during their appointments. Compassion and caring are essential to the equation. These patients require a wide spectrum of care including behavioral health services, home health care, and social services. Their psychosocial needs are of utmost importance. As we age, we lose family and friends to illness, and this can take an emotional toll on our ability to care for ourselves. Physical abilities change, and this can result in isolation and feelings of loneliness. I frequently counsel my older patients on the benefit of communal and assisted living, as well as nursing home care when the time comes. As the palliative care director for Saint Francis, I would be remiss if I didn't mention the importance of crucial conversations regarding end-of-life decisions. Palliative care refers to the comprehensive management of the physical, psychological, social, and spiritual needs of seriously ill patients and their families. We have a specialized team that offers expertise in addressing issues surrounding life-threatening illness. The team includes doctors, advance practice nurses, social workers, chaplains, pharmacists, and dietitians. Our goal is to relieve suffering and improve quality of life for patients with an advanced illness. Saint Francis has always been committed to geriatric medicine and to this point, on October 25, the Staff Nurse III/IV Committee hosted a daylong educational program with Keynote Speaker Wendy Zachary, MD, presenting on the subject of "Understanding the Older Patient: Integrity Versus Despair." In closing, let me wish the San Francisco medical community a very happy Thanksgiving and upcoming holiday season. Congratulations to Dr. Gregory Buncke, who was recently reappointed for a threeyear term as chair of the Department of Plastic Surgery. Dr. Buncke will continue to serve as chair through 2014. Dr. James Kelly has been appointed vice chair of the Department of Plastic Surgery. CPMC California Pacific Medical Center, part of the Sutter Health network of care, was recently named one of the nation's top performers on key quality measures by the Joint Commission, the leading accreditor of health care organizations in America. CPMC's St. Luke's Campus, was honored for its work in treating heart failure, pneumonia, and surgical care. Joint Commission recognition is based on data reported about evidence-based clinical processes that are shown to improve care for certain conditions, including heart attack, heart failure, pneumonia, surgical care, and children's asthma. CPMC is among just 405 hospitals nationwide to earn the distinction of top performer on key quality measures for attaining and sustaining excellence in accountability measure performance. Inclusion on the list is based on an aggregation of accountability measure data reported to the Joint Commission during the previous calendar year. To be recognized as a top performer on key quality measures, an organization must meet two 95-percent performance thresholds. First, they must achieve a composite performance of 95 percent or above after the results of all the accountability measures for which they report data to the Joint Commission are factored into a single score, including measures that have less than thirty eligible cases or patients. Second, they must meet or exceed a 95-percent performance target for every single accountability measure for which they report data, excluding any measures with less than thirty eligible cases or patients. San FranciSco Medicine noveMber 2011 www.sfms.org St. Mary's Francis Charlton, MD uCSF David Eisele, MD Classified ads Prime Medical Office space At Parnassus Heights Medical Center from 350-2,500 sq. ft. Please contact Trask Leonard at Bayside Realty Partners, medical office specialists, at (650) 949-0700. What will geriatric medicine look like in the future? Call me crazy (you'll have plenty of good company), but I think it'll look a whole lot like the practice of medicine looked fifty to a hundred years ago. How can that be? Medicine has been progressing at logarithmic rates for the last half-century. First, do no harm (primum non nocere) has been replaced with an insatiable and hubristic desire to prevent all manner of diseases. It is no longer acceptable to let nature take its course, no matter whether the "pathology" we seek to eradicate is a product of our insane lifestyles in pursuit of perpetual youth and self-gratification or simple wear and tear. We can replace worn-out parts, restore function to limp organs, clean out clogged conduits, remove lethally deranged tissue, and even alter brain chemistry so that life's misery turns to roses. But at what price? We've mortgaged our future and broken the bank to achieve our goals. The cost of our current form of optimal care is unsustainable. We exorbitantly overuse technology and big pharma and grossly underuse our basic skills, knowledge, and experience. We waste untold resources to accomplish little when we use paramedics, ambulances, emergency departments, and hospitals to essentially triage our homebound or institutionalized geriatric patients, whose number is growing rapidly. We can no longer afford to follow this path of least resistance; I foresee the return of the house call. With this simple, cost-effective change in our behavior, the quality of health care will dramatically rise, while the attendant costs will reciprocally fall. The future of geriatric medicine is bright only if we go back to our roots and go out to those in need when we are called, rather than having them physically dragged into our dysfunctional money sump of a health care system. Nearly 8 million people in the United States have balance problems, and another 2.4 million experience chronic dizziness. Besides being frustrating, balance problems can be dangerous, especially for seniors. Falls are the primary cause of accidental deaths in persons over the age of sixty-five years. The mortality rate for falls increases dramatically for everyone, regardless of sex or ethnicity, with falls accounting for 70 percent of accidental deaths in those seventy-five years of age and older. Unfortunately, people often see three to four specialists before receiving an accurate diagnosis for balance disorder. The problem is that there are many organ systems involved in maintaining balance. Muscle and skeletal system problems can cause weakness and result in a fall. Many neurologic problems affect balance. Difficulty with vision can also result in imbalance. And, of course, inner ear problems can cause dizziness. The new UCSF Balance and Falls Center is addressing this important problem by offering a comprehensive approach to balance disorders, with specialists in otolaryngology, neurology, audiology, and physical therapy. Our team is skilled at diagnosing conditions such as migraine-related dizziness, which is often missed by general neurologists and otolaryngologists. The center features many of the latest testing methods available--for example, UCSF is the only clinic in Northern California equipped with a rotary chair that provides specific measurements of inner ear functioning. The team is also involved in a variety of research projects, including a new study on the use of injectable steroids for Meniere's disease. To learn more about our efforts, call (415) 353-2101 or visit www.ucsfhealth.org/ balanceandfalls. Experienced Physician assistants Full-time & Per Diem. Openings: Murrieta, Pomona, Orange, Moreno Valley, Valencia, Chatsworth, Del Amo, Saugus, Oxnard, National City, Stockton, Livingston, Turlock & Modesto. 1 year experience is required. Occupational Medicine and Urgent Care practice experience is preferred. Apply! No new grads please. providerrecruitment@ ushworks.com www.ushealthworks. com. Near Alta Bates Hospital in Berkeley $1100-$2530. Great location! Recently redecorated. Waiting room with receptionist window. 2 exam/ treatment rooms with hand sinks. Denise.email@example.com. Medical Office Treating Cancer in the Elderly Continued from page 25 . . . of other family members or significant others and the use of the Internet have begun to play an ever-increasing role in medical decision making for them. It's a challenging and exciting time, with new technologies for helping patients and their families make better medical decisions; however, decisions will eventually need to be made, and, we hope, made in time to benefit and enrich our patients' lives. As other more senior attendings have said, "The medicine part is easy; it's the social part that is not." Justin P. Quock, MD, FACP, was raised in San Francisco and attended St. Ignatius College Preparatory and the University of San Francisco. He practices both general internal medicine and medical oncology and serves on numerous committees at both St. Francis Memorial Hospital and Chinese Hospital. www.sfms.org noveMber 2011 San FranciSco Medicine 29 2011 CMA House of Delegates Stephen Follansbee, MD, and Steve Heilig, MpH Your SFMS delegation to the California Medical Association's annual meeting took thirteen proposed resolutions for consideration by the statewide gathering. The process is long and sometimes contentious. We succeeded on most every count this year, with a couple of resolutions referred for more study and report next year--where we will work to ensure that they too are adopted. The CMA is a respected and formidable force in Sacramento. Now the real work begins in the halls of politics, translating these policies into legislation or other action that benefits patients, the public, and physicians all over our state and beyond. As has been widely reported, a policy paper recommending decriminalization and regulation of cannabis was adopted--unanimously--by the CMA board. As four SFMS representatives were among the authors of that report, their discussion of this complex and controversial issue will appear elsewhere. What follows are other resolutions taken to the CMA meeting. Subsidies of Tobacco in Films (Gordon Fung): CMA now will work to see that "no tax incentives be given for any motion picture production that depicts any tobacco product or nonpharmaceutical nicotine delivery device or its use, associated paraphernalia, related trademarks, or promotional material, unless the film depicts the tobacco use of historical persons or unambiguously portrays the dire health consequences of tobacco use." Deceptive Pregnancy Centers (Leslie Lopato): "Any entity offering pregnancy counseling that does not provide medical services, provide contraception, terminate pregnancies, and/or refer to medical providers who do must disclose this information onsite and in their advertising and before any services are provided; and any entity claiming to provide medical or health services to pregnant women should be prohibited from marketing medical or any clinical services unless they are licensed to provide such services and have the appropriately qualified and licensed personnel to do so, and abide by federal health information privacy laws." Regulation of Electronic Cigarettes (George Fouras, Tomas Aragon): "CMA supports prohibition of the use of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids in those places where smoking is prohibited by law, and supports requiring a tobacco permit for the sale or furnishing of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids." The California Cancer Research Act (Robert Margolin): CMA will "support the concept of increasing cigarette taxes to raise revenues to support research focused on detecting, preventing, treating, and curing cancer, heart disease, emphysema, and other tobacco-related diseases and to finance prevention programs." Healthy Food Marketing for Children (Arti Desai, Adam Schickedanz, Shannon Udovic-Constant): "CMA will support efforts to regulate the advertising and marketing of unhealthy food and beverages to children; discourage the advertising and market- sfMs Bats (almost) 1000 at the CMa! (Eric Tabas): This intrusion was blocked from the state ballot but will likely be back here and elsewhere, and CMA will oppose any attempt to legally prohibit male infant circumcision. Firearms and Clinical Censorship (Stephen Follansbee): CMA will "oppose any restrictions on physicians being able to inquire and talk about firearm safety issues and risks with their patients," such as a law recently passed in Florida. Contraception as an Insurance Benefit (Judy Silverman, Arti Desai, Ann Myers): "CMA supports the coverage, without copayments, of all FDA-approved contraception methods and sterilization as a mandated health benefit of all health plans." Increasing Organ Donation (Follansbee/Margolin): CMA will study ways of relieving the organ donor shortage, including the presumed consent option; review promising programs in other states and countries; invite input from experts on organ donation; and report back for action. Generic v. Brand Medications (George Susens): CMA "opposes the profit-motivated removal of generic medications from the market in favor of much more expensive brand products." ing of unhealthy food and beverages in public places frequently visited by children or adolescents, such as schools; and encourage media education programs to reduce harmful health influences of food and beverage marketing to children and to promote the consumption of healthy foods." Opposing Legal Prohibition of Circumcision for a report on this statement: "CMA declares it unethical for California physicians to receive remuneration from drug companies to prescribe specific drugs unless it is part of a bioethics-approved research project." (Man-Kit Leung): CMA will "support a statewide effort to ensure that all California preschool children be screened for vision problems in accordance with applicable American Academy of Pediatrics guidelines." Emergency Department Overcrowding (John Maa/Peter Curran): CMA "acknowledges the negative impact of emergency room crowding on patient care and supports that patient acuity should be the primary criterion for hospital resource utilization" rather than financial considerations. Vision Screening for School-Aged Children Unethical Rebates from Pharmaceutical Companies (George Susens): The HOD "punted" on this and will ask Stephen Follansbee (pictured on left at the 2011 HOD) is an SFMS past-president, chairs the SFMS delegation to the CMA, and is an infectious disease specialist at Kaiser San Francisco and a clinical professor at UCSF. Steve Heilig is assistant executive director for the SFMS. 30 San FranciSco Medicine noveMber 2011 www.sfms.org The San Francisco Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000! Now is the time to take a good look at the SFMS/CMA plan if: � Ithasbeenmorethanoneyearsinceyoulastreviewedyour lifeinsuranceprotection � Youhadachangeinlifestyle(e.g.,married,hadachild, adoptedachild,takenoutamortgageorbusinessloanor investedinanewpractice) � Thelong-termassetsthatyouoncecountedonforyour financialplanningnolongerseemassecureastheyoncedid Endorsed by: � Youthinkyoumaybepayingtoomuch � Theamountofcoverageprovidedbyyourmedicalgroup isn'tenoughandyoucan'ttakeitwithyouifyouleave Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance! Underwritten by: Administered by: Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies. *The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice. 51423 (6/11) �Seabury & Smith Insurance Program Management 2011 � d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 � 800-842-3761 � CMACounty.Insurance@marsh.com � www.MarshAffinity.com CA Ins. Lic. #0633005 � AR Ins. Lic. #245544 We Celebrate Excellence � Corey S. Maas, MD, FACS CAP Member and founder of "Books for Botox�" community outreach program, benefitting the libraries of local underfunded public schools 800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo For over 30 years, the Cooperative of American Physicians, Inc. 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