René Bravo, MD:
Your New Trustee HOD Preview SBCH Completes New Pavilions CenCal Health News Hub Fall 2018
FALL 2018 CENTRAL COAST PHYSICIANS
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2019
Healing the Heart
FIRST ANNUAL CARDIOLOGY SYMPOSIUM BY COTTAGE HEALTH
COTTAGE HEART & VASCULAR CENTER SPEAKERS:
FRIDAY, FEBRUARY 1, 2019 RITZ CARLTON- BACARA, SANTA BARBARA
Joe Aragon, MD Interventional Cardiology Peter Baay, MD Cardiovascular-Thoracic Surgery
Featuring nationally recognized guest speakers including local experts from the Heart & Vascular Center at Cottage Health.
Greg Cogert, MD Cardiac Electrophysiology
KEYNOTE: Karol E. Watson, MD, PhD - Professor of Medicine/Cardiology, David Geffen School of Medicine at UCLA, Director, UCLA Women’s Cardiovascular Health Center
Brett Gidney, MD Cardiac Electrophysiology
INVITED SPEAKERS INCLUDE:
Vishal Goyal, MD Invasive Cardiology
Sunil V. Rao, MD - Professor of Medicine, Duke University Health System and The Duke Clinical Research Institute
Taylor Holve, MD Adult Congenital Cardiology
Bojan Cercek, MD, PhD - Professor of Medicine, Director, Coronary Care Unit, Co-Director, Atherosclerosis Research Center, Cedars-Sinai Medical Center Natesa G. Pandian, MD - Medical Director HOAG Heart Valve Center, Director, Non-Invasive Cardiology and Academic Program, Professor of Medicine, Tufts University
Alan Malki, MD Cardiovascular-Thoracic Surgery
Accreditation Statement The Santa Barbara County Consortium for CME is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.
Colin Shafer, MD Non-Invasive Cardiology Michael Shenoda, MD Interventional Cardiology
Credit Designation Statement The Santa Barbara County Consortium for CME designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Early Bird Registration (before January 14): Nursing/Allied Health: $150 | Physicians: $200 For a list of additional speakers and to register, visit cottagehealth.org/healingtheheart 2
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VOLUME 3, NUMBER 4 • FALL 2018
{FEATURES}
6 12 16 Fall 2018
CMA HOD PREVIEW
Reducing Administrative Burdens on Physician Practices
SBCH COMPLETES NEW PAVILIONS
{DEPARTMENTS} 8
MEN’S HEALTH: WILL BOYS BE BOYS?
10 PUBLIC HEALTH: REDUCING ACCIDENTAL OVERDOSES
14 CENCAL HEALTH NEWS HUB 22 RISK TIP: VR FOR PAIN MANAGEMENT 26 NEW MEMBERS
GETTING TO KNOW YOUR NEW TRUSTEE
28 IN MEMORIAM 30 CLASSIFIEDS
CENTRAL COAST PHYSICIANS
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Letter from the CEO
BEING A PART OF THE SOLUTION
This is an especially exciting time of year. As we are about to go to print with this magazine, we are preparing for the House of Delegates (HOD). At HOD, physicians debate health care policy and hold the California Medical Association’s Board of Trustees’ election.
PRESIDENT Jennifer Hone, MD SECRETARY Daniel Berger, MD TREASURER Samira Kayumi-Rashti, MD IMMEDIATE PAST PRESIDENT David Dodson, MD DIRECTORS Kevin Casey, MD; Joseph Freeman, MD; Priti Gagneja, MD; Thomas Hale, MD; Ali Javanbakht, MD; Bindu Kamal, MD; Juan Reynoso, MD; Joseph Schwartz, MD
Our local Trustee nominee, Rene’ Bravo, MD, DANA GOBA is featured in this issue. Dr. Bravo will be the Central Coast’s representative on the Board of Trustees, and he is looking forward to working on solutions to protect your profession and patients.
CHIEF EXECUTIVE OFFICER Dana Goba, MBA CMA HOUSE OF DELEGATES REPRESENTATIVES Sam Ahmad, MD; Sharon Basham, MD; Edward Bentley, MD; Charity Dean, MD, MPH; David Dodson, MD; Priti Gagneja, MD; Jennifer Hone, MD;
HOD consists of nearly 500 delegates elected by members of component medical societies, specialty societies, and CMA sections and forums, representing virtually every mode of practice and region of the state. Delegates debate the most important issues affecting members and the practice of medicine. This year’s topic is addressing the cost and affordability of health care. Since the topic is a complex issue, it has been divided up into four categories.
• Addressing utilization through improved care delivery • Addressing increasing pharmaceutical costs • Reducing administrative burdens on physician practices • Enhancing competitiveness of the health care market
Attendees will hear from experts in these areas, and then decide as a group how we should move forward. I find the entire process captivating and look forward to House of Delegates every year. The Central Coast Medical Association has six delegates and six alternates. If you are interested in participating, please contact me. You have to be a member to be able to shape the future of medicine and be a part of the solution. If you are not a member, go to www.cmadocs.org/join. Together we are stronger.
Christopher Lumsdaine, MD; Jenni Nix, MD; Joseph Schwartz, MD; Steven Yao, MD CENTRAL COAST PHYSICIANS MAGAZINE EDITOR Jennifer Hone, MD MANAGING EDITOR Dana Goba, MBA CREATIVE DIRECTOR Sherry Lavone Design CONTRIBUTING WRITERS Penny Borenstein, MD, MPH; Katherine Boroski; CenCal Health; Cottage Health; David Dodson, MD; Miranda Felde, MHA, CPHRM; Elizabeth Schwyzer CONTRIBUTING PHOTOGRAPHERS CenCal Health, Cottage Health, County of San Luis Obispo, Sean Kirkpatrick, Elizabeth Schwyzer SUGGESTIONS, story ideas, or completed stories written by current Central Coast Medical Association members are welcome. Opinions expressed by authors are their own and not necessarily those of the CCMA. CCMA reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. PLEASE DIRECT EDITORIAL INQUIRIES AND SUBMISSIONS TO: Central Coast Physicians 100 N Hope Ave, Ste 14 Santa Barbara, CA 93110 T 805.683.5333 • F 805.364.5431 E magazine@sbmed.org ADVERTISING rates and information sent upon request. Acceptance of advertising in Central Coast Physicians in
Sincerely,
no way constitutes approval or endorsement by CCMA of products or services advertised. CCMA reserves the right to reject any advertising. All advertising inquiries can be sent to magazine@sbmed.org.
Dana Goba Chief Executive Officer Central Coast Medical Association
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CMA to address cost and affordability of health care at annual meeting By Katherine Boroski, Senior Director of Communications, California Medical Association
THE 147TH ANNUAL SESSION OF THE CALIFORNIA MEDICAL ASSOCIATION (CMA) HOUSE OF DELEGATES (HOD) WILL CONVENE NEXT WEEKEND, OCTOBER 13-14 IN SACRAMENTO. CMA physician delegates meet annually to establish broad policy on current major issues that have been determined to be the most important issues affecting members, the association and the practice of medicine. This year, the delegates will tackle one major issue with many facets —addressing the cost and affordability of health care.
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Because this year’s topic is a complex issue, it
ADDRESSING INCREASING
has been divided up into four categories.
PHARMACEUTICAL COSTS
• Addressing Utilization Through Improved
The cost of pharmaceuticals has been a high-
Care Delivery
profile focus of discussions around health care
• Addressing Increasing Pharmaceutical Costs
costs in the media and legislative bodies. While
• Reducing Administrative Burdens on
California has significant and progressive laws
Physician Practices • Enhancing Competitiveness of the Health Care Market
that address pharmaceutical costs, the issue warrants additional discussion. CMA delegates will discuss whether California should take further steps to address the rising costs of
ADDRESSING UTILIZATION THROUGH
prescription drugs.
IMPROVED CARE DELIVERY CMA currently has extensive policies
ENHANCING COMPETITIVENESS OF THE
supporting and defining a wide range of care
HEALTH CARE MARKET
delivery reforms that support the overarching
California has seen considerable consolidation
goal of promoting access to care through
in insurance, hospital and physician markets.
efficient care coordination in a system built on
CMA delegates will discuss the impacts of
primary care with access to specialty care. CMA
these changes on cost, accessibility and quality
delegates this year will discuss gaps in existing
of care, as well as offer recommendations for
CMA policy, with an emphasis on payment and
additional CMA policy and future advocacy
delivery reforms; social determinants of health;
development.
and the expanded use of telehealth. Reports on these issues are available to REDUCING ADMINISTRATIVE BURDENS ON
members at cmadocs.org/hod.
PHYSICIAN PRACTICES Over time, the level of administrative activity
CMA believes that any health care cost
involved in health care has dramatically
containment proposals must include the
increased, placing significant costs and
entire health care sector. It is paramount that
burdens on the health care system. Meaningful
physicians examine ways to bend the cost
reform to significantly reduce health care costs
curve in all sectors of the health care system. In
will require changing how and when these
addition, there are significant opportunities to
administrative tasks occurs. CMA delegates
improve health care delivery, create efficiencies
will discuss and make recommendations on
and improve health care outcomes. The policy
ways to simplify and streamline administrative
framework that comes out of this year’s HOD
tasks that do not improve quality of care and
will reflect CMA’s priorities for health care cost
outcomes, take time away from patient care
containment and serve the basis for future
and add unnecessary and duplicative costs to
advocacy on this issue.
the overall health care system. STAY TUNED TO OUR NEXT ISSUE FOR UPDATES ON THE POLICIES AND ACTIONS TAKEN BY THE DELEGATES.
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MEN’S HEALTH
Will Boys Be Boys? BY DAVID DODSON, MD
Our nation is currently riveted and being riven by the Bret Kavanaugh Supreme Court nomination hearings. As I write this, the FBI is launching a brief investigation into allegations he sexually assaulted Dr. Christine Blasey Ford in a drunken frenzy 36 years ago. Some have suggested he should not be held accountable
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for what he may or may not have done as a 17-year-old. This argument would hold a lot more weight if he had not opined from the bench on the responsibility of 17-year-olds for their crimes. Some have gone so far as to describe his alleged behavior as normal for 17-year-old boys.
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This latter argument is repugnant. Like Kavanaugh, I was raised in the Catholic Church to which he claims to adhere. Like all members of the Abrahamic faiths - whether Jew, Christian, or Muslim - Catholics are taught the 10 Commandments, not the 10 Suggestions. Catholics are not taught to
consider attempting to rape a 15-year-old girl while drunk to be normal behavior for their 17-year-old son. On the contrary, any parent I’ve ever know would be profoundly ashamed by such a child and far from condoning it as normal for a 17-year-old, would do whatever they could to save such a child from such wicked ways. Such a child would be subjected to “ RAPE IS NOT HUMAN NATURE. SPOUSE the harshest ABUSE IS NOT HUMAN NATURE. THEY ARE discipline, not CHOICES.” - BUFFY ST. MARIE told “boys will be boys”. Boys will be follow the 10 Commandments when they boys, just as girls will be girls. This doesn›t feel like it or when they are sober or when mean they will be rapists. they remember to. To violate any of the My friend, the Reverend Dr. David Moore, Ten Commandments is always and without posted his opinion that 36 years ago Bret exception a grave sin. What is the point of Kavanaugh tried to force himself on Dr. religion, civilization, or law if not to constrain Christine Blasey Ford while Mark Judge our baser instincts? To suggest that sexually stood by and did nothing and now he’s trying assaulting girls is normal behavior for teenage to force himself on the whole country while boys is to slander teenage boys, very few Senate Republicans stand by and do nothing. of whom engage in the sort of behavior Thanks to a last-minute change of heart Kavanaugh has been accused of. Fortunately by Senator Jeff Flake, there will be an FBI for women and for society at large, the investigation, however rushed and cursory. better angels of our nature, reinforced by Dr. Moore was challenged by a reader who good upbringing with or without religious asked how he would feel if his son were indoctrination, inform the behavior of most falsely accused. His reply “I’d want the FBI teens. to investigate and clear his name”, which of Do teenagers have high libidos? Are they course is exactly what the Kavanaugh and his sometimes impulsive? Undisciplined? Is backers did not want. Santa Barbara beautiful? Yes, yes, yes, and However this plays out, let us not tar all yes! Is this a formula for the kind of behavior teenage boys with the same brush. Very few Judge Kavanaugh has been accused of ? have ever engaged in the type of behavior Fortunately, rarely. In Freudian terms, the id Kavanaugh has been accused of, or for that is controlled by the superego. Predators with matter ever considered behaving that way or undeveloped superegos, or who suppress their would be even be capable of doing so. Of superegos with substances such as alcohol course, such predators do exist. Hopefully are pathological, not normal. I don’t think we will not wind up with one on the Supreme I’ve ever had a friend or relative who would Court ruling on women’s health issues.
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Public Health
Update
Reducing the Risk of Accidental Rx Overdose by Penny Borenstein, MD, MPH, Health Officer/Public Health Director, County of San Luis Obispo
In recent years, the local and national dialogue about “risky medications” has focused on opioids—and with good reason, as our communities continue to grapple with the effects of an ongoing opioid epidemic. Yet a recent analysis of medication-related deaths in San Luis Obispo County reveals other less-discussed risks, and an opportunity for physicians to make a difference in stopping accidental overdoses. The analysis highlighted the risk of sedatives and the risk of mixing sedatives with other medications. Our epidemiology team summarized toxicology findings for deaths investigated by the Coroner during a three-year period from early 2015 through early 2018. During this time, the Coroner’s office requested toxicology analysis to aid investigation of 732 cases; of these, 677 (more than 10 percent of total deaths in the County) had positive toxicology reports for opioids, stimulants, sedatives, or a combination of the three. Sedatives were present in 655 of these cases. In 387 cases, only sedatives were present. In 268 cases, sedatives were present in combination with opioids, stimulants, or both.
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While opioid risk is frequently in the news and many patients understand the risk of illegal stimulants such as cocaine and methamphetamine, the risk of sedatives can easily be overlooked. It also appears that many patients may not be aware of the risk of mixing medications, even at doses that may be relatively safe alone. This presents a challenge for physicians, as our patients commonly receive care—and prescriptions—from multiple specialists. We may not be aware if patients take over-the-counter sedatives such as sleep aids. This challenge also presents an opportunity for physicians to play a role in reversing these trends and preventing accidental overdoses. I encourage us all to keep this risk in mind and communicate it clearly to patients. This includes: •C heck CURES. Take a moment to review a patient’s prescription history before you write a prescription for opioids or sedatives, and note any risks for mixing medications. CURES consultation is now mandatory for most new controlled substance prescriptions and at regular intervals if you continue to prescribe the medication. • Ask your patients. When you and your staff review medications with a patient, consider asking about over-the-counter sedatives such as sleep aids. •T alk about the risk of mixing medications. An example I find useful opens the discussion with non-stigmatizing language and a focus on risky drugs, not risky behavior: “The medications you take are potentially very dangerous. Because I care about your safety, I want you to know about the risk and how you can stay safe.” •L imit the number of pills in a prescription, especially if the patient is taking other medications. The analysis did not focus on alcohol at the same level of detail, but did note that around 25-30 percent of the cases
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also involved alcohol. While many prescription labels now advise patients not to drink alcohol while taking a medication, we have an opportunity to make sure our patients understand this risk. I invite you to review this analysis in more detail (www.slocounty.ca.gov/epidemiology) and welcome your input as we work to reduce the risk of accidental overdose in our community.
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SANTA BARBARA COTTAGE HOSPITAL COMPLETES CONSTRUCTION OF NEW PAVILIONS After 13 years of construction, the new buildings of Santa Barbara Cottage Hospital are complete and the hospital opens its two newest pavilions for patient care in November. The two new pavilions, Compton and Arlington, have added approximately 134,000 square feet of space and 90 licensed beds to the hospital. It’s been six years since the hospital opened the first three new pavilions. Cottage broke ground on the Santa Barbara Cottage Hospital rebuild project in 2005 with the goal to replace all inpatient care areas. After the 1994 Northridge earthquake, California lawmakers mandated that all hospitals in the state be retrofitted or rebuilt to withstand a 7.0 earthquake. Cottage choose to rebuild its Santa Barbara location at an estimated cost of more than $820 million. The most notable feature of the newest pavilions (referred to as Phase 6) is all pediatric services are adjacent to each other on the third floor in the Cottage Children’s Medical Center. The Neonatal Intensive Care Unit (NICU) is now next to the Birth Center and Mother Infant Unit, and shares the same floor as the Pediatric Intensive Care Unit (PICU) and Acute Pediatrics Unit.
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There are 22 beds in the new NICU. Skylights in the corridor and large windows allow more natural light in the unit. There is also a private patio with a water feature and seating areas for family to spend time outside. “Perhaps the best part of what we’ve accomplished with the new NICU is that we’ve built a highly technical environment in a way that can also support the caring and nurturing of the family,” explained Dr. Steven Barkley, Chief Pediatric Medical Officer and Medical Director of the NICU at Cottage Children’s Medical Center. In the new PICU, there are eight patient beds in all-private rooms. Cottage Children’s Medical Center is a Level II Pediatric Trauma Center, with the highest level of trauma care between Los Angeles and San Jose. Above the PICU is the rooftop air transport helipad, which allows children from throughout the region to be transported to Cottage very quickly. The Acute Pediatric Unit, now with 38 beds, more than doubles the size of the previous unit. In the Emergency Department, the Phase 6 changes include a dedicated CT scanner and X-ray inside the unit. There are now 24 private treatment rooms in the ED, plus three rooms with video monitoring and four negative pressure rooms. Santa Barbara Cottage Hospital is a regional referral center for Central California and the only Level 1 Trauma Center between Los Angeles and the Bay Area.
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“We’ve completed the first of two phases to expand the Emergency Department,” said Dr. Brett Wilson, Medical Director of Emergency Services for Santa Barbara Cottage Hospital and Department Chair of the Emergency Medical Department at SBCH and Goleta Valley Cottage Hospital. “Having our own CT and X-ray in the unit will save on transport time and expedite diagnosis and evaluations. Next, we’ll begin on the second part of the ED expansion, called Phase 8. That will take 18 months with expected completion in 2020,” he added. Other departments that have moved include oncology and
telemetry to the Compton Pavilion, and dialysis to the first floor of the Arlington Pavilion. A new amphitheatre with a stage and theater seating for 144 people is on the ground floor of the Arlington Pavilion and will be used for graduate medical education and other lectures. The theater foyer features a museum highlighting the hospital’s history. “The thing to remember about a project like this is this isn’t the finish line. It’s the starting line,” said Dr. Barkley. “Where we go from here and where generations beyond us go, that’s the gift to the community and the generations to come.”
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C CenCal
HEALTH
A Model of Managed Care in Santa Barbara County Since 1983 A 1983 experiment in health care in Santa Barbara County gave birth to a health plan recognized by The Ford Foundation and Harvard University for its innovation and efficiency. That plan – originally called the Santa Barbara Health Initiative – is now known as CenCal Health, the first local-control Medicaid program of its kind in the nation. This fall, CenCal Health marks its 35th year providing care to Medi-Cal recipients in Santa Barbara County, and, for the past decade, in San Luis Obispo County. “I think the No. 1 accomplishment of CenCal Health is that we demonstrated that you can both save taxpayer dollars and improve health outcomes in the MediCal program,” said CenCal Health CEO Bob Freeman. “Our longevity is the result of building upon what we’ve learned over time, working together with local doctors and other providers
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to assist them in delivering care to our members, and treating them all as a priority. The result of this has been excellent health care, delivered in a timely and efficient manner.” By the 1980’s, Medicaid costs in the U.S. had skyrocketed and the quality of patient care was deemed low. This was primarily due to a decline in participation by physicians, who found Medicaid regulations and paperwork difficult and time consuming. The Santa Barbara Health Initiative brought local administration to the Medi-Cal management process, streamlining the operation and assigning patients to primarycare physicians who were efficiently compensated, which in turn brought more doctors into the network. This strategy improved care for patients and helped cut government costs. About 91 cents of every dollar CenCal Health receives is spent
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C
CenCal Executive Team left to right: Bob Freeman, CEO; Barrie Parker, CIO; Paul Jaconette, COO; David Ambrose, CFO; Dr. Takashi Michael Wada, CMO
on benefits and services for members, contrasting sharply with commercial health plans. And today, CenCal Health’s contracted network includes safety-net providers, medical groups, clinics, private practice physicians, premier health systems and hospitals. In 1986, the Santa Barbara Health Initiative was selected as a finalist in an Innovations in American Government award program, sponsored by the Ford Foundation and Harvard University. A 1993 editorial in the Santa Barbara News-Press on the 10th anniversary of the Initiative suggested that the “wave of the future, managed care, has been here all along”. CenCal Health further increased its reach on the Central Coast with new programs and services for new members when in 2014, under the Affordable Care Act, California expanded Medi-Cal eligibility for some low-income adults. Based on health outcome and process measures, CenCal Health has been found to be one of the top performing Medi-Cal plans in the state, according to the Healthcare Effectiveness Data and Information Set or HEDIS®.[1] Overall results reported in 2018 mark the best performance that the agency and its network of physicians have achieved since CenCal Health began annual reporting in 2000, with its Santa Barbara County plan ranking 5th out of 53 county or regionspecific Medi-Cal Managed Care plans. CenCal Health currently partners with approximately 90% of local doctors or over 1,500 physicians and other providers, and delivers comprehensive health coverage to nearly 180,000 men, women and children in two counties. “Reflecting on our 35th year, I know all of us at CenCal Health feel most proud of the service we provide daily to people in need, said CenCal Health Chief Medical Officer Takashi Michael Wada, MD, MPH. “People who have left us messages like If I could say more than the words ‘thank you’ for all that you have done for me, I would. You saved my life. It’s member comments like this that will keep us going for another 35 years.” HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). [1]
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René Bravo, MD:
Championing
HUMAN LIFE SLO pediatrician elected to CMA board of trustees Every physician has a different origin story. When San Luis Obispo pediatrician René Bravo, MD considers the circumstances that launched his journey through medicine, he speaks of an earthquake.
BY ELIZABETH SCHWYZER
It’s not a metaphor.
The year was 1971. Bravo was a carefree 8th grader in Bell, California. The son of immigrants from Cuba and Ecuador, he loved music and the outdoors, and he spent hours riding his bike along the concrete path of the Los Angeles River bed. In the early hours of February 9, he woke to a violent shaking. For 12 long seconds, the entire San Fernando Valley jolted and bucked under the forces of a deadly 6.6 tremblor. In the confusion, Bravo ran outside into the morning darkness and fell, injuring his knee. His mother took him to the hospital, where, in addition to treating the knee, the resident noted a hard, enlarged lymph node in Bravo’s groin. A biopsy was performed. Bravo’s parents received a phone call: They needed to meet with the pediatric oncology team. At first, nobody told Bravo the diagnosis: Hodgkin’s Lymphoma. “My reaction was typical teen annoyance at having my ‘busy’ life interrupted,” Bravo recalled of this period. “It wasn’t until the family minister
arrived at our house and spent an hour talking with my parents that I knew something was very wrong. That evening, my father had to do something that no parent should ever have to experience. He sat me down, and, with tears in his eyes, told me that I had cancer -- that it was serious, and that it could even be fatal. He was a tough, strong steel worker who cared for his family deeply. That night, I saw a sorrow that I will never forget.” Thus, Bravo began his medical education: as a patient. There was a surgical excision, cobalt radiation therapy that left him violently nauseated, and countless bone marrow biopsies performed via large bore needle probes without sedation. All the while, the teenage boy continued his schooling from home and remained heavily involved in the Boy Scouts and his church. Other survivors of such an ordeal might have resolved never to set foot in a hospital again. Instead, Bravo was inspired to become a physician. He was the first in his family to attend and graduate college,
Now, Bravo will bring his extensive experience in organized medicine and his passion for protecting the future of the medical profession to the state level. This October, Bravo was elected to represent the Central Coast -- District V -- on the board of trustees of the California Medical Association. It’s a prestigious position, and one in which he will help determine the direction of the CMA.
Those who know him say he’s an ideal fit for the position.
“I think what makes him special is his tireless volunteering of his time for the betterment of the community,”
Dr. Fred Vernacchia and he kept on going: to medical school at UCSF and then a residency at Stanford. He chose to come to San Luis Obispo straight out of residency, and he never left. Today, Bravo is a beloved pediatrician as well as the father of five adult sons, one of whom is now a pediatric resident at Children’s Hospital Los Angeles. Bravo’s former patients now bring their children to his practice. Throughout his career, Bravo said, his early experiences as a patient have remained with him, informing his values and the way he interacts with children and their families. “I consider every moment I have in life a gift,” he said. “When you watch peers around you fade and fail, it changes the way you see things. That experience gave me a real regard for human life and how sacred it is. It gave me a lot of empathy for people.” That empathy has served Bravo well in his personal and family life, in his medical practice, and even in the cooler climates of politics and organized medicine, where too much openheartedness could be seen as a liability. Instead, colleagues say, Bravo brings an unusual balance of diplomacy and humanity to these realms.
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San Luis Obispo psychiatrist Joseph Schwartz, MD, who has served alongside Bravo on hospital committees and medical association boards, spoke of Bravo’s talent for facilitating fruitful discussions and building solidarity. “René has a way of seeing common ground and moving discussions toward solutions -toward viable, effective solutions -- even with lots of disagreements in the room,” Schwartz noted. Radiologist Fred Vernacchia, MD, described Bravo as “a man of incredible integrity and honesty.” Having served alongside Bravo on various medical boards as well as entrusting his children in Bravo’s care has given Vernacchia a broad perspective on his colleague’s character. “I think what makes him special is his tireless volunteering of his time for the betterment of the community,” he reflected, rattling off a long list of Bravo’s community activities, including serving on the board of the regional women’s shelter and playing Santa Claus every year at an event for oncology nurses. In addition to running his own medical practice and devoting his time and energy to many community groups, Bravo has long been involved in professional medical organizations. He has sat on the board of the San Luis Obispo County Medical Society, served as a CMA delegate until the early 2000s, and served for a time as the president of the United States Pharmacopeia or USP: the governing body that regulates drugs manufactured in the US. On top of it all, Bravo has long been politically active at the local and state levels. In 1998, he ran for California State Assembly,
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CMA’s Advocacy Secures $1 Billion+ In 2016, and with a $1 million investment, the California Medical Association (CMA) led a coalition to take on Big Tobacco to improve patient access to care through Medi-Cal, which serves one-third of the state’s population. California voters overwhelmingly approved Proposition 56, which added a $2 tax on tobacco products and stipulated that funds should increase access by improving provider payments. California’s 2018-2019 state budget continues to provide over $1 billion annually to improve provider payments so more Medi-Cal patients can access care when they need it most. Other key investments include graduate medical education (GME) funding increases and medical school loan repayments. Since 1856, CMA has worked tirelessly to ensure that health care professionals serving on the frontlines of medicine in our communities have a voice in the development of health care legislation, regulations and policy. JOIN CMA TODAY and support the next generation of physicians and the future of health care policy and business in California.
“The California Medical Association is proud to leverage a $1 million investment for Proposition 56 into a $1 billion annual return on behalf of California’s physicians, medical groups and patients.” – Dustin Corcoran, CEO CMA’S REACH • 43,000 Members • 37 Component Medical Societies • 27 Specialty Societies • 200+ Medical Groups
To learn more about how this money may apply to you as a physician or medical group, visit cmadocs.org/prop56. 20
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fueled by a sense of outrage at the way health insurance corporations were raking in profits at the expense of patients and providers. (“When I ran for assembly,” he recalled, “it was because I realized that health insurance companies fear legislation more than they fear litigation.”) Vernacchia, for one, believes Bravo’s political savvy will be instrumental in making him an effective member of the CMA board. “He understands how to get things done from a political standpoint,” Vernacchia said. “It involves negotiation and compromise -- things he’s extraordinary at.” Founded in 1856, the California Medical Association represents the interests of more than 43,000 physicians statewide. The CMA is comprised of 11 districts, between them representing every county in the state. Over 500 physicians from across California make up the CMA house of delegates, while the board of trustees includes seven elected officers, elected trustees from each district, and elected representatives of special groups including residents, fellows, and young physicians. Trustees to the board are elected for three-year terms and can serve a total of three consecutive terms. Bravo’s predecessor representing District V on the CMA board, Ron Thurston, MD, served in his role for nine years. In a recent conversation, he spoke of the most controversial issues the CMA faced during that time -- the end of life act and the legalization of marijuana -- and reflected on a major change in governance whereby CMA delegates can now submit resolutions online year-round. As for the work Bravo will face in the coming years, Thurston noted the increasing pressure on the legislature to address the health insurance crisis. “The CMA strongly supports universal healthcare, but we’re under pressure to come up with a plan, and that will be a major focus in the coming year,” he explained. “The board will have to figure out what we can get behind so we can be at the table for discussions.” Bravo, of course, is well-versed in this particular issue. “I’ve come to the conclusion after practicing medicine for 32 years that health insurance companies are the biggest factor in the distressed healthcare delivery system that we all have to work with,” he said. “Unless physicians are able to individually assess and treat patients based on the needs of the patient rather than the needs of corporate health insurance entities, the quality and prestige of our healthcare system will be diminished.” Bravo said he’s honored to have been chosen to represent the Central Coast on the CMA board, and he’s looking forward to the challenge.
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“The CMA has always existed to protect the public health,” he noted. “It has a proud tradition of doing so. It’s the watchdog that defends us against some of the wacky stuff this administration throws at us, for example. It’s a unique amalgam of science and politics, which don’t always mix well.” When asked what he hopes to accomplish in the role, Bravo didn’t hesitate. “I wish to bring the concerns of physicians of the Central Coast to the governing board of the CMA, and to continue in our quest to make sure the CMA remains relevant to the concerns and causes doctors face on a daily basis,” he said. He proceeded to rattle off an impressive list: “To protect the autonomy of physicians and their ability to provide compassionate and scientifically proven healthcare based on the needs of patients, not health insurance companies; To advocate for the public health and good public health policy; To protect physicians from the foibles of a system that sometimes has capricious and arbitrary litigation and lawsuits; To level the playing field between physicians and health insurance companies; To examine different models of healthcare financing and consider all options; To continue to speak into decisions in Sacramento that require science rather than emotion.” In organized medicine as in his medical practice, Bravo aims to conduct himself according to his values and the lessons of his youth. “I was raised in the shadow of the Cuban exile community, he noted. “I worked in Central America during the civil war in the 1980s. I saw the results of that politics. Unless you’re willing to put yourself out there to change the system, then you’ll become a victim of it.” Bravo is a man of strong convictions, and he has a proven record of speaking up when he sees injustice. Yet his deepest beliefs aren’t ultimately about policy or politics; they’re about people, and about the sanctity of human life. Faced at a young age with his own mortality, Bravo came away with profound appreciation for his own life as well as wonder at the miracle of every human life. That perspective remains with him whether he’s treating patients or advocating on their behalf. “Every policy decision I’ve ever been involved with has asked, ‘How does this help the provision of healthcare, help patients, and protect human life?’” Bravo remarked. “I love people. I think they’re the most amazing, wondrous, magnificent, terrifying things on earth. To be able to help people with their illnesses and worries is a unique position. It’s a privilege.”
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BY MIRANDA FELDE, MHA, CPHRM, VICE PRESIDENT, PATIENT SAFETY AND RISK MANAGEMENT, THE DOCTORS COMPANY
VIRTUAL REALITY FOR PAIN MANAGEMENT: An Alternative to Opioids
In 2016, science teacher Bob Jester fell off a roof, broke 19 bones, and underwent surgery for his badly broken back. Doctors prescribed Oxycodone, an opioid, during Jester’s extended recovery. Jester worried that he would become dependent on opioids, so he jumped at the chance to try Virtual Reality (VR) as an alternative to opioids when an acquaintance told him about a company that was using VR for pain management. When he started using a mobile headset connected to a smart phone that plays VR apps, Jester found his pain lessened and the effect lasted for several hours each time. About a year after his accident, Jester was able to wean himself off opioids. Could other patients with severe acute and/or chronic pain experience the same results?
THE STATE OF THE OPIOID CRISIS The number of opioid prescriptions written annually in the U.S. roughly equals the number of adults in the country. And sometimes opioids, though intended to help patients, cause harm: The opioid epidemic claims the lives of 115 people every day.
While the financial costs of the opioid epidemic can be tallied—In 2016, the opioid epidemic’s toll hit $95 billion, with healthcare costs concentrated in emergency room visits, hospital admissions, ambulance use, and Naloxone use —the personal costs to those who have lost loved ones are uncountable. The epidemic’s impact is far-reaching and has emotional, physical, and financial implications for our entire society.
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Fall 2018
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EXPLORING VR FOR PAIN MANAGEMENT Many physicians are exploring VR technologies as an alternative to prescriptions. The Gate Control Theory of pain, proposed by Melzack and Wall, suggests that a person may interpret pain stimuli differently depending upon mental/ emotional factors such as attention paid to the pain, emotions associated with the pain, and past experience of the pain. VR addresses both attention paid to pain and the patient’s emotional state: The immersive distraction of VR can help a patient mentally transport to another space, such as an underwater seascape, which may also positively affect the patient’s emotional state. In 1996, the Harborview Burn Center in Seattle, Washington, successfully piloted the use of VR for burn patients with severe acute pain. Since then, more providers have found VR can provide relief for patients experiencing acute pain, such as the type Jester experienced following surgery. Recent studies have explored whether VR can relieve chronic pain. One small, but promising, study of patients with neuropathic pain found that patients experienced a 69 percent reduction in pain during each session and a 53 percent pain reduction immediately after each session.
GETTING STARTED WITH VR To explore VR as an alternative therapy, first consider the distinctions between two key terms: • Virtual Reality (VR): Provides an immersive experience via a computer-generated 3D environment for the user to explore. The user may be able to move objects or otherwise change the environment. • Augmented Reality (AR): Adds sounds, videos, and/or graphics to an existing environment, such as an outdoor planetarium where AR viewing glasses show constellations highlighted in the sky.
THEN, EVALUATE VR INTERFACES THAT ARE RELEVANT FOR PATIENTS MANAGING PAIN, SUCH AS: • Head-mounted display (HMD): Like a heavy-duty pair of goggles plus headphones. Completely surrounds the user’s visual field for an immersive experience. • Treadmills and haptic gloves: Allow the user to physically move around in the virtual environment, and to physically move objects within that environment.
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AND WEIGH THE VALUE OF INTERFACES THAT ARE MORE RELEVANT FOR PHYSICIAN USE, SUCH AS: • Smart glasses: May look more like regular eyeglasses or more like safety glasses. May display information or help the physician capture information for the electronic health record (EHR). • Desktop VR or Window on a World (WOW): Uses a desktop or laptop computer to run simulation programs, including those for training.
MITIGATING VR PATIENT SAFETY RISKS While therapeutic VR for pain management shows promise, there are patient safety risks. They include: • Falls: Patients wearing a full-surround headset cannot see their real-world environment and may walk into or trip over objects. Even patients in bed can knock things over while waving their arms around. Create a safe physical environment for VR use. • Motion sickness: Many people experience some combination of eye strain, headaches, and/or nausea. Patients who are ordinarily prone to any of these symptoms may not be good VR candidates. • Psychological effects: The brain can store VR experiences as memories in almost the same way it stores physical experiences. Young children, especially, may confuse VR experiences with real experiences, especially when remembering them later. “If you were to do this in the real world, how would it affect you? That’s the way to think about virtual reality,” says Jeremy Bailenson, director of Stanford’s Virtual Human Interaction Lab. • The unknown: VR technology is still in its infancy, and therefore, little is known about the long-term consequences of VR use.
THE FUTURE OF VR FOR PAIN MANAGEMENT Some physicians imagine a future of tetherless headsets that allow patients in pain the freedom to escape reality and transport to another emotional space. To reap the potential benefits of VR while mitigating its risks, clinicians could start with a two-part approach: identifying patients with specific clinical indications that would benefit from the use of VR and assessing patients for potential risk factors. Successful implementation of VR for pain management depends on wisely deciding which patients are VR candidates—and which are not. Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
Fall 2018
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Fall 2018
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13 New
The Central Coast Medical Association welcomes the following physicians as members
...and even more on the way.
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Henning Ansorg, MD Internal Medicine Santa Barbara Santa Barbara County Public Health Department 805.681.5488
John Park, MD Neurological Surgery Santa Barbara Neurosurgical Associates of Santa Barbara 805.682.1912
John Khan-Variba, MD, MPH Pediatrics San Luis Obispo Community Health Centers 805.269.1500
Miriam Parsa, MD, MPH Pediatric Rheumatology Santa Barbara 805.879.4243
Benjamin Johnson, MD Diagnostic Radiology Santa Barbara Pueblo Radiology Medical Group 805.682.7984
Maria Rosen, MD Anesthesiology Arroyo Grande
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RESIDENTS Alex Bergman, MD Radiology Santa Barbara Cottage Hospital
River Saul, DO Family Medicine Marian Regional Medical Center
Jennifer Chen, MD Radiology Santa Barbara Cottage Hospital
Mira Yoon, DO, MPH Obstetrics/Gynecology Marian Regional Medical Center
Justin Greene, MD Radiology Santa Barbara Cottage Hospital
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Baochuong Le, DO, MS Family Medicine Marian Regional Medical Center
nEw LiSting Rebecca Ruebsamen, DO Obstetrics/Gynecology Marian Regional Medical Center
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Greg Bartholomew 805.898.4395
greg@hayescommercial.com
HayesCommercial.com 222 E Carrillo St, Suite 101 Santa Barbara, California
Fall 2018
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In Memoriam
In Memoriam Robert Mayo Failing, MD
Robert “Bob” Mayo Failing was born Oct. 20, 1928, in Ann Arbor, Michigan, the son of Joseph Henry Failing, MD and Virginia Mayo Neely. He passed away Sept. 1, 2018. He attended Duke University School of Medicine and received his MD degree in 1956. He spent the next five years at the Los Angeles County General Hospital in a oneyear rotating internship and a four-year anatomic and clinical pathology residency. During that same time, he moonlighted as an emergency room physician, St. Luke Hospital, Altadena, California, and as a deputy medical examiner for the County of Los Angeles. Bob joined Santa Barbara Cottage Hospital’s pathology department in 1961, and worked there until he retired in 1996. During the same period, he served as a principal forensic pathologist for the Santa Barbara County Sheriff/ Coroner’s Office, medical director of Tri-Counties Blood Bank, chief of laboratory services Santa Ynez Valley and Pinecrest hospitals, and was a founding director of Medical Group Pathology Laboratory, Inc. Because of his forensic expertise and story-telling skills, he frequently consulted with author Sue Grafton for her “alphabet series” detective novels. Ms. Grafton dedicated “Q is for Quarry” to Bob because one of his unsolved cases gave her the idea for the book. Bob joined the Los Padres Search and Rescue Team as its team physician, serving terms as director and president. This turned his interest towards mountains. He was the ninth person of record to summit all 50 state high points. He also reached the top of six continents. His proudest non-mountaineering feat began at age 62. Each year on his birthday, for 12 consecutive years, he would walk, carry his clubs and play the number of holes as his age. At age 72, he walked and played 72 holes (more than 15 miles), and carried his own bag with 14 clubs. He is survived by his wife of 41 years, Nancyann; and children Robert Mayo Failing, Jr., Lee Scheuermann, and Margaret Wrath-Esposito; stepdaughter Carol Crego, step-son Stephen Raber; six grandchildren, and three step-grandchildren. He was pre-deceased by his daughter, Sarah Gronna. Adapted from Noozhawk.
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Lois Jovanovic, MD
Sansum Diabetes Research Institute (SDRI) announced, with great sadness, the passing of Dr. Lois Jovanovic, renowned around the world for her extraordinary contributions to medical science, specifically for pioneering the protocols that make it possible for women with diabetes to deliver healthy babies. Dr. Jovanovic, who passed away on September 18, performed her groundbreaking work at SDRI for 27 years, from 1986-2013, where she served as SDRI’s Chief Executive Officer and Chief Scientific Officer. Under her leadership, SDRI became a center of excellence for diabetes and pregnancy and artificial pancreas technology. Through community outreach, teaching, and working one-on-one with thousands of pregnant women, she has changed the world of diabetes and pregnancy. Dr. Jovanovic, who was classically trained as a ballerina but changed courses, began her academic career with a bachelor’s degree in biology from Columbia University, followed by a master’s degree from The Jewish Theological Seminary. She earned her medical degree from The Albert Einstein College of Medicine, completing her residency and fellowship in Internal Medicine, Endocrinology and Metabolism at the New York Hospital-Cornell University Medical College. Her groundbreaking work in diabetes and pregnancy began with her premise that a woman with diabetes’ chances of having a healthy baby could be on a par with a healthy, non-diabetic woman, if she could achieve normoglycemia. Her first research study showed that strict monitoring and absolute normalization of blood glucose could yield healthy babies. Dr. Jovanovic proceeded to develop a program to monitor a woman’s blood glucose around the clock and provide treatment strategies to achieve and maintain normal blood glucose concentrations throughout pregnancy. Dr. Jovanovic was responsible for establishing global guidelines of care adopted by the International Diabetes Federation. She is survived by her two children; Larisa Taylor, MD, and her husband, Nathan Taylor, and Kevin Jovanovic, MD, and his wife, Kim Many, Esq. She is also survived by her four grandchildren, Caitlyn Taylor, Madeline Taylor, Luke Jovanovic and Dylan Jovanovic. Adapted from The Santa Barbara News-Press Online Edition.
Fall 2018
In Memoriam
In Memoriam Stanley J. Kirk, MD
Stanley J. Kirk, MD Born July 12, 1925, Stanley went to rest on September 2, 2018, at 93. He was a Country Physician for 49 years in Paso Robles. Stanley was a loving husband, father, grandfather, great-grandfather, teacher, and philanthropist. He is survived by his loving wife, Janet; four sons: Alan, Brian, Loren and Richard; 12 grandchildren; and 13 great- grandchildren. Adapted from the Paso Robles Daily News.
Guenther Mayer-Harnisch, MD
Dr. Guenther Mayer-Harnisch, 96, of Arroyo Grande passed away peacefully at home on April 15, 2018. He grew up in Germany and joined the German navy in 1940. He served with an anti-aircraft unit on an island in the North Sea and was ultimately transferred to the Baltic Sea aboard a training sailing ship called the Horst Wessel. In 1945 he was discharged from the navy with the rank of lieutenant. He then worked his way through medical school at the University of Hamburg as a night watchman, graduating in 1951. He met his future wife Anneliese while both were attending medical school. In 1952 they were married and emigrated to the United States, where from 1952-1954 Guenther was a staff physician at the Fairview Home for the developmentally challenged in Salem, Oregon. In 1957 he completed his internship and residency in internal medicine at Emmanuel Hospital in Portland, Oregon and moved to Santa Barbara, California to complete his residency in general practice at Santa Barbara General Hospital. In 1958 he opened his solo practice in general and family medicine in Pismo Beach, California. What became apparent early on, and continued throughout his career, was his selfless dedication to his patients. He was well known for making house calls at any hour. This caring attitude extended to everyone. In 1969 he served as a field physician for Amigos de Las Americas (similar to Doctors Without Borders), helping the indigenous people of Guatemala. In 1972 he became a member of the San Luis Medical Clinic, specializing in family practice. He was also chief of staff for Arroyo Grande Community Hospital in 1978. In 1993, semi-retired, he had a part-time practice with the Central Coast Family Practice Clinic in San Luis Obispo, California. He was a member of the San Luis Obispo County Medical Association, the California Medical Association and the American Medical Association, and was a charter member of the American Academy of Family Physicians. In 2004 he was honored with the Society Group Foundation Lifetime Achievement Award from the California State Legislature. Guenther is survived by his wife of 65 years, Anneliese; sister, Ilse Mayer of Hamburg, Germany; son, Tom (Susanne) of Pleasanton, CA; daughter, Claudia of Arroyo Grande, CA; grandson, Thomas (Wanwisa) of Pleasant Hill, CA; granddaughter, Vanessa of Sacramento, CA; great-granddaughter, Layla of Pleasant Hill, CA and niece, Christina Mayer of Berlin, Germany. He was predeceased by his father, Dr. Alfred Mayer, mother, Ilse Mayer, and brother, Heinrich Mayer. Adapted from the Santa Maria Times.
Fall 2018
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F I S IE S A
Billing Services
K & H MEDICAL BILLING SOLUTIONS We are a local central coast billing company who is in touch with California’s everchanging insurance community. We customize our billing solutions to what it is that you want and need. Contact Heather at kandhmbs@yahoo.com or 805.722.5449.
Positions Available
The COUNTY OF SAN LUIS OBISPO is seeking physicians to fill the roles of Staff Psychiatrist and Medical Doctor at the County Jail - Contract. For more information, go to www.slocounty.ca.gov.
The COUNTY OF SANTA BARBARA Behavioral Wellness Department is seeking physicians to fill the roles of Psychiatrist and Psychiatrist (Child-Adolescent Specialty). For more information, go to www.sbcountyjobs.com. SANSUM CLINIC is the largest and oldest multispecialty group between San Francisco and Los Angeles with over 180 physicians and surgeons and a staff of healthcare professionals in over 30 specialized areas of medicine. Physician openings can be found at www.sansumclinic. org/physician-provider-job-opportunities.
If you would like to submit a listing to our Classifieds, contact magazine@sbmed.org. Listings are free for members with reasonable rates for nonmembers.
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