California Family Physician Magazine (Spring 2014)

California

FAMILY PHYSICIAN Vol . 65 No.2 Sp ring 2014

CAFP’S PreSIDeNT-eLeCT, CT CT, DeL MorrIS, MD, IN FroNT oF THe CAPIToL buILDINg IN SACrAMeNTo, CA.

TreATINg DIverSe PoPuLATIoNS: PATIeNTS wITH CoMPLex DISAbILITIeS MeeT Your INCoMINg PreSIDeNT: DeL MorrIS, MD TreATINg DIverSe PoPuLATIoNS: CArINg For PATIeNTS wITH HIv CovereD CALIForNIA HAS HISTorIC FIrST oPeN eNroLLMeNT PerIoD

10 16 25 28

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

California Family Physician Spring 2014

Loews Coronado Bay Resort San Diego, California September 17–20, 2014

Transforming “disease” care to “health” care.

Join many of the leading names in preventive, nutritional medicine who will be presenting as part of the 2014 International Plant-Based Nutrition Healthcare Conference. Learn first hand from the experts about the efficacy of plant-based nutrition and its ability to prevent, suspend and often even reverse the chronic, degenerative diseases that are pervasive in our patient populations.

Who should attend?

Physicians representing each and every practice specialty area, nurses and allied health practitioners—those who are dedicated to empowering patients and clients with the ultimate prescription. Earn valuable Continuing Medical Education credits (CMEs)—this program is approved for 20 AMA PRA Category 1 Credits.™* Visit pbnhc.com, watch videos of last year’s attendees and faculty members, and register to be part of a medical education event that many have said is “life changing”—for themselves, for their families and for their medical practices and patients. * AAFP Prescribed Credit pending application approval. Please check the CME Accreditation page at pbnhc.com for updates.

It’s exciting when you treat causation of disease: It’s prompt, powerful and persistent.

The power of this option needs to be clearly communicated to patients.

— Caldwell Esselstyn, Jr., MD, Conference Faculty and Author, Prevent and Reverse Heart Disease Faculty pictured above, left to right: T. Colin Campbell, PhD; Thomas M. Campbell, MD; Brian Clement, PhD, NMD, LN; Caldwell Esselstyn, Jr., MD; Michael Greger, MD; Micaela Karlsen, PhD Candidate; Michael Klaper, MD; William Li, MD; Doug Lisle, PhD; James Loomis, Jr., MD; Terry Mason, MD, FACS; John McDougall, MD; Dean Ornish, MD; Michele Simon, JD, MPH; Scott Stoll, MD and Phil Tuso, MD, FACP

©2014 The Plantrician Project. All Rights Reserved.

pbnhc.com California Family Physician Spring 2014 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 Mark Dressner, MD

Allison Bauer

President-Elect Delbert Morris, MD

Sophia Henry

Associate Director, Membership and Marketing

Associate Director, Communications and Publications

shenry@familydocs.org

abauer@familydocs.org

Susan Hogeland, CAE

Immediate Past President Steven Green, MD

Jane Cho

Speaker Jay Lee, MD, MPH

jcho@familydocs.org

Jerri Davis, CCMEP

Adam Francis

Vice-Speaker Lee Ralph, MD Secretary/Treasurer Lisa Ward, MD

Executive Vice President

shogeland@familydocs.org

Manager, Medical Practice Affairs

Deputy Director, Government Affairs

Foundation President Michael Rodriguez, MD, MPH 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

Student, Resident and Social Media Manager

cmitcheltree@familydocs.org

jdavis@familydocs.org

Cynthia Kear, MDiv, CCMEP

Shelly Rodrigues, CAE, FACEHP

ckear@familydocs.org

srodrigues@familydocs.org

Membership Coordinator elundberg@familydocs.org

California FAMILY PHYSICIAN

Cody Mitcheltree

Leah Newkirk Vice President, Health Policy lnewkirk@familydocs.org

Emma Lundberg

Executive Vice President Susan Hogeland, CAE

Workforce Development Manager anarayanan@familydocs.org

Senior Manager, CME/CPD

Senior Vice President

afrancis@familydocs.org

Abhinaya Narayanan

Deputy Executive Vice President

Kelly Goodpaster

Manager, Financial Services

kgoodpaster@familydocs.org

Nathan Hitzeman, MD, Editor Allison Bauer, Manager, Managing Editor

Quarterly p publication of the California Academy of Family Physicians

Communications Committee: Nathan Hitzeman, MD, Chair • Julia Blank, MD • Nathan Hitzeman, MD • Jeffrey Luther, MD

• Jay Mongiardo, MD • Michelle Quiogue, MD • Albert Ray, 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.

pcipublishing.com Created by Publishing Concepts, Inc. David Brown, President • dbrown@pcipublishing.com For Advertising info contact Michele Gilbert • 800.561.4686 ext 120 mgilbert@pcipublishing.com edition 10

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.

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California Family Physician Spring 2014

10 Treating Diverse Populations: Patients with Complex Disabilities

Clarissa Kripke, MD, FAAFP

12 Treating Diverse Populations: Ethnogeriatrics and Dementia

Chris Flores, MD

16 Meet your Incoming President: Del Morris, MD 18 CAFP Foundation Scholar Treats Immigrant Population through The Border Health Project An Interview with Teresa Robbins, MD

Cody Mitcheltree

19 Treating Diverse Populations: the Transgender Community

Jennifer Hastings, MD Catherine Sonquist Forest, MD MPH

25 Treating Diverse Populations: Caring for Patients with HIV

Dineen Greer, MD, MPH

26 Treating Diverse Populations: Athletes

David Kruse, MD

28 Covered California Has Historic First Open Enrollment Period

Catherine Direen

6

Editorial

Time to Connect, Time for Cheese

8

Presidents Message

“Yes, we have no bananas”

9

PCMH Corner

Building Medical Homes for Complex Patients

14 Political Pulse

CAFP-Sponsored Bills on Access to Care Set the Tone for 2014

30 Executive Vice President’s Forum

The Face of Family Medicine Is Changing

Nathan Hitzeman, MD Mark Dressner, MD Leah Newkirk Ashby Wolfe, MD, MPP, MPH Susan Hogeland, CAE

For the upcoming CME calendar go to www.familydocs.org California Family Physician Spring 2014 5

editorial

Nathan Hitzeman, MD

Time to Connect, Time for Cheese

What a treat it was to attend this year’s All Member Advocacy Meeting at The Citizen Hotel in Sacramento in March. Not only was it attended by the core group of what CAFP President Mark Dressner calls the “hyper-involved,” but it was also the most well-attended advocacy meeting in recent history. Advocacy works best when matched by contributions, and our fundraising broke new records thanks to generous attendees. There was also a lot of talk about cheese, mostly symbolic, although Dr. Dressner was packing a gourmet wedge and did eventually share. You are encouraged to read “Who Moved My Cheese?” – the 1998 New York Times business bestseller that speaks to adapting to change in work and life. No one in health care seems to adapt as well as we do. More on cheese in a bit…

Students and residents were well represented, especially those from Southern California. Blockbuster speakers abounded. Dr. Thomas Balsbaugh from UC Davis spoke to Covered California and the Medi-Cal expansion (approaching three million lives at that time). Dr. Kevin Grumbach from University of California, San Francisco spoke to the increasing relevance of family physicians to coordinate care and control costs. His timeless Michael Pollan adaptation to health care rings true once more: “Provide health care. Not too much. Mostly primary care.” Executive Director of Covered California Peter Lee, himself the son of a primary care physician, spoke to the challenges and successes of Covered California to date. He mentioned that among his many public speaking engagements, no one has ever booed him for wanting to insure more people. Indeed, we are moving from a “culture of coping” to a “culture of coverage” where health care is becoming a moral obligation. Dr. Jack Chou, our representative at AAFP, spoke to how we are getting audiences with key policy makers in Washington, even with the big cheese, President Obama.

Lisa Maas, Executive Director for Californians Allied for Patient Protection, and Dustin Corcoran, CEO of the California Medical Association, both spoke to the dirty pool that the trial lawyers are up to in efforts to repeal the Medical Injury Compensation Reform Act (MICRA). This Trojan horse initiative, which would skyrocket health care costs, is couched in nonsensical language that has doctors being drug tested within 12 hours of a catastrophic patient event and mandatory Controlled Substance Utilization Review and Evaluation System (CURES) website checks before any controlled substances are prescribed (never mind that the CURES website isn’t working properly right 6

California Family Physician Spring 2014

now, that the staff doesn’t check voicemails, and by the way, there’s no full-time staff). We also griped about the 10 percent cuts to Medi-Cal reimbursement paradoxically coexisting with the Medi-Cal expansion and parity-withMedicare aspects of the Affordable Care Act (ACA). We carried this energy on to our Monday Lobby Day and made our voices heard.

A couple of resolutions addressed by residents were positively discussed dealing with effective emergency contraception and for inclusion of vasectomy as a covered Essential Benefit under the ACA (who knew?). Way to go CAFP residents! Contra Costa was well recognized too.

Assemblywoman Susan Bonilla spoke to us about AB 2458, a CAFP-sponsored bill she is authoring to fund more residency slots in California as a step to keep our best and brightest local students. Dr. Jeremy Fish from Contra Costa Medical Center received the Hero of Family Medicine award, which he reflected should be more about “heroic teams” than “heroic individuals.”

Incoming CAFP President Del Morris took us through a guided imagery relaxation exercise that not only forced us to stop texting/tweeting, but actually relaxed our muscles and minds and got us to visualize the many aspects of who we are. In short, we walked down a virtual hall and opened various doors of our psyche. The last door involved our conducting an orchestra and holding a glorious wedge of cheese. (OK, maybe you had to be there.)

The Year of the Family Physician is full of excitement, new youth and energy, and strong alliances at all levels of organized medicine and government. Our cheese has been aging for a long time. “Carpe queso,” I say! As you reach for that doorknob to your next patient, send off that email to your legislator; pick up the phone and call family medicine colleagues and CAFP staff with your concerns and stories; know that you are being heard; you are making a difference, and you are becoming the family medicine force that will lead us to the promised cheese. As Mr. Corcoran said, “If the ACA is going to succeed, it has to succeed in California.” We will succeed!

Please enjoy this issue’s stories on how we family docs care for special patient populations. Perhaps enjoy it with some California wine and cheese! Especially you, Dr. Michelle Quiogue, with all your wonderful editor’s work behind you now!

Nearly 100 years ago, Nobel Prize-winning scientist August Krogh and his wife Marie embarked on a journey to revolutionize diabetes care, driven by her needs as a diabetes patient. Today, Novo Nordisk still takes a deeply human approach to everything we do. As a world leader in diabetes care, we are in a position of great responsibility. We must continue to combine drug discovery and technology to turn science into treatment. We must prioritize research, education, and partnership around the world to make diabetes a global priority. We must conduct our business responsibly in every way. And most importantly, we can never lose sight of the patientcentric approach that has driven our vision of innovation since our inception.

Together, we can defeat diabetes in our lifetime.

For more about us, visit novonordisk-us.com

Š2011 Novo Nordisk 141928 June 2011

California Family Physician Spring 2014 7

president’s message

Mark Dressner, MD

“Yes, we have no bananas.”

There was a recent report on the radio, and an article in the New York Times, about the danger to the current banana, that we know and love, becoming extinct. To avoid this, the current type of banana has to evolve and change to fight a rampant type of fungus or a different type of banana from Africa or Asia be cultivated to take our beloved banana’s place.

Change is difficult. Change is a challenge. Change is frustrating. Change is scary. Change can be invigorating.

Change can move things forward. Change is what may be needed to survive.

This has been a year of change.

The quantum leap of change has been the Affordable Care Act. We are poised for every citizen and legal resident of our state to have access to healthcare. This is historic. Our academy has been leading the charge to educate medical professionals about the basics of Covered California so they can spread the word to staff, colleagues, patients, friends and family. How do we now change the way we deliver care to accommodate all of these people into the health care system?

On the flip side, there must be a change in insurance companies. They must be accountable for how they treat physicians, other medical professionals and patients. When there is a contract with an insurance plan with agreed upon rates, plans shouldn’t unilaterally decrease rates paid to doctors when seeing Covered California patients vs. non Covered California patients. There should not be road blocks to patient care. Necessary networks should be in place for primary care physicians and specialists. These specialists should be within reasonable proximity to the patient and the primary care physician. Medications on which a patient has been stable for years should not be suddenly denied by the insurance plan – sometimes causing patient problems resulting in emergency room visits that cost much more than a year’s supply of the denied medication (that lifesaving purple discus anyone?).

Paper charts? I have been fortunate to have worked for a healthcare system with a mostly outstanding electronic medical record (EMR) that, despite some frustration, I love.

Spending the time up front to really get to know the system saves so much time in subsequent months and years. I am much more efficient and can see more patients than I ever 8

California Family Physician Spring 2014

could with paper charts. Cost aside (and I know this is a huge hurdle that I have not had to deal with) having an EMR is a leap into the future.

We need to change, and be paid appropriately for, different modalities of taking care of patients. We must get off the treadmill of seeing patient after patient, face-to-face, as the only way to provide care. We should be embracing group visits, e-visits, and telephonic visits. Not only are there different ways to provide care for some people, but varying the method of providing care makes things more fun – as long as the methods complement one another rather than just being added to what is already being done during a full day.

In addition to what has been taking place in the field of health care, it has been quite the year of change in our society. Twenty-five years ago, who would have thought that my same sex partner – now spouse – and I would be able to marry – or that our son would hand us our rings? Twentyfive years together and about six months married! Society has finally come around to allowing my family the same legal rights and recognition as other families. Our tax accountant is elated.

I have been on the CAFP board for about 15 years – helping shape policy for family physicians and patients in California.

Where do I next fit in within my professional organizations and advocacy work – committee work with CAFP, commission work with AAFP, CMA, eventually being a delegate to the AAFP Congress? My life has always included involvement in so much more than the office in medicine or the classroom in education. Professionally, after 15 years of working in residency education and now five years at a Federally Qualified Health Center, what is next as my son enters middle school and I transition off the CAFP board over the next year?

I hope that I have been able to represent you well. I hope that I have listened well. I hope that I have encouraged and inspired you. I hope that I have been able to prioritize well our different agendas for the year. I hope that I have also made it fun and that I accomplished my goals with humor.

Frustrating, scary, invigorating and moving forward – I look forward to change. As those of you who were at the All Member Advocacy Meeting know – CAFP is moving the cheese to where we want it to be, not just responding to someone else’s moved cheese, but we also must not go the way of the endangered banana.

“Thank you, Matt.”

pCmH Corner

Leah Newkirk

Building Medical Homes for Complex Patients

In an ideal world, every person would have a Patient Centered Medical Home (PCMH). In the real world, one with limited health care resources, the question is often asked whether a practice can serve as a medical home for specific patient populations. In other words, can a practice offer the additional medical home services of increased access or care management to patients with diabetes, patients with multiple chronic illnesses or patients who generate the highest costs?

The answer, derived from a meta-analysis of PCMH interventions, is yes. PCMH interventions tend to focus on older and sicker patient populations. CAFP’s answer, based on our experience developing a PCMH pilot in Fresno, California, is yes…and no. A practice can make some changes exclusively for specific populations. For example, a care manager can coordinate the care of patients with two or more chronic illnesses. Other aspects of PCMH are fundamental to the practice and cannot be separated out for specific populations. Using lean management principles to create a more efficient health care team, for example, will affect all patients seen in the practice.

CAFP continues to urge California family physicians to move to this model to benefit all of your patients. As California family physicians work to transform to PCMH in our world of limited resources, however, certain state developments may help you plan and prioritize. Support from payers may be more forthcoming for medical homes that address the needs of complex, high-cost patients.

Since April 2013, California’s Health and Human Services Agency (CHHS) has been developing an application for a State Innovation Model (SIM) Testing Grant from the Center for Medicare and Medicaid Innovation. The goal is to get federal support to test new ways of delivering and paying for health care in California. The State’s application focuses on four targeted health system and payment reforms, including the development of health homes for complex patients.

CHHS wants to “[i]mplement and spread care models, which include coordinated, team-based care, to improve the quality of care and outcomes for medically complex patients, and reduce costs associated with unnecessary emergency department visits and hospitalizations.” Complex patients are not yet defined.

CHHS is coordinating this effort with the Department of Health Care Services (DHCS) because of the opportunity to draw down additional federal dollars for health homes in the Medi-Cal program. The Affordable Care Act (ACA) includes a “State Option to Provide Health Homes for Enrollees with Chronic Conditions” provision. The provision increases federal financial support for states that develop a health home program for Medicaid-eligible individuals with at least: (1) two chronic conditions; (2) one chronic condition and who are at risk of having a second chronic condition; OR (3) one serious and persistent mental health condition.

This definition will likely influence CHHS’s definition in the SIM Testing Grant described above. The health homes in the DHCS program are required to provide comprehensive care management; care coordination and health promotion; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support; referral to community and social support services; and use of health information technology to link services, as feasible and appropriate.

Finally, health plans in California are starting to implement non-volume based payment (e.g., a per-member-permonth payment or bonus payment) to medical groups that participate in Accountable Care Organizations (ACOs).

The plans expect medical groups to implement a clinical intervention, such as moving primary care practices to the PCMH model, but are not necessarily dictating the patient population or services required in that intervention. Medical groups are targeting high-cost conditions, however, because of the greater potential for quality improvement and cost savings.

Moving to the PCMH model is a hefty undertaking, requiring an accurate assessment of your practice as is and a plan of action to drive change. That plan, and the way you prioritize making change, should account for the increasing focus of payers and regulators on complex, high-cost patients. CAFP urges you to make that plan today. We are here to help.

1.

Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers D. Early Evidence on the Patient-Centered Medical Home.

Final Report (Prepared by Mathematica Policy Research).

AHRQ Publication No. 12-0020-EF. Rockville, MD: Agency for Healthcare Research and Quality. February 2012.

California Family Physician Spring 2014 9

Clarissa Kripke, MD, FAAFP

Treating Diverse Populations: Patients with Complex Disabilities I didn’t start my medical career intending to serve adults with developmental disabilities such as cerebral palsy, intellectual disability and autism. But people with complex disabilities showed up at my clinic. I wasn’t able to care for them. The exam rooms were too small; the appointments were too short; and response times for urgent needs were too slow. As family physicians, we were trained to respond to the needs of our communities. I offered to go to my patients. I tried a new way of delivering care, a home care model that worked better for my patients, their caregivers and for me.

Simple things can make a huge difference in quality of life, such as treating constipation, accommodating non-traditional forms of communication or insisting on a welldesigned wheelchair.

When I started caring for people with disabilities, it was just my job to keep people healthy. When my son was diagnosed with autism, I realized that health for people with disabilities means more than medical care. Doctors control access to medical care. We also control access to all the things required for a full life—transportation, housing, jobs, long-term care, adaptive equipment, therapies and education. People with disabilities are disproportionately affected by health care system problems and by public policies that make access to many services dependent on eligibility for Medi-Cal. While most adults with developmental disabilities have MediCal and Medicare insurance, thanks to provisions in the Affordable Care Act, many now also have private health insurance.

In California, people with disabilities have been enrolled in managed care plans. Many health plans do not have experience caring for the population and lack expertise in their networks. Doctors in a wide range of practice settings will care for people with 10

California Family Physician Spring 2014

complex disabilities.

Access to health care is more than having health insurance and a primary care doctor.

When we don’t have the resources and training we need to serve our patients with disabilities, it is devastating. To serve our patients, we need training.

We need time and staff to do thoughtful assessments, coordinate with our patient’s interdisciplinary teams, educate, support decisions and complete paperwork. We need access to disability-competent consultation and specialty care. We also need support to make our offices physically and programmatically accessible. We need to change the policies that prevent our patients from working and maximizing their potential.

California Academy of Family Physicians (CAFP) is leading a coalition to improve access to care for people with Medi-Cal insurance. Payment reforms will enable cost effective service delivery. Physicians can help by documenting the barriers to care.

CAFP’s Medi-Cal Access Reporting Survey is a simple, on-line form that can be used to document the access problems that you and your patients encounter. The survey will be available all year. You can make multiple entries and share with colleagues. CAFP and its partners will use your stories to advocate for policies that reduce health disparities for California’s most vulnerable citizens. In the meantime, to assist physicians who want to improve the quality of care they provide, many resources are available on the Office of Developmental Primary Care website http://odpc.ucsf.edu.

Dr. Kripke is a Clinical Professor and Director of Developmental Primary Care at the University of California, San Francisco, Department of Family and Community Medicine.

INSPIRE greatness

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Family Practice:

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health.org

GET READY FOR

ICD-10

OCT. 1, 2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing.

CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Plan Your Journey – Look at the codes you use, prepare a budget, and build a team

•

Train Your Team – Find options and resources to help your team get ready for the transition

•

Update Your Processes – Review your policies, procedures, forms, and templates

•

Engage Your Partners – Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes – Test within your practice and with your partners

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

California Family Physician Spring 2014 11

diverse populations

Chris Flores, MD

Treating Diverse Populations: Ethnogeriatrics and Dementia Dr. Chris Flores with his wife, Maricela Fernandez

“I am scared. He has been getting more physically violent at night and sometimes he hits me or kicks me. I don’t know if it is safe for me to be at home.” – Mrs. G. This quote is not from a typical victim of domestic violence or a worried family member panicked about their loved one with mental illness or a substance abuse problem. Mrs. G is a caregiver for her husband with dementia.

Behavioral and psychological symptoms of dementia (BPSD) present some of the most challenging situations facing caregivers and physicians alike. These symptoms include agitation, wandering, refusal of care, paranoid delusions, angry outbursts and physical violence. Such difficult behaviors often overwhelm caregivers and precipitate emergency room visits or placement of dementia patients in nursing homes and other institutional care. These clinical situations are very complex to manage from a primary care standpoint; simple pharmacologic treatment approaches often are not enough to control BPSD and prevent hospitalization and/or institutionalization.

I have seen this type of scenario many times since establishing my private practice in 2005 in the Palm Springs area. I was inspired and challenged to learn about BPSD and improve my knowledge of evidence-based interventions by patients within my own practice. I repeatedly observed preventable emergency room visits and hospitalizations that could have been headed off by better BPSD management in the home setting.

I have a low-overhead, low-volume practice based on L. Gordon Moore’s “Ideal Medical Practice” (www.impcenter. org) business model. I do not accept insurance, Medicare or Medi-Cal. This cash-only practice model allows me to take care of a smaller panel of patients than the typical primary care practice, and it affords me the time to follow patients closely, research their conditions, and pursue clinical research and academic study within the purview of my practice. In addition, because I do not charge an annual retainer fee, I have attracted a very diverse patient panel including Spanishspeaking immigrant families.

Often it is the very small things that can make a big difference in managing BPSD. Removing triggers for behaviors, teaching 12

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caregivers to distract, redirect, and validate a patient’s concerns, removing medications that may be exacerbating cognitive impairment, eliminating clutter and distractions from the home environment, and introducing some exercise or artistic activities, can diminish or resolve difficult BPSD. We can prevent many injuries and hospitalizations if we have more time to evaluate and assess the situation in a holistic fashion.

I work with my wife, Maricela Fernandez, who serves as office manager and occasional impromptu advocate and health educator. Sometimes what dementia caregivers need most is information and guidance on government and community resources for dementia care and education. We are able to help patients like Mrs. G by linking them to language appropriate caregiver support groups, mental health professionals and other social services.

I am currently finishing up a pilot study of physician perspectives on BPSD in ethnically diverse elders. Family physicians are the first-line medical providers for patients with dementia, and I think there is a lot to learn from our collective experience. No specialty is more capable than family doctors to come up with creative, caring, and low-cost solutions to complicated medical problems.

Chris Flores works with his wife, Maricela Fernandez, in a private practice in Palm Desert, California, and he serves as the Vice-Chair of the CAFP Committee on Continuing Professional Development.

THE STRENGTH TO HEAL and get

back to what I love about family medicine.

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©2014. Paid for by the United States Army. All rights reserved.

California Family Physician Spring 2014

Ashby Wolfe, MD, MPP, MPH

politiCal pulse

CAFP-Sponsored Bills on Access to Care Set the Tone for 2014 This year will be an important legislative year for family medicine. With millions of patients projected to purchase private insurance and be added to Medi-Cal rolls through the Affordable Care Act’s (ACA) Medicaid expansion, and with the transition of vulnerable patient populations into Medi-Cal Managed Care, CAFP’s number one priority is to ensure that patients have access to family physicians and other needed care providers. Your Academy is attacking this issue of access to care on several fronts.

adopted in June 2011 and implemented late last year. It will help to ensure that needed access to specialty care is available for Medi-Cal beneficiaries. AB 1759 (Pan) will extend the ACA provision that increases primary care physician Medi-Cal payment to Medicare levels, set to expire at the end of 2014. This bill will also create an annual independent assessment of Medi-Cal provider payment rates and their impact on access and quality of care for patients in the MediCal program.

Our main goal is to pass CAFP’s sponsored bill, AB 2458, authored by Assemblymember Susan Bonilla (D – Concord).

The shortage of primary care physicians in California is well documented. Primary care physicians make up just 34 percent of California’s physician workforce, and approximately 74 percent of California counties have an undersupply of primary care physicians. AB 2458 would help to alleviate access to care problems by making a multimillion dollar state fund investment in increasing medical residency training slots in geographic areas and physician specialties of need. The legislation would increase the number of primary care physicians training and practicing where they are needed in California.

In addition, CAFP and several other associations are collecting provider stories that shed light on the barriers to care for Medi-Cal beneficiaries. As millions of patients enter the health care system at the same time that Medi-Cal payment rates are cut, CAFP and its partners are asking providers to share stories that demonstrate network inadequacy and access issues in our Medi-Cal Access Reporting Survey. Your responses will be essential for mobilizing advocacy efforts around access and payment reform with health plans and the Department of Health Care Services. You can return to the survey any time this year to report additional issues as you experience them. We also ask CAFP members to please share this link with colleagues and ask them to fill out the survey as well: http://www.surveygizmo.com/s3/1526840/Medi-CalAccess-Issue-Reporting

By funding additional training slots at residency programs in underserved areas, California gains an immediate return on investment, drawing resident physicians to practice in areas where they are needed most and providing care at an average of 600 additional patient visits per physician per year during residency training alone. Our long-term workforce will grow significantly as well, as the majority of physicians who train in a region stay in that region to practice. California leads all but one other state (Alaska) in the percentage of residency training program graduates who stay in the state in which they trained – nearly 70 percent!

CAFP is also supporting efforts to ensure that patients in the Medi-Cal program have an adequate network of physicians available to care for them. CAFP-supported AB 1805 (Skinner) will reverse the 10 percent Medi-Cal provider payment cut

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California Family Physician Spring 2014

Finally, there are two resolutions introduced by the Legislature that should be on family physicians’ radar. The first is authored by Assemblymember Richard Bloom (D – Santa Monica), brother of CAFP member Stuart Bloom, MD. It would designate 2014 as the “Year of the Family Physician.”

Another resolution, authored by Assemblymember Richard Pan, MD (D – Sacramento), would define the Patient Centered Medical Home based on CAFP’s sponsored legislation from last year, AB 1208.

Please sign up to be a CAFP Key Contact and stay tuned to Advocacy Alerts sent out by the Academy as the bills move through the legislative process, so you can find out how to support these important efforts!

PHYSICIAN – OBSTETRICS AND GYNECOLOGY

Vista Community Clinic located in North San Diego County Seeking: Part-Time and per diem OB/GYN Physicians.

Requirements: California license, DEA license, CPR certification and board certified in obstetrics and gynecological medicine.

Bilingual English/Spanish preferred. Bilingual English/Spanish

Contact Us: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760-414-3702

MED7 has been providing urgent care services in the Greater Sacramento area since 1987 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.

Keck School of Medicine of USC is seeking a board certified physician to join our residency program. The California Hospital Medical Center/University of Southern California (CHMC/USC) Family Medicine Residency Program, fully-accredited since 1984, is an 8-8-8 program where family medicine is the primary residency in this community hospital. This exciting and challenging full-time opportunity includes full spectrum Family Medicine with responsibilities in private practice, direct in/out patient care, and teaching/ supervision of the program’s residents. Our residents’ primary training site, the USC-Eisner Family Medicine Center, is a Federally Qualified Health Center.

CHMC, part of Dignity Health, is a major not-for-profit safety-net acute teaching hospital, with 318 beds. The hospital provides a myriad of tertiary care services and has specialty areas such as the Los Angeles Center for Women’s Health, 24 hour emergency services, a Level II Trauma Center, Hope Street Family Center, and pediatric and cardiac services.

Selected candidates will have: - Completed an ACGME approved Family Medicine Residency Program - Current CA license - DEA - Board certification Preferred qualifications candidates may have: - Sports Medicine CAQ - Geriatrics CAQ - Inpatient/ICU Medicine - Inpatient Obstetrics

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.

PHYSICIAN – FAMILY MEDICINE Vista Community Clinic located in North San Diego County Seeking: Full-time, part-time and per diem Family Medicine Physicians.

Requirements: California license, DEA license, CPR certification and board certified in family medicine.

Bilingual English/Spanish preferred.

Contact Us: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760-414-3702

The position provides an academic appointment at the USC Keck School of Medicine. USC values diversity and is committed to equal opportunity in employment. Women and men, and members of all racial and ethnic groups are encouraged to apply. Please submit your curriculum vitae to: fmrp@usc.edu The mission of the California Hospital Medical Center/University of Southern California Family Medicine Residency Program is to train family physicians to provide compassionate and comprehensive care to a diverse, urban, medically underserved population and to guide trainees to excel in both academic and clinical medical careers. The program is committed to advance health care through education, research, medical service, and community partnership. Our goal is to produce family physicians capable and dedicated to the total health care of their patients and their patients’ families.

California Family Physician Spring 2014 15

Meet your Incoming President: Del Morris, MD CAFP’s incoming president, Del Morris, MD of Modesto, has had a varied career as a family physician – military physician, solo practice doc, group practice doc, residency program director (twice!) and, now, medical director for a county health system caring for the medically indigent.

Each experience has left its mark in a positive way on Dr. Morris’s outlook about his specialty. The experiences range from managing the “cluster” of cancer deaths among his clinic patients, which influenced his approach to helping patients through the end of life, to working with residents who are feeling burnout from dealing with the emotional pressures of patient care. Serving as full time faculty right out of his residency, he was the residency’s behavior science coordinator and taught parenting and marriage classes for residents at Ft. Belvoir, VA. While there, he once wrote the Surgeon General of the Army that his heavy smoking was providing a poor role model for the officers who worked under him and that he was making Captain Morris’s efforts to get patients to stop more difficult (some of Dr. Morris’s patients worked in the Pentagon for the Surgeon General).

Dr. Morris is Medical Director for the Stanislaus County Health Services Agency and lives in Modesto with his wife, Paula, whom he began dating at a summer science nerd camp between their junior and senior years in high school,

Dr. Morris at a pharmacy in China during a 1984 trip.

and married during his junior year in college. They have two adult children. Their son Kit and his wife live in southern California, and their daughter Josie, her husband and two children (Siena and Grant), live in Texas. The Morrises spend as much time as possible with their grandkids. Paula says Del was born to be a grandfather and absolutely revels in every aspect.

CFP interviewed Dr. Morris recently: CFP: Tell us about your practice.

My practice in the county health system has been to care for childless adults who until January 1st didn’t qualify for MediCal – they were our indigent population. My patients have quite different backgrounds from those whom I saw at the Mason Clinic in Washington State. Many of those patients were college-educated, took parenting classes and winter ski trips. Now my patients ask for bus passes to get to their appointments, are unemployed (and unemployable); many struggle with mental illness and the post- traumatic stress disorder (PTSD) of their own childhood abuse, have multiple chronic diseases, and often struggle with the consequences of addiction. Integration of medical care and behavioral health isn’t an option.

Dr. Morris pictured with wife, Paula, circa 1965.

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California Family Physician Spring 2014

Dr. Morris pictured with parents at his medical school graduation.

CFP: Do you ever feel unsafe?

Yes, at times. One time I was treating a recently new patient for his PTSD symptoms and asked him if they had improved after an adjustment in medication. Instead he switched the subject to his back pain. When I told him I would get to that but wanted to finish getting an idea about how the medication was working he got angry and red in the face, stood up and said angrily, “You’re treating me just like they did in prison.”

He had intermittent explosive personality disorder, and the sister he was living with had sent me messages that she and her family were worried and afraid of him. I had asked him what things made him angry and he gave the example that he got angry when she asked him what he wanted for breakfast. “Why was she bothering me with that? For 12 years in prison I just ate what they gave me. Why would I care?”

The first time I examined him I saw a large tattoo across his abdomen that said “187.” I asked what one hundred and eighty seven stood for and he corrected me, “It’s One-EightSeven, the California penal code for murder” (with malicious intent).

I treated him for PSTD. He couldn’t sleep. He had visual and auditory hallucinations of the victim he had knifed to death. His victim sat in the corner of his bedroom and said repeatedly, “Let me go home.”

He is much better now. His hallucinations have resolved; his nightmares have dramatically decreased. Treatment for his OSA has helped a lot. His HTN and DM2 are controlled and he is getting daily exercise which is helping his back. Now, after twelve months, he asked if I would be his mother’s and sister’s doctor. He trusts me.

Dr. Morris (right) with CAFP President, Mark Dressner, MD (left) at the 2014 AMAM #2014YearFP photo booth.

CFP: Tell us about your typical day In addition to my administrative duties I see patients three half-days a week. I attend residency clinic three half-days a month and supervise their inpatient service one week a quarter. I give an occasional lecture and behavioral science seminar.

This year I have been charged with leading the transformation of the county clinic system to the Patient Centered Medical Home (PCMH) model. The county has six primary care clinics and a specialty center and I am medical director for them. We have 18 (21 by fall) family physicians, two pediatricians, two obstetrician-gynecologists, 32 family medicine residents and 14 mid-levels. Kathleen Kearns is the new residency program director. The residency program has many challenges too, with changes from the Residency Review Committee including documenting milestones and competencies as well as living within the resident hour limitations. We also have a variety of part-time specialty clinics staffed by contracted providers (25).

CFP: What aspect of being president excites you most?

What challenges you most?

What’s most exciting is being involved with my specialty at such a dynamic time – the reaffirmation of family medicine and values that guide how we provide care. Health care reform is integrating so many of the concepts present at the formation of our specialty. In addition, we now have the technology to integrate population health into the care we give. We’re experiencing the most revolutionary change since I became a family physician. I think the closest thing to it was the advent of the capitation system and the hope of promoting the status of primary care – unfulfilled – in the mid-80s. It is our task to deal with the changes and meet the challenges. This whole thing may take a decade or more to evolve.

To read Dr. Morris’ full interview and learn more about your incoming president, please visit www.familydocs.org.

California Family Physician Spring 2014 17

CAFP Foundation Scholar Treats Immigrant Population through The Border Health ProjectAn Interview with Teresa Robbins, MD Congratulations on being selected as a Foundation Scholar. Please talk about your experiences during the first year of the program.

During my first year as a CAFP scholar, I participated in a summer preceptorship with two family physicians in San Francisco. While improving my history-taking and physical exam skills, I also witnessed the rewards and challenges of the day-to-day work of a primary care provider. Last fall, I attended the Family Medicine Summit in Los Angeles, where medical students, residents and family physicians from around California convened to exchange ideas about the future of the field. As a part of a Family Medicine Interest Group (FMIG) at University of California, San Diego (UCSD) I helped organize mentoring opportunities for medical students interested in family medicine.

One of the requirements for the first year includes authoring a blog post for the CAFP Foundation or FMRevolution website. You wrote about the UCSD Border Health Project. Please tell us about the program.

The Border Health Project (BHP) was founded

by UCSD medical students in 2006 under the principle that all people deserve access to basic health services and resources. BHP aims to improve access to care for one of the most marginalized populations in San Diego: migrant farmworkers. In November 2013, more than 50 UCSD undergraduates, medical students, pharmacists and physicians traveled to a large avocado farm in Fallbrook to screen workers and their families for diabetes, high cholesterol, obesity and hypertension. The workers were then guided to health education tables to learn about topics that were personally relevant to them. Flu vaccinations, over-the-counter medications, hygiene supplies and clothing were available for all attendees. For all patients identified as “high-risk” based on their screening values or acute concerns, appointments were made immediately at Vista Community Clinic for the following week. The next BHP health fair is being planned for March 2014.

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California Family Physician Spring 2014

How did you get involved with the program?

I heard about the Border Health Project when I was applying to UCSD, but the specific population it served had dispersed by the time I started my first year. Rene Garcia, another second-year medical student, and I decided to try to find another farmworker community that could benefit from BHP’s services. Through a community activist, we were introduced to a large remote farm in Fallbrook where there was a clear need. During our visits, we heard from many workers about the barriers they face, including difficulty with transportation to distant clinics, fear of deportation, strenuous working conditions and minimal access to healthy foods.

With the help of our faculty advisor, Dr. Miguel Casillas, and the enthusiastic staff at Vista Community Clinic, who provide outreach, transportation assistance and healthcare services for the migrant population in North County, we held the first fair last November.

What is the ultimate goal?

Although health education, flu vaccines and basic resources are helpful, the ultimate goal of the screenings is to connect at-risk patients with the high quality health care and services that already exist at Vista Community Clinic. Also, the majority of the medical student volunteers had not worked with the migrant population prior to the first fair, so we hope that increasing students’ exposure will expand their interest in providing care and advocating for migrant communities as future physicians.

Finally, what are you looking forward to most during your second year in the CAFP-F Scholars Program?

I am very excited to improve my clinical skills as a third-year medical student, and to attend the national AAFP conference this August.

Theresa Robbins, MD

The CAFP Foundation Scholars program is a longitudinal, threeyear program offered to 20 first-year medical students with a strong interest in family medicine and primary care. For more information, please visit the CAFP Foundation website at http://www. cafpfoundation.org/ programs/scholars/.

diverse populations

Catherine Sonquist Forest, MD MPH Jennifer Hastings, MD

Treating Diverse Populations: the Transgender Community Dr. Forest (left) Dr. Hastings (right)

“Are you sexually active?” “What kind of birth control are you using”?

Think for a second. What are the underlying assumptions of these questions? Suppose the closeted transgender person above bravely came to your office for primary care despite the barriers to care.

For example, if this patient is not at risk for pregnancy because the patient is not ‘exposed to sperm’ and actually identifies on gender spectrum as ‘male’ – these questions can be alienating (even if presenting outwardly female and being sexually or sensually active with a natal female). Of course, there are many other possibilities – active with natal males, active with both, etc.

Once you have that information, you can be more sensitive in your questions. “Are you at risk for pregnancy?” “ Are you or any of your sexual partners considering pregnancy in the next 12 months? Can you tell me about that?”

Let’s see if we can do better. This population has THE HIGHEST RISK of any demographic for HIV and the least access to care. Why? Because they are afraid of being humiliated in our offices or have been rejected there.

While many of us have been trained on cultural sensitivity for ethnicity, culture, language and religion, even for gay/lesbian/ bisexual patients – many family physicians have had little diversity training on gender identity. In fact, society’s bias toward binary gender identity is reinforced in most electronic health records (male or female) even though the evidence suggests gender identify falls on a spectrum.

It is estimated that 0.1 to 1 percent of Americans are thought to be transgender. Compare this to the prevalence of the 0.05 percent who have Grave’s disease. Learning how to ask about gender identity sensitively and be comfortable with the diversity of responses (our patients’ stories, their medical needs) is a challenge we ALL must rise to. World consensus guidelines to treat transgender dysphoria with hormones and medications, as well as guidelines for referring for surgery, have existed since the late 1990s. Yet most family doctors have yet to develop the skills necessary to provide a safe environment to provide even basic primary care to transgender patients.

The medicine is not that tough. We all learn how to adapt to changing guidelines for hypertension, diabetes, hyperthyroidism, COPD, hyperlipidemia –this is much easier to master. Why, then, the barriers to care?

We suspect it is because we have yet to address our own biases. Just as we may have biases against people with obesity and mental illness (see past CAFP CME Spotlights) so we may inadvertently stigmatize transgender people. As physicians WE MUST MOVE BEYOND this and treat transgender people with compassion IN OUR PATIENT-CENTERED MEDICAL NEIGHBORHOODS. Their very lives depend on it!

To start, use the table to your right to screen for transgender people in your practice.

California Family Physician Spring 2014 19

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ĹšĆŠĆ‰Í—ÍŹÍŹÇ Ç Ç Í˜ĹľÄžÄšÍ˜ĆľĹľĹ?Ä?ĹšÍ˜ÄžÄšĆľÍŹÄšĹ?Ç€ÄžĆŒĆ?Ĺ?ƚLJ͏ ƉĚĸůĞĆ?ÍŹĹšÄžÄ‚ĹŻĆšĹšĆ‰ÄžĹ˝Ć‰ĹŻÄžÍ˜Ć‰ÄšÄ¨ ĹšĆŠĆ‰Í—ÍŹÍŹĆšĆŒÄ‚ĹśĆ?ĹšÄžÄ‚ĹŻĆšĹšÍ˜ĆľÄ?Ć?Ä¨Í˜ÄžÄšĆľÍŹ ĹšĆŠĆ‰Í—ÍŹÍŹÇ Ç Ç Í˜Ç Ć‰Ä‚ĆšĹšÍ˜Ĺ˝ĆŒĹ?ÍŹĆ?Ĺ?ƚĞͺƉĂĹ?Ğ͘ Ä?ĨžÍ?ƉŏͺĂĆ?Ć?Ĺ˝Ä?Ĺ?Ä‚Ć&#x;Ĺ˝ĹśÍşÇ ÄžÄ?ƉĂĹ?Ğͺ ĹľÄžĹśĆľŃ Ď­ĎŻĎąĎ­Î˜Ć‰ĹŹÍşÄ‚Ć?Ć?Ĺ˝Ä?Ĺ?Ä‚Ć&#x;ŽŜͺ Ç ÄžÄ?ƉĂĹ?ÄžŃ ĎŻĎľĎŽĎ˛ ĹšĆŠĆ‰Í—ÍŹÍŹÇ Ç Ç Í˜ĆšĆŒÄ‚ĹśĆ?Í˛ĹšÄžÄ‚ĹŻĆšĹšÍ˜Ä?Žž͏ώϏϭϯ͏ ĆšĆŒÄ‚ĹśĆ?Ĺ?ÄžĹśÄšÄžĆŒÍ˛Ä‚Ä¸ĆŒĹľĹ?ĹśĹ?ͲŚŽĆ?ƉĹ?ƚĂůͲƉŽůĹ?Ä?Ĺ?ÄžĆ?Ͳ Ĺ?ĆľĹ?ĚĞ͏ ĹšĆŠĆ‰Í—ÍŹÍŹÇ Ç Ç Í˜ĹšĆŒÄ?Í˜Ĺ˝ĆŒĹ?ÍŹÄŽĹŻÄžĆ?ÍŹÄ‚Ć?Ć?ĞƚĆ?ÍŹ ĆŒÄžĆ?Ĺ˝ĆľĆŒÄ?ÄžĆ?ÍŹ DZͺĂŜĚͺdĆŒÄ‚ĹśĆ?Ĺ?ÄžĹśÄšÄžĆŒÍş WÄ‚Ć&#x;ÄžĹśĆšÍ˜Ć‰ÄšÄ¨ ĹšĆŠĆ‰Í—ÍŹÍŹÇ Ç Ç Í˜ĆšĹšÄžĆšÄ‚Ć?ĹŹÄ¨Ĺ˝ĆŒÄ?ÄžÍ˜Ĺ˝ĆŒĹ?ÍŹĆŒÄžĆ‰Ĺ˝ĆŒĆšĆ?Íş Ä‚ĹśÄšÍşĆŒÄžĆ?ÄžÄ‚ĆŒÄ?Ś͏ŜƚĚĆ?ͺžƾůĆ&#x;ĆŒÄ‚Ä?Ĺ?Ä‚ĹŻÍş ĆŒÄžĆ?ƉŽŜĚĞŜƚĆ?

Seeking Patient-Centered Primary Care Physicians Patient-centered primary care, through an Employer-Sponsored Medical Home, is an innovative approach enabling physicians to transform their careers. This is an exciting opportunity for a primary care career where you can truly have it all: a smaller panel where you spend as much time as you want with your patients... without ďŹ nancial risk. Welcome to Paladina Health™, the leader in bringing this transformative model to healthcare!

Paladina Health™ is a subsidiary of $A6ITA (EALTHCARE 0ARTNERS )NC AND currently operates primary care clinics on-site or near employer facilities in 12 states. Our clients are located in urban, MIDSIZE AND RURAL LOCATIONS THROUGHOUT the country.

1UALIl CATIONS s Medical degree from an accredited medical school s #OMPLETION OF A &AMILY 0RACTICE OR )NTERNAL -EDICINE 0EDIATRICS residency program s Board certiďŹ cation or eligibility REQUIRED !CTIVE STATE LICENSE AND $%! PREFERRED

Our Employer-Sponsored Medical Home model offers many beneďŹ ts to both physicians and their patients: s %NHANCED 2ELATIONSHIPS ,IMITED 0ATIENTS WITHOUT PATIENT TIME CONSTRICTIONS s !LIGNED )NCENTIVES &OCUS ON IMPROVING HEALTH OUTCOMES DRIVING PATIENT engagement, and creating an atmosphere where patients are highly satisďŹ ed s &OCUS ON 0REVENTIVE #ARE /UR PHYSICIANS PROVIDE HEALTH CARE NOT SICK CARE s &LEXIBLE 0RACTICE !PPROACH WITH )MPROVED 1UALITY OF ,IFE FOR 9OU AND 9OUR &AMILY s )MPROVED -EDICAL -ODEL 5TILIZE ELECTRONIC MEDICAL RECORDS AND RIGOROUS POPULATION MANAGEMENT TOOLS #OMPETITIVE 3ALARY 7E OFFER A COMPETITIVE base salary with signiďŹ cant upside potential resulting from a quality and satisfaction-based bonus program... no production incentives.

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UCSF FRESNO FAMILY MEDICINE FACULTY POSITION THE UCSF Fresno Medical Education Program and the Central California Faculty Medical Group (CCFMG) are recruiting for a physician to join the teaching faculty.

The successful applicant should be board certified in Family Medicine and be licensed or eligible to practice in California. This position provides an opportunity for teaching, clinical research, and community practice. Proficiency in OB optional. Administrative/leadership opportunities are available. A competitive salary is offered.

The program is based in Fresno, California, where residents enjoy a high standard of living combined with a low cost of living. The result is a quality of life uniquely Californian, yet surprisingly affordable. Limitless recreational opportunities and spectacular scenery is all accessible in a community with abundant affordable housing. While there is much to see and do in Fresno, the city is ideally located for fast, convenient getaways to the majestic Sierra (just 90 minutes away) as well as the scenic Central Coast, just two and one-half hours away. Fresno is the only major city in the country with close proximity to three national parks, including renowned Yosemite National Park.

Interested applicants should apply online at https://aprecruit.ucsf.edu/apply/JPF00026 Visit our websites: www.fresno.ucsf.edu

www.communitymedical.org

“UCSF seeks candidates whose experience, teaching, research, or community service has prepared them to contribute to our commitment to diversity and excellence. UCSF is an Equal Opportunity/Affirmative Action Employer. The University undertakes affirmative action to assure equal employment opportunity for underrepresented minorities and women, for persons with disabilities, and for covered veterans. All qualified applicants are encouraged to apply, including minorities and women.�

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California Family Physician Spring 2014

1 out of 2 U.S. households say they need more life insurance.*

And What About You? With all that’s going on in your life, have you overlooked an indispensable part of your family’s financial security – making sure you have enough life insurance? The AAFP Guaranteed-Level-Premium Term Life Insurance Plan offers up to $2,000,000 in benefits at exclusive AAFP member rates.

For information including exclusions, limitations, rates, eligibility and renewal provisions of The AAFP Guaranteed-Level-Premium Term Life Insurance Plan call (800) 325-8166 or visit www.aafp.org/insurance facebook.com/aafpinsurance

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California Family Physician Spring 2014 21

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For adult patients with type 2 diabetes, Victoza® offers these benefits and more.

Visit VictozaPro.com/Care to learn how the support program helps patients get started.

*Victoza® 1.2 mg and 1.8 mg when used alone or in combination with OADs. † Victoza® is not indicated for the management of obesity, and weight change was a secondary end point in clinical trials.

Indications and Usage

Victoza® (liraglutide [rDNA origin] injection) is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk.

Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise.

Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been observed in patients treated with Victoza®. Victoza® has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for pancreatitis while using Victoza®. Other antidiabetic therapies should be considered in patients with a history of pancreatitis.

Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings.

Victoza® has not been studied in combination with prandial insulin.

Important Safety Information

Liraglutide causes dose-dependent and treatment-durationdependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors.

Victoza® is a registered trademark of Novo Nordisk A/S. © 2013 Novo Nordisk All rights reserved.

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Do not use in patients with a prior serious hypersensitivity reaction to Victoza® (liraglutide [rDNA origin] injection) or to any of the product components.

Postmarketing reports, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis. Discontinue promptly if pancreatitis is suspected. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapies in patients with a history of pancreatitis.

When Victoza® is used with an insulin secretagogue (e.g. a sulfonylurea) or insulin serious hypoglycemia can occur. Consider lowering the dose of the insulin secretagogue or insulin to reduce the risk of hypoglycemia.

Renal impairment has been reported postmarketing, usually in association with nausea, vomiting, diarrhea, or dehydration which may sometimes require hemodialysis. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment.

Serious hypersensitivity reactions (e.g. anaphylaxis and angioedema) have been reported during postmarketing use of Victoza®. If symptoms of hypersensitivity reactions occur, patients must stop taking Victoza® and seek medical advice promptly.

There have been no studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.

The most common adverse reactions, reported in ≥5% of patients treated with Victoza® and more commonly than in patients treated with placebo, are headache, nausea, diarrhea, dyspepsia, constipation and anti-liraglutide antibody formation. Immunogenicity-related events, including urticaria, were more common among Victoza®treated patients (0.8%) than among comparator-treated patients (0.4%) in clinical trials.

Victoza® has not been studied in type 2 diabetes patients below 18 years of age and is not recommended for use in pediatric patients.

There is limited data in patients with renal or hepatic impairment.

Please see brief summary of Prescribing Information on adjacent page.

0513-00015592-1

June 2013

Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatmentduration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies.

Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been observed in patients treated with Victoza®. Victoza® has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for pancreatitis while using Victoza®. Other antidiabetic therapies should be considered in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and prandial insulin has not been studied.

CONTRAINDICATIONS: Do not use in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Do not use in patients with a prior serious hypersensitivity reaction to Victoza® or to any of the product components.

WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies. In the clinical trials, there have been 6 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 2 cases in comparator-treated patients (1.3 vs. 1.0 cases per 1000 patient-years). One comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease.

All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Five of the six Victoza®-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One Victoza® and one non-Victoza®-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin.

Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis, has been observed in patients treated with Victoza®. After initiation of Victoza®, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® should promptly be discontinued and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Consider antidiabetic therapies other than Victoza® in patients with a history of pancreatitis. In clinical trials of Victoza®, there have been 13 cases of pancreatitis among Victoza®-treated patients and 1 case in a comparator (glimepiride) treated patient (2.7 vs. 0.5 cases per 1000 patient-years). Nine of the 13 cases with Victoza® were reported as acute pancreatitis and four were reported as chronic pancreatitis. In one case in a Victoza®-treated patient, pancreatitis, with necrosis, was observed and led to death; however clinical causal-

ity could not be established. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) or insulin may have an increased risk of hypoglycemia. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea (or other concomitantly administered insulin secretagogues) or insulin Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Hypersensitivity Reactions: There have been postmarketing reports of serious hypersensitivity reactions (e.g., anaphylactic reactions and angioedema) in patients treated with Victoza®. If a hypersensitivity reaction occurs, the patient should discontinue Victoza® and other suspect medications and promptly seek medical advice. Angioedema has also been reported with other GLP-1 receptor agonists. Use caution in a patient with a history of angioedema with another GLP-1 receptor agonist because it is unknown whether such patients will be predisposed to angioedema with Victoza®. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.

ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® has been evaluated in 8 clinical trials: A double-blind 52-week monotherapy trial compared Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, and glimepiride 8 mg daily; A double-blind 26 week add-on to metformin trial compared Victoza® 0.6 mg once-daily, Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, placebo, and glimepiride 4 mg once-daily; A double-blind 26 week add-on to glimepiride trial compared Victoza® 0.6 mg daily, Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, placebo, and rosiglitazone 4 mg once-daily; A 26 week add-on to metformin + glimepiride trial, compared double-blind Victoza® 1.8 mg once-daily, double-blind placebo, and open-label insulin glargine once-daily; A doubleblind 26-week add-on to metformin + rosiglitazone trial compared Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily and placebo; An open-label 26-week add-on to metformin and/or sulfonylurea trial compared Victoza® 1.8 mg once-daily and exenatide 10 mcg twice-daily; An open-label 26-week add-on to metformin trial compared Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, and sitagliptin 100 mg once-daily; An open-label 26-week trial compared insulin detemir as add-on to Victoza® 1.8 mg + metformin to continued treatment with Victoza® + metformin alone. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five double-blind controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. In these five trials, the most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Common adverse reactions: Tables 1, 2, 3 and 4 summarize common adverse reactions (hypoglycemia is discussed separately) reported in seven of the eight controlled trials of 26 weeks duration or longer. Most of these adverse reactions were gastrointestinal in nature. In the five double-blind clinical trials of 26 weeks duration or longer, gastrointestinal adverse reactions were reported in 41% of Victoza®-treated patients and were dose-related. Gastrointestinal adverse reactions occurred in 17% of comparator-treated patients. Common adverse reactions that occurred at a higher incidence among Victoza®-treated patients included nausea, vomiting, diarrhea, dyspepsia and constipation. In the five double-blind and three open-label clinical trials of 26 weeks duration or longer, the percentage of patients who reported nausea declined over time. In the five double-blind trials approximately 13% of Victoza®-treated patients and 2% of comparator-treated patients reported nausea during the first 2 weeks of treatment. In the 26-week open-label trial comparing Victoza® to exenatide, both in combination with metformin and/or sulfonylurea, gastrointestinal adverse reactions were reported at a similar incidence in the Victoza® and exenatide treatment groups (Table 3). In the 26-week open-label trial comparing Victoza® 1.2 mg, Victoza® 1.8 mg and sitagliptin 100 mg, all in combination with metformin, gastrointestinal adverse reactions were reported at a higher incidence with Victoza® than sitagliptin (Table 4). In the remaining 26-week trial, all patients received Victoza® 1.8 mg + metformin during a 12-week run-in period. During the run-in period, 167 patients (17% of enrolled total) withdrew from the trial: 76 (46% of withdrawals) of these patients doing so because of gastrointestinal adverse reactions and 15 (9% of withdrawals) doing so due to other adverse events. Only those patients who completed the run-in period with inadequate glycemic control were randomized to 26 weeks of add-on therapy with insulin detemir or continued, unchanged treatment with Victoza® 1.8 mg + metformin. During this randomized 26-week period, diarrhea was the only adverse reaction reported in ≥5% of patients treated with Victoza® 1.8 mg + metformin + insulin detemir (11.7%) and greater than in patients treated with Victoza® 1.8 mg and metformin alone (6.9%).

Table 1: Adverse reactions reported in ≥5% of Victoza®-treated patients in a 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Reaction Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Headache 9.1 9.3 Table 2: Adverse reactions reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Metformin Placebo + Metformin Glimepiride + Metformin N = 724 N = 121 N = 242 (%) (%) (%) Adverse Reaction Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial ® Placebo + Glimepiride Rosiglitazone + All Victoza + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Reaction Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2

California Family Physician Spring 2014 23

Constipation Dyspepsia

5.3 0.9 1.7 5.2 0.9 2.6 Add-on to Metformin + Glimepiride Victoza® 1.8 + Metformin Placebo + Metformin + Glargine + Metformin + + Glimepiride N = 230 Glimepiride N = 114 Glimepiride N = 232 (%) (%) (%) Adverse Reaction 3.5 1.3 Nausea 13.9 5.3 1.3 Diarrhea 10.0 5.6 Headache 9.6 7.9 0.9 1.7 Dyspepsia 6.5 6.5 3.5 0.4 Vomiting Add-on to Metformin + Rosiglitazone Placebo + Metformin + Rosiglitazone All Victoza® + Metformin + Rosiglitazone N = 355 N = 175 (%) (%) Adverse Reaction Nausea 34.6 8.6 Diarrhea 14.1 6.3 2.9 Vomiting 12.4 8.2 4.6 Headache Constipation 5.1 1.1 Table 3: Adverse Reactions reported in ≥5% of Victoza®-treated patients in a 26-Week Open-Label Trial versus Exenatide Victoza® 1.8 mg once daily + Exenatide 10 mcg twice daily + metformin and/or sulfonylurea metformin and/or sulfonylurea N = 235 N = 232 (%) (%) Adverse Reaction Nausea 25.5 28.0 Diarrhea 12.3 12.1 Headache 8.9 10.3 Dyspepsia 8.9 4.7 Vomiting 6.0 9.9 Constipation 5.1 2.6 Table 4: Adverse Reactions in ≥5% of Victoza®-treated patients in a 26-Week Open-Label Trial versus Sitagliptin All Victoza® + metformin Sitagliptin 100 mg/day + N = 439 metformin N = 219 (%) (%) Adverse Reaction Nausea 23.9 4.6 Headache 10.3 10.0 Diarrhea 9.3 4.6 Vomiting 8.7 4.1 Immunogenicity: Consistent with the potentially immunogenic properties of protein and peptide pharmaceuticals, patients treated with Victoza® may develop anti-liraglutide antibodies. Approximately 50-70% of Victoza®-treated patients in the five double-blind clinical trials of 26 weeks duration or longer were tested for the presence of anti-liraglutide antibodies at the end of treatment. Low titers (concentrations not requiring dilution of serum) of anti-liraglutide antibodies were detected in 8.6% of these Victoza®-treated patients.

Sampling was not performed uniformly across all patients in the clinical trials, and this may have resulted in an underestimate of the actual percentage of patients who developed antibodies. Cross-reacting antiliraglutide antibodies to native glucagon-like peptide-1 (GLP-1) occurred in 6.9% of the Victoza®-treated patients in the double-blind 52-week monotherapy trial and in 4.8% of the Victoza®-treated patients in the double-blind 26-week add-on combination therapy trials. These cross-reacting antibodies were not tested for neutralizing effect against native GLP-1, and thus the potential for clinically significant neutralization of native GLP-1 was not assessed. Antibodies that had a neutralizing effect on liraglutide in an in vitro assay occurred in 2.3% of the Victoza®-treated patients in the double-blind 52-week monotherapy trial and in 1.0% of the Victoza®-treated patients in the double-blind 26-week add-on combination therapy trials.

Among Victoza®-treated patients who developed anti-liraglutide antibodies, the most common category of adverse events was that of infections, which occurred among 40% of these patients compared to 36%, 34% and 35% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. The specific infections which occurred with greater frequency among Victoza®-treated antibody-positive patients were primarily nonserious upper respiratory tract infections, which occurred among 11% of Victoza®-treated antibody-positive patients; and among 7%, 7% and 5% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. Among Victoza®-treated antibody-negative patients, the most common category of adverse events was that of gastrointestinal events, which occurred in 43%, 18% and 19% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. Antibody formation was not associated with reduced efficacy of Victoza® when comparing mean HbA1c of all antibody-positive and all antibody-negative patients. However, the 3 patients with the highest titers of anti-liraglutide antibodies had no reduction in HbA1c with Victoza® treatment. In the five double-blind clinical trials of Victoza®, events from a composite of adverse events potentially related to immunogenicity (e.g. urticaria, angioedema) occurred among 0.8% of Victoza®-treated patients and among 0.4% of comparator-treated patients. Urticaria accounted for approximately one-half of the events in this composite for Victoza®-treated patients. Patients who developed anti-liraglutide antibodies were not more likely to develop events from the immunogenicity events composite than were patients who did not develop anti-liraglutide antibodies. Injection site reactions: Injection site reactions (e.g., injection site rash, erythema) were reported in approximately 2% of Victoza®-treated patients in the five double-blind clinical trials of at least 26 weeks duration. Less than 0.2% of Victoza®-treated patients discontinued due to injection site reactions. Papillary thyroid carcinoma: In clinical trials of Victoza®, there were 7 reported cases of papillary thyroid carcinoma in patients treated with Victoza® and 1 case in a comparator-treated patient (1.5 vs. 0.5 cases per 1000 patient-years). Most of these papillary thyroid carcinomas were <1 cm in greatest diameter and were diagnosed in surgical pathology specimens after thyroidectomy prompted by findings on protocol-specified screening with serum calcitonin or thyroid ultrasound. Hypoglycemia: In the eight clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 11 Victoza®-treated patients (2.3 cases per 1000 patient-years) and in two exenatidetreated patients. Of these 11 Victoza®-treated patients, six patients were concomitantly using metformin and a sulfonylurea, one was concomitantly using a sulfonylurea, two were concomitantly using metformin (blood glucose values were 65 and 94 mg/dL) and two were using Victoza® as monotherapy (one of these patients was undergoing an intravenous glucose tolerance test and the other was receiving insulin as treatment during a hospital stay). For these two patients on Victoza® monotherapy, the insulin treatment was the likely explanation for the hypoglycemia. In the 26-week open-label trial comparing Victoza® to sitagliptin, 24

California Family Physician Spring 2014

the incidence of hypoglycemic events defined as symptoms accompanied by a fingerstick glucose <56 mg/ dL was comparable among the treatment groups (approximately 5%).

Table 5: Incidence (%) and Rate (episodes/patient year) of Hypoglycemia in the 52-Week Monotherapy Trial and in the 26-Week Combination Therapy Trials Victoza® Treatment Active Comparator Placebo Comparator None Monotherapy Victoza® (N = 497) Glimepiride (N = 248) Patient not able to 0 0 — self−treat Patient able to self−treat 9.7 (0.24) 25.0 (1.66) — Not classified 1.2 (0.03) 2.4 (0.04) — ® Glimepiride + Placebo + Metformin Add-on to Metformin Victoza + Metformin (N = 724) Metformin (N = 121) (N = 242) Patient not able to 0.1 (0.001) 0 0 self−treat Patient able to self−treat 3.6 (0.05) 22.3 (0.87) 2.5 (0.06) Continued Victoza® None Add-on to Victoza® + Insulin detemir + ® Metformin Victoza + Metformin + Metformin alone (N = 163) (N = 158*) Patient not able to 0 0 — self−treat Patient able to self−treat 9.2 (0.29) 1.3 (0.03) — Add-on to Victoza® + Glimepiride Rosiglitazone + Placebo + Glimepiride (N = 695) Glimepiride (N = 231) (N = 114) Glimepiride Patient not able to 0.1 (0.003) 0 0 self−treat Patient able to self−treat 7.5 (0.38) 4.3 (0.12) 2.6 (0.17) Not classified 0.9 (0.05) 0.9 (0.02) 0 ® Placebo + Metformin Add-on to Metformin Victoza + Metformin + Rosiglitazone None + Rosiglitazone + Rosiglitazone (N = 355) (N = 175) Patient not able to 0 — 0 self−treat Patient able to self−treat 7.9 (0.49) — 4.6 (0.15) Not classified 0.6 (0.01) — 1.1 (0.03) ® Add-on to Metformin Victoza + Metformin Insulin glargine Placebo + Metformin + Glimepiride + Metformin + + Glimepiride + Glimepiride (N = 230) Glimepiride (N = 232) (N = 114) Patient not able to 2.2 (0.06) 0 0 self−treat Patient able to self−treat 27.4 (1.16) 28.9 (1.29) 16.7 (0.95) Not classified 0 1.7 (0.04) 0 *One patient is an outlier and was excluded due to 25 hypoglycemic episodes that the patient was able to self-treat. This patient had a history of frequent hypoglycemia prior to the study.

In a pooled analysis of clinical trials, the incidence rate (per 1,000 patient-years) for malignant neoplasms (based on investigator-reported events, medical history, pathology reports, and surgical reports from both blinded and open-label study periods) was 10.9 for Victoza®, 6.3 for placebo, and 7.2 for active comparator.

After excluding papillary thyroid carcinoma events [see Adverse Reactions], no particular cancer cell type predominated. Seven malignant neoplasm events were reported beyond 1 year of exposure to study medication, six events among Victoza®-treated patients (4 colon, 1 prostate and 1 nasopharyngeal), no events with placebo and one event with active comparator (colon). Causality has not been established. Laboratory Tests: In the five clinical trials of at least 26 weeks duration, mildly elevated serum bilirubin concentrations (elevations to no more than twice the upper limit of the reference range) occurred in 4.0% of Victoza®treated patients, 2.1% of placebo-treated patients and 3.5% of active-comparator-treated patients. This finding was not accompanied by abnormalities in other liver tests. The significance of this isolated finding is unknown. Vital signs: Victoza® did not have adverse effects on blood pressure. Mean increases from baseline in heart rate of 2 to 3 beats per minute have been observed with Victoza® compared to placebo.

The long-term clinical effects of the increase in pulse rate have not been established. Post-Marketing Experience: The following additional adverse reactions have been reported during post-approval use of Victoza®. Because these events are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure: Dehydration resulting from nausea, vomiting and diarrhea; Increased serum creatinine, acute renal failure or worsening of chronic renal failure, sometimes requiring hemodialysis; Angioedema and anaphylactic reactions; Allergic reactions: rash and pruritus; Acute pancreatitis, hemorrhagic and necrotizing pancreatitis sometimes resulting in death.

OVERDOSAGE: Overdoses have been reported in clinical trials and post-marketing use of Victoza®. Effects have included severe nausea and severe vomiting. In the event of overdosage, appropriate supportive treatment should be initiated according to the patient’s clinical signs and symptoms.

More detailed information is available upon request.

For information about Victoza® contact: Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, NJ 08536, 1−877-484-2869 Date of Issue: April 16, 2013 Version: 6 Manufactured by: Novo Nordisk A/S, DK-2880 Bagsvaerd, Denmark Victoza® is covered by US Patent Nos. 6,268,343, 6,458,924, 7,235,627, 8,114,833 and other patents pending.

Victoza® Pen is covered by US Patent Nos. 6,004,297, RE 43,834, RE 41,956 and other patents pending. © 2010-2013 Novo Nordisk 0513-00015681-1 5/2013

diverse populations

Dineen Greer, MD, MPH

Treating Diverse Populations: Caring for Patients with HIV

Family physicians are uniquely qualified to care for patients with HIV/AIDS! Here’s my story…

As a medical student in San Francisco in the early 1990s, I frequently encountered patients suffering with unusual infections – cryptococcol meningitis, pneumocystis pneumonia (PCP) and cytomegalovirus. Previously vibrant, healthy young men were wasting away. One particular patient, “Michael,” still stands out in my memory after all these years.

I was a third year medical student on my internal medicine rotation. Michael had recurrent PCP. I spent many hours talking with Michael about his family, career and the life aspirations that never would be fulfilled. Like the many patients we saw with AIDS, we were only able to make him better temporarily. His CD4 count was extremely low, and he was quickly readmitted. We couldn’t save him.

During residency and for a few years after residency while working in a community health center in Seattle, WA, I continued to see patients diagnosed with HIV/AIDS, but it was not a large part of daily practice. In 2003, my family and I returned to our California roots, and I began teaching family medicine residents in Sacramento. At that time, my colleague, David Pilcher, had a large HIV practice, but he had plans to move to the coast.

It seemed daunting at first, as I felt rusty having not seen HIV patients on a regular basis for two years. Being close to San Francisco allowed me to take advantage of numerous Continuing Medical Education (CME) opportunities, however. I also had the support of other HIV/AIDS providers in my area. I joined the American Academy of HIV medicine (www.aahivm. org) and became a certified HIV specialist through their credentialing process.

I found myself really enjoying this part of my practice. The scientist part of me loves knowing exactly how the HIV antiretroviral medications work to control the virus, and the family doctor part of me enjoys the deep bonds that develop over time with patients with long-term illnesses.

Thanks to amazing advances in our knowledge of the virus, we have turned HIV infection into a long term, chronic disease. I often tell my patients that HIV in many ways is no different

Thanks to amazing advances in our knowledge of the virus, we have turned HIV infection into a long term, chronic disease. from hypertension and diabetes. I enable my patients to live long, healthy lives by encouraging healthy lifestyle choices and by managing antiretroviral medications (HAART).

Patients with HIV have so many of the chronic problems that we see in the typical family medicine office: diabetes, hypertension, obesity and depression. A few years ago, the HIV/AIDS conferences started including sessions on how to treat these conditions as well as the latest U. S. Preventive Services Task Force screening guidelines. I remember thinking “I know how to do that; just give me the update on the new HIV treatment guidelines.”

For example, in late 2012 when the Centers for Disease Control (CDC) recommended that all patients with HIV receive not only Pneumovax but also PCV-13 (Prevnar) for the prevention of pneumococcal infections, it was a problem for many of the non-family medicine HIV care docs as they did not stock pediatric vaccinations in their offices.

I sometimes notice my primary care colleagues shy away from seeing patients with HIV/AIDS when really, they are probably the best doctors for them! For those out there interested in providing this service, please consider additional training in this area. The Pacific AIDS Education and Training Center HIV Learning Network has a program to help primary care docs learn how to treat HIV (www.paetc.org).

I often think about the many “Michaels” who did not live to see this day. I look forward to the time when I can write an article encouraging my family medicine colleagues to treat patients with the medications that cure HIV, not just control it.

Dineen Greer, MD, MPH is faculty at the Sutter Family Medicine Residency Program in Sacramento. GreerD@ sutterhealth.org California Family Physician Spring 2014 25

David Kruse, MD

Treating Diverse Populations: Athletes

community athletic programs still are in need of quality sports medicine coverage. You will find physicians across the state seeing kids on school

campuses, providing medical coverage for sports events, and opening up their clinics for athletes with limited healthcare access.

MIEC Policyholders can take FREE CME Courses in Pain Medication Management.

Family physicians (as well as pediatricians, internists, physiatrists, and emergency medicine doctors) who seek further training in sports medicine call ourselves Primary Care Sports Medicine (PCSM) specialists (visit www.amssm.org for more information). A primary care sports medicine practice involves much more than musculoskeletal care and addresses the whole athlete, recreational or elite. We have an active role in the promotion of exercise as medicine, but we are also there for when exercise becomes pathologic.

PCSM specialists treat a variety of medical conditions in addition to a wide spectrum of musculoskeletal care. During pre-participation sports exams we must screen for sudden cardiac death risk. We address heat illness, cervical spine injures, and concussion. We work with school districts to develop policy to keep our kids safe. We also help our active patients with other health conditions such as asthma, pregnancy, and physical and mental disabilities.

Sports medicine creates many opportunities to provide community service. Many high school and 26

California Family Physician Spring 2014

MIEC has partnered with ELM Exchange, Inc., to provide case-based, online CME programs that teach healthcare providers to identify and mitigate risk in their clinical practices. This no-cost, convenient curriculum is proven to help physicians create a culture of enhanced patient safety and increased quality of care.

CME in pain medication management: From June 2013 to June 2014, the coursework offered to MIEC policyholders will focus on liabilities associated with patients treated for chronic pain management. Policyholders designated as primary care providers have been pre-registered and may log in at the ELM registration page as returning users.

For more information: Call or Email MIEC’s Loss Prevention Department Phone: 800-227-4527 Email: lossprevention@miec.com MIEC 6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com CalFamPhy_ad2_03.13.14

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Our roles as PCSM specialists are to keep our patients exercising and competing by preventing and treating their injuries and illnesses.

you I struggle with that on a daily basis.

It is important to find a balance between success in sport and appropriate injury prevention and management.

For athletes, recreational or competitive, athletic endeavors are a big part of what defines them as individuals. Our roles as PCSM specialists are to keep our patients exercising and competing by preventing and treating their injuries and illnesses.

An equally important role is to help

support them emotionally when they are injured and during the times when they are forced to redefine themselves.

Dr. David Kruse is a primary care, sports medicine specialist practicing in Orange County, CA. He currently serves as USA Gymnastics Men’s National Team physician and helps with medical coverage for USA Water Polo. For more information visit Dr. Kruse’s website: http://www.krusesportsmd.com/.

We also have the opportunity in sports medicine to engage a broad spectrum of healthcare professionals. Treating the whole athlete involves a team approach.

A PCSM specialist routinely reaches out to colleagues in athletic training, physical therapy, orthopedic surgery, nutrition, sports psychology, chiropractic care, acupuncture, and the fitness industry.

PCSM specialists with family medicine backgrounds have the opportunity to treat a wide variety of active, healthconscious individuals. This may range from school-age athletes to the “aging athlete.” A former competitive athlete who is now an aging athlete in his 50s may “no longer be able to bounce back like he used to.” The body undergoes normal physiologic changes over time.

These can include declines in VO2max and tissue compliance, and joint degenerative changes. Training for aging athletes may need to be adjusted or they may find themselves at a higher risk for injury. If older athletes train and play the same way they did in their 20s, they will quickly find themselves in a sports medicine clinic.

.

Many PCSM specialists come to the specialty with a personal sports background; I was once a competitive athlete. All physicians learn in medical school to be aware of the emotional investment we may have in our patients and to avoid countertransference.

Sometimes that is difficult for a sports physician. On a personal note, I can tell California Family Physician Spring 2014 27

CAFP’s Covered California Resources for Family Physicians Want to know more about Covered California and ways to talk with patients about its benefits? CAFP offers instructional videos, slide sets, news updates and more at http://familydocs.org/covered-california.

Covered California Has Historic First Open Enrollment Period When the state’s historic first open enrollment period for Covered California closed on March 31, the state had surpassed its original goals for enrollment. More than two million applications had been processed, more than 830,000 people had been enrolled in private health plans and more than 877,000 in the newly expanded MediCal program.

This is great news in California, where seven million people were uninsured at the end of 2013. Family physicians can help reduce that number even further by continuing throughout 2014 to let patients know that Covered California may be a good source of affordable coverage for them. Open enrollment for 2015 will begin in October and Medi-Cal enrollment is available all year.

Covered California’s mission is to “increase the number of Californians with health insurance, improve the quality of health care for all Californians, reduce health care coverage costs and make sure California’s diverse population has fair and equal access to quality health care.” The state health benefit exchanges were established under the national health care reform law, the Affordable Care Act. Under health care reform, millions of Californians are receiving federal subsidies to help make coverage more affordable. Of the 829,000 people enrolled in private plans by mid-February, 626,000 were eligible for subsidies. Young people through age 26 may remain covered under their parents’ policies, which also helps make care more affordable for many. In addition, other previous barriers to coverage, such as insurers denying coverage to patients with preexisting conditions, have been dismantled.

Despite its many benefits, many of the low-income and uninsured people who most need coverage through Covered California (or other states’ options) are either unaware it exists or unsure how to begin the application process. Also, as of mid-March, Latinos in California and young people in general were under-enrolled. By simply mentioning Covered California and providing the phone 28

California Family Physician Spring 2014

number and website URL, family physicians and their office staff members can help patients access affordable coverage. The exchange’s phone services are available in several languages; all services are free and confidential; and the website is in Spanish and English.

The state’s enrollment efforts are an unprecedented undertaking.

Millions of Californians have used the Covered California website, and the state has trained nearly 5,000 enrollment counselors, more than 11,000 insurance agents, more than 10,000 county eligibility workers, and others.

The state also has launched numerous creative, innovative outreach, media and marketing campaigns, partnering with local community leaders and organizations, social service agencies and celebrities.

Many patients may see these during 2014, but confirmation from a trusted family physician that Covered California offers assistance may be the most important message they hear.

Under the Affordable Care Act, most Americans must have health care coverage beginning this year or incur a penalty of $95 or one percent of their income, whichever is greater. Penalties for 2014 will be assessed on people’s 2014 tax returns filed in 2015.

Recent Kaiser Family Foundation polling shows that the public’s sentiments toward requirements under health care reform are mixed, but a majority say the law should be kept in place. Some 48 percent want Congress to improve the law and eight percent say it should be kept as is. Just 12 percent say the law should be repealed and replaced with a Republican-sponsored alternative and 19 percent say it should be repealed and not replaced.

Family physicians can play an important part in helping patients understand how health care reform is benefitting them. Accessing affordable coverage is the first step. Then patients can realize the benefits of accessing the care they and their families need, when they need it.

Physicians have faced over 90,000 alleged HIPAA violations. Make sure you’re prepared. *

For decades, The Doctors Company has provided the highest-quality medical malpractice insurance. Now, the professionals of The Doctors Company Insurance Services offer the expertise to protect your practice from risks beyond malpractice. From slips and falls to emerging threats in cyber security—and everything in between. We seek out all the best coverage at the most competitive prices. So talk to us today and see how helpful our experts can be in preparing your practice for the risks it faces right now—and those that may be right around the corner.

Call (800) 852-8872 today for a quote or a complimentary insurance assessment. n n n n

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California Family Physician Spring 2014 29 4806_CA_FamilyPhysician_Spring2014.indd 1

3/20/14 4:28 PM

Susan Hogeland, CAE

exeCutive viCe president’s Forum

The Face of Family Medicine Is Changing

Perhaps one of the best ways to meet the health needs of a diverse patient population is to have them cared for by physicians and other clinicians who look like them – who reflect their ethnicity, culture and sexual orientation and speak their preferred language. From 2002 – 2011, CAFP and our foundation convened the Medical Leadership Council on Cultural Proficiency (MLC), funded by grants from The California Endowment. MLC’s mission was to convene the key stakeholders of California’s medical and health organizations to educate, build capacity and engage their respective memberships on issues of racial and ethnic health disparities – sexual orientation later was added to the mission. One of its goals was to, “Examine barriers and means to improve entry into the medical and health professions by members of California’s underrepresented minority and underserved populations and undertake efforts to increase diversity representative of California’s population in the health care workforce.”

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our #FamilyMedicineRevolution and Year of the Family Physician campaigns to raise awareness of the specialty, to say nothing of advocating for better pay for primary care services.

I’m not going to bore you with a lot of statistics about who’s in medical schools or residency training. I will say that as I sat at the head table at CAFP’s first All Member Advocacy Meeting March 1-2 and looked out at the audience – composed of 110 Active, medical student and resident members – those on the younger side of the scale appeared more reflective of what California looks like today than those on the more mature side.

That is not to say, of course, that those on the mature side are insufficiently culturally proficient or that underrepresented minority health professionals are proficient per se. It is only to say that the balance is shifting a bit more and California’s ethnic minorities will be seeing more people who look like them taking care of them in the future.

Our latest salvo to engage and support students and residents is our transition from the old Congress of Delegates to the new All Member Advocacy Meeting, a revised governance structure that allows CAFP to be more nimble on the policy front and maximizes the value of this weekend gathering by educating and motivating students, residents and Active members to become advocates for the specialty and their patients. An added benefit is providing mentorship for the younger members by the older. The motivation quotient was high: from leading family medicine researcher Kevin Grumbach’s keynote speech on how to use both data and anecdote to convince policymakers about actions that should be taken to support primary care, to updates on the attack on the Medical Injury Compensation Reform Act (MICRA) by both Lisa Maas, Executive Director of Californians Allied for Patient Protection and Dustin Corcoran, Chief Executive Officer of the California Medical Association, and from an overview of the accomplishments of Covered California

by Executive Director Peter Lee to the inspiring story of Fresno’s Community Medical Provider group’s transformation to the Patient Centered Medical Home, with CAFP’s help. It was further enhanced by training sessions on “Framing Your Message” with Amy Weitz and “Meeting with Your Legislator” by our own Adam Francis, Leah Newkirk and Jodi Hicks. The real proof of the pudding was the 56 FPs and students who stayed over until Monday to participate in our Lobby Day in Sacramento festivities – a record number we hope to beat next year.

CAFP has supported many efforts to ensure that this is the case – from advocating for loan repayment programs to supporting additional residency slots through increased Graduate Medical Education funding, from our Future Faces of Family Medicine program to

So, mark your calendar now for the 2015 All Member Advocate Meeting at The Citizen Hotel in Sacramento March 7-8 followed by CAFP’s Lobby Day in Sacramento on Monday, March 9. Find out what all the buzz is about – and join in.

California Family Physician Winter 2014

West Coast

Family Medicine Opportunities

Northern, Central and Southern California, The Pacific Northwest and Hawaii

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Inpatient, Outpatient & Traditional Family Medicine options available

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Full & Part-time possibilities

Visit physiciancareers.ah.org or confidentially contact Ryan Rasmusson, Director of Physician Recruitment, at 800.847.9840 to discover why top physicians choose to work with Adventist Health

phyjobs@ah.org  800.847.9840  physiciancareers.ah.org California Family Physician Sspring 2013

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

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“ We listen to policyholders. We provide solid advice and offer real-time solutions to real-time problems.”

Loss Prevention Senior Representative Kathy Kenady

Service and Value MIEC takes pride in both. For almost 40 years now, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with policyholders to keep premiums low.

Added value: n No profit motive and low overhead n $17.5 million in dividends* distributed in 2014 For more information or to apply: n www.miec.com n Call 800.227.4527 n Email questions to underwriting@miec.com * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

Average Dividend as % of Premiums Past five Years

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California Family Physician Spring 2014

38.6%

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6.66%

Med Mal Insurance (PIAA)

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