CFP Magazine (Spring 2013)

California

FAMILY PHYSICIAN Vol. 64 No.2 Sp ring 2013

Meet Your New PreSIdeNt...

MArk dreSSNer, Md, Med

18

eNd oF LIFe ISSueS

20

TAxING LIquID CANDY TO BENEFIT CHILdreN’S HeALtH

22

LESSONS FROM AN IN-FLIGHT EMERGENCY wHAt wouLd You do?

24

FIvE THINGS PHYSICIANS AND PATIENTS SHOuLD quESTION

26

CAFP’s Incoming President Mark dressner, Md with his partner Matt davis, Md and their son trevor

CAlIFoRNIA ACADEMY oF FAMIlY PHYSICIANS FoUNDATIoN 1520 PACIFIC AVE SAN FRANCISCo, CA 94109 -2627

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2 California Family Physician Spring 2013

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Call 877-453-4486 or visit norCalmutual.Com Proud to support the California Academy of Family Physicians Our passion protects your practice

California Family Physician Spring 2013 3

1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org

Officers and Board

Staff

President Steven Green, MD

Allison Bauer

Sophia Henry

President-Elect Mark Dressner, MD

abauer@familydocs.org

shenry@familydocs.org

Immediate Past President Carol Havens, MD

Manager, Medical Practice Affairs

Speaker Delbert Morris, MD

Manager, Communications and Website

Jane Cho

jcho@familydocs.org Adam Francis

Associate Director, Membership and Marketing

Susan Hogeland, CAE

Executive Vice President

shogeland@familydocs.org Jerri Davis, CCMEP

Senior Manager, CME/CPD

Callie Langton, PhD

CAFP-F Executive Director, Director, Health Care Workforce

clangton@familydocs.org Cody Mitcheltree

Student, Resident and Social Media Manager

cmitcheltree@familydocs.org

afrancis@familydocs.org

Cynthia Kear, MDiv, CCMEP

Leah Newkirk Director, Health Policy lnewkirk@familydocs.org

Secretary/Treasurer Lee Ralph, MD

Heather Hayes

ckear@familydocs.org

Shelly Rodrigues, CAE, FACEHP

Executive Vice President Susan Hogeland, CAE

hhayes@familydocs.org

Vice-Speaker Jay Lee, MD, MPH

Foundation President Jimmy H. Hara, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Ashby Wolfe, MD, MPP, MPH Nathan Hitzeman, MD Michelle Quiogue, MD Suman Reddy, MD Kevin Rossi, MD Patricia Samuleson, MD

Deputy Director, Government Affairs

Receptionist and Membership Assistant

jdavis@familydocs.org Senior Vice President

Deputy Executive Vice President

srodrigues@familydocs.org Kelly Goodpaster

Manager, Financial Services

kgoodpaster@familydocs.org

California FAMILY PHYSICIAN Quarterly publication of the California Academy of Family Physicians

• Julia Blank, MD • Nathan Hitzeman, MD

Michelle Quiogue, MD, Editor Shelly Rodrigues, CAE, Managing Editor Communications Committee: Michelle Quiogue, MD, Chair • Jeffrey Luther, MD • Jay Mongiardo, MD

The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year.

Call 415-345-8667 to subscribe.

• Albert Ray, MD

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Looking for a job?

Go to www.fpjobsonline.com where you can: • search jobs for free • post a résumé • be visible to employers • receive e-mail alerts of new job postings Questions? Call 888-884-8242and a HEALTHeCAREERS representative will help you.

4 California Family Physician Spring 2013

P u b l i c H e a lt H a n d Y o u

18 Meet Your New President … Mark Dressner, MD, MEd

An interview with CFP

20 End of life Issues

Bo Greaves, MD

22 Taxing Liquid Candy to Benefit Children’s Health 24 Lessons from an In-Flight Emergency … What Would You Do?

Lenny Lesser, MD Richard N. Gray Jr., MD, FAAFP, DABFP ABFM and AAFP

26 Five Things Physicians and Patients Should Question

6

Editorial

Raise Your Voice on Public Health Issues

Michelle Quiogue, MD

7

President’s Message

We Need to Accept, and Embrace, the Leadership Challenge

8

In the News

Congress of Delegates Update

9

Resident News

Scripps Family Medicine Residency: Making a Public Health Impact through School-Based Programs

Steven Green, MD

Ruth Morgan, MD PGY3

11 PCMH Corner

New Medicare Codes Support the Patient Centered Medical Home

14 Political Pulse

2012 Election Yields Big Wins for Family Physicians and Patients Ashby Wolfe, MD, MPP, MPH

16 Foundation News

CAFP Foundation Update: Investing in our Future!

17 Public Health and You

Dense Breast Notification: Increased Awareness or Frightening Women?

30 Executive Vice Presidents Forum

Where Is the Line between Public Health and Public Policy?

Leah Newkirk

Jimmy H. Hara, MD Lisa Ward, MD Susan Hogeland, CAE

For the upcoming CME calendar go to www.familydocs.org California Family Physician Spring 2013 5

Michelle Quiogue, MD

editorial

Raise Your Voice on Public Health Issues At this year’s CAFP Congress of Delegates, Presidentelect Dr. Mark Dressner spoke of the daily tragedies that continue to occur at the hands of a dysfunctional health care system. His stories of the uninsured underscore the need to continue the work on behalf of all our patients to improve the system.

To share this vision of the possible future serves as a light at the end of the tunnel and provides hope through times of struggle. During the first weekend of February, I had the opportunity to work with family physicians from across the country on the AAFP’s mission to improve the health of patients, families and communities by serving on the AAFP Commission on Health of the Public and Science (CHPS).

these policies can be found on the AAFP website.) Family physicians’ concern about access, quality and reimbursement of mental health services have long been part of AAFP policy as well. Discussion at this year’s meeting included views from across the country and the political spectrum. You should expect to hear the official statement from the AAFP soon.

Yet gun violence is just one aspect of public health. The commission also discussed the March 2012 Institute of Medicine (IOM) report Primary Care and Public Health: Exploring Integration to Improve Population Health. The Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) The aim of CHPS is to provide leadership in health promotion, disease have requested that the Institute of Medicine examine practices that prevention and chronic disease manwould help public health departments and agement. Members are involved in primary care groups engage community, AAFP activities to promote smoking align leadershi, and establish sustainable cessation, active lifestyles and iminfrastructure. Integration of data and munizations. Members also represent analysis could target maternal and child the AAFP at national organizations health, cardiovascular disease prevention The dramatic rise in health such as the Agency for Healthcare and colorectal cancer screening. Already in Research and Quality (ARHQ), the midst of a workforce shortage, many care costs has aligned United States Public Health Task Force are wondering how to increase capacity opposing stakeholders and (USPTF), Advisory Committee on and still deliver improved quality outImmunization Practices (ACIP) and comes. Traditionally, outreach and home primed them to embrace the American College of Physicians visits have been the work of public health innovation.

(ACP) Choosing Wisely Campaign. while panel management and chronic This work, as well as periodic review disease registries have been the work of of current policies, is divided into four primary care offices. What is the potential subcommittees and one work group of integrating these systems toward the within CHPS: the Subcommittee on common goal of population health?

Clinical Preventive Services (SCPS), the Subcommittee on Public Health Several factors are fanning the flames to Issues (SPHI), the Subcommittee on Clinical Practice Guidelines (SCPG), catalyze integration. The dramatic rise in health care costs has aligned the Subcommittee on Health Equity (SHE) and the Opioid Abuse/Pain opposing stakeholders and primed them to embrace innovation.

Management Work Group. A large proportion of the full commission Health research continues to clarify the importance of social and envimeeting this year was spent discussing gun-related violence prevention ronmental determinants of health and the impact of primary prevenand the integration of public health with primary care. tion. An unprecedented wealth of data provides new opportunities to understand community health. Family physicians already are often We are not new to this issue. In 1987, our academy developed policy straddling the two worlds of public health and primary care in comto recognize violence as a public health issue. More than 10 years ago, munities. in response to the school shooting at Columbine High School, the AAFP developed an evidenced-based position paper to oppose violence Like Dr. Mark Dressner, each of us has stories to tell about the social in all forms of media. We have supported efforts to evaluate the efdeterminants adversely affecting our patients’ health. There are limits fectiveness of strategies to prevent gun-related injuries and fatalities, to what can be accomplished during an office visit or with a prescripto oppose the private ownership of assault weapons, and to support tion pad. To continue the progress away from our sick-care system, enforcement of existing gun control laws since 1995, and this policy family medicine should seek ways to extend its reach into communities was reaffirmed at the 2011 AAFP Congress of Delegates. (Details of through collaboration with local public health departments.

6 California Family Physician Spring 2013

President’s message

Steven Green, MD

We Need to Accept, and Embrace, the Leadership Challenge 2014 is quickly approaching, and with it will come changes in how health care is paid for and how it is delivered. Innovation will be necessary to meet the challenges

ahead. As family physicians we have an opportunity to take a leadership role.

Some patients would rather not come to our offices at all. They may have medical concerns they would like addressed over the phone, or by videoconference or even text. Telehealth will never completely replace the office visit, but it could replace many of our visits. Do we really need to make patients come into our office to discuss their diabetes results every time? We may need to double check the blood pressure or foot exam, but probably not at every encounter.

In less than two years, several million more previously-uninsured Californians will have health care coverage, some through an expansion of the Medi-Cal program and some through the newlyLarge employers have realized it is expensive for their workers to take formed health exchange. These newly-insured will likely have more off mid-day and go slug it out at our offices. By the time the patient needs than the average person, because they previously have been has driven there, parked, checked in, waited, waited some more, unable to afford all but emergent care. The steady aging of our been evaluated, checked out, and driven back to work, hours have population only compounds elapsed. Some companies are going this challenge. As Californians around us, hiring nurse practitioners age, their medical needs or physicians to work on-site, making increase. As if this were not it convenient for the employee to walk enough, many older family over and be seen quickly, minimizing lost physicians are nearing productivity.

The challenge for family retirement during the next decade, so the supply of family By now, hopefully everyone reading physicians is to become physicians is unlikely to rise to this has heard of the Patient Centered leaders in embracing new match the need for primary Medical Home (PCMH). It’s hard to argue care services. against the elements of it – Team-based models of care and innovators care with everyone working at the top in meeting the needs of our It is clear we will not be able of their licensure. It makes sense that to practice in a “business as physicians should be spending their time patients, now and in the usual” mode and still meet the doing things that require their advanced future. increasing health care needs of level of training, rather than tasks our patients. Simply tightening that others could be doing. Electronic our belts and working harder health records are rapidly becoming a and faster is not the answer, requirement just to be in the game. No when many family medicine one will tolerate illegible, cryptic notes physicians are already working anymore. at maximum capacity.

This will be a bigger challenge for our small group and solo practices, Patients are demanding convenience. Retail clinics staffed by nurse yet it must happen. We must adopt registries that allow us to practitioners are springing up in our communities. While we may reach out to patients to manage their chronic disease and provide not like this change and its potential for fragmented care, it is here preventive care. For example, if we wait for every patient over age 50 for a reason. Patients want affordable and convenient care. They to come in and ask for colon cancer screening, it will be a long wait. want to pick up eggs and milk and have their sore throats looked at We must reach out to them and educate them about what is needed. all in the same trip, even on evenings or weekends. Our offices may Team-based care with pharmacists, chronic care nurses, dietitians and never be able to compete with this level of convenience, but we must others will not only improve care, but will also allow us to manage acknowledge that our patients want it. We must do what we can to more people and better meet the upcoming demand for more care. meet that need. Evening and weekend hours may not be popular with many of us, yet if we are to be successful in meeting our patients’ The challenge for family physicians is to become leaders in embracing needs, we will have to consider them. new models of care and innovators in meeting the needs of our patients, now and in the future.

California Family Physician Spring 2013 7

in tHe neWs

in tHe neWs

Congress of Delegates Update Such as New Chair...

The big news from the March 2-3, 2013 CAFP Congress of Delegates is final approval of CAFP Bylaws revisions to enable the transition an All Member Advocacy Meeting (AMAM) in 2014.

So … the first All Member Advocacy Meeting will be held in Sacramento at The Citizen Hotel Saturday and Sunday, March 1-2, 2014 followed by our Lobby Day in Sacramento on Monday, March 3. This meeting will be open to all CAFP members, regardless of whether they are Delegates or Alternates from their respective county chapters, and the primary purpose of the new meeting format will be to transform standard issue, dedicated, socially-minded family physicians into SUPER STAR ADVOCATES FOR THEIR SPECIALTY AND PATIENTS! Delegates and Alternates will continue to play an important role at the Congress.

They will elect CAFP officers and oversee policies approved by the Board of Directors during the course of the year.

But the AMAM will be designed to expose family physicians, students and residents to the key issues confronting health care, offer stories from physicians who’ve become active advocates themselves (such as no- chair of the Assembly Health Committee, Assemblymember Richard Pan, MD) and provide the training tools needed to cross the advocacy Rubicon (i.e., a line that when crossed commits a person irrevocably!).

Don’t let your colleagues have all the fun – join them in Sacramento at the all-new All Member Advocacy Meeting Saturday and Sunday, March 1-2, 2014 followed by our Lobby Day in Sacramento on Monday, March 3.

8 California Family Physician Spring 2013

CAFP President Steve Green presented CAFP’s 2013 Family Medicine Champion award to Dr. Richard Pan.

PRIMARY CARE UPDATE IN UROLOGY A COMPLIMENTARY CME PROGRAM PRESENTED BY THE AMERICAN UROLOGICAL ASSOCIATION

REGISTRATION IS FREE. Saturday, May 4, 2013 7 a.m. - Noon

COURSE LOCATION San Diego Convention Center

111 West Harbor Drive San Diego, CA 92101

We invite you to attend this complimentary CME activity with the latest research from expert urologists on the urologic issues most relevant to front-line patient care. Topic areas: • Hypogonadism

• Urologic Emergencies

• Overactive Bladder (OAB)

• Benign Prostatic Hyperplasia (BPH) Visit www.AUAnet.org/PCUSD for detailed program information or to register.

Ruth Morgan, MD, PGY3

resident neWs

Scripps Family Medicine Residency: Making a Public Health Impact through School-Based Programs The Scripps Family Medicine Residency Program is a communitybased program located along the California and Baja California border region. Our residents and faculty are concerned about the health disparities facing our patients: diabetes, obesity and lack of community resources. Our residency has responded by implementing a variety of school-based programs ranging from school-based clinics to health education programs, many of which started as Community Oriented Primary Care (COPC) projects.

School-Based clinics: School-based clinics are a proven health care model shown to be effective in providing health care services to adolescents. We staff three different high school clinics: Southwest, Hoover, and Palomar. This system gives our student patients access to medical and confidential resources at their school site. Our clinic at Southwest High School operates as a satellite clinic of the San Ysidro Health Center, providing those students with seamless continuity of care. The majority of these adolescents are uninsured or underinsured, and our clinics are the only place where they easily access medical care or counseling.

5-2-1-0 – A Healthy Weight Message: 5-2-1-0 messaging is

a well documented, nationally-proven program that originated in Maine and represents the recommendation to: consume 5 fruits and vegetables, use less than 2 hours of recreational screen time, have 1 hour of physical activity and consume 0 sweetened beverages every day. The residency program has incorporated this message in the continuity clinic as part of quality improvement activities. The residency has also collaborated with a local elementary school to support campus-wide 5-2-1-0 wellness efforts for staff, students and parents. A resident COPC project targeting childhood obesity incorporated the 5-2-1-0 message into basic nutrition and exercise activities with fourth and fifth graders within the physical education curriculum. The main goal is to provide students with the skills, knowledge and confidence to create goals and maintain healthy habits. The next COPC project will build on the 5-2-1-0 messaging and incorporate pedometers into the physical education curriculum to encourage students to increase their daily steps.

Mentoring: The Scripps residency works closely with the San

Diego Border AHEC (Area Health Education Center) to provide mentoring opportunities for several high schools in our community.

A classroom-based curriculum initiated several years ago as a Community Oriented Primary Care (COPC) project by a resident who attended Castle Park High School is sustained through residency leadership. Acknowledging the correlation between education and health, residents volunteer to mentor at least one student. Many of these students will be the first in their families to graduate from high school and may have a strong interest in going to college. Residents meet regularly with their mentees to set goals and support the students’ future successes. We assist with SAT planning, college and scholarship applications and provide workshops on health careers. Many students also participate with our residents in the health care exploration program at Scripps Mercy Hospital Chula Vista, sponsored by AHEC. Since its initiation, many students we have mentored have gone on to college and are pursuing careers in the health field.

Nutrition in Cooking Classes: The Nutrition in Cooking Classes

at the area high schools have included both teens and parents.

With the support of the culinary arts teacher and the principal at Palomar High School, this program has been sustained through incorporation into the culinary arts curriculum. Students learn about the health benefits of nutritious foods, the link between unhealthy diet and diseases such as diabetes and cardiovascular disease and skills for healthy cooking. Through pre- and posttesting, residents have found both an increase in students’ nutritional knowledge as well as behavioral changes in which many students have increased their intake of fruits and vegetables over the course of the classes.

Dr. Morgan works with students in a cooking and nutrition class.

Sports Medicine: Partnering with local family and sports

medicine doctors, we participate in football game coverage for Castle Park High School. Working with a team physician and trainers, we go to home and away games and experience real sideline medicine, including on the field evaluation and decisionmaking. During the fall sports season, we also work with the San California Family Physician Spring 2013 9

resident neWs Diego Sports Medicine Foundation (SDSMF), which operates a sports injury clinic for San Diego high school students. Residents work with local sports medicine doctors and fellows, orthopedists and physical therapists to provide free sports injury assessment and treatment for high school athletes and learn about the proper initial treatment of sports injuries. We also partner with the SDSMF and local high schools to provide preparticipation sports screening events. Each year, more than 800 students are screened by residents and faculty prior to participating in school sports.

Through our school-based programs, our residency program continues to build strong relationships with our community and to meet its health needs. We have collaborated with school administrations, staff, nursing and community partners to create unique opportunities to work with K-12 students to educate, mentor and inspire.

16th Annual California Health Care Leadership Academy

May 31 - June 2, 2013 • Planet Hollywood, Las Vegas Welcome to the era of health reform. Increasing demand for services. Intensifying pressure for cost and quality accountability. Small practices joining larger groups seeking safe harbor. Undercapitalized medical groups sinking.

Hospitals and health plans acquiring practices in a “vertical integration” (consolidation?) of the health care market.

Can physicians control their own destiny – and the future of medical practice?

Hear from experts and leaders of change and attend a comprehensive slate of practice management seminars and workshops to position your practice for success.

Early-Bird and Multiple Registration Discounts Save up to $200 per person when you register before May 3!

Register at 800.795.2262 or caleadershipacademy.com 10 California Family Physician Spring 2013

PcmH corner

Leah Newkirk

New Medicare Codes Support the Patient Centered Medical Home The Patient Centered Medical Home (PCMH) ensures care is organized across all elements of the broader health care system, including non-primary specialty care, hospitals, home health care and community services. The PCMH also ensures

that chronic illnesses are managed through proactive identification, creation of care plans, use of new provider team members such as complex case managers and more. Historically, this kind of coordination and care management went uncompensated, incentivizing providers to put it on the back burner in favor of other, compensated services. In 2013, however, this work of the PCMH is recognized by a very powerful payer: the federal government.

Two new sets of Medicare’s Current Procedural Terminology (CPT) codes recognize care coordination and care management. CAFP applauds these additions to Medicare’s CPT codes. They compensate primary care providers for important care coordination and management services in the PCMH and they are likely to have an influence on private payers, who are already moving toward payment for these types of services.

The first set of codes (CPT Codes 99487 - 99489) is for Complex Chronic Care Coordination (CCCC) services. These new CPT codes are for care coordination provided by physicians, other qualified health care professionals and clinical staff to patients with complicated, ongoing health issues living at home or in a domiciliary, rest home or assisted living facility. Patients needing care coordination often have multiple providers treating multiple chronic illnesses and may have significant functional deficits. CCCC codes were created so physicians and other qualified health care professionals could bill for time spent coordinating different services and specialists to better manage the complex nature of these patients’ medical conditions, psychosocial needs and activities of daily living.

99487 Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month.

99488 Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month.

99489 Complex chronic care coordination

services; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

The CCCC services described by these codes involve clinical staff implementing a plan of care established and directed by a physician or other qualified health care professional.

These codes include all non-face-to-face CCCC services and may include one face-to-face office or other outpatient, home or domiciliary evaluation and management visit related to care for the patient’s chronic conditions.

The second set of codes (CPT Codes 99495 and 99496) recognizing the work family physicians do in a PCMH is for Transitional Care Management (TCM) services. The TCM codes are meant to improve care coordination and provide better incentives to ensure patients are seen in physicians’ offices after hospitalization, in order to reduce the risk of readmission. TCM services are for established patients whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care. TCM services address any needed coordination of care performed by multiple disciplines and community service agencies.

California Family Physician Spring 2013 11

PcmH corner

PcmH success stories!

99495 Transitional care management

services (moderate complexity); communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days post-discharge; medical decision making of at least moderate complexity during the service period; and face-to-face visit, within 14 calendar days post-discharge.

99496 Transitional care management services (high complexity); communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days post-discharge; medical decision making of high complexity during the service period; face-to-face visit, within seven calendar days post-discharge.

More information about these two sets of codes can be found in CAFP’s Strategies for Coding, Billing and Getting Paid Appropriately, 2013 Supplement. The AAFP has created additional resources to help members get comfortable assimilating the new codes into their billing processes, including a frequently-asked-questions (FAQ) document on the TCM codes and a transitional care management 30day worksheet designed to help family physicians log important information in patients’ transitional care summaries.

While CAFP applauds these additions to Medicare’s CPT codes, we see the limitations of this kind of piecemeal approach and will continue to advocate for broader payment reform that supports the PCMH model. Medical home payment should be designed to reward the provision of the right care in the right setting and should not encourage the delivery of too much (i.e., fee-for-service) or too little (i.e., capitation) care. Payment should encourage appropriate management of complex medical cases, increased access, patient outcomes measurement, continuous care quality improvement and comprehensive integration and coordination across all stages and settings of a patient’s care.

California family physicians can contact CAFP’s Director of Health Policy, Leah Newkirk, at cafp@familydocs.org or 415.345.8667 with any questions.

12 California Family Physician Spring 2013

My Health Medical Group of San Francisco and CAFP’s Fresno PCMH Initiative CAFP presented the 2013 Patient Centered Medical Home Practice of the Year award to My Health Medical Group of San Francisco, in recognition of its work in delivering patient-centered care, quality improvement, care management and patient outreach efforts, all in the service of achieving superior health outcomes. CAFP member Lawrence Shore, MD, accepted the award on behalf of the medical group on Sunday, March 3, at the CAFP Congress of Delegates meeting in Sacramento. Dr. Shore also announced during his Town Hall session update on progress his medical group had made toward transforming to the Patient Centered Medical Home model that it had successfully achieved Level 3 recognition from the National Commission on

Quality Assurance just a few days before.

CAFP’s Fresno PCMH Initiative – a collaboration of CAFP, Fresno Unified School District and Fresno family and other primary care physicians’ Community Medical Providers (CMP) to use the PCMH model to strengthen primary care, generate savings, manage chronic illness and implement technology to improve quality and generate efficiencies – is showing early success. The official start of the pilot was July 1, 2012. At that point Fresno Unified began measuring CMP practices on the defined clinical, process, cost and patient satisfaction pilot metrics.

Also at that point, Fresno Unified began compensating the CMP practices for their participation.

With data in for the first six months, the CMP practices are demonstrating improvement on every measure and seem to be realizing a 10 percent savings over costs compared to controls.

Family Practice Physician in Peoria, Arizona Family practice physician in Peoria, Arizona.

Opportunity for ownership after a year.

Extremely competitive pay and extensive benefits.

Full or part-time.

Brand new state-of-the-art facility.

Please email CV to narana@pps247.com or call 602-685-9500

PHYSICIAN — FULL-TIME OR PART-TIME for MED7 Urgent Care Centers.

Urgent care clinics are located in Roseville, Carmichael, Folsom & North Sacramento. Board Certified or Board Eligible in family practice or emergency medicine.

All shifts 9am to 9pm. Full time is 13 shifts per month. We offer our full time physicians the following: full malpractice coverage, medical & dental coverage at no cost for the physician & any dependents, disability policy & we have a simple IRA you can contribute to with 3% matching. Part time is 6 to 8 shifts per month. There is no call. There is no tail coverage that needs to be purchased should you leave our employment. We have a single policy that continues on after you leave.

If something were to arise here after you left our employment, you would be covered.

For more information about MED7 and our clinics please visit our website: www.med7.com We offer an attractive compensation package.

Contact Merl O’Brien,MD, at: (916) 483-5400, ext.111; or email CV to: sherry@med7atwork.com.

10Th ANNUAl CApg hEAlThCArE CoNfErENCE

RefoRm, InnovatIon & accountabIlIty

The FuTure Is Now JUNE 6-9, 2013 JW marriott at l.a. live in doWntoWn los angeles

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University of California • Irvine Faculty Position

Family Medicine & Geriatrics in Orange County, CA The University of California, Irvine Department of Family Medicine & Geriatrics, has openings for board-certified/eligible family physicians to join the UC Irvine faculty in the Health Sciences Clinical series at the Assistant, Associate, or Professor level. We are seeking qualified individuals with a strong commitment to teaching of medical students, & residents.

DUTIES: Ambulatory practice which includes direct patient care, residency teaching, medical student teaching and inpatient service coverage. Obstetrical and procedure skills desirable.

REQUIREMENTS: American Board of Family Medicine certified or eligible, excellent clinical skills, interest in clinical teaching, eligible for UC Irvine Medical Center medical staff privileges, and proven leadership skills. Bilingual in either Vietnamese or Spanish desirable. Academic rank and salary are commensurate with experience. Applications will be considered until the positions are filled.

TO APPLY: Please log onto UC Irvine’s RECRUIT located at https://recruit.ap.uci.edu/apply/ or email tarslani@uci.edu Contact: Taleen Arslanian (714) 456-7081 UC, Irvine is an equal opportunity employer committed to excellence through diversity.

California Family Physician Spring 2013 13

Political Pulse

Ashby Wolfe, MD, MPP, MPH

2012 Election Yields Big Wins for Family Physicians and Patients The 2013-14 Legislative Session is upon us and CAFP has begun a full-fledged advocacy effort in support of our two sponsored bills. The CAFP Board of Directors directed our

Government Affairs department to support the Patient Centered Medical Home and the family physician workforce in California.

CAFP is doing exactly that.

AB 1208 –The Patient Centered Medical Home Pediatrician and Chair of the Assembly Health Committee Richard Pan, MD (D – Sacramento) has agreed to author CAFP’s sponsored bill to define the Patient Centered Medical Home (PCMH), AB 1208. CAFP is excited to have a primary care physician champion one of our top priority bills this legislative session. Last year’s author, Senator Ed Hernandez (D – West Covina), remains supportive of the PCMH, but given his many priorities this year, agreed to Dr. Pan’s taking up the mantle. The bill was vetoed last year by the governor with an enigmatic veto message stating that the PCMH is an “evolving concept.” Those of us who have supported the PCMH model beg to differ. Over the next several weeks, CAFP will continue its meetings with the Department of Health Care Services and the governor’s office to grow their understanding of the PCMH generally and our bill specifically. We will also work with the many supporters of the bill to convince the governor that the time has come for his administration to support the PCMH and get the ball rolling in California.

AB 1176 – Primary Care Access and Graduate Medical Education Funding With millions of newly-insured individuals expected to enter the health care system in the next few years, California must take immediate action to address short- and long-term primary care workforce shortages. There is no better solution than increasing primary care residency slots in underserved areas. California can gain an immediate return on investment, drawing physicians to practice in areas where they are needed most and providing an average of 600 additional patient visits per physician per year during training alone. This would also significantly grow our long-term workforce as the vast majority of physicians who train in a region stay in that area to practice. Authored by Assemblymember Raul Bocanegra (D – San Fernando), AB 1176 will follow the example of other states and create a funding source for underfunded medical residency training programs.

A funding pool that draws from private payers, such as health insurance companies, can focus on creating residency slots in geographic areas and specialties of need and provide more flexible funding to support education in community-based specialties. Because many residency training programs serve underserved populations, they are a crucial source of primary 14 California Family Physician Spring 2013

care for these communities. Additional funds will stabilize and expand medical residency training in California, helping to ensure that every Californian has access to a physician when and where they need one.

Other Priority Legislation CAFP is also participating in the debate around other major legislative issues, including: • Funding for CURES: The Controlled Substance Utilization Review and Evaluation System (CURES) tracks patients’ prescription drug history in an effort to curb illegal sales and misuse of prescription medication. California’s recent budget deficits led to the program’s near demise; it is currently operated by one full-time employee. Proposed legislation would fund the program through one-time and/or ongoing fees on health plans, workers’ compensation insurers, drug manufacturers, physicians, pharmacists, dentists and other drug prescribers. It would also create two criminal enforcement teams to investigate suspicious prescribing patterns. It will be important to find a balance between protecting patient access to treatment and ensuring bad actors are caught.

• Scope of Practice Expansion for Nurse Practitioners, Pharmacists and Optometrists: With millions of newly insured Californians expected in coming years, these three particular provider groups are seeking to expand their scope of practice, including possibly the pursuit of independent practice. CAFP believes no matter what changes are proposed, patient safety must be the highest priority. CAFP also believes the focus should be on ensuring the most efficient, effective health care teams possible and avoiding the creation of silos of care.

Dr. Wolfe is Chair, CAFP Legislative Affairs Committee.

CAFP was out in force in Sacramento during Lobby Day on March 4.

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California Family Physician Spring 2013 15

Foundation neWs

Jimmy H. Hara, MD

CAFP Foundation Update: Investing in our Future!

Challenges in the delivery of medicine make for compelling, yet depressing, headlines in mainstream news.

Complaints about the payment gap between primary and non-primary care providers and the primary care physician shortage would lead you to believe that no one in his or her right mind would want to go into family medicine.

the family physician pipeline – consider making a tax- deductible contribution to the CAFP Foundation today!

Your support is what makes the work we do

But, you would be wrong! I think the people we want ARE entering family medicine.

Students are entering medicine, and they are selecting family medicine. They are selecting family medicine despite being told they are “too smart to be an FP,” and despite the deadlines about payment, hassles and lifestyle challenges.

At the recent CAFP Congress of Delegates, in the middle of a room filled with practicing family physicians were three tables of students and residents – passionate students and residents. I saw many familiar faces—students who have attended the Foundation’s annual Family Medicine Summits and participated in our Preceptorship Program as first year medical students, and residents who have represented California’s family physicians in state and national advocacy work. We also welcomed some new students and residents to their first CAFP event, and it is safe to say they will be back. It is gratifying as president of the Foundation to see our family medicine workforce pipeline strengthened by the inclusion of so many passionate, articulate students and residents. The Foundation’s work, focused on building a robust family physician workforce in California, has made this possible.

With your assistance, California has become a leader in student and resident retention, retaining 69 percent of residents who train in our state. CAFP has also increased student and resident membership rates significantly over the previous few years, in part due to Foundation programming supported by our generous donors.

We hope you will join us on this journey to bring passionate students and residents into 16 California Family Physician Spring 2013

with students and residents possible. We welcome your contribution at any level.

We welcome your contribution at any level.

Our best wishes to you for 2013!

Thanks to the California medical students and residents who attended the CAFP’s March COD.

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Lisa Ward, MD, New Physician Director

Dense Breast Notification: Increased Awareness or Frightening Women?

Federal law requires that all patients receive breast imaging results. On April 1, 2013, California’s breast density notification law goes into effect requiring additional language to inform women of the density of their breasts and how this density may impede a diagnosis of breast cancer.

This new California law requires that health facilities that perform mammography include additional information to patients categorized as having heterogeneously dense breasts or extremely dense breasts.

The breast density categorization is based on the Breast Imaging Reporting and Data System established by the American College of Radiology.

When facilities send mammography results to these patients, the letter will now include the following notice: • Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer.

• This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.

The law was authored by State Senator Joe Simitian (D-Palo Alto) and signed into law by Governor Jerry Brown in 2012. California is the fifth state to adopt a breast density notification law, joining Connecticut, New York, Texas and Virginia. Before the bill was signed into law, many family physicians and other health care providers voiced concern about the unintended consequences of this type of notification. The California Academy of Family Physicians joined a large coalition of health care groups asking for amendments to the bill. While the bill passed, the coalition’s amendments softened some of the language in the original legislation.

Family physicians, internists and women’s health providers of all stripes are now positioned to discuss the information about dense breasts and screening options with their patients. How prepared we are for both the frequency and the content of this conversation is unclear. It is estimated that more than half of women younger than 50 years of age and at least one-third of women over 50 years of age have either heterogeneously dense breasts or extremely dense breasts.

Therefore, many women will receive the dense breast notification.

The use of guidelines to inform primary care providers (PCPs) and their patients about expanded imaging is limited. Expert bodies such as the US Preventive Health Services Task Force (USPTF) do not support the use of additional imaging modalities in breast cancer screening and do

not differentiate screening methodologies for women with dense or very dense breasts. In a 2009 report, the USPTF stated that evidence did not identify a significant benefit in using digital mammography and magnetic resonance imaging (MRI) of the breast for screening over film mammography. The analysis acknowledged that detection rates are higher when using these modalities in very high-risk women.

However, this detection is at the expense of higher cost, exposure to IV contrast materials in the case of contrast-enhanced MRIs and a significantly higher false positive rate. While more breast cancers would surely be detected, it is not clear that these cancers would improve overall mortality.

Other expert bodies are notably silent on this issue. The American College of Obstetrics and Gynecology lacks a formal guideline or position statement related to the use of imaging studies beyond mammography in breast cancer screening. The American College of Radiology (ACR) does not have a guideline that supports use of screening modalities beyond mammography and ultrasound for breast cancer screening. According to the ACR, “…Studies have shown that ultrasound and magnetic resonance imaging (MRI) can help find breast cancers that can’t be seen on a mammogram. However, both MRI and ultrasound, show more findings that are not cancer, which can result in added testing and unnecessary biopsies. Also, the cost of ultrasound and MRI may not be covered by insurance.”

The conversation with patients will also involve the tricky discussion of risk. Evidence suggests that MRI as a breast screening modality increases sensitivity of screening in high-risk women. However, these studies typically identify high-risk groups as those women with previous exposure to some radiation treatments or women who have hereditary pre-disposition to breast cancer. Other high-risk groups include some women with breast implants or, in the setting where breast cancer has been diagnosed in one breast, women being screened for cancer in the contra-lateral breast. While women with more breast density are not considered high-risk, breast cancer is difficult to detect in dense breasts. High breast density is not a condition that is considered high-risk and generalizing results between these two groups should be done with caution.

As a consequence, PCPs are left having a discussion in the privacy of their offices with women who are both frightened and confused by the information they receive in the breast density notification.

PCPs should approach this conversation with caution and consider the guidelines described above and the best way to discuss risk. The notification may increase patients’ interest in further imaging, yet the deployment of these screening modalities lies beyond the support of current evidence. It seems as if the law has introduced to women a reason to be fearful without a clear path to reducing that fear.

California Family Physician Spring 2013 17

on tHe cover

Meet Your New President...Mark Dressner, MD, MEd An interview with CFP

Bilingual Dr. Dressner representing CAFP on a Spanish language TV show discussing diabetes care … in Spanish.

I look You have had the advantage of really getting to know CAFP by serving in many position. How will that help you as President?

I have been on the board for more than a decade, have served on the communications and residents and student affairs committees, and also as editor of this magazine. In addition, I have participated in three CAFP strategic planning sessions. I’ve known so many members in their various roles throughout the years the connections I have all over the state will be useful. I know the CAFP staff members so well that they are not only colleagues, some are truly my friends. Most of all, I understand many of our issues well and hope I can add to our strategic thinking.

How do you see your role as steward of CAFP’s strategic plan playing out?

I see myself as the voice and face of family medicine in California over the next year. I hope to represent our mission and our plan to media in all its forms, to legislators and other governmental groups, to the public and to our members. I hope to speak well about where we would like health care to be AND help move it there.

What aspect of being president excites you most? Challenges you most?

I am most excited about talking with members of the media. I recently did a half-hour TV interview on diabetes in Spanish. It was exciting and nerve wracking at the same time. So, speaking with the media is also my biggest challenge. I’m always concerned I’ll blow it and say the wrong thing. The corollary is the challenge of knowing what I am talking about.

I need to know my stuff, but that’s not so different from what a family doc does every day!

Dr. Dressner is a frequent visitor at his son Trevor’s school.

Over the years, you have shared your experiences providing care in other countries, mostly Honduras, through articles in CFP. What motivates you to continue this work?

When I was doing my premed committee interviews, I said one of the reasons I wanted to be a doctor was because I could go anywhere in the world and be a doctor. I was criticized for having an unrealistic view of medicine as a travel opportunity. I wish that I could go back to the committee members and show them that I have lived my dream. My journey of being a doctor has allowed me to live four years in Israel, participate in 14 medical missions to Honduras and in two medical missions along the Amazon in Brazil.

In Judaism, there is a mission of “tikkun olam” – repairing or healing the world and making it a better place. I have tried to conduct my life this way, whether being Ecology Club treasurer in ninth grade or helping the poorest people in rural Honduras. My son, Trevor, at age seven, went with me on my last trip. He helped in the dispensary, accompanied me on house calls and participated in many other adventures. He already embraces this philosophy. Ultimately though, I get so much more than I give. I work hard, but these brigades are the ultimate vacation – experiencing and learning about a culture in a way that a tourist never could.

As a physician providing care in a Federally Qualified Health Center, what are your greatest challenges?

Most of my patients are new Latino immigrants. I love this population.

They have such great values, some of which are being lost in the US. They are here to do just what our immigrant ancestors wanted to do – make a new life for their families. Most of my ancestors were Russian Jewish immigrants from the early 1900s.

The biggest challenge is lack of resources. We can only provide the basics before we have to refer to the big center, Harbor UCLA. Even the

18 California Family Physician Spring 2013

basics sometimes are hard to provide. For example, our clinic has been unable to purchase (or find donations of) tetanus vaccine or pneumovax for six months. My scope of practice is broad, but at an FQHC I am only able to practice a fraction of what I could because of lack of supplies.

You have also been an educator, in residency programs and as faculty for Academy continuing professional development initiatives. How will those skills serve you as CAFP president?

I have done a lot. It is overwhelming to look back at all that I have done in my life and career. I also have a Master’s in Education from USC. Probably the biggest take-home message from the Master’s program was to have very clear objectives, to make these objectives known explicitly and then just work toward them. I also love public speaking, so with clear objectives and loving to get in front of people, I am ready to go. I have a good understanding of issues affecting medical education, so I can represent us as needed and fight for needed changes.

What’s the most fun thing you’ve done so far as a CAFP representative?

Despite how important our work is at CAFP, it all has to be fun or it would not be worth doing. There are so many things. I did a talk on patient advocacy at the family medicine summit a few years ago. It was very interactive and attended mainly by residents. Ideas zoomed around the room – it was wonderful. Attendings such as Tom Bent and Sumana Reddy were there to add their expertise as well. It was a fun and rewarding session. I have loved working with CAFP staff – always great fun despite much work. The strategic planning meetings are full of hard work but very fun, with a lot of bonding and laughter among so many amazing family medicine leaders in California. I also have loved helping create policy at the Congress. It is such a high to be the author of a resolution that passes, or to help pass another resolution about which I have felt passionate.

Of course, we always like to talk about “firsts” at CAFP; you will be our first “out” gay male president. What does that mean to you? To CAFP? I am very proud to be the first openly gay male president of our Academy. I love having my partner of 24 years, family physician Matt Davis, and our son, Trevor, on the cover of the magazine as a very 2013 California family. I am also doubly proud because I think that it really just doesn’t matter. That’s how it should be and is, for the most part, in our Academy and in California. I am also so delighted to have had even just a small part in helping our national Academy pass policy supporting same gender marriage.

You and your partner became dads relatively later than average.

What’s the best thing about having Trevor in your lives?

As older parents, I really believe we have wisdom. We are at a different Ericksonian stage than much younger parents. We are raising an amazingly self-confident person, who is smart, socially-conscious, and funny, already a leader, great at sports and a musician. Despite all the incredible things that I have done in my life, our decision to have Trevor was the best. Otherwise, I never would have found myself teaching

Drs. Dressner and Davis met at the University of Cincinnati. Dr. Dressner practices at The Children’s Clinic in Long Beach and Dr. Davis the Centers for Family Medicine in Cypress.

Spanish at an elementary school or, surprisingly, being a scorekeeper for a baseball team.

When you look back on your presidency, of what do you want to be most proud?

I want to be sure that not only is our voice heard at the table, but we are also one of the leaders at the table when it comes to determining how health care will be provided in California during this crucial period of change in 2013-2014. I want to be sure our media presence stays strong so we are consistently, positively in the public eye advocating that family medicine is a key element of health care reform now and in the future.

What would you like to tell our members about what the Academy does for them?

Our academy does so much. First and foremost, we represent family medicine to legislators. Without the CAFP, family physicians in California would have no specific representation in policy, laws and regulations.

We are here to fight the good fight for our members, our family physician non-members who should be members and all of our patients. Our Academy does so much more as well, in terms of continuing professional development, practice transformation and working with resident and medical student education. The money one spends for membership pays for itself in so many ways!

California Family Physician Spring 2013 19

P u b l i c H e a lt H a n d Y o u

Bo Greaves, MD

Bo Greaves, MD is Tackling End-of-Life Care Issues.

Are You? An interview with CFP How did end-of-life care come to be a priority for your organization?

The Committee for Healthcare Improvement (CHI), which is part of Health Action in Sonoma County, picked end-of-life issues as the area we wanted to focus on as our first project.

Our health center is an active participant in CHI, which brings together all the major hospitals, medical groups and other health care organizations in the county.

The pilot project in our health center is one of a portfolio of projects aimed at improving our community’s performance and offering choices about end-of-life care to our community members. At Vista, we are hoping to learn how to use a team approach to have high-quality conversations with appropriate patients about their end-of-life care wishes.

What does making it a priority mean in practical terms, on an everyday basis, for your physicians and the teams in which they practice?

Making it a priority means several things. It means having help in identifying the most appropriate patients to whom to offer the conversation. It means not forgetting to bring up the topic. It means shifting the focus of care for people with advanced illness to adopting a palliative care approach in the primary care setting. And it means shifting our attitude toward death so that we are not simply fighting death but accepting it as the inevitable last stage of each patient’s life.

The point of our pilot is to move the task of having this conversation off the clinician’s plate and to give special training to others on our team (starting with our nurses) so they can have the conversation on a high-quality level.

What have you found is the best way to approach patients on the issue, and do you discuss it with everyone or only a select group?

We start with a focus on those patients we identify as having advanced illness, meaning that we expect they are approaching the end-of-life phase. These folks have diagnoses such as advanced Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF), dementia or metastatic cancers.

It is sometimes difficult for clinicians to bring up the topic of dying with patients we are actively treating to reduce disease effects. If the goal of the conversation is to support the patient as she considers her own values and desires

20 California Family Physician Spring 2013

about how she wants the remainder of her life to go, the patient generally really appreciates that. The clinician is more likely to feel hesitancy to bring it up, however.

During the debate over the Affordable Care Act, payment for end-of-life treatment discussions with patients morphed into “death panels.” Do you get any blowback on “death panels” when you ask to discuss end-of-life care?

Not if I am clear with a patient that I am introducing the topic with the goal of helping him to articulate his wishes, and to have the health care system honor his wishes. The goal is not to achieve cost-savings, but to make the final stage of life more humane and more connected to what each patient wants. If we succeed, there will be costsavings, but that is not the primary goal.

How could the average family physician practice easily systematize such discussions and care?

Wherever possible, moving the responsibility of having this crucial, values-driven conversation from the primary care clinician to someone else on the team has resulted in improvements in both the number of conversations and their quality.

It is hard to do this work in a 20-minute office visit. Our pilot project is training our health center nurses in how to facilitate a good conversation with patients and families, about what their wishes are regarding care in the future.

The plan will be to help patients consider their choices, and then use the appropriate documentation tool (either a Durable Power of Attorney for Healthcare/Advanced Directive or the Physician Order for Life-Sustaining Treatment (POLST).

Many family physicians work in a practice setting with no nurses, or other staff members with the time or expertise to facilitate these conversations. I would think a model could be developed with community partners (for example, the local hospital, or county agency on aging, or local health education provider) that could provide some trained personnel to help guide anyone interested in going through the advance care planning process. Hospitals, in particular, are very interested in improving our community’s performance in having people, especially those with advanced illness, consider and document their choices regarding care.

Do you personally have an end-of-life plan, or directive?

Yes, Daisy (my spouse) and I both finally completed this process about five years ago. We found a program called “Five Wishes” to be helpful in leading us through considering what was important to each of us; several other high-quality tools are available as well. Communicating that to our children, so they are as clear as possible when the time comes, is probably one of the best gifts we could give them.

Medicare covers hospice care for patients in the last six months of life. What’s been your experience ordering such care for patients? For those with Medi-Cal coverage? Those covered by private insurers?

I believe most payers, including Medi-Cal, cover hospice care. I have never had an experience that someone could not access home hospice because of insurance reasons.

How do you advise family physicians to begin incorporating end-of-life care and discussions into their practices?

As we move toward our goal of patient-centered care, we are shifting the locus of control toward the patient. The patient, hopefully with the support of his/her family, gets to set the agenda for the care, and gets to make decisions along with us.

Improved advance care planning is simply the application of patient-centered care to the care patients will receive as they approach the end of life.

Family physicians, in the coming five decades, will be called upon to provide high quality and comprehensive geriatric and palliative care on a scale for which we are, quite frankly, unprepared. But the demographics in our communities will demand that. Geriatric and palliative care will both require robust support for advance care planning. We must learn to adopt a more patient-centered approach to each patient who develops advanced illness (such as advanced COPD, CHF, or metastatic cancer), which recognizes that the aim of treatment is now more palliation of symptoms, and improving quality of life, and no longer aimed at cure, or even lengthening life. Once we make that shift to providing palliative care, then considering options (and documenting them in a POLST or advanced directive) for the future, when the patient takes a turn for the worse, is a natural extension of the overall care plan.

In the case of actively dying patients, have you seen their care choices changing or remaining the same as a result of your efforts?

We are just starting our pilot, aimed at increasing both the frequency and the quality of end-of-life conversations and documentation in our health center. I know that virtually all family physicians have had the experience of great deaths, where the patient and his/her family were able to decide how they want the dying process to go. Often such patients were able to die at home, in comfort, surrounded by those

they love. Sadly, virtually all family physicians have had the opposite experience as well, in which the patient was not able to direct the pathway of his or her death, and died surrounded by strangers and medical technology trying without success to defeat death at all costs. But this is true of almost everyone.

Whenever I have made a presentation to the public about our pilot project, I hear so many people’s stories of their parents or grandparents, some of whom had experienced great deaths, and others horrible ones. This has touched virtually everybody.

What else would you like family physicians to know about end-of-life care?

We can do better. We can learn to identify those patients at highest risk for bad things happening. We can learn to offer them the opportunity to learn their choices, and help them make and document decisions. We can make sure that we, and everyone in our organizations, have gone through some organized advance care planning training process. We can join with others in our communities to raise awareness about how important it is that we all consider the questions of what choices we want made as we approach the end of our lives.

And we can respect the autonomy of our patients to make their own decisions, with our counsel.

If we do better, we can reduce those experiences that feel like the greatest tragedy of all. That is when, after a difficult death that is isolating for both patient and family, to have the family comment—“But no one ever asked us…”

Physician Orders for Life-Sustaining Treatment (POLST) is a physician order that helps give seriously ill patients more control over their end-of life care. Produced on a distinctive bright pink form and signed by both the doctor and patient, POLST specifies the types of medical treatment that a patient wishes to receive at the end of life. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering and help ensure that patients’ wishes are honored.

The decisions documented on the POLST form include whether to: • Attempt cardiopulmonary resuscitation; • Administer antibiotics and IV fluids; • Use a ventilator to help with breathing; and • Provide artificial nutrition by tube.

Visit the California POLST website at capolst.org California Family Physician Spring 2013 21

P u b l i c H e a lt H a n d Y o u

Lenny Lesser, MD

Taxing Liquid Candy to Benefit Children’s Health “I like to pay taxes. With them I buy civilization.” – Justice Oliver Wendell Holmes, Jr. What caused the obesity epidemic? The increase in weight of the population is likely due to the increase in eating highly processed junk food, with a lot of added sugar. Why are we eating so many of these socalled “food-like substances”? In the words of the Institute of Medicine, “advertising works.” The marketing of junk food has led to an epidemic of poor eating patterns.

Marketing is composed of four elements: product, price, placement and promotion. Take soda as an example. The soda companies continually come up with new products, such as new varieties and flavors of sugary water. By increasing the size of the containers, companies decrease the marginal price of larger sizes. Soda placement is everywhere: you can buy it at the drug store, the gas station or even your local hospital.

Promotion, the most salient type of marketing, is also everywhere: television commercials, Internet ads and banners at sports stadiums constantly remind us to buy sugary drinks. Beverage companies even sponsor medical conferences and websites. In total, beverage companies spent $600 million in 2006 just on marketing to children.

Meanwhile, the research community has been documenting the harmful effects of sugary beverages, also known as “liquid candy.” Physiology research points out that the human body does not recognize liquid calories as filling. Drinking these calories seems to perpetuate hunger and cause overeating.

Research has consistently linked sugary beverages to many harmful conditions: dental caries, obesity, diabetes and heart disease. Recent research in the New England Journal of Medicine showed that eliminating these beverages from children’s diets reduced their weight and risk for obesity. In total, the research has been clear: sugary beverages are harmful to human health.

Physicians can treat patients who drink sugary beverages as they do patients who smoke. (There is emerging evidence that sugar is addicting and activates many of the same areas of the brain as drugs.) Ask your patients if they drink sugary beverages. If they do, advise them of the harm and assist them in eliminating their consumption.

Like the problem of smoking, however, physicians cannot solve the epidemic. What was the single most important intervention that reduced smoking rates? Taxes. Taxes naturally caused a decrease in purchases due to an increase in price. Additionally, sin taxes result in a useful stigma on the product. The social acceptability of smoking decreased as it became apparent that the government was sending a strong signal about the harms of tobacco.

22 California Family Physician Spring 2013

Dr. Lesser, a member of CAFP’s Committee on Continuing Professional Development, is research physician at the Palo Alto Medical Foundation.

Taxing sugary beverages could work both to decrease consumption and raise funds for obesity prevention. The most popular tax proposal is “a penny per ounce.” Thus, a 12-ounce soda would cost 12 cents more; a 64-ounce bottle would be 64 cents more. While this may seem like a small amount, estimates indicate that a national penny-per-ounce tax would: decrease soda consumption by 15 percent, prevent 26,000 deaths a year, save $17 billion in health care costs, and raise about $13 billion a year. The money raised would be a boon to public health organizations, which struggle to nudge people to eat healthier against the consistent onslaught of marketing from the beverage industry.

California was the leader in taxes on cigarettes, and it is poised to be the leader on taxing sugary beverages. Proposals have surfaced in the Capitol and cities of Richmond and El Monte. In both cities, the tax was on the ballot last fall and the measures failed after the beverage industry hired a public relations firm and spent some $4 million to defeat them.

(Marketing is clearly something they are good at.) But, there was victory in defeat. Debating the tax provides health professionals free press coverage to highlight the ills of drinking sugary beverages. Still, hope remains that the public health community will eventually pass a tax. It took many years to pass a cigarette tax, fighting against similar tactics used by the tobacco industry.

Some critics of a tax on sugary beverages say that it would be regressive because low-income individuals would be affected the most. The funds raised from the tax could be directed toward cities and towns that drink the most beverages and suffer the most health consequences, however.

Others say that the government should stay out of private eating behaviors. Individuals should have the freedom to eat what they wish, but these choices are framed by government policy. For example, the government subsidizes corn syrup, allows beverage companies to take a tax deduction for marketing costs and regulates what low-income individuals can purchase with supplemental nutrition assistance.

A tax on sugary beverages will eventually raise a lot of money for public health programs in the state. California law requires that approximately 60 percent of any new tax go to public education. Since education improves health, the funds would improve the health of many communities in California. The rest of the funds could go to providing children nutritious meals in schools, supporting physical education and marketing campaigns against sugary beverages. A tax on sugary beverages is possibly the most effective tool we have to counter the constant barrage of marketing that urges us to drink more liquid candy.

A Physician and His Little Red Wagon Jeff Ritterman, MD The perfect human diet, according to Jeff Ritterman, MD: Kale. Salad.

Tap water. Mercury-free fish. If you insist on eating grains, make it bulgur. No white flour. No sugar.

And absolutely, positively, no soda.

“We all grew up thinking soda could be part of a healthy diet.

It’s not. Soda is the No. 1 cause of the health crisis in America,” Dr. Ritterman said in an article in the San Francisco Chronicle, published October 12, 2012, before the November elections.

Dr. Ritterman recently told his redwagon story of the war on soda at the CAFP Congress of Delegates meeting in Sacramento. The war began at his kitchen table and ended up as a ballot initiative that proposed a Richmond city soda tax, a penny-per-ounce surcharge on sugar-sweetened beverages that would raise $3 million a year to fight childhood obesity. Dr.

Ritterman’s campaign consisted largely of him walking around town and talking about the dangers of sugared beverages while pulling a red Radio Flyer wagon loaded with 40 pounds of sugar … the amount he says the average Richmond child drinks in a year. He also circulates video clips on childhood obesity and the threat of “big soda.”

The campaign has unintended consequences $3 million+ was spent by opponents and boosted the local economy, and the visibility and conversations started by the debate are healthy for public health. Dr. Ritterman was not daunted by the wrath of Coke and Pepsi. If anything, he’s energized.

And despite a loss at the polls, he vows to continue the fight and although he is no longer in public office he remains steadfast to public health. Thanks to Dr. Ritterman for his valiant efforts on behalf of the Richmond Community.

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Fax: 1-800-666-1377 California Family Physician Spring 2013 23

Public HealtH and You

Richard N. Gray Jr., MD, FAAFP, DABFP

Lessons from an In-Flight Emergency … What Would You Do? “Your attention, please! If there are any medical personnel aboard, would you please turn on your call light?” I roused from a fitful stupor, never sleeping well when flying, and hit the call button. Within moments a flight attendant appeared with two other individuals: a nurse and a female physician. “We only need one of you; you come with me,” she nodded to me, dismissing the other two. We quickly moved to the back row of the lower deck of the Airbus A380-800 where a 91-year-old Cantonese female was in obvious distress: dyspneic and confused despite receiving oxygen at 4L/min by mask. The daughter quickly gave me the history: Her mother has asthma and diabetes, and had become short of breath shortly after take-off, but this had never happened before.

Mrs. Li* was leaning back in her seat, diaphoretic, pulse 155, gasping for air, with poor air movement. The attendant provided me with a little, self-contained pulse oximeter – 84 percent.

“Have you given her anything?” I asked.

“Yes, I’ve been giving her the Q-Var, but it doesn’t seem to be helping!”

“Right, that’s to help prevent problems; it’s too late for that now. Do you have another inhaler; some albuterol?”

“Yes, it’s right here.” Pssht! Pssht! To my relief, in just moments her pulse rate dropped to 111 and SaO2 rose to 100 percent. Mrs. Li relaxed a bit and seemed more alert, though air movement remained poor. I repeated the albuterol, and the pulse dropped to 100, as SaO2 held at 98 percent Then the O2 ran out, and Mrs. Li’s pulse went up to 122 as her SaO2 dropped to 91 percent. I repeated the albuterol as the flight attendant conceded, “We should have done more sooner: We’ve been giving her oxygen for the past two hours, but thought she was getting better.” She provided another cylinder.

I had been there for 25 minutes and I suggested that it might be helpful to have a blood pressure cuff. The flight attendant produced a wrist cuff. We put it to use and it showed 89/47.

That didn’t match asthma, so I tried it again: 73/46 with a pulse of 122. Why was she in shock? I asked the flight attendant to move a couple of people so Mrs. Li could lie down.

The purser (chief flight attendant) arrived and asked if I could speak to his airline’s doctor. We walked the full length of the plane to a handset on the forward bulkhead. Dr. Brown, back in the States, asked what was going on and I gave him the above information. He agreed this was a medical emergency and assured me he would talk to the pilot.

24 California Family Physician Spring 2013

Back to Mrs. Li: her blood pressure was now up to 92/49, less diaphoretic, but pulse was still 110 and SaO2 was only 90 percent. More albuterol.

Forty-five minutes into this, and I was increasingly concerned because of the lack of sustained improvement: blood pressure 80/53, pulse 124, respirations near 35/min, and 2+ pretibial edema. I did not know if she had any jugulovenous distention, as she was fully clothed, and I could not risk sitting her up again.

The purser returned and told me the captain wanted to speak with me. Again we made the walk the length of the plane, but this time we bypassed the handset and stepped through the security door. Suddenly I was in the cockpit‡. Dr. Brown was on a speaker and we discussed the situation. We were three hours past Anchorage, Alaska, and it was still three-and-a-half hours to North Japan, the nearest airports that could handle a plane this size. We were six hours from Hong Kong; could we make it? I explained that the patient was in shock and needed emergency treatment. I didn’t know that 30 minutes was the most critical factor, but I didn’t think the patient would survive to Hong Kong. Dr. Brown supported my position and the captain said he would make plans to land in North Japan. He thanked me for helping out.

During the remainder of that leg of the flight, the patient was plagued with persistent hypotension, tachycardia, poor air movement, and desaturations every time she pulled off her mask or the oxygen cylinder ran out. You can imagine my frustration when the purser informed me that the airstrip in North Japan had refused our landing, and we were now headed one hour farther, to Tokyo. The medical kit had limited resources, the only one of which I even considered using being epinephrine, which I immediately rejected due to the ongoing tachycardia. I’m glad I did. Just as the pilot announced the diversion and started the descent into Tokyo, Mrs. Li became increasingly agitated, clawing at the mask and crying. Her daughter asked if her mother could have pain medication.

“Why does she want pain medication?” I asked.

“For pain,” she replied. “She takes pain medication.”

“What kind of pain is she having?”

“Chest pain.”

Click; I finally suspected the cause of the shock!

“She gets chest pains?”

“Oh, yes. She had one just before we took off.” The daughter gave her one of her nitros.

We got down, paramedics relieved me of the patient, I washed my hands, and we took off an hour later.

Take-home lessons: 1. Despite being so groggy, instead of allowing the flight crew to determine who would provide aid, I should have asked for all of us to go and confer prior to releasing anyone. Having more input from the start might have been helpful; 2. History is always paramount. Yes, I had been told the only thing wrong with the patient was asthma and diabetes, but I should have asked for other medical history and all her medications; and 3. I had heard of professional airline oncall physicians, but had not accessed one previously. Though the captain ultimately makes the decision of what is safest for his aircraft, crew and passengers, he relies on the input of that airline professional, who has the experience of knowing when to divert and when it can be avoided†. For anything other than the most minor, routine encounter, do not hesitate to get that input. Good Samaritan laws limit your in-flight liability, but it is helpful to share that liability with someone with greater experience.

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______________________ *Not her real name. ‡When was the last time you were in the cockpit of a commercial aircraft in flight?

That was surprise enough for me but, what to my amazement, instead of a stick the pilot and co-pilot each had a pedestal with a touch-screen, computer tablet on it! “What, no yoke?” I blurted. “No,” the pilot smiled, reaching for a computer-game-sized joystick on the left of his console. “We each have one of these.” The co-pilot had a matching one on the right. † Not only are passengers upset about schedule delays, but diverting a plane to an unscheduled landing is very expensive and time-consuming: airport landing fees, excess fuel charges for climbing back to altitude and overtime pays for the crew. Additionally, the A380-800 requires at least 30-60 min to cool the brakes after landing before to attempting another take-off.

California Family Physician Spring 2013 25

P u b l i c H e a lt H a n d Y o u American Academy of Family Physicians

Five Things Physicians and Patients Should Question Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

1

Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.

2

Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

3

Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients.

4

5

Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

26 California Family Physician Spring 2013

American Academy of Family Physicians

Five More Things Physicians and Patients Should Question

6

7

8

9

Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.

Delivery prior to 39 weeks, 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks and 0 days based on maternal and/or fetal conditions.

A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.

Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care clinicians should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.

There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits.

Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction.

Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.

There is adequate evidence that screening women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit.

10

Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.

There is adequate evidence that the harms of HPV testing, alone or in combination with cytology, in women younger than 30 years of age are moderate. The harms include more frequent testing and invasive diagnostic procedures such as colposcopy and cervical biopsy. Abnormal screening test results are also associated with psychological harms, anxiety and distress.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

California Family Physician Spring 2013 27

P u b l i c H e a lt H a n d Y o u How This List Was Created (1–5) The American Academy of Family Physicians (AAFP) list is an endorsement of the five recommendations for Family Medicine previously proposed by the National Physicians Alliance (NPA) and published in the Archives of Internal Medicine, as part of its Less is More™ series. The goal was to identify items common in primary care practice, strongly supported by the evidence and literature, that would lead to significant health benefits, reduce risks and harm, and reduce costs. A working group was assembled for each of the three primary care specialties; family medicine, pediatrics and internal medicine. The original list was developed using a modification of the nominal group process, with online voting. The literature was then searched to provide supporting evidence or refute the activities. The list was modified and a second round of field testing was conducted. The field testing with family physicians showed support for the final recommendations, the potential positive impact on quality and cost, and the ease with which the recommendations could be implemented.

More detail on the study and methodology can be found in the Archives of Internal Medicine article: The “Top 5” Lists in Primary Care.

How This List Was Created (6–10) The American Academy of Family Physicians (AAFP) has identified this list of clinical recommendations for the second phase of the Choosing Wisely campaign. The goal was to identify items common in the practice of family medicine supported by a review of the evidence that would lead to significant health benefits, reduce risks, harms and costs. For each item, evidence was reviewed from appropriate sources such as evidence reviews from the Cochrane Collaboration, and the Agency for Healthcare Research and Quality. The AAFP’s Commission on Health of the Public and Science and Chair of the Board of Directors reviewed and approved the recommendations.

In the case of the first two items on our list – “Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age” and “Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable” – we collaborated with the American College of Obstetricians and Gynecologists in developing the final language.

AAFP’s disclosure and conflict of interest policy can be found at www.aafp.org.

Sources 1

Agency for Health Care Research and Policy (AIICPR), Cochrane Reviews.

2

Center for Disease Control and Prevention (CDC), Cochrane, and Annals of Internal Medicine.

3

U.S. Preventive Services Task Force (USPSTF), American Association of Clinical Endocrinology (AACE), American College of Preventive Medicine (ACPM), National Osteoporosis Foundation (NOF).

4

U.S. Preventive Services Task Force (USPSTF).

5

U.S. Preventive Services Task Force (USPSTF) (for hysterectomy), American College of Obstetrics and Gynecology (ACOG) (for age).

6

Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L (California Maternal Quality Care Collaborative). Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age. California: March of Dimes; First edition July 2010. California Department of Public Health; Maternal, Child and Adolescent Health Division; Contract No: 08-85012.

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. 450 p.

7

Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:386–97. Gulmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth outcomes for women at or beyond term (review). The Cochrane Collaboration. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD004945.

DOI: 10.1002/14651858.CD004945.pub3. Available from: onlinelibrary.wiley.com/doi/10.1002/14651858.CD004945.pub3/abstract;jsessionid=242792D050CDB79D0D80C0F6FDE85031.d02t03 American Academy of Family Physicians. Carotid Artery Stenosis [Internet]. 2007[cited 2012 Oct 10]. Available from: www.aafp.org/online/en/home/clinical/exam/carotidartery.html

8

U.S. Preventive Services Task Force. Screening for Carotid Artery Stenosis [Internet]. 2007 Dec. [Cited 2012 Oct 10]. Available from: www.uspreventiveservicestaskforce.org/uspstf/uspsacas.htm Wolff T, Guirguis-Blake J, Miller T, et al. Screening For Asymptomatic Carotid Artery Stenosis [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Dec. (Evidence Syntheses, No. 50). Available from: www.ncbi.nlm.nih.gov/books/NBK33504/ American Academy of Family Physicians. Cervical Cancer [Internet]. 2012 [cited 2012 Oct 10]. www.aafp.org/online/en/home/clinical/exam/cervicalcancer.html

9

U.S. Preventive Services Task Force. Screening for Cervical Cancer. 2012 Mar. [cited 2012 Oct 10]. Available from: www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm Vesco KK, Whitlock EP, Eder M, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 May. (Evidence Syntheses, No. 86.) Available from: preview.ncbi.nlm.nih.gov/bookshelf/booktest/br.fcgi?book=es86 American Academy of Family Physicians. Cervical Cancer [Internet]. 2012 [cited 2012 Oct 10]. www.aafp.org/online/en/home/clinical/exam/cervicalcancer.html

10

U.S. Preventive Services Task Force. Screening for Cervical Cancer. 2012 Mar. [cited 2012 Oct 10]. Available from: www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm Vesco KK, Whitlock EP, Eder M, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 May. (Evidence Syntheses, No. 86.) Available from: preview.ncbi.nlm.nih.gov/bookshelf/booktest/br.fcgi?book=es86

About the ABIM Foundation

About the American Academy of Family Physicians

The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice.

Founded in 1947, the American Academy of Family Physicians (AAFP) represents 105,900 physicians and medical students nationwide.

It is the only medical society devoted solely to primary care. Approximately one in four of all doctor’s office visits are made to family physicians. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.

To learn more about the ABIM Foundation, visit www.abimfoundation.org.

®

For information about health care, health conditions and wellness, please visit the AAFPs award-winning consumer website, www.familydoctor.org.

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

28 California Family Physician Spring 2013

Adam Francis

CAFP Family Medicine Lobby Day: FM Revolution Storms the Capitol “First they ignore you, then they laugh at you, then they fight you, then you win.”

You could feel it in the air. The 2013 Family Medicine Lobby Day was going to be different from any previous year. It was not just the record number of family physicians in attendance (they can barely fit in the picture above!). It was not just because students and residents turned out in full force to support the future of primary care. It was the recognition, encountered in the Capitol, that implementation of the Affordable Care Act is going to mean big change for California. Legislators are looking to physicians for input on what this change will mean for their communities. There has never been a better time for family physicians to get involved with family medicine advocacy, and it has never been more important that your voice be heard.

reminded me of a quote that has been mistakenly attributed to Mohandas Gandhi, but does well to illustrate his philosophy of Satyagraha (loosely translated as “insistence on truth”): “First they ignore you, then they laugh at you, then they fight you, then you win.”

Family medicine is no longer being ignored. Some still laugh at us and powerful, moneyed forces still fight us. But the tide is turning. It is time for family medicine to start winning. But we cannot do it without you. Join the Family Medicine Revolution and together we can make a real difference in the lives of your patients and your everyday practice lives. Go to www. familydocs.org/advocacy to learn more about how you can get involved and join us on Twitter using #FMRevolution.

Adam Francis is the Deputy Director, Government Affairs.

The day before Family Medicine Lobby Day, CAFP awarded its 2013 Champion of Family Medicine award to pediatrician and Assemblymember Richard Pan, MD (D – Sacramento) for his commitment to advocating for family medicine and primary care in California. Dr. Pan is the Chair of the Assembly Health Committee and the only practicing physician in the California State Legislature. He is also the author of CAFP’s sponsored bill to define the Patient Centered Medical Home (PCMH). While his voice will be an important one among his colleagues, it is essential that family physicians contact their own legislators to inform them about the health care needs of their communities.

Hearing about what Dr. Pan has achieved was great motivation for CAFP members on Lobby Day. On Monday morning, family physicians began pouring into the Capitol. This group was a lean, mean family medicine advocacy machine. Most of the participants had attended CAFP’s advocacy and messaging training seminars the day before. This was their opportunity to put what they learned into practice. They had scheduled meetings with their legislators to discuss health care reform implementation and CAFP’s sponsored bills on the PMCH and graduate medical education funding in primary care.

A record number of CAFPers participated in Lobby Day 2013, including the Loma Linda team (below).

Long live the FM Revolution!

Dr. Lauren Simon (in blue) and her team from Loma Linda, San Bernardino and Riverside spoke from personal experience about how CAFP’s sponsored bill to fund additional residency slots would be both a short- and long-term solution to California’s shortage of primary care providers.

As we gathered to debrief on the meetings, many noted that this year was different and it felt as if a tide was turning. This California Family Physician Spring 2013 29

Susan Hogeland, CAE

executive vice President’s Forum

Where Is the Line between Public Health and Public Policy?

This issue of California Family Physician is devoted to public health issues, issues upon which family medicine and family physicians have great influence. Family physicians hold great sway

with their patients when it comes to helping them make decisions to lead healthier lifestyles or achieve better health. From that perspective, one could say that transformation to the Patient Centered Medical Home model of care is an outstanding public health strategy!

Family physician and CAFP member Ron Chapman, MD is Director of the California Department of Public Health, where he manages 3,500 employees in 60 offices around the state and a $3.5 billion budget.

Ron was on the CAFP Board of Directors a few years after I joined the Academy. He graduated in one of the first classes of our Physician Leadership Program (PLP), a program designed to teach skills needed by family physicians to assume important positions within managed care organizations, government and/ or medical/group practices to ensure the primary care physician perspective was well-represented.

In Ron’s case, he took that goal to heart: he became director of Public Health in Solano County and then was appointed Director of the Department of Public Health

by Governor Jerry Brown. We are lucky to have him in that key role.

30

until 1989 as an appointee of President Ronald Reagan.

He was known for his strong stands against smoking and efforts to get the government to provide more funding to prevent AIDS. He was credited with the decline in smoking from 33 percent of Americans in 1981 to 26 percent in 1989, and the growth of anti-smoking regulations to some 40 states.

Dr. Koop had tremendous opposition to his efforts to achieve greater funding to prevent and treat AIDS. In this nation, we tend to delay taking appropriate public health steps when we have political or moral judgments about the victims. The third rail of public health politics no longer is AIDS, however; it is guns.

When not discussing sequestration, the budget or government shut downs, our Washington legislators have held hearings about gun violence and potential legislation affecting access to certain kinds of weapons, magazines (the gun kind, not the reading kind) and types of bullets. The Kaiser Family Foundation reports that one in five Americans, including four in 10 AfricanAmericans, know a victim of gun violence, and 42 percent say they worry about being the victim of gun violence. Ironically, legislation has prevented our Centers for Disease Control (CDC) from addressing gun violence as a public health issue.

Nationally, family physician and AAFP member Regina Benjamin, MD is our Surgeon General. Dr. Benjamin is a tremendous role model for both patients and family physicians. She achieved national recognition after rebuilding Bayou La Batre Rural Health Clinic, which she founded in 1990, after it was destroyed by Hurricane Katrina. General Benjamin (very snappy in her Public Health uniform) has focused on prevention during her tenure.. In an interview in January 2012, she cited goals: making healthy communities, empowering people to make good decisions, providing clinical and preventive services and addressing health disparities.

While our rates of obesity are higher than the 20 percent of Americans who know a victim of gun violence, that’s still a pretty high statistic. Claiming gun violence isn’t a public health issue may be more cynical than naive. The CDC should be given authority to pursue every area of research on issues that so adversely affect our citizens. FactCheck.org reports that in 2010, the US had 3.59 gun murders per 100,000, 6.28 gun suicides per 100,000 and the highest rate of gun ownership in the world, along with the highest rate of homicides among advanced countries. On the good news side, it further reports that gun crime has been declining, firearm murders are down and so is gun violence (even though gun ownership has increased).

Although not a family physician, our most famous Surgeon General to date, C. Everett Koop, MD, died February 25. The New York Times carried a nearly fullpage obituary on him and his accomplishments, focused primarily on his tenure as Surgeon General from 1981

Perhaps some sensible compromises can be reached that address both funding better mental health services and new laws about guns that will help prevent tragedies such as the one that occurred in Newtown, CT in December.

California Family Physician Spring 2013

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