e h t d n i M Healing Healing the Mind Mind, Body, and Teeth Hospice for Peace of Mind Technological Future for Mental Health Trials
SPRING 2017
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VOLUME 3, NUMBER 1 • SPRING 2017
{FEATURES}
6 8 12 16 18 20 28 32 Spring 2017
MIND, BODY, AND TEETH CPPPH – WHAT’S THAT? HOSPICE FOR PEACE OF MIND
{DEPARTMENTS} 34 MEN’S HEALTH: ADAM 36 RISK TIP:
A BRIGHT TECHNOLOGICAL FUTURE FOR MENTAL HEALTH TRIALS
SCREENING FOR SUICIDAL THOUGHTS
NEW CLINICAL LEADERSHIP AT CENCAL HEALTH
39 IN MEMORIAM
38 NEW MEMBERS
HEALING THE MIND ENHANCING CARE FOR PREGNANT WOMEN DIAGNOSIS AND TREATMENT OF PATIENTS WITH PAD
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Letter from the CEO
CONTINUING THE FIGHT
At CCMA, we are very concerned about access to care for our Medi-Cal population, and we believe that you should receive proper compensation for caring for your patients. When Proposition 56 passed in November, $1.2 billion was supposed to go towards Medi-Cal provider reimbursement through the new tobacco tax. Governor Brown’s proposed budget DANA GOBA wrongly redistributes that revenue into the general fund, which does nothing to help patients gain needed access to doctors and dentists. With 14.3 million Californians – and over 50 percent of all the state’s children – relying on Medi-Cal programs to provide basic and specialty care for serious diseases, the stakes are high. Please take a moment to call or email your legislators today to oppose Governor Brown’s proposed budget. Legislators value your opinion and need to hear directly from their physician constituents. We will continue to fight for you, but we cannot do it without your support. If you are not part of CCMA/CMA, become a member at www.cmanet.org/join or by calling 800.786.4262. Join us so we can protect our state’s most vulnerable patients. Best,
PRESIDENT David Dodson, MD PRESIDENT ELECT Jennifer Hone, MD SECRETARY Daniel Berger, MD TREASURER Joseph Schwartz, MD IMMEDIATE PAST PRESIDENT Charity Dean, MD, MPH DIRECTORS Jonathan Berkowitz, MD, PhD; Philip Delio, MD; Douglas Jacobson, MD; Bindu Kamal, MD; Samira Kayumi-Rashti, MD; Douglas Murphy, MD; and Juan Reynoso, MD CHIEF EXECUTIVE OFFICER Dana Goba, MBA CMA HOUSE OF DELEGATES REPRESENTATIVES Sam Ahmad, MD; Sharon Basham, MD; Ned Bentley, MD; Charity Dean, MD, MPH; David Dodson, MD; Jennifer Hone, MD; Chris Lumsdaine, MD; Doug Murphy, MD; Jenni Nix, MD; John Sawyer, MD; Joe Schwartz, MD; Steven Yao, MD CENTRAL COAST PHYSICIANS MAGAZINE EDITOR David Dodson, MD MANAGING EDITOR Dana Goba, MBA CREATIVE DIRECTOR Sherry Lavone Design CONTRIBUTING WRITERS Domenic Caluori, DMD; Kevin Casey, MD; CenCal Health; Robin Diamond, MSN, JD, RN; David Dodson, MD; Charles Fenzi, MD; Dana Goba, MBA; Gail Jara; Danny Lickness, MD; Bruce Monroy, MD; National Institute of Mental Health; Angel Pacheco; Elizabeth Schwyzer CONTRIBUTING PHOTOGRAPHERS CenCal Health, Elizabeth Schwyzer, Tenet Health 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
Dana Goba Chief Executive Officer Central Coast Medical Association
5350 Hollister Ave, Ste A4 Santa Barbara, CA 93111 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 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.
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Spring 2017
AU
WELCOME SUMMER IN STYLE
GU
ST
THE CENTRAL COAST MEDICAL ASSOCIATION CORDIALLY INVITES PHYSICIANS TO OUR SUMMER SOCIAL.
Enjoy exotic cars, refreshments, and connecting with your colleagues.
Reservations requested by August 2 • CCMA members complimentary • Nonmembers $25 RSVP 805.683.5333 or sbcms@sbmed.org Limited space available l Due to the nature of the venue, no children are allowed
SATURDAY, AUGUST 12, 2017 l 2:00 — 5:00 PM THE HANGAR l 201 W MONTECITO ST, SANTA BARBARA
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Santa Barbara Neighborhood Clinics is a nonprofit, federally qualified health center that serves 20,000 members of our community in six clinic locations, offering high-quality healthcare, regardless of a patient’s ability to pay. We work closely with multiple community partners to improve the health of our community by addressing all the clinical and social support needs of the most vulnerable members of our community.
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d n i m eeth t y bod
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BY CHARLES FENZI, MD, CHIEF EXECUTIVE OFFICER & CHIEF MEDICAL OFFICER, SANTA BARBARA NEIGHBORHOOD CLINICS DOMENIC CALUORI, DMD, CHIEF DENTAL OFFICER, SANTA BARBARA NEIGHBORHOOD CLINICS
Over the last 100 years, the different fields of medicine have seen a never ending cycle of invention and advancement. The age of vaccines and antibiotics has brought a tremendous improvement to all of our lives. We have seen an onslaught of new technologies such as Computer Tomography (CT), chemotherapy and dental implants which improve diagnosis and treatments that save lives. The mystery of DNA is slowly being unlocked and will ring in a new age of medicine where gene technology will play an important role in the prevention of many severe and chronic diseases. We now possess the understanding that a healthy mind is necessary to have a healthy body. Last but not least, we are now seeing a huge body of research showing that oral health is directly connected to systemic health. One thing that has not changed in all of the decades and decades of progress and invention is how patients receive all of these resources. The patient is still treated in individual silos of the different medical specialties. We see our physician and our dentist and our mental health professional. But they are all in a different place and the communication between them is limited at best if at all. This has to change if we want to improve the quality and lower the cost of healthcare. At Santa Barbara Neighborhood Clinics, we are working very hard to provide integrated services in a single system where medical, dental and behavioral health providers all communicate intimately, use the same electronic health record and work on the same patients, sometimes during the same visit. We believe this represents the new frontier of healthcare leading to better and less expensive delivery of medical care. A huge body of
research confirms we are on the right track. When we just look at the interaction between oral and systemic health we now understand that one provider alone will not be able to diagnose and treat the myriad of conditions. We need a team approach. Regular dental cleanings and exams give dentists an opportunity twice a year to review a patient’s health. Good oral health has been shown to reduce costs associated with chronic disease. A study published in 2014 in the American Journal of Preventive Medicine, with a cohort of 338,891 patients, investigated the impact of periodontal disease on four major systemic conditions over the period of four years. For Type 2 diabetes, the results show a treatment cost reduction of 40% and a reduction of emergency room admission of 39% in patients who received good dental care and had healthy oral tissues vs not receiving any dental care. The same 40% treatment cost reduction was observed with patients who had cerebrovascular disease. A 73% treatment cost reduction was seen for patients having their first pregancy.1 Many other recent research articles have shown good oral health improves outcomes of other systemic conditions like premature low birth weight pregnancies and breast cancer. 2,3 A multidisciplinary team approach is much easier to achieve in a patient centered medical home model where all providers work together in one setting. It is much more convenient for patients and much more rewarding for providers. Achieving integrated care is no easy feat but at the Santa Barbara Neighborhood Clinics, we believe that this care delivery model will reduce treatment cost, improve treatment quality, and save many lives.
References: 1: Jeffcoat et al / American Journal of Preventative Medicine 2014;47(2):166–174 2: Improved Health and Lower Medical Costs: Why good dental care is important. A CIGNA white paper 3: Periodontal Disease and Breast Cancer: Prospective Cohort Study of Postmenopausal Women, Cancer Epidemiol Biomarkers Prev December 21 2015 DOI: 10.1158/1055-9965.EPI-15-0750
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&
SUPPORTING STRENGTHENING BY GAIL JARA, EXECUTIVE DIRECTOR, CPPPH
CALIFORNIA PUBLIC PROTECTION & PHYSICIAN HEALTH (CPPPH) LOOKING OUT FOR PHYSICIAN HEALTH AND WELLBEING.
BACKGROUND CPPPH was incorporated in 2009 as a 501 (c) 3 with organizations convened by CMA and chaired by Jim Hay, MD, then the Speaker of the California Medical Association House of Delegates. He called together those with a long-standing involvement with physician health, namely the California Society of Addiction Medicine, the California Psychiatric Association, the California Medical Association, and the California Hospital Association. Why? Because the Medical Board of California had closed its “Diversion Program for Physicians” and left the medical societies and medical staffs with no central resource and not enough information for responding to physicians with potentially impairing conditions. In the years since, CPPPH has focused on supporting and strengthening the committees responsible for physician health and wellness in our medical staffs and medical societies - all with the understanding that supporting physician health contributes to public safety by providing services for physicians who face medical, substance use, psychological, behavioral and/or emotional issues that, if left unaddressed, could adversely impact their ability to deliver safe patient care. >>
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HELPING MEDICAL STAFFS AND MEDICAL GROUPS Doctor Dean’s article in the Fall 2016 issue of Central Coast Physicians, “How Physicians Treat One Another Matters”, is a reminder of how frequently “behavior” arises as an issue, how it is connected to stress/burnout and physician health, and how easily it can become a problem that a medical staff or medical group has to address. That is the purpose of the CPPPH paper, “Behaviors that Undermine a Culture of Safety.” It addresses behavior defined as “a pattern of personal conduct, or even a single instance, deemed by peers to be outside of professional standards and detrimental to a patient, patient’s family member, the health care team or the efficient delivery of health care services.” We know that there are circumstances where the demands of a situation result in a person’s crossing over the lines of acceptable behavior. What do you do about that? Without an assessment of the specifics and surrounding details, it is not possible to determine what constitutes an appropriate personal response or a medical staff response in each situation. The paper is written to assist in making those decisions. It is the same for the CPPPH guideline titled “Assessing Late Career Practitioners: Age-based Screening: Policies and
CPPPH NEWSLETTER CPPPH eNews comes out three times a year with information and articles for those interested in physician health. All past copies are on the CPPPH website. To get on the mailing list to receive a copy emailed to you when it comes out, send your email address to CPPPHInc@gmail.com.
Procedures.” It is written as an in-depth review of the factors to consider and a description of the kind of personal approach that can be the difference between hostility and peer support.
BURNOUT All organizations and many authors are talking about burnout now, and the challenge is finding what can be done at the level at which most of us function. According to Karen Miotto, MD, the Chair of the CPPPH Board, we have to focus now on learning about the approaches that have been shown to be effective: systemic change that can lessen rates of burnout and prevent the problems we deal with before they start. That is the information CPPPH is finding and sharing. Last August, a day-long workshop featured presentations, tools,
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and how-to exercises from two programs that have been in place for more than three years. The presenters were Jo Shapiro, MD, Director of the Center for Professionalism and Peer Support at the Brigham and Women’s Hospital (BWH) in Boston, and James W. Pichert, PhD, Co-Founder, Vanderbilt Center for Patient and Professional Advocacy. This August, the same conference, called Keys to Physician Wellness -- From Burnout to Professional Satisfaction: Personal and Organizational Stories, will continue the same approach featuring Christine Maslach, PhD and her research on burnout in the workplace and Stephen Beeson, MD and his Physician Effectiveness Program. Both present practical information about what to do, how to do it, and why it is done that way.
PHYSICIAN HEALTH PROGRAM FOR CALIFORNIA The original mission of CPPPH was to advocate for physician health program for California so that physicians here would have the same services that physicians in every other state in the country (except 3) have. Here is the full story of where that stands now. In September of 2016, Governor Jerry Brown signed SB1177 authorizing the Medical Board of California (MBC) to establish the Physician and Surgeon Health and Wellness Program “for the early identification of, and appropriate interventions to support a physician and surgeon in his or her rehabilitation from, substance abuse.” The law requires that the program comply with the 1441 Uniform Standards Regarding Substance-Abusing Healing Arts Licensees. The law as passed has no provision for funding the new program from physician licensure fees or state funds. The law says the program will be paid for by participant fees. The next step is for the MBC to prepare regulations and then issue a Request for Proposal seeking an entity to administer the program in line with the regulations. On January 11, 2017, the Medical Board convened a meeting of interested parties to hear comments on what the Board plans to put in the regulations that will govern the new program. MBC staff distributed their notes showing what they plan to put into the regulations, which can be found on the CPPPH website. According to the schedule announced at that meeting, the Medical Board must complete three separate steps in order to open a program: 1) regulations adopted for operations of the program, 2) an RFP issued and an administering agency selected, 3) a second set of regulations adopted to set the fee that will be charged to each participant. No timeline has been published by the Medical Board. Meanwhile, CPPPH continues its workshops, consultation, and guidelines to strengthen wellbeing committees and physician health resources.
Spring 2017
2017 Workshops for physicians and their office staff Human Resources Law
Medicare Update
Presented by Jonathan Fraser Light
Presented by Cheryl Bradley
Thursday, June 15, noon-2:00 pm CenCal Health, Santa Barbara Thursday, June 29 noon-2:00 pm French Hospital, San Luis Obispo
Monday, June 5, noon-2:00 pm CenCal Health, Santa Barbara Tuesday, June 6, noon-2:00 pm French Hospital, San Luis Obispo
CCMA members/staff $30 Nonmembers/staff $60 Lunch included
CCMA members/staff $30 Nonmembers/staff $60 Lunch included
Cal/OSHA
Cybersecurity
Presented by Carrie Champness
Presenter TBD
Thursday, October 26 8:00-11:00 am French Hospital, San Luis Obispo Friday, October 27, 8:00-11:00 am CenCal Health, Santa Barbara
Tuesday, September 5, noon-2:00 pm French Hospital, San Luis Obispo Wednesday, September 6, noon-2:00 pm CenCal Health, Santa Barbara
CCMA members/staff $100 Nonmembers/staff $200 Continental breakfast included
CCMA members/staff $30 Nonmembers/staff $60 Lunch included
Registration required www.CCMAHealth.org For more information, contact 805.683.5333 sbcms@sbmed.org Spring 2017
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Hospice for
Peace of Mind Hospice of Santa Barbara provides patient care services for anyone who needs it
BY ANGEL PACHECO
As physicians, you never know what complaints patients will bring in with them. Whether it’s a broken bone or unusual symptoms, society looks to doctors for answers and remedies that’ll relieve their pain and ailments. But often, patients and their families are looking for answers that go beyond the physical, searching for guidance to manage their anxiety and fear related to a serious illness diagnosis or even a recent death. At Hospice of Santa Barbara (HSB), we’re proud to have been supporting the Central Coast medical community in providing answers that center on a patient’s emotional and spiritual well-being since we opened our doors in 1974. Whether it’s professional counseling, support groups, palliative care, anticipatory grief or bereavement care management, we offer these services with the utmost sensitivity at absolutely no cost to clients. Traditional medical hospice models require a certification of terminal illness with a six-month or less prognosis and the discontinuation of curative treatments to receive services. Hospice of Santa Barbara has no such requirement and we are honored to provide a continuum of care at any stage of diagnosis and while patients continue pursuing their preferred medical treatments. Through our Patient Care Services (PCS) program, we assess and evaluate each patient’s emotional and practical needs. This can involve anything from family counseling, the coordination of medical/home and other health care resources, and Advanced Care planning. Our PCS social workers and volunteers spend much of their time in
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Looking for medical space? Hospice of Santa Barbara provides no cost patient care services and professional counseling to people who are experiencing the impact of a serious illness, or grieving the death of a loved one. Hospice of Santa Barbara is also present on six local high school campuses to work with children and teens who are grieving the loss of a loved one. For more information about Hospice of Santa Barbara, including volunteer opportunities, call (805) 563-8820 or visit ww.hospiceofsantabarbara.org.
809 CHAPALA ST SANTA BARBARA F E AT U R E S • Exam rooms • Private offices • Lab Space • Showers • Saunas • Private Parking
FOR LEASE: 2,640 SF This freestanding high-identity medical office building is across the street from Paseo Nuevo Mall in the heart of the restaurants, shopping and amenities of downtown Santa Barbara.
Call Caitlin McCahill at 805-898-4374
SOME OF OUR OTHER GREAT MEDICAL SPACES 533 E MICHELTORENA ST, #102, SANTA BARBARA
FOR SALE: 1,080 SF
• Own your own medical condo - $95,000 • Call Caitlin McCahill at 805-898-4374 434 S PATTERSON AVE, GOLETA
FOR LEASE: 2,000 - 20,000 SF
• New building across from Cottage Hospital • Call Francois DeJohn at 805-898-4365 1414 E MAIN ST, SANTA MARIA
FOR LEASE: 1,906 - 10,394 SF
• Great visibility across from Marian Hospital • Call Michael Martz at 805-898-4363 1525 STATE ST, #102, SANTA BARBARA
FOR LEASE: 2,734 SF
• Class A suite downtown • Call Caitlin McCahill at 805-898-4374 1165 COAST VILLAGE RD, D & J, MONTECITO
FOR LEASE: 1,268 - 2,661 SF
• One of Montecito’s finest buildings • Call Michael Martz at 805-898-4363 HayesCommercial.com 222 E Carrillo St, Suite 101 Santa Barbara, California The information contained herein has been obtained from sources deemed reliable. We have no reason to doubt its accuracy, but we do not guarantee it.
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the community at patient’s homes, hospitals and assisted living residences. They fill many roles with clients and their families, as some will need help navigating the maze of treatment options, while others may need a safe space to share their burdens. Patient Care Services include emotional and practical support for patients and their families, advance care planning, resource coordination, and spiritual care counseling including reconnecting with faith community and practices. Among these services is anticipatory grief management, in which we give assistance to those who begin anticipating the death of a loved one following a serious illness diagnosis. Anticipatory grief shares many of the same symptoms as conventional grief – such as anger, sadness, denial, anxiety, depression and acceptance – while also having distinct characteristic signs and symptoms, including an increasing concern for the person dying, imagining or visualizing what the person’s death will be like, and getting ready for what life will be like after a loved one is gone. It is our responsibility to be there for patients and their families during this most difficult time; be it practical assistance for tasks such as funeral arrangements and memorial planning, or simply being there to listen. With many partnerships in the community, we are also able to connect clients with the appropriate supportive services which are not provided at Hospice of Santa Barbara. And we know our job isn’t done when someone dies– often times it’s just beginning as our social workers come into the lives of surviving family and friends. These family and friends are also welcome to join the variety of HSB support groups offered yearround, including groups tailored specifically for widowers, parents, survivors of suicide and more. HSB also provides one-on-one counseling. Hospice of Santa Barbara has been a guiding force for those confronting issues related to mortality in our community for more than 40 years. Without the constraints of regulations or insurance guidelines, we have been able to extend and transform our care as needed to anyone regardless of background, social status or ability to pay. If you believe you have a patient in need, please contact us.
Spring 2017
Do you know What, When and How to Report Child Abuse?
FREE ONLINE COURSE! Course developed by the Child Abuse Prevention Center
Approved for 1.25 AMA PRA Category 1 Credits™ Approved for 1.25 CE credits
ALL healthcare providers (MD, DO, RN, PhD, LCSW, MSW) are encouraged to take this valuable course!
Course available 24/7
Course can be offered in a group training using a single log-in. Contact Leslie Iacopi at (415) 882-5167 for more details. Register NOW at: Spring 2017
http://www.imq.org/education/caprrc.aspx CENTRAL COAST PHYSICIANS
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A BRIGHT
THE BRIGHTEN STUDY ORIGINALLY PUBLISHED BY THE NATIONAL INSTITUTE OF MENTAL HEALTH ON FEBRUARY 19, 2016
TECHNOLOGICAL FUTURE FOR MENTAL HEALTH TRIALS Playing games, watching movies, and paying bills through smartphones and tablets has become commonplace. Americans are used to doing almost everything through the technology in their pockets. Is mobile mental health research the next frontier in this smartphone revolution? Based on Dr. Patricia Areán’s pioneering BRIGHTEN study, research via smartphone app is already a reality.>>
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The BRIGHTEN study was remarkable because it used technology to both deliver treatment interventions and also to actually conduct the trial. In other words, the research team used technology to recruit, screen, enroll, treat, and assess participants. BRIGHTEN was especially remarkable because the study showed that technology is an efficient way to pilot test promising new treatments. Areán’s goal was to see if it was possible to do a randomized controlled trial (RCT) using nothing but mobile devices. An RCT is a study in which participants are randomly assigned to different therapies so that researchers can compare their effectiveness. Areán wanted to know if people would agree to participate in a mobile depression study, if a mobile study would be affordable, and if people would continue to use the mobile therapies. Areán’s findings suggest that it is possible to recruit a large number of participants in a short amount of time. She also found that it was possible to conduct a study for minimal cost. However, keeping participants interested in the study was more challenging.
FINDING PARTICIPANTS
Areán and her team used three methods to recruit people for the BRIGHTEN depression study. They placed ads in city buses, newspapers, and on Craigslist across the country. They used ads on Facebook and Twitter, as well as Google Adwords, which pushed ads out to people using the Internet. The research team hoped to find 150 participants. They reached that goal in one week, which prompted the team to apply for an extension of the study.
A MODEL OF THE U.S.
Five months later, the team had more than 2,900 participants. The group was ethnically similar to the 2013 U.S. Census. In addition, participants represented people from 8 of the 15 most rural states. This diversity and the ability to reach underserved populations was a notable accomplishment for the BRIGHTEN study.
PARTICIPATING
People responding to the BRIGHTEN ads were directed to the study’s website . Those who were interested could answer questions about their mobile devices, watch a consent video, and respond to questions that showed they understood the details of the study. After the consent process, visitors took a quiz to see if they were eligible for the study. Participants were randomly assigned to one of three depression treatments and then watched a video on how to download their treatment app. Each participant had a customized dashboard for monitoring study progress. Participants enrolled for 12 weeks and were asked to use the app daily, as well as complete monthly assessments. The apps provided a depression intervention and also collected data on participants’ social behavior (number of texts sent, places visited, etc.). Participants were compensated for being part of the study.
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THE COST
Typical RCTs for treating depression involve participants working “face-to-face” with a therapist. These traditional, in-person RCTs can be very expensive and may take 3-5 years to recruit enough participants. Finding people who represent the population of the U.S. can be challenging and expensive. For example, it can be difficult to recruit people in rural New Mexico if the study is based on the East Coast. The BRIGHTEN study easily recruited people from all over the country in a very cost-effective way. As a result, the BRIGHTEN study cost less than most studies of the same size.
STAYING THE COURSE
Not all participants stayed with the study for the full 12 weeks: 66% completed four weeks, 50% completed 8 weeks, and 41% finished the 12-week assessment. Of course, not all research participants complete traditional psychotherapy trials that involve conventional, face-to-face therapy; however, dropout rates seem to be lower in trials that involve psychotherapy with some human contact. In more traditional psychotherapy trials, dropout rates vary but appear to average around 20%. In studies that involve computer-administered therapy for depression, dropout rates appear to be lower among psychotherapy conditions that include at least some human contact.
RESULTS
The research team is still analyzing data to determine how well the apps treated depression and if one app was better than the others. However, early results show all three apps had a significant impact on mood and disability over time.
NEXT STEPS
The BRIGHTEN study was not the first to use apps or mobile technology as part of a research project. However it did show that mobile technology is a successful way to recruit participants, reach a wide section of the population, and provide depression-oriented interventions. As more and more studies use app-based treatments as part of their research, finding ways to keep participants interested in using those interventions will be an important next step.
LEARN MORE
Dr. Patricia Areán is professor in Psychiatry at University of Washington & co-director of the BRIGHTEN Center. Dr. Areán is a licensed clinical psychologist and mental health researcher. She runs several clinical trials, and has served on health committees, including the Institute of Medicine committee for setting standards for psychosocial interventions and the National Advisory Council to the National Institute of Mental Health. Dr. Areán’s paper was published in the January issue of BMJ Innovations.
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New Clinical Leadership at CenCal Health
Darryl Leong, MD
Takashi Wada, MD
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Dr. Takashi Wada, Director of the Santa Barbara County Public Health Department, is joining CenCal Health as Deputy Chief Medical Officer. Dr. Wada will join Dr. Darryl Leong, from Care First Health Plan in Los Angeles, who will serve as Chief Medical Officer for CenCal Health. “Dr. Leong and Dr. Wada will create an excellent team to lead the clinical direction of CenCal Health. We couldn’t be happier,” said Bob Freeman, CEO of CenCal Health. “The future of health care is ever-changing. Dr. Leong’s knowledge and expertise in health plan administration; coupled with Dr. Wada’s knowledge of publicly-sponsored health programs and the local medical community, will serve to benefit everyone, but especially our plan members and provider partners,” continued Freeman. Dr. Wada stated, “I greatly enjoyed my time at the Public Health Department, and sincerely appreciate the support of department employees, county administration, and the Board of Supervisors. However, it’s time for me to embark on a new challenge.” “Joining CenCal Health and working with Dr. Leong will be an exciting and educational experience; as well as an opportunity to continue to serve the community as part of a mission-driven health plan,” Wada concluded. “I’m very pleased and excited about coming to the Santa Barbara and San Luis Obispo area to work for CenCal Health,” said Dr. Leong. “After a long career in health care, I embrace the opportunity to work at a community-sponsored health plan with the reputation of CenCal Health. I also look forward to working with Dr. Wada in charting CenCal Health’s clinical direction in the coming years.”
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About Dr. Wada
Takashi Wada, MD MPH is a family medicine physician who has served as the Director of the Santa Barbara County Department of Public Health since March 2010. Dr. Wada was also concurrently Interim Director of the Santa Barbara County Department of Alcohol, Drugs, and Mental Health Services between November 2012 and December 2014. The Public Health Department has a $90 million annual budget and 600 employees, including over 30 physicians and mid-level providers serving patients in eight county-run clinic sites. About Dr. Leong
Darryl Leong, MD is a board-certified pediatrician, public health professional and managed care medical director with over 20 years of local, state, and national experience. He has been a Chief Medical Information Officer and Medical Director for Care First Health Plan in Monterey Park, CA (with a brief interruption) since 2007. Dr. Leong also has extensive experience with federally qualified health centers and other medical practices. About CenCal Health
CenCal Health provides health insurance to the largest number of people on the Central Coast, providing health coverage for approximately 25 percent of residents in Santa Barbara County and 20 percent of residents San Luis Obispo County. CenCal Health coverage is accepted by the vast majority of local health providers. CenCal Health also provides education and assistance to its members in order to reduce potential health problems from chronic illness such as diabetes and asthma. For more information, visit www.cencalhealth.org.
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g n i l eH a the iM nd
Coast Central trists psychia s undarie o b e h t push e isciplin d ir e h t of
BY ELIZABETH SCHWYZER
When it comes to treating physical ailments – a broken bone, a racing pulse – we generally turn to physicians: experts in human biology. Those who suffer from depression or anxiety, on the other hand, are more often directed to marriage and family therapists (MFTs) and clinical psychologists: professionals trained to address the human mind from the vantage point of psychology. Somewhere between the two disciplines lies the discipline of psychiatry: the branch of medicine devoted to the diagnosis, treatment, and prevention of mental health disorders. A blend of biology and psychology, psychiatry is one of the younger medical specialties. The term “psychiatry” was coined in the early 19th century, but it wasn’t until the work of Dr. Sigmund Freud was popularized one century later that the practice of psychiatry began to incorporate psychoanalysis. Today, most psychiatrists utilize both psychotherapeutic and pharmaceutical treatments to address everything from mild to severe mental illnesses. Of the mental health professionals, psychiatrists are best suited to medically treat mental, behavioral, and emotional disorders, as well as to consult on disorders that present with both medical and psychiatric components. Across the United States, the demand for psychiatric treatment is significant. A study conducted by the World Health Organization ranked the U.S. the third most depressed country in the world, after India and China. According to the National Institute of Mental Health (NIMH), more than 18 percent of American adults suffer from anxiety disorder, while nearly 7 percent suffer from major depressive disorder. As a point of comparison, approximately 9 percent of American adults suffer from diabetes; about 12 percent of U.S. women will develop invasive breast cancer in their lifetimes. >>
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g n i l eH a There’s a collaboration with patients
that is needed at a time when it’s hard for them to trust anyone.
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In other words, in any given year, approximately one in four Americans suffers from a diagnosable mental illness. Perhaps unsurprisingly, mental health treatment lags well behind those numbers. Less than half of Americans struggling with depression or anxiety ever receive appropriate care. Whether because of a shortage of providers, insufficient health insurance coverage, or social stigma, too many go without the medical care they need. Here on the Central Coast, as in many parts of the nation, the demand for mental health services exceeds the available resources. At the same time, regional mental health agencies and practitioners are working hard to address the community’s needs. According to Dr. Ole Behrendtsen, medical director of the Santa Barbara County Department of Behavioral Wellness, it has been difficult for the agency to recruit and retain psychiatrists, perhaps in part due to the high cost of living in the region. Nevertheless, the department currently employs 26 full-time equivalent psychiatrists, as well as physician assistants and nurse practitioners qualified to provide psychiatric care. In fiscal year 2015-2016, the department served 9,747 mental health clients and 4,550 alcohol and drug program clients. San Luis Obispo County, with a population roughly half the size of Santa Barbara County, serves a comparable proportion of the population. Last year, the department provided outpatient mental health services to 5,500 individuals; 2,400 people received care for substance use disorders. The ratio of providers to clients, however, differs dramatically from county to county: San Luis Obispo employs just 6.5 full-time equivalent psychiatrists. Understaffed or otherwise, it’s public mental health programs that are best equipped to address the most severe cases of mental illness. At the same time, there are many psychiatrists on the Central Coast who operate private and small group practices, focusing primarily on mild to moderate cases and working in tandem with the counties’ programs. Among these practitioners are doctors Joseph Schwartz, Joann Ng, and Douglas Murphy. Each psychiatrist has experience providing care in larger institutions, and each has found satisfaction in a more intimate clinical setting. Though their styles and methods are distinct, they share an interest in combining traditional psychiatric treatments with more innovative approaches. Read on to learn how these three Central Coast psychiatrists are serving their communities and contributing to the everevolving discipline where biology and psychology meet.
Spring 2017
Dr. Joseph Schwartz: Healing with magnetism If there’s a single popular image that conjures the work of the mental health professional, it’s Freud’s low-slung couch draped in heavy rugs. At the office of San Luis Obispo psychiatrist Dr. Joseph Schwartz, there’s no such couch. Instead, there’s a chair. Tucked into a small and windowless room off the hallway, it looks much like a modern dentist’s chair. Its adjustable back is upholstered in pale blue vinyl, and its arms sport pieces of medical equipment. This is where patients come for transcranial magnetic stimulation, or TMS: an alternative treatment for depression that was approved by the FDA in 2008. Not to be confused with electroconvulsive therapy, or ECT, TMS uses pulses of electromagnetic current to stimulate the dorsolateral prefrontal cortex: an area of the brain associated with mood disorders. Generally prescribed to patients who have not found relief from more traditional sources such as anti-depressants, the therapy is performed every weekday over a period of approximately six weeks. Schwartz, who has been practicing psychiatry in San Luis Obispo for 23 years, is clearly excited about the treatment outcomes from TMS. “We’re seeing about a 50 percent resolution from depression in this process, so I’m really pleased with that,” he explained during a recent interview at his practice, Central Coast Psychiatric Consultants. “Some are people who have been depressed for a long time.” One of the exciting aspects of TMS, Schwartz explained, is that “it taps in to the evolving vision of mood as having to do with neural networks.” “We have been operating in psychiatry with a primary model of depressive disorder as chemical, and so the metaphors used have been about ‘not enough of this,’ or ‘too much of that,’” he said. “The focus has been on chemistry, and the result has been that we do things that affect the brain, and then we tolerate the effects on the rest of the body.” By contrast, TMS seems not to carry unwanted side effects, with the exception of the mild discomfort some patients feel at the treatment site. According to NeuroStar, the company that
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manufactures Schwartz’s TMS equipment, this discomfort usually disappears by the end of the first week of treatment. TMS is not appropriate for all patients, and it’s far from the only psychiatric treatment Schwartz offers, but his implementation of the unusual treatment is characteristic of his practice: He’s committed to helping his patients and open to various methods that might relieve their suffering. Yet the work of psychiatry, Schwartz noted, is about much more than just prescribing drugs, TMS, or other treatments. “There’s a collaboration with patients that is needed at a time when it’s hard for them to trust anyone,” he explained. “Sometimes, evidence-based medicine is not enough. Sometimes, it seems, I have to be able to sit with someone until they develop the courage to work creatively on their problems.” Though he’s a believer in the efficacy of TMS, Schwartz acknowledged it isn’t entirely clear how or why the treatment works. “I’d be prepared to make the argument that it’s probably not about the magnetic field for everybody,” he said. “There’s also something very important about people committing themselves to a nonintrusive treatment over a period of weeks. It provides the psychiatrist with an opportunity to encourage other kinds of structure and activity, a chance to say, ‘Hey, why don’t you meet somebody for coffee after this?’ So there are a lot of other therapeutic elements at play.” At the same time, “There are a bunch of people who undergo TMS for six weeks and it does nothing for them,” he acknowledged. Ultimately, the workings of the human brain remain a mystery. Speaking of human brains, Schwartz keeps one in his office, wrapped up in a dog-eared paper bag from Starbucks. The plasticized brain is on long-term loan from the University of Michigan. Schwartz unwrapped this specimen in order to demonstrate the regions of the brain TMS targets. When conversation turned to other topics, the brain remained in his hands, where he turned it over thoughtfully as he spoke about the challenges of working in his field: the dearth of psychiatric hospital beds, the haphazard nature of insurance coverage, the lack of funding for institutions to provide acute mental health care. “The environment of psychiatry can leave you feeling pretty harassed,” he admitted. “But then you sit down with a patient, and suddenly, all the other burdens are not important. You’re there with someone, working together for things to get better.” He looked up from his brain and smiled. “What a wonderful thing to be able to do.”
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Dr. Joann Ng: Treating both mind and body
I’ve always been interested in people and stories, the written and spoken word.
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The 600 block of State Street in downtown Santa Barbara is lined with retail stores and eateries. On an average weekday, tourists wander toward the beach while locals make their way purposefully to their destinations and a steady stream of traffic slides by. It’s easy to overlook the Fithian Building, a graceful relic of the late 19th century that stands quietly in the middle of the block. It’s here, one story above the city’s busiest downtown street, that Dr. Joann Ng bases her psychiatric practice. To step inside Ng’s office is to enter a tranquil zone: potted plants frame the spacious room, and soft light spills onto sleek, mid-century furniture. The air carries a slight scent of essential oils. Born and raised in New York City, Ng relishes creating this type of oasis in an urban setting. Although she offers traditional psychiatric treatments involving psychotherapy and medication, she also encourages some patients to explore relaxation techniques including meditation, yoga, hypnotherapy, and chi gong. “I’m a strong believer in the mind-body connection,” Ng explained, adding that not all cases call for such approaches: “We cover the basics first.” Having worked in public and private hospitals as well as academic settings, Ng has seen a wide range of patients and become familiar with many models of care. Yet when asked what drew her to the field of psychiatry, she said nothing about assessment, diagnosis, treatment, or medication. Instead, she talked about her love of a good story. “I’ve always been interested in people and stories, the written and spoken word,” she said. As an undergraduate, Ng studied English literature; at Mount Sinai School of Medicine, her first rotation was psychiatry. It soon became clear that this was the field for her. “Psychotherapy is very much about people’s stories: the stories they tell themselves, the stories they tell others, the stories I hear from them,” she said. Though those stories vary greatly, Ng said she sees some themes in her practice. Currently, her interest is in identifying and working with trauma, which she sees as pervasive in the modern world. “I think we live in an increasingly traumatic society,” Ng said. “It used to be thought that post-traumatic stress disorder was only present in combat veterans, not in civilians. But that’s not the case. It doesn’t have to be a shooting or an auto accident,” she said, noting that many people are subjected to trauma repeatedly in their homes, at work, or through media consumption. “A trauma is any event that causes one to feel overwhelmed, shocked, terrified, and/or helpless,” Ng explained. Treatments for trauma vary, but Ng noted that relaxation techniques can be very effective. “I always start with an assessment: Does this person need hospitalization, outpatient treatment, or medication? What
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happened before and during the trauma? What are the effects or symptoms?” In less severe cases, she noted, “hypnotherapy and guided imagery can help people feel more safe, whole, or complete.” Like Murphy, Ng noted the national and local dearth of psychiatrists and expressed concern for the future of the field. “Mental health care is fragile and vital,” she said. “There’s such a huge need for so many different facets of psychiatry, but there are not enough resources. It’s a hard field. It takes a certain amount of training and a certain type of person to be able to navigate the humanities and the science of the discipline, to be able to access the suffering and the story, and also diagnose and prescribe.” Ng also acknowledged that there’s a scarcity of female psychiatrists nationally and locally. By contrast, the Central Coast boasts no shortage of clinical psychologists and MFTs, both male and female. As Ng sees it, the primary reason to seek treatment from a psychiatrist rather than a psychologist or MFT is the psychiatrist’s depth of experience in diagnosing disorders and prescribing treatments. Psychiatric training, she added, generally exposes practitioners to a wider range of clinical cases than a clinical psychologist or therapist ordinarily sees. “Psychiatrists are uniquely positioned to see the full range of mild to severe cases,” she explained, noting that while some patients work with multiple mental health professionals, treatment is found to be most effective when delivered by a single practitioner rather than a team. Having worked on both the East and West Coasts, Ng reflected on the cultural differences between the regions. “New York City is the headquarters of psychoanalysis, so it’s a little more revered there,” she said. “Here, people are more accepting of the psychological benefits of a healthy lifestyle: things like healthy eating, yoga, meditation, and spending time in nature.” In addition to her private practice in Santa Barbara, Ng maintains a practice in Solvang and serves as a consultant for The Dunn School in Los Olivos. Though she doesn’t introduce meditation and chi gong to every patient, Ng emphasizes relaxation across her practice. “Relaxation,” she said, “is a big component in helping patients feel safe and present.”
Dr. Douglas Murphy: Eliciting holistic health “Easy-going” isn’t a phrase generally associated with the field of psychiatry, but that’s how San Luis Obispo psychiatrist Dr. Douglas Murphy describes his youth. “I grew up at the beach in southern California, very active and involved in soccer, baseball, beach volleyball, and surfing,” explained Murphy, whose interest in medicine evolved later. “To everyone’s surprise except my mother’s, I became somewhat of a science jock,” he joked. A few decades and many years of medical training later, Murphy retains his love of science, his active outdoor lifestyle, and a conviction that exercise and nutrition have a role to play in mental health care.
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Murphy is the founder of Pacific Psychiatry, a full-service small group psychiatry practice he shares with one other psychiatrist and two psychiatric mental health nurse practitioners. The practice offers a variety of treatments to both adult and adolescent patients. That variety appeals to Murphy, who decided late in his medical school career to pursue psychiatry. “In medical school, I enjoyed everything about clinical medicine, from surgery to delivering babies,” he said. “I probably would have enjoyed medicine 75 years ago, when a typical doctor developed and practiced a wide range of clinical skills.” Faced with the mandate to choose a specialty, Murphy opted for psychiatry. “An important reason I chose psychiatry is that our approach to treating the patient is quite holistic,” he explained. “What we call the biopsychosocial model – a tool we use in understanding the patient and formulating a treatment plan – considers every aspect of the patient’s life and experience: biological, psychological, and social aspects. We also consider the patient’s psychiatric development and early life experience. A psychiatrist is able to have a positive influence in many areas of a patient’s life.” Like many psychiatrists, Murphy often combines psychotherapy with medicinal treatments. Among the approaches he uses is cognitivebehavioral therapy (CBT), a method that emphasizes shifting thought patterns in order to improve mood. “The founder of CBT, Dr. Aaron Beck, talked about the cognitive
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Spring 2017
An important reason I chose psychiatry is that our approach to treating the patient is quite holistic. triad: what we think, what we do, and how we feel,” Murphy explained. “Those three elements interrelate with one another in both positive emotional states and negative ones, like depression and anxiety. CBT is geared at trying to understand the relationships between these elements and promote positive thinking and acting.” Although treatments like CBT can provide relief to those suffering from depression and anxiety, Murphy said, increasing awareness of one’s thoughts and their impact on one’s emotional state can be of benefit to everyone. “These are issues that in our culture are left to the family to teach,” he noted. “If we had a better understanding what was going on emotionally, a lot of lives and marriages would do better in the long run.” As he looks toward the future of his practice, Murphy sees promising new treatment models on the horizon. “There is good scientific support for exercise as a treatment for depression, and we are beginning to see new science relating to nutrition for mental health,” he said. “I’m working on developing a more holistic and multi-disciplinary treatment approach that incorporates nutrition, physical exercise, psychotherapy, and psychopharmacology in the treatment of mood and anxiety disorders.” A boarded child and general psychiatrist, Murphy brings a background in neuroscience to his work. He noted that recent discoveries in the field of neuroscience are helping psychiatrists better understand mental illness and treatment. In particular, Murphy has been following research on so-called “instant” antidepressants, which he referred to as the “holy grail” of psychiatry. “For the first time in half a decade, we may have genuinely promising new treatments,” he said. Among the drugs Murphy finds
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exciting is ketamine, a medication traditionally used as an anesthetic. “Ketamine may also be a drug of abuse, but it has had some interesting and advantageous effects in research treating depression,” he said, noting that in clinical trials performed at the NIMH, patients’ depression was shown to improve over a period of just three hours, in contrast to the two-to-six weeks typically seen with contemporary antidepressants. The FDA is currently considering approving ketamine for the treatment of depression, Murphy said, but added that the drug’s hallucinogenic properties make such use controversial. “In my practice, we are waiting for safer ways to use ketamine or more consensus surrounding its use in general,” he explained. An article by Dr. Murphy discussing new medications in psychiatry is slated for an upcoming issue of this magazine. When asked what he saw as the greatest challenges to the field of psychiatry, Murphy didn’t skip a beat. “The number of clinicians,” he said. “Everyone is as busy as we can be. We need more psychiatrists.”
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Care for Pregnant Women Enhancing
Sierra Vista Regional Medical Center Announces Obstetric Hospitalist Program & Assessment Area
BY BRUCE MONROY, MD, & DANNY LICKNESS, MD
Sierra Vista Regional Medical Center has added a new layer of safety for women who give birth at the hospital. An experienced, boardcertified obstetric hospitalist will be onsite and immediately available at all times, 24 hours a day, seven days a week, every day of the year. These physicians will specialize solely in caring for patients who are hospitalized, rather than those in a clinical office setting. OB hospitalists focus exclusively on providing care for women who are in their second or third pregnancy trimester that need immediate medical attention or in active labor. The group will be led by physicians already established in San Luis Obispo who have opted to give up their private practices along with additional physicians new to the area. The OB team will evaluate women with emergent obstetric and gynecological medical issues and consult with the patient’s primary OB/GYN until that physician arrives at the hospital. OB hospitalists provide labor and delivery services only for unassigned patients and patients of local providers who have signed out to the hospitalists for a set period of time or in the event of an emergency. The hospitalists will be located full-time in the Sierra Vista Birth Center and will often see patients initially in the newly remodeled obstetric assessment area located within the Sierra Vista Birth Center. This program does not take the patient from her own OB/GYN. Rather, it ensures that every patient, regardless of time of day or physician association, is seen by an OB/GYN right away if she needs urgent care. >>
Spring 2017
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The OB hospitalist will act as the unreferred on-call physician and will see any obstetric or gynecological patients who would normally be seen by the on-call physician. Types of urgent care cases the hospitalist might see include patients 16 weeks pregnant or greater who require emergency care, ectopic pregnancies, miscarriages and tubo-ovarian abscesses. Because OB hospitalists are always onsite, they can provide immediate management of acute conditions until the patient’s own OB/GYN arrives. They are also fully capable of performing emergency surgery as needed. Having physicians immediately available on the unit will enhance patient safety and improve the quality, coordination and efficiency of care. It also provides piece of mind for patients since a doctor is available, at a moment’s notice, to step in to provide care as needed.
Get Informed · Be Resourceful! ty Santa Barbara Coun 2017-2018
SREeSOnUiRoCRrEY
Sometimes an obstetrician may be involved in another birth at the hospital or unable to make it to the patient in time for delivery. Having an OB hospitalist program at Sierra Vista means pregnant women, nursing staff and other support persons and caregivers can be confident an experienced obstetrician will be present for both routine and unanticipated events, even when the patient’s own physician isn’t immediately available. OB hospitalists will also be available to deliver babies for patients who may not have an obstetrician. The Sierra Vista Birth Center provides highly-skilled and nurturing care for both routine and high-risk pregnancies and is the only hospital in both San Luis Obispo and Santa Barbara counties that can accommodate vaginal birth after cesarean section (VBAC). A team of board-certified lactation consultants is available seven days a week to support new mothers in breastfeeding and a deluxe hydrotherapy labor tub offers options for relaxation and pain management. Sierra Vista also houses the only advanced Level III neonatal intensive care unit (NICU) in San Luis Obispo County. For more information about the Sierra Vista Birth Center, visit SierraVistaRegional.com.
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Spring 2017
HERAL DIAGNOSIS AND TREATMENT OF PATIENTS WITH
PERIPHERAL BY KEVIN CASEY, MD, FACS, WEST COAST VASCULAR
ARTERY DISEASE
Peripheral artery disease (PAD) afflicts an estimated 29 million individuals in North America and Europe, resulting in significant disability, loss of wages, and health care expense. The underlying pathology is most commonly atherosclerosis and has similar risk factors as coronary artery disease (CAD) and cerebrovascular disease (CVD): age, diabetes, tobacco use (former or current), hypertension, hyperlipidemia, chronic kidney disease, and obesity. Only a minority progress to limb loss; nevertheless, patients with risk factors should be questioned about the signs and symptoms of PAD and referred to a vascular surgeon when appropriate. PAD can be generally divided into two categories: intermittent claudication (IC) and critical limb ischemia (CLI). Claudication, from the Latin “to limp” after the Augustan emperor Claudius, is defined as pain (usually in the calf) with ambulation relieved with rest. IC, present in up to 15% of the elderly population, is a symptom of underlying arterial blockages which prevent adequate blood flow as demand increases. The lower extremity equivalent to exertional angina, patients typically describe calf cramping after a specified distance or number of minutes of ambulation. Once at rest, the symptoms abate as the demand for oxygen subsides. However, once the patient ambulates again, the symptoms undoubtedly return. Mild claudication can be treated with conservative measures including smoking cessation, a formal walking program, risk factor modification, and medication administration. Patients with IC are at an increased risk for CAD and CVD. As such, an 81 mg ASA and statin are shown to prevent disease progression, although neither has been proven to aid in symptom relief. Cilostazol (PletalR) was found in four large randomized trials to improve the pain-free walking distance in a majority of patients with IC. This medication can be limited by its side-effect profile. Clopidogrel (PlavixR) has been shown in one large trial to aid in patients with PAD; however, this benefit must be weighed against an increased risk of bleeding. Moderate to severe claudication frequently requires endovascular or surgical intervention. A simple arterial
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ultrasound and physical examination (including ankle-brachial index), coupled with a thorough discussion about patient goals and quality of life objectives, will help guide physicians and patients toward the most appropriate course of action. CLI is manifested in two forms: rest pain and lower extremity wounds. Rest pain is often described as an unrelenting pain or burning sensation on the dorsum/toes of the foot and represents end tissue malperfusion of the lower extremities. Patients often have a history of IC and/or prior vascular procedures. Vascular wounds can occur anywhere on the foot, ranging from slowly healing ulcers to wet gangrene. Once a patient presents with CLI, medical management is no longer an option—only surgical intervention will prevent the progression to eventual limb loss. The decision about endovascular or open surgical bypass is individualized to each patient, their anatomy, and comorbidities. For some patients, an angiogram with intervention is the best option. Advantages to endovascular treatment include a smaller incision, decreased post-operative pain, and earlier convalescence. However, open vascular surgery arguably has higher patency and limb salvage rates at the expense of longer operative times, greater blood loss and the possibility of higher complication rates. Long-term follow-up for patients with PAD is essential. Regardless of the intervention, continual surveillance including a regular physical examination and ultrasound is crucial. For patients with claudication, the vascular surgeon ensures that a patient’s symptoms remain controlled. Patients at risk for limb-loss require close and attentive care, often with a multidisciplinary approach to achieve successful long-term limb salvage rates. Close coordination with specialists in podiatry, infectious disease, and endocrinology can yield the best results. PAD has a wide range of presentations, from mild pain with ambulation to life-threatening gangrene. Through early detection, risk-factor control, surgical intervention when appropriate, and close follow-up, PAD can be managed with successful outcomes and acceptable morbidity.
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ANDROGEN DECLINE IN THE AGING MALE
ADAM
To Treat Or t a e r T o T t No THE AGING MALE, AKA IN E IN CL DE N GE O DR AN OR PROBLEM. ANDROPAUSE, IS A MAJ
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BY DAVID DODSON, MD
The term ADAM is preferred to Andropause as there maximally stimulated at Ts of 200, which is quite low. is no pause (Greek for cessation) comparable to That said, while many urologists are comfortable with T menopause, or cessation of menses. Men’s testosterone replacement for symptomatic men who have successfully (T) levels go through the ceiling after puberty and decline completed curative treatment for prostate cancer, such slowly over a lifetime. By age 45, about 40% of men have therapy should, in my judgment, generally be prescribed low T defined by the Endocrine Society as under 300. By only by urologists or oncologists. age 80, the figure is around 90%. Other more common side effects include acne, breast One may say, if ADAM is nearly universal, is it not then swelling or tenderness, and increased hematocrit, In my “natural” and normal? Perhaps, but then so is getting old, experience, the latter is the most common side effect and sick, and dying. Our job is to delay the process. the one most likely to require dose adjustment as it can What is the evidence that ADAM has pathological potentially increase the risk of clots, particularly when crits consequences? There is good evidence that T levels exceed 60. correspond to longevity: i.e., higher T levels correspond The potential risk of adverse cardiovascular side to improved longevity. Unfortunately, we do not yet have effects of T replacement therapy has lead the FDA to evidence that T replacement therapy improves longevity, require manufactures of T replacement products to issue but there are tantalizing clues. Better evidence to address warnings about this potential problem. The evidence is this key question should be available in the near future spotty and low quality however, and a controlled study from ongoing clinical trials. A prominent symptom of low T is decreased libido. There is THE POTENTIAL RISK OF ADVERSE CARDIOVASCULAR evidence that low T contributes to low mood. SIDE EFFECTS OF T REPLACEMENT THERAPY HAS Low T is said to make a man grumpy. Low T is also associated with decreased lean body mass, LEAD THE FDA TO REQUIRE MANUFACTURES OF T increased fat mass, and decreased bone mineral REPLACEMENT PRODUCTS TO ISSUE WARNINGS ABOUT THIS POTENTIAL PROBLEM. density and fractures. Low T is a factor in insulin resistance and the metabolic syndrome. Most type 2 diabetics have low T. of over 1000 Veterans with low T (<250) showed a A confounder to assessing T in men is the fact that hazard ratio for T replacement of 0.61 for MI – a 39% it circulates in plasma tightly bound to SHGB (sex reduced risk – with a P value of 0.008, highly significant. hormone binding globulin) which rises with age, with Resolution of this question awaits clarification from the result that free or unbound T, representing around ongoing clinical trials, but in my judgment, the 2% of total T, declines with age more than total T, preponderance of evidence does not support an increased which includes T bound to SHBG and physiologically risk of MI with T replacement therapy. unavailable as well as T bound to albumin. Measuring There are numerous products available. Topical gels free T is particularly important in older men and in obese are popular because of ease of use, but in my experience men. tend to result in modest increases in T levels and What are the potential side effects of T replacement limited symptomatic improvement, which makes them therapy? Testosterone is a trophic factor for the prostate hard to sell. A convenient and unheralded treatment as well as for prostate cancer. Therefore, it is incumbent is clomiphene 50 mg QOD, which I tell my patients upon the clinician contemplating T replacement therapy makes women’s ovaries produce eggs and men’s testicles for their patient to examine the prostate and check a PSA produce testosterone. I have had great responses with before prescribing T replacement. As a practical matter, this convenient therapy, but because its off-label some this is less foreboding a prospect as it may appear at first insurance companies balk, and some pharmacists will blush, because there is no correlation between T levels think you are nuts because they haven’t heard of this use. and the incidence of prostate cancer. Furthermore, as Injections are of course literally a pain in the ass and may Harvard’s Dr. Abraham Morgentaler points out, prostate be associated with increased CV risk because they give T receptors are saturated at very low T levels, between 50abnormally high levels followed by a trough with the 100. As he puts it, if you water a wilted plant, it may spring cycle repeated with each injection. Other options include back to life, but it will not become a tree. For this reason, dermal patches, buccal troches, and implanted pellets. increased symptoms of LUTS from BPH do happen with For those who would like to explore this subject further T replacement therapy but are rare. Also, raising T from and review references, the subject was updated last month 200 to 400, a typical response to replacement therapy, in UpToDate. As usual, your feedback would be valued is unlikely to have a significant adverse effect on either and appreciated. BPH or prostate cancer because prostate cells are already
Spring 2017
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WATCH FOR THE SIGNS:
SCREEN ALL PATIENTS FOR SUICIDAL THOUGHTS BY ROBIN DIAMOND, MSN, JD, RN, SENIOR VICE PRESIDENT OF PATIENT SAFETY AND RISK MANAGEMENT, THE DOCTORS COMPANY
SUICIDE IS NOW THE 10TH LEADING CAUSE OF DEATH IN THE UNITED STATES.1 MOST PEOPLE WHO COMMIT SUICIDE RECEIVED HEALTHCARE SERVICES IN THE YEAR PRIOR TO DEATH, USUALLY FOR REASONS OTHER THAN MENTAL HEALTH ISSUES OR SUICIDAL THOUGHTS. IT’S A STRONG REMINDER THAT ANY PATIENT CAN BE AT RISK FOR SUICIDE. A CONSISTENT AND FORMAL SCREENING PROCESS, PLUS A RESPONSE PLAN, WILL PROTECT BOTH THE PATIENT AND THE PHYSICIAN.
• E stablish a formal policy on screening and responding to suicide risk. Establish a policy that stipulates what screening will be done and how to respond to suspected risk. All employees should be trained. The policy should include front desk staff and other non-clinicians, who may pick up on signs that the patient could be suicidal. • I mplement an effective screening process. Ask specific questions that can reveal situations that might put the patient at risk for depression and suicide. Examples include asking whether the patient has recently experienced the loss of a family member, a change in marital status, a change in jobs, sleeping difficulty, or loss of appetite. •C onnect with the patient. If in the screening process, the patient demonstrates suicidal tendencies or it’s suspected that the patient may be suicidal, refer the patient immediately to a mental health professional or ask the patient’s permission to contact family members or outpatient treatment providers. Remember that simply advising the patient to seek help is insufficient. Be sure to follow up to confirm that the patient has seen the mental health professional.
• E stablish safety procedures for the patient who may be suicidal. Once this risk is established, the clinician is responsible for protecting the patient from self-harm. That means keeping the patient away from sharp objects, medications, and bed sheets. Having the patient wait in a typical exam room may not be safe because the patient would have access to scissors, scalpels, needles, and other such items. •M onitor the patient closely. If feasible, have staff or the patient’s family monitor the patient continuously, in person or on video, until the next step of care. If continuous monitoring is not possible, check on the patient frequently. Carefully document the monitoring procedure, including frequency and type as well as observed patient behaviors. •C all for help if needed. Call for additional help if the facility has no ability to isolate the patient from dangerous items or provide adequate monitoring, and also if the patient has already left against medical advice. State laws vary regarding how and when a patient may be held against their will.
Detecting and treating suicide ideation in all settings. The Joint Commission. https://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf. Accessed November 14, 2016.
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CENTRAL COAST PHYSICIANS
Spring 2017
CALIFORNIA MEDICAL ASSOCIATION FIGHTING TO ENSURE FEDERAL HEALTH REFORM
IMPROVES PATIENT ACCESS TO PHYSICIANS Long before President Donald Trump began campaigning to repeal the Affordable Care Act (ACA), the California Medical Association (CMA) and it’s county medical society partners began fighting for access to health care for all Californians. In fact, access to quality health care has been a core tenet of CMA for many decades. CMA, which represents over 43,000 physicians across all modes of practice, believes access depends on affordable, quality coverage and reflects the ability of patients to secure appointments with doctors (promptly) for preventative care and when catastrophic circumstances occur. As Congress embarks on the latest health reform debate, CMA remains committed to working with Congress and the Trump Administration to develop a plan that ensures patients can access doctors to receive high-quality and affordable health care. CMA is standing by its core health reform priorities, which are to: •
Improve access to physicians
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Protect state and federal Medicaid funding
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Ensure Californians do not lose coverage
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Provide affordable coverage, particularly for low- and moderate-income families
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Eliminate administrative and regulatory burdens in the Medicaid and Medicare programs
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Provide a choice of insurers, HSAs and physicians.
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Maintain reforms on the insurance industry – coverage for preexisting conditions, 85 percent medical loss ratio and no annual/ lifetime limits on benefits
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Stabilize the individual insurance market
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Provide access to affordable prescription drugs
For more information, visit www.cmanet.org.
Medicaid funding must be protected and increased to care for America’s most vulnerable populations, and more work must be done to deliver access to doctors and affordable, quality care.”
Ruth Haskins, M.D., CMA President
Spring 2017
Rev. 03/16/2017 CENTRAL COAST PHYSICIANS 37
11 New
The Central Coast Medical Association welcomes the following physicians as members
...and even more on the way. Adam Abroms, MD Ophthalmology Pacific Eye Surgeons San Luis Obispo 545.8100
RESIDENTS
Katherine Chung, MD Neonatal-Perinatal Medicine Santa Barbara Neonatal Medical Group Santa Barbara 682.7111
Nathaniel Collins, MD Internal Medicine Santa Barbara Cottage Hospital
Sean Early, MD Orthopedic Surgery Maguire & Early Orthopedics Santa Barbara 687.2424 Darryl Leong, MD, MPH Pediatrics CenCal Health Santa Barbara 685.9525 Anne Little, MD Urgent Care Dignity Health Lompoc 735.4292
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CENTRAL COAST PHYSICIANS
Natalie Achamallah, MD Internal Medicine Santa Barbara Cottage Hospital
Calida Danko, MD Internal Medicine Santa Barbara Cottage Hospital Chelsea Dean, MD Internal Medicine Santa Barbara Cottage Hospital Camille Hunter, MD Internal Medicine Santa Barbara Cottage Hospital Aaron Russell, MD Internal Medicine Santa Barbara Cottage Hospital
Spring 2017
In Memoriam Wilton Doane, MD Wilton Doane, MD, was born in Mansfield, Pennsylvania, to a family of doctors. He attended the University of Pennsylvania School of Medicine and completed his internship and surgical residency at Pennsylvania Hospital. Dr. Doane was awarded a fellowship in thoracic surgery at the Lahey Clinic in Boston. He believed that multi-specialty medical groups were the best way to practice medicine, and he was part the Santa Barbara Medical Clinic from 1956 to 1997. During that time, he worked to have the Medical Clinic become a medical foundation, and he assisted with the merger with Sansum Clinic. Dr. Doane was a member of the Santa Barbara County Medical Society for 60 years, and he participated with the California Medical Association, American Medical Association, American College of Surgeons, Pacific Coast Surgical Association, and Western Thoracic Surgical Association. Besides medicine, Dr. Doane had a passion for travel and visited the Nile River, Iran, Himalayas, and Afghanistan. He also enjoyed tennis, hiking, sculpting, and playing the trumpet. Dr. Doane is survived by his wife Carol, his three children Richard Doane, Nancy Doane Babbott (David Babbott), and John Doane (Kerry Doane), and numerous grand- and great-grandchildren.
Spring 2017
CENTRAL COAST PHYSICIANS
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