Central Coast Physicians Winter 2019

An End New Laws for 2019

to Alz heimer ’s?

Distracting Devices Community Reports Winter 2019

WINTER 2019 CENTRAL COAST PHYSICIANS

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Faith Orcutt 14 YEAR-OLD CANCER SUR VIVOR

Dear 11-year-old me,

the same girl, just taller. You started Imagine you are now 14. Pretty much love your friends and family. high school, are playing volleyball, and going to always be easy. But three And, you’re a cancer survivor. It’s not trips to Cottage with mom and years from now, after a bunch of car tors you could ask for, your dad, to see the best nurses and doc And life is going to be. . . well . . . life. gorgeous curls will have grown back.

Love, Faith

Our new Cottage Children’s Medical Center, featuring the Haselton Level III Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, is now open at Santa Barbara Cottage Hospital.

Serving California’s kids, like Faith, everyday.

CCMC cares for over 14,000 children a year in our Acute Pediatrics Unit, Haselton Neonatal Intensive Care Unit, Pediatric Intensive Care Unit, Emergency Department, Pediatric Trauma Center and eight specialized outpatient clinics. cottagechildrens.org 2

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VOLUME 4, NUMBER 1 • WINTER 2019

{FEATURES}

6 22 24 32 36 Winter 2019

NEW LAWS FOR 2019

PHYSICIANS OF THE YEAR

{DEPARTMENTS} 21 RISK TIP: DISTRACTING DEVICES 30 MEN’S HEALTH:

MARCHING FOR PROSTATE CANCER

34 CENCAL HEALTH NEWS HUB: AN END TO ALZHEIMERS?

COMMUNITY REPORT

40 CLASSIFIEDS VISITING PROFESSOR OF SURGERY

ANNUAL MEETING PHOTOS

42 PUBLIC HEALTH:

HEALTH IMPROVEMENT PLAN

44 NEW MEMBERS 47 IN MEMORIAM

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Letter from the CEO

YEAR IN REVIEW

Thank you to our members for your support this past year. Without you, we wouldn’t be able to protect your profession and patients.

DANA GOBA

A highlight every year are our Annual Membership Meetings, where we welcome new Board members and recognize outstanding physicians. This year we honored Joseph A. Schwartz, MD, in San Luis Obispo, and Charity Dean, MD, MPH, in Santa Barbara County as our Physicians of the Year.

Photos from the events are included in this issue.

Due to strong request, this past year we began holding socials for physicians, which have been very well attended. Physician members and non-members are invited to join us to connect with your colleagues. Watch for upcoming socials on the events tab of our website.

PRESIDENT Jennifer Hone, MD PRESIDENT ELECT Kevin Casey, MD SECRETARY Ali Javanbakht, MD TREASURER Samira Kayumi-Rashti, MD DIRECTORS Bindu Kamal, MD; Daniel Berger, MD; Joseph Freeman, MD; Joseph Schwartz, MD; Julie Fallon, MD; Priti Gagneja, MD; Rachel May, MD; Rahim Raoufi, MD; Thomas Hale, MD CHIEF EXECUTIVE OFFICER Dana Goba, MBA CMA HOUSE OF DELEGATES REPRESENTATIVES Sharon Basham, MD; Edward Bentley, MD; Kevin Casey, MD; David Dodson, MD; Priti Gagneja, MD; Jennifer Hone, MD; Samira Kayumi-Rashti, MD; Christopher Lumsdaine, MD; Joseph Schwartz, MD

We also stared an electronic newsletter, The Pulse. This monthly email shares top news stories, highlights a new member, and lists upcoming events. If you are not receiving these notifications, contact our office, and we will add you to the list so you stay informed.

At the state level, the California Medical Association had many achievements helping the medical profession. You can view details at cmadocs.org/year-in-review, and some highlights are: • Recouped nearly $11 million from payors on behalf of CMA’s physician members • Secured over $1 billion in funding for improved access to care with Proposition 56 • I nfluenced over 1,300 bills and legislative policy initiatives • Defended the medical profession and patients from dangerous legislation, including AB 3087 (Kalra), which would have limited access to health care providers, created state-sanctioned rationing and increased out-of-pocket costs for patients • Helped the Tulare Regional Medical Center medical staff restore independence and self-governance within the hospital

CMA DISTRICT V TRUSTEE Rene’ Bravo, 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; California Medical Association; CenCal Health; David Dodson, MD; Shelley Rizzo, MSN, CPHRM; Sansum Clinic; Elizabeth Schwyzer CONTRIBUTING PHOTOGRAPHERS CenCal Health, County of San Luis Obispo, Sansum Clinic, 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:

We look forward to a successful 2019, but we cannot do it without your support. If you are not a member, help us protect your profession by joining at www.cmadocs.org/join or 800.786.4262.

Together we are stronger.

Sincerely,

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 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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HIGHEST HOSPITAL SAFETY RATING. 7 YEARS IN A ROW. Thank you to our nurses, doctors, staff and volunteers for helping Sierra Vista and Twin Cities Hospitals achieve recognition as two of the safest hospitals in America, every year since 2012.

Just five hospitals in the state of California have the honor of this distinction.

Winter 2019

SierraVistaRegional.com

TwinCitiesHospital.com CENTRAL COAST PHYSICIANS

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Significant New California Laws of Interest to Physicians for 2019 The California Legislature had an active year, passing many new laws affecting health care. In particular, there was a strong focus on health care coverage, drug prescribing, public health, and mental health issues. On the following pages you will find highlights of the most significant health laws of interest to physicians.

ALLIED HEALTH PROFESSIONALS AB 2281 (Irwin) – Clinical laboratories: licensed medical laboratory technicians CMA Position: Support Exempts blood smear reviews other than manual leukocyte differentials, microscopic urinalysis, and blood typing of moderate complexity such as automated ABO/Rh testing and antibody screen testing from the prohibition of licensed medical laboratory technicians from performing microscopic analysis or immunohematology procedures.

AB 2423 (Holden) – Physical therapists: direct access to services CMA Position: Neutral Provides physical therapists with an exemption from the provision in the Physical Therapy Practice Act that prohibits the physical therapist from continuing treatment beyond 45 calendar days or 12 visits, whichever occurs first, without receiving specified doctor approval of the physical therapist’s plan of care to enable them to provide services within their scope of practice under the federal Individuals with Disabilities Act (IDEA) under a school-developed Individualized Education Program (IEP) or an Individualized Family Service Plan (IFSP).

AB 2589 (Bigelow) – Controlled substances: human chorionic gonadotropin Current law lists human chorionic gonadotropin (hCG) as a Schedule III controlled substance under the California Uniform Controlled Substances Act. This bill exempts hCG from being subject to the reagent regulations of the Controlled Substances Act when possessed by, sold to, purchased by, transferred to, or administered by a licensed veterinarian, or a licensed veterinarian’s designated agent, exclusively for veterinary use.

SB 762 (Hernandez) – Optometry: administration of immunizations Requires training programs for certification of optometrists to administer immunizations to be endorsed by the Accreditation Council for Pharmacy Education in addition to the federal Centers for Disease Control and Prevention.

SB 1003 (Roth) – Respiratory therapy CMA Position: Neutral

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Prohibits any state agency, as defined, except for the Respiratory Care Board of California, from defining or interpreting respiratory care for those licensed under the Respiratory Care Practice Act, or from developing standardized procedures or protocols, unless authorized by these provisions or specifically required by state or federal statute.

CONSENT AB 3189 (Cooper) – Consent by minors to treatment for intimate partner violence Authorizes a minor who is 12 years of age or older and who states he or she is injured as a result of intimate partner violence, as defined, to consent to medical care related to the diagnosis or treatment of the injury and the collection of medical evidence with regard to the alleged intimate partner violence.

DEATH AND ORGAN DONATION AB 2096 (Frazier) – Personal income taxes: voluntary contributions: Organ and Tissue Donor Registry Voluntary Tax Contribution Fund Allows a taxpayer to designate an amount in excess of personal income tax liability to be transferred into the Organ and Tissue Donor Registry Voluntary Tax Contribution Fund, which the bill creates.

SB 1163 (Galgiani) – Postmortem examination or autopsy Makes various changes to provisions regarding postmortem examination or autopsies of unidentified bodies or remains, including to provisions regarding dental examinations, tomography scans, and retention of tissue and bone samples. Authorizes an agency tasked with the exhumation of a body or skeletal remains of a deceased person that has suffered significant deterioration or decomposition, where the circumstances surrounding the death afford a reasonable basis to suspect that the death was caused by or related to the criminal act of another, to perform the exhumation in consultation with a board certified forensic pathologist. Authorizes a board-certified forensic pathologist to suggest to the agency tasked with an exhumation to consider retaining the services of an anthropologist, as specified.

DRUG PRESCRIBING AND DISPENSING AB 315 (Wood) Pharmacy benefit management CMA Position: Sponsor Requires a pharmacy in inform a customer at the point of sale for a covered prescription drug whether the retail price is lower than the applicable cost-sharing amount for the prescription drug unless the pharmacy automatically charges the customer the lower price. If the customer pays the retail price, the bill requires the pharmacy to submit the claim to the plan or insurer in the same manner as if the customer had purchased the prescription drug by paying the cost-sharing amount when submitted by the network pharmacy.

AB 1751 (Low) – CURES database: Interstate data sharing CMA Position: Oppose Unless Amended

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Requires the Department of Justice, no later than July 1, 2020, to adopt regulations regarding the access and use of the information within CURES by consulting with stakeholders, and addressing certain processes, purposes, and conditions in the regulations. Authorizes the department, once final regulations have been issued, to enter into an agreement with any entity operating an interstate data sharing hub, or any agency operating a prescription drug monitoring program in another state, for purposes of interstate data sharing of prescription drug monitoring program information, as specified.

AB 1753 (Low) – Controlled substances: Security form CMA Position: Neutral Authorizes the Department of Justice to reduce or limit the number of approved security printers for controlled substance prescription forms to 3, as specified and requires prescription forms for controlled substance prescriptions to have a uniquely serialized number, in a manner prescribed by the department, and requires a printer to submit specified information to the department for all prescription forms delivered.

AB 2037 (Bonta) – Pharmacy: automated patient dis pensing systems Provides an alternative program to authorize a pharmacy located in the state to provide pharmacy services to the patients of covered entities, as defined, that are eligible for discount drug programs under federal law, as specified, through the use of an automated patient dispensing system, as defined. Provides that the responsibility of the operation, maintenance, and security of the automated patient dispensing system would be the responsibility of the pharmacy and requires that the drugs dispensed from the system be labeled in accordance to existing law. Requires the pharmacy to compete an annual self-assessment.

AB 2086 (Gallagher) – Controlled substances: CURES database CMA Position: Support Allows prescribers to access the Controlled Substance Utilization Review and Evaluation System (CURES) database for a list of patients for whom that prescriber is listed as a prescriber in the CURES database.

AB 2256 (Santiago) – Law enforcement agencies: opioid antagonist CMA Position: Support Authorizes a pharmacy, wholesaler, or manufacturer to furnish naloxone hydrochloride or other opioid antagonists to a law enforcement agency, as provided.

AB 2487 (McCarty) – Physicians and surgeons: continuing education: opiate dependent patient t reatment and management CMA Positing: Neutral Authorizes a physician and surgeon to complete a one-time continuing education course of 12 credit hours on opiate-dependent patient treatment and management, including eight hours of training in buprenorphine treatment as an alternative to the mandatory continuing education course on pain management and the treatment of terminally ill and dying patients.

AB 2760 (Wood) – Prescription drugs: prescribers: naloxone hydrochloride and other FDA-approved drugs

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CMA Position: Neutral Requires a prescriber, as defined, to offer a prescription for naloxone hydrochloride or another drug approved by the United States Food and Drug Administration for the complete or partial reversal of opioid depression to a patient when certain conditions are present and to provide education on overdose prevention and the use of naloxone hydrochloride or another drug to the patient and specified others, except as specified. Subjects a prescriber to referral to the licensing board charged with regulating his or her license for the imposition of administrative sanctions, as that board deems appropriate, for violations of these provisions.

AB 2783 (O'Donnell) – Controlled substances: hydrocodone combination products Reclassifies specified hydrocodone combination products as Schedule II controlled substances under the California Uniform Controlled Substances Act.

AB 2789 (Wood) – Prescriptions: electronic data transmission CMA Position: Oppose Requires, on and after January 1, 2022, health care practitioners authorized to issue prescriptions to have the capability to transmit electronic data transmission prescriptions and would require pharmacies to have the capability to receive those transmissions. Mandates electronic prescribing, unless specifi ed exceptions are met.

SB 212 (Jackson) – Solid waste: pharmaceutical and sharps waste stewardship CMA Position: Support Establishes a stewardship program, under which a manufacturer or distributor of covered drugs or sharps, or other entity defined to be covered by the bill, is required to establish and implement, either on its own or as part of a group of covered entities through membership in a stewardship organization, a stewardship program for covered drugs or for sharps, as applicable. Imposes various requirements on a covered entity or stewardship organization that operates a stewardship program, including submitting a proposed stewardship plan, an initial stewardship program budget, an annual budget, annual report, and other specified information to CalRecycle.

SB 1021 (Wiener) – Prescription drugs Extends existing provisions related to formularies for outpatient prescription drugs by health care service plans or health insurers and cost-sharing for covered outpatient prescription drugs until January 1, 2024.

Prohibits, until January 1, 2024, a drug formulary maintained by a health care service plan or health insurer from containing more than 4 tiers, as specified. Requires a prescription drug benefit to provide that an enrollee or an insured is not required to pay more than the retail price for a prescription drug if a pharmacy's retail price is less than the applicable copayment or coinsurance amount, and the payment rendered by an enrollee or insured would constitute the applicable cost-sharing. Extends until January 1, 2023, coverage requirement to antiretroviral drug treatments that are medically necessary for the prevention of AIDS/HIV.

SB 1109 (Bates) – Controlled substances: Schedule II drugs: opioids CMA Position: Support

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Requires training and continuing education under the Medical Practice Act, Nursing Practice Act, Physician Assistant Practice Act, Dental Practice Act, Osteopathic Act, and the Optometry Practice Act to include risks of addiction associated with the use of Schedule II drugs. Requires pharmacy or practitioner dispensing an opioid to a patient for outpatient use to display a notice on the label or container that warns of the risk of overdose and addiction as specified. Requires a prescriber to discuss specified information with the minor, the minor's parent or guardian or other adult authorized to consent to the minor's medical treatment before directly dispensing or issuing for a minor the first prescription in a single course of treatment for a controlled substance containing an opioid. Requires youth sports organizations to distribute specified Opioid Factsheet for Patients to each athlete and requires each athlete and their parent to sign a document acknowledging receipt.

SB 1254 (Stone) – Hospital pharmacies: medication profiles or lists for high-risk patients CMA Position: Neutral Requires a pharmacist at a hospital pharmacy to obtain an accurate medication profile or list for each high-risk patient upon admission of the patient under specified circumstances. Authorizes an intern pharmacist or a pharmacy technician to perform the task of obtaining an accurate medication profile or list for a high-risk patient if certain conditions are satisfied. Requires the hospital to establish criteria regarding who is a high-risk patient for purposes of the bill’s provisions and determine a timeframe for completion of the medication profile or list, based on the populations served by the hospital.

EMERGENCY SERVICES AB 2576 (Aguiar-Curry) – Emergencies: health care CMA Position: Support if Amended Authorizes a pharmacist or a community clinic to furnish a dangerous drug or device in reasonable quantities without a prescription during a declared emergency. Requires the Pharmacy Board to allow for the use of a mobile pharmacy or clinic during an emergency if certain conditions are met. Authorizes the Governor, during a state of emergency, to direct all state agencies to utilize, employ, and direct state personnel, equipment, and facilities for the performance of any and all activities that are designed to allow community clinics and health centers to provide and receive reimbursement for services provided during or immediately following the emergency, including directing DHCS to seek federal approvals to allow community clinics and health centers to provide and be reimbursed for Medi -Cal or other services that are provided either telephonically, or to patients at a shelter or other location within the geographical boundaries of the emergency as stated in the proclamation declaring the state of emergency

END-OF-LIFE AB 282 (Jones-Sawyer D) – Aiding, advising or encouraging suicide: exemption from prosecution Prohibits a person whose actions are compliant with the End of Life Option Act from being prosecuted for deliberately aiding, advising, or encouraging suicide.

AB 3211 (Kalra) – Advance health care directives 10

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Revises the language of the form for written advance health care directives created unde r the Health Care Decisions Law to allow a person to authorize an agent to consent to any temporary medical procedures necessary to maintain organs, tissues, and/or parts for the purpose of donation.

HEALTH CARE COVERAGE AB 595 (Wood) – Health care service plans: mergers and acquisitions CMA Position: Support if Amended Requires a health care service plan that intends to merge or consolidate with, or enter in an agreement resulting in its purchase, acquisition, or control by, any entity, as defined, i ncluding another health care service plan or a licensed health insurer, to give notice to, and secure prior approval from, the Director of the Department of Managed Health Care. Requires a health care service plan subject to these provisions to meet specified requirements and to provide information necessary for the director to make the determination to approve, conditionally approve, or disprove the transaction or agreement, as specified. Requires health care services plans subject to these provisions to pay specified fees and to reimburse the director for specified costs related to making a decision on whether to approval, conditionally approve, or disapprove the transaction

AB 1860 (Limón) – Health care coverage: cancer treatment CMA Position: Support Existing law prohibits, until January 1, 2019, an individual or group health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2015, that provides coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells from requiring an enrollee or insured to pay, notwithstanding any deductible, a total amount of copayments and coinsurance that exceeds $200 for an individual prescription of up to a 30 -day supply of a prescribed orally administered anticancer medication, as specified. Existing law authorizes health care service plans to adjust that $200 limit on January 1 of each year, to the extent that adjustment does not exceed the percentage increase in the Consumer Price Index for that year. Raises the limit on copayments and coinsurance to $250 for an individual prescription of up to a 30 -day supply of a prescribed orally administered anticancer medication, eliminates provisions authorizing health plans and insurers to adjust this limit, and extends the period the limit remains in effect to January 1, 2024.

AB 2119 (Gloria) – Foster care: gender affirming health care and mental health care CMA Position: Support if Amended Makes specified findings and declarations regarding transgender and gender nonconforming children in foster care. Specifies that the rights of minors and nonminors in foster care to be involved in the development of case plan and plan for placement includes the development of case plan elements related to gender affirming health care, with consideration of their gender identity. Provides that the rights of minors and nonminors in foster care to receive medical, dental, vision, and mental health services includes covered gender affirming health care and gender affirming mental health care, as defined, subject to existing consent laws. Requires the Department of Social Services, in consultation with the Department of Health Care Services and other stakeholders, to develop, as specified, guidance and best practices to identify, coordinate, and support foster youth seeking access to gender affirming health care services and gender affirming mental health services.

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AB 2499 (Arambula) – Health care coverage: medical loss ratios CMA Position: Support Existing law requires a health care service plan or health insurer to provide an annual rebate to each enrollee or insured under that coverage, on a pro rata basis, if the medical loss ratio, calculated as specified, is less than a certain percentage. Existing law excludes all specialized health care service plan contracts and specialized health insurance policies from these requirements. Limits the exemption from annual rebate requirements to specialized health care service plan contracts and specialized health insurance policies that provide only dental or vision servi ces.

AB 2674 (Aguiar-Curry) – Health care service plans: disciplinary actions CMA Position: Sponsor Under the Knox-Keene Health Care Service Plan Act of 1975, a health care service plan is prohibited from engaging in an unfair payment pattern, as defined, and allows providers to report instances in which a plan is engaging in an unfair payment pattern to the department. Requires the Department of Managed Health Care to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter and permits the department to conduct an audit or enforcement action pursuant to existing authority if the review of the complaint data indicates a possible unfair payment pattern .

AB 2863 (Nazarian) – Health care coverage: prescriptions Requires a pharmacy to inform a customer at the point of sale for a covered prescription drug whether the retail price is lower than the cost-sharing amount for the drug unless the lower price is charged automatically. Limits the amount a health care service plan or health insurer may require an enrollee or insured to pay at the point of sale for a covered prescription to the lesser of the applicable cost-sharing amount or the retail price. Prohibits a health care service plan or health insurer from requiring a pharmacist or pharmacy to charge or collect a cost-sharing amount from an enrollee or insured that exceeds the total retail price for the prescription drug. Provides that the payment rendered by an enrollee or insured constitutes the applicable cost sharing and shall apply to any deductible as well as to the maximum out-of-pocket limit, as specified.

AB 2941 (Berman) – Health care coverage: state of emergency Requires a health care service plan or health insurer to provide its enrollees or insureds who have been displaced by a state of emergency, as defined, access to medically necessary health care services.

Requires a health care service plan or health insurer, within 48 hours of a declaration of emergency by the Governor that displaces or has the immediate potential to displace enrollees or insureds, to file a notification with the regulator containing specified information regarding how the plan or insurer is communicating with and addressing the needs of its enrollees or insureds during the state of emergency.

SB 997 (Monning) – Health care service plans: physician to enrollee ratios Deletes the repeal date of existing law that would have sunset on January 1, 2019 and requires a health care service plan to ensure that there is at least one full-time equivalent primary care physician for every 2,000 enrollees and authorizes the assignment of up to an additional 1,000 enrollees, as specified, to a primary care physician for each full-time equivalent non-physician medical practitioner, as defined, supervised by that physician. These provisions will operate indefinitely.

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SB 1034 (Mitchell) – Health care: mammograms CMA Position: Neutral Extends, until January 1, 2025, the operation of existing law that requires a health facility at which a mammography examination is performed to include a prescribed notice on breast density in the summary of the written report that is sent to a patient, if specified circumstances apply. Makes technical and conforming changes.

HEALTH CARE FACILITIES AND FINANCING AB 1953 (Wood) – Skilled nursing facilities: disclosure of interests in business providing services Requires an organization that operates, conducts, owns, or maintains a skilled nursing facility to additionally report to the office whether the licensee, or a general partner, director, or officer of the licensee, has an ownership or control interest of 5% or more in a related party, as defined, that provides any service to the skilled nursing facility. If goods, fees, and services collectively worth ten thousand dollars ($10,000) or more per year are delivered to the skilled nursing facility, the disclosure shall include the related party’s profit and loss statement, and the Payroll -Based Journal public use data of the previous quarter for the skilled nursing facility’s direct caregivers.

AB 2428 (Gonzalez-Fletcher) – Federally qualified health centers: rural health clinics Exempts from Medi-Cal provider enrollment a primary care clinic with an additional physical plant added to its consolidated primary care clinic license from the requirement to separately enroll the additional physical plant as a separate provider and from the requirement to submit a complete application package, if the primary care clinic has notified the department of its additional physical plant. Allows an FQHC or RHC adding a new licensed location to its primary care license to elect to have the reimbursement rate for the new location established in accordance with the standard PPS methodology, or to have one PPS rate for all its locations.

AB 2983 (Arambula) – Health care facilities: voluntary psychiatric care CMA Position: Support Prohibits a general acute care hospital or an acute psychiatri c hospital from requiring a person who voluntarily seeks care to be in custody as a danger to himself or herself or others or gravely disabled as a condition of accepting a transfer of that person after his or her written consent for treatment and transfer is documented or in the absence of evidence of probable cause for detention.

SB 1152 (Hernandez) – Hospital patient discharge process: homeless patients CMA Position: Oppose Unless Amended Requires each hospital to include a written homeless patient discharge planning policy and process within the hospital discharge policy. Among other requirements, the policy shall require a hospital to inquire about a patient’s housing status; to connect the patient with available community resources and supportive services; and to identify a post discharge destination for the patient. Requires a hospital to document specified information before discharging a homeless patient, including that the patient has been offered a meal and weather-appropriate clothing. Requires, commencing on July 1, 2019, a hospital to develop a Winter 2019

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written plan for coordinating services and referrals for homeless patients with the county behavioral health agency, health care and social service agencies in the region, health care providers, and nonprofit social service providers, as available, to assist with ensuring appropriate homeless patient discharge.

SB 1397 (Hill) – Automated external defibrillators: requirement: modifications to existing buildings CMA Position: Support Applies the automated external defibrillator (AED) requirements to certain structures that are constructed prior to January 1, 2017, and subject to subsequent modifications, renovations, or tenant improvements, as specified.

INSURANCE SB 910 (Hernandez) – Short-term limited duration health insurance Prohibits a health insurer from issuing, selling, renewing, or offering a short-term limited duration health insurance policy, as defined, for health care coverage in California. Makes conforming changes.

SB 1008 (Skinner) – Health insurance: dental services: reporting and disclosures CMA Position: Support Requires a health care service plan or a health insurer that issues, sells, renews, or offers a health care service plan contract or insurance policy that covers dental services in California to utilize a uniform , specified benefits and coverage disclosure matrix. Requires the Department of Managed Health Care and the Department of Insurance to develop the uniform benefits and di sclosure matrix in consultation with stakeholders and to implement the bill’s provisions relating to the benefits and coverage disclosure matrix through emergency regulations, as specified.

SB 1375 (Hernandez) – Health insurance: small employer groups Amends the definition of "eligible employee" for the purpose of determining whether a business is a "small employer" eligible to purchase group coverage by excluding sole proprietors, partners of a partnership, and the spouses of sole proprietors and partners. Prohibits employer group health care service plans and employer group health benefit plans from being issued, marketed, or sold to sole proprietorship or partnership without employees through any arrangement, and requires that only individual health care service plans and individual health benefit plans be sold to any entity without employees.

MEDI-CAL AB 1785 (Nazarian) – Medi -Cal eligibility: assets Excludes the principal and interest of a 529 savings plan, as defined, from consideration for purposes of any asset or resources test to determine eligibility for certain Medi-Cal benefits, as specified. Excludes qualified distributions from a 529 savings account from consideration for purposes of any income test to determine eligibility for certain Medi-Cal benefits.

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CMA Position: Support Requires, to the extent federal financial participation is available and any necessary federal approvals have been obtained, that a Drug Medi-Cal certified provider receive reimbursement for individual counseling services provided through telehealth by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan.

SB 849 (Committee on Budget and Fiscal Review) – Medi -Cal Establishes, until January 1, 2026, the Proposition 56 Medi-Cal Physicians and Dentists Loan Repayment Act Program, to be developed by the State Department of Health Care Services to provide loan assistance payments to qualifying, recent graduate physicians and dentists that serve beneficiaries of Medi -Cal and other specified health care programs as specified. Allows the department to authorize a dental integration pilot program in San Mateo County as a component of the Medi -Cal 2020 demonstration project

SB 1287 (Hernandez) – Medi -Cal: medically necessary services Revises the Medi-Cal definition of “medically necessary” for purposes of an individual under 21 years of age to incorporate federal standards related to Early and Periodic Screening Diagnostic, and Treatment (EPSDT) services and requires the department and its contractors to update any specified materials to ensure the new medical necessity standard for coverage for individuals under 21 years of age is accurately reflected in all materials.

SB 1423 (Hernandez) – Medi -Cal: oral interpretation services Modifies the minimum qualifications that an interpreter is required to possess to provide oral interpretation services to limited English-proficient (LEP) Medi-Cal beneficiaries enrolled in either a managed care plan or a mental health plan.

MEDICAL CANNABIS AB 710 (Wood) – Cannabidiol Provides that, if specified changes in federal law regarding the controlled substance cannabidiol occurs, a physician, pharmacist, or other authorized healing arts licensee who prescribes, furnishes, or dispenses a product composed of cannabidiol, in accordance with federal law, is deemed to be in compliance with state law governing those acts. Excludes from the Medicinal and Adult-Use Cannabis Regulation and Safety Act (MAUCRSA), any medicinal product composed of cannabidiol approved by the federal Food and Drugs Administration and either classified as a Schedule II-V controlled substance or exempted by MAUCRSA.

AB 1996 (Lackey) – The California Cannabis Research Program Conforms the name of the Cannabis Research Program as the California Marijuana Research Program hosted by the Center for Medicinal Cannabis Research, throughout the code. Authorizes the program to cultivate cannabis for its use in research, as specified and expands the program to in include the study of naturally occurring constituents of cannabis and synthetic compounds that have effects similar to naturally occurring cannabinoids. Authorizes controlled clinical trials on testing methods for detecting harmful contaminants in cannabis, including mold and bacteria.

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MEDICAL RECORDS AB 2088 (Santiago) – Patient records: addenda Requires a health care provider to allow a patient, regardless of their age, who inspects their patient records to provide to the health care provider a written addendum with respect to any item or statement in their records that the patient believes to be incomplete or incorrect.

MENTAL HEALTH AB 1968 (Low) – Mental health: firearms CMA Position: Neutral Prohibits a person who has been taken into custody, assessed, and admitted to a designated facility because he or she is a danger to himself, herself, or others, as a result of a mental health disorder and who was previously taken into custody, assessed, and admitted one or more times within a period of one year preceding the most recent admittance from owning a firearm for the remainder of his or her life, subject to existing notice and hearing procedures.

AB 2099 (Gloria) – Mental health: detention and evaluation CMA Position: Support Requires that a facility accepting a person taken into custody and placed in a designated facility for up to 72 hours for evaluation and treatment pursuant to existing law, treat a copy of the application stating the circumstances surrounding the event the same as the original.

AB 2193 (Maienschein) – Maternal mental health CMA Position: Neutral Requires, by July 1, 2019, health care service plans and health insurers to develop a maternal mental health program, as specified. Requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to offer to screen or to appropriately screen a mother for maternal mental health conditions, subject to specified exceptions.

AB 2315 (Quirk-Silva) – Pupil health: mental and behavioral health services: telehealth technology: guidelines CMA Position: Support if Amended Requires the State Department of Education, in consultation with the State Department of Health Care Services and stakeholders, to, on or before July 1, 2020, develop and post guidelines, as specified, for the use of telehealth technology in public schools, to provide mental health and behavioral health services to pupils on school campuses.

AB 2325 (Irwin) – County mental health services: veterans CMA Position: Support Prevents a county from denying an eligible veteran county mental or behavioral health services while the veteran is waiting for a determination of eligibility for, and availability of, mental or behavioral health

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services provided by the United States Department of Veterans Affairs. Makes specific findings and declarations about the county’s duty to provide mental and behavioral health services to veterans.

AB 2639 (Berman) – Pupil suicide prevention policies: reviews: updates CMA Position: Support Requires the governing board or body of a local educational agency that serves pupils in grades 7 to 12 to review, at minimum every 5th year, its policy on pupil suicide prevention and, if necessary, update its policy.

AB 3032 (Frazier) – Maternal mental health conditions Requires a general acute care hospital or special hospital that has a perinatal unit to develop and implement, a program as specified, relating to maternal mental health conditions including, but not limited to, postpartum depression.

SB 1004 (Wiener) – Mental Health Services Act: prevention and early intervention CMA Position: Support Requires the Mental Health Services Oversight and Accountability Commission to establish priorities for the use of prevention and early intervention funds and to develop a statewide strategy for monitoring implementation of prevention and early intervention services, as specified. Requires the commission to establish a strategy for technical assistance, support, and evaluation to support the successful implementation of the objectives, metrics, data collection, and reporting strategy. Amends the Mental Health Services Act by requiring a portion of funds in the county plan relating to prevention and early intervention focus on the priorities established by the commission. Permits a county to include other priorities, as determined through a stakeholder process

SB 1113 (Monning) – Mental health in the workplace: voluntary standards CMA Position: Support Authorizes the Mental Health Services Oversight and Accountability Commission, in consultation with the Labor and Workforce Development Agency, to establish a framework and voluntary standard for mental health in the workplace that serves to reduce mental health stigma, increase public, employee, and employer awareness of the recovery goals of the Mental Health Services Act, and to provide guidance to California’s employer community to put in place strategies and programs, to support the mental health and wellness of employees.

PROFESSIONAL LICENSING AND DISCIPLINE AB 505 (Caballero) – Medical Board of California: adjudication: expert testimony CMA Position: Sponsor Authorizes the administrative law judge to extend the time for the exchange of specified expert witness testimony information with counsel for the other party to be completed, upon a motion based on a showing of good cause, for a period not to exceed 100 calendar days from the current requirement that the exchange of the information to be completed 30 calendar days prior to the commencement date of the hearing or as specified.

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SB 1448 (Hill) – Healing arts licensees: probation status: disclosure CMA Position: Oppose Requires, on or after July 2, 2019, the licensing boards for podiatrists, naturopathic doctors, chiropractors, acupuncturists, physicians and surgeons, and osteopaths to provide, before the patient's first visit, a specified disclosure to a patient or the patient's representative if the licensee is on probation pursuant to a probationary order made on and after July 1, 2019. Also requires the licensing boards to post specified information related to licensees on probation on their website.

PUBLIC HEALTH AB 2370 (Holden) – Lead exposure: child day care facilities: family day care homes CMA Position: Support Makes various changes to the California Child Day Care Facilities Act including, but not limited to, requiring, as a condition of licensure, health and safety training in the prevention of lead exposure as a part of the preventive health practices course or courses component and requiring child day care facilities to provide the parent or guardian with written information on the risks and effects of lead exposure, blood lead testing recommendations and requirements, and options for obtaining blood lead testing, as specified. Requires specified child day care centers to have its drinking water tested for lead contamination levels.

AB 2507 (Jones-Sawyer) – County jails: infant and toddler breast milk feeding policy CMA Position: Support Requires, on or before January 1, 2020, a county sheriff or the administrator of a county jail to develop and implement an infant and toddler breast milk feeding policy for lactating inmates detained in or sentenced to a county jail that is based on currently accepted best practices.

REPRODUCTIVE HEALTH AB 2289 (Weber) – Pupil rights: pregnant and parenting pupils CMA Positi0n: Support Codifies federal and state regulations that prohibit an educational institution from applying any rule concerning a pupil’s actual or potential parental, family, or marital status that treats pupils differently on the basis of sex. Establishes accommodations for pregnant and parenting pupils including eight weeks of parental leave.

WORKFORCE & OFFICE SAFETY ISSUES AB 1791 (Waldron) – Physicians and surgeons: continuing education Requires the Medical Board of California, in determining continuing education requirements, to consider including a course in integrating HIV/AIDS pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) medication maintenance and counseling in primary care settings, especially as it

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pertains to HIV testing, access to care, counseling, high-risk communities, patient concerns, exposure to HIV/AIDS, and the appropriate care and treatment referrals.

AB 1976 (Limón) – Employment: lactation accommodation CMA Position: Sponsor Requires an employer to make reasonable efforts to provide an employee with use of a room or other location, other than a bathroom, for an employee to express breast milk in private. An employer shall be deemed in compliance if: (1) the employer is unable to provide a permanent lactation location because of operational, financial, or space limitations; (2) the temporary lactation location is private and free from intrusion while an employee expresses milk; (3) the temporary lactation location is used only for lactation purposes while an employee expresses milk.; and (4) the temporary lactation location otherwise meets the requirements of state law concerning lactation accommodation.

AB 2009 (Maienschein) – Interscholastic athletic programs: automated external defibrillator CMA Position: Support If a school district or charter school elects to offer any interscholastic athletic program, require the school district or charter school to: (1) ensure that there is a written emergency action plan in place, and posted as specified, that describes the location and procedures to be followed in the event of sudden cardiac arrest or other medical emergencies related to the athletic program’s activities or events; (2) acquire, commencing July 1, 2019 at least one AED for each school within the school district or the charter school to be available on campus; (3) encourage that the AED or AEDs are available for the purpose of rendering emergency care or treatment, as specified; (4) ensure that the AED or AEDs are available to athletic trainers and coaches and authorized persons at the athletic program’s on campus activities or events; and 5) ensure that the AED or AEDs are maintained and regularly tested, as specified.

AB 2202 (Gray) – U C School of Medicine: San Joaquin Valley Regional Medical Education Endowment Fund CMA Position: Support Creates the University of California San Francisco San Joaquin Valley Regional Medical Education Endowment Fund for the purpose of supporting the annual operating costs for the development, operation, and maintenance of a branch campus of the University of California, San Francisco, School of Medicine in the San Joaquin Valley.

AB 2311 (Arambula) – Medicine: trainees: international medical graduates CMA Position: Support Eliminates the reference to the specific courses in clinical instruction authorized to be offered to the international medical graduate participants in the pre-residency training program at the David Geffen School of Medicine of the University of California, Los Angeles.

SB 1348 (Pan) – Postsecondary education: allied health professional clinical programs: reporting CMA Position: Support Winter 2019

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As part of the Strong Workforce Program, requires, beginning in 2019 and in each year thereafter, the Office of the California Community Colleges must report, for each community college program that offers a certificate or degree related to allied health professionals, specified information, including the number of students participating in the clinical training and the license number or employer identification number of each clinical training site, delineated by program and occupation, with multiyear implementation for the reporting.

These are just a sampling of the new laws impacting health care in 2018 and beyond. For a comprehensive list, see "Significant New California Laws of Interest to Physicians for 2019," at cmadocs.org/new-laws-2019.

Sidebar: Did you know CMA’s online health l aw library is free to members?

The California Medical Association (CMA) online health law library contains nearly 5,000 pages of up -todate legal information on a variety of subjects of everyday importance to practicing physicians. One of CMA's most valuable member benefits, the searchable online library contains all the information available in the California Physician's Legal Handbook (CPLH), an annual publication from CMA's Center for Legal Affairs.

CMA members can access the library documents free at cmadocs.org/health-law-library. Nonmembers can purchase documents for $2 per page.

CPLH, the complete law library, is also available for Whether you’re lookinghealth for funding to start, acquire, or expand

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Distracting Devices in Healthcare: Malpractice Implications Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

By Shelley Rizzo, MSN, CPHRM, Patient Safety Risk Manager II, The Doctors Company Digital distraction in healthcare is emerging as a great threat to patient safety and physician well-being. This phenomenon involves the habitual use of personal electronic devices by healthcare providers for nonclinical purposes during appointments and procedures. Some call it “distracted doctoring.”

But the threat might more aptly be called “distracted practice,” as it impacts all healthcare workers and staff. Personal electronic devices can create a digital distraction so engaging that it consumes awareness, potentially preventing healthcare providers from focusing on the primary task at hand—caring for and interacting with patients. And the consequences can be devastating.

Distraction can be both a symptom of and a contributor to healthcare provider stress and burnout. As a symptom of burnout, digital distraction is a way to escape a stressful environment. As a contributor to burnout, digital distraction impedes human interaction because of the sheer volume of data demanding our attention.

CONTINUED ON PAGE 46 >>

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2018

Physicians

The Central Coast Medical Association honors physicians who have worked to and engaged in community service SAN LUIS OBISPO COUNTY:

Dr. Joseph A Schwartz

The Central Coast Medical Association awarded Joseph A. Schwartz, MD, as the 2018 Physician of the Year for San Luis Obispo County. The honor is for a physician who has worked to improve the quality of health care, contributed to the education of other physicians, and engaged in community service and other activities outside of medicine.

Dr. Fred Vernacchia presented the award and shared stories of Dr. Schwartz. Dr. Vernacchia stated,

“Joe very much practices medicine in the same way he approaches life, with an open heart, integrity, and passion for hard work and intellectual pursuits.�

Dr. Schwartz was born in Philadelphia to Sam and Ruth Schwartz. Following the death of his father at the age of nine, Dr. Schwartz and his family moved to Beverly Hills. Growing up, Dr. Schwartz was encouraged to pursue intellectual opportunities. After completing his undergraduate degree in biology, Dr. Schwartz went on to receive his Doctor of Medicine degree from the University of California, Davis. He completed his residency, internship, and fellowship at the David Geffen School of Medicine at UCLA. Dr. Schwartz then decided to pursue academia where he spent the first 10 years of his career as a professor of psychiatry at the University of Minnesota and at the University of Michigan. Dr. Schwartz eventually left academia to open his own private practice In San Luis Obispo, where he has resided since 1993.

Dr. Schwartz has a passion for exploring other countries and learning about other cultures. Dr. Schwartz has been traveling for more than 30 years and continues to do so with his wife, Barbara Boom. Dr. Schwartz and Barbara have a combined family of five sons and eight grandchildren.

Dr. Fred Vernacchia (left) and Dr. Joseph A. Schwartz (right)

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of the Year improve the quality of health care, contributed to the education of other physicians, and other activities outside of medicine.

SANTA BARBARA COUNTY:

as the assistant director of the California Department of Public Health (CDPH).

Dr. Charity Dean

The Central Coast Medical Association awarded Charity Dean, MD, MPH, as the 2018 Physician of the Year for Santa Barbara County. The honor is for a physician who has worked to improve the quality of health care, contributed to the education of other physicians, and engaged in community service and other activities outside of medicine.

Dr. Kurt Ransohoff presented the award and shared stories of Dr. Dean, who is known by her colleagues for her compassion, work ethic, enthusiasm, and dedication to public service. Dr. Ransohoff stated, “Dr. Charity

Dr. Dean is passionate about public service and has dedicated her life’s work to public health. Dr. Dean has received numerous awards for her work, including the Gerald E Bruce Community Service Award from the Ford Family Foundation. Locally, Dr. Dean has been a vocal advocate during times of disaster for the health department ensuring quality and care for all Santa Barbara County residents.

Dr. Dean and her family will be moving to Sacramento when she begins working at the California Department of Public Health.

Dean was accepted into five medical schools.

I don’t know about you, but I didn’t get accepted into that many schools. Dr. Dean’s hard work is a true testament to where is she today and where she is heading.”

Dr. Dean was raised in rural Oregon. She earned her Doctor of Medicine along with her Master of Public Health and Tropical Medicine from Tulane University in Louisiana. Dr. Dean moved to Santa Barbara to complete her residency at Santa Barbara Cottage Hospital in internal medicine.

Dr. Dean served as deputy public health officer from 2011 to 2014 and then as public health officer from 2014 through 2018 at the Santa Barbara County Public Health Department. Recently, Dr. Dean was appointed by Governor Jerry Brown to serve

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Dr. Kurt Ransohoff (left) and Dr. Charity Dean (right)

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An End

to Al zheimer’s?

UCSB PHYSICIAN-SCIENTIST KENNETH KOSIK SEEKS A CURE

BY ELIZABETH SCHWYZER

One in ten. That’s the percentage of Americans age 65 or over who currently suffer from dementia due to Alzheimer’s disease, a neurodegenerative disease associated with memory loss, cognitive decline, and behavioral changes.

Countless questions surround this disease. What distinguishes those who make up the ten percent?

What can individuals do to reduce their risks for Alzheimer’s? How, if at all, can we treat this debilitating condition? And here’s another question: If you were certain to develop Alzheimer’s disease later in life, would you want to know?

For most people, the question is hypothetical. For a few, it’s very real.

In a remote, mountainous region of Colombia live a group of families that carries the genetic markers for a rare strain of early-onset Alzheimer’s. Fifty percent of these roughly 6,000 individuals develop dementia in their early 40s. Most are dead before 60. Their brains hold a key to better understanding this debilitating disease, and, hopefully, to developing a cure.

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FROM BOSTON TO CALIFORNIA, BY WAY OF COLOMBIA From his sixth-floor corner office at the University of California, Santa Barbara, Dr. Kenneth Kosik looks out over the bluffs of campus point to the bright horizon where the Pacific Ocean meets the sky. The Harriman Professor of Neuroscience and co-director of the Neuroscience Research Institute at UCSB has been studying Alzheimer’s disease since the early 1980s, before the condition had even the entered public consciousness.

It was more than 25 years ago, in another country bordering the Pacific, that Kosik discovered the families that remain central to his research.

The internationally notorious drug lord Pablo Escobar was still alive in 1992 when Kosik traveled to Colombia to give a talk on the biology of Alzheimer’s disease. It was a period of profound political instability in Colombia and a dangerous time for a gringo to be traveling in the country. Guerilla warfare, murders, and disappearances were the norm, particularly in remote regions.

The city of Medellín, where Kosik’s talk was to be held,

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had recently been dubbed the “world’s most dangerous city”

by TIME Magazine. There, the neurologist who was then at Boston’s Brigham and Women’s Hospital was introduced to local neurologist Dr. Francisco Lopera. For the past decade, Lopera explained, he had been studying a group of 12 interrelated Colombian families who experienced an extraordinarily high rate of early-onset dementia. Sufferers generally began by exhibiting forgetfulness and confusion before progressing to much more severe disorientation and personality changes.

Kosik was riveted.

“All [Lopera] knew was that they were getting dementia at a young age,” Kosik said. “I changed all my plans to follow this.”

The appeal of studying these families alongside Lopera was more than intellectual. Kosik knew that if the families’ symptoms were caused by Alzheimer’s, there was hope of isolating the genetic mutation causing the disease, which might in turn point toward a cure.

In order to determine whether this was Alzheimer’s, Kosik and Lopera knew they would need to examine brain tissue beneath a microscope, a process which could only be done

A

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An End Francisco Lopera, Kenneth Kosik, and Lucia Madrigal travel into the Colombian countryside on horseback to visit a family with an Alzheimer mutation. posthumously.

An opportunity finally arose when the matriarch of a family died. Kosik recalled the tensions surrounding their unusual request of her survivors.

“We went to the family and told them we were studying this affliction, and we asked if they would be willing to donate their mother’s brain in the interests of helping their people,” he explained. “All the kids said yes, except for one son. The guy wore big gold chains and had been in the police. People thought he was a sicario -- an assassin. You don’t usually argue with these people.”

The funeral party was already underway by the time the son gave his grudging approval.

“A neuropathist removed the brain and quickly got out of there,” Kosik recalled. “I was waiting in Boston, and eventually he knocked on my door with a bucket of formaldehyde and the brain. We got to the lab in the morning, cut it, stained it, and for the first time saw the plaques and tangles that are the hallmarks of Alzheimer’s.”

WHERE MOLECULAR SCIENCE MEETS GENETICS AND ETHICS It was 1906 when German psychiatrist and neuropathologist Alois Alzheimer first identified amyloid plaques and neurofibrillary tangles in the brain of a

Winter 2019

deceased patient who had suffered from dementia. Nearly a century later, the same technique confirmed Kosik and Lopera’s suspicion that the Colombian families were indeed afflicted with Alzheimer’s disease.

Their discovery marked a major step forward, but it wasn’t Kosik’s first breakthrough in his quest to understand Alzheimer’s. Ten years earlier, Kosik and his colleagues at Harvard Medical School were among the first to isolate the protein -- tau -- that makes up the neurofibrillary tangles characteristic of the disease.

Around the same time, another group determined that amyloid plaques were composed of a peptide called A-beta.

According to neurologist Dr. Bruce Miller, director of UCSF’s Memory and Aging Center at UCSF and the Global Brain Health Institute, Kosik was instrumental in turning the attention of the scientific community toward tau.

“Tau was ignored for many years with too much emphasis on the amyloid protein,” Miller stated in a recent phone interview. “Ken helped change that perspective. I think it’s pretty clear now that where you find tau in the brain is where you find dysfunction.”

It was this relatively new understanding of the molecular basis of Alzheimer’s that Kosik shared when

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he gave his talk in Medellín. When he heard of the Colombian families who experienced such high rates of early-onset dementia, he realized they might hold the key to understanding not the biology but the genetics of Alzheimer’s.

“If it’s showing up generation after generation, it’s likely a genetic mutation,” Kosik explained.

“Genetics is a very profound way to understand disease.”

In the case of the Colombian families, Kosik and Lopera were able to determine that it was a mutation of the gene presenilin 1 that led to this rare variant of the disease. Although the vast majority of Alzheimer’s sufferers -- about 99 percent -- are afflicted late in life, the rare cases of early-onset Alzheimer’s provide an unusual opportunity to study the disease in general.

Once it became clear that every afflicted family member shared the same genetic mutation, it became possible to use a simple blood test to predict whether an individual would develop symptoms. In his article “Fortune Teller,” published in the July/August 1999 issue of The Sciences, Kosik writes poetically of the ensuing ethical dilemma researchers faced.

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One sufferer he describes lives in “a poor and violent barrio in Medellín:”

Emaciated, she sat contorted, her hands gnarled and stuck in an unnatural position, a feeding tube protruding from her nose. Motionless except for her aimlessly roving eyes, she was a constant reminder to her children of the fate that lay ahead for those among them who carried the mutant gene.

I told the grown children that we could now determine which of them would get the disease, and I asked whether they would want to take the test. “Before answering,” I told them, “remember that there is no treatment.” All the children said they would want to take the test. What would they do differently, once they knew the result? I asked. At that point no one had an answer, except a twenty-three-year-old male, who later told our nurse that if his test were positive, he would shoot himself.

It was scenarios such as this one that led Kosik and Lopera to the conclusion that in the absence of adequate genetic counseling, such genetic tests must be done for research purposes only, the results to remain unavailable to the subjects. Still, Kosik was troubled by the fact that this genetic information would be withheld from the subjects, particularly in the cases of young couples who were considering having children.

For so long, Kosik and Lopera had pursued a mystery buried deep in the Colombians’ genetic code. Finally, they had found it, yet it was painful to hold.

“Genetic information,” Kosik said, “is like fire.”

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Winter 2019

CLINICAL IMPLICATIONS AND PREVENTIVE MEASURES At the same time that Kosik and Lopera grappled with the ethical dilemma of their newfound knowledge, they realized they had an opportunity to treat Alzheimer’s in a prevention paradigm. Never before had anyone known with certainty that a given subject would develop the disease, and develop it within a relatively predictable period. Given that knowledge, might a clinical trial yield a drug that could delay the onset of symptoms for five years, 10, or 20? If such a drug could then be introduced preventively in other populations, it might be equivalent to a cure.

Up until this point, pharmaceutical companies had conducted increasingly expensive trials of drugs to treat patients already suffering from Alzheimer’s-related dementia.

Every single one had failed.

In 2008, Kosik and Lopera teamed up with biotech company Genentech/Roche to test a drug that could stave off the onset of Alzheimer’s. One year later, they publicized plans for a clinical trial on the Colombian population.

“When this trial was announced, the Colombian story went from complete obscurity to the front page of the New York Times,” Kosik recalled.

A clinical trial with the Roche drug crenazumab was initiated, one of the first trials intended to prevent the disease. At the time of writing, this trial is 3 years underway.

“In 2 or 3 years,” Kosik said, “we’ll know how it went.”

Meanwhile, Kosik continues his work at UCSB, the academic home he chose specifically for its emphasis on foundational science and its openness to collaboration. Far from jealously guarding his groundbreaking research, Kosik is energized by sharing his findings and working across disciplines. He serves alongside Dr. Miller as co-director of the Tau Consortium, a collaborative research program funded by the charitable foundation of investor Richard Rainwater, who was diagnosed with progressive supranuclear palsy (PSP) in 2009 and died in 2015. Like Alzheimer’s disease, PSP is a tauopathy: a condition characterized by an abnormal build-up of tau in the neurons.

While graduate students hunker over test tubes at the Kosik laboratory in UCSB’s blocky Bio II building, Kosik himself is often on the road. He spends a good deal of time giving public talks, writing for lay readerships, and conducting research in the field. He considers himself a physician-scientist: someone who can bridge the worlds of clinical and laboratory medicine.

“As a physician-scientist, I feel you can create an important bridge,” he explained. “People don’t always understand what’s going on in labs; it feels esoteric. PhDs can’t always communicate well with physicians. At the same time, having medical training helps scientists and students understand what it’s like to be with patients.”

One of the ways Kosik has brought his scientific knowledge to a wider audience is through the publication of his 2015 Reader’s Digest book, Outsmarting Alzheimer’s: What You can

Do to Reduce Your Risk. In it, Kosik outlines two primary ways individuals can take measures to “beat the genes” -- medical and lifestyle interventions. Though the advice he offers is common sense when it comes to general health, the data also strongly supports a correlation between these actions and a reduced risk of dementia due to Alzheimer’s.

There are three primary medical interventions, Kosik explained: 1. Track your blood pressure, and treat high blood pressure.

2. Know your blood sugar; research has established a link between diabetes and Alzheimer’s.

3. Know your lipid profile; the same high cholesterol and triglycerides that can lead to heart disease are also risk factors for Alzheimer’s.

“IF IT’S SHOWING UP GENERATION AFTER GENERATION, IT’S LIKELY A GENETIC MUTATION,” KOSIK EXPLAINED.

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At the same time, Kosik said, there are simple, daily actions we can take to further reduce our risk of Alzheimer’s:

1. Exercise. “The data is very strong here,” Kosik stated, adding that both aerobic and weight-training exercise are important.

2. Watch what you eat; Kosik recommended avoiding red meat and choosing a Mediterranean diet that consists primarily of plant-based foods.

3. Keep up your intellectual activity. Sudoku isn’t necessary, Kosik explained. Talking, thinking, writing -- anything that stimulates the brain counts.

4. Try to limit stress. “We can’t control some of the big stressors in life such as the death of a spouse, divorce, or the loss of a home,” Kosik explained, “But there are other ways we can limit stress, like arriving at the airport early.”

5. Get a good night’s sleep.

6. Be social. “Social isolation is not good for the brain,” Kosik noted.

Physicians, he suggested, should actively encourage both medical and lifestyle risk-reduction measures.

For now, there’s no way for most of us to know whether we’ll develop Alzheimer’s disease in later life, though genetic tests can give us information to suggest we’re at higher or lower risk. Yet it may not be long before we’re faced with the question of how much we want to know about our genetic destiny.

“We’re getting better and better at predicting the disease with genetic markers,” Kosik noted. “So the question in Colombia -- ‘Do you want to know?’ -- will soon be a question for all of us.”

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MEN’S HEALTH

Marching for Prostate Cancer

BY DAVID DODSON, MD

Although prostate cancer remains second only to lung cancer as a cancer killer of men, Willet Whitmore’s famous aphorism still applies “If cure is necessary, is it possible, and if cure is possible, is it necessary?”.

Clearly over-diagnosis and over-treatment remain major problems, and for good reason, namely that our ability to distinguish cancers not destined to be deadly from those that are is still not what it needs to be. This is the key problem in the field, for the simple reason that the great majority of men with prostate cancer will not die from it, rather they will die from the number

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one cause of death for men without prostate cancer: coronary heart disease. Also, the great majority of men (likely 100%) do not wish to become impotent and/ or incontinent as a result of treatment for a disease that will not ultimately threaten their lives. Hence the need to distinguish those prostate cancers which are potentially life threatening from those that are not.

Treatment options have expanded with the FDA approval last February of apalutamide, a next generation androgen receptor blocker for castration resistant prostate cancer, in addition to 4 other new drugs since

Winter 2019

2010 for castration resistant metastatic prostate cancer, with more drugs in the pipeline.

Primary treatment continues to depend upon risk stratification and includes active surveillance for low risk patients, radical prostatectomy either open or robotic (usually the latter), XRT either external beam or brachytherapy, and in some cases cryotherapy.

Risk stratification continues to focus on extent of disease in biopsy cores, tumor grade (Gleason Score), findings on rectal examination, and in some cases imaging studies and genomic characteristics of the tumor. The latter shows promise in refining prognosis but is presently not recommended by the American Urologic Association, The Society for Urologic Oncology, or the American Society for Clinical Oncology. This could change, so stay tuned for further developments.

Because of the high risk of treatment complications, notably incontinence and impotence as well as radiation-induced cystitis and proctitis, and the fact that most men with low risk prostate cancer will do well without treatment, refining our ability to distinguish those cancers that need cure from those that do not remains the key challenge in the field of prostate cancer. A not insignificant part of the problem is that a diagnosis of cancer, even low risk cancer, can be so disturbing to both patient and doctor that the option of active surveillance may be unacceptably anxiety-provoking, leading to unnecessary treatments and complications. Being able to better predict which men would benefit from treatment and which would not be enormously helpful. ASCO, the American Society for Clinical Oncology published its first guidelines for the treatment of localized prostate cancer in September 2018.

And what about screening? The venerable DRE is out, no longer recommended for either prostate or colon cancer screening. In June 2018, the USPSTF updated its recommendations for PSA screening, which had previously been an across the board D, meaning not recommended because its harms

outweigh its benefits. The new guidelines, published in JAMA, remain D for men over 70 but are now C for men aged 55-69, meaning the harms and benefits of screening are closely matched and screening can be considered after discussing the risks and harms if the patient wishes to proceed. The American Urologic Association emphasizes shared decision making

Our ability to distinguish cancers not destined to be deadly from those that are is still not what it needs to be.

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regarding the decision to screen for prostate cancer in men 55-69 adding that men over 70 in excellent health may benefit from screening, and the American Cancer Society also stresses shared decision making for men age 50 and above who have a life expectancy of at least 10 years. So, dust off your crystal balls so you can properly advise only those men destined to live over 10 years to consider screening! Both the AUA and the ACS recommend considering PSA screening in men age 40-50 with a high risk of prostate cancer including African Americans and men with a strong family history of prostate cancer.

I have long been fascinated by the numerous parallels between breast cancer in women and prostate cancer in men. Both involve organs associated with reproduction. Both are second only to lung cancer as cancer killers, and like prostate cancer in men, breast cancer is the commonest cancer in women (leaving aside non-melanoma skin cancer). Both are typically hormone-dependent. Both have long natural histories, with survival often exceeding a decade. Both have screening tests that leave much to be desired in terms of preventing mortality and both mammography and PSA screening seem to be the subject of endless debate and controversy. But one parallel does not exist. Women march for breast cancer. Men do not march for prostate cancer. One wonders, where would the field of prostate cancer be today if men followed women’s example by being proactive in advocating for their health?

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Dr. David V. Feliciano will present a public lecture on Thursday, March 21. There will be a reception at 5:30 pm and presentation at 6:00 pm.

Reservations are required; please contact Juli Askew at 805.681.7762 or jaskew@sansumclinic.org.

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David V. Feliciano, MD

Visiting Professor of Surgery 2019 David V. Feliciano, MD has been selected as the Visiting Professor of Surgery for Surgical Academic Week 2019 (March 18-22) announced Dr. W. Charles Conway, FACS, Visiting Professor of Surgery Program Administrator.

Dr. Feliciano received his medical degree in 1970 from Georgetown University in Washington, D.C. He completed training in general surgery at the Mayo Clinic, in trauma at Wayne State University, and in vascular surgery at Baylor College of Medicine and was a Lieutenant in the U.S. Navy Medical Corps.

He was Professor of Surgery at Emory University and Surgeon-in-Chief at Grady Memorial Hospital in Atlanta, Georgia from 1991 to 2011. After serving as the Battersby Professor of Surgery and Chief of the Division of General Surgery at Indiana University from 2013-2017, he is now a Clinical Professor of Surgery at the University of Maryland and an Attending Surgeon at The Shock Trauma Center/University of Maryland Medical Center, Baltimore. Also, he is a Clinical Professor of Surgery, Mercer University School of Medicine, Macon, Ga., and Adjunct Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. He is a general surgeon with strong interests in endocrine surgery, surgical oncology, and trauma. His research interests are use of ultrasound in truncal trauma; damage control celiotomy; and effect of metabolic state on outcome from vascular injuries. In addition, he is the Co-Editor of the textbook TRAUMA, now in its Eighth Edition.

Dr. Feliciano will present a public lecture on Thursday, March 21 at the Ridley-Tree Cancer Center at Sansum Clinic in the Lovelace Hall at 540 West Pueblo Street. There will be a reception at 5:30 pm and presentation at 6:00 pm.

His topic is “Everything You Wanted to Know about Trauma in the United States.” With 180,000 fatal injuries a year, trauma systems, centers, and surgeons are an integral part of healthcare in the United States. But, how do we prevent injuries, how do we get injured patients to the right place, and how do we treat the

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“We have been fortunate to have had outstanding surgeons, all leaders in their field. The program benefits the surgical residents, surgical staff, and patients. The value to our community, to Cottage Health, and to Sansum Clinic is priceless.” James T. Dunn, MD, FACS injured patient in the modern era?

Reservations are required; please contact Juli Askew at 805.681.7762 or jaskew@sansumclinic.org.

This unique educational program advances the level of surgical care available in our community, and is made possible by generous support from the Title Sponsor, Cottage Health, and grateful patients, medical groups, individual community surgeons and physicians, and corporate donors.

Dr. Feliciano follows seven previous Visiting Professors: Dr. John L. Cameron (Johns Hopkins) 2012, Dr. Hiram C. Polk, Jr. (University of Louisville) 2013, Dr. Julie Ann Freischlag (UC Davis School of Medicine) 2014, Dr. Keith D. Lillemoe (Massachusetts General Hospital) 2015, Dr. Michael G. Sarr (Mayo Clinic) 2016, Dr. Barbara Lee Bass (Houston Methodist Hospital), Professor O. James Garden (University of

Edinburgh) 2018.

Dr. Conway takes over the reins of the Visiting Professor of Surgery Education Program from Dr. Ronald G. Latimer, who established the program in 2010 with the Department of Surgery and Sansum Clinic. Sansum Clinic’s Visiting Professor of Surgery program provides expert educational seminars for practicing Santa Barbara surgeons and physicians. More importantly, the program allows surgical residents in training at Santa Barbara Cottage Hospital the chance to interact with the icons, leaders, and outstanding teachers of the art of surgery.

Dr. Conway joined Sansum Clinic in 2017 and is a fellowship-trained surgical oncologist at the Ridley-Tree Cancer Center, with nearly 10 years of high-volume surgical experience dealing with complex cases.

Reception & Presentation David V. Feliciano, MD Clinical Professor of Surgery University of Maryland SOM

Attending Surgeon Shock Trauma Center, Department of Surgery

Please Join Us Thursday, March 21, 2019 5:30 pm to 7:00 pm Reception Presentation

5:30 pm 6:00 pm

Ridley-Tree Cancer Center at Sansum Clinic Lovelace Conference Hall 540 W. Pueblo Street Free valet parking available RSVP to Juli Askew by March 15 (805) 681-7762 or email jaskew@sansumclinic.org Reservations required

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Speaking on

Everything You Wanted to Know about Trauma in the United States With 180,000 fatal injuries a year, trauma systems, centers, and surgeons are an integral part of healthcare in the United States.

But, how do we prevent injuries, how do we get injured patients to the right place, and how do we treat the injured patient in the modern era?

Title Sponsor

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CenCal Health: 2018 Community Report Goes Digital, Multimedia

CenCal Health, the local Medi-Cal health plan on the Central Coast, has published its 2018 Community Report. New this year is an entirely digital format, complete with videos, photos, audio testimonials, and animation. In the past, the organization has issued the standard printed report but made the switch this year coinciding with its 35th anniversary in Santa Barbara County. A decade ago, the organization expanded coverage to San Luis Obispo County. CenCal Health now serves more than 175,000 Medi-Cal beneficiaries.

The outline of the digital report follows a traditional hardcopy format: a message from the CEO, its mission and vision, achievements, leadership, and financial information. But the online format allows content to be easily shared and repurposed. Perhaps most important, it displays data in a unique way that interacts with the viewer.

“We wanted our report to the community to engage our stakeholders in a different way,” said Bob Freeman, CenCal Health CEO. “And we believe a digital format is the best way to make our efforts,

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successes and value more tangible.”

The report’s content options include a video message from Freeman, animated key indicators, photo collages of providers, audio testimonials and more.

Topics highlighted include the organization’s quality scores, its partnerships with other community-based organizations, how it improves access to care, and how it addresses Social Determinants of Health.

For 2018, the organization reports that its network physicians’ data resulted in the highest quality scores in CenCal Health’s history. Also notable: CenCal Health is one of the first local health plans selected by the State to transition responsibilities for the new Whole Child Model.

The Whole Child Model gives all responsibilities for care coordination - for specific severe medical conditions that fall under California Children’s Services - to a Medi-Cal-eligible child’s health plan, rather than splitting care coordination responsibilities between two different organizations.

By increasing the annual community report’s viewership, the organization hopes to dispel unflattering stereotypes of MediCal members, tens of thousands of whom gained coverage as a result of the Affordable Care Act. The report was created by the CenCal Health Communications and Community Relations department with the help of local marketing agency, Idea Engineering. CenCal Health’s 2018 Community Report is available on its website cencalhealth.org or directly at cencal2018.org.

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ANNUAL MEMBERSHIP MEETING Thank you to our event sponsors

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ANNUAL MEMBERSHIP MEETING Thank you to our event sponsors

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CL

Positions Available The COUNTY OF SAN LUIS OBISPO is seeking a physician to fill the role of Staff Psychiatrist. 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.

DS

F I S IE S A

SANSUM CLINIC is the largest and oldest multi-specialty 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-providerjob-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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Secured the Proposition 56 supplemental budget bill, which appropriates over $1 billion in funding for improved access to care.

Achieved record-setting 6.3 percent increase in membership with a 92.2 percent retention rate.

Drafted and filed a 2020 Sugar-Sweetened Beverages tax ballot initiative.

Stopped predatory practices by health insurance companies, including attempts to substantially limit same-day services (modifier -25 payments).

Launched a mobile app, as well as updated brands and websites for CMA, PHC, CALPAC and 20+ component medical societies.

Defended the medical profession and patients from dangerous legislation, including AB 3087 (Kalra).

Helped the Tulare Regional Medical Center medical staff restore independence and self-governance against the hospital.

Recouped nearly $11 million from payors on behalf of CMA’s physician members – a record year!

Secured $30 million commitment from Blue Shield of California to support the launch of a Physician Services Organization.

Secured $200 million to establish a loan repayment program and $40 million for the University of California to support, retain and expand physicians trained in California.

Visit cmadocs.org for more information.

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Public Health

Update

Launching SLO County’s First Community Health Improvement Plan

by Penny Borenstein, MD, MPH, Health Officer/Public Health Director, County of San Luis Obispo

We face a challenge in San Luis Obispo that leaders in other communities might envy: we have a vast number of dedicated organizations working to improve our community’s health and quality of life. We have many shared goals and powerful potential–but our sheer number of players can make it hard to check in with each other to see if we’re playing from the same sheet of music. It’s easy to duplicate efforts, and easy to miss opportunities to give or receive support that could bolster the effect of our work for the people we serve.

Now, I am pleased to announce a milestone that can help us work together to achieve collective impact for a healthier community. The Public Health Department, in collaboration with more than 95 partners in the non-profit, health care and government sectors, has recently released San Luis Obispo County’s first comprehensive community health improvement plan. Together, these partners make up a collaborative known as SLO Health Counts.

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This five-year plan represents a strategic and collaborative approach to achieving a shared goal: ensuring all San Luis Obispo County residents have the opportunity to be healthy.

It provides a path to measurable improvement in eight priority areas. Those areas and goals are:

Social & Emotional Wellness • Improve consistency of care across the continuum of social and emotional wellness services.

• Improve the social and emotional support network for teens in SLO County.

Access to Care • I mprove coordination of health care among service providers.

•R ecruit and retain providers to the Central Coast.

• I ncrease the proportion of low-income children in SLO County with routine and adequate dental care

Environment • Increase awareness within the agriculture community of the risks associated with Valley Fever and prevention / treatment needed.

• Improve water quality at high priority beach / creek interfaces.

S ocial Determinants of Health • I ncrease CalFresh enrollment to reduce hunger and improve health among SLO County residents.

• I mprove access to affordable, attainable, safe, and supportive housing.

The community health improvement plan is informed by the 2018 County of San Luis Obispo Community Health Assessment, which paints a point-in-time picture of the county’s health and highlights the important social, economic and health conditions that affect SLO County. After publishing this assessment, the Public Health Department brought together partners from across the community to develop a shared vision, identify eight priority areas, and form teams around those priorities. Team members used data, best practices, and their own expertise to define goals, develop measurable objectives and outline strategies for the community health improvement plan.

Maternal, Child & Adolescent Health • I mprove social and emotional supports for new mothers.

• I mplement a Help Me Grow™ (HMG) system in SLO County.

Infectious Disease • Reduce the rate of undiagnosed hepatitis C in SLO County • J ail inmate population.

•R educe the rate of influenza in high-risk SLO County populations.

•R educe the rate of syphilis in SLO County population.

Chronic Disease & Health Behaviors • I mprove diets and increase physical activity in the environments where people eat, live, learn, work and play.

• Reduce rates of chronic disease among county residents.

• R educe smoking initiation, tobacco use and exposure to secondhand smoke.

Injuries • Reduce falls among seniors. ª Reduce vehicle-related injuries.

Now, these teams are working to put the plan in action.

The teams include local health care providers and representatives from our region’s hospitals and clinics as well as many other community partners. I’d like to emphasize that there is plenty of room at the table. This is a true community effort and I hope new partners will continue to join us as we embark on this ambitious plan. Please consider lending your voice and insight to this effort. You can review the full plan and learn more about getting involved at www.SLOHealthCounts.org/CHIP. This type of plan is a first for SLO County and I am thrilled to see our community achieve this milestone through such a broad and dedicated coalition. My hope is that this milestone is one of many in a long history of working together to improve the opportunities for a healthier life for all San Luis Obispo County residents.

Correction: The Fall 2018 Public Health Update for San Luis Obispo County incorrectly stated that sedatives were present in 655 of 732 Coroner-investigated deaths in SLO County from early 2015 through early 2018. The correct number is 288 of 732 cases. The updated full report with this data is available at www.slocounty.ca.gov/epidemiology. We regret the error and welcome inquiries regarding this data. Please contact us online or call 805-781-5500 with questions.

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16 New & Rejoining The Central Coast Medical Association welcomes the following physicians as members

...and even more on the way.

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Mark E Burnett, MD Dermatologic Surgery Santa Barbara Skin Institute Santa Barbara 805.770.3999

Kimberly Painter Grafton, MD General Surgery Advanced Surgical Associates Santa Barbara 805.730.1470

K Charmian Dresel-Velasquez, MD Obstetrics & Gynecology Sansum Clinic Santa Barbara 805.681.7500

Robert Carr Kanard, MD Pediatric Surgery Santa Barbara 805.879.4240

Todd William Engstrom, MD Internal Medicine Sansum Clinic Santa Barbara 805.681.7500

Sarah Kempe-Mehl, MD Neurology Central Coast Movement Disorders Specialists Santa Barbara 805.201.2050

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David C Pires, DO Anesthesiology Pacific Pain Physicians Santa Barbara 805.563.0363

Stephanie Joy Rothman, DO Neurology Sansum Clinic Santa Barbara 805.681.7500

Andrew Gregory Ross, MD Nephrology Santa Barbara 805.563.2400

Douglas Peter Webster, DO Emergency Medicine Emcare Santa Barbara 800.230.5160

RESIDENTS Hamid Alipour, MD General Surgery Santa Barbara Cottage Hospital

Daya Raman, MD Internal Medicine Santa Barbara Cottage Hospital Benita Tjoe, MD Internal Medicine Santa Barbara Cottage Hospital David Tseng, DO Internal Medicine Santa Barbara Cottage Hospital

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William Ganske, MD General Surgery Santa Barbara Cottage Hospital

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CONTINUED FROM PAGE 21 >>

For most healthcare providers, distractions and interruptions are considered part of the job; it is the nature of their work. If we consider healthcare distraction on a continuum, on one end are distractions related to clinical care (e.g., answering team member questions or responding to surgical equipment alarms). On the other end of the continuum are distractions unrelated to clinical care (e.g., making personal phone calls, sending personal text messages, checking social media sites, playing games, or searching airline flights).

From a litigation perspective, the distinction between distractions related to clinical care and those unrelated to clinical care is important. In a medical malpractice claim where there is an

allegation that an adverse event was caused by distracted practice, a distraction caused by a clinical-care-related activity may be found to be within the standard of care and is, therefore, often defensible.

But where it can be shown that the distraction was caused by non-patient matters, the plaintiff’s attorney will certainly use that against the defendant. In these situations, the defendant’s medical care may not even enter the equation, because during eDiscovery the metadata (i.e., cell phone records, scouring findings from hard drives) serves as the “expert witness.” Even if the defendant’s clinical care was within the standard, the fact that there are cell phone records indicating that the healthcare provider was surfing the Internet or checking personal e-mail may imply distraction and could potentially supersede all other evidence.

Two new CME courses from The Doctors Company, How Healthcare Leaders Can Reduce Risks of Distracted Practice in Their Organization and The Risks of Distracted Practice in the Perioperative Area, address addiction to personal electronic devices and provide strategies that individuals and organizations can use to minimize the patient safety risks associated with distractions from these devices.

Find these courses and explore our extensive catalog of complimentary CME and CE activities at http://www. thedoctors.com/patientsafety/education-and-cme/ ondemand/.

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.

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In Memoriam

In Memoriam Dr. Van R. Hamilton - 1937 - 2018 Dr. Van R. Hamilton, a man beloved by patients, colleagues, family, and friends, passed away on September 6, 2018. He was born on December 27, 1937, in Van Nuys, California, the son of Dr. Van R. Hamilton and Cecilia Lindsten Hamilton. He spent most of his youth in Riverside, where his father was a practicing pediatrician. He graduated from Riverside Poly, then went on to earn a degree from University of Oregon, and obtained his medical degree from the University of California San Francisco, graduating near the top of his class.

After service as an army doctor in Vietnam, he settled with his first wife Janice and sons Greg and Eric in Santa Barbara, where he practiced internal medicine for almost fifty years, finally retiring at age 80. He loved his work, and patients loved him, often remarking on his care, compassion, and his willingness to spend whatever time they needed with them. They also appreciated that twinkle in his eye and his sense of humor.

Van was also a man who dearly loved and appreciated family and friends. His relatives always enjoyed his masterful storytelling and his ability to adopt a character and keep us all laughing and highly entertained. He was an avid reader, always willing to share books and book-related conversation. Van also reveled in his hiking, backpacking, and horse-packing with friends and family members. He was never happier than when he was fishing a high country stream or sharing jokes and stories around a campfire.

He possessed an amazing memory, able to recall details of long past events and people. This served him well in his medical practice, as he was able to recall almost everything he had read or learned in medical school, allowing him to be a masterful diagnostician.

Van leaves behind his wife Lois, sons Greg and his wife, Monica, of Santa Barbara and Eric and his wife, Linda, of Los Angeles, his step-daughter Kim Mearig and her husband, Brian, of Carpinteria, along with four grandchildren, Abel, Elaia, Jack, and Meredith and two step-grandchildren, Justin, and Kaitlyn. He also leaves behind his sisters, Valerie Thompson of Oceanside, Diane Jensen and her husband Verlyn of Santa Ana and his brother, Stephen Hamilton and his wife Andrea of Santa Fe, New Mexico, and many nieces and nephews. He will always be missed, but never forgotten.

Originally published in the Santa Barbara Independent.

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Central Coast Medical Association 100 N Hope Ave, Ste 14 Santa Barbara, CA 93110 CHANGE SERVICE REQUESTED

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