2014 September/October

SEPTEMBER/OCTOBER 2014 | VOLUME 20 | NUMBER 5

Also Inside: Autism Rising, Part 2

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65611 (9/14) Copyright 2014 Mercer LLC. All rights reserved.

Mercer Health & benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com

2 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

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 Billing/Collections

Feature Articles 8 Have You Joined the Fight? Vote No On Proposition 46

CME Tracking

15 Prop. 46: How to Talk to Your Patients

Discounted Insurance

18 No on Prop. 46: Get Engaged!

Financial Services

19 Medical Professionals Seek Secure Mobile Communication Platform for Efficient Work Flow – Not Social Networks

Health Information Technology Resources House of Delegates Representation Human Resources Services

Pull-Out r Poster fo n O “Vote No6” Prop. 4

32 Autism Rising – Part 2

Legal Services/On-Call Library

Departments

Legislative Advocacy/MICRA

5 From the Editor’s Desk

Membership Directory iAPP for

6 Message From the SCCMA President

the iPhone Physicians’ Confidential Line

26 On Page

7 Message From the MCMS President

Practice Management

22 TPO Seminar: Excelling as a Manager or Supervisor

Resources and Education

24 Member Benefit: Discount Tickets

Professional Development

41 Medical Times From the Past

Publications Referral Services With

44 Welcome New Members

Membership Directory/Website

46 Classified Ads

Reimbursement Advocacy/

48 In Memoriam

Coding Services

48 New Programs and Benefits From IMQ

Verizon Discount SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President James Crotty, MD President-Elect Eleanor Martinez, MD Past President Sameer Awsare, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Peter Cassini, MD VP-Professional Conduct Seema Sidhu, MD Secretary Seham El-Diwany, MD Treasurer Scott Benninghoven, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Laura Cook, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Erica Timiraos, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Vanila Singh, 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) 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 Jeffrey Keating, MD President-Elect James Hlavacek, MD Past President Kelly O'Keefe, 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 2014 by the Santa Clara County Medical Association.

4 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD Valerie Barnes, MD Ronald Fuerstner, MD Gary Gray, DO Steven Harrison, MD David Holley, MD John Jameson, MD

William Khieu, MD Eliot Light, MD Edward Moreno, MD Marc Tunzi, MD Craig Walls, MD Cary Yeh, MD

AMA TRUSTEE - MCMS David Holley, MD

FROM THE EDITOR’S DESK

JOSEPH S. ANDRESEN, MD Editor, The Bulletin

MICRA and Proposition 46 What Every Physician in California Needs to Know

By Joseph S. Andresen, MD Editor, The Bulletin “Insurance Rates Peril Medical Care,” read the February 23, 1975, headlines of the San Jose Mercury News. “New Bay Area Crises in Medical Care: Doctors Might Halt Practice,” echoed the San Francisco Chronicle. I was in college at the time and had not yet applied to medical school. However, many of our medical society members remember this only too well and were on the front lines of this looming battle.

What led to this confrontation? Insurance companies were pulling out of the California medical malpractice market citing the increasing frequency of frivolous lawsuits and multi-million dollar jury settlement awards. The few remaining carriers raised doctors’ insurance premiums first by 250% and then threatened another 400% increase on May 1 of 1975. Many physicians were forced to quit practice, retire, drop their coverage, or move out-of-state. Those who remained in practice realized that their patients would be the casualties in this battle, either making medical costs unaffordable, or severely limiting access to available doctors.

There was no resolution of this crisis as the May 1 deadline passed by. The CMA initiated a massive grassroots campaign to educate and alert the public. Over 800 physicians, nurses, and hospital staff marched on Sacramento’s Capitol Hill, meeting with Governor Jerry Brown at the time. Through intensive negotiations with legislators, trial lawyers, and the insurance industry, the Medical Injury Compensation Reform Act (MICRA) was signed into law on September 23, 1975. It provides unlimited economic and punitive damages in the judgments of medical malpractice, but limits settlements for pain and emotional suffering to a total of $250,000. For the past forty years, MICRA has served as a nationwide model for medical liability tort reform.

How will November ballot’s Proposition 46 change MICRA if it passes, and why should you care?

Entitled the Medical Malpractice Lawsuits Cap and Drug Testing of Doctors Initiative, it is on the November 4, 2014, ballot in California as an initiated state statute.

If approved it will: • Increase the state’s cap on damages that can be assessed in medical negligence lawsuits to over $1 million from the current cap of $250,000.

• Require drug and alcohol testing of doctors and reporting of positive tests to the Medical Board of California.

• Require the Medical Board of California to suspend doctors pending investigation of positive tests and take disciplinary 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.

action if the doctor was found impaired while on duty.

• Require health care practitioners to report any doctor suspected of drug or alcohol impairment or medical negligence.

• Require health care practitioners to consult the state prescription drug history databank before prescribing certain controlled substances.

Supporters of the initiative refer to it as the Troy and Alana Pack Patient Safety Act of 2014, in reference to two children killed by a driver under the influence of abused prescription drugs. If approved, this would become the first law in the United States to require the random drug testing of physicians. Supporters argue that medical negligence is too common and pain and suffering damage awards are too low. Those who oppose Proposition 46 see it aimed at increasing medical lawsuit payouts to trial lawyers, rather than protecting patients.

Control of prescription drugs that may be abused is an important issue. An effective and robust peer review system that identifies impaired physicians in a timely fashion to protect the public is an equally important issue. Finding the balance for fair and reasonable compensation of those patients injured from medical negligence, while preventing frivolous lawsuits which may ultimately hurt patients as consumers, is also an important issue. In this latter case, for the past 40 years, MICRA has been achieving this goal.

It must be clear by now that Proposition 46 proposes some very drastic measures using a broad stroke to deal with several important issues that will directly affect the practice of medicine in California. Numerous newspaper editorials have commented on the topic: San Jose Mercury News: “Proposition 46 goes too far… this is a drastic measure that requires more thought and supporting data. We urge a no vote on Prop. 46.”

Oakland Tribune Editorial: “Proposition 46 Goes Too Far, We Urge a No Vote.”

Sacramento Bee: “There are powerful arguments for adjusting the 1975 law. Malpractice damages often are based on lost wages. Since children and elderly people have no income, they have little legal recourse if they become malpractice victims. The one-sided Proposition 46, however, is not the solution.”

Despite strong opposition from the California Medical Association and editorial board commentary urging a no vote, it appears that California voters are, so far, set to approve Proposition 46. As recently as August 20, Kaiser Health News reports polling results of California voters showing 58% in support of Proposition 46, 30% opposed, and 12% undecided (Cadelago 8/20).

At this late date, it is our job to educate ourselves, our patients, and the public on these important issues and make all of our voices heard on November 4, 2014.

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 5

MESSAGE FROM THE SCCMA PRESIDENT

JAMES R. CROTTY, MD, MBA President, Santa Clara County Medical Association

Together We Are Stronger!

By James R. Crotty, MD, MBA President, Santa Clara County Medical Association The goals of the Santa Clara County Medical Association are to improve the profession, improve the satisfaction for physicians engaged in the practice of medicine, and to improve the public health.

SCCMA endorses efforts to encourage healthy diet and efforts to encourage exercise. SCCMA has endorsed the efforts to improve access to health care services to citizens of California, including preventative health and management of chronic illness, with implementation of the Affordable Care Act and the creation of Covered California.

To improve the profession, we continue to advocate for efforts to ensure that people who practice the art and science of medicine are adequately trained, obtain and maintain a license, and continue educating themselves on the newest and best ways to treat disease. Patient safety is the utmost concern. Do no harm is a fundamental tenet of the Hippocratic Oath.

To improve the satisfaction for those physicians engaged in the practice of medicine, SCCMA and CMA have made efforts to ensure physician income, ensure that patients have access to physicians, and to ensure a good doctor-patient relationship, including the right to privacy of personal health information.

The path to obtain these goals has included active vigilance and intervention by the California Medical Association. CMA has been aware of many efforts in the past, by the trial lawyers, to change laws implemented as a result of the MICRA (Medical Injury Compensation Reform Act) enacted by the California Legislature and signed by the governor in 1975. CMA was watching when the trial lawyers began circulating a petition to have doctors drug tested, which, by the way, also included a change to MICRA that would enhance the trial lawyers’ income by raising the cap on non-economic damages. CMA leadership realized that this proposition was deceptive and flawed. Planning to fight this proposition ballot initiative began immediately. The implications of this proposition, if passed by the voters, were clear: increases in medical malpractice costs and premiums for malpractice insurance; burdensome, costly, and ultimately impractical and ineffective drug testing; and a mandate to use the CURES database, which is not the 6 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

solution to prescription drug abuse. These increased costs would be passed to consumers and would, ultimately, hurt efforts to improve access and decrease health care delivery costs.

CMA physician leaders have realized the necessity of an infrastructure to further the continuous improvement aims and accomplishments of this organization of physicians. Dustin Corcoran was hired as CEO. He has hired talented and dedicated staff, and created job descriptions, duties, responsibilities, training, and accountabilities.

It is highly efficient and effective.

We will defeat Proposition 46.

When we do, it will be clear that CMA does what no other organized physician group does. It will also be clear that it is in the best interest of physicians in California to be a member. Membership guarantees that you have a voice in what the organization does, and most importantly, your membership pays for these services. Membership is the life blood of the California Medical Association. If you choose not to be a member, it is true that you will reap benefits that others have worked hard to obtain. If this seems fundamentally wrong, then you are probably a full-paying member of CMA. Please understand that dues have created the infrastructure to address issues like Proposition 46. Please understand that ongoing financial support to the organization is necessary to do the tasks and accomplish the mission.

Please understand that it is not OK to stand by and reap benefits without contributing.

If you know of a colleague who is not a member, please urge them to JOIN NOW! It is easy to apply online at http://sccma-mcms.org/ Membership/ApplyOnline.aspx. Together, we are stronger!

James R. Crotty, MD, MBA, is the 2014-2015 president of the Santa Clara County Medical Association. He is a urologist and is currently practicing with The Permanente Medical Group/Kaiser in San Jose.

MESSAGE FROM THE MCMS PRESIDENT

JEFFREY KEATING, MD President, Monterey County Medical Society

Proposition 46

By Jeffrey Keating, MD President, Monterey County Medical Society With the passing of Labor Day, it is safe to say that summer is over.

Hopefully, you have all had some time off to spend with family and loved ones and to get some well-deserved rest and relaxation. If so, getting back to work may be difficult. We all pride ourselves on providing the best care possible to our patients; after all, that is the reason why we pursued a career in medicine. But, as we have all found out, it isn’t just about direct patient care. No, we have to spend time speaking to insurance companies for authorizations. We have to figure out changes to CPT codes and reimbursement from Medicare and other payers, and keep up with all of the other ever-changing billing and compliance issues. We have to keep up with running an office and keeping up with myriad requirements and fees and forms relating to being employers.

We have to figure out maintenance of certification requirements. It seems like, as each year passes, the number of things we have to do, and hoops to jump through, increases, and maybe it’s just me, but at times it seems to be increasing exponentially. All of these things, important as they may be, pull us away from the thing we value most as physicians, patient care.

But, no matter how bad things may feel, one certainty is that they can always get worse – which brings me to Proposition 46. As you probably know, in a back-to-the-future move, certain trial lawyers have decided that MICRA, which was born in crisis and survived the test of time, and which has met the needs of patients, physicians, and the citizens of California, for decades, and served as a national model on how to approach medical malpractice claims, does not sufficiently enrich them. With subversive language, they are using the ballot initiative process to harness the voice of the people to achieve what was not achievable through the legislature or the courts, despite persistent attempts. The effect of a successful ballot initiative would be catastrophic for the state and our profession. By significantly driving up the cost of malpractice insurance, it would serve to drive those in high-risk

specialties, such as obstetrics or neurosurgery, out of the state and reduce further operating margins for practices. That may be a windfall for other states, such as Texas, where comprehensive malpractice reform has passed recently, making it an attractive place to relocate, but it would certainly not help Californians and would only reduce access to care, especially to the underprivileged members of our communities. Many of the increased costs associated with a successful ballot initiative would be born by the taxpayers themselves, making it simply a redistribution scheme, from taxpayers to certain trial lawyers, with no increase benefit to the common good.

I, in no way, want to impugn the reputation or minimize the contribution of the majority of attorneys who work hard to protect the interests of their clients. As stated, MICRA has been such a success as it has balanced the interests of patients and physicians. And the tort system serves a valuable role of keeping everyone attentive, though it has been argued that it does this at the expense of increased costs and questionable additional testing. But, it is safe to say that with our current tort system, an inattentive or even reckless physician would not survive in practice very long. And, that is a good thing.

So, despite being busy and pulled in so many directions, I am asking that you all find time to address Prop 46 with your friends, neighbors, staff, and patients. They will appreciate your point-of-view of how the system works, currently, and how a successful ballot initiative would affect your practice, the practices of your colleagues in high-risk specialties, your professional life, and your ability to continue to provide cost-effective quality medical care. Since 1975, MICRA has been a success for all – as the saying goes “if it ain’t broken, don’t fix it.” So let’s defeat Prop 46 and get back to taking care of our patients (and all those forms, too).

Jeffrey Keating, MD, is the 2014-2015 president of the Monterey County Medical Society. He is a pathologist and is currently practicing with Community Hospital of Monterey Peninsula in Monterey.

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 7

Have You Joined the Fight?

GET THE

FACTS ABOUT

PROP 46 Over the last several months, you may have read information about the Medical Injury Compensation Reform Act (MICRA) lawsuit initiative, Proposition 46, in the pages of this magazine, on our website, in information from the California Medical Association (CMA) and likely from the hundreds of coalition partners that have all pledged to oppose the measure this November. On November 4, 2014, voters will be asked to cast their ballots. In the final months, weeks and days leading up to Election Day, it will be our task as physicians to educate our patients, neighbors, friends and families about the real intentions behind Prop. 46.

8 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 9

NO ON

By William Parrish, MPA CEO, Santa Clara County Medical Association & Monterey County Medical Society

An Overview of Prop. 46

The measure is complex and contains three separate and distinct pieces that trial lawyer proponents have thrown together in an effort to mask their real intent – quadrupling non-economic damages in MICRA, pulling money directly out of the health care delivery system and putting it into their own pockets. The pieces voters will be asked to weigh in on are as follows: • A quadrupling of the non-economic damages limit on medical malpractice awards in California, which will cost consumers and taxpayers hundreds of millions of dollars every year in higher health care costs, and cause many doctors and other medical care professionals to quit their practices or move to places with lower medical malpractice insurance premiums – reducing access to care in California.

• An unfunded mandate that will require physicians, pharmacists and veterinarians to check a government run database before prescribing schedule II or III drugs. This piece in particular threatens patient privacy by requiring a massive expansion of the use of a personal prescription drug database.

• Both a random and mandatory requirement to perform alcohol and drug testing on doctors, which was only added to this initiative to distract from the main purpose.

Let’s not be fooled – Prop. 46 uses alcohol and drug testing of doctors to disguise the real intent – to increase the limit on the amount of medical malpractice lawsuit awards.

10 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

RAISING HEALTH CARE COSTS

I’ve been speaking about Prop. 46 for months now, and explaining to people how it was carelessly thrown together without concern for taxpayers’ pocketbooks, health care or privacy, but one question that comes up repeatedly is, “how will this increase health costs?”

We know that trial lawyers out to profit from medical lawsuits sloppily drafted Prop.

46 and it will result in higher health care costs for everyone. We’ll see money come directly out of the health care delivery system and straight into the pockets of the lawyers that stand to gain most.

These higher costs will be passed to every purchaser and provider of health care: state and local governments, employers, employees, consumers and taxpayers. That’s why such a broad coalition of groups stand in solid opposition to Prop. 46.

According to California’s independent, non-partisan Legislative Analyst’s Office (LAO) Prop. 46 could increase costs for state and local governments by “several hundred million dollars annually.”

The LAO goes on to warn that “even a small percentage change in health care costs could have a significant effect on government health care spending.”

But, how exactly?

State and local governments are hit with higher costs in two ways: • They provide health care benefits for current and retired government employees;

• They also provide health care services for low-income residents through Medi-Cal and other locally-run health care programs like community clinics and public hospitals.

Higher health care costs for state and local governments would reduce funding available for vital local services like police, fire, social services, parks and libraries, to name a few. If Prop. 46 passes, everyone will carry the burden of these increased costs.

A great photo of what some of our physician leaders are doing to help the fight! Dr. While the LAO estimates costs to Martin Fishman got T-shirts for his staff from Century Graphics; 408/616-7700; $10 state and local governments, they aren’t each the only ones who will pay for more lawsuits and higher payouts. everyone. to patients.

According to a study by California’s forFor the future of medicine in California Another concerning piece of this provision mer Legislative Analyst, Prop. 46 will increase – and the nation – and for the safety of your is that the massive ramp up of this database will health care costs across all sectors by $9.9 billion patients, I ask you to get engaged in these last significantly put at risk patients’ private medical annually, which translates to around $1,000/ weeks. You can: information. Prop. 46 doesn’t contain any proyear in higher health costs for a family of four.

• Donate to the campaign. It’s as simple visions or funding to upgrade the database with For many families across the state, that is a as visiting NoOn46.com and clicking increased security standards to protect personal tough choice between groceries and health care on “contribute.” Every dollar counts as prescription information from government in– and one that we can’t afford to let happen. we need to produce material to ensure trusion, hacking, theft or improper access by voters understand the risks associated non-medical professionals.

THREATENING PRIVACY with Prop. 46 The CURES database contains a record of Proposition 46 includes a provision that • Order campaign material. We’ve got every dispensed prescription of a Schedule II, III could significantly jeopardize the privacy of pabuttons, office posters, informational or IV substance and contains highly sensitive, tients’ personal prescription medical informabrochures, lab coat cards and more, all personal and potentially stigmatizing details tion. The initiative forces doctors and pharmaavailable at NoOn46.com. Simply click about a person’s health. It includes prescription cists to use a massive statewide database, called “Take Action” and “Get Campaign information including medicines used to treat CURES, which is filled with patient’s personal Material” and it will be sent directly anxiety, insomnia, obesity, narcolepsy, drug deprescription drug information. Though the to you. toxification, pain, epilepsy, conditions related database already exists, it is underfunded, un• Sign up to be a part of the campaign. to cancer and AIDS, asthma, chronic infection, derstaffed and technologically incapable of hanAs physicians, you see dozens of and other sensitive medical conditions. patients daily. Take the time to let dling the massively increased demands this balWhat’s more - the law gives the Departthem know about the dangers and real lot measure will place on it. In fact, in evaluating ment of Justice unfettered discretion to disclose intent behind Prop. 46.

Prop. 46 the LAO noted, “Currently CURES does confidential patient prescription information • If you know of a colleague who is not a not have sufficient capacity to handle the higher to any state, local, or federal public agencies for member, please urge them to join now. level of use that is expected to occur when providdisciplinary, civil or criminal purposes.

It is easy to join online at http://sccmaers are required to register beginning in 2016.”

There are literally hundreds of entities and mcms.org/Membership/ApplyOnline.

Many of us as physicians want the CURES thousands of individuals who work for those aspx. Together we are stronger! database to work to help keep patients safe. Unagencies that meet this definition providing With the changing times in the health care fortunately, the provision in this ballot measure access to highly-personal and sensitive patient delivery system, I know it can be tough to make isn’t that simple. health information for non-medical reasons. the time for something else. The future of your Prop. 46 will force the CURES database profession depends on you here, and I urge you to respond to tens of millions of inquiries each WHAT NOW? to commit to being involved through November year– something the database simply cannot We’ve got a lot of work to do between now 4 and beyond. do in its current form or functionality. A nonand Election Day. The proponents of Prop. 46 For all of your efforts until now and movfunctioning database system will put physicians continue to mislead the public about the real ing forward – thank you. and pharmacists in the untenable position of intentions behind the measure – quadrupling having to break the law to treat their patients, or the cap on non-economic damages in MICRA, break their oath by refusing needed medications which will result in higher health care costs for SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 11

savings of $ over 86,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s Trial Lawyers have launched an attack to undermine MICRA and its protections and we need your help. Membership has never been so valuable!

wAys sCCMA/MCMs/CMA Is woRkIng foR you!

Physicians in santa Clara & Monterey Counties are saving an average of $86,818 this year.

Are you a sCCMA/MCMs/CMA member?

2013 sCCMA/MCMs MICRA sAvIngs ChART general surgery

Internal Medicine

oB/gyn

Average

(non-Invasive)

santa Clara & Monterey Counties

$22,286

$6,315

$29,188

$19,263

Connecticut

$92,782

$34,700

$170,389

$99,290

District of Columbia

$73,018

$24,010

$147,595

$81,541

new york

$148,454

$35,883

$227,899

$137,412

CT-DC-ny Average

$104,751

$31,531

$181,961

$106,081

MICRA Savings

$82,465

$25,216

$152,773

$86,818

sCCMA/MCMs 700 Empey way, san Jose, CA 95128 sCCMA Phone: (408) 998-8850 fax: (408) 289-1064 MCMs Phone: (831) 455-1008 fax: (408) 289-1064 * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 38, No. 10, October 2013. Annual rates with limits of $1 million/$3 million.

12 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

signup sheet w w w.NoOn46.com Protect Access to Quality Health Care and Patient Privacy – Oppose Prop. 46 YES! I/our organization/company would like to be listed as an official opponent of Proposition 46 - the ballot measure written by trial lawyers to make it easier and more profitable for lawyers to sue doctors and hospitals. Prop 46 will significantly increase health care costs, reduce patient access to care and jeopardize the privacy of our personal health information.

Please select a category (check one):

Organization

Company

Individual

Company or Organization Name/Employer: Name:

Title/Occupation:

Street address: City: Phone number:

State:

Zip:

County: Fax number:

E-mail Address: Signature (Required):

Date:

Return this Form By email: info@NoOn46.com By fax: (916) 442-3510 By mail: NO on 46, 1510 J Street, Suite 120, Sacramento, CA 95814

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 13

Vote no

46

Increased costs. Losing your doctor. Threatening your privacy.

A broad coalition of doctors, community health clinics, hospitals, local governments, public safety, business and labor opposes Proposition 46, which would make it easier and more profitable for lawyers to sue doctors and hospitals.

Have you joined the growing coalition opposed to Prop 46?

L earn M ore A t

www. NO On 46 .com

California PEOPLE

CALIFORNIA STATE

CONFERENCE OF THE

NA ACP

of CALIFORNIA

California Stronger Together

Paid for by No on 46 - Patients, Providers and Healthcare Insurers to Contain Health Costs, with major funding from the Cooperative of American Physicians IE Committee and The Doctors Company

14 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

How to Talk to Your Patients

“ As your MIEC Claims Representative, I will serve your professional liability needs with both steadfast advocacy and compassionate support.”

Senior Claims Representative Michael Anderson

Prop 46 - A costly threat to people’s personal privacy Californians can’t afford.

will appear appear on on the the November November 4, 4, 2014, 2014, By now, many of you you are are familiar with the MICRA lawsuit lawsuit initiative initiative that will ballot.

Proposition 46 is being opposed by a coalition of doctors, community health clinics, Planned Parenthood ballot. Proposition a coalition of doctors, community health clinics, Planned Parenthood Affiliates of of California, California,local localgovernments, governments,working working men men and and women, women, business business groups, groups, taxpayer taxpayer groups, hospitals Affiliates and educators, all all of of whom know that the measure will lead to more lawsuits and higher health care care costs. What’s What’sitmore, it will threaten privacy and jeopardize to theirdoctors trusted doctors or clinics. more, will threaten personalpersonal privacy and jeopardize people’speople’s access toaccess their trusted or clinics.

Service and Value

useful for coalition members who are on the ground working totodefeat Prop.

46.

This information isMIEC intended to be areMIEC thehas ground working defeat Prop. takes pride in both. For nearly 40 years, been steadfast in our protection To that end, please also visit www.NoOn46.com for updated campaign information and to find out what you can 46. To that end, please also visit www.NoOn46.com for updated campaign information and to find out what youdo of an California physicians.

With conscientious Underwriting, excellent Claims management to join efforts individual or organization. can do the to join the as efforts as an individual or organization.

and hands-on Loss Prevention services, we’ve partnered with policyholders to keep

WHO OPPOSES PROP. 46?

TALKING TO YOUR PATIENTS premiums low. to your patients Thousands of organizations and individuals representing Communicating the No on 46 message doctors, nurses, community clinics,as local will be critical to defeating the trial lawyers’ attacks on the Average Dividend %governments, of Premiums Past five Yearsgroups, taxpayer labor unions, business groups, education medical profession. As a trusted medical expert, you are in groups, hospitals, community groups and many others a unique position to Added share howvalue: Prop 46 would truly affect all oppose Prop. health care users and taxpayers. Please use the Frequently 40% 46 because it will lead to more lawsuits, n below No profit motive and low overhead higher health care costs, threaten people’s access to their Asked Questions (FAQ) to guide your conversation 35% trusted doctor or clinic, and jeopardize people’s personal with patients. n $17.5 million in dividends* distributed 30%drug information. prescription WHAT WILL PROP. 46 DO? 38.6% 25% in 2014 WHO SUPPORTS PROP. 46?

Prop 46 does three things: 20% percent of the reported contributions to pay for One hundred • Quadruples the limit on medical malpractice awards signature15% gathering to place this on the ballot in November in California, which will cost consumers and taxpayers moreevery information orhealth to apply: 2014 came10%from trial lawyers and their allies. hundreds of millionsFor of dollars year in higher care costs, and cause many doctors and other medical care www.miec.com HOW WILL5%PROP. 46 INCREASE HEALTH CARE COSTS? professionals to quitn their practice or move to places with 6.66% There is no0% question that more lawsuits against health care lower medical malpractice insurance premiums – reducing n Call 800.227.4527 MIEC and someone Med Mal providers will increase costs, has toIndustry pay. And access to care. that someone is consumers and taxpayers. n Email questions to • Threatens your privacy by requiring a massive expansion of California’s former Legislative Analyst found Prop. 46 would a personal prescription drug database. underwriting@miec.com increase health costs for consumers and the state by about $9.9 billion annually.

• Requires alcohol and drug testing of doctors, which * (On premiums at $1/3 million Future dividends cannot be guaranteed.) was only added to this initiative to distract from limits. the main This translates to more than $1,000/year in higher health purpose. care costs for a family of four.

Proposition 46 uses alcohol and drug testing of doctors to California’s current independent, non-partisan Legislative disguise the real intent – to increase a limit on the amount of Analyst Office (LAO) said impacts to state and local medical malpractice lawsuit awards.

MIEC 6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com SJMS_06.17.14

MIEC

Continued on page 16

Owned by the policyholders we protect.

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 15

And who controls the database? The government – in an age when government already has too many tools for violating your privacy.

governments (i.e. – taxpayers) would be “several hundred million dollars annually.”

In its evaluation, the LAO warned “even a small percentage change in health care costs could have a significant effect on government health care spending.”

WHAT IS WRONG WITH THE PROVISION MANDATING USE OF THE CURES DATABASE? This database sounds simple, but it’s not. While the CURES database is already in existence, Prop. 46 would require an immediate ramp up (the day after the election, on November 5, 2014), and will force the CURES database to respond to tens of millions of inquiries each year – something the database simply cannot do in its current form or functionality.

HOW DOES THIS AFFECT TAXPAYERS? State and local governments pay for current and retired government employee health benefits and they provide health care “safety net” services directly through Medi-Cal, state and county hospitals and community clinics, and other local programs.

If lawsuits increase and health care costs go up, state and local governments pay these out of the budgets they receive from taxpayers. Increased health costs to state and local governments could force cuts to other vital services like education, public safety and social safety net programs. Or, state and local governments may decide to make up that additional cost by raising revenues, and that will come from taxpayers.

In fact, in evaluating Prop. 46 the LAO noted, “Currently CURES does not have sufficient capacity to handle the higher

The physician community and all health care providers are always looking for ways to improve patient safety.

WHAT ABOUT ACCESS TO HEALTH CARE? HOW WILL THAT BE AFFECTED BY PROP. 46?

If California’s medical liability cap goes up, people could lose the ability to see their trusted doctors.

Many community clinics operate on slim margins.

Any significant increase in their costs will force them to reduce or eliminate services for patients. Many doctors will be forced to leave California to practice in states where medical liability insurance is more affordable.

But don’t be fooled by Prop 46.

Respected community clinics, including Planned Parenthood, warn that specialists like OB-GYNs will have no choice but to reduce or eliminate vital services, especially for women and families in underserved areas.

WHY ARE COMMUNITY CLINICS SO STRONGLY OPPOSED TO PROP. 46?

Community clinics, like Planned Parenthood Affiliates of California, Community Clinic Association of Los Angeles County, and the California Association of Rural Health Clinics and hundreds of others say Prop. 46 will raise costs that will cause specialists, like OBGYNs, to reduce or eliminate services to their patients. Many clinics struggle financially, particularly community clinics that serve low-income, uninsured and rural patients. Anything that increases costs could jeopardize access to care for those patients most in need.

HOW WILL PROP. 46 THREATEN PEOPLE’S PERSONAL PRIVACY? Prop. 46 forces doctors and pharmacists to use a massive statewide database filled with Californians’ personal medical prescription information. A mandate government will find impossible to implement, and a database with no increased security standards to protect personal prescription information from hacking and theft – none.

16 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

level of use that is expected to occur when providers are required to register beginning in 2016.”

This poses two problems: • Jeopardizes patient access to their prescriptions. Prop.

46 will force the CURES database to respond to tens of millions of inquiries each year– something the database simply cannot do in its current form or functionality. A non-functioning database system will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing needed medications to patients.

• Significantly puts at risk patients’ private medical information. Prop. 46 contains no provisions and no funding to upgrade the database with increased security standards to protect personal prescription information from government misuse, hacking, theft or improper access by non-medical professionals.

SHOULDN’T DOCTORS BE DRUG TESTED? The physician community and all health care providers are always looking for ways to improve patient safety. But don’t be fooled by Prop 46.

The drug testing provision was included for political, not policy reasons. The lawyers who wrote and funded getting Prop. 46 on the ballot have never gone to the state legislature to propose drug testing of doctors. In fact, the consultant for Prop 46, Jamie Court, cynically told the LA Times on December 10, 2013, that drug testing of doctors was “the

ultimate sweetener,” designed to deceive voters from the real reason behind the initiative, to make lawsuits easier and more lucrative for the lawyers who wrote and funded Prop 46.

The $250,000 cap reduces incentives to file meritless lawsuits, while at the same time ensures that legitimate claims can move forward.

ARE THE DRUG TESTING PROVISIONS IN PROP. 46 THE SAME AS WHAT THE FAA AND DEPARTMENT OF TRANSPORTATION REQUIRE OF PILOTS AND AIRLINE PERSONNEL? No. In fact, Prop. 46 cherry picks portions of the FAA procedure for pilots, but excludes other important provisions that ensure due process and fairness. For instance: Prop. 46 imposes a “presumption of negligence” immediately upon a positive test or if a physician is unable to take the test within the mandated 12 hour timeframe. This is not part of the FAA/Department of Transportation regulatory framework.

WHAT ABOUT CHILDREN, SENIORS, AND LOW-INCOME CALIFORNIANS AND THE $250,000 MICRA CAP? Those who will be most hurt by Prop. 46 and the higher health care costs are the very people who are most vulnerable and least able to absorb higher costs: children, seniors, families and low-income Californians.

More lawsuits, like those that will result from Prop. 46, will increase costs for those who can least afford them. And it will reduce patient access to care.

Increasing lawsuits is not the answer and will do absolutely nothing to improve health care quality.

Anyone (disgruntled patient, co-worker, family member) could make a claim that a physician is impaired. In fact, Prop. 46 grants immunity to anyone who reports any information that “appears” to show that a physician “may” be impaired.

The FAA and Department of Transportation’s drug testing policies are designed to identify and respond to impairment that directly places passengers at risk. In contrast, Prop. 46 focuses on identifying and imposing sanctions for physician substance use during an arbitrary time period, regardless of whether there is any evidence that it places patient safety at risk.

ARE PATIENTS ONLY ENTITLED TO $250,000 IN THE EVENT OF A MEDICAL LIABILITY CASE? No. MICRA was set up to ensure patients received fair compensation if they were injured. Under MICRA, patients receive: • UNLIMITED economic damages for any and all past and future medical costs.

• UNLIMITED economic damages for lost wages and lifetime earning potential.

• UNLIMITED punitive damages - punishment awarded for malicious or willful misconduct.

The bottom line is that Prop. 46 will make it harder for all of California’s patients, including children, seniors, and low-income families to receive quality care.

That’s why groups like the American Academy of Pediatrics – California, California Children’s Hospital Association, Children’s Specialty Care Coalition and senior advocates like those at Curry Senior Center oppose this measure.

WON’T PROP. 46 HELP IMPROVE QUALITY BY HOLDING DOCTORS MORE ACCOUNTABLE? Even one medical error is too many and that’s why the entire health care community is always looking for ways to improve patient safety. But don’t be fooled by this measure.

The bottom line is that Prop.

46 will make it harder for all of California’s patients, including

children, seniors, and low-income families to receive quality care.

Increasing lawsuits is not the answer and will do absolutely nothing to improve health care quality. Worse, the resulting higher health care costs will put health care services even more out of reach for people who already suffer from lack of access. Community clinics, rural practitioners and safety net providers are the most vulnerable to cost increases and could be forced to cut back services.

• Up to $250,000 for speculative “non-economic” damages, often called pain and suffering.

32

SAN JOAQUIN PHYSICIAN

FALL 2014

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 17

No on Prop 46

Get Engaged!

By now, many of you are familiar with the MICRA lawsuit initiative that will appear on the November 4, 2014, ballot. Proposition 46 is being opposed by a coalition of doctors, community health clinics, Planned Parenthood Affiliates of California, local governments, working men and women, business groups, taxpayer groups, hospitals and educators, all of whom know that the measure will lead to more lawsuits and higher health care costs. What’s more, it will threaten personal privacy and jeopardize people’s access to their trusted doctors or clinics.

This information is intended to be useful for coalition members who are on the ground working to defeat Prop.

46. To that end, please also visit www.NoOn46.com for updated campaign information and to find out what you can do to join the efforts as an individual or organization.

WHAT YOU CAN DO SIGN UP FORMALLY (AS AN ORGANIZATION, PRACTICE OR INDIVIDUAL) IN OPPOSITION TO THE CAMPAIGN Visit the campaign website at www.NoOn46.com to add your name to the growing list of groups and organizations opposing Prop. 46.

REQUEST A CMA STAFF MEMBER TO SPEAK TO YOUR GROUP, HOSPITAL OR SPECIALTY SOCIETY Let your local county medical society or CMA know and we can ensure you’re hearing from the right people about the most recent campaign updates.

ORDER CAMPAIGN COLLATERAL Download the Order Form to receive office posters, Englishand Spanish-language patient brochures, campaign buttons, message cards and more. You can also order directly online by visiting NoOn46.com SPREAD THE MESSAGE ON SOCIAL MEDIA If you’re active on social media, start by following the California Medical Association and No on Prop 46. Retweet and repost the information that is being put out to help spread the word about how dangerous and costly Prop.

46 will be for everyone. For questions about how to start a Twitter or Facebook account or how to engage with CMA, please contact Brooke Byrd at bbyrd@cmanet.org.

PARTICIPATE IN MESSAGE/MEDIA TRAINING The campaign is looking for physicians interested in taking on a more public role speaking to community groups about why this ballot measure should be defeated. Contact Molly Weedn at mweedn@cmanet.org for more information.

Twitter

SPEAK TO YOUR COLLEAGUES, PATIENTS AND COMMUNITY Use the resources at NoOn46.com to talk to your colleagues, patients, friends and family. Don’t forget to speak to community members as well – groups such as Rotary, Kiwanis, Soroptimist and more provide great venues for presentations.

Facebook

18 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

CMA: No on 46:

CMA: No on 46:

@cmaphysicians @NoOn46

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Medical Professionals Seek Secure Mobile Communication Platform for Efficient Work Flow – Not Social Networks

By Tracey Haas, DO, MPH THE SOLUTION Co-Founder and Chief Medical Officer of DocbookMD Mobile communication is an integral and growing part of every aspect of modern life, including health care. Fast and secure communication between care team members can measurably improve clinical efficiency as well as patient outcomes—this is a given. In addition, federal and state requirements for electronic health record keeping are pushing many medical professionals to aggressively begin updating and integrating their electronic health records and communications.

However, many physicians and health care organizations still rely on multiple technologies and information systems for their communications. The time it takes to monitor multiple communication portals can take away from time spent with patients and allow important messages to slip through.

THE PROBLEM

Several products are currently on the market to address the need for HIPAA-compliant mobile messaging among medical professionals. However, many of these solutions have serious flaws: they are social networks that make their money by selling physicians’ information to recruiters, or they are silo’d solutions that only help those who work inside a hospital system. Physicians need a mobile communication solution that is not only HIPAA-secure, but also shields their personal information and works regardless of practice type or location.

The ideal messaging application for health care providers should include the following: • Efficient and instantaneous physician-to-physician communication • A secure community to share patient information and collaborate with medical colleagues, in a HIPAA-secure manner • Ability to send medical images securely between physicians • Built-in local physician and pharmacy directories • Ability to scale from small groups, to hospitals, all the way to large multi-enterprise organizations like ACOs • Widespread adoption among medical professionals • Availability across platforms including smartphones, tablets, and the Web • Data that resides on secure servers, not users’ devices • Ability to remotely disable the app on a device that has been lost or stolen • Long-term message archive compliant with HITECH recommendations • Ability to integrate with other Health IT solutions When all the information is at a physician’s fingertips, faster and richer discussions on patient treatment and care can result. Also, with local physician and pharmacy directories built into a secure messaging app, the time physicians spend finding colleagues or tracking down a local pharmacy is cut from hours to minutes.

Continued on page 20

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 19

DOCBOOKMD: A SECURE GATEWAY FOR PHYSICIANS

The only HIPAA-secure instant messaging application that meets all these requirements is DocbookMD. Designed by physicians, for physicians, it creates a secure community, to share patient information and collaborate with medical colleagues as well as third-party services like radiology, labs, answering services, even health plans. Drs. Tim Gueramy and Tracey Haas began developing DocbookMD out of their own need for more efficient and instantaneous physician-to-physician and physician-tocare team communication. Since then, DocbookMD has experienced incredible growth, now serving over 25,000 physician users across 41 states.

In addition, DocbookMD offers CareTeam, a feature that allows physicians to invite members of the patient’s direct care team—including nurses, PAs, admin, care coordinators, and other staff—to join them on DocbookMD to communicate in a secure, fast, and efficient way through their mobile devices.

USE CASES

With DocbookMD, health care providers of all kinds can communicate with colleagues rapidly and securely, with the confidence that their privacy and data integrity will be maintained. Here are some exemplary use cases based on actual users’ testimonials: • A dermatologist can send the ENT surgeon an image of a complicated skin lesion to be removed. The surgeon is able to make a more efficient plan for surgery and reconstruction ahead of time.

• A family doctor in a rural area can collaborate over X-rays with an orthopedic surgeon in the nearest city. The specialist is able to determine if an urgent surgery or just a cast is necessary, saving the patient time, extra office visits, and travel.

20 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

• A radiologist can communicate test results immediately to the ordering physician, who can, in turn, notify the patient and bring in for treatment, if needed, much more quickly.

• An emergency physician is able to rapidly receive and send messages, images, and test results to consultants and referring doctors during a busy shift. They are also able to coordinate transfer of care with outpatient primary care, or inpatient hospitalists, thereby streamlining transitional patient care and closing the loop on any ER visit.

Physicians report improved workflow with the ability to do the same work in far less time. For example, a traveling cardiologist’s assistant can send the doctor lower extremity Doppler studies and EKGs for a patient who may be hundreds of miles away. The cardiologist is able to make treatment decisions without having to return, and the patient receives much quicker and more responsive care.

SELECTING A MOBILE COMMUNICATION PLATFORM

Ultimately, when choosing a secure instant messaging application for medical communications, physicians and health care organizations must carefully consider their professional needs as well as the potential to improve patient care. What features are absolute must-haves? What app characteristics would eliminate an app from consideration? Is the solution scalable? Is it cost-effective? Can it be integrated into existing health IT solutions? Answers to these questions and others will help physicians to evaluate messaging apps and select the right fit for their organization.

A HIPAA-secure mobile medical communication solution should put physicians firmly in control of whom they connect with and who can send them messages. Any other model opens physicians up to unwanted contacts and wasted time.

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During this 2 hour program, we will explore practical techniques, tips and solutions you need to not only succeed, but excel in your leadership role.

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PUBLIC HEALTH

Choosing Wisely An initiative of the American Board of Internal Medicine (ABIM) Foundation

SCCMA-MCMS is publishing various Choosing Wisely® lists of "Things Physicians and Patients Should Question." Choosing Wisely - see next page - is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

28 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

Originally conceived and piloted by the National Physicians Alliance through a Putting the Charter into Practice grant, leading medical specialty societies along with Consumer Reports, have identified tests or procedures commonly used in their fields whose necessity should be questioned and discussed. The resulting lists of "Things Physicians and Patients Should Question" will spark discussion and the need - or lack thereof - for many frequently ordered tests or treatments.

For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org

HOW THE LIST ON THE NEXT PAGE WAS CREATED

The American Society of Clinical Oncology (ASCO) has had a standing Cost of Cancer Care Task Force since 2007. The role of the Task Force is to assess the magnitude of rising costs of cancer care and develop strategies to address these challenges.

In response to the 2010 New England Journal of Medicine article by Howard Brody, MD, “Medicine’s Ethical Responsibility for Health Care Reform – the Top Five List,” a subcommittee of the Cost of Cancer Care Task Force began work to identify common practices in oncology that were both common as well as lacking sufficient evidence for widespread use. Upon joining the Choosing Wisely campaign, the members of the subcommittee conducted a literature search to ensure the proposed list of items were supported by available evidence in oncology; ultimately the proposed Top Five list was approved by the full Task Force. The initial draft list was then presented to the ASCO Clinical Practice Committee, a group composed of community-based oncologists as well as the presidents of the 48 state/regional oncology societies in the United States. Advocacy groups were also asked to weigh in to ensure the recommendations would achieve the dual purpose of increasing physician-patient communication and changing practice patterns. A plurality of more than 200 clinical oncologists reviewed, provided input and supported the list. The final Top Five list in oncology was then presented to, discussed and approved by the Executive Committee of the ASCO Board of Directors and published in the Journal of Clinical Oncology.

ASCO’s disclosure and conflict of interest policies can be found at www.asco.org.

American Society of Clinical Oncology

Five Things Physicians and Patients Should Question The American Society of Clinical Oncology (ASCO) is a medical professional oncology society committed to conquering cancer through research, education, prevention, and delivery of high-quality patient care. ASCO recognizes the importance of evidence-based cancer care and making wise choices in the diagnosis and management of patients with cancer. After careful consideration by experienced oncologists, ASCO highlights five categories of tests, procedures and/or treatments whose common use and clinical value are not supported by available evidence. These test and treatment options should not be administered unless the physician and patient have carefully considered if their use is appropriate in the individual case. As an example, when a patient is enrolled in a clinical trial, these tests, treatments, and procedures may be part of the trial protocol and therefore deemed necessary for the patient’s participation in the trial.

1

Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.

• Studies show that cancer directed treatments are likely to be ineffective for solid tumor patients who meet the above stated criteria.

• Exceptions include patients with functional limitations due to other conditions resulting in a low performance status or those with disease characteristics (e.g., mutations) that suggest a high likelihood of response to therapy.

• Implementation of this approach should be accompanied with appropriate palliative and supportive care.

Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

2

• Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types. However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.

• Evidence does not support the use of these scans for staging of newly diagnosed low grade carcinoma of the prostate (Stage T1c/T2a, prostate-specific antigen (PSA) <10 ng/ml, Gleason score less than or equal to 6) with low risk of distant metastasis.

• Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

3

4

5

• Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types. However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.

• In breast cancer, for example, there is a lack of evidence demonstrating a benefit for the use of PET, CT, or radionuclide bone scans in asymptomatic individuals with newly identified ductal carcinoma in situ (DCIS), or clinical stage I or II disease.

• Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.

• Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (e.g., colorectal). However for breast cancer that has been treated with curative intent, several studies have shown there is no benefit from routine imaging or serial measurement of serum tumor markers in asymptomatic patients.

• False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.

Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.

• ASCO guidelines recommend using white cell stimulating factors when the risk of febrile neutropenia, secondary to a recommended chemotherapy regimen, is approximately 20 percent and equally effective treatment programs that do not require white cell stimulating factors are unavailable.

• Exceptions should be made when using regimens that have a lower chance of causing febrile neutropenia if it is determined that the patient is at high risk for this complication (due to age, medical history, or disease characteristics).

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 29

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Do you have an office EMERGENCY? Call us at (408) 217-6000 30 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

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SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 31

Metabolic, Genetic, and Environmental Mysteries

By Cindy L. Russell, MD VP - Community Health, Santa Clara County Medical Association Researchers have been scrambling to unlock the mysteries behind the alarming rise in autism spectrum disorders (ASD).

Autism causes a dismaying amount of suffering, loss of human potential, as well as financial burden. ASD is increasingly recognized as a serious public health problem. According to the Centers for Disease Control and Prevention, the prevalence of ASD has risen 1200%-1500% over 20 years and is now over 1%.

It affects about 1 in 68 children (one in 42 boys and one in 189 girls). Is this a real phenomenon or just heightened awareness and better diagnosis? It is both. Research indicates that changes in diagnostic criteria have accounted for some, but not all, of the increase. In California, from 1992- 2005, the criteria for inclusion changed, and it is estimated that it accounted for about 25% of the increase in diagnosis. (1)

COMPLEX BRAIN SYSTEMS â&#x20AC;&#x201C; COMPLEX BRAIN RESEARCH Autism is a complex disorder. A plethora of research has also discovered those with ASD have many abnormalities in the brain including loss of cell function, signaling dysfunction, loss of Purkinje cells and astrocytes, metabolism disorders, mitochondrial disorders, oxidative damage, inflammation of the brain, mast cell activation, reduction of protein synthesis, overstimulation of 32 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

“Twenty percent of the known factors associated with autism are genetic, but most are not. It’s wrong to think of genes and the environment as separate and independent factors. Genes and environmental factors interact. The net result of this interaction is metabolism.”

Robert Naviaux, UCSD School of Medicine (43)

some areas of the brain involved in memory, alteration in the excitatory/ inhibitory imbalance of glutamatergic/GABAeric system and systemic immune dysfunction, all connected to the functional behavioral problems seen in autism. How are these connected with one diagnosis?

FAULTY GENES AND THE ENVIRONMENT Research suggests that a myriad of faulty genes are associated with autism, however, differences in gene expression and exposure to environmental factors may contribute to differing autism-related traits. (5) In fact, studies of concordant twins suggest there is a stronger environmental component than previously believed. (6)(70)(71) Genetic, environmental, and immunological factors all appear to play a role in its pathogenesis.

This is an important recent shift in thinking about the issue, as researchers are now looking at environmental influences in addition to genetic links to autism. Identifying the specific biochemical and anatomic abnormalities of ASD, as well as the suspected environmental causes and

triggers, will help not only in treatment, but also urgently guide preventative actions for this difficult and costly syndrome.

ENVIRONMENTAL CAUSES OR CONTRIBUTORS NEED TO BE ADDRESSED As discussed in Autism Rising Part 1 (May/ June 2014 Bulletin issue), we are regularly exposed to a host of known neurotoxins and biologic toxins including heavy metals, pesticides, plastics, industrial chemicals, flame retardants, air pollutants, food additives, and radiation. Umbilical cord samples show babies have some 200 known toxins that have been circulating in their bloodstream during fetal development. Known neurotoxins easily cross the blood brain barrier. (44,45) Endocrine disruptors are likely suspects as well, considering the

Continued on page 34

Part 2 SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 33

Autism Rising, from page 33 development and functioning of the nervous system is intimately tied to immune, reproductive, and thyroid hormones during development, both prenatally and postnatally. (87)(89) What interactions do these have on the developing brain? Is it just the brain that is out of order in autism? Although there is much research to be done, we know a great deal about mechanisms of toxicity for environmental exposures and how they exert their effects on cells and metabolism. In Autism Rising Part 1, these concepts were introduced. In Part 2, we will focus on the highlights of current research into genetic, biochemical changes, and pathophysiology. We will then look at how researchers have connected at least some of the dots with regards to gene and environmental interactions. Scientists and experts in neurotoxicology are especially concerned, and are now calling for precautionary and preventative strategies with regards to potential environmental factors.

“We need a systematic search for potentially preventable environmental causes of autism,” Dr. Philip Landrigan, director of the Children’s Environmental Health Center, Mt. Sinai AUTISM Autism Spectrum Disorder (ASD) is a behaviorally-defined group of neurodevelopmental disorders characterized by impairments of social interaction, communication, and restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. Individuals with autism vary widely in abilities, intelligence, and behaviors. From 30% to 60% of children with an autism spectrum disorder have an IQ measure that falls in the intellectual disability range. (3) It is generally diagnosed within the first three years of life during a time of critical and fragile circuit refinement.

Autism is more common in boys by a factor of four. Some show signs of autism in infancy, while others may grow normally the first few years then suddenly become withdrawn or lose language. (58) Many individuals with ASDs have symptoms of associated medical conditions, including seizures, sleep problems, metabolic conditions, and gastrointestinal (GI) disorders, which have significant health, developmental, social, and educational impacts. (34) Behavioral symptoms include poor eye contact, language difficulty, inappropriate social interaction, repetitive motion or rocking, constant motion, and difficulty with changes in routine.

“Work on the maternal infection risk factor using animal models indicates that aspects of brain and peripheral immune dysregulation can begin during fetal development and continue through adulthood.” (63) THINKING BEYOND GENES Although there has been a dizzying flow of reports in the last five years showing hundreds of genetic alterations associated with ASD, there is no one gene or set of genes found to explain autism. (54) Many cases are sporadic, with no one else in the family affected. Studies in cases where there is no family history show about 10% de novo gene mutations. (67) In addition, spontaneous epigenetic changes in the DNA (methylation 34 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

without DNA sequence changes) can also play a role in behavior disorders, according to twin studies. (7)(70)(71) A variety of toxicants and endocrine disruptors have also been implicated alone or in combination.

Endocrine disrupting chemicals may be a factor, as males are four times more likely to be autistic, suggesting estrogen/testosterone alteration. In addition, adrenal, gonadal, and thyroid hormones play an important role in fetal neurodevelopment. “Any chemical that interferes with the actions of these hormones, therefore, has the potential to disrupt brain development.”(88)

AUTISM RISK FACTORS: MATERNAL INFECTION, PRETERM DELIVERY, PATERNAL AGE, AIR POLLUTION Autism appears to be a heterogenous disorder that is influenced by multiple defective gene family interactions along with environmental factors.(62) In addition, genes affected by mutations in autism overlap those mutated in schizophrenia and intellectual disability. Also, autism risk is known to be elevated with maternal infection, preterm birth, paternal age, and exposure to air pollution. (63)(66)(97)(98) “Progress … has not yet led to a unified understanding of ASD pathogenesis or explained its highly variable clinical expression. With an increasingly firm genetic foundation, the coming years will hopefully see equally rapid advances in elucidating the functional consequences of ASD genes and their interactions with environmental/experiential factors, supporting the development of rational interventions.” (54)

COMMON ASPECTS OF IMPAIRMENT: IMMUNE SYSTEM, INFLAMMATION, OXIDATIVE STRESS Of the hundreds of studies already done, there appear to be some common aspects of biochemical changes and metabolism that link altered genes to environmental factors. A review of research trends shows a strong association between ASD and immune dysregulation and inflammation (416 articles), oxidative stress (115 articles), mitochondrial dysfunction (145 articles), and toxicant exposures (170 articles). (46) In addition, many articles point to subgroups with imbalances in the inhibitory/excitatory and glutamate signaling, a common biologic pattern seen in ADHD, and schizophrenia as well. (60) Toxic chemicals and radiation also cause biochemical changes in cells, reactive oxygen species (ROS), and inflammation that are linked to chronic disease.

“Overproduction of reactive oxygen and nitrogen species can result from exposure to environmental pollutants, such as ionizing and non-ionizing radiation, ultraviolet radiation, elevated concentrations of ozone, nitrogen oxides, sulphur dioxide, cigarette smoke, asbestos, particulate matter, pesticides, dioxins and furans, polycyclic aromatic hydrocarbons, and many other compounds present in the environment. It appears that increased oxidative/nitrosative stress

is often a neglected mechanism by which environmental pollutants affect human health.” (49) In fact, some antioxidants have been shown to have protective effects on cells exposed to ROS. (49) BEHAVIOR DISORDERS LINKED TO IMMUNE SYSTEM DYSFUNCTION A particularly difficult aspect of ASD is intense reactivity, repetitive, and difficult behaviors. A link between altered immune responses and ASD was first recognized nearly 40 years ago. Neurobiological research in ASD has highlighted pathways involved in neural development, synapse plasticity, structural brain abnormalities, cognition, and behavior. “Several lines of evidence point to altered immune dysfunction in ASD that directly impacts some or all of these neurological processes. Extensive alterations in immune function have now been described in both children and adults with ASD, including ongoing inflammation in brain specimens, elevated pro-inflammatory cytokine profiles in the CSF and blood, increased presence of brain-specific auto-antibodies, and altered immune cell function. These dysfunctional immune responses are associated with increased impairments in behaviors characteristic of core features of ASD, in particular, deficits in social interactions and communication. This accumulating evidence suggests that immune processes play a key role in the pathophysiology of ASD.” (17, 20, 21) “Our results surprisingly converge upon immune, and not neurodevelopmental genes, as the most consistently shared abnormality in genome-wide expression patterns. A dysregulated immune response, accompanied by enhanced oxidative stress, and abnormal mitochondrial metabolism seemingly represents the common molecular underpinning of these neurodevelopmental disorders.” Lintas 2012(35)

“Widespread changes in the immune systems of individuals with ASD have been

identified, in particular increased evidence of inflammation in the periphery and central nervous system.” 48 KEY SIGNALING CYTOKINES INCREASED WITH INFLAMMATION IN AUTISM Cytokines are proteins involved in cell signaling and are produced by a variety of cells including macrophages, B and T lymphocytes, mast cells, fibroblasts. They are important in modulating the immune system, inflammation, infection, cancer, and reproduction. (22) Groundbreaking work by Pardo has shown an inflammatory-like state in postmortem autism brains of all ages as indicated by elevated cytokines and activated microglia and astrocytes. “Our findings indicate that innate neuroimmune reactions play a pathogenic role in an undefined proportion of autistic patients.”(65) Smith looked at maternal immune stimulation in mice and found a specific cytokine IL-6 that accurately reproduces the abnormal autistic/ schizophrenic-like behavior in offspring by changing gene expression.(86) Ashwood showed significant increases of a variety of plasma cytokines in ASD. “These findings suggest that ongoing inflammatory responses may be linked to disturbances in behavior and require confirmation in larger replication studies.” (18)

MITOCHONDRIA DYSFUNCTION AND AUTISM Basic science research has now linked mitochondrial abnormalities with abnormal brain development in a subgroup of autism. Mitochondria are intracellular power plants with a three-layer phospholipid membrane and a nucleus containing DNA. They use oxygen to create adenosine triphosphate, or ATP, the chemical energy used in all our cells. The production of cellular antioxidant glutathione is dependent on ATP. The inner folded membrane where ATP is made is called the cristae. Precise regulation of calcium signaling is necessary for proper functioning, and dysregulated mitochondrial calcium has been implicated in several neurode-

Continued on page 36 SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 35

Autism Rising, from page 35 generative diseases. In addition, mitochondria are sensitive to free radical formation and oxidative stress, which can cause damage to the membrane and DNA, causing dysfunction of the mitochondria.

VULNERABLE MITOCHONDRIA Rose found that a subset of children with autism have more vulnerable mitochondria. He states “lymphoblastoid cell lines derived from children with autistic disorder have an abnormal mitochondrial reserve capacity before and after exposure to reactive oxygen species … The results of this study suggest that a significant subgroup of ASD children may have alterations in mitochondrial function, which could render them more vulnerable to a pro-oxidant microenvironment, as well as intrinsic and extrinsic sources of ROS such as immune activation and pro-oxidant environmental toxins. These findings are consistent with the notion that ASD is caused by a combination of genetic and environmental factors.” (41) Valenti has shown that mitochondrial dysfunction is a central factor in intellectual disability-related diseases such as Down Syndrome, Autism, Fragile X, and Rett Syndrome. (24) “The prevalence of developmental regression (52%), seizures (41%), motor delay (51%), gastrointestinal abnormalities (74%), female gender (39%), and elevated lactate (78%) and pyruvate (45%) was significantly higher in ASD with Mitochondrial Disorder (MD) compared with the general ASD population….Most ASD/ MD cases (79%) were not associated with genetic abnormalities, raising the possibility of secondary mitochondrial dysfunction.” (25) “Therapeutic approaches are aimed at improving intellectual disability by activating mitochondrial function and reducing oxidative stress to ameliorate the quality of life in the subjects affected.” (24)

REACTIVE OXYGEN SPECIES: DARTH VADER OF MOLECULES Reactive Oxygen Species (ROS) are chemically active molecules that are normally formed in our cells due to natural processes such as infection and can help kill unwanted bacteria.

Under normal conditions, ROS serve as messengers in the regulation of intracellular signaling.

Excess ROS is harmful and may induce irreversible damage to our cellular components and lead to cell death through mitochondrial pathways. ROS can cause damage to DNA, enzymes, fatty acids, and proteins.

GLUTATHIONE: OUR PERSONAL ANTIOXIDANT Glutathione is the major antioxidant produced in all cells in the human body, as well as in plants, fungi, and bacteria. It serves to protect and balance the organism from damage caused by free radicals, also known as reactive oxygen species, which, in excess, destroy cell structures. In addition, it helps to preserve important antioxidants such as vitamin C and E. After its protective antioxidant reaction is complete, glutathione is regenerated back to its useful state by the enzyme glutathione reductase.

Glutathione is essential in other vital biochemical functions such as energy utilization, immune system activity, detoxification, and disease prevention. “Glutathione (GSH) and related enzymes are critical to cell protection from toxins, both endogenous and environmental, including a number of anti-cancer cytotoxic agents.” (38) Natural glutathione production can be disrupted by toxins such as paraquat. (37)

REACTIVE OXYGEN SPECIES IN AUTISM “Markers of oxidative damage to proteins, oxidative damage to DNA reduced glutathione, chronic inflammation, were found in the brain tissue of autistic individuals compared to controls.” (26) “Glutathione is involved in neuro-protection against oxidative stress and neuro-inflammation in autism by improving the antioxidative stress system. Decreasing the oxidative stress might be a potential treatment for autism. ” (27) In an earlier review article, McGinnis states “Brain and gut, both abnormal in autism, are particularly sensitive to oxidative injury. Higher red-cell lipid peroxides and urinary isoprostanes in autism signify greater oxidative damage to biomolecules. A preliminary study found accelerated lipofuscin deposition – consistent with oxidative injury to autistic brain in cortical areas serving language and communication. Double-blind, placebo-controlled trials of potent antioxidants – vitamin C or carnosine – significantly improved autistic behavior. Benefits from these and other nutritional interventions may be due to reduction of oxidative stress. Understanding the role of oxidative stress may help illuminate the pathophysiology of autism, its environmental and genetic influences, new treatments, and prevention.” (28)

OXIDATIVE STRESS, GLUTATHIONE, AND AUTISM Oxidative stress and glutathione (GSH) levels are another major focus of research. There is increasing evidence of oxidative stress and reactive oxygen species (ROS) formation in the pathophysiology of autism.

36 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

“Several lines of research support the view that both genetic and environmental factors influence the development of abnormal cortical circuitry that underlies autistic cognitive processes and behaviors.” Pardo (65)

MECHANISMS OF TOXIC EXPOSURE IN AUTISM REVIEW OF ENVIRONMENTAL TOXICANTS Rossignal identified many toxicants that may act synergistically with genetic factors at critical times of development to increase ASD. These include “pesticides, phthalates, polychlorinated biphenyls (PCBs), solvents, toxic waste sites, air pollutants, and heavy metals, with the strongest evidence found for air pollutants and pesticides.” (73)

TOXINS CREATE REACTIVE OXYGEN SPECIES Toxins such as tobacco, chemicals, hormone disruptors, and both ionizing and non-ionizing radiation in the environment stimulate reactive oxygen species. This is one mechanism of injury leading to chronic disease and cancer. (110) Natural antioxidants such as glutathione and superoxide dismutase that protect cellular processes may become overwhelmed by this toxic exposure. Antioxidant glutathione levels can drop and protection of cells is abolished, leaving the cell and the organism more vulnerable to other toxic exposures we commonly encounter.

BISPHENOL A CAUSES OXIDATIVE STRESS Bisphenol A, a known endocrine disruptor with widespread exposure, appears to be an environmental risk factor in genetically susceptible autistic children, as it also causes increased oxidative stress and mitochondrial dysfunction. (8)

NEURODEVELOPMENTAL TOXINS DEPLETE GLUTATHIONE CAUSING OR CONTRIBUTING TO AUTISM Waly and Deth from Northeastern University, in Boston, published a sentinel paper in 2008 on the link between neurodevelopmental toxins and autism. It also explains how one or more biochemical disruptions can be involved. (30) They looked at ethanol, arsenic, lead, mercury, aluminum, and the vaccine mercury preservative thimerosal, which are suspected to be etiological factors for neurodegenerative and neurodevelopmental disorders.

They note “Autism is a neurodevelopmental disorder characterized by oxidative stress and impaired methylation status, including decreased activity of the folate and vitamin B12-dependent enzyme methionine synthase (MS). MS-mediated conversion of homocysteine to methionine is crucial for neurons and all mammalian cells to sustain normal methylation status, involving more than 100 different reactions. Glutathione (GSH) protects MS from oxidative inactivation by reactive oxygen species, while MS inactivation increases GSH synthesis by augmenting transsulfuration. Utilizing cultured human neural cells, we found that a one hour pre-incubation of cells with arsenic, lead, mercury, aluminum, and thimerosal caused a 60%–70% reduction of intracellular glutathione. Our findings suggest that heavy metals and ethanol may contribute to the occurrence of neurodevelopmental disorders, such as autism, via a mechanism that involves oxidative stress and inhibition of MS activity.”(30) Deth concludes “oxidative stress, initiated by environment factors in genetically vulnerable individuals, leads to impaired methylation and neurological deficits secondary to reductions in the capacity for synchronizing neural networks.” (31) Agarwal also demonstrated that arsenic, mercury, and lead caused decreased glutathione and surperoxide dismutase levels along with oxidative stress.(72)

“This study confirms earlier studies that implicate toxic metal accumulation as a consequence of impaired detoxification in autism and provides insight into the etiological mechanism of autism.” (76) MERCURY TARGETS BRAIN CELLS Prior to concerns about vaccinations, mercury has been a well established neurotoxin. The phrase “mad as a hatter” was coined to describe toxic symptoms of milliners, as mercury was used in the manufacture of felt hats in the eighteenth and nineteenth century. Manifestations were tremor, ataxia, fatigue, and visual field constriction. With severe poisoning, the patient is in a mute semi-rigid position with primitive motion and speech.

The experience at Minamata, Japan, in the 1950s, where over 2,000 adults and children suffered mercury poisoning over time from ingesting fish contaminated by mercury from a nearby plant is long remembered. It was the first incident that led to the discovery that a poison, such as mercury, could cross the blood brain barrier. Prior to that, everyone thought the blood brain barrier was impermeable to toxins. Many children born to mothers who ingested mercury had delayed motor and development, ataxia, intellectual disability, and convulsions. (94) Small doses of mercury can disrupt normal neurological development, both in utero and in early life. Mercury can also be toxic to the kidneys, digestive, and immune system. It is on the World Health Organization’s top 10 list of chemicals of major public health concern. (94)

A University of Calgary rapid speed video of neural degeneration shows the powerful effect of mercury toxicity. (84) https://www.youtube.com/ watch?v=XU8nSn5Ezd8 Despite the fact that manufacturers have removed mercury from most vaccines, there is still widespread exposure to mercury. Exposure occurs largely from eating larger predator fish, such as tuna and swordfish, but there is also concern about mercury in amalgam fillings and pharmaceuticals (e.g. thimerosal). Elevated mercury is of special concern for pregnant women. Biomonitoring in the U.S. has shown that there are elevated levels of mercury in 6%-15% of childbearing women that could pose a risk for normal neurodevelopment. (95)

MERCURY FROM POWER PLANTS Mercury is also released from coal-fired power plants and cement kilns. Palmer, in 2006, reported in an epidemiological study noting “a significant increase in the rates of special education students and autism rates associated with increases in environmentally released mercury. On average, for each 1,000 lb of environmentally released mercury, there was a 43% increase in the rate of special education services, and a 61% increase in the rate of autism.” (99)

Lead body-burden was associated with ASD severity… This study helps to provide Continued on page 38 SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 37

Autism Rising, from page 37 additional mechanistic support for lead in the etiology of ASD severity” (77) ELEVATED HEAVY METALS FOUND IN HAIR OF AUTISTIC CHILDREN Multiple studies have found elevated levels of heavy metals, such as lead and mercury, in autistic children, thus implicating toxic metal accumulation as a consequence of impaired detoxification in autism, in addition to exposure. (75)(77)(78)(79)(80)(81) “Data showed that the patients with autism spectrum disorder had significantly higher lead and mercury levels, and lower glutathione-s-transferase activity and vitamin E concentrations compared with the controls.” Alabdali 2014 (78) Geler, in 2012, used hair toxic element testing for arsenic, mercury, cadmium, lead, chromium, cobalt, nickel, aluminum, tin, uranium, and manganese. He found “Increasing hair mercury concentrations significantly correlated with increased ASD severity, but no significant correlations were observed between any other of the hair toxic metals examined and ASD severity.” (77) Lakshmi, in 2011, looked at trace mineral levels that may be beneficial (copper, zinc, magnesium, and selenium) versus toxic elements (mercury and lead) in the hair and nail samples of autistic children to evaluate whether the level of these elements could be correlated with the severity of autism. She found “the significant elevation in the concentration of copper, lead, and mercury, and significant decrease in the concentration of magnesium and selenium observed in the hair and nail samples of autistic subjects could be well correlated with their degrees of severity.” (78)

“The regular and long term use of microwave devices (mobile phone, microwave oven) at domestic level can have negative impact upon biological system especially on brain. It also suggests that increased reactive oxygen species (ROS) play an important role by enhancing the effect of microwave radiations which may cause neurodegenerative diseases.” (119)

WIRELESS COMMUNICATIONS: EFFECTS OF EMF RADIATION ON BIOLOGICAL SYSTEMS

Wireless technologies are ubiquitous today, but were developed only in the last 20 years, with a steady and sharp increase in their use and exposure since then. Several decades of peer-reviewed research has confirmed that microwave radiation from a variety of wireless devices such as cell phones, WiFi routers, smart meters, and baby monitors have non-thermal adverse biologic effects on a cellular level. These include leakage of the blood brain barrier, genetic damage with single- and double-stranded DNA breaks, disruption of intracellular communication, immune system deregulation, allergic response, altered sperm function, cardiovascular effects, abnormal protein synthesis, reactive oxygen species, and alteration of DNA expression. (131)(132) In addition, several studies have confirmed sperm genotoxicity after exposure to wireless EMF radiation.

Epidemiological studies have demonstrated an increase in brain tu38 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

mors, with long-term cell phone use – over 10 years. (124) Neurobehavioral effects from EMF have been reported to include memory loss, tinnitus, headaches, hearing loss, and insomnia. Electrosensitivity to wireless devices and EMF is officially recognized as a functional impairment in Sweden and affects about 3% of the population. (117)(118) School children have reported electrosensitivity in school after WiFi was placed, with symptoms of headache, rapid heartbeat, nausea, weakness, shakiness, and rashes. It did not occur when they were home. (120) Considering the wide range of cellular effects from microwave EMF, it seems plausible that WiFi communications would contribute to autistic development through de novo mutations or exacerbate symptoms due to reactive oxygen species production, thus overwhelming glutathione stores.

Many scientists throughout the world have been calling for a reevaluation of the international standards for EMF, as they are not protective of human health.

The current RF-EMF standards are based solely on heat effects of the microwave radiation on tissue and not the biological effects seen in the laboratory at levels more than a hundred times lower than what is allowed and considered safe.

EMF AND REACTIVE OXYGEN SPECIES EMF from wireless devices has been shown to cause reactive oxygen species and enhance free radical formation in numerous studies. (101)(102) (103)(104)(105)(106)(107)(108)(109)(111) Lui found that exposure to radiofrequency electromagnetic radiation (RF-EMR) emitted from mobile phones induced DNA damage in male germ cells. He concluded, that “these findings may imply the novel possibility that RFEMR with insufficient energy for the direct induction of DNA strand breaks may produce genotoxicity through oxidative DNA base damage in male germ cells.” (103)

“We present the first experimental evidence of neuropathology due to in-utero cellular telephone radiation.” (129)

AFFECTS ON SPERM: IMPLICATIONS FOR MALE GENETIC LINK IN AUTISM Scientists looking at the effects of mobile phone microwave frequencies on sperm have been conducted in rats, mice, and rabbits using mobile phone RF exposure for variable lengths of time. The results of these studies have shown that RF-EMR decreases sperm count and motility and increases oxidative stress. (114) Genotoxic effects on sperm have also been found. (116) If autism is linked to aging sperm with presumably more genetic damage, it is possible cell phones and Wi-Fi from different sources could contribute to autism spectrum disorders.

Agarwal reported in Sterility and Fertility journal, in 2009, the effects of one hour of cell phone RF-EMF on human sperm. He found a significant decrease in sperm motility and viability. He concluded that radiofrequency electromagnetic waves emitted from cell phones may lead to oxidative stress in human semen and cautioned against men putting their cell phones in trouser pockets. (115) Mailinkot, in 2009, looked at effects of RF-EMR from mobile phones on free radical metabolism and sperm quality. He exposed rats to a mobile phone for one hour continuously per day for 28 days. The study showed that “rats exposed to RF-EMR exhibited a significantly reduced percentage of motile sperm. Moreover, RF-EMR exposure resulted in a significant increase in lipid peroxidation and low glutathione content in the testis and epididymis.” (113) Avendano was the first to evaluate the effect of laptop computers receiving wireless Internet signals on human spermatozoa. Researchers evaluated semen samples from 15 men. “The samples were separated into two incubation groups: one that was exposed to a laptop computer receiving a Wi-Fi signal for four hours, and another that was not. Despite the fact that the two groups were kept at a controlled temperature (25 °C) to rule out thermal effects, the results showed significant DNA damage and decreased sperm motility in the laptop-exposed group.” (116)

NEURODEVELOPMENTAL DISORDERS WITH CELL PHONE USE Animal and human research is now finding neurodevelopmental and neurologic abnormalities that are of serious concern, especially considering the near universal use of cell phones and wireless devices inside and outside the home.

A study performed on adult rats showed altered behavior after three days of continuous exposure to cell phone radiation. They expressed stress behavior actions. (125) In another study, the rats were exposed to a longer period of intermittent cell phone radiation. “Healthy male albino Wistar rats were exposed to RF-EMR by giving 50 missed calls (within one hour) per day for four weeks, keeping a GSM

(0.9 GHz/1.8 GHz) mobile phone in vibratory mode (no ring tone) in the cage. Results showed passive avoidance behavior was significantly affected in mobile phone RF-EMR-exposed rats … when compared to the control rats. Marked morphological changes were also observed in the CA (3) region of the hippocampus of the mobile phone-exposed rats in comparison to the control rats. They concluded mobile phone RF-EMR exposure significantly altered the passive avoidance behavior and hippocampal morphology in rats.” (126) Rats exposed for an even longer period – 28 days – at peak power density of 146.60 μW/cm(2) showed that mobile phone radiation could affect the emotionality of rats without affecting the general locomotion. (127) Another EMF rat study showed increased oxidation in the hippocampus, which is key to memory and learning. (128)

DANISH STUDIES FIND SURPRISING LINK BETWEEN EMF AND BEHAVIOR Some studies have explored human behavior problems and cell phone use. (122)(123)(124) Two large Danish studies of 13,000 (2008) and 28,745 children (2012) demonstrated that cell phone use was associated with behavioral problems at age seven years in children, and this association was not limited to early users of the technology. Exposure to cell phones prenatally – and, to a lesser degree, postnatally – was associated with behavioral difficulties such as emotional and hyperactivity problems around the age of school entry. The results were a surprise to the authors who expected to find no effect.

AUTISTIC BEHAVIOR WITH IN-UTERO EXPOSURE Adid, in 2013, was the first to demonstrate biochemical changes similar to autism in rats exposed prenatally to cell phone radiation. “Mice exposed in-utero were hyperactive and had impaired memory… recordings of miniature excitatory postsynaptic currents (mEPSCs) revealed that these behavioral changes were due to altered neuronal developmental programming. Exposed mice had dose-responsive impaired glutamatergic synaptic transmission onto layer V pyramidal neurons of the prefrontal cortex. We present the first experimental evidence of neuropathology due to in-utero cellular telephone radiation.” (129)

SUMMARY

The delicate and complex wiring of the brain is especially vulnerable to toxic exposure during early development. There are animal models demonstrating that autism can be created prenatally by exposure to drugs such as valproic acid, thalidomide, misoprostol, maternal rubella infection, and the pesticide chlorpyrifos. (138) This is proof of principle and opens the door to further investigation of toxic interactions in autism.

Scientists believe neurodevelopmental disorders such as autism have common biochemical markers that may vary in subsets. These include reactive oxygen species, glutathione reduction, mitochondrial disorders, inflammation, and DNA alterations with now hundreds of associated gene mutations. Some DNA changes are inherited, but others occur de novo.

Autism, it appears, is not a single disorder, but a range of disorders that may have a variety of causes. While autism may have inherited genetic alterations, there is a significant environmental component. Toxins such as heavy metals, industrial chemicals, food additives, pesticides, plastics, endocrine disruptors such as Bisphenol A, as well as non-ionizing microwave radiation found in wireless devices, can also cause cellular and mo-

Continued on page 40 SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 39

Autism Rising, from page 39 lecular damage with production of reactive oxygen species, inflammation, and genetic damage similar to that seen in autism. These toxins could act in concert to cause an array of biochemical and behavioral manifestations.

Unfortunately, as we are increasingly exposed to the classic toxins, there are novel insults to our cells from newer environmental factors such as nanoparticles in consumer products, and wireless devices whose nonionizing radiation which we now know can cause adverse biologic, and therefore, health effects. Genetically modified foods create genetic pollution and are another area of increasing concern with regards to both human and environmental health.

It is difficult to sort out any one cause of autism or host of other modern diseases. In order to protect public health, a rational and responsible approach to environmental toxins would be to apply the precautionary principle. If an environmental factor has been shown to have toxic effects with a reasonable amount of scientific data, efforts to prevent commercial use or to reduce or eliminate that factor would be addressed rapidly and without excessive corporate or political interests that could obstruct responsible action. A systematic approach and ethical leadership are called for.

THE PRECAUTIONARY PRINCIPLE IN THE EU As per Article 174(2) of the European Community Treaty, the precautionary principle is one of the fundamental principles of the European Union governing policies related to the environment, health, and safety.

The precautionary principle or precautionary approach states that if an action or policy has a suspected risk of causing harm to the public or to the environment in the absence of scientific consensus, that the action or policy is not harmful, the burden of proof that it is not harmful falls on those taking an action.

Environmental scientists propose the precautionary principle as a new guideline in environmental decision-making. It has four central components: taking preventive action in the face of uncertainty; shifting the burden of proof to the proponents of an activity; exploring a wide range of alternatives to possibly harmful actions; and increasing public participation in decision-making. (136)

“Children today are surrounded by thousands of synthetic chemicals. Two hundred of them are neurotoxic in adult humans, and 1,000 more in laboratory models. Yet fewer than 20% of highvolume chemicals have been tested for neurodevelopmental toxicity.”

Dr. Philip Landigan, Children’s Environmental Health Center, Mount Sinai SCIENTIFIC RECOMMENDATIONS: PREVENTION OF DEVELOPMENTAL NEUROTOXICITY (133)

1. Legally mandated testing of existing chemicals and pesticides in commerce, with prioritization of those with the most widespread use.

2. Legally mandated pre-market testing of new chemicals or processes before they enter commercial use.

3. Prioritize those chemicals/processes that have neurodevelopmental toxicity.

40 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

4. Develop a new clearinghouse for neurotoxicity as a parallel to the International Agency for Research on Cancer to assess industrial chemicals and processes with emphasis on precaution and not absolute proof.

5. Shift from Risk Assessment to Alternatives Assessment as a more precautionary approach. (135) 6. Reevaluate the international standards for non-ionizing microwave EMF in wireless communications to include biologically relevant safety limits that coincide with current literature on levels that do not cause human, animal, or environmental harm. (134) Autism Part 3 will explore the link to other potential environmental factors that may contribute to the sharp increase in this disorder.

For a full report of all references, visit www.sccma-mcms.org, and click on the “Committees/Environmental Health” tab.

REFERENCES

1. Diagnostic change and the increased prevalence of autism.

King M. Int J Epidemiol. 2009 Oct;38(5):1224-34. http://www. ncbi.nlm.nih.gov/pubmed/?term=Diagnostic+change+and+the+ increased+prevalence+of+autism++King+Int+j+Epid 2. Autism spectrum disorders and prematurity: a review across gestational age subgroups. Mahoney AD. Adv Neonatal Care. 2013 Aug;13(4):247-51. http://www.ncbi.nlm.nih.gov/ pubmed/23912016 3. Risk for cognitive deficit in a population-based sample of U.S. children with autism spectrum disorders: variation by perinatal health factors. Schieve LA. Disabil Health J. 2010 Jul;3(3):202-12. http://www.ncbi.nlm.nih.gov/pubmed/21122785 4. Prevalence of autism spectrum disorder among children aged eight years – autism and developmental disabilities monitoring network, 11 sites, United States, 2010. MMWR Surveill Summ. 2014 Mar 28;63(2):1-21. http://www.ncbi.nlm. nih.gov/pubmed/24670961 5. The genetics of autism. Muhle R. Pediatrics. 2004 May;113(5):e472-86. http://www.ncbi.nlm.nih.gov/ pubmed/15121991

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.

UCSF Medical School – The Beginning

By Michael A. Shea, MD Leon P. Fox Medical History Committee The first medical school in California was not UCSF. That honor goes to the Medical Department of the University of the Pacific, founded in 1858 by Elias S. Cooper, MD. It was located in San Francisco (population 56,800), with the charter coming from the University of the Pacific, a Methodist Episcopalian college, founded in 1851, and located in San Jose.

The school, successful at first, faltered at the passing of its founder, Elias Cooper, in 1862.

It was at this time that a successful San Francisco surgeon, Hugh Toland, was putting together a new group of teachers in order to open another medical school. At this news, the Pacific Medical faculty “suspended” its function and joined the Toland group.

On November 1864, the Toland Medical school opened its doors at Toland Hall on Stockton Street, near Chestnut, opposite the San Francisco City Hospital. This school would later become UCSF. The dual faculty arrangement was rough from the start. In 1870, the Cooper faculty led by Dr. Levi Cooper Lane (Elias S. Cooper’s nephew) separated themselves from the Toland School. They started their own medical school, which ultimately, would become Stanford Medical School.

The Toland Medical School was successful from the onset. The first class consisted of eight students who attended two four-month lecture courses. This, plus a year of preceptorship, led to the degree of Doctor of

Medicine.

Tuition cost was $150. (This eightmonth curriculum gradually increased to four years by 1893).

Subjects studied were: anatomy, medicine, obstetrics and diseases of women and children, pathology, and chemistry.

Gross anatomy dissection, using H. Toland pauper cadavers, was available to the students when the state approved the dissection statute in 1864.

The medical school was granted entry to the San Francisco City and County Hospital in 1865, which allowed students access to a large volume of clinical experience. This relationship continues to the present day.

In 1869, the University of California opened its academic doors.

Dr. Toland immediately began a courtship of the University. He felt that the perpetuity of his medical school would require university affiliation.

Negotiations failed at one point, when the UC Regents rejected the name Toland Medical College. This stumbling block was overcome when the regents named a chair after Dr. Toland and, in 1872, the Toland Medical College became the Medical Department of the University of California.

Today, UCSF operates four major campus sites in San Francisco and one in Fresno.

In 2013, U.S. News and World Report ranked UCSF fourth among research and primary care medical schools. UCSF is the only medical school in the United States to be so ranked in both research and primary care. Dr. Hugh would be proud.

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 41

HUGH HUGER TOLAND (1806-1880)

Hugh Toland was born April 16, 1806, the son of a South Carolina planter and banker. At 16, he worked with a town doctor in the local apothecary shop. He graduated first in his medical school class at Transylvania University at Lexington, Kentucky. In 1832, he traveled to Paris for postgraduate study at the Salpetriere. The following year, he returned to Columbia, South Carolina, where he began a highly successful surgical practice. In 1852, California beckoned and he traveled to Mokelume Hill in Calaveras County, where he unsuccessfully pursued gold mining.

He relocated in San Francisco and set up his office at Montgomery and Merchant streets, where he became the cityâ&#x20AC;&#x2122;s foremost surgeon. A list of his accomplishments include: vesico-vaginal fistula repair, iridectomy for glaucoma, thyroidectomy, and repair of aneurysms. He founded Toland Medical College in 1864, and transferred the school to the University of California in 1872.

He was also known to send packages of medicine (Iodide of Potash for tuberculosis and other respiratory infections, and mercury with a dash of lobelia for syphilis), plus his advice via Wells Fargo messengers to the

miners in the Sierra foothills. Some criticized his mail order business, but his work as a serious surgeon and medical educator represents his important contribution to California medicine. He died suddenly at age 74 of a stroke, while still active in his Montgomery Street practice.

Parent-Based Prevention Research Study for Mothers with Eating Disorders

Stanford University Eating Disorders Program James D. Lock, MD, PhD Stanford University is conducting a study examining the feasibility and acceptability of a preventive intervention program; designed to improve child feeding in families in which the mother has an eating disorder.

Who can participate?

Adult mothers with children between the ages of 1 and 5 years old Diagnosis of Anorexia Nervosa, Bulimia Nervosa, or Binge Eating Disorder Living with a partner Medically stable for outpatient treatment Able to speak and read English Willing to be randomized to either treatment condition Able to make an 8 month commitment

How Can I Participate?

If you are interested in participating, or would like further information please contact Dr. Shiri Sadeh-Sharvit at (650) 497-4949; shiri_sade@yahoo.com 42 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

408 356-1212 www.edrcsv.org

NOW AVAILABLE

Authors:

From Medicine Man to Medical Doctor The Medical History of Early Santa Clara Valley

31 Chapters covering 110 pages of the local medical history from the Ohlone Period to the American Period • Origin of major Bay Area hospitals (SCVMC, O’Connor Hospital, San Jose Hospital, Agnews State Hospital, and more) • History of UCSF and Stanford medical schools and founders • Biographies of pioneer physicians (e.g., Benjamin Cory, John Townsend, John Marsh, Euthanasia Meade, Henry Warburton, and more) • Topics of interest (e.g., Trephination, Bloodletting, Gold Rush Medicine, Orificial Surgery, Cholera Epidemic of 1850, Famous Grizzly Bear Attack of 1854)

Michael A. Shea, MD; Gerald E. Trobough, MD; Elizabeth Ahrens-Kley

$19.95 incl. S&H FOR INQUIRIES/ORDERS – SEND CHECK TO: Michael A. Shea, MD 6807 Leyland Park Drive San Jose, California 95120 Email: md6996@sbcglobal.net Phone: 408/268-5820 All profits will be donated to the construction of the new medical museum at Santa Clara Valley Medical Center.

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 43

MEMBERSHIP

Welcome 94 SCCMA Members Santa Clara County Medical Association

Name Anuj Aggarwal Antonette Ajayi Derek Atkinson Erika Barbero Peter Binkley Dean Bowker Nicholas Breig Katherine Brooks William Brubaker David Chan Linda Chan Annie Chao Sandy Chen Daniel Cheng Tiffany Cheng Karen Chiu Erin Connor Cristina Cunanan Edward Damrose Robert Day Maryam Dolatshahi Priya Duggal Michelle Engle Alexander Ereso Jennifer Fraser Anna Harter Lisa Hisaw Sandra Hsu Kenneth Ike Emily Johnston Alexa Kaskowtiz Ahlia Kattan

City Specialty Santa Clara AN Santa Clara IM Stanford AN Sunnyvale US Gilroy P Stanford AN Santa Clara OFS Santa Clara US Menlo Park US Santa Clara IM Santa Clara IM Santa Clara US San Jose OPH Santa Clara IM Stanford AN Milpitas PD Stanford AN San Jose AN Stanford OTO Santa Clara OBG San Jose FP San Jose IM San Jose FP Mtn View FPS Stanford AN Stanford AN Santa Clara D Stanford AN Mtn View AN Menlo Park US Santa Clara OBG Stanford AN

Name Amir Kaykha Arieh Kestler Irina Khachatryan Cynthia Khoo Mary Kilkenny Chloe Kim Peter Kim Elizabeth Koch Arunima Kohli Merrit Koskelo Neil Lawande Eric Lee Frank Lee Joshua Lee Erica Lewis Michael Lin Max Liu Frank Longo Adam Luce Robin Matias Laura May Luke McCage Muniba Mohammed Christopher Mow Jason Nagata Heather Narciso Fathemat Nauzo Andrew Nevitt Quynh Nguyen Tuong Van Nguyen Mark Noller Grant Nybakken

City Specialty San Jose CD Mtn View *EM San Jose IM Stanford AN Campbell *OBG Santa Clara IM Santa Clara PN Stanford AN Santa Cruz US Campbell OBG San Jose AN Stanford AN Santa Clara P Mtn View IM Mtn View EM Stanford AN Stanford US Stanford N Menlo Park R Los Gatos PM Stanford AN Stanford AN San Jose IM Sunnyvale ORS Stanford US Santa Clara IM Santa Clara OBG San Jose EM Stanford AN San Jose OBG San Jose U Santa Clara PTH

Name Kelly O'Hear Patrycja Olszynski Marlen Pajcini Punam Patel Hung-Viet Pham Rett Quattlebaum Maya Ragavan Jason Reminick Frain Rivera Jordan Ruby Paul Russell Doris Sarni Kay Saw Neha Saw Austin Schwab Sam Shen David Shin Tajudzwa Shumba Bruce Silver Vanila Singh Amanda Smith Frank Stockdale Erica Timiraos Jimmy Ton Jason Tsukamaki Jessica Vaughn Jack Wang Catherine Xia Meghana Yajnik Catherine Yao

City Specialty Palo Alto IM Stanford AN Santa Clara R Santa Clara FP San Jose IM Palo Alto AN Stanford US Santa Clara AN San Jose AN Stanford AN San Jose PD San Jose P San Jose FP Stanford AN Stanford AN Stanford EM San Jose FP Palo Alto US Los Altos IMG Palo Alto AN San Carlos US Stanford ON San Jose EM Santa Clara IM San Jose EM Palo Alto IM Palo Alto US Campbell AN Stanford AN San Jose PD

*- Board Certified | US - Unspecified

Welcome 16 MCMS Members Monterey County Medical Society

Name Dan Anghelescu Shomir Banerjee Ruel Garcia David Gardner David Goldberg Christian Hansen

City Specialty Salinas DR Salinas FP Monterey GE Carmel PTH Monterey PS Carmel PTH

Name Francis Hardiman Brian Levitt Radhika Mohandas Huy Nguyen Khanh Nguyen Kenneth Nowak

City Specialty Aromas US Monterey GE Monterey FP Monterey GE Monterey GE Salinas OTO

US - Unspecified 44 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

Name Samip Patel Robert Sugar Steven Swengel Huy Trinh

City Specialty Carmel PTH Salinas AN Monterey D Monterey GE

Join Samaritan Internal Medicine

Premier community healthcare providers located in Northern California Samaritan Internal Medicine is

An exceptional practice opportunity awaits you at Samaritan Internal Medicine. Our group has been meeting patients’ needs for more than 30 years in the Silicon Valley.

We believe that excellent communication leads to excellent care and we are dedicated to the health and well-being of our patients and their families.

partnered with University HealthCare Alliance, Stanford Hospital & Clinic’s medical foundation. The structure allows for the preservation of a private practice environment while providing access to one of the world’s leading medical institutions.

JOIN OUR TEAM AND ENJOY •

Professional and personal life balance

•

Income guarantee and comprehensive

OPPORTUNITY - POSITION DETAILS

We are seeking a full-time Internal Medicine physician to begin work fall of 2014. Our office is located in San Jose, CA and we currently utilize Epic EHR. We are a 5 person medical group with 4 MDs and 1 NP/PA providing internal medicine services to our community.

benefits package •

Infrastructure that supports practice growth

•

Providing the most advanced care possible with enhanced quality and service

•

Contributing to SHC’s research, health education and community service mission

CONTACT

Angela Van Ginkel, MBA Manager, Provider Recruitment and Relations

tel: 650.725.1501 email: UHAProvider@stanfordmed.org

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 45

Classifieds OFFICE SPACE FOR RENT/ LEASE WHY ENRICH YOUR LANDLORD? • MEDICAL OFFICE SPACE – MTN VIEW

Rent/Buy/or Option to purchase 2,000 sq. ft. office with minor surgical suite in first class building within walking distance of El Camino Hospital. Full service lease, with or without furnishings. Call 650/961-2652.

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.

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 TO SUBLET • MTN VIEW

Mountain View medical office space to sublet. 1,100 sq. ft. Available three days a week.

In large medical complex, behind El Camino Hospital. Basement storage, untilities included.

Large treatment rooms, small lab space, BR, private office, etc. Call Dr. Klein at cell 650/2691030.

PERFECT SATELLITE OFFICE • MTN VIEW

Beautiful medical office across from Palo Alto Medical Foundation. Professional office with vaulted ceilings, new interior, digital x-ray, natural light, and Wi-Fi. Trained receptionist to

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE

MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS

Second story of professional building across from Salinas Valley Memorial Hospital. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $0.963/sq. ft.

Rent is $1,190/month. Contact Steven Gordon at 831/757-5246.

PRIME MEDICAL OFFICE FOR LEASE • SANTA CLARA

Ideal for medical, dental, physical therapy, optometry, office use. Approximately 1,700 sq. ft., near Santana Row. Excellent parking. Call owner at 408/858-9687.

Tracy Zweig Associates

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

A

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.

schedule patients, make reminder calls, collect paperwork and insurance info. Rent exam room one to five days per week, excellent office – low overhead. Call 650/814-8506.

REGISTRY

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PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

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 46 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

Locum Tenens ~ Permanent Placement V oice: 800- 919- 9141 or 805- 641- 9141 FA X : 805- 641- 9143

tzweig@tracyzweig.com www.tracyzweig.com

NO AVAIL W ABLE!

2014 Physician Membership Resource Directory ORDER YOUR COPIES TODAY! There are a lot of updates and changes in the new 2014 edition.

Make sure to order enough copies for you and your staff!

Contact Maureen Yrigoyen at 408/998-8850 today!

OFFICE SPACE FOR RENT • REDWOOD CITY

Doctor’s space for rent. Prime Redwood City location, one support staff member, new carpet and cabinetry, cleaning included. Call 650/365-1110.

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 e-mail riflovin@allianceoccmed.com for additional information.

INTERNAL MEDICINE PHYSICIAN NEEDED

JOIN SAMARITAN INTERNAL MEDICINE PREMIER COMMUNITY HEALTHCARE PROVIDERS LOCATED IN NORTHERN CALIFORNIA An exceptional practice opportunity awaits you at Samaritan Internal Medicine. Our group has been meeting patients’ needs for more than 30 years in the Silicon Valley. We believe that excellent communication leads to excellent care and we are dedicated to the health and well-being of our patients and their families.

Opportunity - Position Details

We are seeking a full time Internal Medicine physician to begin work fall of 2014. Our office is located in San Jose, CA and we currently utilize Epic EHR. We are a 5 person medical group with 4 MDs and 1 NP/PA providing internal medicine services to our community.

Join our team and enjoy: • • • •

Professional and personal life balance Income guarantee and comprehensive benefits package Infrastructure that supports practice growth Providing the most advanced care possible with enhanced quality and service • Contributing to SHC’s research, health education, and community service mission

CONTACT

Angela Van Ginkel, MBA Manager, Provider Recruitment & Relations 650-725-1501 UHAProvider@stanfordmed.org Samaritan Internal Medicine is partnered with University HealthCare Alliance, Stanford Hospital & Clinic’s medical foundation. The structure allows for the preservation of a private practice environment while providing access to one of the world’s leading medical institutions.

We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@gmail.com.

PART-TIME GENERAL DERMATOLOGIST NEEDED

Sunnyvale Dermatology (Dr. Bernard Recht) is looking for a part-time Dermatologist. We are a well established, busy office and we are looking for someone to work one to two days per week. Please email your CV to judy@sunnyvalederm.com.

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 47

MEMBER BENEFITS

New Programs and Benefits From IMQ IMQ 2014 MEDICAL STAFF CONFERENCE

The IMQ 2014 Medical Staff Conference is the essential learning experience for those facing the challenges of leading a medical staff. This one-day conference is a great chance for physicians to join other medical staff leaders in a one-day learning opportunity that provides a foundation of knowledge, techniques, and best practices to help them succeed. The conference covers practices for credentialing and privileging no-/low-volume practitioners, telemedicine and allied health professionals, and other common challenges. Expert faculty will cover the use of quality measures to make decisions, as well as the legal, regulatory, and human aspects of dealing with colleagues who are aging, disruptive, or impaired. In one day, attendees will gain insights to assist them in successfully leading a medical staff, and in doing so, comply with key accreditation, licensure, and legal requirements. The IMQ 2014 Medical Staff Conference will take place October 30, 2014, at the Embassy Suites Waterfront Hotel in Burlingame, CA (near San Francisco International Airport). For more information, visit www.IMQ.org.

CME CERTIFICATION ONLINE

Users of IMQ’s CME Certification Services are now able to view their transcripts online—anytime, anywhere! This new CME Certification user benefit allows users to check the status of CME credits, keep track of their progress, and print their transcripts at their convenience. The CME Certification user portal is located on the CME Certification page of the IMQ website: http://imq.org/ContinuingMedicalEducation/CMECertification. aspx.

IMQ ONLINE EDUCATION

IMQ has added new courses to its IMQ Online Education platform— new courses cover patient safety, using CME as an organizational improvement, dealing with issues of physicians who are aging, disruptive, or impaired, a variety of clinical issues, and more. IMQ Online Education offers physicians the chance to earn AMA PRA Category 1 CreditTM at their own convenience, and to access CME courses at any time and from any Internet-enabled device. To explore the full selection of available courses, browse at www.imq.inreachce.com.

IMQ EXPANDS PEER REVIEW SERVICES

Does your medical staff need help with peer review? The Institute for Medical Quality is expanding its services to include Clinical Case Review of individual cases and Judicial Review services in addition to our existing Comprehensive Peer Review services.

Through off-site patient chart review, an IMQ Clinical Case Review consultation provides an objective evaluation of the clinical practice of one or more physician members of a hospital medical staff, physician group, or ambulatory care practice through peer review of selected cases. IMQ’s involvement is especially helpful when an organization will benefit from expert review of one or more patient cases, but needs physicians of the appropriate specialty who have no real or perceived conflicts of interest.

Additionally, IMQ is seeking physicians to support this expansion of services. For more information about any of IMQ’s peer review services, or about becoming a physician reviewer, please contact Julie Hopkins at 415/882-5165 or jhopkins@imq.org.

In Memoriam Robert Armstrong, MD

Bulent Jajuli, MD

John E. Marlow, MD

*Infectious Disease 7/22/38 – 6/17/14 SCCMA member since 1972

Internal Medicine 3/2/20 – 4/1/14 SCCMA member since 1972

Family Medicine 11/15/26 – 7/31/14 SCCMA member since 1963

Robert C. Drye, MD

Robert Jelinek, MD

Richard Ziegler, MD

*Psychiatry 10/1/27 – 4/28/14 MCMS member since 1971

Anesthesiology 1/4/26 – 3/21/14 SCCMA member since 1958

Internal Medicine 3/14/31 – 5/15/14 SCCMA member since 1962

48 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 49

50 | THE BULLETIN | SEPTEMBER / OCTOBER 2014

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

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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.

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SEPTEMBER / OCTOBER 2014 | THE BULLETIN | 51

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