2013 September/October

SEPTEMBER/OCTOBER 2013 | Volume 19 | Number 5

MEDICINE AND THE ENVIRONMENT PLUS:

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2 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

OR SCAN TO LEARN MORE!

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS

Feature Articles

Billing/Collections

8 Fracking Our Farmland, Our Families, and Our Future: A New Toxic Legacy

CME Tracking

18 Eating Nano

Discounted Insurance

26 Shallow Minds: How the Internet and Wi-Fi in Schools Can Affect Learning

Financial Services Health Information Technology Resources House of Delegates Representation Human Resources Services Legal Services/On-Call Library

32 Travels With Tesla: A Doctor’s Electrifying Journey 34 Book Review: Pandora’s Lunchbox 36 DNR Orders in the Periprocedural Period: Informed Consent and Refusal 40 Avoiding the Medicare Quality Reporting Penalty in 2015

Legislative Advocacy/MICRA

Departments

Membership Directory iAPP for

6 From the Editor’s Desk

the iPhone

7 Message From the SCCMA President

Physicians’ Confidential Line

14 Affordable Care Act: What You Need to Know

Practice Management

22 IMQ Launches One-Stop Online CME Platform

Resources and Education Professional Development Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/

30 Initiating Change: Health Policy in Action at the 2013 American Medical Association – Medical Student Section Annual Meeting 39 Medical Times From the Past 44 Classified Ads 45 In Memoriam

Coding Services Verizon Discount SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 3

The Santa Clara County Medical Association Officers President Rives C. Chalmers, MD President-Elect Sameer Awsare, MD Past President William S. Lewis, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Eleanor Martinez, MD VP-Professional Conduct Seham El-Diwany, MD Secretary Scott Benninghoven, MD Treasurer James Crotty, MD

Chief Executive Officer

Councilors

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Imtiaz Qureshi, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Seema Sidhu, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Michael Champeau, MD Santa Clara Valley Medical Center: Richard Kramer, MD

AMA Trustee - SCCMA James G. Hinsdale, MD

CMA Trustees - SCCMA Thomas M. Dailey, MD (District VII) Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

Editor

President John F. Clark, MD President-Elect Kelly O'Keefe, MD Past President James Ramseur, Jr, MD Secretary Patricia Ruckle, MD Treasurer Steven Vetter, MD

THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2013 by the Santa Clara County Medical Association.

4 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

David Holley, MD

E. Valerie Barnes, MD

John Jameson, MD

Jose Chibras, MD

Jeff Keating, MD

Ronald Fuerstner, MD

Eliot Light, MD

James Hlavacek, MD

R. Kurt Lofgren, MD

AMA Trustee - mcms David Holley, MD (Alternate)

THIS IS NOT A TEST Trial Lawyers have begun an all- out assault

on MICRA, California’s landmark tort reform law.

Join the Fight Today! Every dollar contributed to CALPAC goes directly to protecting MICRA, ensuring that your doors stay open.

Visit www.cmanet.org/micra or call 916.444.5532 for more information.

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 5

FROM THE EDITOR’S DESK

Joseph S. Andresen, MD Editor, The Bulletin

Politicians Should Listen to the Physician Leaders

By Joseph Andresen, MD Editor, The Bulletin We are on the verge of a government shut down as I write these words. In just a few hours an estimated 785,000 non-essential federal workers will be furloughed. Rangers will lock the gates to our national parks. If you are applying for an FHA home loan or passport, expect a wait. Of course, if this standoff continues, these inconveniences will turn into major headaches to our weak and slowly recovering economy.

Some Congressional leaders believe that everything must be done to stop “Obamacare,” claiming it to be an unconstitutional overreach of government, destined to wreck our economy and take away jobs. Proponents of the new Affordable Care Act (ACA) see it quite differently.

The goals of providing every American with affordable health care insurance, no longer excluding many with pre-existing conditions, and an emphasis on preventative services has the potential to be a landmark achievement. It is easy to forget that medical bills have been a leading cause of personal bankruptcies and home foreclosures.

Where is the public on all of this? Confused to say the least! A recent Kaiser Family Foundation study found that 40% of the public didn’t know that the ACA has become law. Right now a majority of Americans surveyed don’t support implementation of the ACA. However, 11% of those who don’t support the ACA, do so because they don’t feel it goes far enough!

As physicians, we certainly will be in the forefront of these changes with our patients as 2014 unfolds and the health care exchanges and other provisions are fully implemented. Let’s hope that our wisdom and guidance will prevail in making necessary improvements. Our politicians can learn much by listening to our physician leadership in the hard work and construc-

tive dialog we exemplify as we continue to work toward providing the highest quality and most affordable care to all our citizens.

Moving on to a story closer to home, I recently had the opportunity to attend a World Affairs Council presentation in San Francisco.

For some time, I’ve been intrigued with many of the topics presented and this nonprofit, nonpartisan forum for the public to hear firsthand from leading foreign policy and international relations experts to discuss and debate global issues. The International Forum Movie Night entitled “Open Heart” peaked my interest and was worth the drive up to the city despite the busy evening commute. Eric Talbert, Executive Director of Emergency USA presented a moving account of his organization’s success in supporting Salam Center, Africa’s only free-of-charge, state-of-the-art cardiac hospital which is located in the middle of the deserts of Sudan. Most of us think only of Africa’s many infectious disease challenges such as malaria, HIV and cholera. However as I learned, there are millions of children and young adults suffering from rheumatic heart disease. One hundred years

6 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

ago, it was the number one killer of American children. The story of eight Rwandan children was told in the screening of the academy award nominated documentary, “Open Heart” http:// vimeo.com/47069120). It’s a compelling story of the resilience of these children and incredible dedication of the physicians and staff that support them through their treatment, recovery and return home. The film will be shown on HBO later this month and I hope you will be as inspired as I was in watching it. Eric Talbert is based in San Francisco and welcomes questions, comments and support from our medical community (info@emergencyusa.org).

Joseph S. Andresen, MD, is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara Valley area.

MESSAGE FROM THE SCCMA PRESIDENT

SAMEER V. AWSARE, MD, FACP President, Santa Clara County Medical Association

MICRA Challenge

By Sameer V. Awsare, MD, FACP President, Santa Clara County Medical Association The Medical Injury Compensation Reform Act (MICRA), which was enacted in 1975, has protected California’s physicians and health care providers by limiting awards for pain and suffering to $250,000. This has helped control medical liability costs, reduce premiums for health care professionals, and maintain good access for patients to community clinics, health centers, and physicians. The trial attorneys, along with a coalition of interest groups, urged the California legislature to increase the $250,000 cap on awards for non-economic pain and suffering in medical malpractice cases. Having failed to win legislative support to change MICRA, the trial attorneys have filed an anti-MICRA ballot initiative with the Attorney General’s office for the 2014 ballot. Physicians in our county must band together with our colleagues across the state to defend MICRA. MICRA ensures that injured patients receive fair compensation while preserving patient’s access to health care. Under MICRA, injured patients may receive unlimited compensation for any and all economic damages while limiting non-economic damages to $250,000. The $250,000 cap on non-economic damages is an effective way of limiting meritless lawsuits and keeping health care costs lower, but has been targeted by the trial lawyers because it restricts the amount of money they can collect in damage awards. Increasing MICRA’s cap on speculative non-economic damages will have a dramatic, costly, and negative impact on the cost of health care in California, including medical liability rates. William Hamm, a former nonpartisan state legislative analyst, has estimated that doubling the MICRA cap on non-economic damages to $500,000 would raise health care costs in California by $9.5 billion dollars annually. For a family of four, this translates into approximately $1,000 in added costs every year. MICRA also ensures that health care dollars are spent on health care services, rather than being diverted to litigation.

In states outside California, that do not have legislation like MICRA, medical malpractice insurance costs have increased tremendously. This has forced physicians to abandon their practices, and rural areas have been especially hard hit. They have also lead to an increase in Medicaid expenditures. During the last decade, Texas has enacted laws that resemble California’s MICRA law and noted improvement in access to and the quality of health care in their state.

The fight to save MICRA will be extremely expensive, and the California Medical Association (CMA) and its allies have raised several million dollars to protect MICRA. In August alone, groups such as the California Hospital Association, The Doctors Company, the California Dental Association, the Medical Insurance Exchange of California, NORCAL Mutual Insurance Company, Cooperative of American Physicians, Kaiser Permanente, and the Permanente Medical Groups have all put up multimillion dollar figures to derail these efforts. However, we need the help of individual physicians as well. I urge you to learn more about MICRA

and how you can help in the fight by visiting www.cmanet.org/micra, and then make a contribution to CMA’s political action committee (CALPAC) to protect MICRA! If you know of a colleague who is not a member, urge them to join now. Together we are stronger!

In Order to Be Victorious in This Fight, We Need Your Help!

DONATE: A fight of this magnitude will be extremely costly. CMA is urging all physicians to consider a donation to CMA’s political action committee (CALPAC), which for the last 38 years has served as the first line of defense for California’s historic physician protections. Call 800/225-7229.

JOIN: If you are not already a member of SCCMA-MCMS/CMA, please consider joining today. By joining SCCMA-MCMS/CMA, you will help to ensure that the voice of California’s physicians is heard loud and clear in the capitol and beyond. Together, our unified voice can move mountains. Call 408/998-8850 (SCCMA) or 831/455-1008 (MCMS).

Sameer V. Awsare, MD, FACP, is the 2013-2014 president of the Santa Clara County Medical Association. He is a board certified internist and is currently practicing with The Permanente Medical Group in Campbell.

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 7

“It shocks me that we pride ourselves on being a national leader on environmental protection, yet we have allowed this activity to occur largely unregulated. California regulates massage therapists more than hydraulic fracturing.”

Assemblymember Richard Bloom (37)

By Cindy Russell, MD VP-Community Health, Santa Clara County Medical Association A large bus rolls by with a sign on the side that says, in big bold letters, “This bus is running on clean natural gas.” We don’t see a trail of smoke or detect an acrid smell from the tailpipe, and we think to ourselves, what a wonderful alternative to gasoline with its lung damaging sulfur oxides, nitrous oxides, and particulate matter that waft into the air. No pollution necessary, to turn those wheels. Right? Natural gas is important for a healthy clean environment. Right? Unfortunately, scientists who have carefully reviewed this issue contend nothing could be farther from the truth.

Yes, natural gas is largely methane and burns somewhat cleaner than oil, but it is actually dirtier than coal and much worse for the environment, when you look at the entire life cycle of natural gas extraction

with its air pollution, water contamination, hazardous waste disposal, seismic activity, total emissions, and potent global-warming gases released. (90)(91)(92)(93)(178) Rapid removal and use of natural gas and oil will contribute to a more rapid shift in the earth’s climate and limit our ability to prevent catastrophic global warming. (87) An analysis of 36 climate change indicators was recently detailed in a 240-page report by California’s Environmental Protection Agency. (298) It shows that “The science is clear that we are already seeing significant changes in every part of the state.” (87)(93)(99)(128)(130)(133)(134)(165) (178)(204)(205)(206)(213).

Oil and natural gas are extracted by similar methods and both have serious environmental and public health consequences. Modern fracking just carries more risk and more rapidly damages the environment.

Hydraulic fracking is a method to increase oil and gas extraction by drilling into the earth, then injecting fracking chemicals and water under high pressure to break apart rock formations and release trapped gas and oil, forcing them to the surface. After the fractures are created, a “propping” agent such as sand is pumped into the

Fracking Our Farmland, O and Our Future: A New To 8 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

fractured rock to keep the fracture open and keep the gas and oil flowing out. Fracking has been used for decades, however, advancements in technology in the last 10 years now allow deeper drilling, especially in deep “unconventional” oil deposits such as shale and tar sands, where the gas and oil are found in small pockets within the geologic formation.

Oil and gas companies now use horizontal drilling with wells more than seven-empire-statebuildings-deep. (3) Horizontal drilling also uses explosives to open the pipes and create fissures in the rock to allow gas to flow easily. (259)(260)(261) Much of the gas and oil is extracted by perforated pipes. The pipes, however, are not leak proof. Rock layers have been shown to be permeable and the fractured rocks can interlink in unexpected ways, connecting gas deposits to aquifers. Fracked methane seeps into the water and leaks into the atmosphere. (3)

Extending Peak Oil

These newer extraction methods, along with a relaxation of federal environmental laws, have enabled access to vast quantities of previously unrecoverable deep shale natural gas under farms, as well as remote and fragile areas where our drinking water and wildlife are at risk. (3) Oil and gas leases in many states are getting closer to populated areas. Natural gas drilling has mushroomed across the United States in the last decade. In 2007, there were 449,000 gas wells in 32 states, 30% more than in 2000.

(221) According to the American Petroleum Industry, the number of estimated shale wells drilled in 2011 is 43.8% more than 2010. (135)(238) California has over 50,000 oil and gas wells, many of which are “conventional” superficially-drilled wells. Increasingly, deeper hydraulic “unconventional” fracking methods were used in 25%-50% of the drilling operations in the last decade in California. Although exact numbers are not known, it is estimated that there were over 750 wells in California using hydraulic fracking in 2009, mostly in Southern California. (106) (136)(137) (138) It is estimated that there are 15 billion barrels of oil and gas under the Monterey Shale that potentially could be extracted. California counties that have documented hydraulic fracking for oil and gas are home to more than 100 rare and endangered species that are now threatened by this practice. (6) Oil and gas companies are preparing to frack California even more.

Deep horizontal fracking has more than one serious downside.

It uses massive amounts of clean water, which becomes permanently

Continued on page 10

Our Families, oxic Legacy SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 9

Fracking Our Farmland, from page 9 contaminated with toxic chemicals and is then disposed of as wastewater. These chemicals permeate and contaminate groundwater and local streams, leaving lifeless polluted waterways. Toxic air contaminants are released during fracking that have caused grave illness in nearby residents.

(10)(20)(233) Radioactive elements from the earth’s deep core are brought to the surface and become part of the air, soil, and water contamination.

Plugs in old wells may burst, allowing for even more massive contamination of private wells and aquifers, similar to what has happened in Montana. (3) Fracking has been shown to induce earthquakes in a variety of states.

(12) (13)(14)(15)(16) (52)(53)(54)(55)(115)(166)(167) To make matters worse, as the U.S. focuses our attention on high pressure horizontal fracking, an older unregulated, but no less toxic, method of oil and gas extraction is being used called “acid” extraction. “Acid jobs” are an old well completion method that involves pumping chemicals, such as hydrofluoric acid, into wells to melt rocks to allow more of the oil to flow. Companies are not required to report when they do it. (173) Oil and gas extraction are exempted from provisions of seven major federal environmental protections: The Clean Air Act, the Clean Water Act, the Safe Drinking Water Act, the Superfund law (regulation of hazardous spills), the Resource Conservation and Recovery Act (regulation of hazardous waste), the National Environmental Policy Act, and the Toxic Release Inventory. (100)(101)(102)(125)(239) With little federal oversight of the oil and gas industry, scientists and public health experts feel regulations and enforcement in California, and the rest of the nation, are insufficient to handle the expected increase in oil and gas extraction and protect the environment, the public, or our global climate.

“We’re just seeing the tip of the iceberg of what’s coming,” he said of the drilling for Monterey Shale oil here. “It could enrich the state beyond belief, but it could also destroy it.” Rex Parris, attorney and mayor of Lancaster, California (58)

Frack to Tap

The tragic aftermath of fracking is visible in Montana, Texas, Wyoming, Utah, Colorado, and North Dakota, but especially in Pennsylvania, 10 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

where Dimock residents don’t have to worry about a steady supply of natural gas in their homes because it comes right out of their faucets. In fact, residents have fully documented the unique ability to light their kitchen tap water on fire. Other states have documented the same. (1)(2)(147)(156) (157)

Boom and Bust

Some predict we will have a gas and oil boom here in California like the 1849 Gold Rush, especially in the Monterey Shale territory where “unconventional” deeper drilling is necessary for extraction. What will happen to our Golden State, if this continues? Will it be transformed overnight, like North Dakota, into a polluted industrial wasteland where NASA can see the wasted flared natural gas from outer space? (301(302) Or as in Dimock, Pennsylvania, where they have to truck in drinking water to farms? Quick cash, but with larger long term problems that threaten not only our economy, but our health and way of life.

California Dreaming

In California, we have three unique features that make the possibility of increased deep fracking much more frightening.

Food: We have produced the majority of the country’s fruits and vegetables for over 50 years, due to California’s year-round temperate climate and rich soil. We are the number one dairy state. (140) (141) (276) Water: We have an increasing scarcity of water with nature and farms already competing. Government agencies agree we have a water crisis in California. (169) Earthquakes: The Monterey Shale is very close to the San Andreas Fault. (169) Do we really need a flash of oil and gas development to stimulate the economy, or will oil and gas undermine our sustainability goals? California has the opportunity to build on our already strong economy with clean sustainable energy sources including solar, wind, and energy conservation.

Frackings Downsides

• Air pollution • Water contamination – aquifers, wells, rivers, drinking water

• • • • • • • • • • • •

Radioactive contamination Wastewater disposal, treatment Water scarcity Loss of agricultural land Loss of wildlife Deforestation Earthquake induction Fugitive methane Global climate game changer Undermines renewable energy policy Public health studies inadequate Regulation inadequate

Health Professionals Call for Regulations/Moratorium on Fracking

Most of the discussion regarding hydraulic fracking, especially high volume horizontal fracking, focuses on energy production and environmental regulation. However, hydraulic fracturing poses numerous significant threats to public health as discussed in more detail below. Toxins released cause water and air pollution with both acute and chronic health effects. Experts agree that these risks have been inadequately studied prior to hydraulic fracking. Health professionals are joining forces with scientists and law scholars to call for moratoriums on further hydraulic fracking until comprehensive, independent, public health and safety testing is done and adequate regulations are in effect to protect individuals and communities.

The National Association of County and City Health Officials (NACCHO) recommends action to address the environmental and health impacts of hydraulic fracturing and supports numerous recommendations to improve regulations, transparency, and accountability including 1) Federal, state, local, and tribal governments conducting Health Impact Assessments (HIAs) and health equity assessments prior to new hydraulic fracturing development projects, 2) Public health professionals from federal, state, and local governments being increasingly involved in policymaking, managing, and monitoring the natural gas industry, and 3) Federal and state governments closing “loopholes” that exempt natural gas activities in environmental regulations. (211) U.S. Government Accountability Office, September 2012: “Oil and

gas development, whether conventional or shale oil and gas, pose inherent environmental and public health risks, but the extent of these risks associated with shale oil and gas development is unknown, in part, because the studies GAO reviewed do not generally take into account the potential long-term, cumulative effects.” (215) CDC: In January 2012, Christopher Portier, director of the National Center for Environmental Health and Agency for Toxic Substances and Disease Registry at the U.S. Centers for Disease Control and Prevention in Atlanta, stated that “more research is needed for us to understand public health impacts from natural gas drilling and new gas drilling technologies.” (202) The Medical Society of the State of New York, in 2010, passed a resolution to call for a moratorium on fracking, which was renewed in 2013.

“The Medical Society of the State of New York supports a moratorium on natural gas extraction using high volume hydraulic fracturing in New York State until valid information is available to evaluate the process for its potential effects on human health and the environment (Council Action, December 9, 2010).”(185) “Principles of public health emphasize the need for transparency in research and policy, a precautionary approach in the face of uncertainty, baseline and continued monitoring, and adapting management as understanding of risks increases.” Katrina Korfmacher (213) Physicians for Social Responsibility in March 2012, after review of the numerous risks of fracking, including noise, diesel fumes, toxic pollution, fugitive methane, and earthquake induction, adopted the following position on fracking.

“PSR supports a precautionary approach that includes a moratorium on the use of hydraulic fracturing until such time as impartial federal agencies, such as the U.S. Environmental Protection Agency, develop and implement enforceable rules that provide adequate protection for human health and the environment from fossil fuel extraction processes that use hydraulic fracturing. “ (175) New York State Department of Health Commissioner Nirav Shah states in a letter to Governor Cuomo, February 2013, “The time to ensure the impacts on public health are considered is before the state permits drilling.” This quote was included in a separate letter signed by over 250 health and environmental professionals, health organizations, and over

Continued on page 12 SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 11

Fracking Our Farmland, from page 11 150 elected officials to the New York Governor. The letter asked for a moratorium on fracking until completion of ongoing health studies, comprehensive independent Health Impact Assessment (HIA) that is site specific is completed, and that there is transparent participation of health professionals and the public. (201) Cornell Report, a review of 24 case studies describing human and animal effects of adjacent fracking processes. Livestock and house pets suffered a variety of adverse health effects including dermatologic, respiratory, neurological, urinary, digestive, reproductive, and in some cases sudden death. There were similarities in human effects on the same properties studied. Dr. Michelle Bamberger, veterinarian and a member of the Ulysses Gas Drilling Advisory Board, and Robert Oswald, professor of Molecular Medicine at Cornell University, wrote, “Animals, especially livestock, are sensitive to the contaminants released into the environment by drilling and by its cumulative impacts. Documentation of cases in six states strongly implicates exposure to gas drilling operations causing serious health effects on humans, companion animals, livestock, horses, and wildlife.” (10)(216) The researchers recommend: • Full disclosure of chemicals used when hydrofracking • Prohibiting non-disclosure agreements when public health is at stake • Increasing food safety testing and research, as the study documented that animals exposed to chemicals were not tested prior to slaughter, and little is known about the effects of hydrofracking on meat and dairy products • Improving the monitoring of routes of exposure, including in water, soil, and air • Fully testing the air, water, soil, and animals prior to drilling and at regular intervals after drilling is completed “Without knowledge of all the chemicals being used, you can’t test before drilling,” said Bamberger. “And if we don’t have pre-drilling tests, then if you find a chemical post-drilling, how can you prove that “it came from hydrofracking?” (289) They further state, “Without complete studies, given the many apparent adverse impacts on human and animal health, a ban on shale gas drilling is essential for the protection of public health.” (216) Ecologist View: Acclaimed ecologist, distinguished scholar and author, Sandra Steingraber, PhD, who is often cited as a modern Rachel Carson, stated more directly in a press conference, “New Yorkers now know a lot about fracking. The more we find out, the deeper our objections. And that’s because, when you look under fracking’s hood, you see terrifying problems. Behind the hard sell and soothing promises, this contraption is unsafe at any speed.” (217) She later wrote, “Fracking is linked to every part of the environmental crisis—from radiation exposure to habitat loss—and contravenes every principle of environmental thinking. It’s the tornado on the horizon that is poised to wreck ongoing efforts to create green economies, local agriculture, investments in renewable energy, and the ability to ride your bike along country roads.”(218) Cindy Russell, MD, is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in plastic surgery and is currently practicing with the Palo Alto Medical Foundation Group.

12 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

“We’ve got to push the pause button, and maybe we’ve got to push the stop button” on fracking, said Adam Law, an endocrinologist at Weill Cornell Medical College in New York, in an interview at a conference in Arlington, Virginia. (191) Legal Review of Regulation of Hydraulic Fracturing in California. An extensive legal review was performed in April 2013 by Michael Kiparsky, associate director of the Wheeler Institute for Water Law and Policy at Berkeley Law, and Jayni Foley Hein, the executive director of the Center for Law, Energy & the Environment at Berkeley Law. One of their many recommendations states, “The legislature and CDOGGR (California Department of Oil, Gas and Geothermal Resources) should not shy away from finding that there is not enough scientific knowledge or institutional capacity to effectively manage a sharp increase in the expansion of hydraulic fracturing in California. If it makes this determination, it may choose to slow its growth until more knowledge and capacity can be developed.” (212)

Toxic Trade Secrets

“Of particular concern to me is that we learned that over the four-year period studied, fracking fluids used in Colorado contained some of the highest volumes of carcinogens in the country, and some of the most toxic.” U.S. Representative Diana DeGette, House Energy and Commerce Committee (47) According to a report by the Energy and Commerce Commission Oil and Gas, companies use about 750 different chemicals in more than 2,500 hydraulic fracturing products. Chemical additives used in fracturing fluids typically make up less than 2% by weight of the total fluid. This seems small, however, it may amount to 100,000 gallons of chemical additives over the life of each well. (7)(8)(11)(47) Many of these chemicals are solvents and can have short and long term health effects through inhalation and dermal exposure. “High concentrations of most solvents can cause narcosis (dizziness, nausea, fatigue, loss of coordination, coma, and the like). This can increase the chances for mistakes and accidents.” McCann (126) Solvents can cause chronic neurotoxicity with cognitive dysfunction including attention, verbal memory, and visuospatial skills. (310) Manufacturers are not required to disclose the ingredients of their processes as they consider this “proprietary” protected information. (179) Prior to independent tests by environmental organizations, chemicals in fracking were not known. (22) These additives include a toxic slurry of proppants, biocides, solvents, surfactants, viscosity modifiers, stabilizers, and emulsifiers.

A favorite solvent mix is BTEX, a combination of benzene, toluene, ethylbenzene, and xylene, all of which are listed as hazardous air pollutants (HAP) in the Clean Air Act and contaminants in the Safe Drinking Water Act. Toluene, ethylbenzene, and xylenes have harmful effects on the central nervous system. Benzene is a colorless liquid with a sweet odor that evaporates quickly. Short term effects include dizziness, weakness, headache, breathlessness, chest constriction, nausea, and vomiting. Long term benzene is a known carcinogen. It is well established that benzene can cause aplastic anemia and leukemia. (126)(241)(242)(310) Renowned scientist Theo Colborn, in a 2012 study, identified 944 products used in the fracking process in the U.S., of which only 14% provided 95% to 100% of the ingredients, while 43% provided less than 1% of the ingredients. “The researchers generated profiles of possible health effects from the chemicals identified in the natural gas process. Of these identified chemicals, over 90% were found to affect the skin, eyes, and sen-

sory organs; approximately 50% could affect the brain/nervous system, immune and cardiovascular systems, and the kidneys; 37% could affect the endocrine system; and 25% could cause cancer and mutations.”(279) A few of the hundreds of chemicals include: • Methanol (HAP) - Very common ingredient in fracking products. Corrosion inhibitor and surfactant. Efficient solvent causing nervous system dysfunction, headaches, dizziness, sleep disorders, visual damage, nausea, metabolic acidosis. Prompt treatment needed. (126)(245) • Naphthalene (HAP) - Commonly used. Surfactant carrier.

Respiratory tract irritation, nausea, vomiting, abdominal pain, fever, or death. (246) • Sulfuric Acid - Respiratory irritation.

• Formaldehyde (HAP) - Respiratory irritation, sneezing, coughing, asthma, fatigue, skin rash, severe allergic reactions, nasopharyngeal cancer. (247) • Hydrogen Fluoride (HAP) - Powerful toxin. Easily absorbed through skin. Rash, respiratory irritant, electrolyte dysfunction, visual loss, chronic lung disease, death from irregular heartbeat or rapid pulmonary edema. A lethal dose is 1.5 grams. (241)(243) • Ethylene Glycol - Commonly used. Stabilizer. Odorless liquid with a sweet taste. Also used as antifreeze. Ingestion causes CNS depression, dizziness, cerebral edema, nausea, vomiting, abdominal cramps, metabolic acidosis, acute renal failure, cardiac failure. Treatment delay harmful and sometimes lethal.

(126)(244)(245) • Gluteraldehyde - Biocide. Commonly used. Headaches, nausea, respiratory irritation, difficulty breathing, asthma, rash, contact dermatitis, allergic dermatitis, skin sensitizer.

• Crystalline silica dust - Commonly used to keep frack rock open. Progressive pulmonary failure, lung cancer. (203)

and click on the “Committees/Environmental Health” tab.

References Hydraulic Fracturing Video

1. Fracking Hell: The Untold Story. http://www.youtube.com/ watch?v=dEB_Wwe-uBM 2. Farmers Say Fracking Chemicals Contaminate Wells, Kill Almond, Cherry Trees. Kern County Board of Supervisors. November 13, 2012. http://www.youtube.com/ watch?v=b43Wzk6RQ4Y

References

1. Gasland. http://www.gaslandthemovie.com/whats-fracking 2. Affirming Gasland. http://www.gaslandthemovie.com/whatsfracking/affirming-gasland 3. The New Oil Landscape. National Geographic. March 2013, Page 32. http://ngm.nationalgeographic.com/2013/03/bakkenshale-oil/dobb-text 4. Questions about the safety of fracking. http://www.nytimes. com/2011/11/09/opinion/questions-about-the-safety-of-fracking. html 5. Energy and Environment. Environmental Aspects on Unconventional Fossil Fuels. European Commission.

2011. http://ec.europa.eu/environment/integration/energy/ unconventional_en.htm

Shaleshocked

More than 1,000 cases of chemical contamination from fracking have been documented by courts and state and local governments in Colorado, New Mexico, Alabama, Ohio, and Pennsylvania. These included cases where the toxic exposure was caused by well failures in which the concrete or steel meant to protect aquifers cracked under high pressure. In others, frack wastewater was dumped in unlined pits and chemicals seeped into the water table. (221) It is almost impossible to determine the exact cause of each contamination, or examine regional effects on humans, water, or the environment, however, because much of the chemical composition of fracking fluids is considered proprietary. Not even the EPA knows what is in the drilling fluids. Wyoming was the first state, in 2010, to require disclosure. However, because of the trade secrets law, about 30% of the chemicals in fracking fluid are still not reported, according to the Environmental Defense Fund. (47) (48) In addition, fracking operators also can alter what is in the fluid they are using at any time during the fracking process. Thus, the exact composition of the chemicals in the fluid may change moment to moment.

There is no requirement to monitor baseline levels of toxins in deep or superficial water bodies prior to or after fracking. This makes it virtually impossible to track the effects of fracking or conclude with any level of veracity that fracking is safe.

For the complete article and a full report of all references, visit www.sccma-mcms.org, SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 13

Affordable Care Act: What You Need to Know

By Roy S. Lyons,

income ȧȧ In 2015: the greater of $325/ individual (3 per family), or 2% of income

Managing Director, Marsh There is no doubt that the ACA is the most transformational change in health insurance since Medicare. It’s survived a Supreme Court challenge, presidential election, and continuing congressional attempts at repeal, modification or defunding (40 attempts at last count).

One thing is for certain: while there may be delays in implementing certain parts of the law, it is not going away. You’ll need to know the basics to evaluate how it influences your medical insurance buying decisions. The following will help with your decision making process that lies ahead.

ȧȧ In 2016: the greater of $695/ individual (3 per family), or 2.5% of income • Guaranteed Issue – Insurance companies must sell coverage to everyone, regardless of pre-existing conditions, and can’t charge more based on health or gender.

• Penalty – If you elect not to purchase coverage, you are required to pay a penalty

• Health Insurance Exchange – Individuals without access to affordable, employer-sponsored plans that provide qualifying coverage can enroll in plans offered either through the individual insurance market or through Covered California, the state-based exchange with coverage beginning January 1, 2014.

Open Enrollment for Covered California commences on October 1, 2013. Since there will be a great deal of traffic and confusion, you may wish to wait until late in October to review your options. If individuals don’t enroll with the exchange during the initial open enrollment period, they will have to wait until next year’s open enrollment period to obtain coverage.

ȧȧ In 2014: the greater of $95/ individual (3 per family), or 1% of

• Subsidies – Individuals and families may qualify for federal tax credits and

Health Care Reform: The Basics for Individuals

Beginning January 1, 2014, new regulations provide most Americans access to affordable health insurance that covers essential care. The regulations that facilitate this include: • Individual Mandate – Most individuals are required to have and maintain health insurance effective January 1, 2014. There are exceptions for certain individuals.

14 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

benefit subsidies only through Covered California. Tax credits are available to those who meet certain income requirements and do not have access to affordable health insurance that meets minimum coverage standards offered through their employer or another government program.

Eligibility for tax credits is based on family income and size. Individuals and families who make between 138

Minimum Essential Benefits • • • • • • • • • •

Ambulatory services Emergency services Hospitalization Maternity and newborn care Mental health/substance abuse treatments Prescription drugs Rehabilitative services Laboratory services Preventive/wellness services Pediatric services

percent and 400 percent of the federal poverty level (FPL) may be subsidy eligible. Benefit subsidies will also be available to provide assistance with co-pays and out of pocket amounts for individuals who earn less than 250% of the FPL. • Premiums – Premiums can only vary by age, geography, and family composition in California. They may not vary by gender or health conditions.

• Annual or Lifetime Limits – Individual and group plans may not impose limits on essential benefits.

• Out of Pocket Expenses – Limits out-of-pocket expenses for co-pays, co-insurance, deductibles, etc., to $6,350 per individual to a maximum of $12,700/family annually.

Options for Coverage

The impact on individuals depends on a variety of factors.

• No coverage in place: Individuals must purchase and maintain qualifying health coverage or instead pay a penalty. If their income is between 138% – 400% of the federal poverty level and they have no other coverage available to them that is affordable and qualifying, they could be eligible for a tax credit in the exchange. In 2013, the range is between $15,860 – $45,960 for

individuals, and for a family of four between $32,500 and $94,200.

Individual plans in and out of the exchange will provide guaranteed issue coverage and include essential benefits and plan designs that meet the four metal levels: platinum, gold, silver and bronze. A silver plan is meant to cover 70% of an average person’s expenses with the insured expected to pay 30% for deductibles, co-pays, co-insurance, etc.

• Existing coverage: If you currently have an individual policy in force, one of two things can occur: ȧȧ If the plan was in place prior to the ACA signing on March 23, 2010, and has not undergone any significant change since, it may be continued.

Metal Tiered Plans

• Platinum Plan: ȧȧ Plan pays 90% of expenses ȧȧ Insured pays 10% • Gold ȧȧ Plan pays 80% of expenses ȧȧ Insured pays 20% • Silver ȧȧ Plan pays 70% of expenses ȧȧ Insured pays 30% • Bronze ȧȧ Plan pays 60% of expenses ȧȧ Insured pays 40%

ȧȧ If an individual’s plan is not grandfathered, and the plan of benefits does not meet one of the tiered metal levels, the benefits will be modified. This will likely have an impact on plan premiums as well.

Individuals trapped in old, high-priced plans due to health conditions, are now eligible to move to a new plan at possibly lower costs without having to be concerned about underwriting considerations. The individual should look very carefully at the provider networks available under each plan to ensure they are still able to seek care from their personal physician and hospital.

Learn More

Let Marsh be your partner on this new adventure. For more health care reform communications, including information on the Marsh/ Seabury & Smith Insurance Program Management private health care exchange for members, please call Marsh at 800-842-3761 or go to www.

CountyCMAMemberInsurance.com.

Marsh and the association/society do not provide tax or legal advice. Please consult with your own advisors to determine how the law’s changes and your decisions impact your personal situation.

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 15

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Processed Foods and Packaging Already Contain Nanoparticles – Some of Which Could Be Harmful to Our Health

By Brita Belli Reprinted with permission of “Copyright 2013 E/The Environmental Magazine” Our food supply is not nearly as safety-tested as we would like to believe. True, things are not as dire as they were in the early 20th century when Upton Sinclair’s The Jungle exposed the filth of the meatpacking industry, leading to reforms that included the founding of an agency that would become the U.S. Food and Drug Administration (FDA). But there are still unsettling gaps in what we know about the food and food packaging that is already sitting on supermarket shelves.

Unbeknownst to just about everyone, nanoparticles made a quiet entrance into the nation’s food supply at least a decade ago. Nanoparticles are materials that are microscopic – significantly smaller than a red blood cell; and tens of thousands of times smaller than the width of a human hair. These particles can help deliver nutrients, ensure longer freshness of food, act as thickening agents, or enhance taste or flavor. The problem is, scientists are still determining the health and environmental impact of these tiny particles, even as industry is

forging ahead.

“At the moment, there is not much information available on the topic of ingested nanoparticles and human health,” says Birgit Gaiser, PhD, a postdoctoral research fellow at HeriotWatt University in the UK. “Some nanoparticles are present in the human diet, for example titanium dioxide in food products and cosmetics, and silver, which is sold as a nutritional supplement. There is evidence that a small percentage of these particles, or particle components like silver ions which can be released in stomach acid, can move on from the intestinal tract into the blood, and reach other organs. This is why we believe it is important to assess the risk of even small amounts of particles in the human body and ensure that the types of particles present in the human diet and cosmetics, as well as the amounts ingested, can be considered safe.”

The FDA has been slow to catch up. In fact, the agency doesn’t even track which foods contain nanoparticles. Following is a recent e-mail exchange with Sebastian Cianci, a spokesperson at the FDA: E Magazine: What can you tell me about the prevalence of nanomaterials in our food supply?

Brita Belli is editor of E/The Environmental Magazine and the author of The Autism Puzzle: Connecting the Dots Between Environmental Toxins and Rising Autism Rates.

18 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

Sebastian Cianci: FDA does not have a list of food products that contain nanomaterials.

E: Where are nanomaterials most often found within food products? In colorings or additives?

S.C.: FDA does not maintain a list of food products that contain nanomaterials, so we cannot reliably answer this question.

Now With Extra Nano

There is no doubt that nanoparticles are in the food supply and have been for years. Recent research found that foods with caramelized sugar, including bread and corn flakes, contain carbon nanoparticles. Many nutritional supplements – or “nanoceuticals”–come equipped with copper, silver, or iron nanoparticles. Nanoparticles can be used to purify water, as anticaking and gelatin-forming agents and in packaging to protect against UV light, prevent the growth of microbes, or detect contamination. Titanium dioxide is added to a huge swath of products in nano form, including paints, paper, and plastics, but also lends white pigment to most toothpastes and many processed foods, including Mentos, Trident, and Dentyne gum, M&Ms, Betty Crocker Whipped Cream Frosting, Jello Banana Cream Pudding, Vanilla Milkshake Pop Tarts, and Nestlé Original Coffee Creamer. The aforementioned products were featured in a report in February 2012, in the journal Environmental Science & Technology, which concluded that each of us likely consumes some amount of titanium dioxide (TiO2) nanoparticles each day, and children under 10 likely consume the greatest amounts (around 1-2 mg TiO2 per kilogram body weight per day) due to their higher intake of frosted foods, candy, gum, and other sweets.

Then there are the nanoparticles that are not intended to enter the food supply, but because of their miniscule size slip through wastewater treatment in particle or dissolved form and take up residence in the biosolids created at the end of the wastewater treatment process. These biosolids are later applied to fields as fertilizer for their nitrogen and phosphorus content. In August 2012, a team of researchers led by scientists at UC Santa Barbara looked at the impact of two nanoparticles on soybean crops. They discovered that soybean plants absorbed zinc oxide nanoparticles from sunscreens, cosmetics, and lotions into their leaves, stems, and beans. It was certain these particles were entering the food supply, but unclear what impact they might be having. The researchers admitted that these nanomaterials in the wastewater treatment plant systems could be measured, but aren’t.

Besides the foods themselves, dietary exposure to nanoparticles

is also happening through food packaging. The European Institute for Health and Consumer Protection reports that the market for nanomaterials in food packaging is expected to reach $20 billion by 2020 (the nanotech industry as a whole is expected to reach $1 trillion by 2015). There is nanoclay, used by beverage companies to prevent permeation of gases from plastic bottles; nanoaluminum, used to improve the functioning of aluminum foil, making it better able to reflect heat and prevent sticking; nanosilver, used for its antibacterial properties in some food containers; and nanotitanium, which provides filters for home fridges. It’s even likely that we regularly ingest silver nanoparticles that are shed from our forks, spoons, and knives, according to a 2011 study in the journal ACS Nano.

“We know that there’s nanosilver in food wrapping and food packaging,” says Jennifer Sass, a senior scientist with the Natural Resources Defense Council. “That nanosilver releases ions, so those ions could be getting into the food. The ions are toxic, they are the antimicrobial part of the silver.”

From the government’s perspective, nano forms of silver, iron, or titanium are no different, fundamentally, from their scaled-up counterparts which have already been safety tested, so the agency has ushered the particles into the food supply under the Generally Recognized as Safe provision. In other words, companies are not required to disclose these tiny ingredients, hence the FDA’s ignorance on where they are hiding. But as the environmental organization Friends of the Earth notes on their website: “The properties of nanoparticles are not governed by the same physical laws as larger particles, but by quantum mechanics. The physical and chemical properties of nanoparticles – for example, color, solubility, strength, chemical reactivity, and toxicity – can therefore be quite different from those of larger particles of the same substance.”

The FDA issued a draft guidance for manufacturers in the food industry, in April 2012, advising them to consider where using nanotechnology will affect the identity or safety of the food substance, which could lead to an acknowledgment on the product label, but only at the manufacturer’s discretion.

“Under existing statutory and regulatory provisions, manufacturers are able to voluntarily include information about the use of nanomaterials or nanotechnology in the labeling of products,” Cianci wrote to E, “where such information presented in the context of the entire label or labeling is not false or misleading and does not violate other labeling requirements.”

Continued on page 20 SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 19

Eating Nano, from page 19 Companies, Consumers Left Clueless

Before companies consider labeling food products as nano-containing (and with all the consumer skittishness about changes to the food supply, who would?), it would probably help if they knew what was in them.

In many cases, particularly when it comes to food packaging, they don’t.

The environmental and shareholder advocacy organization As You Sow released a report in 2011 on nanomaterials in food and food packaging in which they interviewed five food giants – Kraft Foods, Yum! Brands, Pepsico, McDonald’s, and Whole Foods – in hopes to learn how these companies were using or planning to use nanomaterials. In many cases, says As You Sow’s Senior Strategist Michael Passoff, “They had to go back to their supply chains and check. It’s hard for the companies to know. The manufacturers of nanofood or nanopackaging are not required to identify it anywhere.”

In speaking with representatives from these companies, however, Passoff says most were taking a cautious approach. They didn’t want to risk a negative association with a technology that has potentially harmful health and environmental impacts. “They all admit that ‘We’re watching the technology, if it’s proven safe, then we’ll use it in the future, but right now we’re not using it,” Passoff says. Underscoring that uncertainty, McDonald’s put the following disclaimer on its website: “Given the current uncertainty related to potential impacts of nano-engineered materials, McDonald’s does not currently support the use by suppliers of nano-engineered materials in the production of any of our food, packaging, and toys.”

But McDonald’s is the exception when it comes to informing the public. The Woodrow Wilson International Center for Scholars’ Project on Emerging Nanotechnologies may be the only place trying to keep tabs on which products – including food products and supplements – contain nanomaterials, but its 1,000-plus manufacturer-identified inventory is woefully incomplete, particularly when it comes to food. Just five products are listed under foods, and none of them would create much of a stir: Among U.S. products, just a Saeco Primea Ring Automatic Espresso Maker (which contains a silver ion coating) and Nanoceuticals Slim Shake Chocolate are identified. “They haven’t really updated that for at least a year and a half,” says Passoff. “And the one item on there that we actually looked at (a McDonald’s milkshake, which has since been removed) turned out to be wrong.”

Unknown Health Consequences

While the government remains hands off, consumer health and environmental groups, including As You Sow, NRDC, and Friends of the Earth, are warning of the mounting evidence suggesting that nanoparticles, because of their small size, can cause harm when inhaled or ingested.

In 2011, researchers discovered that silver nanoparticles, when inhaled, cause lung toxicity or inflammation in exposed mice. Similarly, inhaled copper nanoparticles increased the risk of pulmonary infections in mice.

Carbon nanotubes, used in super-strong plastics and for computer chips, have presented a particular worry, when research found in 2008 that the particles can damage lungs much like asbestos, which the particles resemble in shape and size. The pointy microscopic cylinders can lodge in lungs and could give rise, like inhaled asbestos fibers, to cancer.

Of course, such findings pertain more to consumer products – like clothing treated with antimicrobial silver particles – than foods, but eating nanoparticles carries its own consequences. It’s a swift pathway from inhalation to the brain (nanoparticles are small enough to bypass the blood-brain barrier), but ingestion, too, can carry particles into the 20 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

bloodstream where they can travel and accumulate throughout the body.

A guide on the American Society of Safety Engineers’ website sheds chilling light on the potential dangers of nanoparticle ingestion. They write: “Nanoparticles may be ingested through drinking water, food additives, atmospheric dust on food, toothpaste, and dental fillings and implants.

Ingested nanoparticles can then be absorbed through “Peyer’s Plaques” or small nodules in intestinal tissue that are part of the immune defense system. If nanoparticles enter the digestive system and proceed into the bloodstream, they could move throughout the body and cause damage.”

They continue: “Nanoparticles may also accumulate in certain organs, disrupt and impair biological, structural, and metabolic processes and weaken the immune system.

Some of the impacts of chronic exposure to nanoparticles appear to be more subtle. A Cornell research team led by Gretchen Mahler, PhD, found that when chickens consumed large doses of polystyrene nanoparticles, approved for human consumption, it had two opposite effects.

When exposure was acute (i.e., a lot given in a short amount of time), it blocked the animals’ ability to absorb iron. When exposure was chronic (i.e., a little over a longer period of time), it resulted in increased intestinal villi and an increased rate of iron absorption. Chickens absorb iron much like humans, and although Mahler would not speculate if a similar effect may be happening in humans, she admits that her research suggests nanoparticles can induce changes that may not be obvious. “Nanoparticle exposure, even exposure to nanoparticles that are generally considered safe, can have unintended physiological consequences,” Mahler says.

“Nanoparticle-based materials are being developed for many different applications and the human response, especially the more subtle effects related to chronic exposure, is not always known.”

And Mahler notes that each nanomaterial is unique in the way it interacts with the human body. “The nanomaterials that are being developed all have very different reactivity with human tissues,” she says. “This means that you can’t apply results with one type of nanoparticle to all other nanoparticles – you have to test them all individually.”

Gaiser, whose research has looked at the impact of various nanoparticles – including nanosilver – is part of a team of researchers developing InLiveTox, a non-animal (or “in vitro”) model for testing nanoparticles being funded by the E.U. There are so many nanomaterials in need of testing, and tens of thousands of chemicals overall that have been approved in the U.S. despite a lack of basic toxicity testing, that the classic animal testing model is now seen as too time-consuming, and too cruel, to be effective. As one article in ACS Nano noted, our sluggish testing method “leaves us exposed to new toxicological scares on a continuous basis. While admittedly it is impossible to perform risk assessment and management without in vivo (whole, living organism) toxicological data,” the article continues, “it is becoming clear that animal testing may not provide the best test method when con-

fronted with thousands of new chemicals and nanomaterials.”

InLiveTox combines human cell models of the intestine, blood vessels, and liver to simulate the actions of nanoparticles as they travel across these layers, from bloodstream to organs. “The cells at the different steps of the combined system can then be analyzed as a whole or separately for damage by particles, inflammation and other effects, and they can interact with each other, which makes the InLiveTox system more lifelike than standard models,” says Gaiser. “This type of experiment is extremely important, because thousands of different nanomaterials are already in use with more being developed constantly, and it would be unethical to test every single particle using animal models.”

Science has already shown that nanoparticles, once ingested, can be taken up by the intestinal tract and, depending on their size, pass into the lymph nodes, affecting the immune system, or into the capillaries, where they can settle in various organs. For this reason, an article in the Journal of Nanobiotechnology in 2004 cautions that “For those nanoparticles designed to stabilize food or to deliver drug via intestinal uptake, other, more demanding, rules exist and should be followed before marketing these compounds.”

Approach With Caution

In the absence of specific regulations, the onus remains on food producers to figure out if they are unwittingly packaging food in nano-containing wrappings, proceed with caution in including nanomaterials in their products, and keep the public informed with clear labeling. A 2011 report from As You Sow provides companies with a series of steps they can take to achieve transparency – by insisting that their suppliers provide information on nanomaterials and related safety data and by participating in voluntary government reporting and keeping the public up to date on all safety testing information. In many ways, adhering to the pro-

vided framework will prevent future “tox icologica l scares,” which can damage a company’s reputation and bottom line, from happening.

“Kraft has its own scientists,” says

Passoff. “But other companies don’t have an extensive network, so what questions do you need to ask to know ‘Is it in our supply chain?’ ‘Is it safe?’

‘What are the risks and benefits from it?’ ‘Why are we using it?’ ‘Why do our suppliers want to use it?’ That’s how the framework came up. It was really what companies should ask their suppliers regarding the safety of products containing nanomaterials. So businesses can make more informed decisions.” The organization is also in the process of surveying hundreds of companies to compile their own database of those using nanomaterials. In the meantime, shoppers with iPhones can download the findNano app, but it draws its information from the Woodrow Wilson Center’s Consumer Products Inventory, which won’t reveal much, particularly at the grocery store.

At the NRDC, Sass suggests that the FDA needs to move beyond collecting data and into more serious regulation of all chemicals and nanoparticles. The Safe Chemicals Act, which passed the Senate Committee on the Environment and Public Works in July 2012 and would insist on mandatory safety testing for all approved chemicals, does not specifically mention nano. But it alludes to it. The bill would grant the Environmental Protection Agency Administrator the ability to determine whether a chemical substance is being used in a different-than-normal manner and should be considered a distinct substance. If the chemical [i.e., nanoparticle] is determined to be separate, it would be subject to its own safety testing.

While not explicit, that portion of the law would provide some method of controlling the spread of the most suspect nanoparticles.

“We’re just trying to get them [nanoparticles] to be consid-

ered as unique from conventional, to be regulated better,” says Sass. “We think chemicals should be regulated better.”

And safety studies of nanoparticles, says Mahler, need to take into account the long-term, smaller exposures happening over a lifetime. “Safety studies should involve chronic exposure results,” she says, “and should look at the more subtle, sublethal effects of nanoparticle consumption.”

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 21

IMQ LAUNCHES ONE-STOP ONLINE CME PLATFORM The Institute for Medical Quality has launched IMQ Online Education, a new online platform for continuing medical education. IMQ Online Education is a one-stop shop for medical staff seeking CME: the platform offers users a growing selection of courses on a variety of subjects, accessible at any time and from any Internet-enabled device, and the means to keep track of courses completed and credits earned.

IMQ Online Education provides access to courses for AMA PRA Category 1 CreditTM, as well as other forms of continuing-education credit.

A diverse course catalog makes it easy for physicians and other health care professionals to maintain their licenses and meet board certification requirements. IMQ Online Education courses come in a variety of formats, lengths, and credit levels, and are organized by subject category for easy browsing. A searchable course catalog helps users find the courses that are most useful to them.

The accessibility of online education allows users to meet their educational requirements when and where it’s convenient for them. Users earn credits immediately upon completing each course, eliminating the need to wait for credit. For courses already completed, IMQ Online Education makes record-keeping simple. Users can track credits and keep online records on hand for easy access.

To browse the IMQ Online Education catalog and register for courses, visit http://imq.inreachce.com/.

Why Attend Stepping Up to Leadership The Institute for Medical Quality and the PACE Program at UC San Diego are proud to announce an unparalleled opportunity for medical staff leaders. The Stepping Up to Leadership program trains medical staff leaders in issues of communication, problem-solving, and improving outcomes for patients and staff—and it’s more accessible than ever. The Stepping Up to Leadership conference will take place on November 7-9, 2013; March 6-8, 2014; and May 8-10, 2014.

So why should your medical staff attend the Stepping Up to Leadership conference?

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understanding of communication and assessment—and passes them on to medical staff leaders.

Stepping Up to Leadership offers unique hands-on learning opportunities, focusing on interactive small-group teaching modalities for deep understanding. The program features excellent faculty and course work on effective staff leadership, credentialing and privileging, assessing the needs of the organization, using CME effectively, resolving on-call issues, improved communication skills, using quality measures effectively, legal considerations, and managing disruptive or impaired colleagues.

Stepping Up to Leadership is accessible. For the first time, Stepping Up to Leadership is available as a national event, with events in San Antonio, Texas (November 7-9, 2013); San Diego, California (March 6-8, 2014); and Washington, D.C. (May 8-10, 2014). A generous grant from The Physicians Foundation allows IMQ and PACE to offer Stepping Up to Leadership at prices as low as $595 for three days, making this an unbeatable opportunity. To register, visit http://physician-leadership.org.

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How the Internet and Wi–Fi in Schools Can Affect Learning 26 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

By Cindy Lee Russell, MD VP-Community Health, Santa Clara County Medical Association Most of us cannot live without our computers, text messaging, e-mail, and immediate access to the vast cloud of information, especially kids and teenagers who have grown up in the age of the Internet. In fact, more schools are integrating computers at younger ages, even in kindergarten.

Forty-nine states are phasing out cursive handwriting altogether. What effects does it have, however, on learning, brain development, cognition, and brain health? Studies have shown some interesting ways that technology is rewiring and shaping our brain, which may not be “all good.”

A growing body of scientific evidence suggests that the Internet, with its distractions and interruptions, is turning us into scattered, superficial thinkers. What does that portend for our kids?

Multitasking and Internet Addiction

Nicholas Carr explains, in his book “The Shallows,” that we are changing the way we process information. “Dozens of studies by psychologists, neurobiologists, educators, and Web designers point to the same conclusion: When we go online, we enter an environment that promotes cursory

reading, hurried and distracted thinking, and superficial learning….The Net delivers precisely the kind of sensory and cognitive stimuli-repetitive, intensive, interactive, addictive, that have been shown to result in strong and rapid alterations in brain circuits and functions.”

Researchers from Stanford, in 2009, gave a battery of cognitive tests to a group of heavy and light media Internet multitaskers. They found that the heavy multitaskers were much more easily distracted by “irrelevant environmental stimuli” and had less control over their working memory.

In addition, they were much less able to focus on a particular task. Professor Clifford Nass, who led the research, stated intensive multitaskers are “suckers for irrelevancy. Everything distracts them.” (5) “Teaching is a human experience. Technology is a distraction when we need literacy, numeracy, and critical thinking.” Paul Thomas, author and associate professor of education at Furman University

Law School Professors Ban Laptops in Classrooms

Several years ago, professors who were irritated with students surfing the Web and hiding behind laptop screens began banning the use of the Internet or laptops in the classroom. Laptops have been banned in classes at Harvard Law School, Yale, George Washington University, University of Virginia, and South Texas College of Law, to mention a few. (4)(15) A 2006 study by Carrie Fried backed up the policies, demonstrating that students who used laptops in class spent considerable time multitasking. They more importantly found that the level of laptop use was negatively related to several measures of student learning. (3) A 2012 survey by Elon University, the Pew Internet, and American Life Project asked over 1,000 leaders in the U.S. their thoughts about cognition in our millennial generation. They were asked to consider how the Internet and its environment are changing, for better or worse. Overall, the survey found that multitasking is the new norm and that hyper-connectivity may be leading to a lack of patience and concentration. The “always on” ethos may be encouraging a culture of expectation and instant gratification.

Brain Maturation, Learning, Memory, and Intelligence

The maturation of intelligence requires quiet, deep thought, and time.

Established research findings in cognitive science leads to the conclusion that laptop use, especially with Wi-Fi access, could interfere with learning.

The hippocampus, which lies under the cortex, is intimately involved in long-term memory storage. Initial experiences are stored and stabilized in the hippocampus and then later transferred to the cortex. Removal of the hippocampus does not affect long-term memories, but prevents new memories from forming.

Learning depends on the ability to transfer information from our working memory to long-term memory and weave this into other acquired knowledge. There is a bottleneck in the passage of working memCindy Russell, MD, is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in plastic surgery and is currently practicing with the Palo Alto Medical Foundation Group.

ory to long-term memory. We have a limited ability as humans to capture and process information. The Internet provides too many choices and too much information at once. Excess distracting information creates “overload,” preventing long-term memorization and important information is lost. No one disagrees that we need to protect our memories. As author Nicholas Carr highlights, personal memory is not just for the individual to function, but it shapes and sustains our collective cultural memory.

Brain Drain: Adverse Neurologic and Health Effects of Wireless Microwave Communications

A growing body of peer reviewed research is showing neurologic damage to fetal brain and other systems from Wi-Fi and other microwave wireless sources. In a prior article, “Why-Fi: Is Wireless Communication Hazardous to Your Health?” in the Sept/Oct 2010 SCCMA Bulletin, the full range of effects of EMF from our cell phones and wireless devices was discussed. New basic science research in the last three years is confirming these findings. Initially, the Bioinitiative report of 2007 reviewed the biological effects of low level EMF. It found that there was clear evidence of adverse effects to living systems at current environmental exposures and at doses well below the threshold of the International Commission of NonIonizing Radiation Protection (ICNIRP) safety guidelines. Current microwave safety limits are based solely on the heating of tissue and do not take into account research showing negative biological effects on DNA, cancer, protein synthesis, skin tissue changes, sperm motility and viability, cognitive functioning, and disruption of the blood brain barrier.

Current Research on Cognition and Wireless Communication

Fetal Radiofrequency Radiation Exposure From 800-1900 MHzRated Cellular Telephones Affects Neurodevelopment and Behavior in Mice. Scientific Reports. March 2012.

Aldad et al noted that neurobehavioral disorders are increasingly prevalent in children with 3%-7% of school-aged children diagnosed with attention deficit hyperactivity disorder (ADHD). The etiology is unclear, however, an association between prenatal cellular telephone use and hyperactivity in children has been postulated by others. To test this, he exposed pregnant mice to cell phone radiation throughout gestation (days 1-17), with a sham cell phone control group. He found that the exposed group had dose responsive impaired neurologic transmission in the prefrontal cortex and that the mice exposed in utero were hyperactive and had impaired memory. He concluded “that these behavioral changes were due to altered neuronal developmental programming.”(3) Microwave Radiation Induced Oxidative Stress, Cognitive Impairment, and Inflammation in Brain of Fischer Rats. Megha. 2012.

Megha evaluated the intensity of oxidative stress, cognitive impairment, and brain inflammation in rats exposed to typical cell phone microwave radiation. They were subjected to 900 and 1,800 MHz EMF for two hours a day, for 30 days. They state, “Significant impairment in cognitive function and induction of oxidative stress in brain tissues of microwave exposed rats were observed, in comparison with sham exposed groups…

Results of the present study indicated that increased oxidative stress due to microwave exposure may contribute to cognitive impairment and inflam-

Continued on page 28 SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 27

Shallow Minds, continued from page 27 mation in brain.”

Effect of Low Level Microwave Radiation Exposure on Cognitive Function and Oxidative Stress in Rats. Deshmukh. 2013.

The author highlights the exponential increase in wireless communication devices we are exposed to. He evaluated the effects of cell phone radiation on oxidation in tissues, in addition to cognition in rats. They subjected rats to 900 MHz EMF for two hours per day, five days a week, for 30 days, with an unexposed control group. “Results showed significant impairment in cognitive function and increase in oxidative stress, as evidenced by the increase in levels of MDA (a marker of lipid peroxidation) and protein carbonyl (a marker of protein oxidation) and unaltered GSH content in blood. Thus, the study demonstrated that low level MW radiation had significant effect on cognitive function and was also capable of leading to oxidative stress.”

The Internet Can Damage Teenage Brains

A large radiologic study from China, published July 2011, looked at structural brain changes in Internet-addicted teenagers. It is estimated that 24 million teenagers are addicted to the Internet in China. The researchers found a consistent atrophy of grey matter in parts of the brain and shrinkage of the surface of the brain in those addicted to the Internet. The effects were worse the longer the addiction. In addition, the study revealed changes in white matter of the brain, which function to transmit messages in the brain to the grey matter. They concluded these structural abnormalities were most likely associated with functional impairments in cognitive control.

“It strikes me as a terrible shame that our society requires photos of brains shrinking in order to take seriously the common-sense assumption that long hours in front of screens is not good for our children’s health. Dr Aric Sigman, Fellow of the Royal Society of Medicine

WHO Classifies EMF as a Carcinogen

In 2011, The WHO/International Agency for Research on Cancer (IARC) classified radiofrequency electromagnetic fields as “possibly carcinogenic to humans (Group 2B), based on an increased risk for glioma, a malignant type of brain cancer1, associated with wireless phone use.”

France Bans Wi-Fi in Schools, But Replaces With Ethernet

The French National Assembly, March 2013, passed an amendment to ban Wi-Fi in their schools until it’s proven “safe for human consumption.” They instead agreed to install far safer, wired Ethernet cable connections.

The Council of Europe has called for a ban on Wi-Fi use in schools and also recommends a wired alternative.

28 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

In Austria, the Austrian Medical Society has also issued a policy statement asking for a ban of Wi-Fi in schools.

The U.K. has a useful frequently-updated website on Wi-Fi in schools, which provides much scientific research. http://www.wifiinschools.org. uk/ Still the controversy persists.

The Cost of a Virtual World

There are a host of concerns with classroom technology, and the virtual world it creates, that have not been explored in the rush to “modernize” education and prevent our kids from becoming “computer illiterate,” despite the fact that computers are designed for ease of use. These issues range from distraction in the classroom, impairment of cognitive development and long-term memory, deficiency in learning social skills, Internet addiction, cyber bullying, access to inappropriate content, eye fatigue, and security risks to online learning networks. In addition, the sheer cost of computers and continuous upgrades is likely to break many school budgets. We have not mentioned the issue of toxic e-waste, another growing public health problem.

Common Sense

We will not get rid of the Internet or computers. We should not ignore, however, the enlarging body of science that points to real threats to public health and, especially, our children’s safety and well-being. The best approach is precautionary. Reduce the risk by reducing the microwave emissions. It is our obligation as physicians and parents to protect our children. They are the future and our legacy.

1. Remove wireless devices (white boards and routers) in schools in favor of wired connections and fiberoptic.

2. If there is Wi-Fi, then give teachers the authority to turn it off when not in use or if they feel it is not necessary.

3. Ban cell towers near or on schools.

4. Limit screen time on computers.

5. Limit or ban cell phone use in the class.

6. Limit or ban cell phone use at home.

7. Do not allow laptops to be placed on laps.

8. Undertake independent scientific studies on Wi-Fi and computer use that look at acute and long-term health effects.

9. Train teachers how to recognize symptoms of EMF reactions.

10. Conduct meetings with parents and teachers to address this issue in each school.

References

1. The Shallows: What the Internet Is Doing to Our Brains.

Nicholas Carr. 2010.

2. Generation Y: The Internet’s effects on cognition and education. www.Triplehelixblog.com 3. In-class laptop use and its effects on student learning. Carrie B. Fried. Sept 2006. http://www.mcla.edu/Academics/uploads/ textWidget/3424.00018/documents/laptop_use_in_the_ classroom.pdf 4. Banning Laptops in the Classroom: Is It Worth the Hassles?

Kevin Yamamoto. http://intra.albanylaw.edu/cr/insttech/pdfs/ laptopban.pdf 5. Cognitive control in media multitasker. C. Nass. http://www. pnas.org/content/early/2009/08/21/0903620106.abstract 6. Fetal radiofrequency radiation exposure from 800-1,900 MHz-rated cellular telephones affects neurodevelopment and behavior in mice. 2012. Aldad. http://www.ncbi.nlm.nih.gov/ pubmed/22428084 7. Effect of low level microwave radiation exposure on cognitive function and oxidative stress in rats. Deshmukh PS, 2013 April, Indian J Biochem Biophy. http://www.ncbi.nlm.nih.gov/ pubmed/23720885 8. Microwave radiation induced oxidative stress, cognitive impairment and inflammation in brain of Fischer rats. Megha.

Indian J Exp Biol. 2012, Dec;50(12):889-96. http://www.ncbi.nlm. nih.gov/pubmed/?term=microwave+radiation+induced+oxidativ e+stress+fischer+rats+Megha 9. Prevention of mobile phone induced skin tissue changes by melatonin in rat: an experimental study. Ozguner FToxicol Ind Health. 2004 Sep;20(6-10):133-9. http://www.ncbi.nlm.nih.gov/ pubmed/15941010 10. The effects of long-term exposure of magnetic field via 900-MHz GSM radiation on some biochemical parameters and brain histology in rats. Celikozlu SD. Electromagn Biol Med. 2012 Dec;31(4):344-55. http://www.ncbi.nlm.nih.gov/ pubmed/22676902 11. France Bans Wi-Fi From Schools—We Should All Do the Same. http://www.francesfox.com/france-bans-wifi-school/ 12. High Wired: Does Addictive Internet Use Restructure

the Brain? Scientific American. June 17, 2011. https://www. scientificamerican.com/article.cfm?id=does-addictive-internetuse-restructure-brain 13. Too much Internet use can damage teenagers’ brain. Mail Online. 18 July 2011. http://www.dailymail.co.uk/sciencetech/ article-2015196/Too-internet-use-damage-teenagers-brains.html 14. Wi Fi in Schools U.K. http://www.wifiinschools.org.uk/ 15. Wi Fi in Schools Australia. http://www.wifi-in-schoolsaustralia.org/p/worldwide.html 16. Wide Web of diversions gets laptops evicted from lecture halls. http://www.washingtonpost.com/wp-dyn/content/ article/2010/03/08/AR2010030804915.html 17. A Silicon Valley School That Doesn’t Compute. http://www. nytimes.com/2011/10/23/technology/at-waldorf-school-insilicon-valley-technology-can-wait.html?pagewanted=all 18. Effects of the exposure to mobile phones on male reproduction: a review of the literature. http://www.ncbi.nlm. nih.gov/pubmed/21799142 19. Mobile phone radiation induces reactive oxygen species production and DNA damage in human spermatozoa in vitro. http://www.ncbi.nlm.nih.gov/pubmed/19649291 20. Evidence for mobile phone radiation exposure effects on reproductive pattern of male rats: role of ROS. http://www. ncbi.nlm.nih.gov/pubmed/22897402 21. Effects of radiofrequency electromagnetic waves (RF-EMW) from cellular phones on human ejaculated semen: an in vitro pilot study. http://www.ncbi.nlm.nih.gov/pubmed/18804757 22. Rats Exposed to Cell Phone Microwaves Suffer Long-Term Memory Loss, According to New Study by University of Washington Researcher. http://www.sciencedaily.com/ releases/1999/12/991202070403.htm 23. Spatial memory and learning performance and its relationship to protein synthesis of Swiss albino mice exposed to 10 GHz microwaves. http://www.ncbi.nlm.nih.gov/pubmed/23952535 24. Alterations of visual reaction time and short term memory in military radar personnel. http://www.ncbi.nlm.nih.gov/ pubmed/23785684 25. Relationship between cognition function and hippocampus structure after long-term microwave exposure. http://www. ncbi.nlm.nih.gov/pubmed/22998825 26. Impairment of long-term potentiation induction is essential for the disruption of spatial memory after microwave exposure. http://www.ncbi.nlm.nih.gov/pubmed/23786183 27. Influence of microwave radiation on synaptic structure and function of hippocampus in Wistar rats. http://www.ncbi.nlm. nih.gov/pubmed/17535652 28. A aquaporin 4 expression and effects in rat hippocampus after microwave radiation. http://www.ncbi.nlm.nih.gov/ pubmed/20137298 29. Relationship between millimeter wave irradiation in pregnant mice and c-Fos protein expression in hippocampus and learning and memory functions in their offsprings. http:// www.ncbi.nlm.nih.gov/pubmed/16405774 30. Effects of 7 Hz-modulated 450 MHz electromagnetic radiation on human performance in visual memory tasks. http://www. ncbi.nlm.nih.gov/pubmed/12465659 31. Data Security Is a Classroom Worry, Too. http://www.nytimes. com/2013/06/23/business/data-security-is-a-classroom-worrytoo.html?pagewanted=all&_r=0

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 29

Initiating Change: Health Policy in Action at the 2013 American Medical Association— Medical Student Section Annual Meeting

By Janelle N. Ruiz I would like to sincerely thank the Santa Clara County Medical Association for providing funding to allow me to attend the 2013 American Medical Association-Medical Student Section Annual Meeting, in Chicago, this past June. As a future physician with an interest in health policy and reform, I understand that the changing landscape of health care will affect many aspects of my future practice in medical research and clinical care. The AMA conference allowed me the opportunity to participate in health policy discussions directly, through contributing feedback to AMA policy resolutions, which ultimately could influence national health care lobbying and medical decisions.

Nearly 600 medical students from across the country attended this year’s meeting and considered important issues including public reporting of physician outcomes, national support for the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, and athlete concussion management and chronic traumatic encephalopathy prevention.

Important policy issues which have a direct effect on medical education, including ensuring sustainable financing and financial aid for medical education, reforming and potentially eliminating the Step 2 Clinical Skills Exam, and gun safety counseling during medical training, were debated and voted on. In support of diversity initiatives, I attended the Minority Affairs Section meeting, which consists of medical students interested in issues relevant to increasing diversity in medical education and in the health care field, more generally. This counsel also discussed topics relevant to Latino(a) patients and medical professionals. Further, I attended various educational seminars on topics such as leadership, advocacy, community service, health care models and systems, and career development.

Over 50 medical specialty societies attended the meeting and provided an introduction to their field, offering materials and advice to assist me and other medical students in making decisions regarding which specialties to ultimately pursue. A final highlight of the conference was a “Doctors Back to School” community outreach

event, in which medical students and physicians educated nearly 700 Third to Seventh graders about the AMA’s Healthier Life Steps Program wellness initiative and educated them on medicine as an attainable career. Overall, the AMA conference provided me with a unique and powerful opportunity to learn about and participate in health policy discussions and potentially

30 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

make a difference on the national level. I want to again offer my sincere gratitude to the Santa Clara County Medical Association for this incredible opportunity to participate in this national discussion and to proudly represent and bring up health issues relevant for Stanford and Santa Clara County at the national level.

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SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 31

Travels With Tesla: A Doctor’s Electrifying Journey

By Cindy Russell, MD VP-Community Health, Santa Clara County Medical Association One typical sunny California morning, El Camino Hospital anesthesiologist Phil Stillman turned on his computer and began planning a driving tour in his new electric car. He poured a cup of coffee and began studying a map. This was no ordinary car map, however, it was a detailed map of electric supercharger stations that he would depend upon during his travels with his sleek, shiny, burgundy Tesla Model S. There was a feeling of both excitement and apprehension, as some unknowns lay ahead.

How many miles would he really get on a charge? What if he ran out of battery before the next charging station or the station was closed?

We asked Dr. Stillman a few questions about his first electric car tour and how it went.

Question: Where did you travel on your journey and with whom?

Answer: My wife, Siggie, and I drove to Disneyland!

Question: What resources did you use on the web?

Answer: We mapped out our proposed route using Google Maps and the Tesla site, which had a list of all the supercharger stations. We also researched hotels, which advertised on-site charging stations.

Question: Did you have to bring anything special or unusual “just in case?”

Answer: I brought the Tesla mobile connector with adapters so I could plug into public and private J1772 charging station.

Question: What

was your greatest fear before you started your journey?

Answer: No fears! Concerning “range anxiety,” i.e., apprehension about charging, there was very little (except our Santa Barbara experience below). The supercharger stations are 150 miles or Tesla inside shot less apart and the range of the car is 260 miles, so there was a lot of margin for error.

Question: What was your hardest day and what happened?

Answer: We spent the night in Santa Barbara and planned to charge the car up fully, so we could drive north on 101 and cut over on 46 to the supercharger station at Harris Ranch (200 miles). Because the charging station at our hotel was so slow, we could only charge to 210 miles, overnight, and I wasn’t willing to take the risk. Instead of going north, we had to head south a bit, cut over northern Ventura County to I-5 and up to the supercharger station in Lebec, at the foot of the Grapevine. It took extra time, but we enjoyed driving through the citrus orchards.

Question: What was the most fun part…besides driving the car?

Answer: It was fun hanging out at the supercharger stations with the other Tesla owners. At the one in Hawthorne, we met a guy who saved for ten years for his “dream car” and decided to get a Tesla. He was a truck driver and knew more about the car than anyone I’d met.

Question: Overall how would you rate the performance of the car and compare to other cars you have owned?

Answer: By far the best performing and nicest riding car I’ve ever owned!

Cindy Russell, MD, is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in plastic surgery and is currently practicing with the Palo Alto Medical Foundation Group.

Question: Any other amusing stories?

Answer: We went to an event sponsored by the Tesla Motors Club and I got to ask Elon Musk if we were going to have a Model S Hot Wheels. He suggested asking Mattel, so I started a petition, and it’s now before the head of the Hot Wheels division.

Tesla Has Cracked the Code

tested by the agency.

Electric Car Options

Dr. Phil Stillman and his Tesla

Sales of the Tesla have skyrocketed in 2013. In the first half of 2013, it was the top selling luxury car with 8.4% of the luxury car market, with 9,850 cars sold. Overall, electric car sales have jumped in the last two years. Since 2011, more than 131,000 electric autos have been sold in the U.S., and half of them in 2013, according to the Electric Drive Transportation Association. One-third of those cars were sold in California. The popularity of all electric cars was given a jump-start by Tesla. Thilo Koslowski, who is chief auto industry analyst at Gartner, Inc., states “Tesla has cracked the code of making an EV a desirable product to have, rather than just a frugal car appealing to people who want to eliminate the use of fossil fuels and help the environment. The mass market appeal is not there yet, but every manufacturer is chasing EVs that enable full range (without gasoline backup) at the right price point.”

Award Winning Car With the Highest Safety Testing…Ever

Tesla’s sleek Model S was unanimously voted Motor Trend’s car of the year for 2013. It was the first time an all-electric car has won. Consumer Reports has listed the Tesla Model S as its top scoring car for 2013.

“It drives like a sports car, eager and agile and instantly responsive.

But it’s also as smoothly effortless as a Rolls-Royce, can carry almost as much stuff as a Chevy Equinox, and is more efficient than a Toyota Prius,” Motor Trend writes. “By any measure, the Tesla Model S is a truly remarkable automobile, perhaps the most accomplished all-new luxury car since the original Lexus LS 400.”

In August 2013, Tesla’s Model S sedan captured a perfect score of five stars in all categories of the crash safety tests conducted by the National Highway Traffic Safety Administration. In fact, it was the safest car ever

Although the price tag for a Tesla Model S is not one affordable by many, the company is working on another model that will sell for about $35,000. Other all-electric cars on the road are the Nissan Leaf, which is about $30,000, and the Chevrolet Volt, which is about $40,000. There are also plug-in hybrids made

by Toyota, Honda, Ford, and others that you can connect to a household wall socket. As electric vehicles go mainstream, more and more charging stations are being installed by small businesses and major corporations. At a recent electric vehicle show at the S.F. Exploratorium, more than 50 corporate executives showed up alongside Governor Brown to cheer the next generation of electric automobiles and trucks.

Going Solar to Fuel Your Auto

Dr. Stillman has ventured even farther into sustainability by installing solar panels at his home, to power his Tesla. While stated EPA miles per gallon are higher for electric cars (80-120 mpg), they currently do not take into account the extraction, transportation, and refining of gasoline, the combustion efficiencies or thermal energy transfer of fossil fuels from the power plant to your home. When the math is done, the actual MPG is closer to 25 to 50 mpg, depending on the energy source. (4)(5) The analysis still favors electric cars, as they are zero emissions on the road and electricity from the grid can be generated from renewable resources such as solar, wind, and biofuels. In the U.S., 30 of 50 states have Renewable Portfolio Standards (RPS), regulations that require increased use of renewables in energy production. California’s RPS, signed by Governor Schwarzenegger in 2008, requires that electricity sellers derive 33% of their energy from renewable sources by 2020.

In addition, electric cars are simpler machines with fewer moving parts and lower maintenance. While we still need to keep working on curbing our addiction to those pesky fossil fuels, we can have an exhilarating experience at the same time. Dr. Stillman has found a way to reduce his global-warming footprint and get that “Tesla Thrill” every day. To those of you who also own a Tesla, you know what that means.

References

Drs. Phil Stillman and Lawrence Yee – both Tesla owners

1. 2013 Motor Trend Car of the Year: Tesla Model S. http://www. motortrend.com/oftheyear/car/1301_2013_motor_trend_car_ of_the_year_tesla_model_s/viewall.html 2. Automobile of the Year. http://www.automobilemag.com/ features/awards/1301_2013_automobile_of_the_year_tesla_ model_s/viewall.html 3. A Decade Later, Tesla Now Officially a Threat to the Auto Industry. http://gigaom.com/2013/08/26/a-decade-later-teslanow-officially-a-threat-to-the-auto-industry/ 4. Electric Vehicles: Compare Side-by-Side. http://www. fueleconomy.gov/feg/evsbs.shtml 5. Do the Math. MPG Electric Cars. UCSD Physics. http://physics. ucsd.edu/do-the-math/tag/car/ SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 33

BOOK REVIEW

Pandora’s Lunchbox: How Processed Food Took Over the American Meal

By Melanie Warner Reviewed by Cindy Russell, MD Did you ever open a long-expired box of cookies and find they looked and smelled perfectly normal? You may have eaten them without any gastric distress at all. It might have made you wonder, however, what the true expiration of processed foods really is and why. When New York Times business reporter Melanie Warner began writing about the food industry, she pondered the same questions.

Her journey into the processed food world commenced when she started saving a host of processed foods in her pantry. She found even after six years, much of her food collection remained more or less unaltered. She writes, “so eternal, so unappealing to the mold and bacteria that normally feast on ignored leftovers and baked goods.”

Cindy Russell, MD, is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in plastic surgery and is currently practicing with the Palo Alto Medical Foundation Group.

Melanie attended food conventions, taste-tested new “foods,” interviewed food scientists, and did in-depth research, eventually writing an entertaining and explosive primer valuable to anyone who eats, but especially working parents. She learns about the competing issues of shelf-life versus nutrition, and delves into the history and growth of processed foods. Particularly interesting is how Kraft developed its “pasteurized cheese loaf” in 1916, which was promoted as a product that could be “kept indefinitely without spoiling.”

Begs the question, if bacteria can’t degrade it, what happens in your gut? Another intriguing finding was how cereal companies cleverly used six-year-olds to test-drive their sugary cereals. She notes marketing has been an important part of the food industry’s success.

34 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

We also learn that there are serious deficiencies when it comes to processed food regulations. No surprise there. The book is highly recommended, as the author unravels the stories of synthesized food, food science, and agriculture in an amusing and pleasing style that keeps you craving the next chapter. You learn just how far away we have traveled from the farm. A bag of potato chips may never be quite the same for you. I recommend reading the book anyway.

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DNR Orders in the Periprocedural Period: Informed Consent and Refusal

By Faith R. Protsman, MD Chair, SCCMA Bioethics Committee Do Not Resuscitate Orders in the perioperative/periprocedural period are often a source of difficulty and stress for physicians, staff, family members, and patients. With the intention of creating a workable plan that would offer guidance for this challenge, the SCCMA Bioethics Committee developed a “Model Policy for the Perioperative or Periprocedural Treatment of Patients with an Existing Do-Not-Resuscitate Order or Other Directives that may Limit Treatment During Invasive Procedures.” The members of this multidisciplinary committee include physicians, nurses, social workers, ethicists, and attorneys who worked to develop this policy over the past 18 months. Central to the debate of the issues involved is the concept of informed refusal.

Informed refusal is a medico-legal term in which a person has the right to refuse a diagnostic or therapeutic intervention after gaining a full understanding of the risks and benefits of that intervention. Informed refusal is an integral part of the informed consent process. Informed consent laws are evolving to a patient-centric model. Federal requirements for informed consent are delineated in the CMS Conditions of Participation.

This Condition of Participation provides that the patient has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment.

A physician must explain to the patient the risks, benefits, and alternatives for an intervention to allow that patient to make an informed decision about treatment. Adults who have decision-making capacity express their autonomy through the informed consent process. This autonomy is honored when physicians accept the patient’s informed decision, whether or not they consent to treatment. Without informed refusal, informed consent would simply be a patient’s acceptance of the physician’s recommendations.

It has been common practice, in many institutions, to automatically suspend a DNR order during the perioperative/periprocedural period, as the process of anesthesia and effects of surgery can often produce physi36 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

ologic changes of cardiopulmonary dysfunction or arrest. These effects are usually quickly and easily reversible, but utilize procedures that are considered resuscitative. This model policy offers direction and options for suspension of a DNR order and the length of the suspension, through the informed consent process.

Richard J. Kramer, MD, shared a scenario that occurred just after he had received this policy for review: “We were presented with a patient recently at a local hospital in San Jose, who had hepatitis B, cirrhosis, and end-stage advanced hepatoma of the liver. He was discussed at a Liver Tumor Board, and it was felt that no treatment was left for the patient. He was, therefore, put on hospice.

The patient decided that he wanted DNR/DNI status for any admissions.

Subsequently, he was readmitted to the hospital during the night with hematemesis, likely from esophageal varices. The question of his DNR/DNI status clearly arose, and the decision was whether to endoscope the patient and try to stop the bleeding or not. Having seen the proposed policy by the Medical Association about this issue, we discussed the situation with the patient and his family. The patient was still lucid and capable of decision making. He verbalized the desire to attend a family event during the next two-to-three weeks and, despite his DNR/DNI status, he decided he wanted the endoscopy done, understanding that we might be able to temporize his situation by stopping the bleeding. He was clear with us that if something happened during the procedure, his DNR/DNI wishes still stood, but that if we could get him through this time, he preferred it. He fully understood that if he arrested during the procedure, that he would not want anything done. With this in mind, we wrote a note on the chart documenting this decision, the discussion with the patient and family, and the guidelines we would follow. All were in agreement, so we proceeded to endoscopy, stopped the variceal bleeding, and the patient was able to do what he needed to do.

Unfortunately, he did expire within one-to-two weeks after this episode, but he and the family were happy with how we proceeded.

I would like to extend my sincere appreciation to all members of the SCCMA Bioethics Committee for their dedication and diligence in the creation of this policy.”

MODEL POLICY FOR THE PERIOPERATIVE OR PERI-PROCEDURAL TREATMENT OF PATIENTS WITH AN EXISTING DO-NOTRESUSCITATE ORDER OR OTHER DIRECTIVES THAT MAY LIMIT TREATMENT DURING INVASIVE PROCEDURES I. PURPOSE

• To provide guidelines for addressing and respecting patients’ rights to make decisions about the application of resuscitation efforts during the perioperative or periprocedural period • To include in the process of obtaining informed consent a discussion of the feasibility of withholding resuscitation during the perioperative or periprocedural period • To address the need to respect physicians’ professional integrity while honoring patients’ right of self-determination

II. BACKGROUND

Per Health Care Decisions Law, Probate Code Section 4650 (the Patient Self-Determination Act passed in 1990): “in recognition of the dignity and privacy a person has a right to expect, the law recognizes that an adult has the fundamental right to control the decisions relating to his or her own health care, including the decision to have life-sustaining treatment withheld or withdrawn.” This federal legislation was designed to ensure patient self-determination for decisions about health care, including decisions about life-sustaining therapy.

Patients have the right to execute advance directives and have them honored. However, for patients with an existing DNR order, it is a frequent occurrence – in some cases routine – to automatically suspend this order during the periprocedural period. At times, patients have been asked to choose between allowing resuscitation during surgery or the procedure, or forgoing the surgery or procedure.

The application of a DNR order during surgery can be problematic for several reasons: 1. General anesthesia itself involves procedures often indistinguishable from resuscitative efforts.

2. The anesthetic agents themselves may produce adverse physiologic effects including respiratory depression, cardiovascular dysfunction, or even cardiac arrest. These adverse effects may be quickly and easily reversible.

3. In the case of invasive cardiac surgeries, arrhythmias including asystole can be after surgery.

4. Surgery itself may produce adverse effects, such as blood and fluid loss or pathophysiological reflexes that often are quickly and easily reversible.

It is standard practice, prior to any invasive procedure, to discuss with the patient and/or surrogate decision-maker the potential risks and benefits inherent in the procedure. This informed consent process should include a discussion of whether to continue or to suspend an existing DNR order during the peri-surgical/procedural period and the duration of the suspension. Without informed refusal there cannot be informed consent.

III. POTENTIAL OPTIONS

The “Ethical Guidelines for the Anesthesia Care of Patients with DoNot-Resuscitate Orders or Other Directives That Limit Treatment” adopted by the American Society of Anesthesiologists in 1993, with similar policies adopted shortly thereafter by the American College of Surgeons and by the Association of Operating Room Nurses, recommends a required reconsideration and renegotiation of a patient’s existing DNAR directive.

Three options have evolved for patients about to undergo surgery or a pro-

cedure to consider: A. “Full Attempt at Resuscitation: The patient or designated surrogate may request the full suspension of existing DNR directives during the anesthetic and immediate postoperative period, thereby consenting to the use of any resuscitation procedures that may be appropriate to treat clinical events that occur during this time.

B. Limited Attempt at Resuscitation Defined With Regard to Specific Procedures: The patient or designated surrogate may elect to continue to refuse certain specific resuscitation procedures (for example, chest compression, defibrillation or tracheal intubation). The anesthesiologist should inform the patient or designated surrogate about which anesthetic resuscitative management procedures are 1) essential to the success of the anesthesia and 2) which are not and may be refused. The same applies to the surgeon or proceduralist.

C. Limited Attempt at Resuscitation Defined With Regard to the Patient’s Goals and Values: The patient or designated surrogate may allow the anesthesiologist, surgeon, or proceduralist to use clinical judgment in determining which resuscitation procedures are appropriate in the context of the situation and consistent with the patient’s stated goals and values. For example, some patients may want full resuscitation procedures to be used to manage adverse clinical events that are believed to be quickly and easily reversible, but to refrain from treatments that are likely to result in permanent sequelae, such as neurologic impairment or unwanted dependence upon life-sustaining technology.”

IV. POLICY STATEMENT

It is the policy of this institution to provide patients and/or their surrogate-decision-maker a detailed description of the proposed procedure along with the potential risks and benefits that may be involved. Included in this discussion should be determining the patient’s wishes with regard to resuscitation during the perioperative period. If the patient/surrogate chooses to suspend or modify the existing DNR orders, a time frame should be defined for this suspension. The process of informed consent is not complete until the patient/surrogate understands and agrees to a specific course of action. This discussion must be documented in the chart.

All patients and all anesthetics, surgeries and procedures are unique: the above discussion needs to be tailored to the circumstances at hand.

Examples of differing circumstances with differing goals include: • SPECIAL CONSIDERATION: PATIENTS WITH A DIAGNOSIS OF A TERMINAL CONDITION CONSIDERING PALLIATIVE SURGERY These are patients with a limited prognosis from their underlying disease, who are hoping to increase the quality of their remaining time by surgical intervention. It may be difficult to distinguish whether adverse effects happening in the operating room or procedural suite are a consequence of the surgery and/ or anesthesia or are a consequence of the underlying disease.

Understanding the goals and values of these patients, likely focusing on quality rather than quantity of life, might allow a

Continued on page 38 SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 37

DNR Orders in the Periprocedural Period, continued from page 37 DNAR order to remain in place throughout the periprocedural period, according to the above guidelines.

• SPECIAL CONSIDERATION: PATIENTS WITH SEVERE CARDIAC DISEASE UNDERGOING INVASIVE CARDIAC PROCEDURES The risk of invasive cardiac (or, at times, pulmonary) surgery is high; the cardiothoracic surgeons can ask permission that their services not be limited until a realistic estimate of prognosis is established, and then are executed in accordance with the above guidelines.

Any clarification or modifications made to the patient’s directive should be documented in the medical record. In cases where the patient or designated surrogate requests that the anesthesiologist or surgeon/ proceduralist use clinical judgment in determining which resuscitation procedures may become appropriate, the anesthesiologist or surgeon/proceduralist should document the discussion with specific reference to the goals and values of the patient.

Plans for postoperative care should indicate if or when the suspended directive to limit the use of resuscitative procedures will be reinstated.

This generally occurs when the patient has recovered from the acute effects of anesthesia and surgery/procedure. Consideration should be given to whether continuing to provide the patient with a time-limited postoperative/procedural trial of therapy would help the patient or surrogate better evaluate whether continued therapy would be consistent with the patient’s goals and values.

Concurrence on these issues by the primary physician, the surgeon/ proceduralist, and the anesthesiologist is desirable. If possible, these physicians should meet together with the patient or surrogate when these issues are discussed. This duty of the patient’s physicians is deemed to be of such importance that it should not be delegated. Other members of the health care team who are directly involved with the patient’s care during the planned procedure should, if feasible, be included in this process.

V. CONFLICT RESOLUTION

Should conflicts arise, the following resolution processes are recommended: • When a member of the medical team finds either the patient’s or another member of the team’s limitation of intervention decisions to be irreconcilable with his/her own moral views, then this member should withdraw in a nonjudgmental fashion, providing in timely fashion an alternative for care.

• If a member of the medical team finds the patient’s or another member of the team’s limitation of intervention decisions to be in conflict with generally accepted standards of care, ethical practice, or institutional policies, then this member should voice such concerns and present the situation to the appropriate institutional body.

A liaison should be established among representatives from the hospital’s anesthesiology, surgery/proceduralist, and nursing services for presentation, discussion, acceptance, and application of this policy/guidelines. Hospital staff should be made aware of the proceedings of these discussions and the motivation for them.

Modification of this policy may be appropriate in emergency situations involving patients who lack capacity to make their own medical decisions and whose intentions beyond that of resuscitation efforts have not been previously expressed.

38 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

References

1. DNR in the OR: A Goal-directed Approach. Robert D. Truog, David B. Waisel, Jeffrey P. Burns. Anesthesiology 1999; 90:289295.

2. Do Not Resuscitate in the Operating Room: More Than Rights and Wrongs. Perry G. Fine, MD and Stephen H. Jackson, MD. American Journal of Anesthesiology 1995;22:45-51.

3. Ethical Guidelines for the Anesthesia Care of Patients With Do-Not-Resuscitate Orders or Other Directives That Limit Treatment. Committee on Ethics, American Society of Anesthesiologists House of Delegates statement originally published 1993, revised October 17, 2001, and last affirmed October 22, 2008.

4. Goals- and Values-directed Approach to Informed Consent in the “DNR” Patient Presenting for Surgery. Stephen Jackson MD and Gail Van Norman, MD, Anesthesiology, V90, No 1, Jan 1999.

5. Health Care Decisions Law CA, Probate Code Section 46004643 6. Informed Consent for the Patient With an Existing DNR Order.

David B. Waisel and Robert D. Truog, MD. American Society of Anesthesiologists Newsletter 2001;65:13-14.

7. Perioperative Care of Patients With Do-Not-Resuscitate or All-Natural-Death Orders. AORN Position Statement, original approved by the House of Delegates March 1995, revision approved March 2009.

8. Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. American College of Surgeons. Bulletin of the American College of Surgeons, Vol. 79 No. 9, Page 29. Sept 1994.

MEDICAL TIMES FROM THE PAST

Benjamin Cory and Other Pioneer Physicians – Part 2

By Gerald Trobough, MD SCCMA Leon P. Fox Medical History Committee Two San Jose pioneer physicians were notables during Ben Cory’s time. They were Dr. Louis Hazelton Bascom and Dr. Alexander Josephus Spencer. Both physicians became partners of Dr. Cory.

Dr. Louis Bascom (1811-1881)

Dr. Louis and Mrs. Clara Bascom came to California, in 1849, with two mule teams from Kentucky. They settled in San Jose and built two houses on the south side of San Fernando Street between First and Second Streets. They lived in one and the other became a boarding house. “ Slap Jack Hall,” as the boarding house was known, was called that due to Mrs. Bascom’s delicious pancakes.

Dr. Bascom was Dr. Cory’s first partner. Both doctors were very busy during the cholera epidemic of 1850. They admitted the sickest cholera patients to the “Pest House” (later called City Hospital), which was located on Sixth Street. It was a large building located outside the walls of the Pueblo. Uninfected people had to be careful of their complaints because even a headache could land one in the Pest House.

Drs. Cory and Bascom provided all medications and took care of patients in the Pest House, from November 7 – December 25, 1850. When they submitted their bill to the Committee Council (City Council) for $2,472 for their expenses, the Council discounted their fee by $472 and only approved $2000 in February, 1851. The bill was finally certified correct in July, 1853, nearly one-and-a-half years later. Payment of the bill occurred in August, 1853, with depreciated state warrants that were worth much less than face value. (Was this the earliest form of managed care in the United States?)

Drs. Cory and Bascom continued their partnership until 1852. Dr. Bascom retired from medical practice and purchased 135 acres on the southern edge of Santa Clara and became a farmer. He named his home Somerville Lodge. In 1864, the road between San Jose and Los Gatos was named Bascom Avenue in his honor.

Perhaps more famous than her husband, was Clara Bascom. She preferred to be called “Grandma” and was a real character. When they arrived in San Jose, they were short of money and his practice was slow. “Doc,” Grandma said, “I’m going to do something to help!” Bascom laughed and said, “You can’t do anything, but talk.” Grandma insisted she could make slap jacks and sell them. Doc was older than his wife and he loved her enthusiasm.

One day, he came home and found a sign nailed to the side of the house that said “Slap Jack Hall.” No sooner had the sign been hung, she was serving customers. She made slap jacks and served them with syrup and a cup of coffee for a dollar. Her place became famous. Clara had her piano shipped from Kentucky which was first in San Jose. Her daughter

entertained the crowd at Slapjack Hall with beautiful music.

San Jose became the first capitol of California, and the first legislature convened in December, 1849. A number of the legislators would frequent Grandma’s place and stay in the boarding house. Word spread throughout the mines about Grandma’s cooking, and the miners made sure to stop by for some famous pancakes when they came to town. They were always entranced by her constant chatter. Before the year was over, Grandma had more money than Dr. Bascom.

When the State Capitol moved to Vallejo, Slap Jack Hall closed.

Grandma, however, continued to entertain with her laughter and talking.

With her talent for talking, she raised money for charity and the South Methodist Church. People would say, “We’ll pay you five dollars, if you’ll stop talking for five minutes!” Others paid her to talk, as she was a good story teller. Grandma never saw anything but the amusing side of life. No one had ever heard her speak ill of anyone or express unhappiness, even when her son and husband died. Grandma Bascom died in 1894, at the age of seventy-eight.

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 39

Avoiding the Medicare Quality Reporting Penalty in 2015

Prepared and reprinted with permission by the Alameda-Contra Costa Medical Association As part of the Physician Quality Reporting System (PQRS), Medicare will impose a 1.5% penalty in 2015 on physicians and other providers who do not successfully report at least one individual quality measure for at least one patient in 2013. The purpose of this article is to help physicians avoid the penalty in 2015 by providing guidance on how to report at least one measure for at least one patient using Medicare claims. Since most physicians already submit Medicare claims for reimbursement, adding the additional PQRS reporting information to the claim will be the least burdensome way for most physicians to avoid the penalty. This article also touches upon how physicians can qualify for a quality reporting bonus and discusses some additional PQRS reporting options. However, this article is not intended to be an exhaustive discussion of PQRS, and resources are listed at the end of the article for those desiring additional information.

Avoiding the Penalty in 2015 through Claims-Based Reporting

For many physician practices not yet participating in PQRS, the simplest way to avoid the penalty in 2015 will be to report on one quality measure for at least one patient (preferably a few patients) on your Medicare claims. The process can be broken down into three steps: 1) selecting an appropriate measure; 2) identifying your Medicare patients to whom the measure applies; and 3) reporting the quality measure on your Medicare claims after an applicable patient encounter.

Step One: Select an Appropriate Measure Quality measures form the basis of the PQRS program, and are intended to provide information to Medicare about an aspect of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. For purposes of avoid40 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

ing the penalty in 2015, physicians should select a quality measure relating to an aspect of care that you will encounter in your Medicare patient population. Review the list of individual measures that are reportable by claims on page 42, and select the most frequent measure that applies to your Medicare patients. Although there are many individual measures that can be reported via claims, some physicians may not find specialtyspecific measures. Nevertheless, there may be a measure that reflects a general aspect of care that is not specialty-specific that may be applicable and can be reported for purposes of avoiding the penalty.

Step Two: Learn the Details for Each Measure After you have selected which measure to report, it is important to review the specifications for the measure with your billing staff. This will help ensure that eligible Medicare patients are appropriately identified and quality measures are accurately reported on claims. Measure specifications are developed by the Centers for Medicare and Medicaid Services (CMS), and can be accessed online at www.cms.hhs.gov/PQRS..

Although the details vary across measures, each measure specification developed by CMS shares a common format and provides important information about: which Medicare patients are eligible for reporting the measure based on patient demographics (age and gender), diagnosis (ICD 9 codes), and primary service(s) provided (CPT codes); the various “quality codes� that are used for reporting on Medicare claims; and, the clinical rationale and information about the measure. It is important to review this information carefully since compliance with these specifications is required for measures you report to be counted. For example, you will not get credit for reporting if the Medicare patient is outside of the age range indicated or whose diagnosis code is not listed on the measure specification.

Step Three: Start Reporting on Your Medicare Claims Once you understand which Medicare patients are eligible and the

“quality codes” and modifiers that may be used to report the measure, you are ready to start reporting. The final step is to establish a process in your office to ensure that you consistently identify eligible patients, correctly document the correlating clinical information in the patient’s chart, and accurately report the information on your Medicare claims. To ensure you successfully report for at least one patient, it is recommended that you overshoot the target and report the quality measure you select for at least several patients.

With claims-based reporting, a quality code is billed like any other procedure or E/M code (on Line 24 of the CMS 1500 form or electronic equivalent). However, quality codes are billed at a $0.00 charge (or $0.01 if your billing system will not accept zero), and are denied by Medicare with remark code N365 indicating the code is not payable but is counted for tracking purposes. Quality codes are only counted when submitted in combination with an eligible diagnosis and service. Quality codes submitted by themselves or along with services that have already been paid will not be counted (i.e. no retroactive claims-based reporting).

As with any other “billed” Medicare service, quality measures should be supported by documentation in the medical record, which will provide some protection in the event of an audit. Documentation should indicate in clinical terms the basis for the quality code that is reported; it is not sufficient to simply write the code in the medical record.

Earning PQRS Incentives

Physicians and other eligible providers may earn an incentive equal to 0.5% of allowed charges for 2013 and for 2014. To qualify, physicians must report at a higher frequency on at least three different individual measures (instead of just the one measure required to avoid the penalty) or one measures group (consisting of three or more related individual measures). Individual measures must be reported for at least 50% of eligible Medicare patient encounters, and all individual measures within a measures group must be reported for at least 20 unique Medicare patients.

For claims-based reporting, the process for earning the incentive is similar to the process outlined above for avoiding the penalty – select measures, learn the reporting requirements, and start reporting on Medicare claims. To qualify for the incentive bonus, you should identify the three most frequently occurring measures (or the most applicable measures group) and you should report the measures as frequently as you can for eligible Medicare patients. Because the threshold to receive the incentive is so high, it is advisable for physician practices to implement processes that enable 100% reporting, which will maximize your chances of receiving the incentive bonus. This might include training your front-office staff or medical assistants to screen patients for reporting eligibility prior to each visit based on demographic and diagnosis information, and placing some sort of flag in the patient’s record to indicate eligibility. Some practices may even find it helpful to use tracking forms that can be placed in the eligible patient’s chart prior to the visit, completed by the physician and clinical staff during the encounter, and then used by billing staff to complete the reporting process. Also, physicians should be advised that the reporting period is January 1st to December 31st, and it may be challenging or even impossible to meet the 50% reporting threshold for the 2013 incentive.

Regardless of whether you report individual measures or measuregroups, it is important to choose measures that occur frequently in your practice. By choosing relatively common measures or measure-groups, you will improve the likelihood of meeting the reporting thresholds. CMS encourages physicians to also consider your own quality improvement goals when selecting measures. While a physician’s goals for their patients should always be the primary driver behind any quality improvement ini-

tiative, they are unfortunately not even considered by CMS when determining penalties or incentives. Rather, avoiding the penalty in 2015 and obtaining incentives in 2013 and 2014 is entirely contingent on selecting measures that occur with enough frequency to ensure accurate reporting at or above PQRS minimum thresholds.

More Info about PQRS Reporting

EHR and Registry Reporting: In addition to claims-based reporting, physicians and other eligible providers can report PQRS measures through EHR systems (either directly or through a data-submission vendor) or through approved registries. Practices utilizing EHR systems should consult your vendors about implementing PQRS reporting in your practice, either for purposes of avoiding the penalty or earning the incentive bonus.

One advantage of utilizing registry reporting is the ability to “retroactively” report quality measures for patient encounters for which the Medicare claim has already been submitted. Registry reporting provides a mechanism for physicians to report quality measures separate from the claims process. However, registry reporting may be an additional process or system in your medical practice, and you may prefer to utilize claimsbased reporting.

Group Practice Reporting Option: The PQRS Group Practice Reporting Option (GPRO) is open to medical groups of any size, and provides different options depending on the size of the medical group. For example, in 2013, Group practices ranging in size from 25-99 eligible professionals will report 29 quality measures for 218 consecutive Medicare patients, or 411 consecutive patients for group practices with 100 or more professionals. Practices wishing to use GPRO must submit a self-nomination letter indicating interest in participation. The next opportunity for GPRO participation will be for the 2014 reporting period.

Validation Process if Less Than Three Measures Can Be Reported: If fewer than three quality measures can be reported, physicians may still earn the incentive. CMS uses a “measure-applicability validation process” to verify whether a physician could have reported on additional measures before determining whether reporting requirements for the bonus have been met. CMS analyzes claims to determine if other measures could have been reported (based on ICD-9 and CPT codes). If CMS finds that 30 or more patients/encounters during the reporting period were eligible for reporting another measure, then the physician practice will not have met the reporting requirements.

Financial Incentive Paid to TIN: PQRS tracks compliance with the reporting requirements at the individual provider level (using the NPI number), but the PQRS payment will be made to the Taxpayer Identification Number (TIN) used by the reporting physician. Participating physicians within the same practice (using a common TIN) should expect to receive the physicians’ incentives in a lump sum. Likewise, physicians who see patients on behalf of more than one practice (and, therefore, use more than one TIN when submitting Medicare claims) should expect their PQRS payment to be made to the respective TIN under which the services were reported.

Additional PQRS Resources

For more information about PQRS, the California Medical Association has published a guide that is available online at www.cmanet.org.

For official PQRS information, please visit the CMS website at www. cms.gov/pqrs.

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 41

List of PQRS Individual Measures The following is an alphabetical list of PQRS individual measures that can be reported through Medicare claims in 2013. For purposes of avoiding the 1.5% Medicare penalty in 2015, physicians are encouraged to review the list of measures and identify at least one that is applicable to your Medicare practice.

Acute Otitis Externa (AOE): Pain Assessment (92) Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use (93) Acute Otitis Externa (AOE): Topical Therapy (91) Adult Kidney Disease: Blood Pressure Management (122) Adult Kidney Disease: Laboratory Testing (Lipid Profile) (121) Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL (123) Advance Care Plan (47) Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement (140) Age-Related Macular Degeneration (AMD): Dilated Macular Examination (14) Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use (116) Anticoagulation for Acute Pulmonary Embolus Patients (252) Appropriate Testing for Children with Pharyngitis (66) Aspirin at Arrival for Acute Myocardial Infarction (AMI) (28) Asthma: Assessment of Asthma Control (64) Asthma: Pharmacologic Therapy for Persistent Asthma (53) Asthma: Tobacco Use Intervention - Ambulatory Care Setting (232) Asthma: Tobacco Use Screening - Ambulatory Care Setting (231) Atrial Fibrilation and Atrial Flutter: Chronic Anticoagulation Therapy (326) Barrett’s Esophagus (249) Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade (99) Breast Cancer: Hormonal Therapy for Stage ICIIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer (71) Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy (52) Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation (51)

Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (246) Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (245) Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients (72) Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade (100) Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery (44) Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery (43) Coronary Artery Disease (CAD): Antiplatelet Therapy (6) Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation (126) Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear (127) Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient (117) Diabetes Mellitus: Foot Exam (163) Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus (1) Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus (3) Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus (2) Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients (119) Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care (19) Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (18) Documentation of Current Medications in the Medical Record (130) Elder Maltreatment Screen and Follow-Up Plan (181) Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain (54)

42 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope (55) Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic (59) Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs (56) Endoscopy & Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients (320) Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use (185) Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy (268) Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome (267) Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies) (266) Falls: Plan of Care (155) Falls: Risk Assessment (154) Functional Outcome Assessment (182) Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry (70) Hematology: Multiple Myeloma: Treatment with Bisphosphonates (69) Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow (67) Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy (68) Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula (172) Hepatitis C: Antiviral Treatment Prescribed (86) Hepatitis C: Counseling Regarding Risk of Alcohol Consumption (89) Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy (90) Hepatitis C: HCV Genotype Testing Prior to Treatment (85) Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment (87) Hepatitis C: Hepatitis A Vaccination in Patients with HCV (183) Hepatitis C: Hepatitis B Vaccination in Patients with HCV (184) Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment (84)

Hypertension: Controlling High Blood Pressure (236) Image Confirmation of Successful Excision of Image-Localized Breast Lesion (262) Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients (251) Ischemic Vascular Disease (IVD): Blood Pressure Management Control (201) Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein (LDL-C) Control (241) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (204) Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD (9) Major Depressive Disorder (MDD): Diagnostic Evaluation (106) Major Depressive Disorder (MDD): Suicide Risk Assessment (107) Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility (46) Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy (147) Oncology: Cancer Stage Documented (194) Oncology: Radiation Dose Limits to Normal Tissues (156) Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-theCounter (OTC) Medications (142) Osteoarthritis (OA): Function and Pain Assessment (109) Osteoporosis: Communication with the Physician Managing On-Going Care Post- Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older (24) Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older (40) Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older (41) Pain Assessment and Follow-Up (131) Participation by a Hospital, Physician, or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsements (321) Pediatric Kidney Disease: Adequacy of Volume Management (327) Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Levels (328) Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures) (45) Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) (22)

Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin (21) Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics (30) Perioperative Care: Timing of Antibiotic Prophylaxis - Ordering Physician (20) Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) (23) Perioperative Temperature Management (193) Preoperative Diagnosis of Breast Cancer (263) Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol (76) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (128) Preventive Care and Screening: Colorectal Cancer Screening (113) Preventive Care and Screening: Influenza Immunization (110) Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older (111) Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (134) Preventive Care and Screening: Screening for High Blood Pressure (317) Preventive Care and Screening: Screening Mammography (112) Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (226) Preventive Care and Screening: Unhealthy Alcohol Use - Screening (173) Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (12) Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care (141) Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients (104) Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients (102) Radical Prostatectomy Pathology Reporting (250) Radiology: Exposure Time Reported for Procedures Using Fluoroscopy (145) Radiology: Inappropriate Use of “Probably Benign� Assessment Category in Mammography Screening (146) Radiology: Reminder System for Mammograms (225) Radiology: Stenosis Measurement in Carotid Imaging Reports (195) Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness (261)

Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear (188) Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure (255) Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis (179) Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy (108) Rheumatoid Arthritis (RA): Functional Status Assessment (178) Rheumatoid Arthritis (RA): Glucocorticoid Management (180) Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity (177) Rheumatoid Arthritis (RA): Tuberculosis Screening (176) Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older (39) Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage (31) Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy (32) Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered (36) Stroke and Stroke Rehabilitation: Screening for Dysphagia (35) Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence (247) Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence (248) Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer Resection (157) Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use (65) Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain (254) Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older (48) Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older (49) Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older (50)

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 43

Classifieds office space for rent/ lease MEDICAL SUITES • LOS GATOS – SARATOGA

Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital.

Both units currently available. Call 408/3551519.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA

Medical space available in medical building.

Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft.

Call Rick at 408/228-0454.

MEDICAL SUITES • GILROY

First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

West Valley Professional Center, 5150 Graves Ave. Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/867-1815 or 408/2217821.

OFFICE FOR RENT • SAN JOSE

2395 Montpelier Dr #5, San Jose 95116. Rent $2,000 per month. Lease required. Owner pays triple net and monthly H/O dues. Two doctors set up. Three examination rooms. Approximately 1,100 sq. ft., furnished or unfurnished, adequate parking, walk to Regional Med Ctr. Close to X-Ray and lab. Previous tenant doctor retired. Call Marie at 408/268-2040.

MEDICAL OFFICE SPACE TO SHARE • SUNNYVALE

Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.

MEDICAL OFFICE SPACE FOR LEASE

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE

Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

Lease: Approximately 1,900 sq. ft. Free standing building zoned medical. Turn key. Marble entry. Street front. Six treatment rooms. Prestigious physician’s office with balcony. Highway 85 at DeAnza Blvd. Call 408/996-8717.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE

MEDICAL OFFICE SPACE FOR LEASE/ SALE • SAN JOSE

Excellent location. Westgate area. 1,584 sq. ft.

ROTACARE FREE CLINIC NEEDS VOLUNTEERS

Medical volunteers needed for the Rotacare Free Clinic in downtown San Jose at Washington Elementary School on Wednesday evenings 6-9 pm for adults. School address is 100 Oak St. The clinic is on Edwards between Almaden and First.

The neighborhood is residential. Patients are Hispanic, Ethiopian, Asian, and Caucasian. Diabetes, diagnosed and undiagnosed, is often encountered. MDs, RNPs, and PAs are needed. Spanish interpreters always available. Restaurants donate dinner. Can you help…once a month or so?

Please contact Roger Lake, MD at: rogerlake@sbcglobal. net or Henry T. Lew, MD at: henrylew9@aol.com.

Luxury modern 1,300 sq. ft. turn-key office with minor surgery OR. Prime Good Samaritan/Bascom Avenue at Highway 85 location in multispecialty building. Interior amenities and terms negotiable. Email am.1960@yahoo.com.

MEDICAL OFFICE SPACE AVAILABLE • SAN JOSE

1,300 sq. ft. suite in medical office complex, adjacent to, and walking distance from Regional Medical Center of San Jose. Please call 408/568-8323.

OFFICE TO SHARE • MTN VIEW

Established private medical practice in Mountain View has space available for another physician. Expense and space-sharing arrangement negotiable. Call Rashmi at 310/498-8194 for details.

MEDICAL OFFICE SPACE SAN JOSE • NEXT TO REGIONAL MEDICAL CENTER

200 Jose Figueres Ave, San Jose 95116. Five

44 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

exam rooms, two offices, large waiting room and front office, 1,600 sq. ft. Time-share for any days. Rent negotiable. Available now. Please call 650/906-1002.

MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS

Second story of professional building across from SVMH. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $1.25/sq. ft. Rent is $1,544/month. Contact Steven Gordon at 831/757-5246.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY

Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage.

We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or email riflovin@allianceoccmed.com for additional information.

INTERNAL MEDICINE PHYSICIAN NEEDED

We are looking for an internal medicine physician for our multi-specialty group. Please email

METRO MEDICAL BILLING, INC. • • • • • •

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com

WRITE A BOOK? •

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REGISTRY

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Nurse Practitioners ~ Physician Assistants

www.Mrosenconsulting.com 831/884-5490 your CV to kaajhealthcare@gmail.com.

CHEMO-THERAPY NURSE

Part-time chemotherapy certified/infusion nurse for a private practice in Mountain View.

Days and hours negotiable. Call 650/274-5175.

FOR SALE

Locum Tenens ~ Permanent Placement

MEDICAL OFFICE SPACE FOR LEASE/ SALE • SAN JOSE

Luxury modern 1,300 sq. ft. turn-key office with minor surgery OR. Prime Good Samaritan/Bascom Avenue at Highway 85 location in multispecialty building. Interior amenities and terms negotiable. Email am.1960@yahoo.com.

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 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m

In Memoriam Carlos J. Ilano, MD

Charles Sheptin, MD

Reinhold A. Sundeen, MD

Internal Medicine 12/19/37 – 5/31/13 SCCMA member since 1983

*Internal Medicine 1936 – 8/17/13 SCCMA member since 1968

Psychiatry 4/11/17 – 5/16/13 S.C.C.M.A. SCCMA member since 1960

Herbert M. Matthews, MD

Sidney R. Sogolow, MD

G. James Tobias, MD

*Anesthesiology 6/29/28 – 6/6/13 SCCMA member since 1959

*Obstetrics and Gynecology 12/30/38 – 6/5/13 SCCMA member since 1976

*Internal Medicine Cardiovascular Medicine 2/15/23 – 7/25/13 SCCMA member since 1955

8-12-08

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 45

member benefit

You Work to Protect Your Patients We Work to Protect You

By Marsh As a physician, you probably know better than anyone else how quickly a disability can strike and not only delay your dreams, but also leave you unable to provide for your family. Whether it is a heart attack, stroke, car accident, or fall off a ladder, any of these things can affect your ability to perform your medical specialty.

That’s why the Association/Society sponsors a Group Long-Term Disability program underwritten by New York Life Insurance Company, with monthly benefits up to $10,000. You are protected in your medical specialty for the first 10 years of your disability. With this critical protection, you’ll have one less thing to worry about until your return.

Important features of this plan include: • A monthly benefit of up to $10,000, if you become totally disabled. Members age 50–59 are eligible to apply for up to $6,000 per month

46 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

• A 10-Year Medical Specialty Definition of Disability defined as the inability to work in your own medical specialty for the first 10 years after the waiting period (a very important distinction vs. many plans with a broad “inability to do ANY job” definition) • Your monthly benefit payments are not taxable when you don’t take your premium as a tax deduction under current tax law.

That’s not necessarily the case for employer-provided plans, where you could lose up to 40% of your benefit to taxation.

(Always consult your tax advisor.)

• Group rates are negotiated exclusively for SCCMA/MCMS members.

Learn more about this valuable plan today! Call Marsh/Seabury & Smith Insurance Program Management for free information, including features, costs, eligibility, renewability, limitations, and exclusions at 800/842-3761.

Underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010 Under Group Policy No. G-29322-0 on Policy Form GMRFACE/29322-0.

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of 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. (CAP) has provided California’s finest physicians, like San Francisco facial plastic surgeon Corey Maas, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

SEPTEMBER / OCTOBER 2013 | THE BULLETIN | 47

BULLETIN THE

Address service requested

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way, San Jose, CA 95128-4705

PRSRT STD U.S. Postage PAID San Jose, CA Permit No. 503

PROUD TO BE ENDORSED BY THE MONTEREY COUNTY MEDICAL SOCIETY AND SANTA CLARA COUNTY MEDICAL ASSOCIATION

NORCAL Mutual is owned and directed by its physicianpolicyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Contact your broker or call 877-453-4486 today. Visit norcalmutual.com/start for a premium estimate.

A N O R C A L G R O U P C O M PA N Y